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Be Up-To-Date: NICU Feeding
Case Studies Supported by the Evidence
Be Up-To-Date: NICU Feeding
Case Studies Supported by the Evidence
Louisa Ferrara, PhD CCC-SLP, BCS-S, CNT
Jenny Reynolds, MS CCC-SLP, CLC, CNT, BCS-S
Louisa Ferrara, PhD CCC-SLP, BCS-S, CNT
Jenny Reynolds, MS CCC-SLP, CLC, CNT, BCS-S
DISCLOSURESDISCLOSURES
Louisa Ferrara:
Financial : Employed at NYU Winthrop Hospital & Molloy College
Financial : Advisory Board Member Innara Health
Non-Financial : Board Member NTNCB
Jenny Reynolds:
Financial : Employed at Baylor University Medical Center
Non-Financial : Member of the NPC
Louisa Ferrara:
Financial : Employed at NYU Winthrop Hospital & Molloy College
Financial : Advisory Board Member Innara Health
Non-Financial : Board Member NTNCB
Jenny Reynolds:
Financial : Employed at Baylor University Medical Center
Non-Financial : Member of the NPC
OBJECTIVESOBJECTIVES
As a result of participation in this continuing education activity, participants should be able to:
Summarize recent publications supporting specific feeding or pre-feeding strategies in the NICU population.
Describe why evidence-based practice is crucial for feeding development and later infant outcomes.
Identify one therapeutic strategy you can implement with your management team to establish positive change in your NICU.
As a result of participation in this continuing education activity, participants should be able to:
Summarize recent publications supporting specific feeding or pre-feeding strategies in the NICU population.
Describe why evidence-based practice is crucial for feeding development and later infant outcomes.
Identify one therapeutic strategy you can implement with your management team to establish positive change in your NICU.
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ATTENTION: ADVANCED CLINICIANS ATTENTION: ADVANCED CLINICIANS
Focus not on the techniques, but the rationales so you can improve consistency in your units.
Write down the references so you can share with management to implement unit wide, evidence-based changes.
Think about the gaps in the literature and what you think is missing from an efficacy standpoint.
Value that fact that you already know many of these techniques. Feel good about your practice and strive to improve the practice patterns of others.
Focus not on the techniques, but the rationales so you can improve consistency in your units.
Write down the references so you can share with management to implement unit wide, evidence-based changes.
Think about the gaps in the literature and what you think is missing from an efficacy standpoint.
Value that fact that you already know many of these techniques. Feel good about your practice and strive to improve the practice patterns of others.
FEEDING BEGINS DAY OF LIFE #1
FEEDING BEGINS DAY OF LIFE #1
ORAL FEEDING IN THE NICUORAL FEEDING IN THE NICU
OUR GOAL:
To promote a safe feeding experience for
the infant while supporting the
infant-family dyad through
recognizing strategies to support safety,
growth & neuroprotection
OUR GOAL:
To promote a safe feeding experience for
the infant while supporting the
infant-family dyad through
recognizing strategies to support safety,
growth & neuroprotection
Medical causes of feeding & swallowing disorders
Prematurity
Respiratory
Disorders
Cardiac Disorders
GI Disorders
Neurological
Disorders
Anatomic abnormalities of the aerodigestive tract
Genetic conditio
ns
Maternal and
Perinatal issues
(Lefton-Greif 2008; Dodrill and Gosa 2015)
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ADVOCATING FOR BREAST MILKADVOCATING FOR BREAST MILK
All NICU professionals are charged with ways to promote breastfeeding as the exclusive route to providing nutrition for
their infant. (Nyqvist 2013)
Exclusive use of human milk for the first 6 months of life
(Institute of Medicine, 2011; AAP section of Breastfeeding 2012; World Health Organization 2001))
All NICU professionals are charged with ways to promote breastfeeding as the exclusive route to providing nutrition for
their infant. (Nyqvist 2013)
Exclusive use of human milk for the first 6 months of life
(Institute of Medicine, 2011; AAP section of Breastfeeding 2012; World Health Organization 2001))
World Health Organization/United Nations Children’s Fund Baby-Friendly
Hospital Initiative
(Dodrill et al., 2008; Jadcherla, et al., 2010)
ORAL FEEDING IN THE NICU
Healthy premature infants typically achieve full oral feeding skills
by 36–38 weeks postmenstrual age, & co-morbidities are important
confounders to the acquisition of timely feeding milestones.
Acquisition of independent safe oral feeding
among NICU infants is an essential criterion for hospital discharge as per American
Academy of Pediatrics.
(AAP Committee on Fetus and Newborn, 2008)
STRESS = BRAIN ALTERATIONSSTRESS = BRAIN ALTERATIONS
(Smith et al., 2011)
INCREASED EXPOSURE TO STRESSORS IN THE NICU WAS ASSOCIATED WITH:
• Decreased brain size in the frontal and parietal regions
• Altered brain microstructure
• Altered functional connectivity within the temporal lobes
• Alterations in neuro-behavior at term equivalent
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STRESS CAN CAUSE…STRESS CAN CAUSE…
(Smith et al., 2011)
Abnormal reflex development
Stunts later motor, sensory, psychological and cognitive
development
Stressful procedures prime preterm infant’s system to subsequent
handling, producing heightened responses
to routine handling
Abnormal behavioral response to their environment
LEARNED AVERSIONS
SOOOOO…WHAT ARE YOU TRYING TO SAY?
SOOOOO…WHAT ARE YOU TRYING TO SAY?
LESS STRESS = LESS MORBIDITYLESS STRESS = LESS MORBIDITY
All possibilities should be exploited to
decrease potential stressors
&routine caregiving
tasks should be performed in the
least stressful manner
(Lyngstad et al.,2014)
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RECOGNIZE & INTERPRET BEHAVIORAL STRESS CUES DURING FEEDING
RECOGNIZE & INTERPRET BEHAVIORAL STRESS CUES DURING FEEDING
(Thoyre et al., 2012)
EXTENDED AIRWAY CLOSURE
• Pulling away• Finger splays• Extending arms • Pushing nipple• Eyebrow raise/ Eye
lid flutter • Furrowed brow• Gaze Aversion• Flailing
FLUID THREATS TO THE AIRWAY
• Drooling• Hard swallows • Wet breathing • Multiple swallows• Sputtering• Yelping• Gulping• Coughing• Nasal Congestion
REDUCED RATE & DEPTH
OF BREATHING
•WOB• Head bobbing• Head back• Stridor• Grunting• Color change• Nasal Flaring
Arching/turning away
DISENGAGEMENT CUESDISENGAGEMENT CUES
Shutdown
“Stop” sign
Looking away
OBVIOUS
NOT SO OBVIOUS
Eyebrow raise
Crying
CASE STUDY: BABY ECASE STUDY: BABY E
Born at 26 weeks gestation
Twin B
IUGR, PDA, PFO
Intubated 2 weeks, nCPAP 3 weeks, NC 1 week,
Room Air since 32w CGA
Initiated PO trials at 33 w CGA within a volume-driven unit
Feeding consult at 35w CGA due to frequent As,Bs,Ds with feedings, poor volume intake, frequency fatigue and long feeding
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CASE STUDY: BABY EWithout Feeding TechniquesCASE STUDY: BABY EWithout Feeding Techniques
OH NO!
NOW WHAT?
Evidence Based Practice
Evidence Based Practice
PRE-FEEDING
• States of arousal
• Presence of oral reflexes
• NNS/Oral stimulation
FEEDING
• Swaddling• Positioning• Slow Flow
Nipple• Elevated
Side-Lying Position
• Pacing
FUTURE DIRECTIONS
• Technology
Lets Get Up-To-Date!!!
FEEDING INTERVENTIONS
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STATES OF AROUSAL STATES OF AROUSAL Quiet awake state is
optimal for achieving successful full oral feeding
(McGrath et al., 2002; Pickler et al., 1996)
The maturity of their state system allows them to
wake when hungry and maintain that alertness for eating, then transition to a deep sleep to rest for the
next feeding
Premature infants have more difficulty maintaining
arousal long enough for adequate intake
More difficulty achieving a deep sleep state, so they are not as rested for the
next feeding
(Ludwig & Waitzman, 2007)
STATES OF AROUSAL STATES OF AROUSAL
PARK et al., 2020• Two distinct feeding groups were
identified: typical and delayed feeding progression (FP).
• In infants with delayed FP, rates of active and quiet sleep development during the day were delayed compared to those with typical FP.
• Infants with delayed FP were more likely to be awake more often during the night compared to infants with typical FP.
RESULTS:
• Delays in sleep–wake state development may be associated with delays in feeding progression during hospitalization
• Infants with delayed feeding skill development may require more environmental protection to further support their sleep development.
CASE STUDY: BABY EWithout Feeding TechniquesCASE STUDY: BABY EWithout Feeding Techniques
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NNS decreases…
• Transition gavage to full oral feeding
• Transition from start of oral feeding to full oral feeding
• Length of hospital stay in preterm infants
• Need for NGT at discharge (Foster et al., 2016; Fucile, Gisel & Lau 2012; Pinelli et al., 2000, 2005; Kamisuka et al, 2017)
PIOMI
• 5 min oral stim intervention to build strength
• Infants in 1x/day group transitioned to full oral feedings sooner than control (Lessen et al., 2011)
NNS paired with olfactory stimuli (smell of EBM)
• Reduces time to oral feeding and earlier discharge compared to NNS alone (Khodagholi et al., 2018)
NNS and Breastfeeding
• Use of pacifier shortened transition to full breastfeeding and sucking skills of infant in NICU
(Aytekin et al., 2017)
NON-NUTRITIVE SUCKINGNON-NUTRITIVE SUCKING
Rooting and Mouth Opening Reflex
Sets stage for correct tongue position Tongue on floor of mouth - not roof
Initiates proper suckingSucking initiates safe swallowing
Rooting and Mouth Opening Reflex
Sets stage for correct tongue position Tongue on floor of mouth - not roof
Initiates proper suckingSucking initiates safe swallowing
PRESENCE OF ORAL REFLEXESPRESENCE OF ORAL REFLEXES
Not Rooting = Not Ready
SWADDLINGSWADDLINGWHAT WE KNOW
Supports general physical organization while reducing
extraneous movements, resulting in increased
endurance and focus for feeding
(Ross, 2008)
Provides external support for the infants' postural stability
NEU & BROWNE,1997
• 14 preemies• Mean PMA: 32weeks• Measured behavioral
organization during weighing
RESULTS:Infants who were swaddled
experienced: physiologic distress motor organization
effective self-regulatory ability
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ELEVATED SIDE-LYINGELEVATED SIDE-LYING
WHAT WE KNOW
• Affords more ease of anterior-posterior rib cage movement (Vandergehm et al., 1983)
• Increases lung compliance and decreases airway resistance
• Makes it easier to maintain head and trunk alignment
• Reduces potential for bolus misdirection • Reduced bolus flow rate due to lower hydro-
static pressure (Lau, 2013)
• Similar to the cross-cradle position for breastfeeding
(Shaker, 2017)
ELEVATED SIDE-LYINGELEVATED SIDE-LYING
CLARK et al., 2007
• Oxygen saturations
• Work of breathing
• HR variability
THOYRE et al., 2014
• State regulation
• Swallowing safety
• Physiologic stability
PARK et al., 2014
• Less HR variability
• O2 variability
• Endurance for feeding
NIPPLE SELECTION: FLOW MATTERSNIPPLE SELECTION: FLOW MATTERS
Respiration, feeding
ability and swallowing safety are
all affected by flow rate
Higher flow rate makes the
coordination of sucking, swallowing
and breathing more challenging
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Milk flow rate is affected by teat:
material shape
hole size rigidity
compressibility
The bottle material & rigidity
The pressures used by the infant
(da Costa et al., 2010; Goldfield et al., 2006; Mathew, 1990; Nowak et al., 1994; Walden & Prendergast,
2000)
Bottle and nipple characteristics were
revealed to affect infant feeding and milk intake
(Ardran et al., 1958; da Costa et al., 2010; Goldfield et al., 2006; Mathew, 1988; Pados,
Park, & Dodrill, 2019; Pados, Park, Thoyre, Estrem, & Nix, 2016; Weber et al., 1986)
NIPPLE SELECTION: FLOW MATTERSNIPPLE SELECTION: FLOW MATTERS
FAST FLOW NIPPLES Disposable nipples
FAST FLOW NIPPLES Disposable nipples
Matthew, 1991• Apneas and bradycardia
during feedings in preterm infants
Hiss, et al., 2001•Reduced ventilation as
more time is spent in swallowing, less time is available for breathing.
Martin, et al., 1994• Inspiratory post-swallow
breath, instead of an expiratory post-swallow breath, which increases the risk of aspiration
Sheppard et al., 2007•Result in poor use of mouth
musculature and can lead to oral dysfunction
Chang et al., 2007• Inhibits infants' ability to self-
regulate flow and can contribute to subsequent oral aversion and feeding dysfunction
PREEMIE
SIMILAC
STANDARD FLOW
SIMILAC
ENFAMIL STANDARD FLOW
ENFAMIL
STANDARD FLOW
NUK
SLOW FLOW NIPPLES Disposable nipples
SLOW FLOW NIPPLES Disposable nipples
SIMILAC
ENFAMIL
Teal Slow Flow
Purple Extra Slow Flow
ENFAMILSIMILAC
Yellow Slow Flow
Jackman, 2013Allow infants to self-regulate flow and pace themselves better, which results in:• Increased feeding efficiency• Shorter feeding duration • Quicker acquisition of oral feeding
skills
Allow 3-5 days for an infant to adjust to the slow flow nipple
Bridges
the Gap
between our
“normal”
breastfeeding
to the bottle
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Dr. Brown’s Bottles and Nipples Offer Great Variety in Flow-RatesDr. Brown’s Bottles and Nipples Offer Great Variety in Flow-Rates
www.drbrownsbaby.com
FLOW RATE : PADOS et al., 2019 FLOW RATE : PADOS et al., 2019
VARIABILITY : PADOS et al., 2019 VARIABILITY : PADOS et al., 2019
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Use of imposed breaks during an infants feeding to facilitate improved:burst/pause rhythm breathing regulation bolus control
Which results in optimal:endurancesafety(Shaker, 2013)
Use of imposed breaks during an infants feeding to facilitate improved:burst/pause rhythm breathing regulation bolus control
Which results in optimal:endurancesafety(Shaker, 2013)
Encourages positive, stress-free
feeding skill development
PACINGPACING
o Reduces infant stress during a feedingo Improves respiratory status throughout feeding
o Bradycardia (1)o SaO2 variability, decline, and time spent in a desaturated state; o HR fluctuation and decline (2)
o Reduces risk of liquid misdirection into the airwayo Behavioral disorganization (2)o Efficiency of their sucking patterns at discharge (2)
o Most similar to Breastfeeding, which is our gold standardo Routing neural pathways
(1,Law-Morstat et al., 2008; 2, Thoyre, et al. 2012)
o Reduces infant stress during a feedingo Improves respiratory status throughout feeding
o Bradycardia (1)o SaO2 variability, decline, and time spent in a desaturated state; o HR fluctuation and decline (2)
o Reduces risk of liquid misdirection into the airwayo Behavioral disorganization (2)o Efficiency of their sucking patterns at discharge (2)
o Most similar to Breastfeeding, which is our gold standardo Routing neural pathways
(1,Law-Morstat et al., 2008; 2, Thoyre, et al. 2012)
PACINGPACING
CASE STUDY: BABY EWith Feeding TechniquesCASE STUDY: BABY EWith Feeding Techniques
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WHAT ABOUT WHEN YOU TRY ALL THE FEEDING STRATEGIES… WITHOUT SUCCESS?
WHAT ABOUT WHEN YOU TRY ALL THE FEEDING STRATEGIES… WITHOUT SUCCESS?
Don’t worry. Just call your SLP to see if the infant is a candidate for an instrumental swallow examination! Don’t worry. Just call your SLP to see if the infant is a candidate for an instrumental swallow examination!
INSTRUMENTAL SWALLOWING ASSESSMENTS
INSTRUMENTAL SWALLOWING ASSESSMENTS
Using Feeding Interventions DiscussedUsing Feeding Interventions Discussed
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FUTURE DIRECTIONS…FUTURE DIRECTIONS…
o nfant
o Ntrainer
o High resolution cervical auscultation
TECHNOLOGY
LET’S GET BACK TO BABY T…….LET’S GET BACK TO BABY T…….
Born at 39 weeks at a birthing center
Apgar 0 0 1
Total Body Cooling
Seizures post delivery and post warming
Hypoxic Ischemic Encephalopathy
Continuous EEG monitoring for 7 days
Born at 39 weeks at a birthing center
Apgar 0 0 1
Total Body Cooling
Seizures post delivery and post warming
Hypoxic Ischemic Encephalopathy
Continuous EEG monitoring for 7 days
BABY T IS HEADED HOMEBABY T IS HEADED HOME
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GROWING & THRIVINGGROWING & THRIVING
CONSISTENCY MATTERS: FOR BOTH INFANTS AND CAREGIVERS
CONSISTENCY MATTERS: FOR BOTH INFANTS AND CAREGIVERS
A positive relationship exists between the consistency and
continuity of feeding management practices and
improved feeding performance (Sables-Baus et al., 2013)
A positive relationship exists between the consistency and
continuity of feeding management practices and
improved feeding performance (Sables-Baus et al., 2013)
TherapistNICU Staff
There should be unit-wide consensus
for which feeding techniques each
baby needs
CALL TO ACTION!CALL TO ACTION!
Identify one therapeutic strategy you can implement
with your management team
to establish positive change
in your NICU
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LOUISA.FERRARA123@GMAIL.COM
JENNY.REYNOLDS@BSWHEALTH.ORG
LOUISA.FERRARA123@GMAIL.COM
JENNY.REYNOLDS@BSWHEALTH.ORG
Your Babies Thank You For Always Being Up-To-Date!!
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