EATING IN “SINC” - · PDF fileFollowing principles of the Oral Feeding ... Stage F...

Eating in “SINC” Stacey Dalgleish, NP

Canadian Association of Neonatal Nurses – ONE Day of Education

Monday, October 6, 2014

3:05 p.m. – 4:05 p.m. 1

EATING

IN “SINC”

A Quality Improvement Project

Calgary Zone NICUs

CALGARY STATUS 2012

�

�

�

�

� Safety concerns

� oral feeding while on CPAP

� Developmental concerns

� missing opportunities for

feeding skill acquisition

� Long term burden of oral

aversion

� No local data

2




3:05 p.m. – 4:05 p.m. 2

“AND” IS BETTER THAN “OR”

� Breathing…… optimal lung development

� AND

� Eating…… food is pleasant and satisfying

Optimal lung = endurance and capacity to eat

Eating and Breathing are co-dependent

actions

3

CAN WE HELP BABIES BORN AT

<32 WEEKS TO BREATHE AND EAT?

1. Physiologic stability

2. Demonstrate cues of readiness to feed

3. Require time and/or support for optimal lung

development

� Thousands of new alveoli and neuronal connections being

built every day!!

4




3:05 p.m. – 4:05 p.m. 3

EVIDENCE

� There can be oral sensory deprivation OR

overload with learning to eat• No opportunity to suck or taste

• Forced opportunity to suck or taste

• Overwhelmed by situation

� “Skill” acquisition = building neural pathways� Immaturity alone alters the typical path to developing

feeding skills

5

LONG TERM CONSEQUENCES

• Feeding difficulties are associated with language delay in preterm infants• J Peds, 2013 (Adams Chapman et al.)

• 18-22 month Bayley

• 1477 preterm infants, < 26 weeks

• < 1 % of preterm infants required supplemental tube feeds at time of NICU discharge.• Advances in Neonatal Care, 2007 (Kirkby, et al.)

• 10-80% of parents report problems feeding NICU graduates in the first 24 months• J Paeds and Child Health, 2002 (Cerro et al.)

• Archives of Dis (fetal), 2003 (Wood et al.) 6




3:05 p.m. – 4:05 p.m. 4

BURDEN OF ORAL AVERSION

� Oral aversion may present:

• In NICU

• At end of reflexive sucking

• At introduction of solids

� Babies are not free from this morbidity until 1 year of life

� Burden of oral aversion

� Non-standardized definition

� Rates of 10-70%

� Neurodevelopmental delay, BPD

� ? standardized definition, referral process, or

approach to NICU graduate feeding difficulties7

EATING ORGANIZATION DEVELOPS

IN AN ORDERLY FASHION

• Stable non-nutritive sucking may not be identified until 32-34 weeks (or it may be earlier)

• Poor sucking pressures, frequencies, duration and efficiency

• Preterm infants show progression of oral-motor development between 30 and 45 weeks

• Robust NNS is not predictive of ability to manage fluid

• Infant ventilation stops during swallowing

• Eating may over-ride respiratory chemical control

• External pacing, skill for the feeder

• Orienting to own mother’s scent and breast milk

• More stable vital signs, improved brain growth

• Early nuzzling

• Organization of arousal

• Lifelong importance of state organization

• Neuronal mapping

• Clin Perinat, 2011 (Browne and Ross)8




3:05 p.m. – 4:05 p.m. 5

NICU EATING CARE MAP

NNS

Breast

Eatin

g

9

“SUFFICIENT” EATERS VS

“SKILLED” EATERS

� Poor feeding outcomes increase as

gestational age decreases

• <600 gram neonates followed to 3 years of age

� 62% had continued eating problems

• Food as reward, coaxing, food refusal

• Poor weight gain, vomiting, chronic diarrhea

� 29% had gastrostomy tubes

� J Paed Child Health, 2007 (Cerro, et al)

• Sufficient rather than skilled feeders

• JOGNN, 2007 (Thoyre et al.)

10




3:05 p.m. – 4:05 p.m. 6

CANADIAN LAMBS

� NNS and CPAP

� Nutritive sucking and CPAP

� Praud and associates

� Journal of applied physiology, 2005, 2012

� Journal of pediatric gastroenterology and nutrition,

2013

11

PRETERM BABIES CAN BREAST FEED

� Nyqvist

� 1999 – early human development

� 2008 – Acata Paediatr

� 2013 – J Human Lact

12




3:05 p.m. – 4:05 p.m. 7

SINC: BREATHING & EATING

� Safe Individualized Nipple Feeding Competency

1. < 32 weeks at birth

2. Required CPAP for optimal lung development.

3. Demonstrates cues of readiness to feed

4. Physiologic stability

Fragile feeders audit

13

HOW?

� Baseline audit

� Multi-disciplinary team

� Literature review

� Expert opinion� Sherbrooke, Quebec

� Scandinavia

� Pilot project on the NP team

� Fragile neonates cue for feeding and have

opportunity to “taste” at breast or with drops

offered during NNS with a pacifier

14




3:05 p.m. – 4:05 p.m. 8

EARLY AND FREQUENT FEEDING PRACTICE

• Howe, et al. Nursing Research, (2007)

• Offered on basis of cardio-respiratory and behavioral

responses

• Sooner to fully orally fed

• Diminished LOS

15

QUALITY EATING

� Feeding is

relationship based

� Positive experience

� The baby is learning

to feed and skills are

emerging

� Learning to eat is a

developmental skill

focusing on the baby

� Feeding is a

competitive sport

� Intake is most

important

� The baby is a “good

feeder” or a “poor

feeder”

� Feeding the baby is

about who can “get the

volume in”

Cue Based Volume Based

16




3:05 p.m. – 4:05 p.m. 9

EATING = PLEASURE

� No arbitrary feeding schedules or expectations

� Obligate suck as reflex

� Volitional = choice

� Cue based

� Cues for Engagement and DIS-engagement

� More breast feeding focus

17

“EATING IN SINC”

� Therapeutic Tasting on CPAP (July 2012)� Pilot at FMC

� Implemented by NNPs for “Fragile Feeders” (still on CPAP at

32 weeks)

� Following principles of the Oral Feeding

Protocol…

� NNS

� Then small volume feeding progression while on

CPAP

� Maximum feeding times and volumes defined

� Infant must prove skill and endurance before

advancing to larger volume or longer time18




3:05 p.m. – 4:05 p.m. 10

THE ALGORITHM V.15

19

“COMPETENCE”?

� No decompensation: � Increased apnea/bradys

� Need for increased respiratory support

� *Deterioration often subtle at first

• Infant must prove competence

0

2

4

6

8

10

12

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55

Volu

me (mLs)

"Decompensation"

0.21

2 lpm

0.23-0.25

2 lpm

0.25

2 lpm

3 lpm

0.21

0.23

3

0.21

2 lpm

0.24

2 lpm

0.21

2 lpm

20




3:05 p.m. – 4:05 p.m. 11

NO DISENGAGEMENT:

� LOW tolerance for stopping the feed –

�“No” means “NO!”

�Feeding experiences must be positive� Building neural connections

� Goal is to hard-wire food + pleasure vs food + discomfort/fear.

� Infant does not have to prove disengagement

21

BREASTFEEDING

� Included at EVERY stage: First oral experience should be at breast

� If cueing, baby can/should go to breast every time the mom is present and the baby is cueing

� Requires conversation/coaching/management of pumping

� “Baby should breastfeed at an APPROPRIATELY pumped breast”

� Careful assessment of infant while at breast (swallowing, flooding, etc)� *If mom reports milk transfer, assume baby took max oral volume for that

feeding

� This means: Subtract the max SINC stage oral volume from the gavage feed

� Stage F or greater with milk transfer – decrease the gavage top-up by 50% or more

22




3:05 p.m. – 4:05 p.m. 12

“CAUTION EVENTS”

� Vaccinations

� Eye exam

� Tub bath

� Procedures

� GERD

� Site transfers (prepare the parents!)

� Consider the baby’s planned/ recent “workload” prior to each feeding opportunity

� Implications for planning SINC stage advancements/ allowance for regression

23

0

5

10

15

20

25

30

1 4 7

10

13

16

19

22

25

28

31

34

37

40

43

46

49

52

55

58

61

64

67

70

73

76

79

82

85

88

91

94

97

100

103

106

109

112

115

118

Volu

me (mLs)

Oral feeds over 14 days

Eye

“Caution Events”

24




3:05 p.m. – 4:05 p.m. 13

SINC PROJECT

� Control population 2012� Born < 32 weeks

� Calgary Oral Feeding Guideline

� Inconsistent application

� SINC population 2013

� Born at < 32 weeks defined as fragile feeders

� Follow the SINC algorithm

� Volume and time protected

� Cues for engagement and disengagement

� No change in respiratory management guidelines 25

AUDITING

We review every feed on every baby from first oral feed to discharge home.

1. Compliance with algorithm - Need for conversation/ education?

2. Gestational age:• at introduction of oral feeds

• at full oral feeds

• at discharge home

3. Breastfeeding patterns

4. Rates of oral aversion � Retrospective comparison with Open Lung cohort

� Plus: � Safety

� Impact on other feeding/health/development issues26




3:05 p.m. – 4:05 p.m. 14

BASELINE FEEDING PATTERN

(2012)

0

10

20

30

40

50

60

1

17

33

49

65

81

97

113

129

145

161

177

193

209

225

241

257

273

289

305

321

337

353

369

385

401

417

433

449

465

481

497

513

529

545

561

577

593

609

625

641

657

673

689

Volu

me per feed (mLs)

Baby M: 33 - 45 weeks CGA

27

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

mL

of

fee

d

Baby S. Born at 24 weeks

CPAP +5, 0.21

****

CPAP +6,

0.22

CPAP +6,

0.21

CPAP+5,

0.21

1 lpm, 0.21

**********

**********

RA

**********

*********

CPAP +4,

0.21 1 lpm,

0.21

28




3:05 p.m. – 4:05 p.m. 15

SINC PROJECT RESULTS

� Discharged on gavage

� Discharged on home oxygen

� LOS

� Time of first feeding

� Time of first breast feeding

� Amount of breast feeding at discharge

29

GESTATION AT FIRST BREASTFEED

28

29

30

31

32

33

34

35

36

37

38

23-24 weeks 25 weeks 26 weeks 27 weeks 28 weeks 29 weeks 30 weeks 31 weeks

Completed w

eeks

2012

2013

30




3:05 p.m. – 4:05 p.m. 16

GESTATION AT FIRST ORAL FEED

31

32

33

34

35


Completed w

eeks

2012

2013

31

AVERAGE NUMBER OF BREASTFEEDS, LAST

7 DAYS PRIOR TO DISCHARGE HOME

0

2

4

6

8

10

12


2012

2013

32




3:05 p.m. – 4:05 p.m. 17

GESTATIONAL AGE AT FULL FEEDS

32

33

34

35

36

37

38

39

40

41

42


Completed w

eeks

2012

2013

33

INFANTS DISCHARGED HOME WITH

FEEDS PER GAVAGE

0

1

2

3

4

5

6

7

Jan-Jun 2012 Jul-Dec 2013

34




3:05 p.m. – 4:05 p.m. 18

Median Age to Discharge

Open Lung 2012 vs Open Lung + SINC

2013

32

34

36

38

40

42

44

23 (n=0)

(n=1)

24 (n=0)

(n=12)

25 (n=5)

(n=7)

26 (n=12)

(n=7)

27 (n=5)

(n=12)

28 (n=8)

(n=19)

29 (n=15)

(n=22)

30 (n=18)

(n=16)

31 (n=29)

(n=33)

Gesta

tion at Discharge (weeks)

Median Gestation at

Discharge 2012

(n=92)

Median Gestation at

Discharge (SINC)

2013 (n=129)

35

NO SAFETY CONCERNS TO DATE

� Babies stay on CPAP to allow optimal lung development

� Babies SAFELY “train” with small volumes until consistently capable and then advance slowly

� Breastfeeding is the preferable mode for all oral feeding experiences

� Parents become more engaged with infant feeding, and have reported self-confidence with feeding

� As with all QI projects, close auditing for safety, efficacy and unintended consequences

� Enormous national interest (CNN)36




3:05 p.m. – 4:05 p.m. 19

NEXT STEPS

� Follow to 1 year for feeding difficulties

� Physiologic studies underway

� Stability during all modes of careful eating

37

CHART AUDIT

0

5

10

15

20

25

30

35

40

1 5 9

13

17

21

25

29

33

37

41

45

49

53

57

61

65

69

73

77

81

85

89

93

97

101

105

109

113

117

121

125

129

133

137

141

145

149

153

157

161

165

Volu

me (mLs)

Oral feeds over 21 days

Case 5

38




3:05 p.m. – 4:05 p.m. 20

THE TEAM

� Stacey Dalgleish (Team Lead)

� Noreen Blachly

� Linda Kostecky

� Jammey Kerik, Susan Charron (FMC)

� Jeanne Scotland, Ann Smith (RGH)

� Dallas Baumler (SHC)

� Kirenza Holland, Darlene MacDonald (PLC)

� Deborah Clark (Neo Lead)

� Super User RNs, Nursing Admin (all sites)

� Donna Dressler-Mund (consultant)

� Karen Lasby (NTT consultant) 39

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EATING IN “SINC” - · PDF fileFollowing principles of the Oral Feeding ... Stage F...

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