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FUN-damentals of Feeding in the

NICU Lynn  S  Wolf,  MOT,  OTR,  IBCLC  

Four  Key  Concepts  

• Have  a  plan  • The  baby  is  boss?  • You’ve  got  to  able  to  breathe  • Go  with  the  (correct)  flow  

1.  Have  a  plan  

Dodrill,  2008  • Survey  of  NICUs  in  Queensland  Australia  

• 80%  response  rate  

• None  had  formal  written  policies  or  procedures  for  transitioning  from  tube  to  oral  feeding  

• 14%  had  formal  evaluation  of  readiness  for  oral  feeding;  few  had  guidelines  for  assessing  tolerance  with  oral  feeding  

Failing  to  Plan  is  Planning  to  Fail  

Alan  Lakein  

A  Plan  vs  Standard  Care  Semi  demand  (McCain  2001)  

Cue  based  (Puckett  2008)  

Infant  driven  (Chrupcala  2015)  

Criteria  driven  (Simpson  2002)  

Hybrid  (Kirk  2007)  •  All  have  clear  criteria  for  when  to  offer  feeding  •  Sometimes  criteria  for  when  to  stop  feeding  •  All  provide  some  research  support  for  shorter  time  

to  full  oral  feeding  or  shorter  time  to  d/c  

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Other  Components  •  Non-­‐nutritive  sucking:  shorter  LOS;  faster  transition  to  

full  oral  (Pimenta  2008,  Foster  2016,  Fields  1982)  

•  Oral  motor/sensory  intervention:  decreased  LOS,  faster  transition  to  full  oral,  better  efficiency,  improved  wt  gain  (Fucille  et  al  2002,  2005,  2010,  2011,  2012,  Lessen  2011,  Rocha  2007)  

•  Skin  to  skin:  milk  supply,  breastfeeding  exclusivity  and  duration,  self-­‐regulation,  LOS,  weight  gain    (Hake-­‐Brooks  2008,  Hurst  1997,  Jayaraman  2017,  Ludington-­‐Hoe  2011,  Oras  2016,  Conde-­‐Agudelo  2011)  

•  Smell,  oral  care  with  EBM:  improved  sucking  skills,  feeding  interest  (Rodriguez  2010,  Yildiz  2011)  

Characteristics  of  a  Plan  to  Progress  to  Oral  Feeding  

•  Evidence  based  

• Developed  to  meet  the  needs  of  your  NICU  

• Development  and  implementation  includes  many  stakeholders  

•  It  looks  at  the  continuum  of  factors  that  contribute  to  a  positive  oral  feeding  outcome  

•  Clear  criteria  to  move  along  continuum  

•  It  is  family  friendly,  including  strong  support  of  breastfeeding;  families  are  active  participants  

The  Complete  Plan  for  Oral  Feeding  Progression  

•  Pre-­‐Oral:  trophic  feeds,  progress  toward  full  enteral,  STS,  NNS,  Oral  motor/sensory  interventions,  smell  and  oral  care  with  EMB;  building  milk  supply  

•  Early  Oral:  breast  if  possible;  clear  criteria  to  start  this  step;  follow  baby’s  lead    

•  Skill  Building:  Gaining  energy/endurance,  wakefulness,  strength  and  coordination;  balance  between  breast  and  bottle;  this  is  the  longest  stage  and  there  can  be  tension  between  breast  and  bottle  feeding  

•  Discharge  Planning:  transition  to  home;  competent,  confident  care  givers  

Step  Wise  Plan  

Kamitsuka  et  al,  2017  

Step  1  

• 23  –  30  weeks  • Odor  cloths,  Non-­‐nutritive  suck;  skin  to  skin;  oral  care  with  breastmilk;  minimize    noxious  oral  facial  input  

Step  2  • 30+  weeks;  full  enteral  feeds;  HFNC  ≤3L;  oral  readiness  eval  • Oral  sensory-­‐motor  activities;  pacifier  dips;  nuzzling  at  breast  

Step  3  • 31+  weeks;  Successful  at  step  2  for  7  days;  HFNC  ≤2L  • Swallow  practice  –  binky  trainer  5mL  over  10  min;  slowly  increased  to  10mL    

Step  4  

• 32+  weeks;  completed  Step  3;  on  bolus  feeds;  min  resp  support    • Followed  Kirk  el  al  (2007)  plan  with  oral  advancement  a  combo  of  infant  driven,  but  with  step  wise  advancement  

Alberta  Oral  Feeding  Progression  Plan    

(Premji  2004  ,  Lasby  2011)  

PRE-ORAL

Infant

Characteristics

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NUTRITIVE SUCKING

STAGE IInfant Characteristics

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Stage IIA: 10% to <25%

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Stage IIC: 50% to <80%

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STAGE IIIInfant Characteristics

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Disengagement/Distress Cues:

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Abbreviations:

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NEONATAL ORAL FEEDING REFERENCE POSTER

Lasby  2011  

to the NICU per year. The project took place in the level II NICU where allhealthy premature infants born at ≥30 weeks’ gestation were included.

Overall Framework

A quality improvement model was developed to translate IDF modelof care into nursing practice in our NICU. The IDF task force was formedand included representatives from nursing, physicians, occupationaltherapists, and lactation specialists. Task force members met regularlyonce or twice a month for the duration of the project and ultimately be-came IDF champions. As task force members, they were responsible fordeveloping the IDF guideline for the unit, educational materials fornurses and parents, a tool for auditing charts, and were responsible forconducting parental and nursing surveys. Teammembers performed lit-erature searches and group interviews with physicians, nurses, and par-ents to identify facilitators and barriers for developing and implementingIDF policies in premature infants. The project was divided into before-and after intervention phases, each lasted about 6months. The transitioninterval lasted about 3 months with a pilot study-taking place duringthat period. The after-intervention phase was measured after the IDFmedical guideline and nursing education campaign were completed.

Intervention and Implementation

All nurses working in the level II NICU were required to complete afive hour continuing education program which included a literature re-view, neurodevelopmental approach to oral feeding, principles of IDF,breastfeeding in the NICU, and a nipple feeding workshop. Numerousquestion and answer sessions with the nursing staff were conducted to

educate staff regarding specific implementations strategies for our NICU.The project was also discussed with the physicians in a division meetingto elicit their acceptance and incorporate their suggestions.

On the bases of the literature review, expert opinions and numerousunit discussions, an algorithm was developed to determine when aninfant was ready to start the IDF pathway and how the oral feedingscould be advanced (Fig. 1). Oral feeding progress was monitored forachievement of first and all oral feedings, weight gain, and necessity forfeeding therapist involvement. Feeding performance was not onlyevaluated by the amount of volume transferred during a feeding andtime of feeding, but also by readiness (behavior) behavior and qualitativefeeding assessments, used with permission from the IDFS© created andvalidated by Ludwig, S. & Waitzman, K.A. (2007; 2014) (Table 1).4,5 Spe-cial attentionwas given to the breast fed infants since direct breastfeedingis often overlooked in the NICU and evidence has shown that duration ofbreast milk feeding is positively associated with breast feedings in theNICU and the first oral feeding being at the breast.9 Exclusive breastfeedingfor at least 3 days before initiating any bottle feedings was offered tothe infants whose mothers were interested in breastfeeding. Details areaddressed in the algorithm for infant driven breastfeeding (Fig. 2). Educa-tion related to infant driven feeding was offered to all parents. A parentaleducational booklet containing language appropriate information on IDFwas given to every family participated in the project; neonatal nursesreviewed the material with parents before initiating feeding protocol.

Methods of Evaluation

A chart audit tool was developed to monitor infants’ feeding prog-ress. It was created to collect information on the PCAs at birth, at

Fig. 1. Algorithm for Infant Driven Feeding.

65P. Gelfer et al. / Newborn & Infant Nursing Reviews 15 (2015) 64–67

Decision  Making  Algorithms  Gelfer  et  al,  2015  

Algorithm  for  Infant  Driven  Feeding  

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2.  The  Baby  is  Boss!  

Or  is  he/she?  

Feeder  Controls  Feeding  

Infant  Controls  Feeding  

Co-­‐regulated  Feeding  

“Just  Right  Challenge”  

Who  is  the  BOSS  of  the  Feeding?     Why  Co-­‐regulated  Feeding?    

• At  one  end:  stress,  physiologic  compromise  

• At  the  other  end:  lack  of  progress  

•  Feeding  is  about  learning:  best  learning  is  when  there  is  the  highest  level  of  success  (the  “just  right  challenge”)  in  a  non-­‐stressful  environment.    •  None  of  us  learn  well  in  a  stressful  environment  

Feeder  Controls  Feeding  

Infant  Controls  Feeding  

Co-­‐regulated  Feeding  

“Just  Right  Challenge”  

Impact  of  Feeding  on  Brain  Development  

• Rapid  brain  growth  in  NICU  

• Baby  is  “building  their  brain”  during  NICU  stay  

• Experience  impacts  brain  development  

• Current  research  supports  the  concept  that  early  stress  changes  the  way  the  brain  develops  in  potentially  negative  ways  

Pain   Lack  of  satiation  with  drip  feeds  

NG  tubes  

Suction  ET  tube  

Impact  on  brain  development    

Poor  resilience  to  stress    

More  easily  stressed  by  small  things  

 Anxiety/depression/  hypervigilence      

Food  =  stress      Food  selectivity  and/or  refusal  

Maternal  separation   Gagging  

Physiologic  stress  with  feeding  

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Long  term  impacts  of  stress  around  feeding  

• Emotional  problems  from  anxiety  to  phobias  to  PTSD  have  roots  in  fear,  trauma  and  stress  

• Preschoolers  with  very  selective  eating  are  more  likely  to  be  anxious  or  depressed  and  have  hypersensitivity  to  taste  and  texture  (Zucker  et  al,  2015)  

Co-­‐regulated  Feeding:    Choosing  a  Feeding  Time  

Feeder’s  Role:  

•  Knows  the  window  when  feeding  is  expected  

•  Watches  for  signs  baby  is  becoming  more  wakeful  

•  At  that  time  helps  baby  come  to  most  full  arousal;  slow  and  gentle  

Baby’s  Role:  

•  Has  periods  of  greater  wakefulness  

•  Show’s  feeder  if  he/she  is  ready  to  wake  fully  or  not  when  provided  with  appropriate  help  with  arousal.    

Co-­‐regulated  Feeding:  Starting  the  Feeding  -­‐  bottle  

Feeder’s  Role:  

•  Makes  sure  baby  is  interested  in  sucking  (pacifier)  

•  Proper  position  (adequate  postural  support)  

•  Chooses  appropriate  nipple  flow  rate  

•  Starts  with  empty  nipple  

•  Always  uses  pacing  at  the  beginning  of  feeding  to  assess  baby’s  initial  response  to  feeding  

Baby’s  Role:  

•  Shows  interest  in  sucking  

•  Able  to  initiate  sucking  on  empty  bottle  nipple  

•  Physiologic  stability  as  feeding  starts  

Co-­‐regulated  Feeding:  During  the  Feeding  

Feeder’s  Role:  

•  Monitors  baby’s  moment  to  moment  response  to  feeding  (physiologic,  behavioral)  watch/feel/listen  for  very  subtle  cues  

•  Adjusts  feeding  as  needed  through  pacing  

•  Recognizes  importance  of  baby’s  sucking  pauses      

•  May  provide  some  gentle  encouragement  as  sucking  pauses  are  longer  

Baby’s  Role:    

•  Coordinates  suck/swallow/breathe  to  the  best  of  their  ability  

•  Provides  cues  to  feeder  as  to  how  feeding  is  working  

•  As  little  drama  as  possible  

 

During  the  Feeding:    Subtle  Stress  Cues  

WATCH  -­‐  especially  the  face  

•  Eye  brows  raised  

•  Eyes  closed  tight  

•  Eye  blink  

•  Gaze  aversion  

•  Brow  furrow  

•  Color  change  

FEEL  -­‐  the  babies  body  

•  Changes  in  tone    

•  Head  pulls  back  or  turns  slightly  

LISTEN  –  to  breathing  and  swallowing  

•  Tachypnea,  apnea,  stridor,  rattle,  obstruction  

•  Time  between  breathing  pauses  

•  Swallow  sounds  

•  SSB  timing  

Co-­‐regulated  Feeding:  Ending  the  Feeding  

Feeder’s  Role:  

•  Notices  baby  slowing  down  and  adjusts  techniques  

•  More  pacing?    

•  Depending  on  age  and  behavior  may  stop  feeding  to  burp  and  re-­‐wake  

•  Does  not  keep  pushing  baby  when  they  get  sleepy  

•  Does  not  use  techniques  to  make  baby  suck  “a  little  bit  more”  (cheek/chin  support)  

Baby’s  Role:    

•  Sucking  slows  way  down  and  probably  stops  

•  Baby  will  probably  get  sleepy  

•  Gentle  ending;  no  drama  

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3.  You’ve  got  to  be  able  to  Breathe!!  

Sucking  

Swallowing   Breathing  

Foundations  of  Infant  Feeding  

Medical  Stability  

State  and  Behavior  

Parent  Knowledge  and  Skill  

Normal  S/S/B  Coordination  

•  Precisely  coordinated  timing  

•  Sucking  is  organized  in  bursts  and  pauses  

•  During  the  burst:  SSB  

•  During  the  pause:  breathing  only  

Swallowing  Suppresses  Breathing  

• Swallowing  and  breathing  do  not  occur  simultaneously  

• Breathing  must  stop  for  every  swallow  

• TRY  IT!!  Suck  -­‐  Stop  breathe  -­‐  Swallow  -­‐  Start  breathe  -­‐-­‐-­‐  Repeat  

The  Anatomic  Challenge  to  Breathing  During  Feeding  

Factors  That  Can  Impact  Breathing  During  Feeding  

• Feeding  induced  apnea  

• Ventilatory  reductions  during  feeding  

• Respiratory  insufficiency  • Structural  • Disease  related  

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Feeding  Induced  Apnea    (Deglutition  Apnea)  

Term  -­‐  bottle   Preterm  -­‐  bottle  Selley  et  al  1986  

Cascade  of  Events  in  Feeding  Induced  Apnea  

• Most  frequently  at  the  beginning  and  end  of  feeding;  only  noticed  with  very  close  observation  

•  This  is  a  maturational  issue;  common  to  preemies,  but  not  term  infants  

Mathew,  1988  

Ventilatory  Reductions  During  Feeding  (Bottle)  

Young  preterm  infants  do  not  recover  as  well  from  the  ventilatory  reductions  associated  with  bottle  feeding.    

Baseline Continuous Sucking

Intermittent Sucking

Recovery

Respiratory Rate

TcO2

36-38 weeks

34-35 weeks Shivpuri  et  al,  1983  

Pulmonary  and  Cardiorespiratory    Changes  

• Respiratory  Distress  Syndrome  

• Bronchopulmonary  Dysplasia  

• Congenital  Heart  Disease  

Impact  of  IRDS/BDP  on  Feeding  

• Reduced  sucking  rate  and  length  of  sucking  bursts  at  term  corrected  age  

0

10

20

30

40

50

60

70

80

No BPD Mild BPD Severe BPD

Sucks/Minute

Sucks/Burst

0

2

4

6

8

10

12

No BPD Mild BPD Severe BPD

Sucks/Burst

Mizuno  et  al,  2007  

Impact  of  IRDS/BDP  on  Feeding  

•  Lower  O2  saturations  with  feeding,  at  term  corrected  age  

82

84

86

88

90

92

94

96

98

100

Non BPD Mild BPD Severe BPD

Oxyg

en

Satu

rati

on

Baseline

During feed

Mizuno  et  al  2007    

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Impact  of  IRDS/BDP  on  Feeding  

Feeding  is  very  inefficient  

ml/minute

0

1

2

3

4

5

6

7

8

9

10

Non BPD Mild BPD Severe BPD

Feed

ing

Eff

icie

ncy (

ml/

min

ute

)

ml/minute

Mizuno  et  al  2007  

Other  Respiratory  Conditions    that  Impact  Oral  Feeding  

• Congenital  anomalies    • diaphragmatic  hernia  • Congenital  adenomatoid  malformation  (CAM)  • Pulmonary  hypoplasia  • Paralyzed  diaphragm  

• Respiratory  obstructions  • Choanal  stenosis  • Malacia  (laryngo,  broncho,  tracheo)  • Glossoptosis  

Parting  Words  on  Breathing    

(Let  them  take  your  breath  away!!)    

• Feeding  is  the  most  energy  expending  work  of  infants  

• If  you  can’t  breathe,  you  can’t  feed  

• So  understanding  respiratory  issues  for  each  baby  is  key  to  determining  appropriate  expectations  

4.  Go  with  the  (Correct)  Flow  

If  you  don’t  have  the  correct  flow  there  are  many  dangers……  

Impact  of  Flow  on  Feeding  

•  The  higher  the  flow,  the  more  challenge  to  the  SSB  mechanism  

• High  flow:  1  suck  per  swallow  

•  Low  flow:  4-­‐5  sucks  per  swallow  

•  Low  flow  allows  much  more  time  for  breathing  •  Does  the  baby  get  less?      •  Think  of  the  sprinter  vs  the  distance  runner  

High  Flow    

• More  likelihood  of  feeding  induced  apnea  

• More  likelihood  of  physiologic  compromise  which  leads  to  increased  fatigue  

• More  stress  with  feeding  (trying  to  drink  from  a  fast  flowing  hose)  

• In  general  higher  fatigue  and  less  intake  •  Think  of  the  sprinter  and  distance  runner  •  High  flow  makes  babies  sprinters  

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How  do  we  manage  flow?  

At  the  breast:    

• Depends  on  mom  milk  supply  and  baby’s  ability  to  transfer  milk  

• High  flow:  pre-­‐pump  some  or  all  of  milk;    nipple  shield?    pacing?    

• Low  flow:  add  supplemental  flow  system;  wait  for  maturation  

How  do  we  manage  flow?  

With  a  bottle:    

• Choose  the  right  nipple  

• Choose  the  right  position  

• Pacing  during  feeding  

Nipple  Flow  Rates  

0   5   10   15   20   25  

Enfamil  Preemie  

Enfamil  Standard  

Enfamil  Slow  Flow  

Similac  Premature  (red)  

Similac  Orthodontic  

Dr.  Brown's  #1  

Similac  Slow  Flow  

Dr.  Brown's  Preemie  

Simlac  Standard  

Dr.  Brown's  Ultra  Preemie  

0   0.05   0.1   0.15   0.2   0.25   0.3  

Similac  

Enfamil  

Dr.  Brown's  

mL  per  min   Coefficient  of  Variation  (CV)  

Comparative  Flow  Rates  for  Specific  Nipples  

Variability  of  Flow  Rate  Between  Same  Type  Nipples  

Pados  et  al  2015  

Extra  Slow  Fl0w  

For  training  of:  •  SSB  timing  and  coordination  •  Swallowing  

Binky  Trainer              Bionix    Ultra  Preemie  

Feeding  Position  Horizontal  Bottle  Position  

NO  –  Gravity  increases  flow  rate  

YES  –  Gravity  effect  is  minimal  

Feeding  In  Sidelying  Support  for  Baby  

•  There  are  several  choices  for  a  horizontal  bottle  position  in  sidelying  or  very  upright  

•  Amount  of  support  needed  depends  on  head  control,  maturation,  and  general  medical  condition  •  To  optimize  feeding,  want  to  give  as  much  postural  

support  as  possible.    •  Less  postural  support  may  help  keep  baby  awake,  

but  carefully  weigh  cost  and  benefit  

•  Younger  babies  will  do  best  in  a  fully  supported  sidelying  position  

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Pacing  • Stop  flow  by:  

•  Tipping  baby  up,  bottle  down  (no  milk  in  nipple)  •  Breaking  suction  •  Removing  bottle    

• For  feeding  induced  apnea  •  Stop  flow  after  2-­‐3  sucks  

• For  insufficient  ventilatory  support  •  Stop  flow  after  5-­‐10  sucks  

• Has  to  be  done  before  baby  gets  in  trouble  •   Must  be  completely  tuned  in  to  baby  to  do  it  well  

In  Summary…  •  Your  NICU  should  have  a  clear  plan  for  oral  feeding  

that  is  multi-­‐dimensional  

•  You  are  in  charge  of  co-­‐regulating  every  feeding  you  do  with  a  baby  to  provide  the  “just  right”  challenge  

• Always  consider  the  impact  of  breathing  on  feeding  

•  Lean  toward  slower  flow,  rather  than  faster  flow;  volume  will  come  when  the  baby  has  matured,  gotten  healthier  and  felt  successful  

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