Oral Feeding the Infant What can we do?

Oral Feeding IssuesChantal Lau, PhDBaylor College of MedicineDepartment of Pediatrics/NeonatologyTexas Childrens HospitalHouston TX, USA

October 31, 2012

Financial Interest: Feeding for Health LLC1Outline Our philosophyCommon problems Bottle feeding approaches CurrentPotentialOral Feeding Skills (OFS) Assessment ScaleConsider- interventions to enhance OFS- tools to facilitate oral feedingBreastfeeding the Oral Feeding Puzzle

2Our philosophy has a long-term goalTo train successful feeders, i.e., well-developed functional oral feeding skills- negative oral sensory inputs in nursery- developmental delay from ex-utero maturation

Quality over quantity: quality of feeding skills vs. quantity of milk ingested

Oral feeding must be a positive experience: - avoid short- and long-term feeding issues and aversion3 A preterm infant is NOT a fullterm infant- not appropriate to feed a preemie as we do a fullterm infant

But, pressure to attain full oral feeding for earlier discharge Remember immature suckingpoor enduranceunstable behavioral statesnot as efficientcannot feed for a long time4physiciansnursesfeeding specialistsOTlactationspeech

Oral feeding is a multi-disciplinary tasknutritionImportant to give a consistent message to mother and babyRC Gorman5Adequate weight gain ( 10-15 g/kg/day)Safety : to minimize aspirationmust avoid O2 desaturation, apnea, bradycardia, aspiration-pneumoniaSuccess: to complete entire feeding within allotted time (e.g., 20 - 30 min)limiting energy expenditure to favor weight gainWhat is the current practice?6What should our goals be?Adequate weight gain ( 10-15 g/kg/day)Safety: no aspiration, O2 desaturations, apnea, bradycardiaSuccess:- not necessary to complete a feeding, but to develop good feeding skillsOral feeding ought to be a pleasant, nurturing experience to minimize feeding aversion

7Outline Our philosophyCommon problems Bottle feeding approaches CurrentPotentialOral Feeding Skills (OFS) Assessment ScaleConsider- interventions to enhance OFS- tools to facilitate oral feedingBreastfeeding - the Oral Feeding Puzzle

8Signs of fatigue:Poor toneState change, e.g., sleep, shut downLengthy sucking pauses Feeding duration > 20 minIncreased milk leakage, droolingIncreased respiratory rateOxygen desaturation/apnea/bradycardiaPoor endurance9RefluxSigns of reflux:EmesisChoking/coughing/aspirationArchingOesophagitisOral feeding aversion

10Suck-swallow-breathe incoordinationSigns of incoordination:Coughing/choking/aspirationPoor self-pacingApnea/bradycardiaOral feeding aversion11PhysiologicalOxygen desaturationApnea/bradycardiaTachypneaChoking/coughing/AspirationEmesisMilk leakageBehavioralPoor toneFall asleep AgitatedPushing awayTurning head awayState change -shut downaversive to feedingEnd result difficulty diagnosing primary causesConsequencesall the sameIf caretakers persist on feeding infants12Are we doing right by our babies?

Outline Our philosophyCommon problems Bottle feeding approaches CurrentPotentialOral Feeding Skills (OFS) Assessment ScaleConsider- interventions to enhance OFS- tools to facilitate oral feedingBreastfeeding - the Oral Feeding Puzzle

14Current Approachesfocused primarily on sucking issues, butlack of evidence-based data to objectively support the current practicesfew clinical studies available to differentiate: true benefits vs. natural maturation process15Use jaw and cheek support Why? - immature muscle tone- wide jaw excursionHow? - gentle sustained pressure- make sure not to impede breathing and infants self-pacingEnhanced non nutritive sucking pressures and feeding performance, while reducing oral feeding transition time (Boiron et al 07) 16

17Use pacing techniqueWhy? - infant sucking, forgets to breathe- gives time for breathing and restinghelps re-coordinate suck-swallow- breathe

How? - 3-5 sucks- tilting bottle back without removing bottle (infants organization)pulling nipple out

18Cue-Based ApproachBecoming popular as a marker for readiness to oral feed, but lack evidence-based support (McCain et al 01; Ludwig & Waitzman 07; Crowe et al 12)are Cues ~ to NIDCAP states and behaviors, i.e. observable events?

Examples of concerns - Infant cues: are subjective to the observer, e.g., is an infant in a light sleep state or slowing down due to fatigue?do not provide information re. limitations of infants oral feeding skills, if anyabsence of adverse cues does not imply all is well, e.g., silent aspiration

Use of cues along with quantitative measures may be more reliable re. infant feeding readiness and aptitudeOutline Our philosophyCommon problems Bottle feeding approaches CurrentPotentialOral Feeding Skills (OFS) Assessment ScaleConsider- interventions to enhance OFS- tools to facilitate oral feedingBreastfeeding - the Oral Feeding Puzzle

20Based on combinations of: common sensephysiologyevidence-based informationobjective integration of old and new information Watch out for: subjectivity/bias/over interpretation

Potential Approaches 21Adjust feeding positionWhy?- facilitates organization & breathing -facilitates safer swallowing -decreases reflux- intra-abdominal pressure esphageal peristalsis (Ren et al 91)

How? -slightly upright, cradled, - body and head midline position, -ensure upper chest and head supported, no crouching-head tilting changes cerebral hemodynamics (Tax et al 11)

22Limit feeding durationWhy? - reduces fatigue, risk of aspiration, feeding aversion

How?- decrease # oral feedings/day or feeding duration- complement with NG feeding to preserve caloric intake- follow feeding specialists recommendations if consulted23Regulate flowUse pacing if necessary Increase viscosity (thickener)e.g., rice cereal difficulty in replicating by the bedside the viscosity identified via modified barium studyBut do we really know our babies limitations in absence of overt behavioral and/or clinical responses? Maybe best would be..

24Let infants feed at their own paceWhy? allows infants to: develop appropriate functional feeding skills have a positive experience re. oral feedingminimize oral aversionHow? gives infants control to: regulate milk flow rest if necessarybreathe25Baby communicates: ready to feedWatch for cuesEyes may be open or closedResponsive to light touchLooks at caregivers faceHands towards mouthRooting or sucking Smooth motor movementsCalm and quiet26Baby communicates: NOT ready, STOP feeding

Watch for cuesStaring or gaze aversionPanic or worried lookcannot wake up, excessive yawningTremor, startling Hiccupping, spitting up, gagging, gaspingFrantic, arching, arms extended, fingers splayed Color changesIncreased respiratory rate and vital instability27

Wait, give me a break!28

Outline Our philosophyCommon problems Bottle feeding approaches CurrentPotentialOral Feeding Skills (OFS) Assessment ScaleConsider- interventions to enhance OFS- tools to facilitate oral feedingBreastfeeding - the Oral Feeding Puzzle

30Oral Feeding Skills Levels (OFS) scale(Lau & Smith 11)Novel objective indicator No equipment needed, simply measure: volume prescribed, taken at 5 min, during entire feedingduration of feeding (min)Monitored over timeOutcomes computed:overall transfer ( % ml taken/ml to be taken)rate of milk transfer over entire feeding (ml/min)proficiency (% ml taken at 5 min/ml to be taken)Interpretation:rate of transfer ~ resultant of skills + enduranceproficiency ~ PO skills when fatigue minimal

Level 1skills :LOWEndurance: LOWLevel 2Skills :LOWEndurance: HIGHLevel 4skills :HIGHEndurance: HIGHLevel 3skills :HIGHEndurance: LOW Oral Feeding Skill (OFS) levelsGA2526-2930-34Endurance(RT)

GOOD

POOR Skills POOR GOOD(PRO)30% 1.5 ml/minOFS LevelsFeeding skills (Pro)Endurance(RT)Potential Interventions1lowlownonnutritive oral motor stimulation + endurance training2lowhighnonnutritive oral motor stimulation 3highlowendurance training4highhighnoneInterpretations/interventionsOFS LevelPotential Intervention(s)

Overall Transfer (%)Rate of Transfer (ml/min)OFS 3OFS 4OFS 1OFS 2p < 0.05OFS1 < OFS 2-4OFS 2,3 < OFS 4(Lau & Smith 12)Feeding Performance vs. OFS levelsOutline Our philosophyCommon problems Bottle feeding approaches CurrentPotentialOral Feeding Skills (OFS) Assessment ScaleConsider- interventions to enhance OFS- tools to facilitate oral feedingBreastfeeding - the Oral Feeding Puzzle

35Uni-modal interventions:tactile/kinesthetic stimulate vagal activity, gastric motility, weight gain, decreases energy expenditure (White & LaBarba 76; Rausch 81; Diego et al 07; Lahat et al 07)NNOMT and massage therapy shorten times from start to independent oral feeding (Fucile et al 11)

Multi-modal interventions: Auditory, tactile,vestibular and visual stimulations greater volume ingested, attained independent oral feeding faster and discharged earlier (White-Traut et al 02) NNOMT + Massage therapy (Fucile et al 11)

Types of interventions36 Subjects - VLBW between 25 to 33 wks GAStudy Design - Preventive approach, ie, interventions provided when infants off CPAP and on full enteral feeding for 14 days or till full PO attained Methods Nonnutritive sucking on a pacifier till full PO Swallow exercise - till full PONonnutritive oral motor therapy (NNOMT) and/or infant massage therapy (MT) for 14 days Feeding positioning: Upright and SidelyingInterventions to enhance OFS skillsControl(Lau & Smith 12)Intervention durationOff CPAP- 8 PO/dNonnutritive oral motor (NOMT)NNOMT+MTMassage therapy (MT)Control Occurrence (%)Occurrence (%)(Fucile et al 11)1 8 1 10 11 8 1 11 11 16 1 21 1Days from SOFDays from SOF14-dayinterventionOccurrence (%)Occurrence (%)Semi-reclined (control)SidelyingUprightdays from SOF 1 7 6 17 9 1 5 3 15 8 1 8 6 22 12Feeding Positions(Lau 12)Outline Our philosophyCommon problems Bottle feeding approaches currentPotentialOral Feeding skills Assessment ScaleConsider- Interventions to enhance feeding skillstools to facilitate oral feedingBreastfeeding - the Oral Feeding Puzzle

41Tools to facilitate oral feedingCup-feeding (Mizuno & Kani 05;Collins et al08; Huang et al 09)

Paladai feeding (India) (Aloysius & Hickson 07)

Self-paced feeding system

(Lau & Schanler 00; Fucile et al 09; in Prep) Self-paced feeding systemVacuum buildupHydrostatic PressureParafilm

Standard BottleSelf-paced system

Vacuum Build-upVacuum Build-upSelf-paced bottle(Lau & Schanler 00)43

p < 0.001p = 0.007

p = 0.016Standard

Self-pacedStandardSelf-PacedGA27.7 1.2 (26-29)27.9 1.0 (26-29)PMA @ 1-2 PO/day34.3 1.0 (33-37)34.2 0.8 (33-36)PMA @ 6-8 PO/day36.3 1.5 (34-39)36.8 2.0 (34-42)(Lau & Schanler 00; Fucile et al 0944

p < 0.001p < 0.001p < 0.001p = 0.002p < 0.001p < 0.001p < 0.001p = 0.002Standard

Self-paced45Standard Self-paced BottleOccurrence (%)1-2 oral feedings/day6-8 oral feedings/dayStandard Self-paced BottleOFS levels Standard vs. Self-Paced (In prep)

Breastfeeding RC Gormanthe Oral Feeding Puzzle47Mother-Infant DyadMaternalbehaviorLactation

Non-nutritionalbenefits growth/developmentNutritional benefitsoral feeding skillsMotherInfantequilibrium(Lau 02)48MaternalbehaviorLactation

Non-nutritionalbenefits growth/developmentNutritional benefitsoral feeding skillsMotherInfant(I)(II)(III)imbalance(Lau 02)With a preterm infant49Maternal attributes / LactationMammary development/anatomyglandular and ductal development (lactogenesis I)Milk synthesis/ejection (lactogenesis II)nipple types infants ability/inability to latch onto the breast (Lau & Hurst 99)PrematurityTo what extent are lactogeneses I and II impaired? 50Milk Synthesis/Ejection (lactogenesis II)Milk Synthesislactogenic hormones: prolactin, glucocorticoids, insulinleptin mammary development (Laud et al,99)opiates lactogenic hormones (Lau,92; Merchenthaler94)

Milk EjectionOxytocin pulsatile release, T1/2 = 2 min (Higuchi et al 02)

51Value of mothers milkLactation Insufficiency Common following premature deliveryDonor milk advocated (Schanler89; Eidelman-AAP 12)Mothers milk favors maturation of innate immunityFormula favors maturation of adaptive immunity(Andersson et al 09) Pasteurization vs raw human milkpasteurization of human milk reduces fat absorption, weight gain, and linear growth in preterm infants (Andersson et al 07; Montjaux-Regis et al 11)MaternalbehaviorLactation

Non-nutritionalbenefits growth/developmentNutritional benefitsoral feeding skillsMotherInfantimbalance(Lau 02)With a preterm infant53Maternal attributes/ Maternal behaviorImportance of preserving the integrity of the nursing dyad and lactationto nurtureto sustain maternal drive to breastfeed/express milkmaternal psychological well-being (Li et al 08)Maternal behavior is a resultant of varying behaviorsThus, factors affecting maternal behavior vary:psychological traitpersonal healtheducation social support: family, friends, professionals stress: anxiety, depression, work

54Maternal obstaclesMotivation (25%)Knowledge (24%)Anxiety (14%)Work (14%) Health professionals obstaclesLack of supportInapropriate lactation management (19%)Lack of knowledge (15%)Negative attitudes (5%)Lack of support (20%)Staff shortages (5%)Social obstaclesLack of support (27%)Life-styles (29%)Obstacles to successful breastfeeding(Bergh, 93)MaternalbehaviorLactation

Non-nutritionalbenefits growth/developmentNutritional benefitsoral feeding skillsMotherInfantimbalance(Lau 02)With a preterm infant56Infant attributes/Non-nutritional benefitsTo preserve integrity of the nursing dyadbonding hypothesis (Tessier et al 98; Reyna & Pickler 09; Taylor et al 05), 2-way street offers:psychosocial benefits (Charpak et al 97)growth and development via physical contact, e.g. skin-to-skin, psychosocial dwarfism (Schanberg et al 84; Ronca & Abel 96; Nyqvist et al 10;Munoz-Hoyos et al 11; www.fundacioncanguro.co) NICU environmentPotential risk for preterm infant neurodevelopment (Pickler et al 10)Prematurityprolonged mother-infant separationinappropriate mother-infant environmentdecrease physical contact

57Infant attributes / Nutritional benefitsSafe and successful oral feeding relies on:ability to latch on to the breastefficacious sucking skillscoordinated suck-swallow-breatheendurance

Prematurity/sickness/hospitalizationimmature oral feeding skillsdecreased oral feeding opportunitiespoor endurance

58maternalbehaviorlactationMotherInfantExternalFactors environment caretakerSuckSwallowRespirationInfant Oral Feeding Performance

SafetySuccessBreastfeedingBottle FeedingCentral Nervous System

Peripheral Nervous System DevelopmentStressFetal Development59

To be launched Fall 2012

If interestedsend me your contact (name & email address) to:chantal.lau@infanthealthfoundation.orgwww.infanthealthfoundation.org

1 atmOpen to ambient airNo vacuum build-upelimination of hydrostatic pressureNipple holeChart50.5009461460.93644144140.32022454140.13711305080.70175713660.97204301080.34177729380.1082769538

SBVFBOral feedings/dayOverall Transfer (%)

Stats OvertimeClosedOpent-Test: Paired Two Sample for Meanst-Test: Paired Two Sample for MeansT1 % OTT3 % OTT1 % OTT3 % OTMean0.5009461460.7017571366Mean0.93644144140.9720430108Variance0.10254375690.1168117185Variance0.01879998870.0117238987Observations1515Observations1515Pearson Correlation0.6307916228Pearson Correlation-0.1282368493Hypothesized Mean Difference0Hypothesized Mean Difference0df14df14t Stat-2.727965472t Stat-0.7441630637P(T