Feeding Fundamentals In The Nicu: Supporting The Preterm/late

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Feeding Fundamentals in the NICU: Supporting the preterm/late preterm infant Erin Sundseth Ross, Ph.D., CCC-SLP Developmental Specialist HealthONE Hospital Systems Denver, Colorado Clinical Instructor U. Of Colorado Denver, School of Medicine, Department of Pediatrics Section of Nutrition Honorary Research Fellow Clinical Nutrition Research Center University of Queensland, Australia Feeding Fundamentals, LLC Objectives • Describe the role of development in the acquisition of feeding skills for preterm and late preterm infants • Discuss the efficacy of interventions designed to hasten and/or to improve feeding skills • Describe the prevalence of feeding and growth problems in preterm infants • Describe parameters of a feeding approach based upon quality indicators Background • Goal in NICU: establish feedings quickly, transition to full oral feedings, discharge • Very real pressure from insurance companies because feeding is not considered a “medical intervention” – it is something that all babies do… • Feeding is often the last milestone achieved in preterms • 32.2% of late preterm infants (35-36 6/7) with diagnosis of poor feeding (Wang, et al., 2004) • Early intervention has focused on accelerating the acquisition of oral feedings with a belief that “practice makes perfect” • Interventions often focus on the oral phase of feeding (sucking) rather than on the ability to feed safely and successfully (suck/swallow/breathe) What we know • Infant feeding is a function of both maturation and experience (as is most of infant development, e.g., talking, walking) – infant must be developmentally ready, and then have the opportunity to practice • The outcome measure chosen directly influences decisions made (i.e., first full oral feed, full oral feeds, discharge date, transitions across first year of feeding skill development & growth) Maturation Longitudinal cohort study: development of feeding Mizuno and Ueda, 2003 Longitudinal cohort study: development of feeding Medoff-Cooper, 2005 What about your practice? • What gestational age do you use to determine a delay? • How much of a delay is worrisome? (i.e., 2 standard deviations) • Are you respecting the role of development? • Or, are you thinking you can do better than normal? Experience Despite interventions to speed the process, the mean gestational age of acquisition of full oral feedings is typically ≥ 36 weeks However, there are individual variations Normal variation GA (preterm infants with no medical complications) 40 39 38 37 36 35 34 33 32 31 30 * * * E C Initiation First Full Full *= p<.05 RCT, n=29 healthy preterms mean GA 27w at birth; Mean BW C = 1033g, E=1205g (NS) O2 therapy mean days C= 27.4, E= 15.5 (NS) D/C Simpson, et al., 2002 Infant determined pace of progression Simpson, et al., 2002 Individual skill acquisition Interval in days 25 20 * 15 E C 10 5 0 Intro to Full First to Full *p<.05 Simpson, et al., 2002 Late preterm feeding development Cross-sectional, n=186 Dip in maturation between 35 and 37 weeks PMA Medoff-Cooper, et al., 2001 What experiences do you support in your practice? • Do you focus on communication with the infant? • Do you focus on movement? • Do you use evidence-based practices? • Do you monitor physiologic, motor, state communications? Limitations of current interventions • Data assessing efficacy of early intervention has focused much attention on oral stimulation/oral supports • Little information about how the infant tolerates oral stimulation (physiologic) • Questionable negative influence on weight gain • NO DIFFERENCE in length of stay or attainment of full oral feeding GA Attainment of all oral feeds 40 38 36 34 32 30 Bragelien 2008 Boiron, 2007 Fucile, 2005; 2002 Control Exp (Stim) Exp Exp (Sup) (Stim+Sup) Group Bragelian, RCT n=36; Boiron, RCT n=43;Fucile, RCT n=32 * No significant differences in any study Problems with programs • Oral phase is not typically the phase that is most difficult for preterm infants – non-nutritive sucking develops around 28-30 weeks – nutritive sucking develops 32-36 weeks • Programs can be aversive/exhausting • No data regarding physiologic response to program • Programs address oral movements that are NOT involved in breast/bottle feeding Fucile, et al, 2002 Oral structures involved in infant feeding • Tongue – Lateral edges elevate to wrap around nipple/teat • Suction – Entire tongue elevates to compress nipple/teat • Compression • Palate – compression and suction • Jaw – compression Oral structures NOT involved • Lips – Used once food is introduced anteriorly – Used during chewing • Cheeks – Buccal pads support sucking – Cheeks are not active players Fucile, et al, 2002 Weight Gain 2500 2000 1500 Exper Control 1000 500 0 Birth weight Weight at start Weight at end (Fucile, et al., 2002, 2005) Feeding development • Ability to suck and to suck/swallow is observed prior to the ability to coordinate all of the phases of swallow • Intervention studies focused on only the ability to suck lack an understanding of why feeding is so challenging for many preterm infants • Coordination of suck/swallow and breathe is highly related to and influenced by gestational age and respiratory status (Vice and Gewolb, 2008; Mizuno, et al., 2007; Mandich, et al., 1996) Key: Integration of breathing • Cross-sectional (n=20 preterm, 16 term) • Apneic swallows (% over the feeding) decreased with increasing PMA – 16.6% in preterm infants ≤35wks' PMA – 6.6% in preterms >35wks – 1.5% in term infants (p<0.001) • Swallowing and respiration improved in coordination with increasing PMA: – decreased apnea – significant increase in percentage of swallows occurring at end-inspiration Gewolb & Vice, 2006 Longitudinal development of suck/swallow/breathe in BPD/non BPD preterms • n= 34 (14 with BPD, 20 without) • BPD – significant increase in apneic swallows after 35 weeks (mean 13.4% [SE 2.4]) compared with non-BDP infants (6.7% [SE 1.8]; p<0.05). • BPD - significantly higher swallow-breathe coefficient of variance (COV) as well as breathto-breath COV compared to non-BPD. Gewolb and Vice, 2006 Thoyre, S and Carlson, J., (2003) • 22 VLBW infants, each videotaped PTD • Mean 10.8 desaturations episodes/feeding • Mean duration 29.3 seconds – 20% of feeding time <90% – 59% (n=140) SpO2 85-89% – 20% (n=47) SpO2 81-84% – 21% (n=51) SpO2 ≤ 80% Summary • Individual variation in maturation and in medical comorbidities influences feeding ability • Use of a gestational age to determine readiness to feed appears to be inappropriate • NICU’s often lack a systematic process to determine readiness to feed and/or progress in feeding due in part to this variation • All NICU’s need to contain costs and length of stay Problem • Only 0.8% of moderately preterm infants (32-34) discharge home with supplemental tube feedings • 55% of preterm infants have problematic feeding behaviors by 6-18 months of age • 40% of preterm infants have weights, lengths and head circumferences < 10% by 18-22 mo corrected • Preterm infants 3.6X more likely to have feeding problems than full term infants at 6 years of age • Parents of children with feeding problems report increased stress, anxiety, and diminished family functioning Kirkby, et al., 2007; Dusick, et al., 2003; Hawdon, 2000; Samara, et al., 2009;Thoyre, 2007 What happens between discharge and 6 months? • Feeding skills change from reflexively based to volitional < 3 months of age Primitive Action > 3 months of age Volitional Action • Learning has occurred (Classical conditioning) • If learning has been negative, feeding problems reveal themselves Growth Faltering • Majority of infants who have feeding difficulties and poor growth falter between 3 and 6 months developmental age. Kelleher, et al., 1993; Ramsay, et al., 1993, 2002; Casey, et al., 1984; Batchelor, 1996; Wright, et al., 1991, 1998, 2000; Shrimpton, 2001 Early Indicator of Growth Faltering • Longitudinal cohort (n=3727) • Odds Ratio for reaching a weight-for-length ratio z-score of ≤ -1.67 (≤ the 5th percentile) between 7 and 24 months for infants who fell more than 0.85 standard deviations in their weight-for-age between two and four months of age were 3.6 times that compared to infants without this level of deceleration (p=0.0153) Ross, 2007 Challenge • Outcomes are rarely defined in terms of the parent-infant relationship, or by quality of feeding skills and stability • Need to change focus from faster to better quality without negatively influencing length of stay • How to accomplish? What constitutes Quality? • • • • Stability of the infant Pleasurable for both infant and feeder Supportive of adequate growth Flexible to meet the unique needs of every infant • Supportive of the relationship between the caregiver and the infant • Supportive of skill development past the transition to volitional feeding Stability • Physiologic, Motor and State stability all influence feeding – both short and long term • The environment may influence the stability of the infant • Caregivers need assess and support stability in the infant • Feeding ability is acutely influenced by overall stability of the infant Als, 1982 Are you listening? • Infants communicate through their behavior • What are these infants telling you? • How do they communicate? • Are you listening? • How are you responding? Physiologic • Provides the core stability for all other systems • Underlies feeding skills • The infant communicates through: – Color – Respiratory patterns – Visceral behaviors Adapted from Als, 1982 Color • Ideal (striving) – Pink, stable color over entire body • Organizing? – Pale – Flushed/Red – Mottled – Dusky – Blue Respiratory • Ideal • (striving) – Regular intervals – 40-60 bpm, slowing as infant ages • Organizing? – Irregular – Over 60 bpm – Pauses in breathing – Hiccups – Gasping – Nasal flaring – Panting – Coughing – Yawning Visceral • Ideal (striving) – Stable digestion, stooling • Organizing? – Spitting up/vomiting – Diarrhea – Constipation – Feeding intolerance Maybe infants are telling us something? Motor • Provides information regarding the feeding progression • Interacts with other systems • Can be used to support the other systems • The infant communicates through: – Tone – Posture – Movement Adapted from Als, 1982 Motor • Ideal (striving) – Flexed posture – “Muscle energy” – Smooth movements – Rounded face, body, arms and legs • Organizing? – Flaccid – Tight – Frantic/flailing – Tremors Supporting stability through Motor • Infants obtain proprioceptive input through: – Hands to face – Hands to mouth – Bracing feet – Being swaddled – Mouthing/Sucking State • States become more defined over time • Can be used to support the other systems • The infant communicates through: – Range of states – Clarity of states – Transitions between states Adapted from Als, 1982 Sleep-Wake States • • • • • • • • Deep Sleep Active (Light) Sleep Drowsy Quiet Alert Hyperalert Hypoalert Fussy Crying Brazelton, 1973; Als, 1986 States • Ideal (striving) – Clear states – States that last at least 15 seconds – Smooth transitions up and down the state continuum – Able to control incoming stimuli – Able to calm – Developing predictability – Appropriate for situation • Organizing? – Messy states – Rapid transitions – “Jumping” across states – At the mercy of incoming stimuli – Unconsolable* – Unpredictable – States inappropriate for situation (ie., sleeping when should be eating) Impact of Environment • Distal and proximal environment can support stability, or create instability • Some infants are more at the mercy of incoming stimuli than others How are you determining success? • Are you listening to the infant? • Are you helping the infant progress through development? Or, – Are you interfering with development? – Are you having a monologue? Preliminary Data (Ross) • Longitudinal study • N=27 (20 males, 7 females) • Visits at discharge, term, 2 weeks, and 1,2,3,4 months • Weights, lengths and parental interviews at all visits • Nutritional analysis term, 2 and 4 months • Videotaped feedings at discharge, 2 and 4 months Anthropometric Data • Preliminary analysis: – Weight gain/day term to 2 weeks ranged from 6.3 to 90.3 grams/day (mean = 36.2g) – Kcal/kg/day at term (after discharge) ranged from 56 kcal/kg to 225 kcal/kg (mean = 135 kcal/kg/day) Mean z-scores (corrected to term) Weightfor-age Term 2 weeks 1 month -0.25 -0.21 -0.10 -0.01 0.58 0.66 0.53 Weight0.40 for-length 2 month 0.60 3 month 0.47 Z-score 0.00 = 50th percentile; 1.0 = 85th percentile; -1.0 = 15th percentile Parental interviews • Qualitative analysis beginning on parental interviews: – How do you feel when you are feeding your baby? – How do you feel when you are finished feeding your baby? – What behaviors does your baby demonstrate when he/she is having a good feeding/poor feeding? Video analysis • Code book developed, piloted • First and last 6 minutes coded, added • Behaviors coded positive if observed at all within a 2 minute window (total possible per behavior, per baby = 6) • Interrater reliability 93-100% (6/28 initial) Video analysis • Behaviors coded: – 12 Physiologic – 6 Motor – 7 State – 23 Oral-Motor – 2 Non-Baby Interruptions Physiologic • 5/12 never observed (RR>60, sneeze, sigh, yawn, O2 <90) • GI Grunting (22) • Respiratory noises (15) • Pauses > 3 sec in RR (10) • Nasal flaring (9) • Color change from baseline (7) • Retractions (5) • Hiccups (3) Motor • • • • • • Extensions (38) Head turning (22) Flaccidity (21) Arching (13) Pulling away from bottle (12) Defensive maneuver, hands (2) State * • • • • • Quiet alert (67) Drowsy (65) Light sleep (22) Aroused/Fussy (4) Deep sleep (2) More than one state could be observed within each 2 minute time period Oral-Motor • 6/23 never observed (burp during feeding, tight lips, mouthing/biting nipple, nasal regurgitation, slow/inefficient suck, spitting up) • Stop sucking (71) • Dripping/dribbling (55) • No initial sucking attempts (41) • Isolated sucks (31) Oral-motor • • • • • • • • Vocal sounds (29) Tongue clicking (21) No latch (13) No resistance to removal of bottle (12) Cough (8) Pushing nipple out (8) “Bad face” (7) Gag (5) Oral-motor • • • • • Lip smacking (4) Multiple swallows (>3) without a pause (4) Choke (3) Gulp (2) Crowing sounds (2) Non-baby related interruptions • Bottle is empty (3) • Parent is distracted from feeding (1) Discharge EXAMPLES OF POOR FEEDING Discharge EXAMPLES OF GOOD FEEDING Still to come… • Analysis of all videotapes, across all 3 time periods • Correlation between videotaped behaviors, growth, nutrient intake, and parental reports of 1) behaviors reported during poor and good feedings, and 2) parental reports of emotions during and after feedings What to consider… • Feeding is more than just calories in • Parents are successful at getting calories in, during the reflexive time period, but it gets more difficult as the infant matures • Perhaps we can do better? • What can we do now (i.e., Monday!) Stability and Growth • Integration of suck/swallow and breathe matures later than the ability to suck, and infants communicate instability through behavioral cues and by pausing in feeding • Decreased flow rate and pacing of the infant feeding to support suck/swallow and breathe both shown to improve feeding without compromising weight gain or LOS Faster is not better…. • RCT: Infants fed with single-hole nipple units compared to those fed with a cross-cut nipple: – Higher intake (57.5 ± 8.3 ml vs. 51.6 ± 9.5 ml, p=.011) – Decreased duration feeding time per meal (11.5 ± 4.9 min vs. 20.9 ± 5.0 min, p<.001) – Higher efficiency (5.8 ± 2.5 ml/min vs. 2.7 ± 1.0 ml/min, p<.001) • With cross-cut nipple units – Higher RR (44.4 ± 4.6 breaths/minutes vs. 40.8 ± 4.9 breaths/minutes, p=.002) Chang, et al., 2007 Pacing • Non-randomized consecutive study • 36 infants – 18 in control, 18 in paced group • Paced infants demonstrated significant decreases in Bradycardic incidences • Gains in development of more efficient sucking patterns at discharge • No change in discharge or average weekly weight gain Law-Morstatt, et al., 2003 Individualized and Growth • RCT: control (n = 41); experimental (n = 40) • Oral feedings offered contingent on infant behavior of alerting to at least a drowsy level • If alert, offered an oral feeding; if not alert, gavage fed • Feedings stopped based on infant fatigue, infant stopping sucking, or infant instability • Remaining volume gavaged if necessary • The semi-demand method shortened the time for infants to achieve oral feeding by 5 days, no difference in weight gain (P < .001) McCain, et al., 2001 Family intervention • Randomized, repeated measures intervention • n=34, <1500 grams • Decrease in: – – – – grimacing (P < .001) gagging (P < .05) Maternal interruptions during feeding (P < .001) Maternal bottle stimulation (P < .01) • Increase in: – – – – – Maternal smiling (P < .001) Maternal vocalization (P < .01) Sensitivity to infant behavior (P < .001) Quality of physical contact (P < .001) More positive affect (P < .01) Meyer, et al., 1994 Relationship based RCT, n=91; p<.05 at 36 months and 9 years 11 total one-hour sessions Longitudinal across 9 years Achenbach, et al., 1993 BROSS Approach • Designed to – facilitate stability – provide a method for assessing development of feeding across the hospitalization – provide a method to identify known oral-motor patterns – build a strong foundation of skills – facilitate caregiver recognition and support of individual strengths and challenges Browne & Ross, 2001 Integrated Coordinated Intermittent Alternating Obligatory Stability in arms with NNS Systems Stability with Holding Stability in Bed with Handling BROSS Approach (Browne and Ross, 2001) • Uses the Synactive theory as a paradigm • Builds upon the organization of each subsystem • Uses a holistic approach towards the development of feeding skills in the preterm infant BROSS (2001) • • • • • • • BABY REGULATED ORGANIZATION of SUBSYSTEMS and SUCKING Browne & Ross, 2001 Integrated Coordinated Intermittent Alternating Obligatory Stability in arms with NNS Systems Stability with Holding Stability in Bed with Handling Systems Stability in bed • • • • Physiologic Motor State During routine interactions Systems Stability With Holding • Physiologic • Motor • State Mosca, 1995 • Holding premature infants during gavage feeding increased time spent in more desirable infant behavioral states, resulted in less apnea at the beginning of feedings, and did not compromise infant physiologic stability. Stability with NNS • • • • • Physiologic Motor State Holding Rhythmic sucking, pacifier or finger – 5-10 sucks/burst Obligatory • Sucking burst can be 15-25 sucks • Does not stop to breathe – Apnea – Loss of subsystem stability • Caregiver needs to intervene Alternating • Oxygen stabilizing – Alternating sucking/breathing • sucking burst (3-7) • period of breathing – Sometimes “roller coaster” saturations • Limited state availability to complete feeding Intermittent • Integration of breathing during sucking – brief catch breath, once every 2-3 sucks – longer sucking bursts appear – Longer, more efficient suck (suction/expression) – Greater volume transferred • Alert state, some social availability Coordinated • Mature coordinated suck pattern – sucking bursts 20-30 sucks and breathing integrated with sucking – individual pattern of s/s/b – modulated suction and expression • Integrating alert state • Alert during the entire feeding Integrated • Integration of social interaction during feeding • Full coordination of sucking/swallowing and breathing, without tachypnea • Demanding prior to feedings Intervention strategies • Think about each step - both the currently achieved, as well as the next to emerge • With intervention, can the infant reliably remain stable at the next emerging step? Intervention strategies • If not stable, support at the current step, and design supports to facilitate next steps: – decrease flow/volume – decrease environmental impacts – increase supports Correlation gesage 40 39 38 37 36 35 34 33 32 31 30 29 28 1 2 3 4 5 6 7 8 gr p n=27 Ross & Browne, 2002 Ultimate Goal • • • • Support parental competence in feeding Support parent/infant relationship Support successful feeding in NICU Support transition to successful feeding after discharge, across the first years of life Feeding should be fun References • Achenbach, T. M., C. T. Howell, et al. (1993). "Nine-year outcome of the Vermont intervention program for low birth weight infants." Pediatrics 91(1): 45-55. • Als, H. (1982). Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Mental Health Journal, 3(4), 229-243. • Boiron, M., L. Da Nobrega, et al. (2007). "Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in preterm infants." Dev Med Child Neurol 49(6): 439-44. • Bragelien, R., W. Rokke, et al. (2007). "Stimulation of sucking and swallowing to promote oral feeding in premature infants." Acta Paediatr 96(10): 1430-2. • Browne, J. and E. Ross (2001). BROSS: Baby regulated organization of systems and sucking. • Chang, Y. J., C. P. Lin, et al. (2007). "Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants." J Nurs Res 15(3): 215-23. • Dusick, A. M., B. B. Poindexter, et al. (2003). "Growth failure in the preterm infant: can we catch up?" Semin Perinatol 27(4): 302-10. References • Fucile, S., E. Gisel, et al. (2002). "Oral stimulation accelerates the transition from tube to oral feeding in preterm infants." J Pediatr 141(2): 230-6. • Fucile, S., E. G. Gisel, et al. (2005). "Effect of an oral stimulation program on sucking skill maturation of preterm infants." Dev Med Child Neurol 47(3): 158-62. • Gewolb, I. H. and F. L. Vice (2006). "Abnormalities in the coordination of respiration and swallow in preterm infants with bronchopulmonary dysplasia." Dev Med Child Neurol 48(7): 595-9. • Gewolb, I. H. and F. L. Vice (2006). "Maturational changes in the rhythms, patterning, and coordination of respiration and swallow during feeding in preterm and term infants." Dev Med Child Neurol 48(7): 589-94. • Hawdon, J. M., N. Beauregard, et al. (2000). "Identification of neonates at risk of developing feeding problems in infancy." Dev Med Child Neurol 42(4): 235-9. • Kirkby, S., J. S. Greenspan, et al. (2007). "Clinical outcomes and cost of the moderately preterm infant." Adv Neonatal Care 7(2): 80-7. References • Law-Morstatt, L., D. M. Judd, et al. (2003). "Pacing as a treatment technique for transitional sucking patterns." J Perinatol 23(6): 483-8. • Mandich, M. B., S. K. Ritchie, et al. (1996). "Transition times to oral feeding in premature infants with and without apnea." J Obstet Gynecol Neonatal Nurs 25(9): 771-6. • McCain, G. C., P. S. Gartside, et al. (2001). "A feeding protocol for healthy preterm infants that shortens time to oral feeding." J Pediatr 139(3): 374-9. • Medoff-Cooper, B. (2005). "Nutritive sucking research: from clinical questions to research answers." J Perinat Neonatal Nurs 19(3): 265-72. • Medoff Cooper, B., W. Bilker, et al. (2001). "Suckling behavior as a function of gestational age: A cross-sectional study." Infant Behavior and Development 24(1): 83-94. • Meyer, E. C., C. T. Coll, et al. (1994). "Family-based intervention improves maternal psychological well-being and feeding interaction of preterm infants." Pediatrics 93(2): 241-6. References • Mizuno, K., Y. Nishida, et al. (2007). "Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain breathing during feeding." Pediatrics 120(4): e1035-42. • Mizuno, K. and A. Ueda (2003). "The maturation and coordination of sucking, swallowing, and respiration in preterm infants." J Pediatr 142(1): 36-40. • Ross, E. (2007). Early growth faltering predicts longitudinal growth failure. Clinical Sciences, Health Services Research. Denver, University of Colorado Health Sciences Center. Ph.D.: 279. • Ross, E. and J. Browne (2002). Baby Regulated Organization of Systems and Sucking (BROSS). The Physical and Developmental Environment of the High-Risk Infant. Clearwater, FL. References • Samara, M., Johnson, S., et al, (2009). “Eating problems at age 6 years in a whole population sample of extremely preterm children.” Dev Med Child Neur. http://dx.doi/org/10.1111/j.14698749.2009.03512.x • Simpson, C., R. J. Schanler, et al. (2002). "Early introduction of oral feeding in preterm infants." Pediatrics 110(3): 517-22. • Thoyre, S. (2007). Feeding Outcomes of Extremely Premature Infants After Neonatal Care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36(4), 366-376. • Thoyre, S. M., & Carlson, J. (2003). Occurrence of oxygen desaturation events during preterm infant bottle feeding near discharge. Early Hum Dev, 72(1), 25-36. • Vice, F. L. and I. H. Gewolb (2008). "Respiratory patterns and strategies during feeding in preterm infants." Dev Med Child Neurol 50(6): 467-72. • Wang, M. L., D. J. Dorer, et al. (2004). "Clinical outcomes of nearterm infants." Pediatrics 114(2 part 1): 372-6.