1. Promoting Long-Term Feeding Success
SLP in the Neonatal ICU
Taylor M. Leech, M.A. CCC-SLP, CLEC

2. SLPs role in the NICU Short and long term success
Traditional vs research based infant feeding
Quantity vs Quality

5. Traditional Feeding Techniques in the NICU
From an article on about.com by an RN - May 2014
“Sit your baby up”
“Use chin and cheek support”
“Encourage Nurses to take the tube out”

6. Traditional Feeding Techniques in the NICU
And my favorite…
Do your exercises: Ask NICU nurses or therapists to show you a series of mouth exercises you can perform on your baby to help prepare her for feeding. Exercises like circling the lips with your fingers, stroking the chin, and gently squeezing the cheeks together can help your baby to feed better.

7. Problems Driven by the caregiver, not the baby
Does not take into account what the infant wants
Can be over-stimulating
Can be unsafe and increase risk for aspiration
Is focused on finishing the bottle
Short-term success for long-term failure

8. Research-Based Feeding Techniques in the NICU
Infant-driven feeding
Cue-based feeding
Focus on quality rather than quantity

9. Quantity Quality A “good” feeding is finishing the bottle
Does not take into account infant’s behaviors or needs
Success is dependent on the feeder
A “good” feeding may only consist of a few minutes or a few mLs
A partnership between caregiver and infant

10. Cue-Based Feeding Protocols
What are they?
Evidence based practices
Implementing in the unit
Benefits

11. What’s so important about feeding in the NICU?
Infants born under 28 weeks PMA have significant risk for feeding delay
Preterm infants are at increased risk of neurologic, gastro-intestinal, and cardiac pre-morbidities that can affect ability to safely feed by mouth
Has historically been the primary reason discharge home from the NICU is delayed

12. Obtaining full oral feeding
Study by Pickler et al (2009) describes the attainment of oral feeding comparing number of days to full oral feeding, how many bottles an infant was offered a day, and comorbidities

13. Obtaining full oral feeding

14. What is Cue-Based Feeding?
On demand feeding schedule vs scheduled feedings
In the NICU, maintaining a schedule while following infants readiness cues
Focusing on infant’s behaviors before and during feeding times to determine when to start, when to take breaks, and when to stop

15. What is Cue-Based Feeding?
Readiness Cues
Awake/alert state
Squirming
Rooting
“ooo” face
Hands to face

16. What is Cue-Based Feeding?
Stress Cues (I’m not ready!)
Crying
Panicked expression
Saluting, finger splay, or extremity extension
Drowsy

17. What is Cue-Based Feeding?
“In volume-driven feeding, success is measured by how much an infant ingests, and caregivers may use strategies intended to empty the bottle without regard to what the infant communicates Volume-driven caregiving tends to feed past the infant's stop signs, which say, ‘I want to stop, I am done’. Failure to respond to the infant's communication may lead to maladaptive feeding behaviors, learned feeding refusals and long-term feeding aversions. Caregivers often pass on this volume-driven philosophy to parents, for whom feeding becomes something they do ‘to’ their infant, instead of a relationship-based experience through which communicative interactions build trust.” (Shaker, 2013)

18. Kirk et al (2007)
Infants fed once per shift and advanced base on behavioral cues
Attainment of full oral feeds was significantly less by 6 days PMA for study group using clinical pathway compared to control cohort.

19. Sudharshan et al (2012)
Comparison of historical (routine care) vs modern and innovative feeding programs and protocols and attainment of full or partial oral feeds at discharge and one year

20. Ludwig & Waitzman (2007)
Describes the traditional feeding practices of focusing on time and volume compared to infant-driven practices focusing on quality and infant cues and behaviors
Focus is on infant, improvement of parent education and understanding

21. McClain et al (2012)
Infants divided into a control group (standard care gradually increasing number of bottles and amount expected to take) and experimental group (offer bottle only when stable and showing readiness cues)
Infants in experimental group transitioned to full oral feeds on average 6.4 days before the control group

22. Puckett et al. (2008)
Compared preterm infants born 4-6 weeks early on a cue-based feeding program to a control group
No significant difference in weight or weight gain
Experimental group had significant difference in length of stay – 4.5 days
Experimental group had significantly less adverse events (desaturations, bradycardia, coughing) during and after oral feedings

23. Implementing in the NICU
Initiated at CRMC Spring 2014
Readiness scores recorded at each feeding
1 – Awake prior to care/touch time, showing readiness behaviors
2 – Wakes during or after cares, showing readiness behaviors
3 – Wakes only briefly during cares
4 – Sleeps through cares
5 – Exhibits stress, caregiver is unable to calm, and/or is physiologically unstable

24. Implementing in the NICU
If an infant score 1 or 2, they are offered a bottle or breast fed
If an infant scores a 3 or 4, they may be offered breast only if mom is at bedside
If an infant scores a 5, they are not offered oral feeding in any form

25. Implementing in the NICU
Online education for established nurses
In-person education for every new nurse
Ongoing education at bedside
Reviewing with parents
Written education and information for parents at bedside

26. Poor Feeding and Impact on Long-Term Nutrition
Thoyre ( 2007) – longitudinal study with follow-up at 6 to 8 moths born less than 1000g and less than 29 weeks
“Healthy” infant with no diagnoses in regards to neurologic, GI, or lung dysfunction
80% reported to have long-standing feeding problems including poor intake, fatigue with feeding, and delayed skills
40% had episodes of aspiration
85% with a diagnosis of GER

27. Poor Feeding and Impact on Long-Term Nutrition
Cerro et al. (2002) – longitudinal study of children with very low birth weight (under 1500g) without significant neurological impairment
33% of infants vomited frequently
32% were on reflux medications
28% had poor weight gain
27% had reported diarrhea
67% of parents interviewed stated that their children “consistently refused food”

28. Poor Feeding and Impact on Long-Term Nutrition
Sweet et al. (2003) – interviewed parents of children at 2 years corrected age that were born less than 600g
62% reported feeding problems
29% had G-Tubes at some point

29. Organic vs Behavioral Feeding Problems
Behaviors
Refusal
Gagging
Texture preferences
GERD
Vomiting
Poor digestion
Weak oral-pharyngeal muscles / Dysphagia

30. Early Intervention in the NICU
Promotes early successful nipple feeding
Parent and caregiver education to promote long-term success
Interventions documented to decrease hospital length of stay and time to attainment of full oral feeds
More research – longitudinal studies of infants cue-based feeding protocols and feeding behaviors during infancy and childhood

31. Therapeutic Interventions and Diagnostic Tools
Neonatal FEES
Devices to measure suck patterns and abnormalities

32. Neonatal FEES FEES – Fibro optic Endoscopic Evaluation of the Swallow
Avoids radiation exposure
Can be completed at bedside
Doctor/Radiologist does not need to be present
Parent/Caregiver education
Quantified/objective evaluation

33. Quantifying Intra-Oral Pressures During Nutritive Suck
Visually measures sucking behaviors and patterns
Typical periodicity
Prolonged sucking and swallowing without pauses
Very irregular

34. References
Bird, C. (2014, May 28). Successful tips for bottle feeding your preemie. Retrieved from /a/bottlefeedingtips.htm
Cerro, N., Zeunert, S., Simmer, K. N., & Daniels, L. A. (2002). Eating behavior in children years born preterm: parents' perceptions. Journal of Pediatrics and Child Health, 38(.),
Jadchela, S. R., Peng, J., & DiLorenzo, C. (2012, Jan). Impact of personalized feeding program in 100 NICU infant: Pathophysiology-based approach for better outcomes. J Pediatr Gastroenterol Nutr, 54(1),
Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2009, Oct 8). Impact of prematurity and co-morbidities on feeding millstones in neonates: a retrospective study. Journal of Perinatology, 30. Retrieved from
Kirk, A. T., Alder, S. C., & King, J. D. (12 Juley 2007). Cue-baed oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology, 27, Retrieved from
Lang, W. C., Buist, N. R., Geary, A., Buckley, S., Adams, E., Jones, A. C., Gorsek, S., Winter, S. C., Tran, H., & Rogers, B. R. (2011, Sept 26). Quantification of intraoral pressures during nutritive sucking: methods with normal infats. Dysphagia, 26(3),

35. References Continued
Ludwig, S. M., & Waitzman, K. A. (2007, Sept). Changing feeding documentation to reflect infant-driven feeding practice. Newborn and Infant Nursing Reviews, 7(3),
Martin, G. C., Gartside, P. S., Greenberg, J. M., & Wright Lott, J. (30 Jan 2001). A feeding protocol for healthy preterm infants that shortens time to oral feeding. The Journal of Pediatrics, 139(3),
McClain, G. C., Del Moral, T., Duncan, R. C., Fontaine, J. L., & Pino, L. D. (2012, Nov/Dec). Transition from gavage to nipple feeding for preterm infants with bronchopulmonary dysplasia. Nursing Research, 61(6),
Pickler, R. H., Best, A., & Crosson, D. (2009, Oct 2). The effect of feeding experience on clinical outcomes in preterm infants. Journal of Perinatology, 29. Retrieved from jp a.html
Puckett, B., Grover, V. K., Holt, T., & Sankaran, K. (2008). Cue-based feeding for preterm infants: a prospective trial. American Journal of Perinatology, 25(10),
Shaker, C. S. (2013, Feb 1). Reading the feeding. ASHA Leader. Retrieved from
Sweet, M. P., Hodgman, J. E., Pena, I., Barton, L., Pavlova, Z., & Ramanathan, R. (2003). Two-year outcome of infants weighing 600 grams or less at birth and born 1994 through Obstetrics and Gynecology, 101(.),
Thoyre, S. M. (2007, July/Aug). Feeding outcomes of extremely premature infants after neonatal care. JOGNN, 36(4),