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Oral Feeding Issues Chantal Lau, PhD Baylor College of Medicine Department of Pediatrics/Neonatology Texas Children’s Hospital Houston TX, USA October.

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Presentation on theme: "Oral Feeding Issues Chantal Lau, PhD Baylor College of Medicine Department of Pediatrics/Neonatology Texas Children’s Hospital Houston TX, USA October."— Presentation transcript:

1 Oral Feeding Issues Chantal Lau, PhD Baylor College of Medicine Department of Pediatrics/Neonatology Texas Children’s Hospital Houston TX, USA October 31, 2012 Financial Interest: Feeding for Health LLC

2 Outline  Our philosophy  Common problems  Bottle feeding approaches  Current  Potential  Oral Feeding Skills (OFS) Assessment Scale  Consider - interventions to enhance OFS - tools to facilitate oral feeding  Breastfeeding – the Oral Feeding Puzzle

3 Our philosophy has a long-term goal…, i.e., well-developed functional oral feeding skills To 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 aversion

4 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 sucking poor endurance unstable behavioral states not as efficient cannot feed for a long time

5 physicians nurses feeding specialists OTlactation speech Oral feeding is a multi-disciplinary task… nutrition Important to give a consistent message to mother and baby RC Gorman

6  Adequate weight gain (  g/kg/day)  Safety : to minimize aspiration  must avoid O 2 desaturation, apnea, bradycardia, aspiration-pneumonia  Success: to complete entire feeding within allotted time (e.g., min)  limiting energy expenditure to favor weight gain What is the current practice?

7 What should our goals be?  Adequate weight gain (  g/kg/day)  Safety: no aspiration, O 2 desaturations, apnea, bradycardia  Success:- not necessary to complete a feeding, but to develop good feeding skills  Oral feeding ought to be a pleasant, nurturing experience to minimize feeding aversion

8 Outline  Our philosophy  Common problems  Bottle feeding approaches  Current  Potential  Oral Feeding Skills (OFS) Assessment Scale  Consider - interventions to enhance OFS - tools to facilitate oral feeding  Breastfeeding - the Oral Feeding Puzzle

9 Signs of fatigue: Poor tone State change, e.g., sleep, ‘shut down’ Lengthy sucking pauses Feeding duration > 20 min Increased milk leakage, drooling Increased respiratory rate Oxygen desaturation/apnea/bradycardia Poor endurance

10 Reflux Signs of reflux: Emesis Choking/coughing/aspiration Arching Oesophagitis Oral feeding aversion

11 Suck-swallow-breathe incoordination Signs of incoordination: Coughing/choking/aspiration Poor self-pacing Apnea/bradycardia Oral feeding aversion

12 Physiological -Oxygen desaturation -Apnea/bradycardia -Tachypnea -Choking/coughing/ -Aspiration -Emesis -Milk leakage Behavioral -Poor tone -Fall asleep -Agitated -Pushing away -Turning head away -State change -“shut down” -aversive to feeding End result  difficulty diagnosing primary causes Consequences…all the same… If caretakers persist on feeding infants

13 Are we doing right by our babies?

14 Outline  Our philosophy  Common problems  Bottle feeding approaches  Current  Potential  Oral Feeding Skills (OFS) Assessment Scale  Consider - interventions to enhance OFS - tools to facilitate oral feeding  Breastfeeding - the Oral Feeding Puzzle

15 Current Approaches  focused primarily on sucking issues, but  lack of evidence-based data to objectively support the current practices few clinical studies available to differentiate: true benefits vs. natural maturation process

16 Use jaw and cheek support Why? - immature muscle tone - wide jaw excursion How? - gentle sustained pressure - make sure not to impede breathing and infant’s self-pacing Enhanced non nutritive sucking pressures and feeding performance, while reducing oral feeding transition time (Boiron et al ‘07)

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18 Use pacing technique Why? - infant sucking, forgets to breathe - gives time for breathing and resting -helps re-coordinate suck- swallow- breathe How? sucks - tilting bottle back without removing bottle (infant’s organization) -pulling nipple out

19 Cue-Based Approach  Becoming 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 infant’s oral feeding skills, if any  absence 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 aptitude

20 Outline  Our philosophy  Common problems  Bottle feeding approaches  Current  Potential  Oral Feeding Skills (OFS) Assessment Scale  Consider - interventions to enhance OFS - tools to facilitate oral feeding  Breastfeeding - the Oral Feeding Puzzle

21 Based on combinations of:  common sense  physiology  evidence-based information  objective integration of old and new information Watch out for:  subjectivity/bias/over interpretation Potential Approaches

22 Adjust feeding position Why?- 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)

23 Limit feeding duration Why? - 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 consulted

24 Regulate flow  Use pacing if necessary  Increase viscosity (thickener)  e.g., rice cereal  difficulty in replicating by the bedside the viscosity identified via modified barium study  But do we really know our babies’ limitations in absence of overt behavioral and/or clinical responses?  Maybe best would be…..

25 Let infants feed at their own pace Why? allows infants to:  develop appropriate functional feeding skills  have a positive experience re. oral feeding  minimize oral aversion How? gives infants control to:  regulate milk flow  rest if necessary  breathe

26 Baby communicates: ready to feed Watch for cues…  Eyes may be open or closed  Responsive to light touch  Looks at caregivers’ face  Hands towards mouth  Rooting or sucking  Smooth motor movements  Calm and quiet

27 Baby communicates: NOT ready, STOP feeding Watch for cues…  Staring or gaze aversion  Panic or worried look  cannot wake up, excessive yawning  Tremor, startling  Hiccupping, spitting up, gagging, gasping  Frantic, arching, arms extended, fingers splayed  Color changes  Increased respiratory rate and vital instability

28 Wait, give me a break!

29

30 Outline  Our philosophy  Common problems  Bottle feeding approaches  Current  Potential  Oral Feeding Skills (OFS) Assessment Scale  Consider - interventions to enhance OFS - tools to facilitate oral feeding  Breastfeeding - the Oral Feeding Puzzle

31 Oral Feeding Skills Levels (OFS) scale (Lau & Smith ’11)  Novel objective indicator  No equipment needed, simply measure:  volume prescribed, taken at 5 min, during entire feeding  duration of feeding (min)  Monitored over time  Outcomes 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 + endurance  proficiency ~ PO skills when fatigue minimal

32 Level 1 skills :LOW Endurance: LOW Level 2 Skills :LOW Endurance: HIGH Level 4 skills :HIGH Endurance: HIGH Level 3 skills :HIGH Endurance: LOW Oral Feeding Skill (OFS) levels GA ≤ Endurance (RT) GOOD POOR Skills POOR GOOD (PRO) 30% 1.5 ml/min

33 OFS LevelsFeeding skills (Pro) Endurance (RT) Potential Interventions 1low nonnutritive oral motor stimulation + endurance training 2lowhighnonnutritive oral motor stimulation 3highlowendurance training 4high none Interpretations/interventions OFS LevelPotential Intervention(s)

34 Overall Transfer (%) Rate of Transfer (ml/min) OFS 3 OFS 4 OFS 1 OFS 2 p < 0.05 OFS1 < OFS 2-4 OFS 2,3 < OFS 4 (Lau & Smith ‘12) Feeding Performance vs. OFS levels

35 Outline  Our philosophy  Common problems  Bottle feeding approaches  Current  Potential  Oral Feeding Skills (OFS) Assessment Scale  Consider - interventions to enhance OFS - tools to facilitate oral feeding  Breastfeeding - the Oral Feeding Puzzle

36  Uni-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 interventions

37  Subjects - VLBW between 25 to 33 wks GA  Study 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 PO  Nonnutritive oral motor therapy (NNOMT) and/or infant massage therapy (MT) – for 14 days  Feeding positioning: Upright and Sidelying Interventions to enhance OFS skills

38 Control (Lau & Smith ‘12) Intervention duration Off CPAP- 8 PO/d

39 Nonnutritive oral motor (NOMT) NNOMT+MT Massage therapy (MT)Control Occurrence (%) (Fucile et al ’11) 1 8 ± 1 10 ± ± 1 11 ± ± 1 21 ± 1 Days from SOF 14-day intervention

40 Occurrence (%) Semi-reclined (control) Sidelying Upright days from SOF 1 7 ± 6 17 ± ± 3 15 ± ± 6 22 ± 12 Feeding Positions (Lau ‘12)

41 Outline  Our philosophy  Common problems  Bottle feeding approaches  current  Potential  Oral Feeding skills Assessment Scale  Consider - Interventions to enhance feeding skills -tools to facilitate oral feeding  Breastfeeding - the Oral Feeding Puzzle

42 Tools to facilitate oral feeding  Cup-feeding (Mizuno & Kani ’05;Collins et al‘08; Huang et al ’09)  Paladai feeding (India) (Aloysius & Hickson ‘07)  Self-paced feeding system (Lau & Schanler ‘00; Fucile et al ’09; in Prep)

43 Self-paced feeding system Vacuum buildup Hydrostatic Pressure Parafilm Standard Bottle Self-paced system Vacuum Build-up Vacuum Build-up Self-paced bottle (Lau & Schanler ’00)

44 p < p = p = Standard Self-paced StandardSelf-Paced GA27.7 ± 1.2 (26-29)27.9 ±1.0 (26-29) 1-2 PO/day34.3 ± 1.0 (33-37)34.2± 0.8 (33-36) 6-8 PO/day36.3 ± 1.5 (34-39)36.8 ± 2.0 (34-42) (Lau & Schanler ‘00; Fucile et al ’09

45 p < p = p < p = Standard Self-paced

46 Standard Self-paced Bottle Occurrence (%) 1-2 oral feedings/day6-8 oral feedings/day Standard Self-paced Bottle OFS levels – Standard vs. Self-Paced (In prep)

47 Breastfeeding RC Gorman the Oral Feeding Puzzle

48 Mother-Infant Dyad Maternal behavior Lactation Non-nutritional benefits growth/development Nutritional benefits oral feeding skills Mother Infant equilibrium (Lau ’02)

49 Maternal behavior Lactation Non-nutritional benefits growth/development Nutritional benefits oral feeding skills Mother Infant (I) (II) (III) imbalance (Lau ’02) With a preterm infant…

50 Maternal attributes / Lactation  Mammary development/anatomy  glandular and ductal development (lactogenesis I)  Milk synthesis/ejection (lactogenesis II)  nipple types infant’s ability/inability to latch onto the breast (Lau & Hurst ’99)  Prematurity  To what extent are lactogeneses I and II impaired?

51 Milk Synthesis/Ejection (lactogenesis II) Milk Synthesis  lactogenic hormones:  prolactin, glucocorticoids, insulin  leptin mammary development (Laud et al,’99)  opiates lactogenic hormones (Lau,‘92; Merchenthaler‘94) Milk Ejection  Oxytocin pulsatile release, T 1/2 = 2 min (Higuchi et al ’02)

52 Value of mother’s milk  Lactation Insufficiency – Common following premature delivery  Donor milk advocated (Schanler’89; Eidelman-AAP ’12)  Mother’s milk favors maturation of innate immunity  Formula favors maturation of adaptive immunity (Andersson et al ‘09)  Pasteurization vs raw human milk pasteurization of human milk reduces fat absorption, weight gain, and linear growth in preterm infants (Andersson et al ’07; Montjaux-Regis et al ‘11)

53 Maternal behavior Lactation Non-nutritional benefits growth/development Nutritional benefits oral feeding skills Mother Infant imbalance (Lau ’02) With a preterm infant…

54 Maternal attributes/ Maternal behavior  Importance of preserving the integrity of the nursing dyad and lactation  to nurture  to sustain maternal drive to breastfeed/express milk  maternal psychological well-being (Li et al ’08) Maternal behavior is a resultant of varying behaviors  Thus, factors affecting maternal behavior vary:  psychological trait  personal health  education  social support: family, friends, professionals  stress: anxiety, depression, work

55 Maternal obstacles Motivation (25%) Knowledge (24%) Anxiety (14%) Work (14%) Health professionals obstacles Lack of support Inapropriate lactation management (19%) Lack of knowledge (15%) Negative attitudes (5%) Lack of support (20%) Staff shortages (5%) Social obstacles Lack of support (27%) Life-styles (29%) Obstacles to successful breastfeeding (Bergh, ’93)

56 Maternal behavior Lactation Non-nutritional benefits growth/developmen t Nutritional benefits oral feeding skills Mother Infant imbalance (Lau ’02) With a preterm infant…

57 Infant attributes/Non-nutritional benefits  To preserve integrity of the nursing dyad  bonding 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;  NICU environment  Potential risk for preterm infant neurodevelopment (Pickler et al ‘10)  Prematurity  prolonged mother-infant separation  inappropriate mother-infant environment  decrease physical contact

58 Infant attributes / Nutritional benefits  Safe and successful oral feeding relies on:  ability to latch on to the breast  efficacious sucking skills  coordinated suck-swallow-breathe  endurance  Prematurity/sickness/hospitalization  immature oral feeding skills  decreased oral feeding opportunities  poor endurance

59 maternal behavior lactation Mother Infant External Factors environment caretaker SuckSwallowRespiration Infant Oral Feeding Performance SafetySuccess Breastfeeding Bottle Feeding Central Nervous System Peripheral Nervous System Development Fetal Development

60 To be launched Fall 2012 If interested send me your contact (name & address) to:


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