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Oral Feeding Issues Chantal Lau, PhD Baylor College of Medicine

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Presentation on theme: "Oral Feeding Issues Chantal Lau, PhD Baylor College of Medicine"— 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…
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 Remember … 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 immature sucking poor endurance unstable behavioral states not as efficient cannot feed for a long time

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

6 What is the current practice?
Adequate weight gain ( g/kg/day) Safety : to minimize aspiration must avoid O2 desaturation, apnea, bradycardia, aspiration-pneumonia Success: to complete entire feeding within allotted time (e.g., min) limiting energy expenditure to favor weight gain

7 What should our goals be?
Adequate weight gain ( g/kg/day) Safety: no aspiration, O2 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 Poor endurance 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

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 Consequences…all the same…
If caretakers persist on feeding infants 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

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? - 3-5 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 Potential Approaches Based on combinations of: common sense physiology
evidence-based information objective integration of old and new information Watch out for: subjectivity/bias/over interpretation

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
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 (Lau & Smith ’11)

32 Oral Feeding Skill (OFS) levels
Skills POOR GOOD (PRO) Endurance (RT) GOOD POOR Level 2 Skills :LOW Endurance: HIGH Level 4 skills :HIGH Endurance: HIGH 30% 1.5 ml/min Level 1 skills :LOW Endurance: LOW Level 3 skills :HIGH Endurance: LOW GA ≤25 26-29 30-34

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

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

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 Types of interventions
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)

37 Interventions to enhance OFS skills
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

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

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

40 Feeding Positions Semi-reclined (control) (Lau ‘12) Sidelying Upright
Occurrence (%) (Lau ‘12) days from SOF ± ± 9 Sidelying Upright Occurrence (%) ± ± ± ± 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 Build-up Self-paced system (Lau & Schanler ’00) Parafilm Vacuum buildup Standard Bottle Self-paced bottle Vacuum Build-up Hydrostatic Pressure

44 Standard Self-Paced GA 27.7 ± 1.2 (26-29) 27.9 ±1.0 (26-29)
27.9 ±1.0 (26-29) 1-2 PO/day 34.3 ± 1.0 (33-37) 34.2± 0.8 (33-36) 6-8 PO/day 36.3 ± 1.5 (34-39) 36.8 ± 2.0 (34-42) p = 0.016 Standard Self-paced p = 0.007 p < 0.001 (Lau & Schanler ‘00; Fucile et al ’09

45 Standard Self-paced p = 0.002 p = 0.002 p < 0.001 p < 0.001

46 OFS levels – Standard vs. Self-Paced
1-2 oral feedings/day 6-8 oral feedings/day Occurrence (%) Standard Self-paced Bottle Standard Self-paced Bottle (In prep)

47 the Oral Feeding Puzzle
Breastfeeding RC Gorman the Oral Feeding Puzzle

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

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

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)
lactogenic hormones: prolactin, glucocorticoids, insulin leptin mammary development (Laud et al,’99) opiates lactogenic hormones (Lau,‘92; Merchenthaler‘94) Milk Ejection Oxytocin pulsatile release, T1/2 = 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 With a preterm infant… Infant Mother imbalance Non-nutritional
benefits growth/development Maternal behavior imbalance Nutritional benefits oral feeding skills Lactation (Lau ’02)

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 Obstacles to successful breastfeeding
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%) (Bergh, ’93)

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

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 Stress Infant External Mother Factors maternal behavior environment
Fetal Development Infant External Factors Central Nervous System Mother Development maternal behavior Peripheral Nervous System environment caretaker Suck Swallow Respiration Breastfeeding Bottle Feeding lactation Infant Oral Feeding Performance Safety Success

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


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