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A Collabora)ve Approach To Infant Feeding In The NICU:
Occupa&onal Therapists, Speech Therapists, and Lacta&on Specialists Working As A Team
Jada Wright Nichols, MS, OTR/L, CLC
Blossom Health and Maternal Wellness
The Journey
The Journey
The Journey
The Journey
The Journey
We Will • Compare and contrast the scope, roles, and specialty areas of occupa@onal therapy, speech therapy, lacta@on consul@ng • Iden@fy limita@ons in parent educa@on concerning infant feeding in the NICU • Iden@fy 3 way to increase communica@on among the infant feeding team • Describe 4 race-‐based dispari@es in the NICU related to infant feeding
Occupa)onal Therapy • The assessment and treatment to develop, recover, or maintain the daily living skills (occupa@ons) of individuals with physical, cogni@ve, or psychological challenges.
• Client-‐centered focus
• Adapt the environment • Modify the task • Teach a skill • Educate the client and caregivers
Occupa)onal Therapy in the NICU
• Physical and Cogni@ve Development • Posi@oning • Appropriate Elicita@on and Integra@on of reflexes • Head Control • Sensory Processing
Occupa)ons of a Neonate • Thrive: breathe, eat, grow • Fight infec@on • Process the sensory environment • Receive care • Interact with others: family, medical staff
Speech-‐Language Pathology • Communica@on • Cogni@on • Feeding • Swallowing
Speech Therapy in the NICU • Dysphagia • Oral-‐Motor Control • Suck-‐Swallow-‐Breathe Reflex Coordina@on
Neonatal Therapist Does Not • Rehab the infant • Give the babies a workout • Divide a 600 gram baby into body parts • OT hands or sensory issues • PT legs and feet • ST mouth
Neonatal Therapist • Maximizes Developmental Outcomes • Supports infant mental health • Facilitates family interac@on • Provides direct care and/ or consulta@on
NICU Therapy is Vital • Facilitates brain development in sick and preterm infants, even those without bleeds • Altered neurobehavior in infants less than 30 weeks, Pineda et al • Varia@ons in stress responses and self-‐regulatory behaviors, Grenier et al • Neuroprotec@on in the preterm infant, McGrath et al
• Babies need to learn to move, and need to move to learn • Flexion • Midline orienta@on • Posterior pelvic @lt • Hands to face • Facilita@ng normal skills into a developing body, in an abnormal environment
Therapy Facilitated Brain Development
• Significant brain growth in the last 8 weeks • Final 6 weeks, significant change in func@on and structure • Sleep pa_erns, posi@ons during sleep, quality of sleep • Posi@oning influences development
• Decreases stress response • Enhances infant’s ability to self-‐soothe and interact with environment • Meets infant’s needs for containment, while also allowing movement
• Incurs posi@ve and nega@ve effects of environmental experiences • Sensory integra@on • Sensory overload • Benefits of touch, especially skin to skin • Stress of being away out of the womb and away from mother
Neuroprotec)on • Posi@oning impacts development of brain pathways • Posi@oning impacts postural development • Posi@oning impacts motor organiza@on • Posi@oning impacts sensory development
Mon@rosso et al, found that the greater the use of developmental care prac@ces, the be_er neurobehavioral stability and neuromatura@on Therapists are uniquely trained in the understanding of how neurobehavioral expecta@ons are influenced by posi@on to support brain development, across the life span
Physiological Stability • Decreasing stress pa_erns, especially in preterm infants • Least amount of stress in prone, prone nested, and side-‐lie nested, Grenier • Stress related to decreased oxygen levels in small or sick infants, Harrison et al • Promo@ng flexion pa_erns through boundaries helps infants to engage and self-‐soothe • Controlled exposure to sensory s@mula@on
• Suppor@ng the respiratory system, including diaphragm and lung func@on • Decreasing the impact of gravity on lung func@on
• Supports the diges@ve system by decreasing reflux
Prone Benefits • Increased @dal volume • Improved diaphragm func@on • Improved thoraco-‐abnominal coordina@on • Improved ability to oxygenate • Decreased oxygen desatura@ons • Improved quality of sleep resul@ng in energy conserva@on • Decreased FiO2 needs • Weaning ven@lator secngs
Feeding in the NICU • May be OT or ST based, PT may provide if confident & competent • Facilitate infant directed feeding, rather than caregiver directed (feeding a rock) • Elicit primary reflexes necessary for ea@ng • Facilitate and support head and hand posi@ons for feeding • Monitor early (and late) hunger cues • Iden@fying stress, overs@mula@on, and sa@a@on cues • Involving nursing and FAMILY
Feeding Challenges in the NICU • When is an MBS required • Coughing, choking, apnea, bradycardia during feedings
• When to adjust milk consistency • When to supplement calories or nutrients • Iden@fying the appropriate flow nipple • Helping (mul@ple) caregivers to feel confident in feeding the infant
Neonatal Therapists Need Help!
Human Milk in the NICU!!! • Species specific • Gesta@onal age specific • Decreased risk of sepsis • Decreased risk of meningi@s • Decreased risk of infec@ons, in general • Fewer diges@ve challenges • Fewer incidents of necro@zing enterocoli@s (NEC)
• Exclusively formula fed babies are 6 to 10 @mes mores likely to contract it
• Moms who begin breasheeding in the NICU con@nue longer than moms of full-‐term babies aier discharge
• Long term immunological and developmental benefits
Lacta)on Consultant in the NICU • Prepares for successful nursing, even if infant cannot go to breast • Helps mother to ini@ate pumping and/ or breasheeding • Creates a plan for baby’s feeding • Troubleshoots and resolves issues ini@a@ng the plan (especially if the infant is at the breast) • Resolves issues related to latch, supply, pain, engorgement, infec@on • Explores ways to posi@on infant at the breast for comfort and efficiency • Develops a discharge plan for con@nuing to nurse at home
Booby Traps in the NICU Best For Babes
• Not being informed of the importance of breasheeding a preterm baby • Emphasis on breastmilk, but not breastfeeding • Belief that preterm or sick babies are incapable of breasheeding effec@vely • Not being given the opportunity to perform skin to skin • Lack of access to lacta@on support • Poor help of establishing milk supply • Lack of access to donor milk • Poor post discharge support
Addi)onal Barriers to BreasOeeding in the NICU • Physical or emo@onal state of the mother • Proximity of mother to infant • Frequency of NICU visits • Educa@onal level • Educa@on on breasheeding and human milk • Readiness to breasheed • Accessibility to a pump • Family support • Community support
AND More Barriers to BreasOeeding in the NICU • Lack of exposure to breasheeding • Lack of guidance from hospital staff • Lack of available hospital resources • Limited ability for follow-‐up at bedside or at home • Increased accessibility to formula • Decreased accessibility to nursing supplies • Return to work
Collabora)on Is Vital
Create A Dream Feeding Team • Neonatal Therapists • OT, PT, ST
• Lacta@on Consultants • Already a rela@vely diverse field
• NICU Nurses • Nutri@on Specialists*
Integra)ve Training and Service Provision • Segmented services may confuse and overwhelm the parents • Every service provider cannot do everything • Every service provider CAN reinforce what another provider offers
• Posi@oning • Sensory Processing
• Environmental: noise, lights, touch (frequency, quality) • Swaddling, nes@ng
• Elicita@on of Reflexes • Oral Anomalies
• Clei lip or palate • Tied lip or tongue
• Oral Motor Control and S@mula@on • Oral care with human milk
Transi)ons • Feeding tubes, spoons, and cups to breast (or bo_le) • Isola@on to room air • An@bio@cs • Rooming in • Home
Race Based Dispari)es • Healthy People 2020 • Highest rates of formula supplementa@on before 2 days of life • Infant mortality • Poverty • Lack of connec@on with lacta@on professionals
Collabora)on and Consulta)on • Play to the strengths of each team member, but do not disengage
• Feeding • Posi@oning • Sensory Processing • Breasheeding
• No Team “Leader” • Facilitator • Any team member may have a more prominent role at any@me, depending on the infant’s needs
Collabora)on and Consulta)on • Respect all professionals on the team, no hierarchy • Be transparent about theories, professional prac@ces, and frames of reference • Be willing to learn new informa@on, or old informa@on that you’ve never heard • Use evidence to guide prac@ce
• Nipple shields, pacifiers, ar@ficial milk, bo_les • Be agreeable in determining the best plan of care for the infant • Conduct regularly and frequently scheduled mee@ngs
• Team rounding • Scholarly ar@cle review • Current and/ or community event
Collabora)on and Consulta)on • Debunk NICU and Breasheeding myths • Discharge to early interven@on services • Secure lacta@on consultant home visit • Establish and facilitate support and developmental play groups • Provide community resources
• Physicians, support groups, play groups, delivery services, nutri@on services
References and Resources • Progress in Increasing Breasheeding and Reducing Racial/ Ethnic Differences-‐ 2000-‐2008 Births Weekly, February 8, 2013/ 62(05);77-‐80.
• Occupa@onal Therapy and Breasheeding Promo@on: Our Role in Societal Health
• Jennifer S. Pitonyak American Journal of Occupa@onal Therapy, May/June 2014, Vol. 68, e90-‐e96. doi:10.5014/ajot.2014.009746
• Racial and Ethnic Dispari@es in Breasheeding. Jones KM1, Power ML, Queenan JT, Schulkin J. Breasheeding Medicine. 2015 Apr 1.
• The Speech-‐Language Pathologist and the Lacta@on Consultant: The Baby's Feeding Dream Team, Kara Fletcher & Barbara Ash, ASHA Leader, February 8, 2005.
Resources and References • Breasheeding Among Minority Women: Moving From Risk Factors to Interven@ons, Champan, DJ, Perez-‐Escamilla, R., Yale School of Public Health
• Respiratory Func@on in Late Preterm Infants Delivered at 33-‐36 Weeks of Gesta@on Cindy McEvoy, MD, MCR, Sridevi Venigalla, MD, Diane Schilling, RRT, Nakia Clay, BA, Patricia Spitale, MD, Thuan Nguyen, PhD! Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR Published Online: November 08, 2012
• Pa_erns of Altered Neurobehavior in Preterm Infants within the Neonatal Intensive Care Unit, Roberta G. Pineda, PhD, OTR/L, Tiong Han Tjoeng, MD, MPH, Claudine Vavasseur, MD, Hiroyuki Kidokoro, MD, Jeffrey J. Neil, MD, PhD, Terrie Inder, MD, PhD! Published Online: October 02, 2012
• Neuroprotec@on in the Preterm Infant: Further Understanding of the Short-‐ and Long-‐term Implica@ons for Brain Development, Jacqueline M. McGrath, PhD, RN, FNAP,, Sharon Cone, PhD(c), RNC, NNP-‐BC, Haifa A. Samra, PhD, RN