Developmental Feeding

Considerations for Acute and Critical

Neonatal Care

Keren Eliav, MS, OTR/L

Occupational Therapist

Infant Therapy Team

Seattle Children’s Hospital keren.eliav@seattlechildrens.org

Disclosure Statement

• I do not have any conflict of interest nor will

I be discussing any off-label product use.

• This class has no commercial support or

sponsorship, nor is it co-sponsored.

Objectives:

• Learners will be able to describe

components of safe and effective oral

feeding.

• Learners will be able to develop strategies

to improve oral feeding competency in

NICU infants.

• Learners will be able to identify

disengagement cues during feeding.

Seattle Children’s Hospital

OT/PT Infant Team

Feeding

• Most challenging task

required of an infant in the

NICU

• Feeding involves a dynamic

relationship between infant

and caregiver

• Early feeding experiences lay

the foundation for future

feeding skills and can impact

the parent-infant bond

Three NICU babies

Three different paths of feeding

• Lauren: 30 weeks, minimal respiratory support,

mom desires to breastfeed.

• Sofia: 31 weeks, emergency c-section, ventilatory

support, VP shunt placed

• Arjun: 36 6/7 weeks, twin, minimal medical

intervention, NICU re-admission

Lauren

• 30 week premature infant

• Born via vaginal delivery due to premature rupture of

membranes

• Needed CPAP briefly after birth, transitioned to room air

within 2 days

• Caffeine for apnea of prematurity, stopped at 34 weeks

• Parents have 2 year old twins who were born at 34

weeks

• Mom desires to breastfeed

Positive pre-feeding experiences

• Reduce negative medical interventions around face and

mouth

• Elicit the rooting reflex (starting at 28 weeks) prior to

entering the baby’s mouth for cares

• Use as little tape on the face as possible

• Transition from an OG to NG as soon as medically

appropriate

• Allow infants to explore hands to face and mouth

• Opportunities for infants to smell mother’s milk

• Improved transition to feeding (Yildiz, 2011)

Positive pre-feeding experiences • Skin to skin with mom and opportunities to practice

latching at the breast.

• Milk supply, BF exclusivity and duration, self-regulation, LOS,

weight gain (Hake-Brooks 2008, Hurst 1997, Jayaraman 2017,

Ludington-Hoe 2011, Oras 2016, Conde-Agudelo 2011)

• Gentle oral care- using breastmilk whenever possible

• Improved sucking skills, feeding interest (Rodriguez 2010)

• Oral motor/sensory intervention- positive touch to

face/cheeks/lips, input to gums.

• Decreased LOS, faster transition to full oral, better efficiency,

improved wt gain (Fucille et al 2002, 2005, 2010, 2011, 2012,

Lessen 2011, Rocha 2007)

• Non-nutritive sucking using correct pacifier size

• Shorter LOS; faster transition to full oral (Pimenta 2008, Foster

2016, Fields 1982)

Thoughtful First feedings

• Ideal Scenario:

• Infant at least 32-34 weeks, depending on clinical

status and cueing to feed.

• If mother is intending to breastfeed, exclusive

breastfeeding opportunities for at least 3 days.

• Parents involved in decision to start

• Parents at bedside to participate if possible

• Either feeding therapist present OR the nurse is freed

up to allow more time to devote to the session.

• Set expectations appropriately, remember the goal is

a positive practice experience NOT a volume goal.

Supporting breastfeeding in the NICU

• Most NICUs are striving to improve their rates of

breastfeeding at discharge

• It’s important to include breastfeeding in each stage of

oral feeding progression

• Power of language for negative influence

• It’s easier for the baby to bottle feed

• It is safer for us to know exactly how much he’s eating

• If you want to leave here quicker, we can focus on bottle feeding

• The scale shows he only took 2 mL…

Supporting breastfeeding in the NICU

• Careful positioning becomes even more important for

small babies

• Tips for breastfeeding small babies

• Ensure mom is in a well supported position

• Remove barriers between mom and baby

• Cross cradle hold works nicely, “tuck” infant under mom’s

opposite breast

• Have infant “hug” breast they are feeding from

• Appropriate breast shaping in a “U” position

• Mom’s input is using her wrist against infant’s shoulders

Lauren’s feeding progression

• 30-33 weeks: Regular skin to skin time, room air

• 33 weeks: Began latching to a recently pumped breast

• 34 weeks:

• PO feedings per cues

• Latching to a more full breast

• Started practicing with Dr. Brown bottle with Preemie nipple.

• Prioritized breastfeeding for at least 3 feedings per day.

If energy for more feedings, bottle was used.

• 37 3/7 weeks: D/C, breastfeeding ad lib and 4 bottles per

day of fortified breastmilk.

Sofia

• 31 week premature infant, emergency c-section due to

placental abruption

• Transferred to higher level care for ventilatory support

and treatment for Group B strep sepsis, treated with 21

days of ampicillin

• Progressive increase in ventricular size and head

circumference. VP shunt placed at 35 weeks

• Cranial ultrasound revealed Grade III, IV bleeds

• No oral interest or sucking skills observed between 35-

37 weeks

• Mom not interested in breastfeeding.

Effective Infant Feeding

Wolf, Glass 1992

Coordination of S/S/B

• Breathing should occur at regular intervals

during sucking (after every 1-2 sucks)

• Swallowing momentarily interrupts breathing

• Breathing rate is faster during pauses • Wolf, Glass 1992

Problems with Coordination of S/S/B (Wolf, Glass 1992)

• Feeding induced apnea

• Short sucking bursts

Wolf, Glass 1992

Sofia: Feeding evaluation at 36 6/7 weeks

• Optimize feeding conditions:

• Bottle/nipple choice

• Feeding position

• Pacing

Impact of Flow on Feeding

• The higher the flow, the more challenge to the SSB

mechanism

• Increased likelihood of physiologic compromise, which

leads to increased fatigue

• High flow puts an infant at risk for aspiration, even if

swallow integrity is normal

• Low flow allows much more time for breathing and

feeding in a comfortable manner

Common flow rates in our hospital

SLOWEST

• Binky trainer (can be used this way if needed)

• ULTRA Preemie nipple on Dr. Brown bottle system

• Preemie nipple on Dr. Brown bottle system

• Level 1 nipple on Dr. Brown bottle system

• Yellow Similac disposable nipple (variance in flow rate)

• Dr. Brown Level 2, 3, 4

FASTEST

Sidelying position for feeding

• Excellent position for young

infants

• Sidelying provides good

postural support/stability for

an infant

• Consider partial swaddle

• Slows down the flow rate

from the bottle

Feeding Position Horizontal Bottle Position

NO –

Gravity

increases

flow rate

YES –

Gravity

effect is

minimal

Feeding In Upright with Horizontal

Bottle Position

• Amount of support needed depends on head control, maturation, and general medical condition

• To optimize feeding, want to give as much postural support as possible.

• Less postural support may help keep baby awake, but carefully weigh cost and benefit

Pacing • Allows sufficient opportunity and time to

breathe during feeding by interrupting the flow

• For feeding induced apnea, stop flow after 2-3 sucks

• For insufficient ventilatory support, stop flow after 5-10 sucks

Pacing

• Simple technique that can greatly improve the

quality and comfort of an infant’s feeding

• Goal is to MAINTAIN physiologic stability rather

than respond to distress

• Provides the neurobehavioral practice that

facilitates development of mature skills

Pacing as a treatment technique for

transitional sucking patterns

Law-Morstatt, et al (2003)

• First 18 infants were traditionally fed. Once

discharged, nursing staff completed CE on

paced feedings. Next 18 infants were given

paced feedings.

• Demonstrated statistically and clinically

significant decrease in bradycardic incidences

during feeding and improved sucking efficiency.

Sofia’s feeding evaluation at 36 6/7 weeks

• Demonstrated improved interest and more organized

sucking ability.

• Used ULTRA Preemie nipple, fed in elevated sidelying

with VERY careful pacing due to feeding induced

apnea.

• Took 13 mL with normal physiologic responses

• Plan: 10 mL 3-4x/day, ULTRA Preemie nipple,

sidelying and pacing

Sofia’s feeding progression

• 37 2/7 weeks: feedings were going OK, but with

occasional brady/desats. Trialed chilled liquids, with

improved timing overall.

• Feeding plan advanced to 20 mL 5x/day until she can do so

without desats or bradys.

• Cold liquids have been shown to improve swallowing

safety in pilot study. (Ferrara, 2018)

• The occurrence of deep penetration and aspiration

decreased significantly with cold liquids compared to the

room temperature liquids.

Cold liquids

Ferrara, 2018

Sofia feeding progression

• 37 6/7 weeks

• Advanced to PO 20 minutes per cues

• Chilled liquid, ULTRA Preemie, pacing

• 38 1/7 weeks

• Advanced to Preemie nipple.

• Taking 10-45 mL of 67 mL bolus feeding

• 39 6/7 weeks

• Tried to advance to cradle position coughing

• Tried to reduce pacing coughing.

• Advanced time limit to 30 minutes

• Preemie, sidelying, chilled, consistent pacing.

Sofia feeding progression

• 41 2/7 weeks:

• Preparing to discharge

• Full oral feeding with Preemie nipple, sidelying, chilled, pacing

• Some nurses trialed Level 1 coughing

• Education to father on feeding techniques

• Plan for a VFSS outpatient at 44 weeks

Role of the Videofluoroscopic Swallow

Study (VFSS)

• Evaluate safety of the pharyngeal swallow

• Can trial various treatment techniques

• Thoughtful timing of VFSS is crucial

• What question do you want answered?

• How will it change recommendations?

• Need to be able to take a minimum

• Not recommended for infants under 40 weeks

• Limitations:

• Moment in time

• Not designed to assess reflux or ascending aspiration

Sofia’s VFSS

• Done at 43 6/7 weeks as

an outpatient

• Began test in upright

position, with the intention

of moving to sidelying if

needed

• Used Preemie nipple

• Good participation

• Mom was primary feeder

Sofia’s VFSS

• Fatigue related changes in swallowing

• The bolus with room temperature liquid quickly moves

down to the pyriform sinuses, putting her at risk for

aspiration.

• Improved swallowing safety with chilled liquid.

• Able to maintain safe swallow through entire feeding

volume using chilled liquid.

Sofia’s growth

Sofia’s growth and update

• Mom reports that feeding is going very well at home.

Sofia enjoys eating and there is little to no stress

surrounding feeding times.

• Sofia takes about 80 mL every 2-4 hours (8 feedings

per day).

• Mom says cold milk is working well. She describes

that she keeps a small refrigerator in the bedroom for

evening bottles and a cooled lunch pack during the

day when they are out.

Arjun

• Twin born at 36 6/7 weeks, initial NICU stay for 4 days,

took 20-30 mL at a time, using disposable nipples,

discharged to home with twin.

• Readmitted after three days at home due to

thermoregulation difficulties, poor endurance, inadequate

feeding.

• OT feeding evaluation at 38 4/7 weeks

• 60 mL q 3 hours, taking 4-27 mL by mouth mainly with Enfamil

slow flow nipple

• High arched palate, short sucking bursts

• Hyperalert baby, needs minimal stimulation/movement

• Recommended use of Preemie nipple

Arjun

• 39 4/7 weeks

• Similar feeding performance, 13-23 mL (out of 61 mL).

• Continues to get very sleepy quickly.

• Family interested in learning NG tube care and being discharged

with NG tube.

• 40 1/7 weeks

• Nursing had progressed him to Level 1 nipple (from Preemie)

• NG tube removed and he is feeding PO ad lib, taking 50-61 mL

at a time

• Preparing for discharge with outpatient f/u

• OT concerned with quality of feeding and “pushing” to complete

feedings and meet daily goal volumes

Respect Infant’s Cues During Feeding

WATCH - especially the face

• Eye brows raised

• Eyes closed tight

• Eye blink

• Gaze aversion

• Brow furrow

• Color change

FEEL - the

babies body

• Changes in

tone

• Head pulls

back or turns

slightly

LISTEN – to breathing and swallowing

• Tachypnea, apnea, stridor, rattle, obstruction

• Time between breathing pauses

• Swallow sounds

• SSB timing

Why is this so important?

• Early feeding experiences in the NICU can potentially

impact an infant and a family’s relationship with feeding

far beyond discharge.

• Hawdon et al (2000)

• Although less than 1% of preterm infants required

supplemental tube feedings at time of discharge, over

50% of parents report problematic feeding behaviors

at 18 and 24 months.

• Parents of NICU graduates reported disorganized

feeding- including coughing, vomiting, feeding refusal

in 39% at 6 months and 37% at 12 months.

Prevalence of Feeding Problems

• Ross & Browne (2013)

• Over 50% of parents describe difficulties in feeding

their infant after discharge from the NICU.

• Even in older children (6 years of age), extremely

preterm infants (<28 weeks) are 3-5x more likely to

have feeding problems.

• DeMauro et al (2011)

• Feeding problems were prevalent in both the early

born (25 to 33.6 weeks GA) and later born (34 to 36.6

weeks GA) groups evaluated at 3, 6, and 12 months.

Arjun outpatient follow-up

• 41 3/7 weeks:

• Has been home for 9 days. Poor growth for the first week. Past

few days, has gained 1 ounce per day.

• Feeding every 2-4 hours, alternating between sidelying and

cradle position with Level 1 nipple.

• Quickly falls asleep during feeding, so significant stimulation is

given even during normal breathing breaks

• OT recommended Level 1 nipple in sidelying position (or

Preemie in cradle) and VFSS

Arjun VFSS

• 45 weeks PMA

• Feedings take 1 hour

• Weight gain below goal (20 grams per day)

• VFSS was limited due to significant refusal behaviors

• Pulling away from bottle, turning his head, crying

• Multiple episodes of laryngeal penetration

• Improvement noted with ½ strength nectar thick liquids

• Reviewed overall concerns with family, suggested might

need to return to NG feedings

• Family would like to trial thickened feedings first.

Thickening

• Creates a more cohesive bolus and slows transit

time.

• ALL thickeners have pros and cons.

• Balance medical considerations, nutritional/fluid

needs, and oral motor skills.

• Formula: usually use Thick-It or rice cereal.

• Breastmilk: consistent thickening can only be

achieved with gum based thickener (Gel Mix or

Simply Thick).

• FDA advisory regarding Simply Thick

• SCH: we do not typically consider thickening as an

option until 42-44 weeks

Arjun older infant

• Received early intervention for feeding therapy

• Feeding continued to be a struggle over the next 5

months, inconsistent weight gain, multiple respiratory

illnesses.

• Repeat VFSS at 5 ½ months (adjusted age)

• Goal feeding volume is 4 ounces.

• Feedings take 1 hour

• First ounce by bottle using a Level 2 nipple

• 3 ounces are then given by syringe

• Needs 30 kcal/oz in order to gain weight

• Dysfunctional feeding pattern, tube feedings

recommended

Arjun older infant

• 1 month later (6 ½ months adjusted age) admitted for

NG placement. Mom made this decision based on

impact of feeding on quality of life.

• Upper GI:

• Persistent posterior impression upon the midesophagus raising

suspicion for a vascular ring.

• CT scan

• Left-sided ligament arteriosum in the setting of a right-sided

aortic arch consistent with a vascular ring.

Arjun older infant

• Began NG feedings

• First slow bolus feedings, then moved to continuous

drip due to vomiting

• Plan for G-tube placement and vascular ring repair

Arjun update

• Continuous G-tube feedings for 20 hours/day

• Mom reports things are going very well at home with little

to no vomiting

• Excellent growth, increased energy level, happy overall,

improved sleep

• Working on accepting some solids, focus of family time

is on improving development skills and enjoying Arjun

Strategies to optimize oral feeding

• Provide positive pre-feeding experiences

• Thoughtful first feedings including family

• Offer opportunities for breastfeeding at each stage

• Lean toward slower flow with appropriate postural

support and pacing as needed

• Follow infant’s cues for starting and stopping feedings

• Success should be defined in terms of quality, rather

than in terms of volume or age of acquisition

• Promote a team approach to oral feeding progression

• Help parents feel comfortable and confident in feeding

their infant, setting them up for increased success at

home

Feedback/Questions?

keren.eliav@seattlechildrens.org

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