NICU Role of the Therapist in the NICU - Indiana Speech

NICU
Mary Ewing M.A., CCC-SLP, CLC, BCS-S
Catherine Seitz M.A., CCC-SLP, BCS-S
ISHA Fall Conference 2014
mjewing@bsu.edu
cseitz1@iuhealth.org
1
Role of the Therapist in the
NICU
ASHA statement
“Speech-Language Pathologist who practice independently
in the NICU environment and provide service to infants
and families are required to hold the Clinical Competence
in Speech-Language Pathology and abide by the ASHA
Code of Ethics (2003), including Principle of Ethics II
Rule B, which stated: “individuals shall engage in only
those aspects of profession that are within the scope of
their competence, considering their level of education,
training, and experience.”
2
Role of Therapist
Determined by need of NICU
Team approach to ensure successful feedings
Promote developmental care, positioning, infant
massage and positive feeding
Help ensure long term developmental maturation
Provide education to hospital staff
Empower Families through education, demonstration
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Babies in NICU
35 weeks gestation or less
Ill newborn
Respiratory distress
Cardiac Issues
Congenital Anomalies
Prenatal exposure to narcotics
Difficult Delivery
4
Brain Development at 36
Weeks Gestation
Motor
Variety resting postures
Flexor tone extremities
Reflexes present
State
Wake on own
Alert for up to 30 min.
Feeding
Active root
1 suck, 1 swallow, several breaths (immature pattern)
Mildly consistent burst-pause pattern
Consistent compression, but variable suction
Feeding completed in 30 min.
.Kinney HC. Semin Perinatol. 2006;30:81-88.
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Intra-Uterine Development
of Feeding
Sucking develops around 15 to 16
weeks gestation
Swallowing develops around 14 to 17
weeks gestation and can be observed
during ultrasound at 28 to 29 weeks
gestation
A fetus swallows approximately 15 oz
of amniotic fluid per day
The coordination of suck:swallow:breathe pattern evolves
around 31 to 33 weeks and is mature around 37 to 38 weeks
gestation
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Development of Feeding
Newborn
Newborns demonstrate a coordinated
suck:swallow:breathe pattern with 1 suck, 1 swallow and 1
breath throughout the feeding
A consistent burst-pause pattern should be evident
throughout the feeding
Newborns exhibit a more efficient sucking pattern that
has consistent suction along with compression
Ability to exhibit feeding cues and demonstrate state
regulation
A newborn should be able to complete a feeding within 20
to 25 minutes
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Development of Feeding
Infant
Suckling is demonstrated by an infant up until around 6
months of age
Sucking begins around 6 months until weaned from bottle/
breast feeding
Oral skills for spoon feedings develop around 6 months of age
Open cup may be introduced around 6 months of age
Straw drinking may be introduced around 6 to 7 months of
age.
Finger foods may be appropriate around 8 to 9 months
Dissolvable solids introduced when infant on hands and
knees
Chewy solids when infant is walking
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Development of Feeding
~continued
Must consider corrected age for premature
infants for initiation of each diet level
New studies and AAP recommend waiting until
6 months to initiate solids to reduce allergies
and childhood obesity
immature digestive system
poor head and trunk stability for safe swallow
reflexes versus volitional movements
9
Interventions Within NICU
Indirect/Decreased lighting
Monitoring of noise levels
Pain management
Odor neutral environment
Positioning and positioning aids
Baby Friendly which promotes breast-feeding
10
Developmental Care
Sensory System
Tactile
Visual
Vestibular
Olfactory
Taste
11
Kangaroo Care
An evidence based
practice involving skin
to skin contact with
mother/father of baby.
Benefits include, but
not limited to,
increased bonding,
feeding success,
temperature/sleep
regulation, and pain
management.
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Infant Massage
Benefits include improved:
Circulation, skin integrity, skin
tone, weight gain, digestion,
pain tolerance, and alert states
for the neonates
Attachment, interaction, and
communication with parents
Parental understanding of
infant cues
Prolactin levels in mothers
Oxytocin levels in babies to
promote growth, circulation,
and decrease stress
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What can complicate
early feeding success?
Multiple caregivers
Prolonged use of OG/NG tubes
O2 nasal cannula
Bili lights
Suctioning and intubation
Preterm infants have to deal with a lot of sensory input.
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Common reasons SLP is consulted:
Difficulty coordinating breathing with eating or drinking
Difficulty sucking from a bottle and/or breast
When stress signs are noted/observed
Concern for possible aspiration
Recurrent pneumonia or respiratory infections
Feeding periods longer than 30-40 minutes
Sustained drooling with open mouth posturing not associated with teething
Increase in work of breathing with feeding or breathing disruptions during feeding
Excessive/consistent spitting up after feeding
Craniofacial anomalies
Weak suck
Unexplained food refusal or failure to accept different textures of food
Failure to thrive
Choking, coughing, gagging, vomiting
If alternative feeding methods are being considered.
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Dysphagia clinical
evaluation
What the SLP assesses
Birth History
Oral structures/oral phase of feeding/swallowing
Initiation of the pharyngeal phase of swallow
Respiration/Work of breathing
Sensory System
State Regulation
Reflexes
Non-nutritive vs. Nutritive sucking
Stress signs
Gross motor
Risk for aspiration
Determine safest diet level
Determine need for VFSS
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How Feeding Works
Oral Phase
Pharyngeal Phase
Esophageal Phase
infant anatomy
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Work of Breathing
✦
Respiration is foremost a survival function!!!!
✦
Feeding is an infant’s aerobic exercise and physiologic work (running a
marathon every time they eat)
✦
Sucking may override breathing to the point of apnea.
✦
Increased work of breathing can lead to respiratory fatigue, shutdown and
excessive burning of calories resulting in weight loss
✦
Always need to consider the impact of work of breathing on child’s ability
to be a successful oral feeder
✦
Increased work of breathing may delay gastric emptying resulting in reflux
✦
If an infant is not actively swallowing then the airway is open!!!
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Respiratory System
History and length of intubation and ventilation
History of prematurity
Post-conceptual age
Length of hospitalization
Need for oxygen
During hospitalization/after discharge
History of respiratory infections
Bronchitis
RSV
Pneumonia
Chronic upper respiratory infection
Current respiratory diagnosis or issues
Asthma
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Allergies
Non-nutritive versus Nutritive sucking
Non-nutritive
Nutritive
2 sucks per second
1 suck per second
Involves only the sucking
component
Involves the coordination
of suck:swallow:breathe
Can be elicited in all states
except deep sleep and crying
Most efficient in awake/
alert state
Suck:swallow:breathe ratioat least 6 to 8 sucks prior to
swallow
Suck:swallow:breathe
pattern 1:1:1 ratio (preterm
infants demonstrate
difficulty with this
coordination)
Not necessarily a predictor of
feeding success
May increase the work of
breathing and fatigue the
infant prior to po feedings.
20
Oral Stimulation
Need to monitor stress signs
during all stimulation activities to
maintain positive experience
Hands to face
Oral exploration of hands and/or
pacifier
Positive touch when oral gastric
(OG), nasal gastric (NG) tube or
oral ventilator tube present
Tactile stimulation to cheeks and
lips
sustained touch/pressure
stroking/movement
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Positioning
Maintain postural control
Hands midline
Swaddle
Left/Right sidelying versus upright
Head elevated above hips
angle of elevation dependent
on nasal regurgitation
Air way stability
ear, shoulder, hip in straight line
consider laryngo/tracheomalacia
Transition to supine/upright as appropriate
2 to 4 months in preparation for anatomical changes and spoon
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Pacing
Why pace?
Teaches the infant an organized pattern for safe feeding
Allows infant to coordinate breathing during nutritive sucking
How to pace?
To teach coordinated suck:swallow:breathe
Pre-term: 3 sucks then tip nipple downward for 3 second
break for breathing for first 1 to 2 minutes of feeding or until
infant begins to self pace
Term: 5-10 suck:swallow:breathe patterns then tip nipple
downward to allow for catch-up breathing
Baby will show signs of when to resume feeding!!!
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Cervical auscultation
Use as a clinical tool to help
determine S:S:B in infants and
trigger of swallow in all age
groups
Swallowing is lower frequency
and respiration is high frequency
Use bell side of stethoscope to
laryngeal area for swallow and
diaphragm side for respirations
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Videofluoroscopy Swallow
Study
View anatomical structures during dynamic swallow
Determine severity of penetration/aspiration episodes and/or rule
out silent aspiration
Effectiveness of therapeutic/compensatory strategies
Make suggestions/recommendations for direction of skilled
therapy
When appropriate establish goals
Provide thorough description of swallow deficits to aid in safe
progression of diet in treatment
25
VFSS Clips
Nasal Regurgitation
Work of Breathing
26
VFSS Clips
Aspiration
Thickened Liquids
27
Difficulty with Breast/Bottle
Feeding
What to look for:
Increased feeding time (longer than 20-30
minutes)
Anterior loss
Noisy feedings
Demonstrates 2 or more stress signs
Increased work of breathing
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Breast and Bottle Feeding
Breastfeeding
Infant is able to control the rate
of milk
Multiple streams which coat oral
cavity
More stability for tongue and
jaw
Infant able to pace better
Better body position
Mother may need to pump until
let down occurs
Suck:Swallow:Breathe
coordination for breast feeding
is earlier than for bottle feeding
Bottle Feeding
Infant unable to control the rate
of milk
Steady stream from single hole
nipple directed at posterior
pharyngeal wall
Less stability for tongue and jaw
More difficulty self-pacing
More difficulty to position
Not nipple confusion but flow
confusion
Studies indicate increased
obesity linked to bottle fed
infants
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BMH Feeding Protocol
Pre-oral stage
NPO/NG feeding only
Non-Nutritive Suckling Stage
NPO/NG feedings only
Nutritive Sucking Stage I (critical stage)
Minimal oral intake <10%
Nutritive Sucking Stage II
Mod. Oral intake > 10% to <80% 9Oral/NG)
Nutritive Sucking Stage III
Full oral intake >80% oral/24hours
30
Feeding Readiness Scale
Use in overall evaluation to initiate oral feedings (1, 2 good)
Used with each individualized assessment
Used with cue based feeding practices
Assess & document feedings
Evaluate infant behavior: maturity, stability, interest in feeding
Implementation per “Oral Feeding Pathway”
Consistent scores of 4 or 5 referral to SLP
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Quality of Nippling Scale
Focuses on safe feedings
Encourages observation of infant’s feeding behavior
Documentation of behavior
Assist caregiver in necessary techniques needed for
oral feeding
Evaluates fatigue, coordination, swallow, etc.
Consistent scores of 4 or 5 referral to SLP
32
Initial/Early Stress Signs
Occur prior to feeding or early in
feeding
Are subtle and may be easily
missed
Tongue thrust
Tongue elevated to alveolar
ridge
Lip pursing
May occur due to difficulties with
reflexes, state regulation, sensory
information, respiration and/or
coordination/abnormalities of oral
structures
Finger splaying
Infant is telling us “this does not
feel good”
Eye blinking
Furrowed brow
Raised eye brows
33
Moderate Feeding Stress Signs
Occur when infant is pushed
through a negative feeding
experience
The body begins to react to the
negative event
May occur due to difficulty with
bolus flow rate, respiration, oral
motor skills and/or coordination
of suck:swallow:breathe
Infant is telling us that the airway
is compromised
Squirming
Head turning
Averting eye gaze
Falling asleep
Increased hypertonicity/
hypotonicity
Jaw/limb trembling
Gasping
Straining/bearing down/bowel
movement
Sweating
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Major Feeding Stress Signs
Occur when infant is no longer
able to maintain adequate
airway protection
May occur in attempt to
prevent aspiration or following
an aspiration or penetration
event
Coughing
Choking
Congestion during and/or after
feeding
Wet breathing
Wet/gurgly vocal quality
35
Things to Consider
Fat from breastmilk and formula provide energy for
continued brain growth and cognitive development
Between 3 to 6 months of age children may begin to
refuse to eat or demonstrate more difficulties
Around 6 months of age the nervous system matures
and the sucking reflex fades. Feeding then becomes a
volitional act
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37
Bottles/Nipples
Wide base/narrow base
Tip to phlange
Material
Levels/flow
standard, slit,
y-cut, cross cut
Venting system
38
Flow rate
Not all slow flow nipples are created equal
Each manufacturer has their own rating and can
not be compared with other brands.
A slow flow in one brand may be equivalent to a
medium in another brand.
Turn bottle upside down and watch the size and
rate of drip.
Utilize cervical auscultation during feedings
39
Flow rate of common
nipple
Nipple Brand
cc per 60 sec
Dr. Brown preemie
7.3
Dr. Brown level 1
7.7
Enfamil green
8.8
TommeeTippee
12
Enfamil blue
12.3
Ross yellow
13.5
Ross red
15.3
Avent #1
16
Medela Breast
16.3
Kelli Tracy Jackman, MPT
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Why we like Dr. Brown
Pros
Laser cut
Shape and material
promotes appropriate latch
Variety of levels
Ultra-Preemie
Preemie
Level 1-4
Y cut
Able to use with multiple
populations
Able to use with multiple
thickening methods
Other hospitals using Dr. Brown
bottles?
Cons
Multiple parts
Cost/price?
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Consistency
Ultra-thin
Thin
1/2 nectar
Thin-nectar
Nectar
Thin-honey
Honey
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Thickening?
Any patient on thickened liquids for swallowing difficulties needs to be followed by
their physician and a certified feeding therapist
Consider when infant on increased calorie formula with added scoops and the
impact of thickening on digestive process including kidneys
Consider type of bottle/nipple for thickened liquids that continue to promote age
appropriate oral motor skills
standard versus cross cut
Why complete VFSS/MBS
Is thicker always better?
Type of thickeners
applesauce, yogurt, pudding, rice, oatmeal, Thik and Clear, Simply Thick
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Types of Thickeners
Starch based
Rice cereal--no age restriction
Thick-it--37 week gestation or older with need to be
followed by a physician
Thicken up/Thicken up clear--3 years or older
Gum based
Thik n Clear--currently no age restriction
Simply Thick--12 months or older and 12 years with a
history NEC
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Thickened Liquids
Rice/oatmeal
Pros
Cost
Ease of purchase
Cons
Does not thicken breastmilk because of the amylase
Does not maintain consistency throughout feeding
Constipation (which can cause or worsen reflux)
Obesity versus growth
Thickens differently dependent on brand and method
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Thickened Liquids
Thik and Clear
Pros
Prepackaged for easy measuring
Used by many children’s hospitals around the country
Mixes with variety of liquids including breastmilk
Cons
No research
Can clump during mixing
May cause increased gas in GI system
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Thickened Liquids
Simply Thick
Pro
Maintains consistency
Mixes easily
Has more research within pediatric realm
Cons
FDA warning for use in premature infants and more recently
in infants
May cause increased gas in GI tract
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Gastrointestinal Development
Development
Develops based on input
GI system provides sensory feedback
Food acceptance, feeding schedules, amounts
consumed are adjusted in response to this feedback
48
Gastrointestinal
~continued
Normal Reflux–Infants and Children
50% of 0-3 month olds regurgitate 2 or more times
per day
70% of 4-6 month olds
25% of 7-9 month olds
Less than 10% of 10-12 month olds
Archives of Pediatric and Adolescent Medicine, 1997
49
Successful Feeding
Volume vs. Experience
When an infant is learning to oral feed, the experience is
more important than the volume of P.O. intake
Perfect practice makes perfect
Feeding is a developmental skill.
Slow and Steady WINS the race.
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Evidence Based Feeding
Goals for Discharge
Preterm Infants demonstrate competent oral feeding skills prior to hospital discharge
Infant driven model (cue based)
Feedings are safe,functional, nurturing, individualized and developmentally
appropriate
PO all prescribed volume in 15 to 20 min
Maintain steady weight gain
Precise coordination of S:S:B maintaining physiologic stability
Parents comfortable and ready
Appropriate follow-up with SLP if warranted
Improved communication between providers
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When to refer for outpatient
feeding evaluation
Difficulty with or late initiation of oral feeding
Inability for child to breastfeed
Poor transition to bottle feedings from breast feeding
Difficulty transitioning to spoon feedings
Any use of thickened liquids
Food preferences or avoidance
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Things to consider during
treatment after NICU
Birth Trauma-nerve damage, neurological damage
Heart defects-can affect respiration and stamina
Premature lungs- asthma, respiratory infections, respiratory
disease
Prenatal exposure-withdrawal
Weight and growth-growth chart percentiles, FTT
Sleep habits-snoring, frequent waking
Voiding-frequency
Reflux-amount, frequency
Respiratory system-has a significant impact on feeding for all ages
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Question Time????
?
54
References
Breton. S, & Steinwedner, S. (2008). Timing Introduction and Transition to Oral Feeding in
Preterm Infants: Current Trends & Practice. Newborn & Infant Nursing Reviews, vol. 8 (3); pp.
153-158.
California Perinatal Quality Care Collaborative (2008)> Quality Improvement Toolkit.
Chang, Y., Chun-Ping, L., Lin, Y. et al. (2007). Effects of Single-Hole and Cross-Cut Nipple Unit
on Feeding Efficiency and Physiological Parameters in Premature Infants. Journal of Nursing
Research. vol. 15 (3); pp. 215-222.
Kenner, C., & McGrath, J. (2010). Oral Feeding and the High Risk Infant. Developmental Care
of Newborns and Infants. A Guide for Health Professionals. 2nd ed.
http://nurse211w08researchfinal.blogspot.com/2008/02/roughly-12.html
http://specialneedspublications.blogspot.com/2009/07/supportingfeeding-oral.developmentin.html
Ettema, Sandra, MD, PhD, CCC/SLP, Cheri Franker, MS, CCC/SLP, CLC, Laura Walbert, MS,
CCC/SLP, CLC. “Pre-Chaining Programs for Infants & Children with Swallowing Disorders:
Much to DO about Pediatric Dysphagia.” Indianapolis, IN. November 4&5, 2011. Conference.
55
References
Dodrill, P., McMahon, S., Ward, E., Weir, K., Donovan, T., and Riddle, B. (2004). Long-term oral
sensitivity and feeding sills of low risk pre-term infants. Early Human Development, vol. 76; pp. 23-37.
Down Syndrome Ireland. Supporting Feeding & Oral Development in Young Children: Guidelines
for Parents, Support Feeding & Oral Development in young children with Down Syndrome,
Congenital Heart Disease and Feeding difficulties. 2009. PDF <http://
specialneedspublications.blogspot.com/2009/07/supporting-feeding-oral-development-in.html>
Drenckpohl, D., MS, RD, CNSC, LDN. (2010). On Thin Rice: A therapeutic option with
nutritionconsequences. Therapy Times.com .HTTP//www.threapytimes.com/0503NutF1
Fishbein, Mark, MD, Cheri Franker, MS, CCC/SLP, CLC, Laura Walbert, MS, CCC/SLP,
CLC. “Food Chaining II: It Takes A Team-Dealing with Digestive Tract Disorders.” St.
Louis, MO. December 2&3, 2011. Conference.
Fucile, S., Gisel, E., & Lau, C. (2002). Oral stimulation accelerates the transition from
tube to oral feeding in preterm infants. The Journal of Pediatrics, vol. 141 (2); pp. 230-236.
Garcia, J., Chambers. E., Matta, Z., Clark, M. (2008). Serving Temperature Viscosity
Measurements ofNectar- and Honey-Thick Liquids. Dysphagia 23; pp.p65-75.
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References
healthychildren.org. American Academy of Pediatrics, 2/27/2012. Web. 4/25/2012. <http://
www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-ToSolid-Foods.aspx>
Jackman, K.T., (2013). “Go with the Flow: Choosing a Feeding System for Infants in the
Neonatal Intensive Care Unit and Beyond Based on Flow Performance” http://
www.drbrownsbaby.com/medical/articles/go-flow
Ludwig, S. & Waitzman, K. (2007). Changing Feeding Documentation to Reflect InfantDriven Feeding Practice. Newborn & Infant Nursing Review, vol. 7 (3); pp. 150-160.
McCain, G. (2003). An Evidence-Based Guideline for Introducing Oral Feeding to
Healthy Preterm Infants. Neonatal Network, vol. 22 (5); pp. 45-50.
McKaig, T. Neil. “Cervical Auscultation.” Indianapolis, IN. March 31, 2011. Indiana
Speech-Language Hearing Association Conference.
Quenqua, D. The New York Times, 3/25/2013. Web. 3/26/2013. Infants are Fed Solid Food
Too Soon, C.D.C Finds. http://www.nytimes.com/2013/03/25/health/many-babies-fedsolid-food-too-soon-cdc-finds.html?_r=0
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References
Shaker, Catherine, M.S. CCC-SLP. “Pediatric Swallowing and Feeding.” Lexington, KY. July 11-13,
2003. Conference.
Shaker, Catherine. “Advanced Pediatric Dysphagia.” Indianapolis, IN. July 17, 2005. Conference.
Scottland, J. (2004). The Regional Neonatal Oral Feeding Protocol. http://
www.calgaryhealthregion.ca/
Shaker, C., & Woida, A. (2007). An Evidence-Based Approach to Nipple Feeding in a Level III
NICU: Nurse Autonomy. Developmental Care and Teamwork. Neonatal Network, vol. 26 (2); pp
77-83.
VanDahm, K., Kern, S., Rosoff, J. (2009). The Use of Thickening Agents in the NICU. ICAN:
Infant, Child, &Adolescent Nutrition, vol. 1 (2); pp 83-87
Wolf, Lynn, MOT, OTR, IBCLC and Robin Glass, MS, OTR, IBCLC. “Feeding and Swallowing
Disorders in Infancy: Assessment and Management. “ Indianapolis, IN. November 12-13, 2010.
Conference.
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