Treatment:
A. Immature State Control (Feeding Intervention Guidelines for Fatigue):
Alternate feeding schedules should be considered, including frequent small feedings, oral feedings of 20 minutes without any residual gavaged, and possibly alternated gavage and oral feedings. The nipple being utilized should be evaluated in order to ensure that it is soft enough to facilitate sucking but should not be soft enough to collapse. Milk should flow freely from the nipple hole but not in excess of the infant’s ability to control the volume consumed or swallow it. The shape of the nipple should enable easy contact with oral and intraoral structures. Adequate postural support should be provided so that the infant’s energy is aimed at feeding instead of position control. Efficiency and stability of oral motor function can be increased by providing buccal and/or mandibular control if needed. Ad lib feedings should be incorporated when possible to take advantage of wakeful or hungry states, and caloric density should be adjusted as tolerated to decrease volume of intake and length of time feeding (Semmler 2000).
Intervention for Prematurity:
Functioning of the oral sensorimotor system is the most primary goal once the infant is medically stable off of tube feeds as the baby has not been able to develop hunger sensations or appetite satiation due to the continuous tube feeds. They need to develop an awareness of food in the mouth and feeling hunger satiation. Stimulation of the nonnutritive suck, i.e., sucking on any object such as a finger, pacifier or toy, is one way in which this can be done as the nonnutritive suck is a skill that is important for “successful oral feeding,” (Arvedson, p. 423). In order to stimulate the nonnutritve suck, the infant’s face and tongue can be stroked, taste experiences can be provided, and sensory stimuli can be reduced (reduced light and noise). Sometimes, a simple pacifier may stimulate the nonnutritive suck. In order to provide taste experiences to evoke a swallow, the preemie can be given breast milk, water, or formula in a syringe or medicine dropper or on a Q-Tip. One drop of liquid should be introduced initially. It is important to encourage breast feeding due to its nutritional value as well as bonding for mother and baby and protection against allergies. Breast milk can initially be given to the infant via tube feedings, and the mother can pump her breasts to maintain a supply of milk. When the infant transitions to oral feedings, nipple feedings should be finished in 30 minutes and the quantity of milk should be sufficient enough that the baby takes a feeding every 3 to 5 hours (Arvedson).
B. Feeding for Immature Postural Control
C . Feeding Intervention Guidelines for Respiratory Issues:
Hypoxia:
The magnitude and duration of hypoxia should be monitored, and nasal cannula oxygen may be used to keep oxygen saturations at an appropriate level. Calories may be increased as tolerated in order to decrease the amount of needed by the infant and decrease the feeding time. The effects of position should be assessed in order to determine its effect on the infant’s airway patency. The SLP should obtain the baseline of the infant’s respiratory status in order to notice any signs of respiratory distress (Semmler).
Feeding Intervention for Excessive Mucus Production, Oral and Pharyngeal Pooling of Secretions:
For excessive mucus production, suction the infant 15 to 30 minutes before feeding. Additionally, try non-nutritive sucking before actually feeding the infant in order to facilitate swallowing and consequently clear secretions. Small volumes of fluid should be given initially with time allowed for swallowing. Determine the significance of any choking incidents (Semmler).
Feeding Intervention for Pulmonary Edema:
The physician’s instructions concerning fluid restrictions should be followed if given. A high-calorie diet may be indicated due to fluid restriction, and this may not be well tolerated by the infant. If the infant has severe diarrhea or vomiting, this may lead to dehydration requiring more fluid consequently causing pulmonary edema once again. It is important to note that a diet high in carbohydrates may lead to retention of excess carbon dioxide when pulmonary difficulties are present (Semmler). The parents should be provided instruction regarding the management plan and training on ways to interact with and calm the infant by other means than feeding (Semmler).
D. Feeding Intervention to Coordinate Suck/Swallow:
The suck and swallow ability develops prenatally, and the ability to swallow is believed to appear around 12 to 17 weeks of gestation. As the ability to suck is not established firmly until 30 to 34 weeks of gestation, premature infants may have difficulty sucking. Weakness of the lungs and facial muscles may lend to this difficulty as well (Gilliam, Marquardt, & Martin 2000). Treatment for difficulties with suckling or sucking include gently arousing the infant with adequate sensory stimulation. Postural support for feeding should additionally be provided. Then provide stimulation by stroking the lips and applying deep pressure to the perioral area. This should elicit the rooting response. Encourage non-nutritive suck between feedings and during tube feeds. An appropriate nipple should be selected; soft nipples may compress if too soft; however, they do encourage sucking. The nipple hole should be checked to ensure that it is on top of the infant’s tongue and not underneath it. The nipple may be used to stroke the tongue down and forward to the tempo of a stroke per second that encourages a rhythmical suck. In order to provide sensory reminders of a nipple’s presence to a lethargic infant or to reinflate a collapsed nipple, it may be rotated back and forth on the infant’s tongue. To encourage latching on, the bottle can be pulled gently forward in a slight tugging motion. The liquid being given to the infant may be warmed to facilitate sensory awareness and improve sucking. For an infant with a normal swallowing mechanism but difficulty obtaining milk due to a poorly coordinated or weak suck, a cleft palate nipple or one with a faster flow rate may be used. Environmental distractions should be evaluated and reduced as necessary. Sick or preterm infants should nurse for 20 minutes maximum since longer feedings have not demonstrated any benefit and may even be counterproductive. Stability should be provided to the buccal and mandibular musculature to improve coordination of the oral motor mechanism (Semmler).
E. Feeding Intervention Guidelines for Cleft Lip and Palate: Need more references.
The infant should be fed in a vertical position in order to use gravity to keep the bolus for going into the naospharynx. When feeding at the breast, the infant should be positioned in such a manner that a seal may be established. A soft or crosscut nipple or one with an enlarged hole may be utilized if indicated. “The nipple should be directed toward the side of the oral cavity with the most intact palatal tissue to allow for maximum compression.” (Semmler ____) The baby should be burped often. Water should be used to end feeding as it will facilitate cleaning of the cleft (Semmler).
F. Feeding Intervention for gastrointestinal reflux and associated aspiration:
A Medical evaluation and management of reflux is important. Emesis secondary to allergies, poor feeding technique, or behavior should be ruled out (Semmler). If an allergy is suspected in infants taking formula, a formula change can be implemented. A trial of thickened formula can be implemented as this may possibly reduce the volume and frequency of emesis (Roche). Smaller feedings should be given more frequently. After feeding the infant should be positioned prone, either held upright by caregiver’s shoulder, or with the head of bed elevated 30 to 45 degrees. An infant walker may also be a used for an older infant who does not nap after feeding and would not tolerate the positioning listed above. A pacifier may help facilitate gastric emptying and therefore reduce reflux (Semmler). In spite of measures aimed at reducing reflux, some infant’s may still require medication for this.
References
Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding. Assessment and management.
Albany, NY: Singular Publishing Group.
Gilliam, R. B., Marquardt, T. P., & Martin, F. N. (2000). Communication sciences and disorders: From
Science to clinical practice. San Diego, CA: Singular Publishing Group.
Roche, W. J., Martorana, P., Vitello, L., Eicher, P., & LaCour, T. (2008). Feeding and reflux: A parent and
professional perspective (Feeding and swallowing: Part three) (Disease/Disorder overview). The
Exceptional Parent. [Electronic version]. (NEED VOLUME #).
Semmler, C. J., & J. G. Hunter (1990). Early occupational therapy intervention: Neonates to three years.
_)________
