(d) Maturation of mechanical and neural control of sucking, swallowing, and breathing
(e) Relationship among nutritive and non-nutritive sucking, respiration, and oxygenation
(f ) Positioning and handling
(g) Feeding readiness cues
(h) Physiologic issues, such as metabolic and neurologic
(i) Competency of the infant as a partner
(j) Relationship with primary caregivers
(k) Tolerance of oral-facial and intraoral sensations
Directly from: Vergara, E., Anazalone, M., Bigsby, R., Gorga, D., Holloway, E., Hunter, J., Laadt, G., & Strzyewski, S. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. American Journal of Occupational Therapy, 60(6), 659-668.
NICU (Neonatal intensive care unit) has 3 levels of care:
I – Basic – postnatal care to healthy newborns; able to sustain and stabilize ill newborns until they can be transferred to a higher level of care.
II - Specialty – care to infants with moderate medical issues expected to resolve quickly or those recovering from serious illness
III – Subspecialty – care to infants with critical illness, extreme prematurity, or those requiring surgery
From: American Academy of Pediatrics, & American College of Obstetricians and Gynecologists. (2004). Guidelines for perinatal care (5th ed.). Elk Grove Village, IL
Precautions for SLPs working with neonates in NICU:
If baby has bronchopulmonary dysplasia (BPD) (scarring and chronic lung disease due to ventilation for various breathing difficulties) the therapist must:
Avoid stressing the baby because s/he needs to use the calories for breathing
Be especially careful to prevent aspiration
Ascertain that baby is getting enough oxygen during treatment. Oral feeding may mandate higher levels of oxygen during feeding. Oral stimulation may cause increase in saliva which increases aspiration risk.
2. Some babies need restricted fluid intake to decrease chance of congestive heart failure (why?)
3. A baby with necrotizing enterocolitis (NEC) usually is npo and receiving intravenous fluids. Oral feedings can result in severe diarrhea and tiny amounts in the mouth, even flavoring used with oral stimulation. Other means to decrease chance of oral sensitivity should be used.
Sensory:
Oral hypersensitivity can develop in babies not fed orally or those with treatment around mouth (either surgery, or tubes entering mouth or nose, or tape on tubes around oral area).
Treatment:
May involve parent education and support as much as direct work with neonate
Should often be coordinated with other professionals in what is known as "cluster care," in which therapies/treatments are given close together to allow a longer period for the baby to rest in between
Breast feeding may not be recommended for infants weighing less than 1,250g, due to special dietary needs. (Arvedson, Brodsky, 2002) Very small infants need higher amounts of protein and calcium than usually found in breast milk. It is recommended that the mother continues to pump her milk because of the immunological and allergy benefits. The pumped breast milk can be stored until the infant has matured enough to benefit from the breast mild or a calcium and phosphorus supplement may be added.
Formula Feeding
The formulas for premature infants specially formulated to provide 24 calories per ounce, compared with the 20 calories per ounce in standard formulas and human milk. By providing higher calorie content the formula allows the premature infant to receive the needed calories while ingesting less fluid ounces. The formulas designed for premature infants provide a protein mixture of 60% whey and 40% casein, this is similar to human milk. Traditional formula is 80% casein and 20% whey. (Arvedson, Brodsky, 2002) This special formula is helpful forming smaller, softer curds in the infant’s stomach making it easier to digest.
A study published in the Archives of Disease in Childhood shows that premature infants fed human milk or special designed preterm formula display superior developmental scores at 18 months of age, when compared to those who are fed regular infant formula. (Lucus, Morley, Cole, & Gore, 1994) Formulas that are specifically designed for premature infants have been proven to promote growth and bone mineralization similar to intrauterine rates. (August, 2002)
August, D., Teitelbaum, D., Albina, J., Bothe, A., Guenter, P., Heitkemper, M., Ireton-Jones, C., Mirtallo, J.M., Seidner, D., & Winkler, M. (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition, 26(1), 97SA-109SA.
Breast feeding transition
Non-nutritive Suck
At first the infant is fed their mothers pumped milk by a feeding tube. By using non-nutritive oral-motor stimulation (NNS) the infant can practice the skills they will need for future oral feedings. It can help the infant strengthen their oral muscles therby providing a better lip seal when they are ready to nipple feed. The NNS can be done by having the child such on a pacifier, finger, or the mother’s empty breast after she has pumped her milk. This method does not necessarily trigger a swallowing response, so it should not be the only factor used in determining an infant’s readiness for oral feedings. A study by Pinelli and Symington showed that non-nutritive sucking reduced the length of a preterm infants hospital stay without posing any adverse affects if used correctly. (1998)
Stimulating Infant Sucking
Around 32 weeks gestation infants with stable respiration can tolerate brief period of stroking to help stimulate a sucking reflex. First the child is stroked on the cheeks and chin, gradually moving closer to the lips and mouth. Finally the caregiver strokes the tongue in a forward motion. The tongue is stoked at a rate of 1 stroke per second for 6-8 times. The finger is then left in the mouth to see if the child starts to suck. If not then the pattern is repeated for 5-10 minutes, unless the child shows signs of stress or fatigue, and the session is immediately stopped.
Breast feeding
An infant is ready to transition to breast feeding when they show signs of oral feeding readiness. During the feeding the infant needs to be placed in a flexed position and have jaw and cheek stability maintained. For infants that are ready for oral feedings, but need additional nourishment a supplemental nursing system can be used. A supplemental nursing system provides a regulated amount of additional breast milk or formula to the infant through a tube placed next to the nipple. The system can be phased out as the infant is able to receive more milk from the breast.
Arvedson, J.C. & Brodsky, L. (2002). Pediatric swallowing and feeding (2nd ed.). Canada: Thomas Delmar Learning.
Pinelli, J. & Symington, A. (1998). Non-nutrive sucking in premature infants. Cochrane Review.
Oral Feeding Readiness
•Position/posture- flexor
•Neck, trunk & shoulder stability
•Anatomically set for sucking
•Strong suck strength
•Can maintain lip seal
•Cheek stability
•Jaw stability for repetitive suck
•Hunger and thirst signals
•Neurologic status- organized
•Rythmic suck/swallow/breathe pattern
•Oral-motor reflexes
Arvedson, J.C. & Brodsky, L. (2002). Pediatric swallowing and feeding (2nd ed.). Canada: Thomas Delmar Learning. 305.
Bedside assessment conducted at rest
•State, posture, and position
•Sensitivity to stimuli
•Respiratory status
•Heart rate
•Oral-peripheral mechanism
Infants should be able to receive an appropriate amount of milk within 30 minutes, so that they do not expend more calories than they are taking in. In addition they should be able to take in enough calories to keep them content for a 3-5 hour periods and show adequate growth and development.
Infants usually need to be off ventilator support before oral feeding can begin. To begin oral feedings it is recommended that the infant have a resting respiratory rate less than 70 breaths per minute. Once oral feeding has commenced the infant’s respiratory rate should not exceed 80-85 breaths per minute or oral feeding should be stopped. (Arvedson, Brodsky, 2002)
A premature infant may be ready for oral feedings as early as 32 weeks, depending upon the infant’s development and other complications they may have. Most premature infants are able to be completely feed orally by 37 weeks gestation.
NG OG tube feedings
Enteral feedings may begin once an infant’s digestive system is able to tolerate human milk or formula. These feeding may be provided through orogastric OG or nasogastric NG tubes until the infants is able to demonstrate their ability to receive nutrition orally. Small infants are primarily nose breathers, therefore OG tubes are preferred by many NICU professionals.
Parenteral Nutrition
Parenteral nutrition (PN) is nutrition that is provided intravenously for infants that do not have a digestive system that is able to process nutrition. PN may be provided in the following ways:
A study conducted at the Children’s hospital of Illinois compared the traditional feeding protocols for introducing bottle feedings to premature infants and a new more regulated method. The new feeding method requires that the infant successfully feed for 48 hours before the introduction of more bottle feedings, while the traditional method only required successful feeding for 24 hours. The study also showed that infants using this method could bottle feed at about 31 weeks gestational, without adverse side affects. This is an earlier age than previously thought possible.
Drenckpohl, D., Dudas, R., Justice, S., McConnell, C., & Macwan, K.S. (2009). Outcomes from an oral feeding protocol implemented in the NICU. ICAN: Infant, Child, & Adolescent Nutrition. 1, 6.
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
CASE STUDY - NICU patient "Darcy," Treacher Collins Syndrome
Darcy was born at 38 weeks gestational age. She weighed 2,731 grams (slightly over 6 pounds). As soon as she was stablized she was transferred to the NICU at Children's Hospital Oakland. She was diagnosed with Treacher Collins syndrome (mandiblofacial dysostosis). Darcy was given an NG tube for feeding and was seen initially by the SLP at one day of age.
All neonatal reflexes present, but suck reflex was weak
Saliva was normal consistency but greater than average quantity
In resting position, the tongue moved posteriorly and obstructed the pharynx, worse in supine position due to the pull of gravity—this also caused intermittent stridor
SPEECH THERAPY GOALS:
Oral feeding when doctor's orders allow, with appropriate nipple for alveolar cleft
Strengthened suck reflex
Minimized difficulties posed by tongue retraction and pooling of saliva
Decreased hypersensitivity of orofacial region (this frequently occurs in the NICU due to the imposition of tubes and tape around the mouth/nose/cheeks)
TREATMENT:
The SLP found that a soft cross-cut bottle nipple was most effective. At first small amounts of formula were presented with this nipple attached to a preemie bottle. This amount was increased steadily for two days; by Darcy's 4th day of life the NG tube was removed and she was fed orally.
In order to strengthen the suck reflex, first the SLP provided facilitory stimulation to the tongue for alerting, lingual curling, elongation, and tongue tip elevation. When the sensory receptors were primed, the SLP introduced a nipple to the tongue in a facilitory manner, pressing down and tapping, and would gently "tease" the tongue (i.e. intermittent tactile stimulation) as it began to move into sucking position and then suck.
The SLP and OT worked together to find the optimal positioning for Darcy. It turned out that sidelying with the head of the isolette raised up 25 degrees worked best. Her tongue did not block the larynx, which decreased her stridor, and her saliva would come out of the side of her mouth rather than remaining inside and creating a risk for aspiration. They recommended that the nursing staff turn Darcy from one side to the other at least one time per hour.
Inhibitory techniques were used to desensitize Darcy's cheeks/nose/lips/mouth. These included firm, continuous pressure and slow stroking in the direction of the muscle fibers. In the mouth, the SLP would move a steady, gloved finger around the top gums, the bottom gums, and finally the alveolar area. Pressure was applied on her tongue inferiorly and laterally.
CASE STUDY – NICU patient "D'Shawn," Harlequin Ichthyosis
D'Shawn was born at 35 weeks gestational age. He weighed 1,377 grams (3.6 pounds). As soon as he was stablized he was transferred to the NICU at Children's Hospital Oakland. He was diagnosed with Harlequin Ichthyosis (Ichthyosis Fetalis). The SLP evaluated D'Shawn the afternoon of his arrival. As the first step in the evaluation, she familiarized herself with Harlequin Ichthyosis, as she had never treated a patient with this diagnosis before.
HARLEQUIN ICHTHYOSIS
A condition of extreme hyperkeratinization of the skin (the body produces as many skin cells in a day as non-affected persons do in two weeks, resulting in shiny hyperkeratotic scales with deep fissures between the scales)
Tightness of the skin causes:
Flexion contractions of the extremities
Ectropion (everted eyelids) and sometimes exophthalmia (anterior bulging of eyes), with eyes susceptible to bleeding
Eclabium (everted lips) fixed in an open, stretched position
The ineffective skin barrier presents a number of serious problems, including:
Trouble regulating temperature (inability to sweat; tendency for hyperthermia)
Electrolyte abnormalities
Dehydration due to excessive loss of water (and tachycardia from the dehydration)
High risk of sepsis
Other common sequelae
Absent or underdeveloped pinnae
Underdeveloped nose
Polydactyly
Medication
Isotretinoin -- given orally; increases pliability of skin; among other benefits this may strengthen ability to suck
Acitretin – decreases hyperkeratosis, ectropion, and eclabium; side effect of increasing dryness of mucosa
Until recent years, harlequin ichthyosis was always fatal. Now medications and NICU care allow some of these children to survive beyond infancy and even, occasionally, into adolescence or adulthood.
ORAL MOTOR EXAMINATION
Due to priority of medical need to stabilize D'Shawn, only a limited oral motor exam was possible.
Inability to close or move lips
Oral dryness
Limited tongue movement in all directions
ADDITIONAL MEDICAL INFORMATION
Intervenous tube for medication/hydration/nutrition through umbilical cannulation
Must remain in humidified incubator at all times
D'Shawn's mother expressed strong desire to eventually breastfeed if possible
SPEECH THERAPY GOALS
Increased movement of lips and tongue as eclabium decreases, including ability to maintain lip closure
Increased suckle and suck abilities
Ability to tolerate sensory stimulation to orofacial area
Ability to breastfeed if possible
TREATMENT
As Acitretin began to improve eclabium, the SLP applied sterile wet compresses and petroleum jelly to lips and began gentle facilitation of lip movement. Within three days, D'Shawn was able to maintain lip closure; within five days he
(photo from Extraordinary Children, http://www.mymultiplesclerosis.co.uk/misc/harlequin.html )
