• one in five very preterm infants is subject tofeeding problems at age two years• Infants characterized by hypotonia in the NICU and infants whose

parents were from lowerSES backgrounds were at higher risk of feeding problems at age two years.

Crapnell, et al 2014• TL Crapnell, OTD1, CE Rogers, MD2,3, JJ Neil, MD, PhD3,4,5, TE

Inder, MBChB, MD3,4,5, LJ• Woodward, PhD3,6, and RG Pineda, PhD1,3Acta Paediatr. 2013

December ; 102(12): e539–e545. doi:10.1111/apa.12393.

Infant Feeding Difficulties:A Look at High-Risk Populations

Amber Valentine Forston, M.S., CCC-SLP, BCS-S, IBCLC, CNTSpeech-Language Pathologist

Board Certified Specialist in Swallowing and Swallowing DisordersInternational Board Certified Lactation Consultant

Certified Neonatal Therapist

October 26, 2019 Albuquerque, NMNew Mexico Speech and Hearing Convention

Amber Valentine Forston, M.S., CCC-SLP, BCS-S, IBCLC, CNT

Baptist Health Lexington2019

• AmberEmployed by Baptist Health Lexington. No further relevant financial or non-financial relationships to disclose.

Participants will be able to…• identify at least three populations at risk for feeding difficulty.• list at least two commonly seen characteristics in each of these

populations that may adversely impact feeding.• list at least two strategies for each of the populations to

enhance feeding success either at bottle or breast.

Age descriptions • Gestational age (GA)

• Length of pregnancy measured in weeks since mother’s last menstrual cycle (e.g. baby born at 36 3/7 wks GA)

• Post-menstrual Age (PMA)• GA + # wks alive= PMA

• Adjusted Age (AA)• Used from D/C until 2 yrs of

age

Birth Weight• Age appropriate to GA (AGA)• Small for gestational age (SGA)• Large for gestational age (LGA)• Intrauterine growth restriction

(IUGR)

Gestational Age

• Extremely Preterm <28 wks• Very Preterm 28<32wks• Moderate to Late Term

32<37wks• Term 37>42wks• Post-term 42wks +

Descriptors for Infants

• Chronically Ill Preterm Infant• Preterm infant• Late Preterm Infant• Sick Term Infant• Healthy Term Infant

• Oral-Motor: integrated, reflexes, suck • State: calm alert during feeding• Environmental: relief, pleasure, hunger, self-regulates• Feeding: timely, predisposed to feed, in utero preparation

• Motor: hypo- or hypertonic, sensory motor• State: disorganized• Oral-Motor: etiology of problems, reflexes, impact on swallow• Airway: support, maintenance, regulation• Respiratory: etiology, effort, endurance/stamina, impact• Feeding: methods and impact varies

• Motor: immature sensory-motor control• State: decreased arousal and endurance• Respiration: increased WOB• Airway: fragile due to the above• Environmental: often in Newborn Nursery• Feeding: coordination, stamina, safety, timing/schedule

• Neurological Issues• Cardio-Respiratory Issues• Nutritional and Gastrointestinal Issues

• NEC, IDMS, GER

• Congenital Anomalies/Syndromes• Prenatal Drug Exposure (NAS)

How do they go hand in hand?

• Feeding is a • time to continue to develop positive motor and sensory neuro-pathways• the most complex task an infant is asked to do• critical element of patient care • a time for family and infant to build a relationship

• Positive feeding experiences during infancy lead to positive relationships with food and meal times for child and families throughout life

Shaker, 2013

• Professionals should foster the parent-infant relationship during feeding by

• Supporting and guiding the parents and infant to have a positive feeding experience

• Facilitating parent-baby attachment/ “dance of attachment”• Empower the parents to

• Understand the infant’s behaviors• Trust in establishing the parent-infant bond

A lack in continuity of the feeding approach and communication can adversely affect the baby’s overall feeding experiences

leading to decreased PO intake and longer hospital stay

Shaker, 2013

• Experience vs. Volume• When an infant is learning to oral feed, the experience is more

important than the volume of PO accepted• Perfect, consistent infant practice leads to faster learning• Feeding is a developmental skill• The goal is to have infants become successful feeders NOT just

successfully feeding (for one meal for example)

Slow and steady WINS the race

Ewing & Seitz, 2014

Major stress cues

• Coughing/Choking• Change in color• Bradycardia• Breath holding or apnea• Stridor• Decreased O2 saturations• Multiple swallows• Moderate drooling

Minor stress cues• Irritable/frantic• Disorganized/ difficulty

latching• Respiratory fatigue• Tachypnea or increased

WOB• Nasal flaring/blanching• Gulping• Minimal drooling• Anterior loss

Shaker, 2014

Clocks have batteries

=

Babies have brains =

• “The American Speech-Language-Hearing Association (ASHA) has long accepted the prevention of communication disorders as one of the profession's primary responsibilities.” • GI, Respiratory, Otitis media (Ip et al., 2007), IQ* (Belfort et al., 2013)

• “Developmentally supportive” care • “…support the infant's physiological stability, self-regulation, behavioral

organization, and developmental progressions…” • Babies are more stable at the breast (Bier et al., 1993; Chen et al.,

2000; Goldfield et al., 2006)

• ASHA Practice Recommendations • Clinicians providing pediatric dysphagia services should have knowledge

and skills to assess and treat breastfeeding as well as bottle feeding.

Blake, McComish, Crais, & Thoyre, 2014

Lactation Consultant

• Assessment and evaluation• Adequate milk supply• Infant latch

• Knowledge on frenulum and tongue tie

• Intervention• Provide instructions and

education to increase milk supply

• Positioning for nursing

Speech-Language Pathology• Assessment and evaluation

• Pre-feeding readiness• Oral swallow function

• Oral mechanism exam• Latch• Transfer of milk

• Pharyngeal swallow function• Stress cues• Instrumental swallow assessment

• Intervention• Promote infant feeding readiness• Positioning for nursing• Tools (nipple shield• Provide education to parents and

support staff

• SLP is often referred as the “feeding and swallowing expert/specialist” in facilities

• Should be providing feeding services for breast and bottle fed babies with feeding difficulties

• Swallowing:• Studies show better swallowing and breathing coordination with

breast milk (2002 Biology of the Neonate)• Less ventilation interruption during breastfeeding (1998 Nursing

Research)• Allows infant more control of flow correlating with

suck/swallow/breathe sequencing (SSB)

• Why not just let lactation handle breastfeeding?• Breastfeeding support should be every care providers concern

• Should be a team effort to provide the best possible care and opportunities for successful feeding for these infants and their families

• Often times, lactation is not consulted until well after problems arise with breastfeeding

• Some facilities do not have lactation counselors or they are understaffed• Look for a CLC course on your own: Become a lactation counselor to

help support your NICU families

• “Feeding and swallowing evaluation and intervention, to include prefeeding, assessment and promotion of readiness for oral feeding, evaluation of breast and bottle-feeding ability, and completion of instrumental swallowing evaluations”

• prepared by the Ad Hoc Committee on Speech-Language Pathology Practice in the

• Neonatal Intensive Care Unit (NICU)

• Sometimes difficult to transition infant to breast in NICU because mother is not present for all feedings

• May need to consider supplemental feeding/adaptations when mother not present:• Use of cup instead of bottle nipple• NG tube supplements• ? Consideration of orthodontic nipple• ? Use of nipple shield

Synthesis Stage Triggered BY MilkSecretoryDifferentiation or Lactogenesis I

Placental hormones Colostrum

Secretory Activation or Lactogenesis II

Complete delivery of placenta, leading to rapid drop in progesterone

Transitional Milk

Lactation, or Lactogenesis III, or Galactopoesis

*prolactin from frequent nipple stimulation and frequent removal of milk

Mature milk

Onset of copious milk production Progesterone withdrawal from removal of placenta, causes

physiological trigger Adequate plasma levels of prolactin necessary Adequate levels of cortisol and glucocorticoids required Insulin (metabolic balance allowing flux of nutrition to mammary

glands) Early removal of colostrum from the breast: Sodium and chloride levels fall Lactose concentrations increase Secretory immunoglobulin A and lactoferrin increase dramaticallyOligoschharide concentrations high

• Poorly controlled diabetes• Correlates with high serum glucose levels

• Stress• Correlates with high cortisol levels• Can temporarily affect oxytocin levels

• Inadequate milk removal• High milk sodium levels reported prior to lactation failure in mothers whose infants were not latching well and removing milk adequately

• Why is Breast Best?• Milk composition is complex• Each species of mammal milk is different (species specific)

• The composition of a mammal species’ milk and their feeding frequencies are related

• Human milk is one of the highest in lactose of all mammalian milks, high in water, low in protein and fat. It is a very dilute mammal milk

1. Unrealistic expectations2. Lack of timely interventions

• The fastest drop-off is in the first ten days after discharge (note this is not after birth but after d/c from the hospital)

3. Misunderstanding about why mothers stop breastfeeding

• Providing breast milk for 6-12 months is very difficult for mothers who exclusively PUMP

• Providing breast milk even to discharge in the NICU is extremely difficult if there is no direct contact/breast feeding

• When a mother in NICU is able to establish successful ACTUAL breastfeeding during the infant’s stay, long-term breastfeeding success is much more likely

Pineda, R. (2011)

• Not pumping often enough• Not emptying breasts completely• Use of poor quality pump• Significant postpartum bleeding• High blood pressure• Treatment with magnesium sulfate at birth• Retained placental fragments• Lack of breast development during pregnancy and delivery • History of breast reduction surgery• Hypothyroidism

• Breastfeeding Assessments:• Systematic Assessment of the Infant at Breast (SAIB)• Preterm Infant Breastfeeding Behavior Scale (PIBBS)• Breastfeeding Evaluation

• Important to encourage kangaroo care or skin-to skin• Helping mothers establish supply • A healthy infant would need to nurse a minimum of 8-12 times in a

24 our period • Expect NICU infants to have the same criteria of “feeding” in some

way every three hours minimum (whether actually nursing or being provided gavaged expressed milk from mother)

• Mother needs to start pumping as soon after birth as possible, especially if not able to have contact with infant

• Mother needs to pump at least 15-20 minutes each time

Ganaway, 2019

• Breast milk expression via pump:• Pulsing oxytocin release• Increased prolactin release• Improved milk production

• Maternal psychological well being:• Decreased stress • Improved milk ejection reflex response• Empowerment as a parent• Improved milk production

• Infant benefits from contact:• Comforts and consoles• Stabilizes temperature, heart rate, respiratory rate• Improved oxygen saturation• Improved mother-infant bonding• Leads to 65-82% decrease in pain symptoms (Pediatrics, 2000)• Increased incidence of quiet sleep (Pediatrics 2006)• Allows mother to be exposed to infant’s flora

• Enables mothers to continue to build immunity in the breast milk

Skin to Skin

Early signs of hunger Eye twitching behind lids Tight fists Cycle between REM and deep sleep (~every 27 minutes) REM is opposite for babies than adults (REM is light sleep for babies)

• Assess breastfeeding readiness similarly to bottle feeding, however keeping in mind that infants may be able to attempt breastfeeding slightly earlier than bottle feeding due to state regulation with skin to skin contact

• Look for:• Stability with handling• Showing oral interest• All infant led***Progression from skin to skin position actual exposure to the breast

to eventual latching and non-nutritive sucking

• Why is proper latch establishment so important?:• Breastfeeding will be unsuccessful and most likely extremely painful

without the appropriate latch• Without proper latch, the signals the body is designed for will not be

properly activated and an adequate milk supply will not be supported• If a proper latch is not established, there will not be an adequate transfer

of milk from breast• Causes infant slow or little weight gain• Causes mother’s supply to either not be established or to diminish

• Proper latch:• Lips flanged out• Angle opening of lips should be 146* or more• No clicking or smacking sounds when attempting to suck• No dimples in cheeks• Initial rapid sucks (to establish let down), then open-pause sucking once let

down has occurred• Jaw should produce a rocking motion during proper latch, rather than a

pistoning motion if latch is not correct• Chin and nose should be rested close to breast• Baby should be lined up: ears, shoulders, and hips

• When possible (remember to watch for cords, IV, monitors, etc. in NICU infants)

• Infants knees and feet close to body

• Infant tummy to mother tummy if possible

• Start with nose at nipple level• Tilt head back angling chin

towards breast

• Wait for infant to show signs of rooting• Only attempt with wide open mouth, avoid half open mouth

sliding onto nipple• Firm gentle push from behind shoulders to guide them forward

once in proper placement

• Make sure the baby's mouth is opened wide and his or her tongue is down when latching on.

• Make sure to support the breast with hand, positioning thumb on top and fingers at the bottom, keeping thumb and fingers back far enough so that the baby has enough of the nipple and areola (the circle of skin around the nipple) to latch onto.

• Gently glide the nipple from the middle of the baby's bottom lip down to his or her chin to help prompt the baby to open his or her mouth.

• When the baby opens his or her mouth wide and the tongue comes down, quickly bring the baby to the breast (not the breast to the baby). The baby should take as much of the areola into his or her mouth as possible, with more areola showing at the top lip than at the bottom.

• Make sure the baby's nose is almost touching the breast (not pressed against it), his or her lips are turned out (or flanged), and you see and hear the baby swallowing. (You should be able to tell by seeing movement along the baby's lower jaw and even in the baby's ear and temple.)

• 1.

2.

3.

• Signs that latch is incorrect:• Painful nipples

• Shallow latch• On and off latch-why is infant not able to maintain latch?• Tongue clicking-while trying to latch? While trying to suck?• Cheeks: is there dimpling? Is the cheek nice and round?• Absence of ability to maintain suck/swallow-where is the coordination

break down?• Clenching or biting

• On and off latchor loose latch

Shallow Latch

Kotlow, 2017

• Cradle position• Cross cradle position• Clutch/football hold

***There are more positions that can be used for difficult circumstances*****

• Also known as the Madonna position• The mother sits in any posture that is comfortable• The baby lies on his or her side, facing the mother• The side of the baby’s head and body rest on the mother’s

forearm of the arm next to the breast being used • Nose at nipple level• Knees and feet close to body• Head tilted with chin angled toward body• Can be adjusted to semi-upright

• Consider especially useful for the mother of a newborn or pre-term infant

• The mother sits in any posture that is comfortable• The infants lies on his or her side facing the mother• The side of the infant’s body rests on the mother’s forearm of the

arm of the opposite side of the breast being used• Palm on upper back or• The hand supports the baby’s neck and shoulders in such a way the

baby can tilt his or her head

• The mother sits in any posture that is comfortable • The infant lies on his or her back, curled between the side of the

mother’s chest and her arm• The infant’s upper body is supported by the mother’s forearm• The mother’s hand supports the infant’s neck and shoulders• The infant’s hips are flexed up along the chair back or other

surface that the mother is leaning against

• The mother lies on her side• The infant is placed on his or her side, lying chest to chest with

mother• The mother’s arm closest to the mattress or a rolled blanket

supports the infant’s back

• The mother sits in a comfortable chair, or reclines in a bed (hospital bed)

• The mother leans back and the baby lies against her body, usually prone

• Use same latching techniques used in cradle position• Also known as “laid back” nursing

• The mother is “down-under” lying on her back• The baby is support on her chest

• Infant is placed in front of mother’s breast• Legs can either be straddling mother’s leg or if infant is still too

small, infant bottom can be placed on a pillow to elevate infant to level of mother’s breast

• A newborn or low tone infant will need back/neck support from mother or can be propped up with pillows

• An older infant may be able to sit unsupported

Frequent Nursers Infrequent Nursers

• 10 times per 24 hours• 138 minutes/day• ~14 minutes per nursing• Gain @ 15 day: 561g

• 7 times per 24 hours• 137 minutes/day• ~20 minutes per nursing• Gain @ 15 day: 347g

• Pre and Post- feeding weight• Provides a guide as to

amount of milk a baby is receiving during nursing

• Flow Rate/respiratory• Positioning

• A device that allows baby to receive extra milk at the breast.

• May be used• Baby

• with weak suck• Transitioning from bottle to

breast

• Mother with decreased supply

• Mother’s milk has not “come in” yet

• Bottle feeding may alter self-regulation of intake, contributing to later obesity• Because the adult is in charge• Infants are not allowed to self-pace• They become over eaters• An infant at the breast can take as much or as little, and stop at their own

pace

• No bottle nipple is most like the breast

• Be aware of certain nipple shapes• Orthodontic nipple• Nipples with abrupt change from nipple to base

• Make bottle feeding more like breastfeeding• Mimic breastfeeding by letting baby pause and rest periodically while

bottle feeding• Allow baby to have burst on bottle just like on breast, then take a pause

for catch up breathing, simulating a let down• Continue allowing burst cycles and rest cycles throughout bottle feed; can

leave bottle in the mouth just like a breast would be, just pausing for rests

You always hear bottle feeding is very different from breastfeeding. . . .

But why?

• Breast:• 1. wider mouth opening• 2. tongue rolling or peristalic

motion• 3. muscle activation of mentalis,

masseter, temporalis and medial pterygoid

• 4. shape of breast nipple is determined by the internal

geometry of the infants mouth

• Bottle:• 1. varies, dependent on nipple size

and shape• 2. pistoning motion or squeeze-like

motion• 3. muscles activation of buccinator

and obicularis oris• 4. artificial nipple has a formed

shape that is less able to be manipulated by infant with less pliable materials

• Soft breast nipple tissue flattens and broadens against the palate in response to infants tongue movements• This way the palate is allowed to form appropriately• May lead to less teeth malocclusions 2’ proper alignment from palate

forming correctly

• An artificial nipple can cause the bones of the palate to shape around it over time, leading to teeth malocclusions and a misformed palate

• Dr. Brown’s NUK

• Tommee Tippee NUK Orthodontic

• Easier for infant to manage flow thus will accept more PO

• Increased breathing stability• Babies show less signs of stress• More similar to breast flow rate• Helps in maintain physiologic stability during feeding• Myth: “infant is working too hard”

• Research indicates it is not the work of sucking that fatigues the infant but work of trying to breathe when the flow rate is beyond the infant’s capacity.

Chang et al 2007; Eishima, 1991; Lau, 1997; Al-Sayed, Schrank and Thach, 1997

(Pados et. al, 2015)

Benefits:• Increased O2 saturations • Less HR variability• RR closer to baseline• More regular intervals between

breaths are noted• Easier for infant to organize and

control fluid in oral cavity to prepare for swallowing

• Left side down allows for improved stomach emptying

• Right side down after the feed has been shown to reduce reflux.

Clark et al, 2007; Park et al, 2014

• Sit comfortably in a chair so that your feet are flat on the floor

• Support swaddled infant with infant’s head in caregivers left palm and infant’s spine along caregiver’s forearm. Be sure infant’s shoulders, hips, and knees are aligned.

• Caregiver should use a pillow or cross his/her legs to support the infant in the elevated position.

McGrattan, 2015

• Mature Non-Nutritive Suck Ability

• Nutritive Bottle Feeding Success

≠

McGrattan, 2015

• Co-regulated approach• Partnership between infant and caregiver• Caregiver understands and uses the infant’s communication to guide feeding

• Physiologic and behavioral communication during feeding• During the feed

• Observes the infant for movement and signs of stress• Continuously modifying the feeding approach in accordance with the infant’s

communicationA lack in continuity of the feeding approach and communication can

adversely affect the baby’s overall feeding experiencesleading to decreased PO intake and longer hospital stay

Shaker (2013)

• Transitioning from volume driven feeds to infant driven • Anderson et al. (1990) and McCain et al. (2001)

• Infants 32-34 Post menstrual age• Experimental group

• Received bottle feeds based on physiologic and behavioral responses

• Control group• Received standard care (volume driven)

• Results• Experimental group achieved full PO nutrition sooner and gained

more weight.

Shaker (2013)

• McCain et al. (2012)• Infants born at <24 weeks GA with chronic lung disease• Experimental group

• Offered bottle feeding based on cardiorespiratory and behavioral responses

• Results• Experimental group achieved full PO 5-6days sooner than control

group• Thoyre et al (2012)

• Infant born at <32 weeks GA with lung disease • Provided co-regulated approach to feeding had more stable oxygen

saturation, less heart rate fluctuation and decline, improved swallowing, less excessive breathing effort

Shaker (2013)

Dietician Lactation counselor

• Cue based feeding• Adequate latch/transfer• Positioning for feeding

• Infant right side down

• Formula for nutrition• Partially hydrolyzed: 100% whey• Intact Protein: 52 whey/48 casein• Intact Protein: 40 whey/60 casein

• Consider CMP

Occupational Therapy Physical Therapy

• Stability before mobility• Need to be held upright for 30 min. • Ensure no pressure on stomach• Supervised “tummy time”• Limit time in baby equipment• Avoid positioning in car seats

• Sensory aspects to feeding • Oral aversion• Sensory integration

• Positioning• Self-feeding skills

Always remember, when providing support, to discuss with the mother/family their goals!!

1. What are her ideas about breastfeeding?2. How does she feel about allowing bottle feeding? 3. Find out what is most important to her and their family?

• View infant as a co-regulatory partner with his/her own agenda

• Revisit the “Dance of attachment” • Provide neuroprotective supports• Watch infant closely for change in state and stress cues

Jadcherla, 2012; Vandenberg & Ross, 2008

•Down Syndrome•Cleft lip/palate•Infants of Diabetic Mothers (IDM)•Neonatal Abstinence Syndrome (NAS)

• Hypotonia• Low muscle tone

• Deficiency in smooth muscle tone• Stomach and intestines

• Depressed reflexes• Decreased root activity• Weak suck

• Skeletal abnormalities of mouth and skull• Easily fatigues• Weight loss will happen if the infant’s feeding problem remains undiscovered

• Sleepy babies who do not always wake to eat or who spend time at the breast not getting sufficient quantities of milk.)

• Individual babies may be over or under-sensitive to stimulation• Some babies may feed best in a dark, quiet environment where they can

concentrate fully on the task at hand.• Other babies respond better to loud, exciting music with a bouncy beat and

being patted on the back to help keep them stimulated and awake during a feeding.

• Continue monitoring for signs of discomfort throughout feeding, monitoring for possible signs/symptoms of aspiration and/or reflux

• Collaborate with the OT and/or PT

Oral Mechanism Exam• Decreased or absent suck reflex due

to hypotonia• Weak or absent suck• Weak or inadequate latch/seal• Look for a gap in the corner of his/her

mouth/lips• Philtrum (area between the upper lip

and nose) looks flatter than that of typical newborns

• Facial muscles may be less active than typical newborns

• Diminished facial expressions• Baby smiles less or not at all

Intervention• Milk Supply

• Ensure mother has the greatest possible milk supply with early and frequent feedings and milk expression when not able to feed baby

• Feed baby often• expect smaller/shorter feedings due to

infant fatigue factor• Provide sensory input to the mouth

(involve OT when able)• Ensure providing oral experience vs. just

oral stimulation (want to set infant up with positive reinforcement for oral feeds)

• Position for tone• Collaborate with PT to help with positioning

and muscle tone increase• Dancer technique/saddle position

• Try alternate massage/breast compression

• Feed baby frequently • Positioning

• Swaddle baby with arms at midline• Semi-elevated sidelying• Collaborate with PT

• Bottle type• Consider Valved bottle system if suck is very weak

• Haberman or Dr. Brown’s Specialty Feeder• Consider flow rate if baby has anterior loss

• External supports• Cheek or chin support may be used to assist with decreased latch

• Birth to surgery• As natural of a feeding method as possible• Adequate growth and weight gain

• Amstalden-Mendes, Magna, and Gil-da-Silva-Lopes (2007) report delays in surgery due to poor weight gain in 67.7% of neonates

• Surgery • Lip repair about 3 months old• Palate repair about 10 months old

• Post surgery• Babies may continue to nurse immediately after surgery• Babies may be more successful at the breast post surgery

Dailey (2013); Riski (2007)

• What is the extent of the cleft lip and/or palate? • Lip involvement, palate only, or both lip and palate• Unilateral or Bilateral palate

• Problems coordinating breathing and feeding• Signs of respiratory distress• Circumoral cyanosis during feedings• Creating intraoral pressure which is necessary for adequate

suction to accept PO from breast or bottle• Difficulty with compression • Have difficulty creating seal and/or vacuum

• Breastfeeding is always an option for infants with cleft lip• Baby can breastfeed before and after surgical repair

• Positioning• Positions to help the infant create an adequate seal

• Dancer technique• Football cradle

• Mother may be able to angle her breast so that the soft tissue fills the space in the lip

• Mother may also use fingers to help “close the space”

• External support• Mother may use alternate massage/compression on the breast• Consider nipple shield to help occlude cleft• Mother may need to express mild after feeding to encourage adequate supply

• Collaboration with the SLP and lactation consultant is important in helping mother and baby achieve this goal.

Garcez and Giuglinani (2005)

• Garcez and Giuglinani (2005) indicate that some infants who have a small cleft palate or a submucous cleft may also be able to successfully feed at the breast.

• Positioning• Unilateral cleft

• assist mother in angling her breast in the infant’s oral cavity in order for the soft tissue of the breast to fill the cleft area

• Supports• Consider nipple shield to help

occlude cleft• Alternate breast massage and

compression during nursing

Garcez and Giuglinani (2005)

• Those infants who are successful at the breast will likely be successful with a standard bottle such as Dr. Browns, Avent, etc.

• Supports for successful bottle feeding• Positioning

• Semi-upright• Semi-elevated sidelying

• Bottles• Valve bottle systems

• Dr. Brown’s Specialty Feeder• Haberman

• External Supports

Dailey (2013), Riski (2007)

Pigeon Feeder Mead Johnson

• Large for gestational age• Many think they should be more mature• Glucose (turns to fat) accumulates in

shoulders, chest, and belly• Hyperviscosity or Polycythemia

• Too much red blood cells • Hypoglycemia• Congenital malformations• Respiratory distress• Hypotonia

• May be “floppy” babies, lower tone• Secondary to hypoglycemia

• Hyperbilirubin• Lethargy• May be neurologically immature• Often born via cesarean section

• Baby better able to control feedings• Baby able to nurse on demand• Accept less volume but more frequently• Baby determines when baby is full thus not over fed

• Benefits of breastfeeding• Helps baby regulate body physiology

• Mimic breastfeeding patterns• Smaller volume more frequently• Slower flow nipple

• Positioning• Monitor full body tone

• Swaddled with hands at midline• Elevated sidelying position

• NAS increased 5x in the US from 2000-2012• 5 per 1000 births • Should be monitored in hospital for minimally 4-7 days

(dependent on drug type/exposure)

• Active metabolites enter CNS of Fetus causing neuronal cell injury or death

• Physiologic brain changes• Impact on cognitive and behavioral development • Vasoconstriction and decreased blood supply• Placental abnormalities, IUGR, preterm delivery

Neurologic Excitability Gastrointestinal Dysfunction Autonomic Signs

Tremors Reflux-Vomiting Poor Feeding Frequent Yawning or Sneezing

High-Pitched Crying Dysfunctional Suck/Swallow Increased Sweating

Hypertonia Poor Weight Gain Temperature Instability

Increased Wakefulness Diarrhea Tachypnea

Irritability Dehydration Lacrimation

Hyperactive DTRs Acidosis (metabolic) Mottling

Exaggerated Moro Reflex Nasal Stuffiness

Seizures

• Mothers in a methadone treatment program are encouraged to breastfeed if they are not• HIV positive• Abusing sustenance• Free of disease or infection that could contaminate breast milk

• Environment• Calm, quiet place free of distractions• Low or natural lighting

• Positioning• Swaddle with arms at midline• Collaborate with PT/OT as able for organization

• Collaborate with Lactation consultant and MD Maguire, 2013

• Environment• Calm, quiet• Low or natural light

• Positioning and organization• Swaddle tightly• Elevated Sidelying• Collaborate with PT/OT

• Bottle type• Slow flow nipple

• Hyperactive suck reflex

• ESC care assessments should be performed every 3-4 hours at the time of other routine infant care, such as with feedings and vital signs

• Initiated within 4-6 hours of birth• Continued for 4-7 days (or until symptoms dissipated) • For pharmacologically treated infants, ESC assessments should

continue for 24-48 hours after stopping opioid replacement medications

• Assessments should reflect the entire 3-4 hour interval since the last ESC assessment, and should incorporate input from all infant caregivers (mother/other parent, nurse, cuddler) who interacted with the infant during this time period

• Assessed in own room• Not removed from caregiver • Recommend using Newborn Care Diary • Broken down into scoring of three components: Eat, Sleep,

Console

• The first component of the ESC Care Tool is infant feeding: “Does the infant have poor eating due to NAS – Yes / No?”

• Eating well is based on gestational age and weight • Including weight gain/loss

• Glucose levels

• Bilirubin levels

• Breastfeeding recommended 8-12 times daily

• Bottling according to above

• Poor eating due to NAS: Baby is unable to coordinate feeding within 10 minutes of showing hunger AND/OR is unable to sustain feeding for 10 minutes at breast or with 10 cc of finger- or bottle-feeding due to NAS symptoms (e.g., fussiness, tremors, uncoordinated or excessive suck).

• OPTIMAL FEEDING: • Baby feeding when showing early feeding cues and until content

without any limit placed on duration or volume of feeding. • Breastfeeding: Baby latching deeply with comfortable latch for mother,

and sustained active suckling with only brief pauses noted. Assist directly with breastfeeding to achieve more optimal latch/position and request lactation consultation if any concerns present.

• Bottle feeding: Baby effectively coordinating suck and swallow without gagging or excessive spitting up; modify position of bottle or flow of nipple if any concerns present.

• The second component of the ESC Care Tool is infant sleep: “Did the infant sleep less than 1 hour after feeding due to NAS – Yes / No?”

• Sleep < 1 hour due to NAS: Baby unable to sleep for more than a one hour stretch after feeding due to NAS symptoms (e.g., fussiness, restlessness, increased startle, tremors).

• Do not include yes for normal sleep disruptions including interruptions due to testing, cluster feedings, other withdrawal symptoms (nicotine, caffeine, SSRIs)

• The final symptom component of the ESC Care Tool is infant consoling: “Is the infant unable to be consoled within 10 minutes due to NAS –Yes/No?”

• Unable to console within 10 minutes due to NAS: Baby unable to be consoled within 10 minutes by infant caregiver effectively providing recommended Consoling Support Interventions.

• Special Note: Do not indicate “Yes” if infant’s inconsolability is due to infant hunger, difficulty feeding or other non-NAS source of discomfort (e.g., circumcision pain) or non-opioid withdrawal. If it is not clear if the inability to console within 10 minutes is due to NAS, please indicate “Yes” and continue to monitor the infant closely while optimizing all non-pharm interventions.

• Consoling Support Interventions (CSIs)

• Providers should perform these consoling support interventions in the following order to assess the level of support required for the infant to console. Parents and other caregivers are not expected to follow a specific order when consoling their infant. This approach was adapted from the Newborn Behavioral Observations (NBO), Nugent et al.11

• 1) Caregiver/provider begins by softly and slowly talking to the infant, using his/her voice to calm the baby.

• 2) Caregiver/provider looks for hand to mouth movements and facilitates as needed by gently bringing the baby's uncovered hand to his/her mouth. Watch for signs of consoling (eye opening, stilling, calming, slowed breathing).

• 3) Caregiver/provider continues talking to infant while placing hand firmly but gently on baby's abdomen.

• 4) Caregiver/provider continues softly talking to baby while bringing baby’s arms and legs to the center of body.

• 5) Caregiver/provider picks up infant, holds skin-to-skin or swaddled in blanket, and gently rocks or sways infant.

• 6) Caregiver/provider offers a finger or pacifier for infant to suck, or a feeding if infant showing hunger cues.

• SOOTHING SUPPORT USED TO CONSOLE INFANT • Providers are asked to rate the consolabilty of the infant on a

scale of 1 to 3. • 1. Soothes with little support: Consistently self-soothes or is easily

soothed with one of first 4 CSIs above • 2. Soothes with some support: Soothes fairly easily with skin-to-skin

contact, being held clothed or swaddled, rocking or swaying, sucking on finger or pacifier, or feeding

• 3. Soothes with much support or does not soothe in 10 minutes: Has difficulty responding to all caregiver efforts to help infant stop crying OR does not soothe within 10 minutes; never self-soothes

• Rooming-in with parent throughout the hospital stay • Ensuring parental presence at the bedside as often as possible during the hospital stay • Encouraging skin-to-skin contact • Encouraging holding / gentle rocking / swaying by a caregiver or cuddler• Swaddling / flexed positioning • Ensuring optimal feeding quality including encouraging breastfeeding for mothers

without concerns for continued concerning substance use or other medical contraindication (e.g., HIV)

• Non-nutritive sucking with pacifier or finger (ensuring baby is well fed first) • Ensuring a quiet environment with low light stimulation in the room • Limiting visitors to one at a time (and to those that will be quiet / supportive) • Providing uninterrupted periods of sleep / clustering infant’s care

• only 10-40% of infants with prenatal opioid exposure will require pharmacologic treatment using the ESC method for NAS assessment with most infants initiating pharmacologic therapy between day 3-4 of life for methadone and buprenorphine-exposed infants.

• Most studies report initiating pharmacologic therapy at a rate of 50-80% when using a numerical, score based-approach.

• EATING, SLEEPING, CONSOLING (ESC) IRR TOOL • Assess infant after feedings, preferably while skin-to-skin or held

swaddled by mother/caregiver. • Review baby’s ESC behaviors since last assessment 3-4 hours

ago using Newborn Care Diary with parents. • If infant with “Yes” for any ESC item or receiving “3s” for

“Soothing Support Used to Console Infant”, perform team huddle with mother/parent & RN to determine non-pharm interventions that can be optimized further.

• If infant continues with “Yes” for any ESC item or “3s” for “Soothing Support” despite optimal non-pharm care and symptoms felt likely due to NAS, perform full team huddle with mother/parent, RN, and Infant Provider to determine if medication treatment is needed.

• DATE/TIME: RN “Gold Star” Rater • EATING • Poor eating due to NAS? Yes / No • SLEEPING • Sleep < 1 hr due to NAS? Yes / No • CONSOLING • Unable to console within 10 min due to NAS? Yes / No • Soothing support used to console infant: • Soothes with little support: 1 • Soothes with some support: 2 • Soothes with much support or does not soothe in 10 min: 3 • MANAGEMENT DECISION • Recommend a Team Huddle? Yes / No • RELIABLITY PERCENTAGE %

Alcohol: FAS MethadoneHeroine NeurotinCrystal Meth And many, many more

Opioids causing NAS in exposed infants include:

Agonists Diamorphine (Heroin) Fentanyl Hydromorphone Meperidine (Pethidine) Methadone Morphine (including prodrug Codeine) Oxycodone Propoxyphene Mixed agonists-antagonists BuprenrophineButorphanolNalbuphinePentazocine

• http://www.uichildrens.org/uploadedFiles/UIChildrens/Health_Professionals/Iowa_Neonatology_Handbook/Pharmacology/Neonatal%20Abstinence%20Syndrome%20Treatment%20Guidelines%20Feb2013%20revision.pdf

• Onset of withdrawal symptoms• • Onset of withdrawal depends on the half-life of the drug, duration of the addiction, and time of last• maternal dose prior to delivery. On average, observation period for symptoms to appear is 3 days.• Drug Approximate time to onset of withdrawal symptoms• Barbiturates 4-7 days but can range from 1-14 days• Cocaine Usually no withdrawal signs but sometimes neurobehavioral abnormalities (decreased• arousal and physiologic stress) occur at 48-60 hours• Alcohol 3-12 hours• Heroin Within 24 hours• Marijuana Usually no clinical withdrawal signs• Methadone 3 days but up to 5-7 days; rate of severity of withdraw cannot be correlated to dose of• maternal methadone• Methamphetamines Usually no withdrawal signs but sometimes neurobehavioral abnormalities (decreased arousal,

increased physiologic stress, and poor quality of movement) occur at 48-60 hours• Opioids 24-36 hours but can be up to 5-7 days• Sedatives 1-3 days• SSRIs Several hours to several days—withdrawal linked with 3rd trimester use

• Scoring of NAS

• • Finnegan scoring (tool to quantify severity of NAS) (See last page for Finnegan Scoring System)

• o Begin scoring within 2 hours of life

• o Continue scoring every 4 hours• • Used to determine initiation of pharmacologic therapy

• Originally developed in 1975; “Modified” in 1986• 200 term, opiate exposed newborns• Assessed from the beginning of one feeding til the beginning of thenext feeding, Q 3-4 hrs– Challenging with breastfed neonates• Recommended: start scoring at 2 hours of age; if score= 8, continueto score Q2 hrs until less than 7• OPQC treatment protocol: begin treatment for 2 consecutive scoresof >8 or one score ≥12.

Central Nervous SystemExcessive Crying (2-3)Sleep (1-3)Hyperactive Moro (2-3)Tremors (1-4)Increased muscle tone (2)Excoriation (1)Myoclonic jerks (3)Convulsions (5)

Autonomic Nervous SystemSweating (1)Fever (1-2)Frequent Yawning (1)Mottling (1)Nasal Stuffiness (1)Sneezing (2)Nasal Flaring (2)Resp rate (1-2)

Gastrointestinal SystemExcessive sucking (1)Poor feeding (2)Regurgitation (2)Projectile Vomiting (3)Stools (2-3)

NAS Assessment Tools• Finnegan Neonatal Abstinence Scoring Tool• Neonatal Withdrawal Inventory (NWI)• The Neonatal Narcotic Withdrawal Index• The Neonatal Drug Withdrawal Scoring System (Lipsitz)• Ostrea Tool• Neonatal Drug Withdrawal Scoring System (NDWSS)

• Especially if you are going to be working in a NICU graduate clinic or with outpatient babies after discharge

• Look for local support groups for families • Network with area to continue providing support

• Should really be seeing all of these populations

• 12 week course for mothers with drug exposure • Child birth• Breastfeeding• NAS• HANDS and WIC• Nutrition/SLP/PT• Domestic Violence and Security• Infant Massage• Safe Sleep and Hospital Tours• Be Mindful• Car Seat Safety/Birth Control

• Child Safety

• PT/SLP/Dietician • Provided familiar face and

confident• Prenatal yoga classes• NAS meetings• Support groups• What is in your community?

• No judgment! • Mother needs assistance as much as baby• Be there to support

• Normal infants/children• Oral aversion (picky/poor feeders)• Gagging/reflux• Poor weight gain/FTT• Sensory integration feeding issues

• Medically Complicated infants/children• Chronic conditions (CHD, CP, Down syndrome, BPD/chronic lung, other

neurological disorders, genetic disorders)• Post discharge NICU patients • **GOAL: intervene early to prevent developing feeding difficulties

• Easier to create early positive feeding experience then to correct ingrained poor behavioral feeding development!

• “Practice does not make perfect but does make permanent”• Let’s make sure the practice is GOOD practice from the beginning to

ensure development of proper feeding habits• Promote positive neuropathways

• GI Signs and Symptoms:• back arching; • frequent congestion, particularly after meals; • gagging; • Decreased bowel movements or other stomach difficulties • weight loss or lack of appropriate weight gain. (could also be metabolic)• vomiting (more than typical "spit up" for infants);

• Respiratory Signs and Symptoms:• increased respiratory rate during feeding, • skin color change such as turning blue, • apnea, • stopping frequently due to uncoordinated suck-swallow-breathe pattern, • desaturation (decreasing oxygen saturation levels); • changes in normal heart rate (brachycardia or tachycardia) in association with feeding;

ASHA 2014

• Dysphagia Signs and Symptoms:• difficulty chewing foods that are texturally appropriate for age (may spit out partially chewed food); • difficulty initiating swallowing; • difficulty managing secretions (including non-teething related drooling of saliva); • coughing and/or choking during or after swallowing; • loss of food/liquid from the mouth when eating; • noisy or wet vocal quality noted during and after feeding;

• Failure To Thrive or other Difficulties with Feeding:• crying during mealtimes; • decreased responsiveness during feeding; • dehydration;

• Behavioral Related Signs and Symptoms:• disengagement cues, such as facial grimacing, finger splaying, or head turning away from food source; • frequent respiratory illnesses; • prolonged feeding times; • refusing foods of certain textures or types; • taking only small volumes, over-packing the mouth, and/or pocketing foods;

Many symptoms overlap in

categories!!!

• Common causes of pediatric dysphagia include • developmental disability (i.e., disability with onset before the age of 22 that warrants lifelong or extended medical, therapeutic, and/or residential

supports and is attributable to a mental or physical impairment or a combination of mental and physical impairments); • neurological disorders (e.g., cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, muscle

weakness in face and neck); • factors affecting neuromuscular coordination (e.g., prematurity, low birth weight); • complex medical conditions (e.g., heart disease, pulmonary disease, gastroesophageal reflux disease [GERD], delayed gastric emptying); • structural abnormalities (e.g., cleft lip and/or palate, laryngomalacia, tracheoesohageal fistula, esophageal atresia, head and neck abnormalities,

choanal atresia); • genetic syndromes (e.g., Pierre Robin, Prader-Willi, Treacher-Collins, 22q11 deletion); • medication side effects (e.g., lethargy, decreased appetite); • sensory issues as a primary cause or secondary to limited food availability in early development (e.g., in children adopted from institutionalized

care; Beckett et al., 2002, Johnson & Dole, 1999); • behavioral factors (e.g., food refusal); • social, emotional, and environmental issues (e.g., difficult parent-child interactions at mealtimes). • Results or long-term effects for a child diagnosed with pediatric dysphagia include • poor weight gain velocity and/or under nutrition (failure to thrive), • aspiration pneumonia and/or compromised pulmonary status, • food aversion, • oral aversion, • rumination disorder (unintentional and reflexive regurgitation of undigested food that may involve re-chewing and re-swallowing of the food), • dehydration, • ongoing need for enteral or parenteral nutrition.

• The 'incidence' of pediatric dysphagia refers to the number of new cases identified in a specified time period. The 'prevalence'of pediatric dysphagia refers to the number of children who are living with pediatric dysphagia in a given time period.

• Estimated reports of the incidence and prevalence of pediatric feeding/swallowing impairment vary widely due to multiple factors, such as variations in the populations sampled, how feeding and/or swallowing impairment is defined, and the choice of assessment methods and measures (Arvedson, 2008; Lefton-Greif, 2008). Pediatric feeding and/or swallowing impairment incidence and prevalence data from the review papers cited below reflect this high variability.

• It has been reported that 25%-45% of typically developing children demonstrate feeding and swallowing problems (Arvedson, 2008; Bernard-Bonnin, 2006; Brackett, Arvedson, & Manno, 2006; Burklow, Phelps, Schultz, McConnell, & Rudolph, 1998; Lefton-Greif, 2008; Linscheid, 2006; Manikam & Perman, 2000; Rudolph & Link, 2002).

• Prevalence is estimated to be 30%-80% for children with developmental disorders (Arvedson, 2008; Brackett, Arvedson, & Manno, 2006; Lefton-Greif, 2008; Manikam & Perman, 2000).

• Significant feeding problems resulting in severe consequences (e.g., growth failure, susceptibility to chronic illness) have been reported to occur in 3%-10% of children, with a higher prevalence found in children with physical disabilities (26%-90%) and medical illness and prematurity (10%-49%; Manikam & Perman, 2000).

• It is reported that the prevalence of pediatric dysphagia is increasing due to improved survival rates of children born prematurely, with low birth weight, and with complex medical conditions (Arvedson, 2008; Lefton-Greif, 2008).

ASHA 2014

Gastroesophageal reflux disease (GERD) Spitting Up

• Reflux causes troublesome symptoms or complications including• Failure to gain weight• Respiratory problems• Bleeding• esophagitis

• Can develop at any age• Often runs in families• Kids frequently complain of

abdominal pain/tummy ache• Often can be managed with

lifestyle changes

• More than 50% of babies spit regularly within the first month of life.

• Baby does not show symptoms of discomfort

• Infant spit up is perfectly healthy even if it is frequent

• Resolves by 6-7 months of age in 71% of infants

• Breastfed infants typically improve sooner • Determine mother’s diet

Gold, 2016; Campanozzi et al., 2009

Younger than 2 years Older than 2 years• Irritable feeding• Chronic cough• Recurrent pneumonia• Generally unhappy baby• Failure to thrive• Torticollis

• Sandifer's Syndrome• Persistent vomiting 18-24months• Hematemesis• Stopping mid feed/not

“finishing” feeds

• Persistent emesis since before 2yrs of age

• New onset of recurrent emesis

• Anemia• Dysphagia/odynophagia• Chronic cough• Recurrent pneumonia• Non-seasonal asthma

• High risk population• Decreased “tummy time”• Weak sphincters• Arching• Food allergies• High volume feeds• Constipation• Increased abdominal pressure• Higher calorie formulas

• Neurological impairment• Congenital abnormalities of esophagus• Cystic fibrosis• Respiratory malformities/malacias• Obesity• Esophagitis/erosion of esophagus• Feeding delays/picky eating• Chronic ear infections• Asthma or pneumonia• Behavior issues

• Case history• Symptoms before, during,

and after the feed• Assess the feeding in all

modalities the child is using.• Insure adequate feeding skills• Identify signs of discomfort vs

signs of distress• Determine suspected etiology

of symptoms

• Full “Clinical” Feeding Evaluation • Behavior markers are not always indicative of GERD• Premature infants at corrected age of 35wks were assessed

using PH monitoring• Symptoms frequently observed

• Discomfort• Head retraction• Regurgitation• Gagging• Thumb sucking

• Symptoms did not coordinate with change in pH

Schurr & Findlater, 2012; Snell A, Barnett C, Cresp T, et al., 2000

When? To whom?

• If you suspect GERD that cannot be managed by behavior changes

• If growth is sufficient, but infant continues to suffer from GER

• If growth is insufficient, • work on breastfeeding

management to meet family goals and health

• Pediatrician• Formula change for suspected Cow Milk

Protein allergy in infants; meds if needed

• Pediatric Radiologist• Determine further diagnosis via imaging

for etiology • Allergist

• Allergy• Celiac• Cow Milk Protein

• Pediatric Dietician • Lactation Consultant• GI

• metabolic workout

• MBS (modified barium swallow)• Neurologic• Premature/laryngeal penetration• Nasopharyngeal reflux• CHD• Infants on CPAP• BPD infants (or other chronic lung conditions)

• Esophagram• TE fistula• Vascular ring

• Evaluation of breast/bottle/solid foods for oral, pharyngeal, and esophageal phases• Depends on age of infant/child• Depends on etiology

• Motor• Sensory• Dysphagia• Combination and comorbidities

• Breastfeeding management• Latch, milk supply, introduction of solids

• Bottle feeding management• Flow rate, position changes, introduction of solids

• Dysphagia Management• Tube to PO transition

• Aspiration risks/PO safety, reflux considerations, oral aversion possibilities • Picky eating management

• Oral aversion, food chaining/shaping, SOS/other sensory therapies

• Behavioral Interventions • Reinforcements

• Postural/Positioning Techniques

• Diet Modification • Thickened liquids (past age 2 years)

• Solid texture changes

• Non-cohesive boluses

• Mixed Consistencies

• Equipment/Utensils • Biofeedback

• Maneuvers ASHA 2014

• Oral-Motor Treatments• Functional tasks• No oral motor just for exercises purposes

• Pacing and Cue-based Feeding Strategies• Both breast and bottle for infants• Strategies for children after infancy

• Sensory Stimulation • SOS• Sensory Integration with other activities

• Feeding Protocols• Non-Nutritive Sucking (NNS) Facilitation• Interdisciplinary Care

• Working with PT/OT

• Family and patient will leave with treatment options and plan of care after evaluation/session completed.

Pharmaceutical Surgical

• Proton pump inhibitors• FDA no PPI under 1 year• Infants can still have “gut”

damage

• H2 receptor antagonist• Ask about OTC acid buffer

• Nissen fundoplication• Wrapping the fundus of the

stomach around distal esophagus

• Often completed when PEG placed in infant

• Effectiveness has varied • Stomach loses 25-50% of

volume

• Arvedson & Brosky 2002

• proton pump inhibitors include:• omeprazole (Prilosec, Prilosec OTC)• aspirin and omeprazole (Yosprala)• lansoprazole (Prevacid, Prevacid IV, Prevacid

24-Hour)• dexlansoprazole (Dexilent, Dexilent Solutab)• rabeprazole (Aciphex, Aciphex Sprinkle)• pantoprazole (Protonix)• esomeprazole (Nexium, Nexium IV, Nexium 24

HR)• Esomeprazole/magnesium/naproxen (Vimovo)• omeprazole/sodium bicarbonate (Zegerid,

Zegerid OTC)

FEES

• Assesses pharyngeal phase before, during, and after the swallow

• Inferences are made about the oral (containment) phase and esophageal phase (if reflux is observed)

• Primarily from the superior view

MBS

• Assesses the oral, pharyngeal, and cervical esophageal phase

• Primarily from the lateral phase but can be completed in A-P view

FEES• Can be performed in any

location: hospital, SNF, OP clinic, patient’s home, bedside, wheelchair, or chair

• Very few patients can not participate in FEES. Problems may occur with craniofacial trauma, dementia, brain trauma, or confused patients. Uncooperative patients may not participate.

MBS• Can be performed in hospital

radiology suite, mobile radiology van, and sometimes with portable C-arm fluoroscopy at bedside

• Patients who cannot participate in MBS include: pts unable to leave bed, unable to be positioned in upright position, uncooperative patients. Patients on the ventilator or in intensive care may have more difficulty.

FEES

• Best indicated for patients who c/o choking on foods or liquids, suspicion of penetration/aspiration, especially from clinical swallowing evaluation

• May need diet upgrade or consistency change

MBS

• Patient may benefit from if complaints of oral stage prep problems, suspicion of penetration/aspiration

• Complaints of food sticking in throat

• May need to be followed with UGI

FEES• Limitations of the exam: • Can’t tolerate nose insertion• “white out” moment of

swallow• May miss

penetration/aspiration• Does not address oral and

esophageal phase of swallow

MBS• Limitations of exam:• To reduce radiation, fluoro is

turned on and off• Prone to miss behaviors after

the swallow• Unable to view laryngeal

surface anatomy• Barium is mixed with foods,

and may change viscosity

FEES

• Bonus:• Secondary assessment of VP

closure• Assessment of

laryngeal/pharyngeal surfaces and functions

• Bilateral cavity residue visibility

• Therapy biofeedback

MBS

• Bonus:• Screening of esophagus to

lower esophageal sphincter during swallow

(Ashford et. Al, 2017)

• Pediatric vs. Neonatal Scope• Age of child• Anesthesia

ASHA, 2012

• Al-Sayed, L. E., Schrank, W. I., & Thach, B. T. (1994). Ventilatory sparing strategies and swallowing pattern during bottle feeding in human infants. Journal of Applied Physiology, 77(1), 78-83.

• Belfort MB, Rifas-Shiman SL, Kleinman KP, et al. Infant feeding and childhood cognition at ages 3 and 7 years: effects of breastfeeding duration and exclusivity [published online July 29, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.455.

• Blake, A; McComish, C; Crais, E; Thoyre, S. (2014) Breastfeeding Knowledge and Clinical Manegment among Speeh-Language Pathologist. ASHA Convention 2014.

• Bier, J.B., Ferguson, A., Anderson, L., Solomon, E., Voltas, C., Oh, W., & Vohr, B.R. (1993). Breast-feeding of very low birth weight infants. Journal of Pediatrics, 123, 773- 778. Retrieved from http://ac.els-cdn.com/S0022347605808583/1-s2.0-S0022347605808583-main.pdf?_tid=5e0ff2a6-606d-11e3-9273 00000aab0f02&acdnat=1386551039_b8094b34166164d2367b205306ce8bcf

• Chang, Y.J., Lin, C.P., Lin, Y.J. et al. (2007). Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants. Journal of Nursing Research, 15(3); 215-223.

• Clark, L., Kennedy, G., Pring, T., & Hird, M. (2007). Improving bottle feeding in preterm infants: Investigating the elevated side-lying position. Infant, 3(4), 354-358.

• Colson, S.D., Meek, J., & Hawdon, J.M. (2008). Optimal positions triggering primitive neonatal reflexes stimulating breastfeeding. Early Human Development, 84(7), 441-449

• Dailey, S. (2013). Feeding and Swallowing Management in Infants With Cleft and Craniofacial Anomalies. Perspect Speech SciOrofac Disord, 23(2), 62-72. doi: 10.1044/ssod23.2.62.

• Eishima, K. (1991). The analysis of sucking behaviour in newborn infants. Early human development, 27(3), 163-173.• Ewing, C. & Seitz, M (2014) NICU. ISHA Fall Conference 2014 [PowerPoint Slides].• Fletcher, K. & Ash, B. (2005, February 08). The speech-language pathologist and the lactation consultant: The baby’s feeding

dream The ASHA Leader, Retrieved from http://www.asha.org/Publications/leader/2005/050208/f050208b/

• Goldfield, E., Richardson, M., Lee, K., & Margetts, S. (2006). Coordination of sucking, swallowing, and breathing, and oxygen saturation during early infant breast-feeding and bottle-feeding. Pediatric Research, (60), 450-455. doi: 10.1203/01.pdr.0000238378.24238.9d

• Ip, S., Chung, M., & Raman, G., et al. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2007). Breastfeeding and maternal and infant health outcomes in developed countries (07-E007). Retrieved from website: http://www.ncbi.nlm.nih.gov/books/NBK38337/

• Jadcherla, S. R., Peng, J., Moore, R., Saavedra, J., Shepherd, E., Fernandez, S., ... & DiLorenzo, C. (2012). Impact of personalized feeding program in 100 NICU infants: pathophysiology-based approach for better outcomes. Journal of pediatric gastroenterology and nutrition, 54(1), 62.

• Lau, C. & Schanler, R.J. (2000) Oral feeding in premature infants: advantages of a self-paced milk flow. Acta Paediatrica, 89(4), 453-459

• Manikam, R., & Perman, J. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology,30(1), 34-46. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10636208/

• Pados, B., Park, J., Thoyre, S., Estrem, H., Nix, W. (2015) Milk flow rate from bottle nipples used for feeding hospitalized iinfants. Manuscript

• Park, J., Thotre, S., Knafl G.J., Hodges, E.A. & Nix W.B. (2014) Efficacy of Semielevated Side-Lying Position During Bottle-feeding of Very Preterm Infants: A Pilot Study. The Journal of Perinatal & Neonatal Nursing, 28 (1), 69-70.

• Riski, J. E. (2007). Feeding the Infant Born With Cleft Lip/Palate: A Literature Review. Perspect Swal Swal Dis (Dysph), 16(3), 12-17. doi: 10.1044/sasd16.3.12.

• Shaker (2015). NICU Swallowing and Feeding: In the Nursery and After Discharge. Conference Indianapolis, In• Shaker, Catherine (2014). Nipple Feeding Profile. Submitted for publication.• Shaker, Catherine (2013). Cue-based feeding in the NICU: Using the infant’s communication as a guide. Neonatal Network.

32(6):404-408• Shaker, Catherine (2013). Cue-based Co-regulated Feeding in the Neonatal Intensive Care Unit: Supporting Parents in Learning

to Feed their Preterm Infant. Neonatal & Infant Nursing Reviews. 13, 51-55• VandenBerg, K. A., & Ross, E. S. (2008). Individualized developmental care in the neonatal intensive care nursery. SIG 13

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