Less is more m luther

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Less is More : The Key to a Positive Feeding Experience

Maureen Luther, B.Sc (P.T) MA

Paediatric Physiotherapist

06/04/131

Luther

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Objectives

1.Discuss the implementation of developmentally supportive feeding interventions within the NICU

2.Evaluate the theoretical framework that guides cue based feeding and use this framework to maximize feeding potential of the preterm infant

3.Discuss the long term ramifications of negative feeding experiences and the interventions utilized by the Neonatal Follow-up clinic

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Goals of Developmentally Supportive Care in the NICU

NICU intervention Strategies for the infant focuses on stress reduction (Als, H, 1982)

• Evidence is accumulating that stress during early human ontogeny is also associated with long-term modifications of neurobehavioural development

• Sensitivity of the young nervous system to stress-related factors implies that reduction of stress is an important goal of early intervention before term age. (Hadders-Algra,2011)

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Neurodevelopmental processes during human ontogeny(De Graaf-Peters & Hadders-Algra, Early Hum Dev 2006; 82: 257-66

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Goals of Developmentally Supportive Care in the NICU

• Facilitate responsive parenting

“ sensitive to their infants cues and have the

ability and knowledge to alleviate infant’s stress” ( NCAST, 1994)

• Foster positive parent- child relationship

-attachment fostered by the mother/infant dyad learning about each other

-disrupted for preterm infants

“Vulnerable to forming lower-quality attachment to caregiver due to disruption of early experiences and separation” ( Sullivan et al, 2011)

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Goals of Developmentally Supportive “Feeding” Care

• Oral feeding - interactive, developmental task (Thoyre and Brown, 2004)

- the most complex and highly co-ordinated

sensorimotor mode of oral feeding

- requires appropriate oral motor development and

function with neurological maturation

- is dependent on the mother / child interaction

- feeding needs to be a pleasant, relaxed and a

controlled experience

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Understanding Oral Motor Development for Successful Feeding

• Somatesthetic (Tactile) Development

• First sense to develop:

8weeks – the perioral area 10 weeks - palms of hands, plantar surface of feet 11 weeks - entire face

• Sensation of pressure, pain, and temperature

• Protective mechanism • Provides information through which

neurodevelopment and cognition is enriched

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Understanding Oral Motor Development for Successful Feeding

• Taste cells: form at 7-8 weeks GA, functionally mature by 17 weeks

• Fetal swallowing – begins at 12 weeks GA• Rhythmical bursts of jaw opening and closing - 14

weeks GA

• Non Nutritive Sucking – 18 weeks GA

• Safe, effective Swallow -32 weeks GA• Coordinated sucking and swallowing – by 35 to 40

weeks (Lipchock et al, 2012, Brown,J & Ross, E, 2011)

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Medical issues affecting feeding

• Hypotonia - related to GA, BW, Severity of illness

• Respiratory:Bronchopulmonary Dysplasia (BPD):

contributes to poor SSB coordination

significant increases in deglutition apnea

poor sucking endurance and performance ( Gewolb,IR & Vice, FL 2006, Mizuno,K et al, 2007)

• Neurological Dysfunctional suck– may exclude breastfeeding

(NOMAS, Palmer,M 1992)

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NICU: Positive Feeding Strategies

• Developmentally supportive environment during the feeding process:

-appropriate lighting

-sound levels within the unit

• Primary Nursing Care:

- essential to consistency and relationship building

- cluster of non-emergent care

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• Positioning : a positive oral experience

- Flexion – sucking is a flexion activity

- Midline – hands to mouth

- Promoting comfort and sleep

• Non Nutritive Sucking:

-provides comfort and self-soothing ( Pinelli and Symington, 2010)

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• Stressful procedures: Are we providing support and comfort?

• Opportunities for a positive oral experience

Ventilation

Procedures: Diaper change , vital signs

Bolus feeds

“ Tube fed infants increase NNS when exposed to smell of Expressed Breast Milk which suggests this may assist in transition to oral feeding” (Lipchock SV et al , 2011)

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Pain Management :• Negative oral experiences: are they painful?

- Taping

- Suctioning

- Placement of OG/NG tubes

- Intubations

• Use of pharmacological and non-pharmacological

pain management strategies

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• Skin to Skin Care • Infant Benefits:

– Improved physiological stability– More organized sleep wake cycles (Ludington Hoe,S 2006)

– Decreased nosocomial infections– Non-pharmacological pain management strategy (AAP,

2006, Johnston,C et al, 2003, 2008)

• Parent Benefits:– Improved breastfeeding duration and milk production

– Improved attachment– Increased confidence (Johnson, AN. 2007)

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“Kangaroo care is crucial for babies to grow and develop and is also medicine for the souls of parents.”

quote from parent during our Kangaroo-a-thon

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• Cue-based feeding – Quality versus Quantity?

- a positive feeding experience for the infant

- a developmental process that requires support from moment to moment ( Shaker, CS 2012)

• Need to move away from the viewpoint that a successful feed is based on numbers

( Ross,E & Philbin,K 2011)

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• A successful Cue-Based Feeding involves:• Infant - physiologically stable - actively participating - self regulated - comfortable

• Caregiver - sensitive to infants cues – state and physiologic - responds appropriately to cues - competent feeding skills (Ross,E & Philbin K, 2011)

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NICU: Positive Feeding Strategies:Understanding the Infant’s Cues

Stress Cues:

Vital Signs: RR, HR, O2 sat Respiratory: increased WOB

Visceral: gagging, vomiting

State : rapid state change

Sensory: facial/ gaze aversion

Oral Motor: uncoordinated SSB Motor: head turning, extension,

increased limb movement (NOMAS,1993,2002)

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NICU: Positive Feeding Strategies:Understanding the Infant’s Cues

Stability Cues

• Vital Signs: stable RR 40-60

• Respiratory: pause = burst

• State regulation

• Oral Motor: rooting, coordinated SSB

• Motor: gentle forward flexion

• Hunger and satiation cues

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NICU: Positive Feeding Strategies: Understanding the Infant’s Cues

Consequences of not responding to stress cues:

• Compromise physiological stability

• Loss of state regulation and postural control

• Stress++ • Possible Laryngeal penetration/ aspiration • Eventually Feeding Refusal Behaviour/ Feeding • Aversion

• Altered Brain Development

• Altered parent/infant attachment

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Feeding Readiness: • Begins with physiologic stability “ stable vital signs, good colour, and good muscle tone

when the infant is alone in the bed or during simple handling “( Ross,E & Philbin,K, 2011)

• Infant begins to show signs of hunger

• Infant can maintain physiologic stability and a drowsy or alert state while being held with NNS ( Ross,E & Philbin,K, 2011)

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Feeding Readiness® Scale (Ludwig and Waitzman 2007)

If scores 1 or 2 – can attempt to orally feedIf scores 3-5 – do not attempt to orally feed

1) Alert or fussy prior to care. Rooting and/or hands to mouth behavior. Good tone.

2) Alert once handled. Some rooting or takes pacifier. Adequate tone.

3) Briefly alert with care. No hunger behaviors (i.e. rooting, sucking). Adequate tone.

4) Sleeping throughout care. No hunger cues. No change in tone.

5) Significant HR, RR , 02, or WOB outside of baseline HR <100 bpm, RR > 60 bpm , SaO2 <80 % WOB=nasal flaring, tracheal tugging

Action: Stop feeding, reassess, if scores 1-2 and physiologically

returns to baseline, retry once more

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NICU: Positive Feeding StrategiesBreastfeeding

• Physiologically easier “infants with BPD who were breastfed were found to

have higher O2 saturations during feeding than bottle feeding” ( Mizuno et al, 2007)

• Baby active participant, mother is supportive

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NICU: Positive Feeding StrategiesBottle feeding

• An appropriate feeding alternative

-can be physically easier

-with cue based feeding the feeder needs to be

carefully watching the infant and taking his lead

-infant is a co-regulatory partner in the feeding process (Shaker,C 2013)

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NICU: Positive Feeding StrategiesBottle feeding

• Goals:

• Safety: prevent aspiration, physiologic instability, excessive fatigue

• Functional : adequate volumes for growth without undue stress to infant

• Relationship based – nurturing – infant and parent – should be pleasant for both

• Individual and developmentally supportive

(Ludwig and Waitzman, 2007)

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NICU: Positive Feeding Strategies: Responding to cues

• Feeding continues if infant maintains strong coordinated suck

• Allow for opportunities for “catch up” breathing

AVOID PASSIVE MANIPULATION OF THE NIPPLE

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NICU: Positive Feeding Strategies: Responding to cues

• Respond to disengagement/stress cues

STOP FEEDING

“Feeding is stopped when infant communicates that he is done or the inability to continue for whatever reason NOT just when the bottle is empty/volume driven” ( Shaker,CS 2013)

• Intake is a byproduct of a quality feeding interaction and within the context of the emerging feeding skills

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NICU: Positive Feeding Strategies: Providing individualized support

External pacing: a method of providing external control of the infant’s

SSB ( Palmer,M 1993,Philbin&Ross, 2011)

-Assists infant’s physiologic stability

-Prevents the formation of maladaptive, oromotor

problems

-Increases infant’s comfort with feeding

-Assists an appropriate intake volume

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External Pacing:

Need to be anticipatory and preventative

start with horizontal bottle

count the Sucks and Swallows ( allow 3-5)

if followed by breathe, allow pause

if no breathe, tip bottle down, keep nipple in mouth

Signs to pace – raising eyebrows*, nasal flaring, eyes widening, pulling back ( Ludwig, SM & Waitzman, KA 2007)

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Postural Control: supportive swaddling with a blanket ( Wolf L & Glass,R 1992)

“hand swaddling ” control with hands ( Philbin &Ross, 2011)

by grasping hand – promotes flexion

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Positioning

- good alignment for best function

- promoting attachment enface “the position in which the caregiver’s face is

rotated so that the eyes and those of the child’s can meet fully in the same vertical plane of rotation” (NCAST, 1994)

No difference in semi reclined vs upright vs elevated side lying positioning in improving oral feeding skills

( Lau,C 2013)

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• Appropriate Nipple selection:

• Consistency of liquid:

to thicken or not?

• Therapeutic techniques: When are they really necessary?

Jaw support

Jaw and cheek support

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Feeding Plan:

-consistency is critical

-communication of the plan

-need to reduce variation – interferes with learning to

feed

- plan needs to be developed by the various members of the team including the parent

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NICU: Positive Feeding Strategies Fostering parent /child relationship

• Start early to include parents in the care of their infants

• Modeling

• Coaching

• Anticipatory Guidance

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NICU: Positive Feeding StrategiesFostering parent /child relationship

Goals of the NICU caregiver:

-Facilitate the parent/ child relationship by promoting a

co-regulated feeding approach

- Foster confident and competent parents

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NICU: Positive Feeding StrategiesFostering parent /child relationship

Understanding the stressors for the parents:• Inconsistent information• Excluded from the feeding plan and changes in the

plan

• Respecting the parents choice – breast or bottle • Not watching the baby’s cues • Feeding should be a joyful experience• Feeding – “this is the worst” – when baby not feeding

• Parent really feels like a bad parent

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NICU: Positive Feeding StrategiesPreparing for Discharge

Successful and safe feeding often delays discharge ( Shaker, CS, 2012, Lau C, 2003)

Goals:

• Parent - confident and competent

• Infant:

medically stable

a safe feeding plan

supports growth and nutrition

promotes positive parental interaction

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NICU: Positive Feeding StrategiesAvoiding Feeding difficulties/problems

• Absence of early ( normal) postnatal chemosensory experiences , disruption in maternal attachment and negative associations with early feeding experiences contribute to future feeding difficulties (Lipchock, SV et al, 2011)

• Strong association between feeding and discomfort

( including struggling to breathe and reflux) can develop an aversion to feeding (Philbin & Ross, 2011)

• Most infants who develop feeding problems are averse to food and feeding (Ross,E and Philbin,K 2011)

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Neonatal Follow-up: Early Intervention Feeding issues in the first year

• Higher incidence of early regulatory disorders ( excessive crying, sleeping difficulties and/or feeding

problems) in preterm infant (Arpi E, Ferrari F. 2013)

• Crying, feeding and sleeping problems has a correlation with poor cognitive outcome and behavioural problems (Wolke,2009 )

• Regulatory problems in infancy can increase the likelihood of developing behavioral problems in childhood (Hemmi MH et al, 2011)

• By school age, ELBW children have a greater risk to have eating problems ( Samara M et al, 2009)

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Neonatal Follow-up: Early Intervention

• First 6 months: Feeding

De – medicalize feeding• Feeding : 3 pronged approach

– Growth & nutrition– Age appropriate oral motor

skill, positioning and assist in transitions

– Positive Maternal /child feeding interaction

( Arvedson, J. 2002 )

• Address GERD - criteria for intervention and management

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Neonatal Follow-up: Early Intervention

• 6-12 months: Feeding to “Eating”

• Expanding texture acquisition• Decreasing fluid intake• New utensils• Proper seating • Mealtime rules and routines

( Chatoor et al, 1997 and DeGangi, G, 2000)

• Self-feeding• Social activity

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Conclusion: Less is More

Less:• Emphasis on quantity of feed• Stress during feeding

More• Skin to Skin • Emphasis on quality of feed • Cue based feeding• Parental input

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Less is more m luther