Maximize NICU Feeding Success
10/12/2016
Feeding Strategies to Maximize
NICU Feeding Success
Objectives
 Name three common feeding challenges in the NICU
 Identify five strategies that help facilitate infant’s
feeding quality
 Become familiar with use of Videofluoroscopic
PNANN Conference, October 2016
AMY FAHERTY, MS, CCC-SLP &
TIFFANY ELLIOTT, MS, CCC-SLP
Infant’s Feeding Goals
Swallow Study (VFSS) to assist with decision making
of feeding modifications
Supporting Feeding Journey
 Safe oral feeding
Neurologic
Immaturity
Feeder
 Efficient oral feedings
True
Neurological
Dysfunction
 Full oral feedings
 Breastfeeding is
preferred feeding mode
State Regulation
FEEDING
Structural
Integrity
 Reunite baby with
family to discharge
home
GI intolerance
Feeding Developmental Model
BROSS (Baby Regulated Organization of Sucking and Subsystems)
F
E
E
D
~37-42 wks
~40+ wks
Sensory
Integration
Pre-Feeding Skills
• Physiologic stability
• Secretion management
• State maintenance
• Reaction to handling
F
E
E
D
~ 34-36 wks
Muscle Tone
Endurance
Respiratory
Status
~32-35 wks
Oral-Motor
Control
• Non-nutritive sucking
• Parent/caregiver training
~34-36 wks
P
R
E
F
E
E
D
(adapted from Browne & Ross, 2001)
Faherty & Elliott, PNANN 2016
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Maximize NICU Feeding Success
10/12/2016
Supporting Feeding Journey:
Pre-Feeding Activities
P
R
E
 Enjoyable pre-feeding experiences to support
•Fully pre-pumped breast
•Pacifier progression
•Tastes or dips of milk
F
E
E
D
Pre-Feeding Goals
maturation
 Recommended for
 Developmentally immature infants
 Medically immature infants
 Infants with limitations on oral feedings
•Hold baby during tube
feedings
•Kangaroo care (skin-to-skin)
•Neurobehavioral supports
(swaddling, nesting,
positioning)
•Positioning in bed
•Neuroprotective activities
•Oral care
Provide enjoyable experiences to support feeding at every stage
Feeding Readiness
Feeding Readiness
 General Guidelines for Oral
 Parent Goal Consideration: Breast, bottle, combo?
 Infant and family-driven decision
Feeding Initiation:

Typically breastfeeding with flow can start at 33 weeks if infant is
medically ready
 In general, bottle feeds can start as early as 34 weeks dependent
on infant’s status and family wishes
33-34 weeks+ and medical readiness
 Factors to Consider:
 Pre-feeding skill competency
 Adjusted age
 Medical co-morbidities, including
respiratory status and feeding tolerance
 Infant’s cues
 Family presence and preferences

“Feeding cannot be
accelerated…. so let the
child show you the way”
(Ross, 2002)
Optimum Feeding Experience
Typical Observations during Feeding
• State Regulation
• Breath Integration
• Postural Control
• Sucks per Burst
• Quality of Root, Latch &
• Respiratory Needs, WOB
•
•
•
•
•
Suck Initiation
Quality of Suction
Structural Stability
Quality of Swallow
Rhythmicity of
Suck/Swallow/Breathe
Ratio of Suck to Swallow
• Infant’s Pacing Needs
• Physiological Stability
• Signs of Stress,
Discomfort or
Disorganization
• Response to Feeder
Inputs/Supports
Glass 2012, Faherty 2012, Thoyre 2011, Brown & Ross 2011, Wolf & Glass 1992, Arvedson & Brodskey 1994, Lau 1997, Lau
& Schandler 2000, Mathew 1991, Shaker 1999, Shaker 2010, Ross 2009
Faherty & Elliott, PNANN 2016
Successful Feeding = Consistent, Quality Practice
• Relaxed posture
• Stable vital signs
• Minimal to no disengagement or stress cues
•
•
•
•
•
•
Any stress cues are immediately alleviated by feeder response
Developmentally expected suck-swallow-breathe pattern
given experience, adjusted age and medical status
Coordinated swallow
Feeder attentive throughout feed
Feeder anticipating and/or matching infant needs
Infant’s stop/all done cues are clear and respected without
fatigue-decline in feeding quality
Brown & Ross 2011, Glass 2012, Lau 1997, Lau & Schandler 2000, Mathew 1991, Shaker 1999, Shaker 2010, Ross 2009,
Chang et al 2007, Gewolb et al 2006, Goldfield et al 2006, Thoyre 2011
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Maximize NICU Feeding Success
10/12/2016
Supporting Feeding Journey
Neurologic
Immaturity
Feeder
 Suck-swallow-breathe integration
Oral-Motor
Control
True
Neurological
Dysfunction
 Endurance
State Regulation
FEEDING
Structural
Integrity
Three Common Feeding Challenges
 Feeder variables
Muscle Tone
GI intolerance
Endurance
Respiratory
Status
Sensory
Integration
Feeding Developmental Model
BROSS (Baby Regulated Organization of Sucking and Subsystems)
F
E
E
D
~37-42 wks
~40+ wks
F
E
E
D
~32-35 wks
~ 34-36 wks
~34-36 wks
P
R
E
F
E
E
D
Potential Feeding Modifications
 Positioning
 Feeding modality & Flow
 Pacing
 Respect endurance
 Volume
 Frequency
 Stridor precautions
 Swallow specific
 Temperature
 Viscosity*
(adapted from Browne & Ross, 2001)
Positional Modifications
Sidelying, cross-cradle at breast
Sidelying, often helpful for premature
Infants. More horizontal for those with
respiratory compromise. Head supported.
Faherty & Elliott, PNANN 2016
Feeding Modality & Flow Modifications
Swaddled, arms flexed and at midline
If more mature: Semi-reclined,
may need c-hold for additional
support
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Maximize NICU Feeding Success
Flow Modifications: Breast
 Pre-Pump (pre-feeding activity)
10/12/2016
Flow Modifications: Bottle/Binky Trainer
 Nipple Selection
 Partially Pre-Pump (many ways to achieve

this)
 Nipple Shield
 Recline mother “biological position”
Binky Trainer with Resistance, Binky Trainer,
Dr. Brown’s Ultra Preemie, Dr. Brown’s
Preemie, Avent Natural First Flow, Similac
Yellow slow flow, Dr. Brown’s #1, Avent
Natural #1, Standard nipple
 Amount of Milk in Nipple
 Half-full nipple head vs full nipple head
 Positioning: sidelying vs semi-reclined
Pacing Modifications
With Breastfeeding:
 Unlatch briefly
 Stop milk flow by occluding milk ducts
With Bottle Feeding:
 Bottle is horizontal, with half-full nipple
 Then feeder tips it down to remove milk from nipple per
infant’s needs
 Resume milk flow once infant is ready for next sucking burst
With Binky Trainer
 Pull-back liquid based on sucks/burst, volume, cues
Respecting Endurance & Limitations
 Medical and Developmental Limitations



Respiratory
GI tolerance
Neurodevelopmental status
 Reading and responding to Infant’s cues


Infant driven, with feeder following cues
Feeder responsive to infant’s cues to dictate: when to eat, how fast,
how much help is needed, when to stop...
 Endurance Strategies



Volume recommendations
Frequency guidelines
Stridor precautions
Faherty & Elliott, PNANN 2016
Pacing Modifications
 Strategy to assist the infant in improving consistency
of self-pacing
 Conducted by the feeder for the first several sucking
bursts then decreased as appropriate to allow the
infant to pace independently


May need to be reintroduced with fatigue
May need to be consistent and strict throughout feeding
 Consistent across feeders, but also dynamic by
following infant’s cues
Respectful of Infant’s Cues
 Readiness Cues
 Stop cues
 Disengagement vs Stress cues
 Variety of Cues
 Autonomic (physiologic stability)
 Motoric (tone)
 State (how transitions, ability to
engage)
 Interest
 Competence
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Maximize NICU Feeding Success
10/12/2016
Supporting Feeding Journey:
Feeding Modifications
How much help you give, depends on baby’s stage
Position - Sidelying head elevated or Upright
Flow - Gradually continue to increase in flow
Pacing - Occasional, every 5-7 sucks,
Less need for long breath breaks
“I can do this myself!”
No help by feeder
Position - Sideling, likely head elevated
Flow - Gradually increase flow
Fuller nipple head, less pre-pumping
Pacing - Intermittent, every 3-5 sucks,
May still need longer breath breaks
Position - Side lying, likely horizontal, supported on pillow/lap
Flow - Slower flow, likely half-full nipple, partial pre-pumping
Pacing - Frequent, every 2-3 sucks
Will need longer breath breaks between bursts
“HELP ME!”
High amount of
help by feeder
(BROSS, adapted from Browne & Ross, 2001)
(BROSS, adapted from Browne & Ross, 2001)
Supporting Feeding Journey:
Feeding Modifications
Videos – Feeding Examples
Infant able to integrate with feeder and environment
actively during feeding. Likely does not require
specific feeding modifications.
Position - More upright, may still need c-hold for neck
support
Flow - No pre-pumping
May use newborn nipple or fuller nipple
Pacing - Not needed or only when baby is tired
(BROSS, adapted from Browne & Ross, 2001)
Benefits of Feeding Plans/Crib Programs
 Communication Among the Team to assure Infant’s





Best and Consistent Practice
Continuity of Care to Set Infant up to Succeed
New Feeder / Parent Able to Support infant
Infant more likely to Enjoy Feeding
Eliminate Infant’s Need for Compensatory
Adaptations with Each Feed
Consistent feeding experience
Faherty & Elliott, PNANN 2016
Communicating Feeding Progress
 Common feeding supports and modifications
 Quality
 Caregiver ability feeding infant
 Volume
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Maximize NICU Feeding Success
10/12/2016
Assessment of Progress
What to Do When Feeding is Not Going Well?
 Confirm consistent feeding plan is in use
 Provide break from feeding and attempt to resume
 Attempt online modification of feeding plan
 Stop oral feeding
 Document, specifically to aid problem-solving
 Communicate regarding discrepancy between
expected and actual performance
 24-hour analysis
 Level of dependence on feeding modifications:


Improving independence?
Increased support?
 Overall trend(s):





Quality ratings/narrative reports
Consistency of feeding performance
Frequency of oral feeds
Volume average per feed
Total PO %
 Stability & endurance
 Parent/caregiver competence feeding their baby
If Not Progressing, Now What?
 When things aren’t progressing, differential diagnosis on what
barrier(s) are impacting feeding:







Respiratory
GI tolerance
Neurologic
Immaturity
Structural
Parent variables
Think back to variables listed on the ‘supporting feeding journey’
 Everyone’s input and perspective is important
 RN documentation and input is critical
 If additional information of swallow safety is warranted as
part of the differential, then proceed to VFSS if medically
appropriate to do so
Feeding Modifications to Trial for
Respiratory Issues
 Increase frequency of external pacing: shorten suck




burst length
Sidelying position with more horizontal position,
rather than head elevated
Small intermittent 1-2 minute break to replenish
respiratory reserves mid-feeding
Prolonged breathing breaks as warranted to allow
return to adequate respiratory rate
Slow down the flow
Feeding Modifications to Trial for Sucking Issues
 Slow down the flow – Slower nipple, less milk in
nipple, more frequent pacing, sidelying position
 Reduce flow of milk – at breast increase amount of
partial pre-pumping, with bottle reduce amount in
nipple or change to slower nipple
 Regroup with non-nutritive suck on pacifier before
resuming oral feeding
 Rare instances, change nipple shape / density to
provide change in oral-sensory input
Potential Clinical Signs of Dysphagia
 Wet or gurgly vocal quality
 Upper airway sounds, wheezing
 Stridor
 Disengagement with feedings
 Decreased physiologic stability with feedings
 Coughing*, choking, gagging
Jadrechla, 2016; Fraker & Walbert, 2003; Arvedson, 2011
Faherty & Elliott, PNANN 2016
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Maximize NICU Feeding Success
10/12/2016
Supraglottal / Laryngeal Penetration
Aim of Pediatric VFSS
Liquid within the laryngeal inlet, ABOVE the vocal folds
 Instrumental Evaluation of the Anatomy and Physiology
of swallowing mechanism

Identify Patterns & Consequences of atypical physiology
 Identify effective therapeutic interventions to enhance
swallow safety
 Criteria for Neonatal VFSS at UWMC


>37 weeks adjusted age or older
Potential candidate if:
Arytenoid
Clinical signs of aspiration on serial clinical swallowing evaluations
Poor feeding progression with concern for aspiration as contributing
factor
 High risk of silent aspiration given underlying medical status
 Medical stability to tolerate procedure
Thyroid Cartilage


Vocal Folds
Aspiration
Videos – VFSS Examples
Liquid BELOW the vocal folds
Arytenoid
Thyroid Cartilage
Vocal Fold
Potential Outcomes of VFSS
What’s safe for infant?
 Full oral
 Partial oral feeds
 No oral feeds with pre-feeding developmental exposure as focus
If infant appears safe to continue oral feedings:
 Adaptations to current feeding plan with one or more of following:





Positioning
Feeding Modality & Flow
Pacing
Respect Endurance
 Volume
 Frequency
 Stridor Precaution recommendations
Swallowing Specific Modifications
 Temperature
 Viscosity*
Dysphagia Management
 VFSS is only one moment in time
 Was your sample representative?
 Plan identified in VFSS booth has to be vetted in the
“real feeding” situation




What’s safe for infant in “real life”?
Plan reliability?
Is it doable and family friendly?
GI tolerance?
 Maintain current feeding plan and modifications
Faherty & Elliott, PNANN 2016
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Maximize NICU Feeding Success
10/12/2016
Balancing Act of Dysphagia Management
Objectives Review
 Named three common feeding challenges in the
SAFETY
NICU
 Identified five strategies that help facilitate infant’s
feeding quality
 Became familiar with use of VFSS to assist with
decision making of feeding modifications
QUALITY
OF LIFE
REALITY
Questions?
“Astute assessment of why the behavior occurs allows you
~Every feeding experience matters~
to strategize what caregiver techniques will ensure safe,
functional, nurturing, and developmentally appropriate
feedings for that infant in that moment. Feeding is a dance
between you and the infant with a continuous cycle of
assessing, strategizing, and providing appropriate
techniques during every moment of the feeding.”
– Ludwig & Waitzman, Infant Driven Feeding Scale
Faherty & Elliott, PNANN 2016
Amy Faherty, MS, CCC-SLP, 206-598-8316, [email protected]
Tiffany Elliott, MS, CCC-SLP, 206-598-4746, [email protected]
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