3/18/2016
Making Infant Feeding
Successful: Skillful Evaluation
and Treatment Techniques
Financial Disclosure
• We have no financial disclosures other
than we are all employees of Gillette
Children’s Specialty Healthcare
Karri Larson, RD
Kathy Maroney, OTR/L
Michelle Seim, MA, CCC-SLP
Feeding as a system
Infant Feeding
Evaluation
Sensory
/Oral
Aversion
Oral
motor
Behavior
Family Dynamics
Positioning
Medical/Dysphagia
Order
• We are presenting in the order we try to
accomplish the evaluation
• Be flexible
History section
• What brings you to feeding clinic?
• Past Medical History
• Current Services
– Sometimes they are hungry and fussy at the
beginning. At least try to get major medical
information first but you might have to feed
before oral motor exam, feeding schedule,
etc.
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Past Medical History
Family Support
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Anxiety around feeding
Fears of FTT
Coping with parental expectations
less science and more art/reading cues of
the infant
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Diagnoses?
Food Allergies?
Chronic nasal congestion?
History of respiratory illness, intubation, asthma, or
pneumonia?
• Difficulties managing secretion?
• Diagnoses like laryngomalacia, vocal fold paralyses?
Past Medical History
• Cry frequently, arching, Sandifer’s reflex, draw the legs
up to the stomach or other behaviors that suggest
abdominal discomfort/reflux?
• Constipation?
• History of tube feeding? When and why?
• History of diagnostic tests—Video fluoroscopy swallow
study, GI emptying study, upper GI study for reflux?
When and results?
Analysis of Medical History
• Allergies: eosinophilic esophagitis (EE) or gut or
esophageal inflammation
• Nasal congestion: mouth breathing, poor
suck/swallow, morning vomiting, tonsils/adenoids,
referral to ENT
• Respiratory: aspiration? VFLO?, positioning,
breathing over eating, poor pacing, poor
coordination, tonsils/adenoids, referrals to
pulmonology, pulse oxymeter, cardiac history,
implication of intubation
Review of systems
Analysis of Medical History
• Abdominal discomfort/reflux: reflux, motility,
allergies or tolerance, muscle tone, volumes,
positioning (during and after), constipation, referral to
GI
• Tube feeding: why? Volume, alertness, airway,
growth, type of tube-G or GJ?, type of formulaelemental?, rate and timing
• Diagnostics: any diagnoses? Any ruled out issues?
• Reflexes: 4-6 months rooting and suckling reflex
deminishes
• Consider in the assessment how this
affects treatment planning
– Structures and muscles of:
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mouth
nose
respiratory system
digestive system
cardiac systems
overall postural control
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Sensory considerations
Feeding Schedule
• Review:
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Diet
Timings
volumes/reflux
red flags
• We use a feeding schedule form for family to fill
out
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Previous experiences highly important
Proprioception
Vision
Hearing
Taste
Tactile
Oral Motor
• Make your observations as functional as
possible
• Infant state at rest and non-nutritive suck
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try to initiate a suck on finger-slight upward position
dip finger for a taste
similac/nuk pacifier with finger inside
stroke tongue mid-tongue to front
Start Feeding Observation
• Parent should feed the infant first
– as they would typically do at home
• Therapist should try to feed prior to infant
finishing feed
– know timing and amounts and hunger level
Oral Motor
• Areas to look at with nutritive and non-nutritive suck:
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Oral tongue movement
Control
Strength and ROM
Lip closure/lip seal
Liquid loss (when and where)
Frenulum/tongue tie
Oral transit (efficiency)
Munch vs. suckle
Jaw
Voice-quality
Gag-observed
Documentation
• Presented by
• Equipment used
– Bottles
– Nipples
– Positioning
• Description of swallow function
• Sensory responses/adverse reactions
• Other observations
• Strategies assessed and outcomes
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Positioning
• In what?
– Arms
– Swaddled
– With boppy pillow
– Tumbleform
– Pillows on couch
• By whom?
– Mother
– Father
– Nurse/PCA
– Extended family
– Daycare provider
• Position?
– Upright
– Semi-reclined
– Full reclined
– Side-lying
– Breast feeding position
Description of swallow
• Suck: Swallow Ratio (should be 1:1), number of sucks in
the burst.
– Any signs or symptoms of aspiration: coughing,
gurgly voice, increased congestion.
– If possible palpate swallow to describe timing of
trigger and laryngeal elevation (particularly in older
children 1 year and up).
– Increased respiratory rate or effort, gag, stridor?
– Watch for: Nasal flaring, pacing, munch vs. suckle,
color change, watery eyes
Nutritive and Non-Nutritive
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Strength: ___strong ___moderate ___weak
Suction?
Compression?
Coordinated?
Breaks in suction? When?
Initiates sucking?
Rhythmic?
Infant State
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Oral aversion
State at rest versus feeding
Respiratory quality
Stress signals
• Nasal flaring, watery eyes, shutting eyes, arching,
breathing changes, unstable heart rate and O2
sats, increased movement, crying, color change,
gulping, gurgly sounds, repeat swallows, coughing
Description of swallow
• Good seal with a suck every 1 second
• Burst-pause pattern:
– 10-15 sucks, pause, swallow, take a breath and
repeat
– normal but more important is consistent, coordinated,
rhythmic pattern to reduce risk of aspiration
• Bubbles should be seen with every suck in bottle to
show good flow
• Burping as needed/burping hesitancy
Breastfeeding
• Looking for similar swallow patterns with breastfeeding
as bottle
– latching=lip seal on bottle
– Coordination of suck, swallow, breathe
– Jaw and tongue movement
• Breastfeeding variables
– Child vs. parent initiated latch
– Flow / amount
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Swallow Documentation
• Description of swallow should include more than
just signs and symptoms of aspiration and
penetration
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Signs and symptoms of aspiration
When see signs and symptoms of aspiration
Coordination
Oxymetry reading (if appropriate)
Fatigue
Baby’s alertness/reactions
Timing of reactions
Clinician input
• Therapist should try to feed prior to infant
finishing feed.
• Modifications:
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Pacing
Positioning
Support
Thickening
Swaddling
Is he/she a VitalStim candidate?
Positioning
Pacing
• External
– Rhythmic patting, tap of bottle
– Take bottle out
• Bottle
– Flow too fast or too slow? Thickening?
– Don’t get bogged down with the types and nipples
– Start with what they come in with and try to adjust within that
system based off of what you see
– Air to liquid ratio
• Volume
– With dietician, consider changing amounts and schedule
• Consider changing positioning during and after the
feeding
• More upright- consider for reflux
• Elevated side-lying-consider for strong/weak sides or
vocal cords and for more stable oxygen and heart rate
• In front for better external support of head and oral
structures
Support
Swaddle
• External support can improve:
– Organization of body
– Feedings with hyper/hypotonic
– Temperature regulation
– Alertness
• Be weary of too tight of a swaddle during
and after the feeding with reflux
• Facial support
– Hold bottle with one to two cheek and/or chin
support if extra oral loss
• Consider the feeder’s hand and bottle type
(sometimes a narrower bottle makes it easier)
– Front to bottom of jaw to reduce jaw thrusting
– Press up on bone under chin to help with
stripping action of tongue
– Pull jaw forward
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Thickening
• The goal is to reduce thickening
• Each facility has different guidelines and at
Gillette we require a physician recommendation
for thickening due to NEC concerns
• Normally they come in with recommendations
from VFLO and have changes based on VFLO
but it is fair to recommend another VFLO to
assess thickening or change in session for a trial
• Check they are thickening appropriately
Consider NMES/VitalStim
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FDA approved modality for treatment of dysphagia
Certification is required
VFLO prior to treatment with NMES and repeat VFLO
NMES is a modality in treatment
3x/week for 8-12 weeks
Studies show improvement as a modality in conjunction
with traditional therapy
Christiaanse et. al, 2011, Rice, 2012
How to move forward?
Infant Nutrition Tidbits
• What would be treatment strategies you would try with this child?
– 8 month infant with Down’s syndrome
– low tone
– Incoordination of suck/swallow/breathe
– increased illness-decreased weight gain
– intubation leaving left vocal cord paralysis
– VFLO: silent aspiration. Watery eyes observed. Study
recommended honey thick and NMES
Karri Larson, RD
Ultimate Goal of Infant Nutrition
GROWTH!
Goal of Infant Nutrition
• Secondary Goal
– Prepare infant for successful eating in the real
world
– 12 months of age
• Eating modified version of what family is eating
• 3 meals + 2-3 snacks
• Drinking from a sippy cup
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Division of Responsibility
(Ellyn Satter)
The Division of Responsibility for infants:
• The parent is responsible for what.
• The child is responsible for how much (and everything
else).
• Parents choose breast- or formula-feeding, and help the
infant be calm and organized. Then they feed smoothly,
paying attention to information coming from the baby
about timing, tempo, frequency, and amounts.
Medically Complex Infants
• This goal may need to be modified or the
timeline to reach this goal altered
• Developmental delays interfere with timeline
• Goals need to be adapted to fit each infant
– No two infants are the same
• Goal should never be “I want my baby to
sleep through the night”
• Consider quality of life issues for child/parent
Calories Please!
Babies need a lot of calories
• Calorie goal is 108 calories/kg up to 6 months
• Calorie goal is 98 calories/kg for 6-12 months
• Adults get 25-35 calories/kg (68 x 30 = 2040)
Division of Responsibility
(Ellyn Satter)
The Division of Responsibility for babies making the
transition to family food:
• The parent is still responsible for what, and is becoming
responsible for when and where the child is fed.
• The child is still and always responsible for how much
and whether to eat the foods offered by the parent.
• Based on what the child can do, not on how old s/he is,
parents guide the child’s transition from nipple feeding
through semi-solids, then thick-and-lumpy food, to finger
food at family meals.
Infant Feeding Practices
• Breastfeeding is best
• Bottle Feeding Expressed breast milk is
close 2nd
• Formula feeding is a wonderful alternative
– Many options on the market
– Low lactose, broken down proteins, added
rice, hypoallergenic, soy
– Names, additives, concentrations constantly
changing
Baby calories
• Baby born 8 pounds = 3.64 kg
– 3.64 x 108 = 393 calories
• Most breast milk and formula averages to be 20
calories/ounce so baby would need to drink ~ 20
ounces/ day
• Newborn stomach is the size of a walnut so that
is why they need to eat 8-12 times a day
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A note about reflux
• Some degree of spit up is normal
– Esophageal sphincter is immature
• when baby is in pain and uncomfortable, it
may need to be treated
• Reflux meds do not cure reflux, they treat it
• Research has shown that thicker formula
does not lessen reflux
– Should not be adding rice cereal for reflux
– Can be added for dysphagia but it displaces
nutrients
– Enfamil AR is better than adding it ($$)
Tube feedings
• Goal is for tube feedings to mimic similar feeding
pattern for age
– For example a 2 month old infant would get 3
ounce bolus 6-7 times/day
– an 11 month old would get 6 ounce bolus 3
times a day and 4 ounce bolus 2 times a day
• If tolerance is an issue, may need to consider
continuous feeds via pump
Starting Solids
Weaning tube feedings
• To wean from feeds, infant must be able to
demonstrate:
– feeding skills
– ability to eat safely
– intact hunger/satiety cues
• Most often a large decrease in calories is
needed to promote hunger
• May need to consider appetite stimulant
Allergies
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On the rise, but not as prevalent as you think
More common in babies with family history
4 in 100 children have a confirmed food allergy
90% of food allergies are from: milk, eggs,
peanuts, tree nuts, fish, shellfish, soy, and wheat
(protein)
– Much less common to be allergic to fruit or
vegetables
• Current recommendation from AAP is 6 months of
age
• This is from a physiological perspective, some
babies many not be developmentally ready
• What to begin with?
– Anything!
– Some countries, start with avocado and mashed
beans, some countries start with rice or (grain)
porridge, some countries start with pureed fruit or
vegetable, new trend to start with meats to help with
iron levels
– Baby lead weaning (trend in Europe)
When to seek help from an RD
• Weight loss or FTT
• Very limited diet
– I can’t get a kid to eat any more than you can, but I can
recommend supplements to bridge the gap until feeding
skills have improved and the repertoire of foods has
expanded
• Oral intake has improved and tube feedings may need
to be weaned
• Tube feeding routine is impeding progress in feeding
therapy
• Diagnosis has nutrition considerations
– Bartter syndrome=salt wasting disease=Na/K rich foods
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3/18/2016
Making Infant Feeding
Successful: Skillful Evaluation
and Treatment Techniques
Karri Larson, RD
Kathy Maroney, OTR/L
Michelle Seim, MA, CCC-SLP
How to move forward?
• What would be treatment strategies you would try with this child?
– 8 month infant with Down’s syndrome
– low tone
– Incoordination of suck/swallow/breathe
– increased illness-decreased weight gain
– intubation leaving left vocal cord paralysis
– VFLO: silent aspiration. Watery eyes observed. Study
recommended honey thick and NMES
Feeding as a system
Infant Feeding
Treatment
Sensory /Oral
Aversion
Oral motor
Behavior
Family Dynamics
Positioning
Medical/Dysphagia
Outcomes of successful
treatment
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Safe feeder
Appropriate duration of feeding times
Optimal weight gain
Pleasure and bonding from feeding
Evidence
• Bag of tricks
– Get Permission/Marsha Dunn Klein
– Food Chaining/Cheri Fraker
– Oral Motor/ Beckman
– NMES/Vital Stim
– SOS/ Kay Toomey
– Division of Responsibility/Ellyn Satter
– Cue-based Feeding/Catherine Shaker
• There is more evidence but it is still limited
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Family Dynamics
• Feeding is social
• Bottling/Breastfeeding has a bonding
component
• Parental stress
• Negative experiences
Issues seen in Evaluation
• Prolonged feeding times
– Changing daily scheduling, limiting to 20-30 minute feedings
• Grazing
– Changing the schedule and caregiver’s expectations
• Forced Feedings
– Positive successful experiences most important, don’t want to
see signs of stress during feedings
• Sleeper feeding
– Place to start but need to develop skill versus reflexes, consider
breathing as component, work on gentle arousal strategies
Feeding Schedule/Duration
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Facilitate hunger
Consider endurance and fatigue
Pacifier versus nutritive
Routine
Always end with positive experience
Bottling
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Tube feed or FTT typically
Stress pleasure feeding versus volume
Quality is more important that quantity
Non-Nutritive suck can be helpful in
treatment
Strategies
• Modifications:
– Feeding duration
– Safety/thickening
– Positioning/Swaddling
– Support/oral motor/non-nutritive
– Pacing/bottling
Safety
• Oral hygiene is a consideration for all infants that
aspirate to help reduce aspiration pneumonia
• Pulse oximeter
– Get baseline information on O2 saturations
– Use with your signs and symptoms you are
seeing to create a better feeding plan
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Thickening
Thickening
• Types of thickening
– Oatmeal/rice cereal
– Gel for thickening breastmilk
– Commercial thickeners
– please check with their doctor before the age of one year of age
• Liquid thickness:
– Thin
– Nectar
– Honey
– Pudding
• Normally they come in with recommendations from
VFLO but it is fair to recommend another VFLO to
assess thickening or trial a different texture in therapy
• Check they are thickening appropriately
• Goal is to get to a thinner liquid for infants
• Consider thickening may affect digestion
• Consider NMES/Vital Stim
NMES/VitalStim
• NMES is a modality in treatment to
strengthen the swallow
• 3x/week for 8-12 weeks
• This is in addition to all other treatment
techniques
Positioning
• Consider changing positioning during and after
the feeding
• More upright
– consider for reflux
• Elevated side-lying
– consider for strong/weak sides or vocal cords
and for more stable oxygen and heart rate
• In front for better external support of head and
oral structures
Support
Swaddle
• External support can improve:
– Organization of body
– Feedings with hyper/hypotonic
– Temperature regulation
– Alertness
• Be wary of too tight of a swaddle during
and after the feeding with reflux
• Commercial swaddle blankets are an
option
• Facial support
– Hold bottle using your fingers to support one
or two cheeks and/or chin (if seal issues and
extra oral loss)
• Consider the feeder’s hand and bottle type
(sometimes a narrower bottle makes it easier)
– Front to bottom of jaw to reduce jaw thrusting
– Press up on bone under chin to help with
stripping action of tongue
– Pull jaw forward
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Oral Motor/Non-nutritive
• Where are skills with lips, cheeks, and
tongue?
– Consider
– Consider
– Consider
– Consider
Beckman depending on needs
pacifier
nuk brush, vibration
different tactile stimuli
Flow rates
• Different nipples have different flow rates
• These change all of the time
– Avent:1-4, variable
– Gerber: visualized with drops, S, M, F, X, Y
– Dr. Brown Premie, Specialty,1-4, Y
– Medela: S, M, F
– Playtex: S, M, F
– Tommy Tippie: S, M, F
Oral Aversion
• What about the infant that refuses the bottle?
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PLEASURE is key
Remind the family that it is a slow process
Start where the infant is at and take the next baby step
Note the different stimuli the infant allows in the mouth
Start with toys/pacifiers/teethers for oral exploration
Consider caregiver kisses for oral tactile input
Dipping into formula for taste exploration
May consider spoon before bottle depending on the age
Stop while your ahead and it is still a positive experience
Pacing
• External
– Rhythmic body patting or tap of bottle
– Take bottle out-move to corner
• Bottle
– Flow too fast or too slow? Thickening?
– Don’t get bogged down with the types and nipples
– Start with what they come in with and try to adjust within that
system based off of what you see
– Air to liquid ratio
• Volume
– With dietician, consider changing amounts and schedule
Nipple types
– First problem solve flow rate, then lip seal,
then nipple shape
– All number systems are not the same
– Nipple length is a consideration
– Flatter nipples vs. straight
– Wide nipple (in vogue) vs. standard size
– Generally you can interchange standard
nipples on a standard size bottles
– Specialty nipples like Haberman, Dr. Brown
Spoon to bottle?
• Depending on age and developmental age
the infant may have more success with
purees first before bottle
• Some infants skip bottles all together
• Especially consider for infants with
thickened liquid recommendations
• Variety of sip cups could be considered
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Spoons
Bottle to spoon
• Limit wiping- best if only at end
• Positive atmosphere- no force feeding or
tricks
• Start with spoon only and/or formula they
already know
• Use pacifier, fingers, nuk with tastes
• Consider spoon type
• Spoon presentation
Case Example 1
• History:
– 8 mo infant with Down’s syndrome
– low tone
– Incoordination of suck/swallow/breathe
– increased illness-decreased weight gain
– intubation leaving left vocal cord paralysis
– VFLO: silent aspiration. Watery eyes observed. Study
recommended honey thick and NMES
Case Example 1
• Treatment:
– NMES
– right side lying for VF paralysis from intubation
– pulse oximeter/signs for breathing breaks – history of cardiac
and coordination needs
– swaddled for additional support- low tone
– patting
– thickened liquids-honey per VFLO
• Results:
– NMES: 8 weeks resulted in nectar liquids, no aspiration, no
positioning needed
– Intubation injury resolved
– More coordination and continued pacing
• Consider bowl depth
– Smaller/ shallow: duospoon, Beckman EZ
spoon, maroon, infant coated, Dr. Brown
spatula spoons, take n toss
– Deeper/wider: maroon, munchkins, gerber
Case Example 1
Goals:
– Will drink 5 oz of thickened formula in less than 25 minutes over
an 8-10 week period to reduce fatigue and feeding times
– Will drink thickened liquids without any signs of aspiration as
determined by a follow up VFLO after NMES treatment is
complete
– His family will learn and implement oral hygiene into his feeding
routine as noted by parent report over 3 sessions within 8 weeks
Case Example 2
History:
• Chronic lung disease
• Bilateral Grade IV IVH
• s/p shunt
• Increased tone
• Born at 23 weeks gestation
• Arrived to clinic on oxygen via nasal cannula
• G-tube feeds and history of silent aspiration but
moved up to nectar during NICU stay.
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Case Example 2
Goals:
• Will demonstrate coordinated suck/swallow/
breathe pattern with no s/s of aspiration.
• Will take 60 mls of nectar thickened formula in
30 minutes 4 times per day.
• Will be cleared for thin liquids following NMES
with no s/s of aspiration.
Case Example 2
Case Example 2
Treatment:
• NMES using Vital Stim
• Recommended swaddling which did not work.
• Re-positioned him to a better visual field for mother to
watch cues.
• Taught Beckman oral motor.
• Exchanged nipple and bottle for increased efficiency
(moved away from self cut nipple and decreased volume
of bottle)
• Pacing for breath and rhythm (nasal flaring, butt/back
patting)
Questions?
Results:
• Off of oxygen 2-3 weeks into treatment
• Moved to all oral feeds and g-tube removed by 8 weeks
• Video swallow study resulted in moving to thin liquids via
medium to slow nipple rate.
• Continued with some oral dyscoordination with
suck/swallow/breathe
• Discontinued speech and continued OT for transition to
puree and overall developmental concerns
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