Feeding Fundamentals in the NICU:
Supporting the preterm/late preterm
infant
Erin Sundseth Ross, Ph.D., CCC-SLP
Developmental Specialist
HealthONE Hospital Systems
Denver, Colorado
Clinical Instructor
U. Of Colorado Denver, School of
Medicine, Department of Pediatrics
Section of Nutrition
Honorary Research Fellow
Clinical Nutrition Research Center
University of Queensland, Australia
Feeding Fundamentals, LLC
Objectives
• Describe the role of development in the
acquisition of feeding skills for preterm and late
preterm infants
• Discuss the efficacy of interventions designed to
hasten and/or to improve feeding skills
• Describe the prevalence of feeding and growth
problems in preterm infants
• Describe parameters of a feeding approach
based upon quality indicators
Background
• Goal in NICU: establish feedings quickly, transition to
full oral feedings, discharge
• Very real pressure from insurance companies because
feeding is not considered a “medical intervention” – it is
something that all babies do…
• Feeding is often the last milestone achieved in preterms
• 32.2% of late preterm infants (35-36 6/7) with diagnosis
of poor feeding (Wang, et al., 2004)
• Early intervention has focused on accelerating the
acquisition of oral feedings with a belief that “practice
makes perfect”
• Interventions often focus on the oral phase of feeding
(sucking) rather than on the ability to feed safely and
successfully (suck/swallow/breathe)
What we know
• Infant feeding is a function of both maturation
and experience (as is most of infant
development, e.g., talking, walking) – infant
must be developmentally ready, and then have
the opportunity to practice
• The outcome measure chosen directly
influences decisions made (i.e., first full oral
feed, full oral feeds, discharge date, transitions
across first year of feeding skill development &
growth)
Maturation
Longitudinal cohort study:
development of feeding
Mizuno and Ueda, 2003
Longitudinal cohort study:
development of feeding
Medoff-Cooper, 2005
What about your practice?
• What gestational age do you use to
determine a delay?
• How much of a delay is worrisome? (i.e., 2
standard deviations)
• Are you respecting the role of
development?
• Or, are you thinking you can do better than
normal?
Experience
Despite interventions to speed
the process, the mean
gestational age of acquisition
of full oral feedings is typically
≥ 36 weeks
However, there are individual variations
Normal variation
GA
(preterm infants with no medical
complications)
40
39
38
37
36
35
34
33
32
31
30
*
*
*
E
C
Initiation
First Full
Full
*= p<.05
RCT, n=29 healthy preterms mean GA 27w at birth;
Mean BW C = 1033g, E=1205g (NS)
O2 therapy mean days C= 27.4, E= 15.5 (NS)
D/C
Simpson, et al., 2002
Infant determined pace of progression
Simpson, et al., 2002
Individual skill acquisition
Interval in days
25
20
*
15
E
C
10
5
0
Intro to Full
First to Full
*p<.05
Simpson, et al., 2002
Late preterm
feeding
development
Cross-sectional, n=186
Dip in maturation between
35 and 37 weeks PMA
Medoff-Cooper, et al., 2001
What experiences do you
support in your practice?
• Do you focus on communication with the
infant?
• Do you focus on movement?
• Do you use evidence-based practices?
• Do you monitor physiologic, motor, state
communications?
Limitations of current interventions
• Data assessing efficacy of early intervention
has focused much attention on oral
stimulation/oral supports
• Little information about how the infant tolerates
oral stimulation (physiologic)
• Questionable negative influence on weight gain
• NO DIFFERENCE in length of stay or
attainment of full oral feeding
GA
Attainment of all oral feeds
40
38
36
34
32
30
Bragelien 2008
Boiron, 2007
Fucile, 2005; 2002
Control
Exp (Stim)
Exp
Exp (Sup)
(Stim+Sup)
Group
Bragelian, RCT n=36; Boiron, RCT n=43;Fucile, RCT n=32
* No significant differences in any study
Problems with programs
• Oral phase is not typically the phase that is
most difficult for preterm infants
– non-nutritive sucking develops around 28-30
weeks
– nutritive sucking develops 32-36 weeks
• Programs can be aversive/exhausting
• No data regarding physiologic response to
program
• Programs address oral movements that are
NOT involved in breast/bottle feeding
Fucile, et al, 2002
Oral structures involved in infant
feeding
• Tongue
– Lateral edges elevate to wrap around nipple/teat
• Suction
– Entire tongue elevates to compress nipple/teat
• Compression
• Palate
– compression and suction
• Jaw
– compression
Oral structures NOT involved
• Lips
– Used once food is introduced anteriorly
– Used during chewing
• Cheeks
– Buccal pads support sucking
– Cheeks are not active players
Fucile, et al, 2002
Weight Gain
2500
2000
1500
Exper
Control
1000
500
0
Birth weight
Weight at start
Weight at end
(Fucile, et al., 2002, 2005)
Feeding development
• Ability to suck and to suck/swallow is observed
prior to the ability to coordinate all of the phases
of swallow
• Intervention studies focused on only the ability to
suck lack an understanding of why feeding is so
challenging for many preterm infants
• Coordination of suck/swallow and breathe is
highly related to and influenced by gestational
age and respiratory status (Vice and Gewolb, 2008;
Mizuno, et al., 2007; Mandich, et al., 1996)
Key: Integration of breathing
• Cross-sectional (n=20 preterm, 16 term)
• Apneic swallows (% over the feeding) decreased
with increasing PMA
– 16.6% in preterm infants ≤35wks' PMA
– 6.6% in preterms >35wks
– 1.5% in term infants (p<0.001)
• Swallowing and respiration improved in
coordination with increasing PMA:
– decreased apnea
– significant increase in percentage of swallows
occurring at end-inspiration
Gewolb & Vice, 2006
Longitudinal development of
suck/swallow/breathe in BPD/non BPD preterms
• n= 34 (14 with BPD, 20 without)
• BPD – significant increase in apneic swallows
after 35 weeks (mean 13.4% [SE 2.4]) compared
with non-BDP infants (6.7% [SE 1.8]; p<0.05).
• BPD - significantly higher swallow-breathe
coefficient of variance (COV) as well as breathto-breath COV compared to non-BPD.
Gewolb and Vice, 2006
Thoyre, S and Carlson, J., (2003)
• 22 VLBW infants, each videotaped PTD
• Mean 10.8 desaturations episodes/feeding
• Mean duration 29.3 seconds
– 20% of feeding time <90%
– 59% (n=140) SpO2 85-89%
– 20% (n=47) SpO2 81-84%
– 21% (n=51) SpO2 ≤ 80%
Summary
• Individual variation in maturation and in medical
comorbidities influences feeding ability
• Use of a gestational age to determine readiness
to feed appears to be inappropriate
• NICU’s often lack a systematic process to
determine readiness to feed and/or progress in
feeding due in part to this variation
• All NICU’s need to contain costs and length of
stay
Problem
• Only 0.8% of moderately preterm infants (32-34) discharge
home with supplemental tube feedings
• 55% of preterm infants have problematic feeding behaviors by
6-18 months of age
• 40% of preterm infants have weights, lengths and head
circumferences < 10% by 18-22 mo corrected
• Preterm infants 3.6X more likely to have feeding problems
than full term infants at 6 years of age
• Parents of children with feeding problems report increased
stress, anxiety, and diminished family functioning
Kirkby, et al., 2007; Dusick, et al.,
2003; Hawdon, 2000; Samara, et al.,
2009;Thoyre, 2007
What happens between discharge
and 6 months?
• Feeding skills change from reflexively based to
volitional
< 3 months of age
Primitive Action
> 3 months of age
Volitional Action
• Learning has occurred (Classical conditioning)
• If learning has been negative, feeding problems
reveal themselves
Growth Faltering
• Majority of infants who have feeding
difficulties and poor growth falter
between 3 and 6 months
developmental age.
Kelleher, et al., 1993; Ramsay, et al., 1993, 2002;
Casey, et al., 1984; Batchelor, 1996;
Wright, et al., 1991, 1998, 2000; Shrimpton, 2001
Early Indicator of Growth Faltering
• Longitudinal cohort (n=3727)
• Odds Ratio for reaching a weight-for-length
ratio z-score of ≤ -1.67 (≤ the 5th percentile)
between 7 and 24 months for infants who fell
more than 0.85 standard deviations in their
weight-for-age between two and four months of
age were 3.6 times that compared to infants
without this level of deceleration (p=0.0153)
Ross, 2007
Challenge
• Outcomes are rarely defined in terms of
the parent-infant relationship, or by quality
of feeding skills and stability
• Need to change focus from faster to better
quality without negatively influencing
length of stay
• How to accomplish?
What constitutes Quality?
•
•
•
•
Stability of the infant
Pleasurable for both infant and feeder
Supportive of adequate growth
Flexible to meet the unique needs of every
infant
• Supportive of the relationship between the
caregiver and the infant
• Supportive of skill development past the
transition to volitional feeding
Stability
• Physiologic, Motor and State stability all
influence feeding – both short and long term
• The environment may influence the stability of
the infant
• Caregivers need assess and support stability in
the infant
• Feeding ability is acutely influenced by overall
stability of the infant
Als, 1982
Are you listening?
• Infants communicate through their
behavior
• What are these infants telling you?
• How do they communicate?
• Are you listening?
• How are you responding?
Physiologic
• Provides the core stability for all other
systems
• Underlies feeding skills
• The infant communicates through:
– Color
– Respiratory patterns
– Visceral behaviors
Adapted from Als, 1982
Color
• Ideal (striving)
– Pink, stable
color over
entire body
• Organizing?
– Pale
– Flushed/Red
– Mottled
– Dusky
– Blue
Respiratory
• Ideal
• (striving)
– Regular
intervals
– 40-60 bpm,
slowing as infant
ages
• Organizing?
– Irregular
– Over 60 bpm
– Pauses in
breathing
– Hiccups
– Gasping
– Nasal flaring
– Panting
– Coughing
– Yawning
Visceral
• Ideal
(striving)
– Stable
digestion,
stooling
• Organizing?
– Spitting
up/vomiting
– Diarrhea
– Constipation
– Feeding
intolerance
Maybe infants are telling us something?
Motor
• Provides information regarding the feeding
progression
• Interacts with other systems
• Can be used to support the other systems
• The infant communicates through:
– Tone
– Posture
– Movement
Adapted from Als, 1982
Motor
• Ideal (striving)
– Flexed posture
– “Muscle energy”
– Smooth
movements
– Rounded face,
body, arms and
legs
• Organizing?
– Flaccid
– Tight
– Frantic/flailing
– Tremors
Supporting stability through Motor
• Infants obtain proprioceptive input through:
– Hands to face
– Hands to mouth
– Bracing feet
– Being swaddled
– Mouthing/Sucking
State
• States become more defined over time
• Can be used to support the other systems
• The infant communicates through:
– Range of states
– Clarity of states
– Transitions between states
Adapted from Als, 1982
Sleep-Wake States
•
•
•
•
•
•
•
•
Deep Sleep
Active (Light) Sleep
Drowsy
Quiet Alert
Hyperalert
Hypoalert
Fussy
Crying
Brazelton, 1973;
Als, 1986
States
• Ideal (striving)
– Clear states
– States that last at least 15
seconds
– Smooth transitions up and
down the state continuum
– Able to control incoming
stimuli
– Able to calm
– Developing predictability
– Appropriate for situation
• Organizing?
– Messy states
– Rapid transitions
– “Jumping” across states
– At the mercy of
incoming stimuli
– Unconsolable*
– Unpredictable
– States inappropriate for
situation (ie., sleeping
when should be eating)
Impact of Environment
• Distal and proximal environment can
support stability, or create instability
• Some infants are more at the mercy of
incoming stimuli than others
How are you determining
success?
• Are you listening to the infant?
• Are you helping the infant progress
through development? Or,
– Are you interfering with development?
– Are you having a monologue?
Preliminary Data (Ross)
• Longitudinal study
• N=27 (20 males, 7 females)
• Visits at discharge, term, 2 weeks, and
1,2,3,4 months
• Weights, lengths and parental interviews
at all visits
• Nutritional analysis term, 2 and 4 months
• Videotaped feedings at discharge, 2 and 4
months
Anthropometric Data
• Preliminary analysis:
– Weight gain/day term to 2 weeks ranged from
6.3 to 90.3 grams/day (mean = 36.2g)
– Kcal/kg/day at term (after discharge) ranged
from 56 kcal/kg to 225 kcal/kg (mean = 135
kcal/kg/day)
Mean z-scores
(corrected to term)
Weightfor-age
Term
2 weeks
1 month
-0.25
-0.21
-0.10 -0.01 0.58
0.66
0.53
Weight0.40
for-length
2 month
0.60
3 month
0.47
Z-score 0.00 = 50th percentile; 1.0 = 85th percentile; -1.0 = 15th percentile
Parental interviews
• Qualitative analysis beginning on parental
interviews:
– How do you feel when you are feeding your
baby?
– How do you feel when you are finished
feeding your baby?
– What behaviors does your baby demonstrate
when he/she is having a good feeding/poor
feeding?
Video analysis
• Code book developed, piloted
• First and last 6 minutes coded, added
• Behaviors coded positive if observed at all
within a 2 minute window (total possible
per behavior, per baby = 6)
• Interrater reliability 93-100% (6/28 initial)
Video analysis
• Behaviors coded:
– 12 Physiologic
– 6 Motor
– 7 State
– 23 Oral-Motor
– 2 Non-Baby Interruptions
Physiologic
• 5/12 never observed (RR>60, sneeze,
sigh, yawn, O2 <90)
• GI Grunting (22)
• Respiratory noises (15)
• Pauses > 3 sec in RR (10)
• Nasal flaring (9)
• Color change from baseline (7)
• Retractions (5)
• Hiccups (3)
Motor
•
•
•
•
•
•
Extensions (38)
Head turning (22)
Flaccidity (21)
Arching (13)
Pulling away from bottle (12)
Defensive maneuver, hands (2)
State *
•
•
•
•
•
Quiet alert (67)
Drowsy (65)
Light sleep (22)
Aroused/Fussy (4)
Deep sleep (2)
More than one state could be observed
within each 2 minute time period
Oral-Motor
• 6/23 never observed (burp during feeding,
tight lips, mouthing/biting nipple, nasal
regurgitation, slow/inefficient suck, spitting
up)
• Stop sucking (71)
• Dripping/dribbling (55)
• No initial sucking attempts (41)
• Isolated sucks (31)
Oral-motor
•
•
•
•
•
•
•
•
Vocal sounds (29)
Tongue clicking (21)
No latch (13)
No resistance to removal of bottle (12)
Cough (8)
Pushing nipple out (8)
“Bad face” (7)
Gag (5)
Oral-motor
•
•
•
•
•
Lip smacking (4)
Multiple swallows (>3) without a pause (4)
Choke (3)
Gulp (2)
Crowing sounds (2)
Non-baby related interruptions
• Bottle is empty (3)
• Parent is distracted from feeding (1)
Discharge
EXAMPLES OF POOR FEEDING
Discharge
EXAMPLES OF GOOD FEEDING
Still to come…
• Analysis of all videotapes, across all 3
time periods
• Correlation between videotaped
behaviors, growth, nutrient intake, and
parental reports of 1) behaviors reported
during poor and good feedings, and 2)
parental reports of emotions during and
after feedings
What to consider…
• Feeding is more than just calories in
• Parents are successful at getting calories
in, during the reflexive time period, but it
gets more difficult as the infant matures
• Perhaps we can do better?
• What can we do now (i.e., Monday!)
Stability and Growth
• Integration of suck/swallow and breathe
matures later than the ability to suck, and
infants communicate instability through
behavioral cues and by pausing in feeding
• Decreased flow rate and pacing of the infant
feeding to support suck/swallow and breathe
both shown to improve feeding without
compromising weight gain or LOS
Faster is not better….
• RCT: Infants fed with single-hole nipple units compared to
those fed with a cross-cut nipple:
– Higher intake (57.5 ± 8.3 ml vs. 51.6 ± 9.5 ml, p=.011)
– Decreased duration feeding time per meal (11.5 ± 4.9 min
vs. 20.9 ± 5.0 min, p<.001)
– Higher efficiency (5.8 ± 2.5 ml/min vs. 2.7 ± 1.0 ml/min,
p<.001)
• With cross-cut nipple units
– Higher RR (44.4 ± 4.6 breaths/minutes vs. 40.8 ± 4.9
breaths/minutes, p=.002)
Chang, et al., 2007
Pacing
• Non-randomized consecutive study
• 36 infants – 18 in control, 18 in paced group
• Paced infants demonstrated significant
decreases in Bradycardic incidences
• Gains in development of more efficient sucking
patterns at discharge
• No change in discharge or average weekly
weight gain
Law-Morstatt, et al., 2003
Individualized and Growth
• RCT: control (n = 41); experimental (n = 40)
• Oral feedings offered contingent on infant behavior of
alerting to at least a drowsy level
• If alert, offered an oral feeding; if not alert, gavage fed
• Feedings stopped based on infant fatigue, infant
stopping sucking, or infant instability
• Remaining volume gavaged if necessary
• The semi-demand method shortened the time for
infants to achieve oral feeding by 5 days, no difference
in weight gain (P < .001)
McCain, et al., 2001
Family intervention
• Randomized, repeated measures intervention
• n=34, <1500 grams
• Decrease in:
–
–
–
–
grimacing (P < .001)
gagging (P < .05)
Maternal interruptions during feeding (P < .001)
Maternal bottle stimulation (P < .01)
• Increase in:
–
–
–
–
–
Maternal smiling (P < .001)
Maternal vocalization (P < .01)
Sensitivity to infant behavior (P < .001)
Quality of physical contact (P < .001)
More positive affect (P < .01)
Meyer, et al., 1994
Relationship based
RCT, n=91; p<.05 at 36 months and 9 years
11 total one-hour sessions
Longitudinal across 9 years
Achenbach, et al., 1993
BROSS Approach
• Designed to
– facilitate stability
– provide a method for assessing development
of feeding across the hospitalization
– provide a method to identify known oral-motor
patterns
– build a strong foundation of skills
– facilitate caregiver recognition and support of
individual strengths and challenges
Browne & Ross, 2001
Integrated
Coordinated
Intermittent
Alternating
Obligatory
Stability in arms with NNS
Systems Stability with Holding
Stability in Bed with Handling
BROSS Approach
(Browne and Ross, 2001)
• Uses the Synactive theory as a paradigm
• Builds upon the organization of each subsystem
• Uses a holistic approach towards the
development of feeding skills in the preterm
infant
BROSS (2001)
•
•
•
•
•
•
•
BABY
REGULATED
ORGANIZATION
of
SUBSYSTEMS
and
SUCKING
Browne & Ross, 2001
Integrated
Coordinated
Intermittent
Alternating
Obligatory
Stability in arms with NNS
Systems Stability with Holding
Stability in Bed with Handling
Systems Stability in bed
•
•
•
•
Physiologic
Motor
State
During routine interactions
Systems Stability With Holding
• Physiologic
• Motor
• State
Mosca, 1995
• Holding premature infants during gavage
feeding increased time spent in more
desirable infant behavioral states, resulted
in less apnea at the beginning of feedings,
and did not compromise infant physiologic
stability.
Stability with NNS
•
•
•
•
•
Physiologic
Motor
State
Holding
Rhythmic sucking, pacifier or finger
– 5-10 sucks/burst
Obligatory
• Sucking burst can be 15-25 sucks
• Does not stop to breathe
– Apnea
– Loss of subsystem stability
• Caregiver needs to intervene
Alternating
• Oxygen stabilizing
– Alternating sucking/breathing
• sucking burst (3-7)
• period of breathing
– Sometimes “roller coaster” saturations
• Limited state availability to complete
feeding
Intermittent
• Integration of breathing during sucking
– brief catch breath, once every 2-3 sucks
– longer sucking bursts appear
– Longer, more efficient suck
(suction/expression)
– Greater volume transferred
• Alert state, some social availability
Coordinated
• Mature coordinated suck pattern
– sucking bursts 20-30 sucks and
breathing integrated with sucking
– individual pattern of s/s/b
– modulated suction and expression
• Integrating alert state
• Alert during the entire feeding
Integrated
• Integration of social interaction during
feeding
• Full coordination of sucking/swallowing
and breathing, without tachypnea
• Demanding prior to feedings
Intervention strategies
• Think about each step - both the currently
achieved, as well as the next to emerge
• With intervention, can the infant reliably
remain stable at the next emerging step?
Intervention strategies
• If not stable, support at the current step,
and design supports to facilitate next
steps:
– decrease flow/volume
– decrease environmental impacts
– increase supports
Correlation
gesage
40
39
38
37
36
35
34
33
32
31
30
29
28
1
2
3
4
5
6
7
8
gr p
n=27
Ross & Browne, 2002
Ultimate Goal
•
•
•
•
Support parental competence in feeding
Support parent/infant relationship
Support successful feeding in NICU
Support transition to successful feeding
after discharge, across the first years of
life
Feeding should be fun
References
• Achenbach, T. M., C. T. Howell, et al. (1993). "Nine-year outcome of the
Vermont intervention program for low birth weight infants." Pediatrics 91(1):
45-55.
• Als, H. (1982). Toward a synactive theory of development: Promise for the
assessment and support of infant individuality. Infant Mental Health Journal,
3(4), 229-243.
• Boiron, M., L. Da Nobrega, et al. (2007). "Effects of oral stimulation and oral
support on non-nutritive sucking and feeding performance in preterm
infants." Dev Med Child Neurol 49(6): 439-44.
• Bragelien, R., W. Rokke, et al. (2007). "Stimulation of sucking and
swallowing to promote oral feeding in premature infants." Acta Paediatr
96(10): 1430-2.
• Browne, J. and E. Ross (2001). BROSS: Baby regulated organization of
systems and sucking.
• Chang, Y. J., C. P. Lin, et al. (2007). "Effects of single-hole and cross-cut
nipple units on feeding efficiency and physiological parameters in premature
infants." J Nurs Res 15(3): 215-23.
• Dusick, A. M., B. B. Poindexter, et al. (2003). "Growth failure in the preterm
infant: can we catch up?" Semin Perinatol 27(4): 302-10.
References
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158-62.
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References
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Development 24(1): 83-94.
• Meyer, E. C., C. T. Coll, et al. (1994). "Family-based intervention improves
maternal psychological well-being and feeding interaction of preterm
infants." Pediatrics 93(2): 241-6.
References
• Mizuno, K., Y. Nishida, et al. (2007). "Infants with bronchopulmonary
dysplasia suckle with weak pressures to maintain breathing during feeding."
Pediatrics 120(4): e1035-42.
• Mizuno, K. and A. Ueda (2003). "The maturation and coordination of
sucking, swallowing, and respiration in preterm infants." J Pediatr 142(1):
36-40.
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Clinical Sciences, Health Services Research. Denver, University of Colorado
Health Sciences Center. Ph.D.: 279.
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and Sucking (BROSS). The Physical and Developmental Environment of the
High-Risk Infant. Clearwater, FL.
References
• Samara, M., Johnson, S., et al, (2009). “Eating problems at age 6
years in a whole population sample of extremely preterm children.”
Dev Med Child Neur. http://dx.doi/org/10.1111/j.14698749.2009.03512.x
• Simpson, C., R. J. Schanler, et al. (2002). "Early introduction of oral
feeding in preterm infants." Pediatrics 110(3): 517-22.
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