1 / 60

Oral Feeding Issues

Oral Feeding Issues. Chantal Lau, PhD Baylor College of Medicine Department of Pediatrics/Neonatology Texas Children’s Hospital Houston TX, USA. October 31, 2012. Financial Interest: Feeding for Health LLC. Outline . Our philosophy Common problems Bottle feeding approaches Current

titus
Download Presentation

Oral Feeding Issues

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Oral Feeding Issues Chantal Lau, PhD Baylor College of Medicine Department of Pediatrics/Neonatology Texas Children’s Hospital Houston TX, USA October 31, 2012 Financial Interest: Feeding for Health LLC

  2. Outline • Our philosophy • Common problems • Bottle feeding approaches • Current • Potential • Oral Feeding Skills (OFS) Assessment Scale • Consider - interventions to enhance OFS - tools to facilitate oral feeding • Breastfeeding – the Oral Feeding Puzzle

  3. Our philosophy has a long-term goal… To train successful feeders, i.e., well-developed functional oral feeding skills - negative oral sensory inputs in nursery - developmental delay from ex-utero maturation Quality over quantity: • quality of feeding skills vs. quantity of milk ingested Oral feeding must be a positive experience: - avoid short- and long-term feeding issues and aversion

  4. Remember … A preterm infant is NOT a fullterm infant - not appropriate to feed a preemie as we do a fullterm infant But, pressure to attain full oral feeding for earlier discharge

  5. Oral feeding is a multi-disciplinary task… physicians nurses feeding specialists lactation OT RC Gorman Important to give a consistent message to mother and baby nutrition speech

  6. What is the current practice? • Adequate weight gain ( 10-15 g/kg/day) • Safety : to minimize aspiration • must avoid O2desaturation, apnea, bradycardia, aspiration-pneumonia • Success: to complete entire feeding within allotted time (e.g., 20 - 30 min) • limiting energy expenditure to favor weight gain

  7. What should our goals be? • Adequate weight gain ( 10-15 g/kg/day) • Safety: no aspiration, O2desaturations, apnea, bradycardia • Success:- not necessary to complete a feeding, but to develop good feeding skills • Oral feeding ought to be a pleasant, nurturing experience to minimize feeding aversion

  8. Outline • Our philosophy • Common problems • Bottle feeding approaches • Current • Potential • Oral Feeding Skills (OFS) Assessment Scale • Consider - interventions to enhance OFS - tools to facilitate oral feeding • Breastfeeding - the Oral Feeding Puzzle

  9. Poor endurance Signs of fatigue: • Poor tone • State change, e.g., sleep, ‘shut down’ • Lengthy sucking pauses • Feeding duration > 20 min • Increased milk leakage, drooling • Increased respiratory rate • Oxygen desaturation/apnea/bradycardia

  10. Reflux Signs of reflux: • Emesis • Choking/coughing/aspiration • Arching • Oesophagitis • Oral feeding aversion

  11. Suck-swallow-breathe incoordination Signs of incoordination: • Coughing/choking/aspiration • Poor self-pacing • Apnea/bradycardia • Oral feeding aversion

  12. Consequences…all the same… If caretakers persist on feeding infants • Physiological • Oxygen desaturation • Apnea/bradycardia • Tachypnea • Choking/coughing/ • Aspiration • Emesis • Milk leakage • Behavioral • Poor tone • Fall asleep • Agitated • Pushing away • Turning head away • State change -“shut down” • aversive to feeding End result  difficulty diagnosing primary causes

  13. Are we doing right by our babies?

  14. Outline • Our philosophy • Common problems • Bottle feeding approaches • Current • Potential • Oral Feeding Skills (OFS) Assessment Scale • Consider - interventions to enhance OFS - tools to facilitate oral feeding • Breastfeeding - the Oral Feeding Puzzle

  15. focused primarily on sucking issues, but • lack of evidence-based data to objectively support the current practices • few clinical studies available to differentiate: • true benefits • vs. • natural maturation process Current Approaches

  16. Use jaw and cheek support Why? - immature muscle tone - wide jaw excursion How? - gentle sustained pressure - make sure not to impede breathing and infant’s self-pacing Enhanced non nutritive sucking pressures and feeding performance, while reducing oral feeding transition time (Boiron et al ‘07)

  17. Use pacing technique Why? - infant sucking, forgets to breathe - gives time for breathing and resting • helps re-coordinate suck-swallow- breathe How? - 3-5 sucks - tilting bottle back without removing bottle (infant’s organization) • pulling nipple out

  18. Cue-Based Approach • Becoming popular as a marker for readiness to oral feed, but lack evidence-based support (McCain et al ’01; Ludwig & Waitzman ’07; Crowe et al ’12) • are Cues ~ to NIDCAP states and behaviors, i.e. observable events? • Examples of concerns - Infant cues: • are subjective to the observer, e.g., is an infant in a “light sleep” state or “slowing down” due to fatigue? • do not provide information re. limitations of infant’s oral feeding skills, if any • absence of adverse cues does not imply all is well, e.g., silent aspiration • Use of cues along with quantitative measures may be more reliable re. infant feeding readiness and aptitude

  19. Outline • Our philosophy • Common problems • Bottle feeding approaches • Current • Potential • Oral Feeding Skills (OFS) Assessment Scale • Consider - interventions to enhance OFS - tools to facilitate oral feeding • Breastfeeding - the Oral Feeding Puzzle

  20. Potential Approaches Based on combinations of: common sense physiology evidence-based information objective integration of old and new information Watch out for: subjectivity/bias/over interpretation

  21. Adjust feeding position Why? - facilitates organization & breathing - facilitates safer swallowing - decreases reflux - intra-abdominal pressure  esphagealperistalsis (Ren et al ’91) How? - slightly upright, cradled, - body and head midline position, - ensure upper chest and head supported, no crouching - head tilting changes cerebral hemodynamics(Tax et al ‘11)

  22. Limit feeding duration Why? - reduces fatigue, risk of aspiration, feeding aversion How? - decrease # oral feedings/day or feeding duration - complement with NG feeding to preserve caloric intake - follow feeding specialists recommendations if consulted

  23. Regulate flow • Use pacing if necessary • Increase viscosity (thickener) • e.g., rice cereal • difficulty in replicating by the bedside the viscosity identified via modified barium study • But do we really know our babies’ limitations in absence of overt behavioral and/or clinical responses? • Maybe best would be…..

  24. Let infants feed at their own pace Why? allows infants to: • develop appropriate functional feeding skills • have a positive experience re. oral feeding • minimize oral aversion How? gives infants control to: • regulate milk flow • rest if necessary • breathe

  25. Baby communicates: ready to feed • Watch for cues… • Eyes may be open or closed • Responsive to light touch • Looks at caregivers’ face • Hands towards mouth • Rooting or sucking • Smooth motor movements • Calm and quiet

  26. Baby communicates: NOT ready, STOP feeding Watch for cues… • Staring or gaze aversion • Panic or worried look • cannot wake up, excessive yawning • Tremor, startling • Hiccupping, spitting up, gagging, gasping • Frantic, arching, arms extended, fingers splayed • Color changes • Increased respiratory rate and vital instability

  27. Wait, give me a break!

  28. Outline • Our philosophy • Common problems • Bottle feeding approaches • Current • Potential • Oral Feeding Skills (OFS) Assessment Scale • Consider - interventions to enhance OFS - tools to facilitate oral feeding • Breastfeeding - the Oral Feeding Puzzle

  29. Oral Feeding Skills Levels (OFS) scale • Novel objective indicator • No equipment needed, simply measure: • volume prescribed, taken at 5 min, during entire feeding • duration of feeding (min) • Monitored over time • Outcomes computed: • overall transfer ( % ml taken/ml to be taken) • rate of milk transfer over entire feeding (ml/min) • proficiency (% ml taken at 5 min/ml to be taken) • Interpretation: • rate of transfer ~ resultant of skills + endurance • proficiency ~ PO skills when fatigue minimal (Lau & Smith ’11)

  30. Oral Feeding Skill (OFS) levels Skills POOR GOOD (PRO) Endurance (RT) GOOD POOR Level 2 Skills :LOW Endurance: HIGH Level 4 skills :HIGH Endurance: HIGH 30% 1.5 ml/min Level 1 skills :LOW Endurance: LOW Level 3 skills :HIGH Endurance: LOW GA ≤25 26-29 30-34

  31. Interpretations/interventions OFS Level Potential Intervention(s)

  32. Feeding Performance vs. OFS levels OFS 4 OFS 2 p < 0.05 OFS1 < OFS 2-4 OFS 2,3 < OFS 4 OFS 3 Overall Transfer (%) OFS 1 Rate of Transfer (ml/min) (Lau & Smith ‘12)

  33. Outline • Our philosophy • Common problems • Bottle feeding approaches • Current • Potential • Oral Feeding Skills (OFS) Assessment Scale • Consider - interventions to enhance OFS - tools to facilitate oral feeding • Breastfeeding - the Oral Feeding Puzzle

  34. Types of interventions • Uni-modal interventions: • tactile/kinesthetic stimulate vagal activity, gastric motility, weight gain, decreases energy expenditure (White & LaBarba ’76; Rausch ’81; Diego et al ’07; Lahat et al ’07) • NNOMT and massage therapy shorten times from start to independent oral feeding (Fucile et al ‘11) • Multi-modal interventions: • Auditory, tactile,vestibular and visual stimulations  greater volume ingested, attained independent oral feeding faster and discharged earlier (White-Traut et al ’02) • NNOMT + Massage therapy (Fucile et al ‘11)

  35. Interventions to enhance OFS skills • Subjects - VLBW between 25 to 33 wks GA • Study Design - Preventive approach, ie, interventions provided when infants off CPAP and on full enteral feeding for 14 days or till full PO attained • Methods • Nonnutritive sucking on a pacifier – till full PO • Swallow exercise - till full PO • Nonnutritive oral motor therapy (NNOMT) and/or infant massage therapy (MT) – for 14 days • Feeding positioning: Upright and Sidelying

  36. Control Intervention duration Off CPAP- 8 PO/d (Lau & Smith ‘12)

  37. NNOMT+MT Nonnutritive oral motor (NOMT) 14-day intervention Occurrence (%) Days from SOF 1 8 ± 1 10 ± 1 Massage therapy (MT) Control Occurrence (%) Days from SOF 1 8 ± 1 11 ± 1 1 16 ± 1 21 ± 1 (Fucile et al ’11)

  38. Semi-reclined (control) Feeding Positions Occurrence (%) (Lau ‘12) days from SOF 1 7 ± 6 17 ± 9 Sidelying Upright Occurrence (%) 1 5 ± 3 15 ± 8 1 8 ± 6 22 ± 12

  39. Outline • Our philosophy • Common problems • Bottle feeding approaches • current • Potential • Oral Feeding skills Assessment Scale • Consider - Interventions to enhance feeding skills • tools to facilitate oral feeding • Breastfeeding - the Oral Feeding Puzzle

  40. Tools to facilitate oral feeding • Cup-feeding (Mizuno & Kani ’05;Collins et al‘08; Huang et al ’09) • Paladai feeding (India) (Aloysius & Hickson ‘07) • Self-paced feeding system (Lau & Schanler ‘00;Fucile et al ’09; in Prep)

  41. Self-paced feeding system Self-paced system Vacuum Build-up (Lau & Schanler ’00) Parafilm Vacuum buildup Standard Bottle Self-paced bottle Vacuum Build-up HydrostaticPressure

  42. p = 0.016 Standard Self-paced p = 0.007 p < 0.001 (Lau & Schanler ‘00; Fucile et al ’09

  43. Standard Self-paced p < 0.001 p < 0.001 p = 0.002 p = 0.002 p < 0.001 p < 0.001 p < 0.001 p < 0.001

  44. OFS levels – Standard vs. Self-Paced 1-2 oral feedings/day 6-8 oral feedings/day Occurrence (%) Standard Self-paced Bottle Standard Self-paced Bottle (In prep)

  45. Breastfeeding RC Gorman the Oral Feeding Puzzle

  46. Mother-Infant Dyad Infant Mother Non-nutritional benefits growth/development Maternal behavior equilibrium Nutritional benefits oral feeding skills Lactation (Lau ’02)

  47. With a preterm infant… Infant Mother (III) Non-nutritional benefits growth/development Maternal behavior imbalance (II) (I) Nutritional benefits oral feeding skills Lactation (Lau ’02)

  48. Maternal attributes / Lactation • Mammary development/anatomy • glandular and ductal development (lactogenesis I) • Milk synthesis/ejection (lactogenesis II) • nipple types infant’s ability/inability to latch onto the breast (Lau & Hurst ’99) • Prematurity • To what extent are lactogeneses I and II impaired?

More Related