Intervention for the High Risk Infant:

Providing Services in the NICU and During

the Transition Home

Rosemarie Bigsby, ScD, BCP, ORT/L, FAOTA

FEEDING
A Contextual Approach to Feeding

Assessments in the NICU

Start With the Baby
• Infant Centered Competencies: Facilitating feeding competency of the infant
– Infant behavior & organization support competency at feeding

• Infant-Caregiver Centered Competencies: Promoting caregiver-infant interaction

– Caregiving environment, home, and community resources support infant-
caregiver interaction
Breastfeeding Basics
Mother’s Milk is Best
• Breast milk is an optimal food for infants, whether term or preterm (Pronczuk, et
al., 2004)

• Breastmilk has medicinal qualities for infants, particulary preterms (Hilton, 2011;
Pract Midwife)

• There is a direct positive relation between the amount of breastmilk consumed

during the NICU stay and
– Higher Bayley Mental Development & Behaviour Index scores at 30 months
– Fewer rehospitalizations after D/C
(Vohr, et al., 2007)
 Breastfeeding Literature
• Infants who are breastfed at any time during infancy have a lower incidence of
sudden infant death syndrome (SIDS)
- Longer breastfeeding was associated with lower risk of SIDS (Chen & Rogan, 2004)

• Fully breastfed infants have

- Less diarrhea, coughing, wheezing and vomiting
- Fewer ear infections

• Infants who were partially breastfed did not show these health benefits (Raisler, et al.,
1999)
 Breastfeeding Literature
• Premature weaning largely due to avoidable problems of breast pain and concerns
re. adequacy of milk supply (Zembo, 2002)

• Late preterm infants are at increased risk of poor lactation outcomes

- May lack the ability to consume an adequate volume of milk at the breast
- Mothers are at risk for delayed lactogenesis

• What is needed are strategies to help mothers of preterm infants establish and
maintain their milk volume while facilitating infant’s feeding skill (Meier, et al.,
2007)
 Normal Sequence of Events in Breastfeeding

• Infants generates negative intra-oral pressure to position and

stabilize the nipple

• Uses the tongue to compress and elongate the nipple to extract

milk
 Breastfeeding Literature
• Breastfeeding efficiency is related to :
- Higher BW
- Less time on vent
- Less reliance on oxygen
- Less time bottle feeding (Hedberg, et al., 1999)
Gavin Breastfeeding
 Breastfeeding Literature
• Preterm infants do not fatigue more at the breast than at the bottle; actually
have fewer desats

• Skin-to-skin care enhances breastfeeding outcomes (Bier, et al., 1996)

 Breastfeeding Literature
• Preterm infants/mother pairs
- A unique group
- Breast and bottle feeding methods should be based on spesific evidence with
this population (Meler, 2001)

• Resources for Breastfeeding in NICU:

- Strategies for Success (Cosimano & Sandhurst, 2011; Neonatal Network)
- Late Preterms (Munson, et al. 2011; Neonatal Network)
 Additional Interventions
• Positioning for Comfort
• Nipple shield
• Gavage while on breast

• Supplemental Nursing System

• Finger feeding
 Pathway for Breastfeeding Support
• Provision of pumped breastmilk
• Kangaroo Care – preparation for breastfeeding
• Gavage feeding during Kangaroo Care
• Nuzzling: Non-nutritive “comfort” sucking at the pumped breast during gavage
feeding
• Suckling at pumped breast while gavage feeding
• Suckling at “full” breast, supplemented with gavage
 Breastfeeding Interventions
• Reference : Supporting Sucking Skills in Breastfeeding Infants

- Catherine Watson Genna

- 2008
- Jones and Bartlett, Publisher
Bottlefeeding Basics
 Normal Sequence of Events in Bottle Feeding

• Uses gums, tongue and palate to stabilize the nipple

• Cups and elevates tongue to compress nipple against palate

• Generates negative intra-oral pressure to express formula
Is this baby ready to be nipple fed ?
 Common Feeding Concerns
• Slow transition to nipple feeding (breast/bottle)
• Physiologic distress associated with feedings
• Either can be a sign of:
– Immature feeding organization
– Swallowing dysfunction
 Preliminary Data Gathering
• History
• Current mode(s) of feeding
• Schedule of feedings & medications
• Parent involvement
• Typical range of physiologic parameters
• Need for supplemental oxygen at rest & during feeding
• Frequency of As, Bs, & desats – with feeding?
• Caregiver’s perception of the problem
 Fueling Development:
Evidence-based Strategies for Feeding
Assessment & Intervention in the NICU
 Regulation of States of Arousal For Feeding

The drive to feed is strong

A typical newborn
- Awakens at feeding times
- Shows signs of hunger
- Maintains an awake state
- Responds to alerting strategies
 Regulation of States of Arousal For Feeding
If generally under-aroused
- Cardio-respiratory
- CNS – overall body posture & tone
- Jaundice
- Medication effect ?

“Shutting down” during feeding – fatigue; discomfort

 Sucking As Oral Preparation for the Swallow
• Stabilizes nipple against palate
• Cups to gather the bolus
• Combines compression & suction
• Carries the bolus back for the swallow
 Clinical Observation of the Tongue
Muscle Tone & Movement
High tone – elevation & retraction
• Low tone – bunching & protrusion
• Predominance of biting or
compression vs. cupping/stripping
Sensitivity to touch around & inside
mouth
- Diminished
- Heightened
Importance
• Point of stability for sucking &
swallowing
- Loses contact with nipple
- Loses control of liquid
- May dribble or choke
• If diminished sensitivity
- Infant does not attempt tp
control liquid
- May derrible or choke
• If heightened
- May gag prematurely
 Sucking & Swallowing Characteristics
Preterms with CLD Term Infants with HIE; ECMO
The problem is sensory/motor dysfunction
The problem is organization
Initially
Decreased • Low lingual tone
• Stability of sucking rhytm • Attenuated reflexes
• Aggregation of sucks into burst-patterns - Gag
• Length of bursts - Cough
• Percentage of swallows - Sucking
- Rooting

Subsequently
• Increased lingual tone
• Clamping
(Gewolb, et al., 2001) • Oral hyper-sensitivity
 Typical Interventions
• Sensory
– Graded touch pressure around mouth and on tongue (Lamm, et al., 2005; Dysphagia)
– Pleasurable non-nutritive sucking experiences with own hand, pacifier, breast

• Motor
– Nipple choice consistent with tongue action :
 Long, firm nipple for retracted, elevated tongue
 Flat, broad nipple for compression-style suck ( Miller and Kang,2007; Dysphagia)
– Cheek support to enhance suction
 Clinical Observation of the Jaw
Movement of Jaw Importance
• Rhythmicity • Synchrony with swallowing
- Clamping vs. rhytmic opening • Limited opening impedes sucking
& closing • Excessive opening limits action of
• Degree of Jaw excursion hyoid for swallowing
- Limited - Allows liquid loss
- Excessive
Possible Contributors to Atypical Tongue & Jaw
Movement in The NICU
• Atypical Sensory-Motor Experiences
- Early prolonged sedation
- Prolonged intubation
 ET tube limits tongue action
 Taping limits lip, jaw, cheek movement
 Frequent suctioning – noxious stimulus; triggers/inhibit gag
 Lateral neck rotation – limits action of the hyoid
 Typical Interventions
• Midline positioning
• Overall relaxation
- Skin to skin holding
- Containment
- Gentle massage – particularly to face and jaw
• Pleasurable oral experiences provided after suctioning
- Touch pressure around and inside the mouth
- Swab or pacifier dipped in breast milk
• Non-nutritive sucking on pacifier, own hand or breast during gavage feeding
• Jaw support to provide proprioceptive feedback
 Pharyngeal Phase
Voluntary Initiation Of A Swallow
• Elevates the soft palate against the pharynx
• Opens the space between the tongue and

the soft palate

 Clinical Observation of Initiation of Swallow
• Handling of Oral Secretions
– Pooling of oral/pharyngeal secretions
– Thick, stringy secretions or bubbles
– Dribbling when liquids introduced
– Decreased jaw range of motion & active mobility

• Considerations:
– Motor vs. sensory
– Anatomic necessity vs. protective response
Anatomic Limitations:
 Retrognathia
 Glossoptosis
 Tracheomalacia
 Laryngomalacia
 Possible Contributors to Lack of Initiation
of the Swallow
• Prolonged intubation, often with sedation
• ECMO (Extracorporeal membrane oxygenation)
– Prolonged positioning with head in one side
• Respiratory compromise
- Tachypnea – impedes swallow
- Immature suck-swallow-breathing coordination
• Self – protection
– Anatomic differences – glossoptosis
– Airway insufficiency
– Pharyngeal/esophageal irritation (extubation; GERD)
Dynamic Systems Theory Applied to Feeding
• Multiple interacting subsystems (Barlow, 2009; Goldfield, et al 2007)
- Physiological Functioning – altered cardio-pulmonary functioning
 Breathing patterns
 Endurance
- Neurologic Functioning – immature neurologic system
 Oral Motor/Pharyngeal Functioning
 Behavioral Organization/State
- Environmental Context – physical environment and caregiver approaches
 Characteristic of Preterm Infant Feeding
Greater difficulty with swallow-breathe coordination than with suck-swallow
(Lau, et al., 2003; Thoyre, et al., 2012)

• Shorter suck bursts, to allow for more breathing time – slows the feeding
• May suck reflexively without pausing
• Arhythmic breathing pattern; variation in sucking pressures may contribute to
nasopharyngeal reflux
• Progress with swallowing/breathing coordination varies by individual – not
specifically tied to gestagional age (Vice & Gewolb, 2008)
• Additional challenge :
- Longer esophageal clearance time – may need a “break” during feeding
(Pediatr Pulmon 2003, 36, (4) 330-334)
 Preterms Give Limited Behavioral Indicators
Prior to Oxygen Desaturation

• Caregiver needs to attend to:

- Changes in breath sounds and pattern of sucking
- Pauses in sucking ( to regulate breathing) (Thoyre & Carlson, 2003)
Clinical Observation of Breathing Coordination

• Pause in breathing to enable the swallow

– See movement of the hyoid
– Hear characteristic sound of swallow (auscultation)
 Clinical Observation of Breathing Coordination
• Rhytmic timing of the swallow
– Delayed initiation of the swallow – dribbling; pooling; upper airway
congestion
 Bradycardia
 Stridor
– Holding the breath
 Oxygen Desaturation
 Clinical Observation of Breathing Coordination

• Re-initiation of breathing
– Expiration
– Delayed inspiration
– Insufficient interim breaths
 Oxygen desaturation
 Speculation: Early Practice and Oral Motor
Intervention Enhances Oral Motor Skill
• Early Practice: Nipple feedings introduced to healthy preterms as soon as
tolerating full gavage
- Increased opportunities to bottle-feed facilitated full bottle feedings (Mizuno & Ueda,
2001; Pickler & Reyna, 2003)

• Oral Motor Intervention: 5 minutes intervention to lips, cheeks (internal and

external), jaw, tongue and palate. Once per a day. Achieved total oral feedings 5
days sooner
- No significant difference in length of stay (Lessen,2011; Adv Neonatal)
 Typical Interventions

• Pacing
• Cheek & jaw support – no difference in rate of sucking or number of bursts (Hill, et al.,
2000)
• Positioning alterations
- Feeding in sidelying & “prone” – improved oxygen saturation
 Typical Interventions
• Oral preparation for sucking and swallowing
– Non-nutritive sucking on pacifier, own hand or breast during gavage
feeding

• Slow the nipple flow (Lau & Schanier, 2000; Goldfield, et al., 2005)
- or keep nipple ½ full to limit size of bolus to be managed
 Typical Interventions
• External Pacing (Law-Morstatt, et al., 2003; J Perinatology)
Removing nipple or tipping to stop flow or liquid according to

 Behavioral cues
 Posture changes – pulling back
 Eye widening
 Finger splaying & arm extensions
 Physiologic cues
 Pale; cyanosis
 Oxygen desaturation
 Bradycardia
 Typical Interventions
• Externally pace the feeding, by tipping or removing the nipple to stop flow, while
infant engages in catch-up breathing
• Position in elevated left-side-lying vs. semi-upright
- Fewer desaturations (Mizuno, et al., 2000; Clark, 2007)
- Similar position to breastfeeding – consistency across breast and bottle
feedings
- Slows progression of the liquid; allows more time to form a bolus and
swallow – more time to take breaths between suck bursts
- Allows excess liquid to dribble out rather than triggering gulping/choking
(Thoyre, et al., 2012; Nursing Research)
- Reduces reflux events during feeding (Corvaglia, et al., 2007, J Peds; Omari, et al., 2004; Poets,
2004, Pediatrics)
Side-lying vs. Semi-upright
Elevated Side-Lying
These Are Temporary Interventions
• Suck-Swallow-Breathing Efficiency Improves by 34-36 Weeks
• Neural development of medulla has peaked
• Significant improvement in sucking pressure
• Stability of sucking rhythm
• Coordinates swallowing with breathing
– At end of inspiration after 35 weeks ( Gewolb, et al., 2001; Miller et al., 2003; Mizuno, & Ueda,
2003; Vice & Gewolb,2008)

With maturation & comfortable feeding practices preterm babies eventually are able to
feed competently in varied positions.
 Characteristics of Infants With Chronic
Lung Disease

• Decreased functional lung capacity

• Low endurance
• Low reserve/slow recovery after a drop in heartrate or oxygen saturation
 Pharyngeal Phase
Involuntary Completion of Swallow
• Protects the trachea :
– Epiglottis closes
– Vocal folds close
– Bolus moves toward upper esophageal opening

• Bolus clears the pharynx

 Clinical Observation of Pharyngeal Phase of the
Swallow
• Inability to safely clear the pharyngeal spaces
- Prolonged pooling
• Hear upper airway congestion; stridor
- Coughing/choking/gagging
- Bradycardia
 By. A
• 31 weeks gestational age

• G1 P1; C/S ? Abruption

• Respiratory distress syndrome; ventilator several days

• ROP

• Reffered a 35 weeks for feeding consult; deep bradycardia with desats during
feeding
 By. A
• Strong non-nutritive suck, but tendency to require time to organize nutritive suck

• Appears to be self-pacing, then abruptly chokes and desats to 50’s with very slow
recovery

• Upper airway congestion can be heard only during feeding

• Recommend feed only with slow flow nipple and obtain a modified barium
swallow study
 By. A
• Swallow study showed:
 Pooling
 Penetration
 Nasopharyngeal reflux, even with thick barium
 Full-column gastro-esophageal reflux
 By. A
Recommendations:
 Feed cautiously with thickened (honey-consistency) milk
 Attention to cues; posture
 Tincture of time
 Clinical Observation of Pharyngeal Phase of the
Swallow
• Considerations:
- Immature swallowing coordination
- Need for additional postural support
- GERD
- Sensory: Laryngeal sensation contributes to involuntary control of the
swallow
 Improved swallowing after treatment for GERD
(Suskind, et al., 2006; Laryngoscope)

- Dysfuntional swallow (nasopharyngeal reflux) vs. Anatomic Differences

(laryngeal cleft; vocal cord paralysis)
 Typical Interventions
Positioning semi-upright

Thickening of liquid for increased sensory input

- Easier to form a bolus for transport
- Easier to complete the swallow - less likely to pool or trickle into the
laryngeal spaces
- Caution – this intervention may mask aspiration/ penetration
 Strategies for Supporting Physiologic
Functioning During Breast & Bottle Feeding
• Increasing FiO2
• Alternating gavage and nipple feeding or feed according to infant cues of arousal
and ability to participate – stop nipple feeding and gavage remainder when infant
show signs of distress or fatigue
• Hi flow nasal canul – decrease the liter flow and increase
• Thickening feedings
To reduce reflux
To enhance efficiency of the swallow
 Greater sensory feedback with nectar thick consistency than thin
consistency among preterm infants (Goldfield, et al., 2013, Dysphagia)
 Thickening to Enhance Efficiency of the
Swallow- Increased Sensation
• Those portions of the swallow under voluntary control are reliant upon sensory
feedback from the oral structures and the pharynx (Rogers & Arvedson, 2005; MRDD Research
Reviews)
• Sensation of liquid I pharyngeal space triggers swallow sequence:
– Inspiration & suck
– Pause in breathing
– Swallow
– Expiration (Kelly, et al., 2007; Respiratory Physiology & Neurobiology)
• Thickening slows the bolus and provides additional sensory input to enhance
swallowing control for preterm infants (Goldfield, et al., 2013)
 Practical Issues Around Thickening

Addition of Variables to Feeding Process

- More difficult to express milk from nipple
- Amount of rice
- Amount of time milk rests during feeding – thickens as it rests
- Types of additives – mixes thicker with ready to feed than powder/water
formula mixtures

• Displaces nutritive part of the feeding

• Infant may have earlier

 Challenges of Thickening Breast Milk
• Enzymes in the breast milk break down the starches within 20 minutes after mixing

• Current suggestions:
- Warm the breast milk before mixing cereal in
- Add rice immediately before mixing
- Mix only an ounce at a time payment thinning while the milk rests
 Issues Around Thickening
• Oatmell congeals when mixed with breastmilk; not easily digested in early infancy

• Package recommendations for other starch-based thickeners (usually corn-based)

are NOT RECOMMENDED for children under age 3 years
 Esophageal Phase
• Involuntary transport of the liquid
– Through the upper esophageal sphincter
– Toward the lower esophageal sphincter
– Into the stomach
 Clinical Observation During Esophageal Phase
of Swallow
• Initially eager to feed but inability to take full volume without the need for a
“break”
• Refusal to continue feeding after taking ½ oz or more
– “Fighting” the nipple
– Shutting down – becoming drowsy; falling asleep
• Considerations:
– Slow esophageal motility
– Gastro-esophageal reflux
– Cardio-Respiratory compromise – poor endurance
 Evaluating the Infant At Rest & During Feeding
• Trouble signs
– Tachypnea
– Stridor
– Upper airway congestion
– Poor management of oral secretions
• Thick secretions
• Need for oral/pharyngeal suctioning
– Tight jaw
 Factors Influencing Maturation of Sucking and
Swallowing Organization
• Physiologic instability
– Oxygen dependency
– Central apnea
– Obstructive events:
 Apnea and Bradycardia
– Oxygen desaturation
– Apnea of prematurity
• Motor/CNS Immaturity/Dysfunction
- Decreased axial tone
- Floppy airway
- Weak/Atypical Suck
- Immature swallowing coordination
 Additional Consideration
• Influence of Other Syndromes and Conditions
– Multiple congenital contractures
– CNS Involvement
– Genetic Syndromes
– Cardiac Involvement
• Importance of Team Approach, Including Family
• Psychosocial Aspects of Feeding
 Protective Strategies for Positive Results with
Feeding
• Early skin to skin holding – positive touch
• Midline head positioning when possible
• Early introduction of non-nutritive sucking on pacifier and breast
• Attunement of caregivers to infant behavioral and physiologic cues
 Assiting Parents in Modifying Breast and Bottle
Feeding Approach to Enhance Success
• Attention to:
– Positioning

– Infant behavioral cues

– Physiologic cues

– Changes in arousal/engagement

• Lactation consultation; Nipple shield

• External pacing/nipple flow rate
Encouragement of Holding and Interaction
 What Influences Outcomes in Early
Intervention ?
• Child Caracteristics
– Account for a significant amount of the variance in developmental outcomes
– For children with established disabilities, severity is inversely related to the
effectiveness of interventions (Guralnick, 1991)

• Severity of Family Risk

– However, family risk and biologic risk interact to influence the effectiveness
of a program (Guralnick, 1997)
 Contextual Assessment in Infancy
• Observations in natural settings
• Minimal handling
• Consider environmental affordances
• Involve family members
 Which services make a difference ?
• Social support
• Parent-child interaction
• Curricula
• Each of these will have differing effects, depending upon the dynamics of the
situation: the biological, family & environmental risks