Promoting
Long-Term
Feeding Success
SLP in the Neonatal ICU
Taylor M. Leech, M.A. CCC-SLP, CLEC
SLPs role in
the NICU
Short and long term success
Traditional vs research based infant feeding
Quantity vs Quality
Traditional Feeding
Techniques in the NICU
From an article on
about.com by an RN
- May 2014
 “Sit
your baby up”
 “Use chin and
cheek support”
 “Encourage Nurses
to take the tube
out”
Traditional Feeding
Techniques in the NICU
And my favorite…
 Do your exercises: Ask NICU nurses or
therapists to show you a series of mouth
exercises you can perform on your baby
to help prepare her for feeding. Exercises
like circling the lips with your fingers,
stroking the chin, and gently squeezing
the cheeks together can help your baby
to feed better.
Problems
 Driven
by the caregiver, not the baby
 Does not take into account what the
infant wants
 Can be over-stimulating
 Can be unsafe and increase risk for
aspiration
 Is focused on finishing the bottle
 Short-term success for long-term failure
Research-Based Feeding
Techniques in the NICU
 Infant-driven
feeding
 Cue-based feeding
 Focus on quality rather than quantity
Quantity
A
“good” feeding
is finishing the
bottle
 Does not take into
account infant’s
behaviors or needs
 Success is
dependent on the
feeder
Quality
A
“good” feeding
may only consist of
a few minutes or a
few mLs
 A partnership
between caregiver
and infant
Cue-Based
Feeding Protocols
What are they?
Evidence based practices
Implementing in the unit
Benefits
What’s so important about
feeding in the NICU?
 Infants
born under 28 weeks PMA have
significant risk for feeding delay
 Preterm infants are at increased risk of
neurologic, gastro-intestinal, and cardiac
pre-morbidities that can affect ability to
safely feed by mouth
 Has historically been the primary reason
discharge home from the NICU is delayed
Obtaining full oral feeding
 Study
by Pickler et al (2009) describes the
attainment of oral feeding comparing
number of days to full oral feeding, how
many bottles an infant was offered a day,
and comorbidities
Obtaining full oral feeding
What is Cue-Based Feeding?
 On
demand feeding schedule vs
scheduled feedings
 In the NICU, maintaining a schedule while
following infants readiness cues
 Focusing on infant’s behaviors before and
during feeding times to determine when
to start, when to take breaks, and when
to stop
What is Cue-Based Feeding?
Readiness Cues
 Awake/alert
state
 Squirming
 Rooting
 “ooo”
face
 Hands to face
What is Cue-Based Feeding?
Stress Cues
(I’m not ready!)
 Crying
 Panicked
expression
 Saluting, finger
splay, or extremity
extension
 Drowsy
What is Cue-Based Feeding?

“In volume-driven feeding, success is measured by
how much an infant ingests, and caregivers may
use strategies intended to empty the bottle
without regard to what the infant communicates
Volume-driven caregiving tends to feed past the
infant's stop signs, which say, ‘I want to stop, I am
done’. Failure to respond to the infant's
communication may lead to maladaptive feeding
behaviors, learned feeding refusals and long-term
feeding aversions. Caregivers often pass on this
volume-driven philosophy to parents, for whom
feeding becomes something they do ‘to’ their
infant, instead of a relationship-based experience
through which communicative interactions build
trust.” (Shaker, 2013)
Kirk et al (2007)
 Infants
fed once per
shift and advanced
base on behavioral
cues
 Attainment of full oral
feeds was significantly
less by 6 days PMA for
study group using
clinical pathway
compared to control
cohort.
Sudharshan et al (2012)

Comparison of
historical (routine
care) vs modern
and innovative
feeding
programs and
protocols and
attainment of full
or partial oral
feeds at
discharge and
one year
Ludwig & Waitzman (2007)
 Describes
the traditional feeding
practices of focusing on time and volume
compared to infant-driven practices
focusing on quality and infant cues and
behaviors
 Focus is on infant, improvement of parent
education and understanding
McClain et al (2012)
 Infants
divided into a control group
(standard care gradually increasing
number of bottles and amount expected
to take) and experimental group (offer
bottle only when stable and showing
readiness cues)
 Infants in experimental group transitioned
to full oral feeds on average 6.4 days
before the control group
Puckett et al. (2008)
 Compared
preterm infants born 4-6
weeks early on a cue-based feeding
program to a control group
•
•
•
No significant difference in weight or weight
gain
Experimental group had significant
difference in length of stay – 4.5 days
Experimental group had significantly less
adverse events (desaturations,
bradycardia, coughing) during and after
oral feedings
Implementing in the NICU


Initiated at CRMC Spring 2014
Readiness scores recorded at each feeding
•
•
•
•
•
1 – Awake prior to care/touch time, showing
readiness behaviors
2 – Wakes during or after cares, showing
readiness behaviors
3 – Wakes only briefly during cares
4 – Sleeps through cares
5 – Exhibits stress, caregiver is unable to calm,
and/or is physiologically unstable
Implementing in the NICU
 If
an infant score 1 or 2, they are offered a
bottle or breast fed
 If an infant scores a 3 or 4, they may be
offered breast only if mom is at bedside
 If an infant scores a 5, they are not
offered oral feeding in any form
Implementing in the NICU
 Online
education for established nurses
 In-person education for every new nurse
 Ongoing education at bedside
 Reviewing with parents
 Written education and information for
parents at bedside
Poor Feeding and Impact on
Long-Term Nutrition


Thoyre ( 2007) – longitudinal study with followup at 6 to 8 moths born less than 1000g and
less than 29 weeks
“Healthy” infant with no diagnoses in regards
to neurologic, GI, or lung dysfunction
•
•
•
80% reported to have long-standing feeding
problems including poor intake, fatigue with
feeding, and delayed skills
40% had episodes of aspiration
85% with a diagnosis of GER
Poor Feeding and Impact on
Long-Term Nutrition

Cerro et al. (2002) – longitudinal study of
children with very low birth weight (under
1500g) without significant neurological
impairment
•
•
•
•
•
33% of infants vomited frequently
32% were on reflux medications
28% had poor weight gain
27% had reported diarrhea
67% of parents interviewed stated that their
children “consistently refused food”
Poor Feeding and Impact on
Long-Term Nutrition
 Sweet
et al. (2003) – interviewed parents
of children at 2 years corrected age that
were born less than 600g
•
•
62% reported feeding problems
29% had G-Tubes at some point
Organic vs Behavioral
Feeding Problems
 Behaviors
•
•
•
Refusal
Gagging
Texture preferences
 GERD
 Vomiting
 Poor
digestion
 Weak oral-pharyngeal muscles / Dysphagia
Early Intervention in the NICU
 Promotes
early successful nipple feeding
 Parent and caregiver education to
promote long-term success
 Interventions documented to decrease
hospital length of stay and time to
attainment of full oral feeds
 More research – longitudinal studies of
infants cue-based feeding protocols and
feeding behaviors during infancy and
childhood
Therapeutic Interventions
and Diagnostic Tools
Neonatal FEES
Devices to measure suck patterns and abnormalities
Neonatal FEES
 FEES
– Fibro optic Endoscopic Evaluation
of the Swallow
 Avoids radiation exposure
 Can be completed at bedside
 Doctor/Radiologist does not need to be
present
 Parent/Caregiver education
 Quantified/objective evaluation
Quantifying Intra-Oral
Pressures During Nutritive Suck
Visually measures
sucking behaviors
and patterns
 Typical periodicity
 Prolonged sucking
and swallowing
without pauses
 Very irregular
References






Bird, C. (2014, May 28). Successful tips for bottle feeding your preemie.
Retrieved from http://preemies.about.com/od/parentingyourpreemie
/a/bottlefeedingtips.htm
Cerro, N., Zeunert, S., Simmer, K. N., & Daniels, L. A. (2002). Eating behavior in
children 1.5-3.5 years born preterm: parents' perceptions. Journal of Pediatrics
and Child Health, 38(.), 72-78.
Jadchela, S. R., Peng, J., & DiLorenzo, C. (2012, Jan). Impact of personalized
feeding program in 100 NICU infant: Pathophysiology-based approach for
better outcomes. J Pediatr Gastroenterol Nutr, 54(1), 62-70.
Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2009, Oct 8).
Impact of prematurity and co-morbidities on feeding millstones in neonates: a
retrospective study. Journal of Perinatology, 30. Retrieved from
http://www.nature.com/jp/journal/v30/n3/abs/jp2009149a.html
Kirk, A. T., Alder, S. C., & King, J. D. (12 Juley 2007). Cue-baed oral feeding
clinical pathway results in earlier attainment of full oral feeding in premature
infants. Journal of Perinatology, 27, 572-578. Retrieved from
http://www.nature.com/jp/journal/v27/n9/full/7211791a.html
Lang, W. C., Buist, N. R., Geary, A., Buckley, S., Adams, E., Jones, A. C., Gorsek,
S., Winter, S. C., Tran, H., & Rogers, B. R. (2011, Sept 26). Quantification of
intraoral pressures during nutritive sucking: methods with normal infats.
Dysphagia, 26(3), 277-286.
References Continued








Ludwig, S. M., & Waitzman, K. A. (2007, Sept). Changing feeding
documentation to reflect infant-driven feeding practice. Newborn and Infant
Nursing Reviews, 7(3), 154-160.
Martin, G. C., Gartside, P. S., Greenberg, J. M., & Wright Lott, J. (30 Jan 2001).
A feeding protocol for healthy preterm infants that shortens time to oral
feeding. The Journal of Pediatrics, 139(3), 374-379.
McClain, G. C., Del Moral, T., Duncan, R. C., Fontaine, J. L., & Pino, L. D. (2012,
Nov/Dec). Transition from gavage to nipple feeding for preterm infants with
bronchopulmonary dysplasia. Nursing Research, 61(6), 380-387.
Pickler, R. H., Best, A., & Crosson, D. (2009, Oct 2). The effect of feeding
experience on clinical outcomes in preterm infants. Journal of Perinatology,
29. Retrieved from http://www.nature.com/jp/journal/v29/n2/full/
jp2008140a.html
Puckett, B., Grover, V. K., Holt, T., & Sankaran, K. (2008). Cue-based feeding for
preterm infants: a prospective trial. American Journal of Perinatology, 25(10),
623-628.
Shaker, C. S. (2013, Feb 1). Reading the feeding. ASHA Leader. Retrieved from
http://www.asha.org/Publications/leader/2013/130201/Reading-theFeeding.htm
Sweet, M. P., Hodgman, J. E., Pena, I., Barton, L., Pavlova, Z., & Ramanathan,
R. (2003). Two-year outcome of infants weighing 600 grams or less at birth and
born 1994 through 1998. Obstetrics and Gynecology, 101(.), 18-23.
Thoyre, S. M. (2007, July/Aug). Feeding outcomes of extremely premature
infants after neonatal care. JOGNN, 36(4), 366-376.