Oral Feeding Issues

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)

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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…..

25. 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

26. 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

27. 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

28. Wait, give me a break!

30. 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

31. 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)

32. 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

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

34. 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)

35. 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

36. 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)

37. 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

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

39. 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)

40. 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

41. 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

42. 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)

43. 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

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

45. 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

46. 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)

47. Breastfeeding RC Gorman the Oral Feeding Puzzle

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

49. 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)

50. 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?