Cue Based Feeding in the NICU ANNA ELSENBROCK, MS, OTR/L, CPST, CNT - - PowerPoint PPT Presentation
Cue Based Feeding in the NICU ANNA ELSENBROCK, MS, OTR/L, CPST, CNT LAURA LUCAS, MS, RD, CSP, LD ALLISON PARKER, MS, CCC-SLP, CNT Objectives : u Understand what cue-based feeding is u Provide overview to protocols/research on cue-based feeding u
ANNA ELSENBROCK, MS, OTR/L, CPST, CNT LAURA LUCAS, MS, RD, CSP, LD ALLISON PARKER, MS, CCC-SLP, CNT
u Understand what cue-based feeding is u Provide overview to protocols/research on cue-based feeding u Be able to recognize readiness cues and signs of
disengagement as well as when to end a bottle feed based upon cues
u Ideas for implementing cue-based feeding in your setting
u Scheduled: q3, PO q/day, BID, TID u This is the more traditional approach to feeding u May also hear it referred to as staff-led feeding u Cue Based: offering oral feeding based on infant readiness u May also hear it referred to as infant-driven or infant-led feeding u On Demand/ Ad Lib: feed when awake with cues no specified time or
volume
feed, not to get them to eat or ‘get it all in.’ Safety becomes the primary goal (Ludwig & Waitzman, 2007).
cues and ends when the infant demonstrates satiation (Tosh & McGuire, 2007).
u Oral feeding initiation in preterm infants needs to take into account
infant’s physiologic maturity levels, skills, and capabilities
u Protocols have been initiated in NICUs and are the gold standard;
however, are widely misused
u Completing all feeds orally is comparable to running a marathon to a
preterm infant: infants need time to “train” to complete all feeds like any
person/adult would train for a marathon
u Individualized based on infants continuous feedback
What IT IS: What IT’S NOT:
(relationship)
uInteraction during feeding provides
the opportunity for the caregivers to learn their infant’s cues
uThe ability to respond to the infant’s
needs increases attachment and confidence
uGives the caregiver ownership of
something they can do for their baby in an ever changing environment
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u Eliminates pressure to complete
volume
u Eliminates pressure of feeding a
disengaged infant
u Supports infant neurodevelopment
u Application of evidenced-based
practices
u Opportunity to educate parents
about behavior responses
u Consistency across all caregivers u Sensitive to infant-led feeding
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when to apply external feeding strategies
behaviors
Thoyre, 2003; Shaker, 1999
u Early Feeding Skills Assessment (EFS) u Preterm Infant Breastfeeding Behavior Scale (PIBBS) u Supporting Oral Feeding in Fragile Infants (SOFFI) u Infant Driven Feeding Scale (IDFS)
u
From infants perspective and to teach adult to “read the feed”
u
Can be administer by anyone with the goal to each parents
u
Check list
u
Readiness
u Motor u Behavioral State u Oral Motor behavior during non
nutritive suck
u
Early feeding skills assessment
u Respiratory u Engagement u Oral-motor function u Swallowing Coordination u Physiological stability
u
Recovery
u Behavioral State u Energy Level
u
Two day training required to use tool
u Used to assess development of sucking behavior during
breastfeeding
u Scale allows for observer and maternal input. u Evaluates rooting, latch, sucking, swallowing, infant state, and let
down reflex.
u Used for preterm and fragile infants u Based on the Synactive Theory u Algorithm with sequence of assessments, questions and decisions that lead to
actions taken.
u Focus on readiness scoring prior to feeding and quality scoring during feeding u Includes both breastfeeding and bottle feeding u Two day training course
u Similar to SOFFI principles u Ranks readiness and quality of the feed u Each item will have a 5 point scale (1= most optimal and 5= least optimal) u Quality:
u Coordination u Consistency u Rhythm u Strength of suck, swallow, breath
u Readiness:
u Engagement and disengagement
u Taste buds develop at 7-8 weeks u Suckle movements begin at 9-10 weeks u Babies will begin to swallow amniotic
fluid in the early 2nd trimester
u Lick & suck hands/thumb as early as 18
weeks
u True sucking begins around the 18th and
24th week in utero
u In the last trimester, the fetus swallows up
to 23-25 ounces of amniotic fluid per day
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u Remember, infants have had a lot of practice sucking and swallowing in
utero, starting around 12-13 weeks
u At 32-33 weeks, sucking begins to become more rhythmical u At 34 weeks, a true suck/swallow is developed (which is why this is
typically a better time to consider starting oral feeds)
u To be an efficient with oral intake, the baby needs to coordinate suck,
swallow, AND breathing; this comes closer to 40 weeks (longer for very preterm or medically complex infants)
u That’s a 6 week period where they may not be prepared to
do what we’re asking and will require support.
u Preterm infants will not present with a mature s/s/b pattern. u More often, they present with an immature pattern. u Sometimes, a non-rhythmical, unpredictable pattern is observed.
This is considered disorganized.
u With these babies, it’s hard to know what’s coming next and how
to respond to the babies cues
u You can probably imagine the infant with the pattern that’s all
uSuck, suck, breathe, suck, breathe, breathe, suck, suck, suck,
suck…
u Awakens spontaneously at the scheduled feeding times u Demonstrates hunger cues prior to/during care times u Rooting and/or hands to mouth and midline, seeking suckle on
pacifier and hands for at least 2-5 minutes
u Good muscle tone and maintaining alertness u Maintains all of the above when transitioned to caregivers’ lap in
preparation to initiating feeding
Attributes for feeding success:
eating
suck/swallow/breathe pattern
Google images
Challenges to feeding success:
uncoordinated
u suck/swallow/breathe pattern u brain development
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STATE & ATTENTIONAL MOTOR AUTONOMIC Gaze aversion Glassy eyes Irritability Poor level of alertness Diffuse sleep states Raised eye brows Furrowed brow Drowsy Inconsolability Sitting on air Saluting Grimacing Finger splaying Squirming Arching of trunk Tongue thrusting Decreased muscle tone
Pulling away Turning head Open mouth at rest Moderate Stress: Yawning Hiccuping Gagging Sneezing Color change Stooling Major Stress (when related to feeding): Spitting up Gagging/choking Color changes Respiratory pauses Irregular respiration
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Early feeding experiences impact later feeding skills and behaviors:
u 55% of preterm infants have feeding problems by 6-18 months of
age
u Although less than 1% of preterm infants required tube feedings at
discharge, over 50% of parents reported problematic feeding behaviors at 18 & 24 months
u Parents of NICU graduates reported disorganized feeding
(coughing, feeding refusal, vomiting) in 39% of infants at 6 months and 37% at 12 months
u Parents of children with feeding problems report increased stress,
anxiety, and diminished family functioning
Kirby et al, 2007; Dusick et al, 2003; Hawdon, 2000; Samara et al, 2009; Thoyre, 2007
development and influence long term feeding behaviors
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https://www.albertafamilywellness.org /resources/video/brains-journey-to- resilience
Resource: Center for the Developing Child, Harvard University
u https://youtu.be/D49D2z2fGAM u https://www.youtube.com/watch?v=6E66ErDjt_o u https://youtu.be/nJLASs_pafo u https://youtu.be/qFKIP67IWDM u https://youtu.be/8sxEYZifV0M
u Remember how we feed our babies in infancy translates to how well/poor they will
feed in the future, you are the difference!
u Unified language, understanding the jargon:
u Follow-up with tools provided today u Shaker for Swallowing and Feeding (website)
u Stay current with research and steer away from quantity-driven feeding practices u Honor infants’ stress cues, allow infant to speak to you during a feeding with their
cues
u Providing appropriate compensatory strategies and know when to fade
compensatory strategies
u Knowing the benefit of a slower flow rate nipple, and the appropriate signs/maturity of
when to transition to faster flow nipple (assistance from feeding therapist when needed)
u Buy-in and support from nursing administration, medical director,
educators and staff,
u Without this, it is not sustainable
u Research based, ease of use and comprehensive education
u Global understanding of the protocol
u Annual re-checks/education as well as champions to preserve
protocol integrity
u Update and implement protocol changes
u Ludwig, S.M., Waitzman, K.A. (2007). Changing feeding outcomes to
reflect infant –driven feeding practice. Newborn and Infant Nursing
u McCormick, F. M., Tosh, K., & McGuire, W. (2010). Ad libitum or
demand/semi-demand feeding versus scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD005255.pub2
u Tosh K, McGuire W. Ad libitum or demand/semi-demand feeding vs
scheduled interval feeding for preterm infants. The Cochrane Database of Systematic Reviews 2006; April 7(2) CD005255
u Shaker CS. Nipple feeding preterm infants: an individualized,
developmentally supportive approach. Neonatal Netw. 1999;18(3):15-22.
u Shaker CS, Woida AM. An evidence-based approach to nipple feeding in
a level III NICU: nurse autonomy, developmental care, and teamwork. Neonatal Netw. 2007;26(2): 77-83
u
Kirby et al, 2007;
u
Dusick et al, 2003;
u
Hawdon JM, Beauregard N, Slattery J, Kennedy G. Identification of neonates at risk of developing feeding problems in infancy. Dev Med Child Neurol. 2000;42(4):235-239.
u
Ross ES, Brown JV. Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Semin Neonatol. 2002;7(6):469-475.
u
Ross ES. Feeding in the NICU and issues that influence success. Perspect Swallowing Swallowing Disord. 2008;17:94-100
u
Ross ES, Philbin MK. Supporting oral feeding in fragile infants: an evidence-based method for quality bottle-feedings of preterm, ill, and fragile infants. J Perinat Neonatal Nurs. 2011;25(4):349-357
u
Samara et al, 2009;
u
Thoyre SM, Shaker CS, Pridham KF. The early feeding skills assessment for preterm infants. Neonatal
u
Thoyre SM. Feeding outcomes of extremely premature infants after neonatal care. J Obstet Gynecol Neonatal Nurs. 2007;36(4):366-375.
u
Thoyre SM, Holditch-Davis D, Schwartz TA, Melendez Roman CR, Nix W. Coregulated approach to feeding preterm infants with lung disease: effects during feeding. Nurs Res. 2012;61(4):242-251.