NICU feeding neonates

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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PURPOSE 1. To provide guidelines for family, staff and physicians for the introduction and management of oral feeding for high-risk infants.

2. To create positive feeding experiences while assisting infants to achieve full oral feeding and to attempt to prevent the development of oral aversive behaviors.

UNDERLYING PRINCIPLES 1.

2.

3.

4.

Feeding is an active social interaction between caregiver and infant.

Development of oral feeding follows stages that can be identified.166,172 Stages are used to plan physiologically appropriate feeding experiences.172 Movement within and between stages may be bi-directional.

PRINCIPLES OF FEEDING ASSESSMENT 1. Continuous assessment of infant state and responses before, during and after non nutritive sucking (NNS) as well as nutritive sucking (NS), is essential. 146, 152, 154,166 2. Providing interventions that are contingent on infant responses is needed to achieve specific goals within each stage. 76, 152, 156 3. Reassessment of oral feeding process and plans should occur when: 3.1. Engagement/readiness cues are present and if positive signs persist: • Identifiable hunger cues • Increased/enhanced quiet alert state • Stable physiologic responses 3.2. Disengagement/distress cues are present and if distress signs persist: • Significant changes in heart rate (bradycardia, tachycardia) • O2 saturation outside normal limits • Color changes (pallor, cyanosis, mottled) • Significant changes in respiratory status (rate, grunting, nasal flaring, retractions, apnea) • Loss of postural tone • Loss of state 3.3. Feeding skills improve: • Improved suck/swallow/breathe (SSB) coordination • Satiety cues

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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POINTS OF EMPHASIS 1. Most premature infants will be able to feed by mouth without difficulty as they approach term gestation.

2. Gestational age and severity of illness may play a role in how long an individual infant remains in any one stage.

3. There is a wide range in ability at various gestational ages. For example a healthy preterm infant at 33 weeks adjusted age may be able to achieve total oral feedings while a 44 week adjusted age infant with chronic lung disease may not.

OVERVIEW OF THE ORAL FEEDING PRACTICE GUIDELINE: Non-oral stages Pre-oral Stimulation Stage Non-nutritive Sucking Stage Nutritive Sucking Stages Stage I: Minimal oral intake (<10% oral) Stage II: Moderate oral intake (10 to <80% oral) Stage III: Full oral intake (> 80% oral)

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Appendix I: Definitions

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Appendix II: Development of Premature Infant Feeding Behavior

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Appendix III: Parameters for Feeding Assessment

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

Date Established: April 30, 2004

ORAL FEEDING

Date Reviewed: March 2009

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STAGES OF NEONATAL FEEDING Pre-Oral Stimulation Stage GOALS Minimize negative oral stimulation8, 36, 52, 66, 76, 78

Promote behavioral organization Establish and maintain mother’s milk supply

INFANT CHARACTERISTICS Responds adversely to handling Poor physiologic, motor & state regulation with or without stimulation 78, 127, 128, 129, 148 None to very weak oral reflexes (transient) 66 None to very weak non-nutritive skills 8, 36, 52, 66, 76, 78, 79

INTERVENTIONS Use developmental care interventions to facilitate midline position and flexion which promotes hand to mouth experience and behavioral organization 78,127, 128, 129

Skin-to-skin care (Kangaroo care©) Positive experiences to the facial area as tolerated by infant. 33 • Sustained touch • Kisses by family

WHEN TO REFER Refer to LC when mother: • Has difficulty establishing/ maintaining lactation • Experiences complications as a result of pumping • Has difficulty in accessing breast pump Refer to OT when infant: Fails to progress or has extreme hypersensitivity to oral touching NB: first consider gestational age and severity of illness

•

0 % oral intake Not managing secretions (Neurological infants) 66

Support the mother in initiating and maintaining lactation 11, 41 (See: Booklet: Breastfeeding Your Preterm Baby) Discuss with parents realistic expectations for initiation and progression of feeding 61, 185 Tube feeding only (Refer to Policy: 2-G-1 Gastric Tubes)

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Non-Nutritive Sucking Stage GOALS INFANT CHARACTERISTICS Promote positive oral stimulation and NNS 66

Support the establishment and maintenance of mother’s milk supply 0 % oral intake

Stable with handling and able to maintain physiologic, motor and state stability with NNS interventions148 Oral reflexes present or emerging Demonstrates licking and rooting By the end of this stage the infant will be able to demonstrate NNS by: • Establishing and maintaining latch • Rhythmical sucking bursts • Coordinating sucking and breathing

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INTERVENTIONS Provide positive facial experiences and NNS: • Infant’s fingers: position to support hand to mouth contact to allow the infant to suck when needed171 • Pumped breast: allows infant to nuzzle and practice sucking.

• Skin-to-skin care (Kangaroo care©) • Soother/ pacifier: standard shaped nipples are recommended 18, 66, 171 (no orthodontic, flat or bulb shaped pacifiers); never force a nipple into the infant’s mouth Note: If baby has difficulty sucking and breathing, attempt to provide external pacing Transition to Pairing NNS and Tube Feeding: •

•

Consider placing a warmed drop of milk on the infant’s lip to promote the infant to bring their tongue forward to lick the milk Once infant demonstrates coordination of NNS (breathing and sucking), all above methods of NNS can be combined with tube feeding (e.g. gavage feeding while nuzzling at breast)

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WHEN TO REFER Refer to LC when: There is a concern with mother’s milk supply

•

Refer to OT: After first considering gestational age and severity of illness, refer to OT when infant: • Is evasive or refusing NNS, or having difficulty coordinating sucking and breathing (e.g. chronic lung disease, neurological impairment) • Fails to progress from this stage Refer to Home Nutrition Support Service, OT, and Neonatal Transition Team (NTT) or Pediatric Home Care when: • Infant is to be discharged home on any amount of tube feeding

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

Date Established: April 30, 2004

ORAL FEEDING

Date Reviewed: March 2009

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Nutritive Sucking Stage I: Minimal Oral Intake CRITICAL STAGE GOALS

INFANT CHARACTERISTICS

INTERVENTIONS

Oral practice only

Infants who are breastfed may exhibit better O2 saturations than infants who are bottle fed. 40, 58, 168 Infants ~32 weeks adjusted age may begin to demonstrate readiness cues and be able to achieve this stage of nutritive sucking 100, 134, 164, 169, 170 Good NNS; emergent but no sustained SSB coordination Oral Intake < 10% daily volume

Minimize distracting stimuli 109,152

Quality and ambiance is more important than quantity taken 228 Experience is positive for infant and caregiver Infant is able to take small amounts of feeding orally in a controlled setting 8, 24, 28, 52, 66, 76

Positive Readiness Cues: • Manages secretions 24, 66 • Maintains a quiet/alert state 25, 109,166

•

Emergent but not sustained coordination of SSB • Beginning to self pace • Licking/ Rooting/ Mouthing • Resting RR <80 with no respiratory distress cues 24 Disengagement/ Distress Cues: • Easily becomes physiological unstable • Pooling of bolus • Aspiration • SSB becomes disorganized

Aid infant to awake state a.c.

(<10% oral intake within a 24 hour period) WHEN TO REFER

146, 148, 171

Skin-to-skin care (Kangaroo care©) a.c.152.

Intervene to prevent distress.

Feedings should not be pushed 45, 78, 90,134,155 ,173 Therapeutic tasting – drop milk onto soother from 1 ml syringe 1 drop at a time.

External pacing – to aid or prevent disorganized SSB 7, 27, 28, 97,121,147, 167 - Infants capable of limited self-pacing: gently roll infant forward (bottle in the mouth) until milk is out of nipple; allow infant to breath, reorganize, and cue for readiness - Infant not able to self-pace: Allow the infant to suck 3-4 times on the milk filled nipple, break suction, remove nipple from mouth. Allow infant to breath, reorganize, and cue for readiness. If infant does not open mouth spontaneously, elicit rooting reflex Note: Pauses need to be > length of sucking burst to allow adequate recovery

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Refer to LC when: • Mother’s milk supply is a concern • Unable to achieve latch • Infant is consistently frustrated at breast • Complications present (e.g. cracked nipples, mastitis) Refer to OT when: (NB: first consider gestational age and severity of illness) • Infant is at high risk for dysphagia (e.g. neurological impairment) 13; symptoms include: - Gurgling sounds in pharynx.

- Coughing during feeding.

- Congestion or noisy breathing during feeding - Good NNS but

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

Date Established: April 30, 2004

ORAL FEEDING • • • • •

Fatigues easily (falls asleep) Difficulty initiating feeding Head bobbing Loss of postural tone Loss of state

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refuses NS Difficulty managing secretions (Aspiration may be silent)

Breastfeeding: Nuzzle at breast: encourages infant to root, smell, touch, lick, taste, or latch 31,

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42, 44

•

•

• •

If infant has difficulty with strong milk ejection reflex, try placing infant on a partially pumped breast 85 If infant behavior is disorganized at breast, try NNS (mom’s finger, infant fist, pacifier); once organized try placing back on breast Pair tube feeding with nuzzling at breast Refer to Pamphlet “Breastfeeding Your Premature or Sick Infant”

Bottle Feeding: Check for excessive milk flow: release pressure or change nipple before feeding • Swaddle to promote organized behavior152 Provide postural stability147, e.g. side lying157 on pillow with head elevated • Begin all feedings with 1-2 minutes NNS 32,64, 74, 89, 93 to help organize infant state and skills • Place a drop of milk on the lip before feeding to help the infant organize for oral feeding • Use low flow single-hole nipple 21, 40, 56, 80, 97,163,172 (losing liquid is OK to allow the infant to adjust volume).

• Do not allow the infant to become distressed.

• Do not jiggle or turn nipple to stimulate NS; this practice is contraindicated 152,173 •

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•

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Persistent feeding induced apnea and bradycardia Poor or unsustained latch i.e. an excessive wide jaw excursion Failure to progress from this stage

Refer to Home Nutrition Support Service, OT and NTT or Pediatric Home Care when: • Infant is to be discharged home on any amount of tube feeding

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Nutritive Sucking Stage II: Moderate Oral Intake GOALS To ease the transition to full oral feeding by supporting endurance, skills and physiologic stability Quality and ambiance is still more important than quantity taken

(10% to <80% of oral feedings in a 24 hour period) INFANT CHARACTERISTICS INTERVENTIONS Identifiable readiness cues: • Hand to mouth, rooting • Increased motor activity prior to feeding

Aid infant to awake state a.c. 146, 173; NNS may help with state control and SSB coordination 148

The infant may demonstrate readiness to feed at some feedings throughout the day, but not necessarily all the feedings166

When a breastfeeding infant becomes more consistent with positive breastfeeding experiences, consider test weighing as this is the only accurate way to determine intake 11,12,19

Functional to good SSB 28, 31, 52, 66, 169

Watch for distress/ disengagement cues closely and assess infant’s readiness to continue feeding; the infant should be alert, actively sucking, pacing, and coordinating their SSB; if infant does not demonstrate readiness to continue feeding or the infant demonstrates disengagement cues, remainder of feeding should be tube fed: 24, 52, 66, 76 Watch O2 10, 27, 87 and if the infant desaturates consider replacing with a #5 tube or removing the OG/NG tube for the feeding 63, 72 • If tube in place, gavage remainder of feeding • If tube not in place, make up the difference within a 24 hour period • Consider concentrating milk to decrease volume required

Improved endurance but not enough to maintain full oral feeding Immature state control – unable to maintain quiet alert state throughout entire feeding 25 Consistent self- pacing may or may not be present A positive breastfeeding experience is defined as: an infant who demonstrates a good latch, sustained bursts of nutritive sucking, and audible swallowing for several minutes 41, 143

Feedings should not be pushed.

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WHEN TO REFER Refer to LC when: Poor latch evident Infant falls asleep at breast • Poor milk transfer suspected • Considering test weighing • Considering use of nipple shield 142 • •

Refer to OT when: NB: first consider gestational age and severity of illness 38 • Poor unsustained latch evident • Flooding present • Good NNS but poor NS • Signs of dysphagia • Persistent feeding induced apnea and Bradycardia • Failure to progress from this stage

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Infants who demonstrate an ability to take ≥ 30% of required volume and ≥ 1.5ml during the first 5 minutes of feeding may attain oral feeding earlier than others. 40 Note: Infants may develop physiological instability if pushed at this stage and require ongoing monitoring of saturation and heart rate

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External and self- pacing may still be indicated, particularly in the first few sucks of a feeding, and if infant has chronic lung disease157.

External Pacing for breastfed infants may be necessary for mothers with strong milk ejection reflex: Strategies include: • Having mother pump breast a little before feeding 85

•

Removing baby from breast during milk ejection reflex • Allowing baby to reorganize before placing back on breast Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding 42, 41 Nutritive Sucking Stage II interventions may be further matched to the percentage oral intake as follows: Stage IIA: 10% to <25% oral vs tube • Maximum 5-10 minute oral feeding time (breast or bottle) • Oral practice only when cueing; likely 1-2 times/day • Assess whether baby needs nonpumped or pumped breast for breastfeeding • NNS &/or therapeutic tasting with tube feeds

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Refer to Home Nutrition Support Service, OT , and NTT or Pediatric Home Care when: •

Infant is to be discharged home on any amount of tube feeding

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Stage IIB: 25% to <50% oral vs tube • Typically >10 minute oral feeding time • BF/B opportunities dependent on infant cues; aid to awake state ac • Occasional full bottle taken Stage IIC: 50% to <80% oral vs tube • Maximum 30 minute oral feeding time • Offer BF/B opportunities every time infant cues • May or may not need supplementation after BF/B; determine TFI range to allow flexibility in amount of tube feeding top up needed • Assess need for indwelling vs intermittent NG/OG

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

Date Established: April 30, 2004

ORAL FEEDING

Date Reviewed: March 2009

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Nutritive Sucking Stage III: Full Oral Feeding (≥80% oral feedings in a 24 hour period) GOALS

INFANT CHARACTERISTICS

WHEN TO REFER INTERVENTIONS

Full oral feeding that supports growth Feeding experience is positive to infant and caregiver

Sustains SSB throughout the feeding 24 , 28, 31, 66 Endurance to maintain nutritional intake to support growth Demonstrates clear hunger cues: • Hand to mouth, rooting • Increased motor activity • Wakes to feed Demonstrates satiation cues: Slips off nipple at end of feeding • Falls asleep at end of feeding

Continue side lying and external pacing as required Transition to cue base feeding before discharge; intervals between feedings may vary greatly throughout day 11, 73, 112,118,136,147,149,150,152,156,160 If infant demonstrates disengagement cues, delay feeding until infant cues again Consider no top-up if infant consumes >80% of feed Consider oxygen saturation monitoring for 24 hours during all states including feeding (especially infants with chronic lung disease) 10,71

•

Most infants by 37-42 weeks adjusted age should be able to achieve Stage III of nutritive sucking 100, 134, 169

Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding, and to room in for 48 hours before discharge 42, 41 Before discharge, the infant should be transitioned to the nipple and feeding regime that parents are planning to use at home.31,73 This will enable matching of the infant’s skills to the nipple to be used. A commercial single hole, straight nipple is recommended. If the infant does not tolerate this nipple, then the hospital supplied low flow nipple should be sent home 24, 52, 66 Ideally infant should spend >3 days in stage III pre-discharge

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Refer to LC when: • Poor latch evident • Poor milk transfer suspected • Poor weight gain • Poor milk supply

Refer to OT when: Infant discharged on total oral feeding but feeding skills are suspect 38: • SSB incoordination • Poor endurance • Prolonged feedings > 45 minutes • Neurological impairment

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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APPENDIX 1: DEFINITIONS External Pacing (imposed breaks) 52, 66, 76, 126,145,161 - caregiver assists the infant in appropriately interspersing breaths during sucking bursts, to facilitate organization and rhythmicity; to decrease fatigue; and provide time for the infant to clear the bolus from the mouth or throat. This will support respiration by promoting deep breathing. Some infants require the nipple to be removed from the mouth because the nipple remaining in the mouth will continue to stimulate a sucking reflex 52. As a result, the infant will not swallow and take a breath, or will be sucking air on the empty nipple.

External Pacing is done in 2 ways 52, 66, 126 • If infant is capable of limited self-pacing (swallows and breathes during pauses): Gently and slowly roll infant forward with the bottle in the mouth until the milk is out of the nipple. Allow the infant to resume effective breathing, reorganize, and cue for readiness before rolling back to fill the nipple with milk again. If infant does not open mouth spontaneously, attempt to elicit rooting reflex. Verbalize infant’s cues for readiness to parents.

• If infant demonstrates no self-pacing: Then removal of the bottle for external pacing may be necessary. Allow the infant to suck 3-4 times on the milk filled nipple, then break suction and remove nipple from mouth and allow the infant to effectively breath, reorganize and cue for readiness. If infant does not open mouth spontaneously, attempt to elicit rooting reflex.

Continue oral feeding only if infant demonstrates readiness cues. This allows the infant the choice to resume feeding. In this circumstance, the caregiver is pacing for the infant before distress cues are noted.

Gastroesophageal Reflux (GER): a return or backward flow of gastric contents into the esophagus.

Milk Ejection Reflex ( MER): another term for let down or the strong release of milk generally occurring at the beginning of a feeding which may also occur several times during the feeding.

Non-nutritive sucking (NNS): 24, 66, 149, 171 repetitive sucking bursts and pauses in the absence of nutrient flow; numerous sucks (approx. 6 –8) can be taken before a swallow, because the infant needs to accumulate a large enough secretion bolus before a swallow is triggered; a mature NNS rate is 2 sucks per second; the premature infant pattern usually begins with single sucks with long or irregular pauses; purpose is as a state regulatory mechanism and to satisfy sucking desire.

Nutritive Sucking (NS): 24, 66 occurs during active sucking for the purpose of nourishment; this pattern is complex and significantly more challenging than non-nutritive sucking; twenty-six muscles and six cranial nerves must be coordinated for the pharyngeal swallow itself, to occur safely and efficiently; sucking pressure consists of compression and suction; mature rate is one

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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suck per second; Suck: Swallow Ratio is 1:1 but at the end of the feeding or with older infants may increase to 2:1(rate dependent on flow rate and size of oral cavity).

• Breastfeeding: - rate of sucking and suck: swallow ratio is variable and dependent on rate of milk flow • Bottle feeding: - in the mature pattern, sucking bursts are longer at the beginning of the feeding and become shorter with longer pauses over the course of the feeding; the return of bubbles into the bottle is a reflection of the liquid flow; strength of suck is reflected in the resistance to removing the nipple and the rate of flow.

Oral Feeding- nutritional intake by breastfeeding, cup feeding or bottle feeding.

Suck/Swallow/Breathing Coordination (SSB): 24, 66, 76,164,169 Safe feeding requires precise coordination of processes that provide airway maintenance for breathing and airway protection during swallowing. Rhythmicity is the hallmark of normal feeding and is a reflection of smooth, split second coordination between sucking, swallowing and breathing. Immaturity or abnormality in any of these functions can have a profound effect on the other component and on the infant’s feeding ability. Assessment of SSB involves careful assessment of each of the components individually as well as the coordination and organization of all the components together Supplement Feeding: Feeding the infant via a mode other than the mother’s chosen feeding goal-this may account for minimal amount of feed up to a complete feeding (100%).

Tube Feeding: Nutritional intake by oral gastric, nasal gastric, nasal jejunal or gastrostomy tube.

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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APPENDIX II. DEVELOPMENT OF PREMATURE INFANT FEEDING BEHAVIOR Breastfeeding 31, 41, 143, 168 It is important to be aware of mother’s milk supply as only non nutritive sucking will be observed if supply is very low; higher milk flow requires more mature sucking patterns. Sucking bursts are related to the flow of milk.

Immature Mixed Mature • Licking predominates • Some rooting evident • Obvious consistent rooting • Little rooting evident • Repeated short sucking • Deep latch maintained bursts of ~ 6-15 sucks • Shallow latch or • Repeated long sucking difficulty maintaining bursts of ~ 15-30 sucks • Swallowing beginning to latch be integrated into • Swallow audible sucking burst • Occasional short • Pattern of bursts - suck sucking bursts of ~ 3- • ~ 6-10 minutes of swallow breath or suck 5 sucks suck swallow breath nutritive sucking • Pattern of burst is ~1• > 11 minutes of sucking 5 sucks pause and breath • < 5 minutes of nutritive sucking Bottle Feeding 6, 47,50,75, 97, 100, 134, 151, 153, 159, 164 Immature •

• • • •

• •

Predominantly expression/compression rather than suction usually ~ 2-3/second If suction is present it is of low amplitude Pattern is irregular or arrhythmic Expression/suction is not paired with swallow < 50% of expressions/sucks are organized into bursts <10 sucks per burst when burst present Breathing not consistently integrated into expression and swallow

• •

•

•

• • •

Mixed

Predominantly expression/compression Expression/compression pattern rhythmic usually ~ 1/second (55/min) Alteration of suction/expression emerging but arrhythmic Expression/suction inconsistently paired with swallow 50-90% of expressions/sucks organized into bursts Pauses irregular and generally long 10-20 sucks per burst

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Mature •

• • • • • •

Rhythmic alteration of suction and expression/compression Rate increases ~ 65/min Suck of consistently high amplitude Swallow consistently paired with suck > 90% of sucks organized into bursts Pauses more regular and short 10-40 sucks/burst

CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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Immature Feeding Patterns That May Require Intervention: 24, 66 1. Prolonged Sucking (can lead to feeding induced apnea): Baby has lengthy sucking bursts without inter-dispersing breaths at appropriate intervals. The baby has difficulty with pacing SSB. Baby often has a strong, rapid suck but may have difficulty initiating breathing even after the nipple has been removed. The infant may terminate sucking to recover during the pause. If unable to terminate sucking independently, the infant becomes apneic with oxygen desaturation, cyanosis or bradycardia.

2. Short Sucking Bursts: Infant only takes 1-3 sucks before pausing to breathe. Pattern is rhythmic but pauses are frequent and long compared to the bursts. This pattern may result in decreased intake due to respiratory compromise and/or swallowing dysfunction.

3. Disorganized Sucking: Characterized by very disorganized and uneven sucking pattern.

Duration of bursts and pauses vary considerably and there is an uncoordinated pattern of breathing and swallowing153, 165. Coughing and choking are frequent. Infants may be disorganized throughout the feeding or may begin organized and suddenly become disorganized. Causes: disorganized state and behavior, neurological deficit, respiratory problems158 or incompatible nipple flow rate.

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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APPENDIX III. PARAMETERS FOR FEEDING ASSESSMENT 1. Heart Rate 6, 24, 66,173 • Tachycardia: If baseline heart rate is elevated or heart rate dramatically increases and remains elevated for prolonged time. This indicates work of feeding may be excessive.

Increases in 10 bpm during feeding are not uncommon. Larger increases may indicate that demands of feeding are excessive. However if an infant has a high baseline heart rate, even small increases in heart rate can indicate great physiologic stress.

• Bradycardia: A drop in heart rate below 90 or 100 BPM. When observed with feeding, bradycardia is a significant and possibly life threatening event. Common causes include: - Poor positioning during feeding - Aspiration, structural anomalies, vagally mediated laryngospasm - Prolonged sucking pattern and stretch receptors (sensory receptors) in pharynx stimulated by large bolus - Presence of nasogastric tubes (touch-pressure receptors) or - Micro aspiration of food or by reflux (chemoreceptors) 2. Respiratory Status 24, 52, 66, 173 • Respiratory rate should be evaluated at the beginning, mid and post-feeding and time required to return to baseline should be measured.

• Respiratory rate is individual and depends on the infant’s ability to compensate for the reduction in ventilation imposed by feeding.

• Increase RR leads to increase risk of incoordination of SSB and increase risk of aspiration.

• For infants with respiratory compromise, a resting RR (when awake), <65 to 70 breaths per minute is a conservative guideline for initiating feeding. Respiratory rates>80 breaths/min. during pauses and prolonged recovery to baseline, indicate that work of breathing is too great and non-oral feeding is recommended until respiratory work during feeding is reduced.

• Signs of respiratory distress: Tachypnea = >60 breaths per min. Nasal flaring/blanching, Retractions Chin tugging, Shallow catch breaths.

Neck extension/arching O2 desaturation

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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10, 24, 70, 66, 87, 131, 134, 173

3. Oxygen Saturation • Term and preterm infants experience slight but measurable oxygen desaturation with bottle feeding (dips with continuous sucking & return to baseline during intermittent sucking).

However for compromised infants with borderline saturations, theses reductions can be significant. Sudden dips may be associated with apneic or bradycardic episodes, whereas a gradual decline may indicate inadequate respiratory support for feeding. Desaturation may be an isolated event and seen with out significant observable change e.g. no change in color.

During breastfeeding, oxygen saturation levels usually remain higher and exhibit less fluctuation than during bottle feeding. 40, 70,162 Refer to Guideline: 2-P-3 Pulse Oximetry in Neonates.

4. Clinical Indications of Swallowing Dysfunction (risk for aspiration) 66 • Choking during swallowing • Inability to handle own oral secretions • Noisy, “wet” upper airway sounds after individual swallows or increasing noisiness over course of feeding • Multiple Swallows to clear single bolus • Apnea during swallowing • History of frequent upper-respiratory infections or pneumonias 5. Aspiration can result from a primary swallowing dysfunction or from incoordination between sucking, swallowing, and breathing. Aspiration can be descending (during feeding) or ascending (during gastroesophageal reflux). 24 Sometimes aspiration occurs with fatigue towards the middle or end of a feeding and is referred to fatigue aspiration. 66, 126 Aspiration can be silent (no coughing present). It can only be confirmed with a videofluoroscopic swallow study (VFSS). 24, 126

6. Videofluoroscopic Swallowing Study (VFSS) is a radiographic study that evaluates the status and safety of the pharyngeal swallow. Barium is used to image pharyngeal structures and function. During the study, treatment techniques (altering the texture, temperature, and bolus size) are attempted to determine if swallowing can be improved. 66, 173

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CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title:

ORAL FEEDING

Date Established: April 30, 2004

Date Reviewed: March 2009

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CROSS REFERENCES MANUAL: 1. Booklet: Breastfeeding Your Preterm Baby 2. Book: From Here Through Maternity 3. Child Health Policy 2-G-1

SUBJECT/TITLE: On units On units Gastric Tubes: Neonates

REFERENCES 1.

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Lau, C., & Schanler, R. J. (1996). Oral Motor Function in the Neonate. Clinics of Perinatology, 23(2), 161-178.

Medoff-Cooper, B., Weininger, S., & Zukowsky, K. (1989). Neonatal Sucking As A Clinical Assessment Tool: Preliminary Findings. Nursing Research, 38(3), 162-165.

Kinner, M. D., & Beachy, P. (1994). Nipple Feeding Premature Infants in the Neonatal Intensive-Care Unit: Factors and Decisions. JOGNN, 23(2), 105-112.

Mandich, M. B., Ritchie, S. K., & Mullet, M. (1996). Transition Times to Oral Feeding in Premature Infants With and Without Apnea. JOGNN, 25(9), 771-776.

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140. Malhotra, N., Vishwambaran, L., Sundaram, K.R., & Narayanan, I. (1999). A controlled trial of alternative methods of oral feeding in neonates. Early Human Development, 54(1), 29-38.

141. Martin, M., and Shaw, N.J. (1997). Feeding problems in infants and young children with chronic lung disease.

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142. Meier, P.P., Brown, L.P., Hurst, N.M., Spatz, D.L., Engstrom, J.L., Borucki, L.C., & Krouse, A.M. (2000). Nipple Shields for preterm infants: Effect on milk transfer and duration of breastfeeding. Journal of Human Lactation, 16(2), 106-114.

143. Nyqvist K.H.., Sjoden P., Ewald U. (1999). The development of preterm infants' breastfeeding behavior. Early Human Development, 55: 247-264.

144. Brazelton TB.(1984). Neonatal Behavioral Assessment Scale 2nd edition. Philadelphia: J.B. Lippincott Co. 145. Als H. Manual for Naturalistic Observation of Newborn Behavior: Preterm and Full term Infants. (1984). Boston MA: The Children's Hospital.

146. McGrath, J.M & Medoff-Cooper, B. (2003). Alertness and feeding competence in extremely early born preterm infants. Newborn and infant nursing reviews, 9(3), p. 174-186.

147. Ludwig, S.M. (2007). Oral feeding and the late preterm infant. Newborn & infant nursing reviews, 7(2), p. 72-75.

148. Pickler, R.H. (2005). A model of feeding readiness for preterm infants. Neonatal intensive care, 18(4), p. 17-22.

149. Pridham, K.F., Kosorok, M.R., Greer, F., Kayata, S., Bhattacharya, A. & Grunwald, P. (2001). Comparison of caloric intake and weight outcomes of an ad lib feeding regime for preterm infants in two nurseries. Journal of advanced nursing, 35(5), 751-759.

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ACKNOWLEDGEMENT We wish to thank the following staff for their dedication and contribution to the Regional Neonatal Oral Feeding Protocol: Joanna Chan Jo Chang Donna Dressler-Mund Tanis Fenton Darlene Goodwin Sharon Harvey Heather Howarth Maureen Jobson Lucy Kim

Linda Kostecky Ruth Kovacs Karen Lasby Toni MacDonald Laurie McCormack Debbie McNeil Carolyn Miron Cathy Orton Shahirose Premji

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Jennifer Reed Pattie Schumacher Jeanne Scotland Edie Scott Tammy Sherrow Ann Smith Marilynne Steward Carol Turko April von Platen

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Date Established: April 30, 2004

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DISCLAIMER All content in this policy and/or procedure is Š copyright, Calgary Health Region. All rights reserved. This information, and as amended from time to time, was created expressly for use by Calgary Health Region staff and persons acting on behalf of the Calgary Health Region for guiding actions and decisions taken on behalf of the Calgary Health Region. The Calgary Health Region accepts no responsibility for any modification and/or redistribution and is not liable in any way for any actions taken by individuals based on the information herein, or for any inaccuracies, errors, or omissions in the information in this policy and/or procedure. Any modification and/or adoption of this policy and/or procedure are done so at the risk of the adopting organization.

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