Chantal Lau PhD Baylor College of Medicine Department of PediatricsNeonatology Texas Childrens Hospital Houston TX USA October 31 2012 Financial Interest Feeding for Health LLC Outline ID: 280223
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Slide1
Oral Feeding Issues
Chantal Lau, PhD
Baylor College of MedicineDepartment of Pediatrics/NeonatologyTexas Children’s HospitalHouston TX, USA
October 31, 2012
Financial Interest: Feeding for Health LLCSlide2
Outline
Our philosophy
Common problems Bottle feeding approaches CurrentPotential
Oral Feeding Skills (OFS) Assessment Scale
Consider- interventions to enhance OFS
- tools to facilitate
oral feeding
Breastfeeding – the Oral Feeding PuzzleSlide3
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 aversionSlide4
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
Remember …
immature sucking
poor endurance
unstable behavioral states
not as efficient
cannot feed
for a long timeSlide5
physicians
nurses
feeding specialists
OT
lactation
speech
Oral feeding is a multi-disciplinary task…
nutrition
Important to give a consistent message to mother and baby
RC GormanSlide6
Adequate weight gain (
10-15 g/kg/day)
Safety : to minimize aspirationmust avoid O2 desaturation, apnea, bradycardia, aspiration-pneumoniaSuccess: to complete entire feeding within allotted time (e.g., 20 - 30 min)
limiting energy expenditure to favor weight gain
What is the current practice?Slide7
What should our goals be?
Adequate weight gain (
10-15 g/kg/day)Safety: no aspiration, O2 desaturations, 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 aversionSlide8
Outline
Our philosophy
Common problems Bottle feeding approaches CurrentPotential
Oral Feeding Skills (OFS) Assessment Scale
Consider- interventions to enhance OFS
- tools to facilitate
oral feeding
Breastfeeding - the Oral Feeding PuzzleSlide9
Signs of fatigue:Poor tone
State change, e.g., sleep, ‘shut down’Lengthy sucking pauses
Feeding duration > 20 minIncreased milk leakage, droolingIncreased respiratory rateOxygen desaturation/apnea/bradycardiaPoor enduranceSlide10
Reflux
Signs of reflux:Emesis
Choking/coughing/aspirationArchingOesophagitisOral feeding aversionSlide11
Suck-swallow-breathe incoordination
Signs of incoordination:Coughing/choking/aspiration
Poor self-pacingApnea/bradycardiaOral feeding aversionSlide12
Physiological
Oxygen desaturation
Apnea/bradycardiaTachypneaChoking/coughing/AspirationEmesisMilk leakage
Behavioral
Poor toneFall asleep Agitated
Pushing awayTurning head away
State change -“shut down”aversive to feeding
End result
difficulty diagnosing primary causes
Consequences…all the same…
If caretakers persist on feeding infantsSlide13
Are we doing right by our babies?Slide14
Outline
Our philosophy
Common problems Bottle feeding approaches CurrentPotential
Oral Feeding Skills (OFS) Assessment Scale
Consider
- interventions to enhance OFS- tools
to facilitate oral feeding
Breastfeeding - the Oral Feeding PuzzleSlide15
Current Approaches
focused primarily on sucking
issues, butlack of evidence-based data to objectively support the current practicesfew clinical studies available
to differentiate:
true benefits
vs.
natural maturation processSlide16
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)
Slide17Slide18
Use pacing technique
Why?
- infant sucking, forgets to breathe- gives time for breathing and restinghelps re-coordinate suck-swallow- breathe How? - 3-5 sucks
- tilting bottle back without removing bottle (infant’s organization)
pulling nipple outSlide19
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 anyabsence 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 aptitudeSlide20
Outline
Our philosophy
Common problems Bottle feeding approaches CurrentPotential
Oral Feeding Skills (OFS) Assessment Scale
Consider- interventions to enhance OFS
- tools to
facilitate oral feeding
Breastfeeding - the Oral Feeding PuzzleSlide21
B
ased on combinations of: common sense
physiologyevidence-based informationobjective integration of old and new information Watch out for: subjectivity/bias/over interpretation
Potential Approaches Slide22
Adjust feeding position
Why?
- facilitates organization & breathing - facilitates safer swallowing - decreases reflux -
intra-abdominal pressure
esphageal peristalsis (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)Slide23
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 consultedSlide24
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 studyBut do we really know our babies’ limitations in absence of overt behavioral and/or clinical responses?
Maybe best would be…..Slide25
Let infants feed at their own pace
Why? allows infants to:
develop appropriate functional feeding skills have a positive experience re. oral feedingminimize oral aversionHow? gives infants control to:
regulate milk flow rest if necessary
breatheSlide26
Baby communicates: ready to feed
Watch for cues…
Eyes may be open or closedResponsive to light touchLooks at caregivers’ faceHands towards mouth
Rooting or sucking Smooth motor movements
Calm and quietSlide27
Baby communicates:
NOT ready, STOP feeding
Watch for cues…Staring or gaze aversionPanic or worried lookcannot wake up, excessive yawningTremor, startling
Hiccupping, spitting up, gagging, gaspingFrantic, arching, arms extended, fingers splayed
Color changesIncreased respiratory rate and vital instabilitySlide28
Wait, give me a break!Slide29Slide30
Outline
Our philosophy
Common problems Bottle feeding approaches CurrentPotential
Oral Feeding Skills (OFS) Assessment Scale
Consider- interventions to enhance OFS
- tools to
facilitate oral feeding
Breastfeeding - the Oral Feeding PuzzleSlide31
Oral Feeding Skills Levels (OFS) scale
(Lau & Smith ’11)
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 minimalSlide32
Level 1
skills :
LOWEndurance:
LOW
Level 2Skills :
LOWEndurance:
HIGH
Level 4skills :HIGH
Endurance:
HIGH
Level 3
skills :
HIGH
Endurance:
LOW
Oral Feeding Skill (OFS) levels
GA
≤25
26-29
30-34
Endurance(RT)GOOD
POOR
Skills POOR GOOD
(
PRO)
30%
1.5
ml/minSlide33
OFS Levels
Feeding
skills (
Pro)
Endurance
(RT)
Potential Interventions
1
low
low
nonnutritive oral
motor stimulation
+
endurance training
2
low
high
nonnutritive oral motor stimulation
3
high
low
endurance training
4
high
high
none
Interpretations/interventions
OFS Level
Potential Intervention(s)Slide34
Overall Transfer (%)
Rate of Transfer (ml/min)
OFS 3
OFS 4
OFS 1
OFS 2
p < 0.05
OFS1 < OFS 2-4
OFS 2,3 < OFS 4
(Lau & Smith ‘12)
Feeding Performance vs. OFS levelsSlide35
Outline
Our philosophy
Common problems Bottle feeding approaches CurrentPotential
Oral Feeding Skills (OFS) Assessment Scale
Consider
- interventions to enhance OFS
- tools to facilitate oral feeding
Breastfeeding - the Oral Feeding PuzzleSlide36
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)
Types of interventionsSlide37
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 PONonnutritive oral motor therapy (NNOMT) and/or infant massage therapy (MT) – for 14 days
Feeding positioning: Upright and Sidelying
Interventions to enhance OFS skillsSlide38
Control
(Lau & Smith ‘12)
Intervention duration
Off CPAP- 8 PO/dSlide39
Nonnutritive oral motor (NOMT)
NNOMT+MT
Massage therapy (MT)
Control
Occurrence (%)
Occurrence (%)
(Fucile et al ’11)
1 8 ± 1 10 ± 1
1 8 ± 1 11 ± 1
1 16 ± 1 21 ± 1
Days from SOF
Days from SOF
14-day
interventionSlide40
Occurrence (%)
Occurrence (%)
Semi-reclined (control)
Sidelying
Upright
days from SOF 1 7 ± 6 17 ± 9
1 5 ± 3 15 ± 8 1 8 ± 6 22 ± 12
Feeding Positions
(Lau ‘12)Slide41
Outline
Our philosophy
Common problems Bottle feeding approaches currentPotential
Oral Feeding skills Assessment Scale
Consider- Interventions to enhance feeding skills
tools to
facilitate oral feeding
Breastfeeding - the Oral Feeding PuzzleSlide42
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)Slide43
Self-paced feeding system
Vacuum buildup
Hydrostatic Pressure
Parafilm
Standard Bottle
Self-paced system
Vacuum
Build-up
Vacuum Build-up
Self-paced bottle
(Lau & Schanler ’00)Slide44
p < 0.001
p = 0.007
p = 0.016
Standard
Self-paced
Standard
Self-Paced
GA
27.7 ± 1.2 (26-29)
27.9 ±1.0 (26-29)
PMA @ 1-2 PO/day
34.3 ± 1.0 (33-37)
34.2± 0.8 (33-36)
PMA @ 6-8 PO/day
36.3 ± 1.5 (34-39)
36.8 ± 2.0 (34-42)
(Lau & Schanler ‘00; Fucile et al ’09Slide45
p < 0.001
p < 0.001
p < 0.001
p = 0.002
p < 0.001
p < 0.001
p < 0.001
p = 0.002
Standard
Self-pacedSlide46
Standard
Self-paced
Bottle
Occurrence (%)
1-2 oral feedings/day
6-8 oral feedings/day
Standard Self-paced
Bottle
OFS levels – Standard vs. Self-Paced
(In prep)Slide47
Breastfeeding
RC Gorman
the Oral Feeding PuzzleSlide48
Mother-Infant Dyad
Maternal
behavior
Lactation
Non-nutritional
benefits
growth/development
Nutritional benefits
oral feeding skills
Mother
Infant
equilibrium
(Lau ’02)Slide49
Maternal
behavior
Lactation
Non-nutritional
benefits
growth/development
Nutritional benefits
oral feeding skills
Mother
Infant
(I)
(II)
(III)
imbalance
(Lau ’02)
With a preterm infant…Slide50
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? Slide51
Milk Synthesis/Ejection (lactogenesis II)
Milk Synthesis
lactogenic hormones: prolactin, glucocorticoids, insulin
leptin mammary development
(Laud et al,’99)opiates
lactogenic hormones
(Lau,‘92; Merchenthaler‘94)
Milk EjectionOxytocin
pulsatile
release, T
1/2
= 2 min
(Higuchi et al ’02)Slide52
Value of mother’s milk
Lactation Insufficiency – Common following premature delivery
Donor milk advocated (Schanler’89; Eidelman-AAP ’12)Mother’s milk favors maturation of innate immunityFormula favors maturation of adaptive immunity (Andersson et al ‘09) Pasteurization vs raw human milkpasteurization of human milk reduces fat absorption, weight gain, and linear growth in preterm infants
(Andersson et al ’07; Montjaux-Regis et al ‘11)Slide53
Maternal
behavior
Lactation
Non-nutritional
benefits
growth/development
Nutritional benefits
oral feeding skills
Mother
Infant
imbalance
(Lau ’02)
With a preterm infant…Slide54
Maternal attributes/ Maternal behavior
Importance of preserving the integrity of the nursing dyad and lactation
to nurtureto sustain maternal drive to breastfeed/express milkmaternal psychological well-being
(Li et al ’08)
Maternal behavior is a resultant of varying behaviors
Thus, factors affecting maternal behavior vary:psychological trait
personal health
education social support: family, friends, professionals
stress: anxiety, depression, workSlide55
Maternal obstacles
Motivation (25%)
Knowledge (24%)
Anxiety (14%)
Work (14%)
Health professionals
obstacles
Lack of support
Inapropriate
lactation management (19%)
Lack of knowledge (15%)
Negative attitudes (5%)
Lack of support (20%)
Staff shortages (5%)
Social obstacles
Lack of support (27%)
Life-styles (29%)
Obstacles to successful breastfeeding
(Bergh, ’93)Slide56
Maternal
behavior
Lactation
Non-nutritional
benefits
growth/development
Nutritional benefits
oral feeding skills
Mother
Infant
imbalance
(Lau ’02)
With a preterm infant…Slide57
Infant attributes/Non-nutritional benefits
To preserve integrity of the nursing dyad
bonding hypothesis (Tessier et al ’98; Reyna & Pickler ‘09; Taylor et al ‘05), 2-way street offers:
psychosocial benefits (
Charpak et al ‘97)
growth and development via physical contact, e.g. skin-to-skin, psychosocial dwarfism (Schanberg
et al ‘84; Ronca & Abel ‘96; Nyqvist
et al ’10;Munoz-Hoyos et al ’11; www.fundacioncanguro.co)
NICU environment
Potential risk for preterm infant neurodevelopment
(
Pickler
et al ‘10)
Prematurity
prolonged mother-infant separation
inappropriate mother-infant environment
decrease physical contactSlide58
Infant attributes / Nutritional benefits
Safe and successful oral feeding relies on:
ability to latch on to the breastefficacious sucking skillscoordinated suck-swallow-breathe
endurance
Prematurity/sickness/hospitalization
immature oral feeding skills
decreased oral feeding opportunities
poor enduranceSlide59
maternal
behavior
lactation
Mother
Infant
External
Factors
environment
caretaker
Suck
Swallow
Respiration
Infant Oral Feeding Performance
Safety
Success
Breastfeeding
Bottle Feeding
Central Nervous System
Peripheral Nervous System
Development
Stress
Fetal DevelopmentSlide60
To be launched Fall 2012
If interested
send me your contact (name & email address) to:chantal.lau@infanthealthfoundation.orgwww.infanthealthfoundation.org