NICU: Infant Feeding and Skills

NICU and Infant Feeding

• Oral feeding success is achieved if the infant has a positive feeding experience, appears comfortable with minimal distress, maintains oxygen saturation near pre-feeding levels, recovers quickly, finishes feeding with midline flexed body posturing, and exhibits overall stability.
• The primary goals for swallowing are efficiency and safety.

Feeding Skills Factors

• Feeding skills factors encompass oral sensory functioning, oral motor functioning, pharyngeal anatomy and sensation, and skilled-based dysfunction.
• Psychosocial factors include developmental, mental and behavioral health, infant mental health, social influences, and environmental considerations.
• Intervention goals should prioritize airway patency, nutrition, and development.
• Responsive feeding is a process where infants and caregivers learn to recognize and interpret verbal and nonverbal communication signals, essential for emotional bonding and social-emotional functioning.
• Responsive feeding involves paying attention to the baby, observing their reactions, learning their cues, and responding supportively to their needs.

Feeding Assessment & Interventions in the NICU

• A coordinated suck-swallow-breathe ability is crucial for independent oral feeding.
• Immature oral feeding ability can hinder preterm infants' development, increase aspiration risk, hypoxemia, bradycardia, pneumonia, and mortality.
• Delays in transitioning from tube to full oral feeding can slow preterm infants' growth and development, potentially leading to feeding disorders, longer hospital stays, reduced mother-infant interaction, and higher costs.
• Key questions during assessment include whether the baby can or should eat and what the baby communicates.

Indicators of Readiness for Feeding

• Initial readiness indicators include being around 34 weeks gestational age, not intubated, having an acceptable degree of respiratory support, and showing readiness cues like stability, interest or hunger, and a positive NNS assessment.
• Readiness cues include general stirring, moving extremities and head, moving hands to face/mouth, and mouthing/sucking movements.
• Indicators of not being ready include little to no facial or extremity movement, or showing shallow, irregular breathing.
• Strategies to avoid include vigorously stimulating a sleeping infant, feeding a sleeping infant, waiting for scheduled times if the infant shows earlier hunger cues, and feeding a crying infant.
• Signs of readiness include a quiet alert and drowsy state, increased alertness or arousal, and starting to fuss.
• Additional cues include mouth opening, rooting, turning of the head, increased movement, and mouthing hands, though calming may be needed first.

Stability and Positioning

• Stability involves the infant handling being picked up and touched with stable vital signs.
• Optimal positioning supports stability and state regulation to promote the possibility of PO trials.
• Ideal alignment involves head, neck, and shoulders in alignment.
• Sidelying is also good for feeding purposes.
• With sidelying positioning it is important to have the ears in front of the shoulders with no large spaces between the chin and chest.
• Other important things to consider are swaddling the hands near the face (not in a straight jackets), which provide external stability and promote calming, also helping to control bolus flow, directing dribble out of the side of the mouth.

External Supports for State Regulation

• Consider using external supports for state regulation; they can be helpful, especially when feeding preterm infants.
• Interventions can include skin-to-skin contact, swaddling, positioning, swaying, shushing, light adjustment, bum pats, and hand hugs.
• Be cautious with motion as it can be calming for some infants, but overstimulating for others.

Assessment Considerations for Non-Nutritive Sucking (NNS)

• During non-nutritive sucking assessment, assess if the infant roots and latches onto the pacifier, can keep it in their mouth, and if it helps them calm.
• Look for tongue cupping, watch for stability signs such as vitals and color changes during NNS, feel for suction when pulling back on the pacifier, and assess secretion management.
• If the infant is unstable, adverse, or lacks strong skills, try pacifier dips.
• Consider pre-feeding oral stimulation (OS) and nonnutritive sucking (NNS) to improve oral feeding skills and facilitate transition to independent oral feeding
• Interventions can include a pumped breast as intervention and use of pacifier.

Treatment Considerations for Non-Nutritive Sucking (NNS)

• NNS interventions support the transition to oral feeding and positively impact oral feeding time.
• NNS helps with readiness to PO feed, swallow saliva, provides slight resistance against the tongue for lingual cupping, and pacifier dips help transition, offering tastes without demanding full flow management.
• Gentle touch or infant massage around the face can be a positive element.
• Milk drops promote safety/immunity and provide oral enjoyment.

Feeding Interventions for PO Readiness - Milk Drops

• Milk drops address oral aversion risk in extremely low birth weight (ELBW) and low birth weight (LBW) infants, who may lack typical oral feeding experiences (typically between 39-44 weeks)
• Currently only one study measures milk drops' impact on oral enjoyment, focusing on 23-26 week infants, and evidence shows it has positive impact.
• Intervention includes giving infants a droplet or two of milk at 3 days of age (in normal, nested, and stable bedside care).
• If the infant licks their lips or accepts a swab/pacifier, they receive more milk drops based on cues.
• A swab or pacifier remains in place as the droplets are given, with volumes limited by gestational age (just little drops).

SOFFI Method

• A quiet approach to the infant can be achieved first, by the providing an acoustic alerting of speech directed to the baby.
• Proximal alerting can be achieved with a light hand swaddle or a touch on the head.
• Wrap the infant in a non restrictive manner with extremities flexed toward midline with the head secured by the blanket.
• The caregiver can then offer the pacifier and observe, and then assess the ability and readiness of the child.

Analyzing Feeding Readiness

• When analyzing feeding readines one should look at stability, acceptance, body positioning, coloring, monitor readings, and environmental factors.
• It is important to measure Readiness, stability, coordination, positioning, efficiency, also keep an eye for body language from the child.
• If the baby is shows coordinations with the pacifier, milk drops or as previous experience with PO feeds you may proceed with assessing feeding.

PO Feeding ASSESSMENT and INTERVENTION

• For the assessment of PO feeding in NICU infants SOFFI (Supportive Oral Feeding in Fragile Infants) framework is reviewed.
• It revolves around factors like quality quantity, motor, autonomic and behavioral stability.
• Synactive theory is the framework to support SOFFI.
• Synactive theory posits that infants are biologically striving toward self regulation, where caregivers support this with attentiveness and responses so that the infant remains functionally organized and self regulated.
• SOFFI is designed with a systematic algorithm that provides guidance to clinicians and caregivers about encouraging quality feeding experiences, and promote the the overall development.

Maximizing Infant Stability

• SOFFI focuses on maximizing baseline motoric, autonomic, and behavior stability during oral feeding.
• Feeders should identify if oral feeding stresses the infant by observing behaviors indicating autonomic, motoric, and/or behavioral state changes.
• This way feeders can respond to the infant's communications (behaviors and/or distress) while helping maintain/regain physiological balance.

SOFFI Method Algorithm

• The SOFFI Bottle Feeding Algorithm helps to guide assessment to promote feeding ability, encourage healthy behaviors and stimulate a positive feeding experience.
• The algorithm relies on assessment to establish infant stability and support a return to a position so that they may regulate and feed at best potential.

Guiding Principle Of Feeding

• While Guiding the principles of feeding it is important to feed and read the child but consider ignoring as necessary, like postural stability and control, engagement and SSB for the health of the child.

Considerations for Assessment and Intervention

• Assessments include therapeutic interventions, such as adjustments and modifications to the feeding strategy.
• Elevated side-lying is one way to ensure muscles are relaxed, and head and trunk alignment are maintained.
• With this angle one may achieve anterior-posterior tongue movement and increase lung capacity, decreases airway resistance thus allowing for horizontal milk flow.
• Pacing allows for a compensatory technique that can be used between bottle and breast feeding to allow the baby to retain oxygen levels.
• Additional pacing can be achieved by tilting the bottle down to allow for opening (with constant lip seal), moving the bottle laterally, or removing the bottle all together allowing for the baby to catch up on breathing.

Feeding Interventions

• It is very important to modify the feed to the rate it needs to be, and it is recommended to not rely on specific packaging as some of them are not accurate.
• Consider the Bolus feeding temperatures the bolus is going to have an this assists with improving the airway protection (for preterm) when there is a dysphagia.

Dysphagia and Theoretical Approaches to Use

• Dysphagia consideration should be had when feeding preterm babies
• To follow with DYSPHAGIA consider caution while thickening, and follow Theoretical Approached in combination
• Infant-driven feeding approach principles include parents and caregivers learning to read the infant's cues and respond appropriately, understanding state regulation, physiological support, and behavioral and hunger cues, while making appropriate modifications.
• A clear distinction must be made between"being fed" and "supported to feed" during the process of feeding.
• The Infant Driven Feeding is similar to SOFFI in principal and application
• Infant Driven is baby-led, following the infants' cues of hunger and satiety to promote milk supply.
• Breastfeeding additionally provides increased skin-to-skin contact for the mother-infant dyad & responsiveness (which leads to maternal bonding).

Family Centered Care

• Family Centered Care is built and composed of many layers, where the main one revolves and requires a strong therapeutic alliance, where the caregiver is recognized as the expert on their child.
• A referral to mental health should be a priority if issues are being demonstrated and observed.

Body System Considerations

• There are other considerations that should be had while performing assessment and treatment of an infant in the NICU
• One specific component includes the level of respiratory support.
• With tachypnea cases often can be taxing on the child and require additional intervention or assistance to complete task.
• IF HFNC (High Flow Nasal Cannula) is being used one should consider the infant is already with a taxed respiratory system.