Question to the Blog About Feeding Preterm Infants in the NICU:
My observation, like other therapists, is that many of the micro preemies and/or babies that have had very involved respiratory issues and complex treatment needs because of these issue, often require increased sensory input related to feeding (temperature variance, thickened consistency). What we have observed is that these babies often benefit from increased FIO2 during feeds despite having adequate O2 levels. Do you have any thoughts on this matter? Our primary Neonatologist says that there is no physiological reason that this rational would be helpful. I believe the extra flow provides the sensory input that these babies often need, especially while learning to feed.
Answered by: Sue Thoyre, PHD, RN, FAAN,Francis Hill Fox Distinguished Term Professor , School of Nursing, The University of North Carolina at Chapel Hill
Oxygen is a stabilizer of the smooth muscles of the pharynx. Another reason it may be helping is that RR decreases overall by 5-10 breaths per minute during feeding so oxygen reserves are quickly depleted.
I do not agree with giving thickener – this is altering the infant’s microbiome and leading to a need for a larger bore nipple which increases the bolus size, increases the need for swallowing and reduces the opportunity for breathing.
Prioritize support on the respiratory system with good postural/diaphragm support, resting within the first minute of the feeding and often thereafter, pacing individualized to the child’s respiratory rate (higher rate, less duration of sucking), low flow nipples, side lying.
A few thoughts. “Flow ” and Fi02″ are two different parameters. Due to the concern for the potential adverse effects of oxygen (Fi02), many NICU infants in need of increased respiratory support are weaned to 21% Fi02 with flow. That flow can be delivered via NCPAP, HHFNC, and low flow nasal cannulae. The flow rate itself (PEEP or LPM), has been shown to often help prevent pharyngeal collapse and facilitate maintenance of functional residual capacity (FRC). These two parameters to some extent are likely part of the underpinnings for effective feeding, when WOB and respiratory stability permit PO. However, when an infant is requiring significant Fi02 at baseline, one might question his/her readiness for the aerobic demands of feeding. Depending on the “extra flow” you describe (typically that means for example, PEEP or LPM), it may also create possibly an unsafe feeding environment, as what a conclusion of the recent study by Ferrara et al. See Ferrara, L., et al. “Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates.” Journal of Perinatology 37.4 (2017): 398-403. The answers are not fully in but this well done paper suggests certain flow may clearly be worrisome for particular infants.
Regarding thickening feedings in the NICU – As I travel and teach across the US about feeding preemies, I am consistently finding that thickened feedings are viewed only as the final consideration after position change, further slowing the flow rate and use of increasing strict co-regulated pacing. The potential adverse effects of thickened feedings are many, and require us as to be “clinical scientists”, i.e., carefully weigh the risk-benefit ratio for each preterm infant, and create a unique algorithm for that infant’s plan of care, in collaboration with the NICU team. Each infant’s history, co–morbidities, respiratory history, and current clinical picture and as well as the impact on the infant’s swallowing physiology, must be carefully considered and weighed. We have such a complex job when it comes to supporting safe and neuroprotective feeding. We lack the research to fully guide us, so in addition to evolving research, I think our critical thinking, living in the “grey zone”(having more questions than answers) and dialogue with the medical team are our current optimal strategies.
I hope this is helpful.
Excellent response Catherine. It is such a grey zone. When we approach these tiny clients with a one size fits all mentality we create so many problems.
Our little clients are our teachers, we need to individualize our approach to them and learn from them.
Thank you Catherine!