To Pace or Not To Pace – And the Survey Says…

By Lisa Kleinz MA, SLP/L, CLC CNT Director of Education, Dr. Brown

Dr. Brown’s Medical Healthcare Professional Pacing Survey Results– Where to go if guided by the data?  

Last month, Dr. Brown’s Medical discussed pacing as a strategy to assist infants with the complex task of coordinating sucking, swallowing, and breathing. Since the concept of pacing was first introduced in 1984 by Rosen, Glaze, and Frost, studies have shown that pacing can improve oxygen saturations, heart rate stability, behavioral organization, and efficiency of sucking patterns (Law-Morstatt 2003, Thoyre 2012). 

Although there are benefits of pacing, disadvantages also exist, due to the inconsistencies that sometimes occur with the pacing methods practiced.  The questions surrounding pacing prompted Dr. Brown’s Medical to ask the professionals about their opinions and practices regarding pacing. After 175 responses from therapists and nurses from the US and Canada, below are some of the highlights/results: 

Pacing is only one effective strategy, although is not typically used as a first strategy. 

In order of preferred use –

1. 43% – lower flow nipple 
2. 38 % – side-lying
3. 14% – pacing 

How we pace varies.  

There was a variety of responses when asked to rank the methods of tilt bottle, tilt baby, remove bottle, or break seal. There are advantages and disadvantages to each method, and most likely feeders use what they were taught. 

Even pacing strategies vary.  

The literature has reported on many strategies of pacing, including pacing based from cues, pacing for a prescribed number of sucks, and more recently, a ‘co-regulated’ method of pacing as described by Shaker and Thoyre. While 19% pace ‘reactively’ per stress cues, 66% pace both by cues and more proactively, to support neuroprotection. Of those who pace proactively, 40% pace according to a ‘set’ number of sucks. 

There is a consensus on why to pace. 

Although the methods and ways to pace seem to vary, there is an unanimity on why to pace.  In a world where ‘know the why’ has become common language, this is great news. The top three answers for why to pace are:

Reduces physical stress (89%)

Improves respiratory status throughout feeding (91%)

Reduces risk of bolus misdirection into the airway (75%)

Importantly, all of these components promote neuroprotection. 

Key finding: Staff are not confident that parents are receiving consistent information on pacing. 

In fact, 70% of the respondents reported they were either not confident or less than confident that parents were receiving consistent training on pacing.    This is very concerning taking into consideration articles and research have supported that the parent–infant interaction can be adversely affected by lack of consistency in information provided to parents or a lack of continuity in the approach to feeding advocated by professional caregivers. This can then interfere with development of parental competence and confidence (Shaker 2017 Part I).  Furthermore, caregiver-preterm infant feeding interaction and caregiver responsiveness to preterm infant feeding distress have been shown to be associated with preterm infant Bayley MDI at 1-year corrected gestational age. Improvement in feeding behaviors of caregivers and infants may represent modifiable mechanisms to improve further the developmental outcome of at-risk preterm infants (Parker and Thoyre 2018).   It is about more than feeding. 

So what do YOU think?  Where do WE all go from here?

In the NICU:

-Provide consistent messages surrounding feeding and cues to staff and parents.

-Position in sidelying, offer a slower flow rate nipple and provide consistent training to staff on how to pace. 

-Implement more opportunities with parents to teach infant-guided feeding.  Catherine Shaker describes a wonderful way to guide parents in her article “Mom, you got this” (2018).

-Education! There are many articles and webinars on pacing and cue-based feeding strategies. Dr. Brown’s Medical offers free, continuing education webinars at https://www.drbrownsbaby.com/medical/webinars/, as well as an online Infant-Paced Feeding program at www.infantdrivenfeeding.com. 

After discharge, at home visits or in the clinic:

-Be a good observer not only of infant behavior, but of caregiver-infant interaction during the feeding process. There are several assessment tools that can be used, including the Nursing Child Assessment Feeding Scale. 

-Talk to parents about how they feel feeding their infants. Is it enjoyable? Are they scared? The Infant and Child Feeding Questionnaire© by Feeding Matters (https://www.feedingmatters.org)  asks parents questions such as “Do you enjoy feeding time with your baby?” 

As a feeding specialist, continue to assess how parents are educated and determine whether supportive strategies are done because “that’s what you’ve always done,” or if they are truly supportive and neuroprotective in nature. After all, feeding is for life!

Click here to read the original articles

To Pace or Not to Pace, Part I 

To Pace or Not to Pace, Survey Says, Part II

References:

Law Morstatt et al. Pacing as a treatment technique for transitional sucking patterns. Journal of Perinatology 2003;23:483-488.

Parker  M, Rybin D, Heeren T, Thoyre S, Corwin M. Postdischarge feeding interactions and neurodevelopmental outcome at 1-year corrected gestational age. J Pediatr 2016;174:104-110. 

Rosen C, Glaze D, Frost J. Hypoxemia associated with feeding in the preterm infant and full-term neonate. American Journal of Diseases of Children 1984;138:623-8. 

Shaker C. Mom, you got this. ASHA Leader. Oct 2018. 

Shaker C. Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part I: Theoretical underpinnings for neuroprotection and safety. Part II: Interventions to promote neuroprotection and safety.  Seminars in Speech and Language 2017;38:96-105;106-115. 

Thoyre S, Hubbard C, Park J, Pridham K, McKechnie A. Implementing co-regulated feeding with mothers of preterm infants. MCN Am J Matern Child Nurs. 2016;41(4):204-211. 

Thoyre S et al. Co-regulated approach to feeding preterm infants with lung disease: Effects during feeding. Nursing Research 2012;61(4);242-251.