• Multiple Lessons • Interactive Exercises • References ...

Developmental Care by Speech-LanguagePathologists in the Neonatal Intensive Care Unit

ASHA Self-Study 4400 1

© 2011 American Speech-Language-Hearing Association

• Multiple Lessons• Interactive Exercises• References• Related Resources• CEU Test



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This course is offered for 0.3 ASHA CEUs (Intermediate level, Professional area).

Claire Miller, PhD, CCC-SLP, BRS-SAnn Clonan, MEd, CCC-SLP

Brenda Thompson, MA, CCC-SLP



• Implementation of developmentally-supportive care leads to improvedoutcomes for preterm infants

• Explore terminology and diagnoses specific to the NICU• History of developmental care and knowledge• Etiologies of oral motor and feeding problems in premature infants• Clinical indicators highlighting the need for objective swallowing

assessment• Develop supportive non-nutritive and nutritive oral motor stimulation

plans in the context of the overall developmental care plan.

• Recognize infant states, cues of stress, and levels of comfort• Utilize appropriate assessment/management methods• Discuss the role of speech-language pathology in interdisciplinary

assessment and treatment• Identify clinical indicators of swallowing dysfunction that signal the

need for objective assessment• Design treatment goals that can be implemented in the infant's

overall developmental care plan



Ann Clonan, MEdInpatient Speech

Pathology ProgramCincinnati Children's

Hospital Medical Center

Brenda Thompson, MARegional Center for

Newborn Intensive CareCincinnati Children's


Claire Miller, PhDAerodigestive CenterCincinnati Children's


II. Diagnoses: Impact on Feeding

III. Developmental Care

IV. Assessment and Intervention

V. Instrumental Assessment of Swallowing

VI. Using Current Evidence to Guide Intervention

I. Introduction to the NICU Click ona sectionto begin



Section I: Objectives

• Overview of the NeonatalIntensive Care Unit (NICU)

• ASHA Policy Documents

(see Additional Resources)

– Position Statement

– Technical Report

– Guidelines

– Required knowledge andskills

TOOLBARAccess Additional

Resources



Levels of Care

• Level I: Newborn Nursery

– Cares for healthy, term infants or infants who arephysiologically stable and born at 35-37 weeksgestation

• Level II: Special Care Nursery

– Provides level I care plus care for infants >32 weeksgestation and >1500 grams with physiologicalimmaturity (poor feeding, temperature instability,apnea)

– Infants in need of respiratory assistance such asmechanical ventilation for < 24 hours

Levels of Care (cont.)

• Level III: Neonatal Intensive Care Unit

– Levels I and II in addition, depending onintensity of needs, gestational age (<28weeks) and weight (<1000 grams)

• Advanced respiratory support, major surgicalrepairs, cardiopulmonary bypass, ECMO, accessto subspecialty consultants, access to advancedimaging (CT, MRI, echocardiography)



Multidisciplinary Environment

• Neonatologists

• Neonatal nursepractitioners

• Resident physicians

• Nurses

• Registered Dietitians

• Pharmacists

• Respiratory therapists

• Pediatric Specialists (ENT,cardiology, neurology, GI,etc.)

• Speech-languagepathologists

• Occupational therapists

• Physical Therapists

• Audiologists

• Social Workers

• Chaplin

• Psychologists

• Holistic Health

• Child Life

• Developmental Specialists



Birth Weight Definitions

• Low birth weight (LBW): less than 2,500grams or 5 pounds, 8 ounces

• Very Low birth weight (VLBW): less than1,500 grams or 3 pounds, 4 ounces

• Extremely Low birth weight (ELBW): lessthan 1,000 grams

Premature Birth Rate

• More than 525,000 babies (12.7%)

• Current data shows continued increase

• 20% increase since 1990

• 60,000+ born with a birth weight of < 1500grams

• 90% survive

• 10% significant disability

• 25-50% experience later cognitive & behavioraldeficits

National Center for Health Statistics (www.cdc.gov/nchs)(Foster-Cohen et al., 2010; McCormick et al., 2011; Laughon et al., 2009)



Statistics for Very Low BirthWeight

Birth Weight Percentage of Total Births

< 2,500 grams (5.5 lbs) 7.9%

2,000 - 2,499 grams (4.4-5.5 lbs) 4.9%

1,500 -1,999 grams (3.3-4.4 lbs) 1.4%

1,000 -1,499 grams (2.2-3.3 lbs) 0.7%

500-999 grams (1.1-2.2 lbs) 0.6%

< 500 grams (<1.1 lbs) 0.2%

National Center for Health Statistics

Increased Complications inPremature Birth

• Hypothermia

• Hypoglycemia

• Perinatal asphyxia

• Respiratory problems

• Fluid and electrolyteimbalances

• Hyperbilirubinemia

• Anemia

• Impaired nutrition

• Feeding problems

• Infection

• Neurological problems –intraventricularhemorrhage

• Ophthamologiccomplications

• Hearing deficits

• Sudden infant deathsyndrome (SIDS)



Risks for Long TermComplications

• Generally the smallerthe baby, the higher therisk

• Increased likelihood of

– Cerebral palsy

– Blindness

– Deafness

– Developmental Delay

The Role of the SLP

• Communication evaluation and intervention

• Feeding and swallowing evaluation andintervention

• Parent/caregiver education and counseling, staff(team) education, and collaboration

• Active participant in the NICU in developingrelated protocols for infant care anddevelopment



Section I: Summary

• Preterm birth rate is on an upward trend

• Prematurity is associated with increasedrisk for neurodevelopmental problems

• The pediatric speech pathologist has aspecific role in the assessment andintervention of high risk preterm infants

Impact on Feeding



Section II: Objectives

• Prevalent medicaldiagnoses

• Implications forfeeding

• Equipment in theNICU

Prematurity Concerns

Issues of Prematurity• Periodic breathing, apnea of

prematurity (AoP),bradycardia, cyanosis

• Difficulty digesting andabsorbing food

• Temperature control

• Hyperbilirubinemia

• Metabolic: hypo andhyperglycemia, hypocalcemia,and problems with electrolytes

• Anemia

• Increased likelihood ofinfection

Possible Effects onFeeding

• Poor state modulation

• Reduced endurance

• Difficulty sucking: wide jawexcursions, anterior loss,tongue elevated

• Reduced coordination of suck-swallow-breathe



Video: Recognizing InfantStates

Video: Recognizing InfantStates



The infant shifted from a drowsy state to?

Question: Recognizing Infant States

Light sleep

Active alert state

Quiet alert state

Deep sleep

The infant shifted from a drowsy state to?

Question: Recognizing Infant States

Light sleep

Active alert state

Quiet alert state

Deep sleep



• State transition

– Quiet alert state

• Critical for supportinginfant development

– Discriminate infantstates

– Spot state transitions

– Cues for stimulation

Analysis: Recognizing InfantStates

Gastrointestinal (GI)Concerns

GI Conditions• Gastroesophageal Reflux

(GER)

• Necrotizing Entercolitis (NEC)

• Omphalocele

• Gastroschisis

• Hirschprung’s disease

• Pyloric Stenosis

• Midgut Volvulus

• Malabsorption

• Esophageal Atresia


• Delayed introduction of oralfeeding

• Motility

• Emesis

• Altered sensation in pharynx

• Oral aversion

• Reduced intake

• Possibly slow transition to oralintake



Video: GI Concerns

Video: GI Concerns



Question: GI Concerns

Coughing and choking

Gagging and grimacing

Vomiting

Rooting

The stress cues this infant displayedinclude?

Question: GI Concerns

Coughing and choking

Gagging and grimacing

Vomiting

Rooting

The stress cues this infant displayedinclude?



• Discern cues ofstress or acceptanceof feeding

– Break

– Pause

– Continue

Analysis: GI Concerns

Cardiac Concerns

Cardiac Anomalies• Patent Ductus Arteriosis (PDA)

• Coarctation of Aorta

• Tetrology of Fallot (TOF)

• Transposition of the GreatVessels

• Congenital Aortic Stenosis

• Congenital Pulmonic Stenosis

• Atrial Septal Defect (ASD)

• Ventricular Septal Defect(VSD)


• Fatigue

• Reduced endurance

• Reduced oral intake

• Reduced weight gain

• Tachypnea

• Apnea and Bradycardia




Neurological Concerns

Neurologic Conditions

• Hemorrhage: Intracranial,Intraventricular,Subarachnoid

• PeriventricularLeukomalacia (PVL)

• Myelomeningocele

• Chiari Malformation

• Hypoxic IschemicEncephalopathy (HIE)

• Central apnea


• State Modulation

• Endurance

• Tone Issues

• Reflexes

• Reduced coordination ofsuck-swallow-breathe

• Possibility of aspiration

Video: Neurological Concerns



Video: Neurological Concerns

Question: Neurological Concerns

Drifting into a sleep state

Grimacing

Calmed relaxed face and body

Arrhythmic suck

Best description of readiness cues forfeeding include?



Question: Neurological Concerns

Drifting into a sleep state

Grimacing

Calmed relaxed face and body

Arrhythmic suck

Best description of readiness cues forfeeding include?

• Discern cuesindicating readinessfor feeding

– Quiet alert state isideal

Analysis: NeurologicalConcerns



Respiratory Concerns

Respiratory Conditions• Pulmonary Hypertension

• Tracheoesophageal Fistula(TEF)

• Laryngomalacia

• Tracheomalacia

• Bronchopulmonary Dysplasia(BPD)

• Obstructive Apnea

• Congenital DiaphragmaticHernia (CDH)


• State and Endurance


• Tachypnea, increased work ofbreathing

• Increased potential foraspiration due to reducedcoordination and highrespiratory rate

• Possibly reduced weight gain

Craniofacial Concerns

Craniofacial Anomaliesand Syndromes

• Cleft lip

• Cleft palate

• Combined cleft lip and palate

• Pierre Robin Sequence(micrognathia, glossoptosis,+/- cleft palate) (PRS)

• Goldenhar syndrome

• CHARGE

Possible Effects on Feeding

• Reduced lip seal resulting inanterior loss

• Functional compression of nippletypically

• Reduced negative pressure

• Nasal regurgitation

• Need for specialized feeder thatprovides assistive squeeze tocompensate for reduced negativepressure

• Arousal, endurance, tachypnea,hypoxia particularly withobstruction with PRS

• Possibility of aspiration due tofeeder assistance variability



Video: Craniofacial Concerns

Video: Craniofacial Concerns



Question: Craniofacial Concerns

Provide an assistive squeeze with eachsuck

Watch the infant’s cues to determinewhen to squeeze

Provide squeezing when infant stopssucking

Provide squeezing towards the end ofthe feed

When feeding using a specialized feeder, itis important to?

Question: Craniofacial Concerns

Provide an assistive squeeze with eachsuck

Watch the infant’s cues to determinewhen to squeeze

Provide squeezing when infant stopssucking

Provide squeezing towards the end ofthe feed

When feeding using a specialized feeder, itis important to?



Equipment in the NICU

The Infant’s Environment

• Beds:

– Incubators: closedenvironment

– Cribs: openenvironment

• Monitors

– Heart rate

– Respiratory rate

– Oxygen saturation

It is important to developthe ability to read the

infant’s cues and signs ofstress without total reliance

on monitors for feedback

Oxygen Delivery Systems

• Oscillator

• Ventilator

• Continuous positive air pressure (CPAP)

– uses mild air pressure to maintain anopen airway during sleep

• High Flow

– refers to oxygen delivery, inspired gasesat a preset oxygen concentration"

• Nasal Cannula

– oxygen delivered via a nasal cannula(tubing with nasal prongs from whichoxygen flows)



Section II: Summary

• There are a number of medical and feedingconcerns that are associated with prematurity

• Infants can have associated or isolatedproblems that affect the gastrointestinal, cardiac,respiratory, neurological, or craniofacial system

• There are several common pieces of equipmentwithin the NICU environment that allow closemonitoring and support of infants.

Recognizing Infant States

Maximizing Oral Potential



Section III: Objectives

• Developmental Care

• Infant states and cues

– Respond appropriately

• Maximize oralpotential

Developmental Care

• Infant’s neurobehavioralorganization and how NICUenvironment care can fosterdevelopment

• Defines “competence” ofnewborn’s functioning as

– interplay between infant’sautonomic, motor, state/regulatory,attentional/interactional, and self-regulatory systems and theenvironment

(Lawhon, 2003)



NIDCAP

• Newborn Individualized Developmental Careand Assessment Program (NIDCAP)

– Process-oriented approach

– Focuses on a relationship based, individualized,developmentally focused framework of care

(Als, 1996)

Caregivers

• Parents should understand

– Infant’s strengths and challenges

– How the infant communicates

– How to best interact with the environment

• Can become a guide for all caregivers



Infant Behavior

• Infant communicatesthrough behaviors

– State

– Movement

– Autonomic system

• React appropriately toensure optimalsupportive interventions

Environment

• Alter sensorial input to supportneurobehavioral organizationand development

– tactile, auditory, olfactory,vestibular, visual, taste

• For example:

– lighting, sound, positioning,containment, touch



Infant States of Consciousness

• Relate to sleeping and waking cycles

• Each state has a unique set of behavioral,neurological and physiologicalcharacteristics

• Indicates when infants may be ready foran activity

State Transitions

• Indicator of infant’s maturation

• Maintenance of state supports infant’sability to take advantage of theirorganization to learn, sleep for recovery,grow

• Smooth transition between state supportsinfant’s organization



Quiet Sleep

• Face relaxed

• Eyelids closed, still

• Relaxed body

• No body movements; rarestartles

• Breathing regular

• Decreased heart rate andblood pressure

• Decreased brain activity

Active Sleep

• Eyes closed butinconsistently flutter

• Motor activity varies

• Rapid eye movement

• Breathing irregularand faster than quietsleep

• May suck or “chew”with mouth



Drowsy

• Typically, as infant wakesup or falls asleep

• Slow movements withsome smiling, frowning,lip pursing

• May stretch

• Eyes may be opened(glazed, rolling up) witheyelids droopy or shut

Quiet Alert

• Eyes open and bright

• Looking at caregiversface/eyes

• Motor activitysuppressed

• Energy seemsfocused onhearing/seeing



Active Alert

• Frequent movements

• Eyes looking about

• Making small sounds

• Attention less focused

• Often occurs prior tofeeding or when fussy

Crying

• Eyes open or closed

• Breathing irregular

• Obvious sign ofcommunication

• Occurs with infanthunger, discomfort, orlonely



StabilityCopingStress

InfantCues

Identifying Cues

• Attention

• State

• Motor

• Physiologic



Stability

• Attention:

– smiling, mouthing, cooing/ooh face, looking at you

• State:

– awake and relaxed

• Motor:

– hands to face, limbs moving smoothly, minimal motoractivity

• Physiologic:

– pink color, easy breathing, good heart rate

Coping

• Attention:

– looking away

• State:

– shifting to a lower state

• Motor:

– grasping, leg bracing, fisting, hands to mouth,clasping hands or feet

• Physiologic:

– sucking, yawning



Stress

• Attention:– avoid social interaction

• State:– gaze aversion, glassy eyes,

irritability, decreased alertness

• Motor:– limb stiffening, finger/toe splaying,

arching, frowning, tonguethrusting, generalized hypotonia

• Physiologic:– color change, heart rate change,

drop in O2, apnea, hiccoughs,yawning, coughing, sneezing

Aversion Development

• Long term NPO

• Reflux

• Neurological issues

• Significant medicalinterventions aroundface/mouth/throat

• Negative intraoralexperiences

• Limited experiencewith oral sensoryexperiences: taste,smell, touch

• General sensoryissues of prematurity

• Aspiration

• “Forced” experiences(i.e., infant not incontrol)



Care to Maximize OralPotential

• Proactive intervention

• Developmental Care/nursing

• Oral Care

• Taping

• Tube Feeding

• Gavage Feeding Support-held/pacifier during feed

• Kangaroo care

• Respiratory Care

– Choice of suctioning

• Whole body sensory input

– Massage

• Maximizing pleasant oral/facialexperiences

– Non-nutritive suckingopportunities

• Pacifier

• Empty breast

• Inclusion of Parents

• Oral Intake of any volume:tastes/ sham

– Interplay of sensory-motorreceptivity

– Capability in handlingactivity of PO feeding

Section III: Summary

• Developmental care:

– Interventions designed to minimize the stressof the environment

• Newborn Individualized DevelopmentalCare and Assessment Program(NIDCAP):

– Individual strategies combined into a program

• Behavioral cues guide the timing ofinteraction



Section IV: Objectives

• Key components of theevaluation of non-nutritiveand nutritive skills

• Typical and atypicalmaturation characteristicsof nutritive sucking

• Assessment andintervention strategies



CreateOpportunity for

Success

Continuum of Care

• Assessment directs intervention

• Integration of multiple systems

• Focus on quality

IdentifyStrength’s andChallenges

Perspectives in Feeding

Readiness considerations go beyond oralmotor and swallowing considerations

• Consider whole infantand how to maximizetheir abilities

• Team approachrequired



Considerations forAssessment and Intervention

• Neurobehavioral organization– State– Cues

• Caregiver–Infant psychodynamics• Nutrition Issues• Physiological/Autonomic• Anatomy/Structure• Non-nutritive skills• Nutritive skills• Swallow function and assessments

Formal Assessments

• Few in number and limited in range ofassessment

• Only a few have been tested for validity:

– SAIB (Systematic Assessment of the Infant at theBreast)

– PIBBS (Preterm Infant Breast-Feeding BehaviorScale)

– The Early Feeding Skills Assessment for PretermInfants (Thoyre, et al., 2005)

– NOMAS (Neonatal Oral-Motor Assessment Scale)• Useful for full-term infants, less reliable for preterm (Mizuno,

2005)



• Full range of states– Oral feed only with infant in drowsy or quiet alert

state

• Coordinate suck/swallow (McCain, et al, 2001)– Pattern is more 3/4:1 which can result in deglutition

apnea

• Non-nutritive suck for calming (Lemons, 2001)

• Coordinate SSB with 1/1/1 pattern forappropriate burst (Lemons, 2001)

• Nutritive suck with longer bursts (10 to 30)(Lemons, 2001)

32

34

38

40

36

Weeks

Nutritional Readiness

• Demonstrating adequate growth

• Sequence

– Total Parenteral Nutrition and lipids

– Supplemental Enteral

• Nasojejunal, nasoduodenal, nasogastric

– Flow rate

• Continuous

• Bolus



Nutritional Readiness (cont.)

• Formula or Breast Milk

• Schedule:

– Hourly timed

– Ad lib

– On-demand

• Remain aware of how supplemental feedingtransitions are affecting oral intake

– Change in caloric density, volume or time

– Motility

Maturation

• Ability to:

– Tolerate handlingand transitions

– Achieve andmaintainappropriate state

– Remain organizedfor length offeeding



Physiological Considerations

• Respiratory Status

– Between 20-50 breaths per minute, no greaterthan 70 bpm (Shaker & Woida, 2007)

• Cardiac Status:

– Between 120 and 160 beats per minute

• Color:

– Remains pink, not mottled, pale, or blue

• Effects of positioning on physiologicalsystem (non-nutritive and nutritive skills)

Anatomy

• Physiological flexion

– Cheeks/fat pads lateralsupports

– Tongue fills oral cavity

– Jaw supported withapproximation of neck/chest

– Hard palate close withapproximation and sealsanteriorly

– Soft palate is posterior seal



Anatomical Considerations

• Less support

• Less efficient/effective

• More fatiguing

How do anomalies impact feeding?

Initial Observation

• Management ofsecretions

• Both non-nutritive andnutritive activities

• Sensory and motorresponsiveness

• Lip placement andtongue cupping

• Strength of suck



Initial Evaluation (cont.)

• Rhythmicity of suck

– Non-nutritive: 2sucks/second

– Nutritive: 1 suck/second

– Premature infants:arrhythmic with morecompression affect withvariable suction

• Length of sucking burst

Nutritive Evaluation

• Suck/swallow/breath coordination

– Sucking Bursts

– Ability to handle flow of intake

• Liquid viscosity

• Taste

• Nipple

• Endurance



Nipples

No one size fits all

• Pliability

• Shape

• Size and length

• Hole type and size

• Individualize to:

– Support infant’s structure and function

– Matching nipple’s structure and function



Pacifiers (cont.)

• Helps with statemodulation (calming,arousing)

• Positive effect onoxygenation, GI function

• Match shape with one tobe used for feeding

Ability to suck on a pacifier does notassure success at oral feeding

Video: Pacifier



Video: Pacifier

Video: Pacifier

• Lack of fat pads incheeks

• Still behavior

• Short bursts withgood pauses



Considerations of Bottleand/or Breast Feeding

• Typically dictated by medical status

– Volume limits

– Inability to control flow

– Oral coordination

• Coordinate with lactationconsultant

• Activities that support eventualBreastfeeding

– Kangaroo care

– “Dry breast”

Interventions

• Oral Feeding is one component

– QUALITY not QUANTITY

– Assure for experience with stable:• Coordination of SSB

• Maintenance of autonomic system, state

– Competent caregiver• Understanding global process

• Successful provider

Remember Infant’s Goals



Intervention: SpecificConsiderations

• Stimulation Control

– Environment

– Tactile Input

– Timing of care

• Position

– No one size fits all

– Adjust per infantissues/stability

Interventions (cont.)

• Supports for autonomic system

– Increase O2

– More frequency respiratorybreaks

• Coordination with enteral feeds

– Max. calories/min. volume

– Therapeutic feedings

– Minimal volumes

– Sham feedings

• Caregiver Training




• Pre-feeding oralstimulation (touch,pacifier)

• Bottle / Nipple systems

• Flow rate:

• Bolus size and rate

• Single and/or slowchain

• Dipped tastes on pacifier ornipple

• Syringepresented/controlled

• Pacifier/nipple

• Thickening:developmentally ormedically appropriate?


• Pacing

– Self

– External

– Burping

• Extending trunk/abdomen

• Gentle: patting

• Respiratory break

• Oral supports

– Jaw/cheek support

– Caution



Video: NNS to NS

Video: NNS to NS



Video: NNS to NS

• Positioning

• Stimulated

• From NNS withpauses to NS

• Pacing

Video: Pacing Cues



Video: Pacing Cues

Video: Pacing Cues

• Gulping

• Pulling back

• Eyes widening

• Labored breathing



Section IV: Summary

• Gestational age, medical status andstability in physiologic, motor, and statesystems determines readiness for feedingin preterm infants

• Interventions should be individualized tomatch an infant’s skills

Options in the NICU



Section V: Objectives

• Clinical indicators

• Available tests

– Strengths

– Limitations

• Video examples

Instrumental Assessments

Only appropriate on physiologically stable infants

• Indirect Assessment– Cervical auscultation: used in conjunction with clinical

observation in some settings, but not standardized

– Dye testing: used to assess evidence of aspiration, but poorspecificity

– Scintigraphy/Radionuclide scanning

• Direct Assessment– Videofluoroscopy

– Endoscopy

– Ultrasonography



Infant Swallowing Patterns

• Relation between swallowing and respiration changes withmaturation

• Mature infants:

– Swallowing occurs at end of inspiration, .672 sec (apnea), rhythmicalternation of compression, suction, expression, swallow-breath (SW-BR) (Gewolb & Vice, 2006)

– Observations: Intermittent nasopharyngeal reflux, hesitation in cervicalesophagus (Newman, et al., 1991)

– Swallowing occurs during pauses in respiration at 32-33 weeks(Bu’Lock et al., 1990; Lau et al., 2000)

– Sucking behavior matures ~ 34 weeks in regard to number of sucks perswallow, intensity of sucking pressure (Gewolb et al., 2001)

• Preterm infants:

– Immature pattern, can be successful, but not as efficient (Lau et al.,2003)

Other Considerations

• Preterm infants

– physiologically stable

– medical complications

– co-morbid conditions

• Term infants

– medical diagnoses that may impactupon coordination of respiration,sucking, swallowing



Suck, Swallow, andRespiration

• Sucking rate and strength

• Ability to integrate breathing with sucking, swallowing

• Bolus volume, consistency, and delivery

• Impact of swallowing on respiration– During swallowing, respiration is inhibited

– Feeding supersedes normal ventilatory chemoreceptor controlmechanisms

– Swallowing rhythm maintained (Goldfield, et al., 2006) (Vice &Gewolb, 2008)

• Implications of respiratory compromise (i.e., BPD)

• Implications of poor oxygen saturation on strength ofsucking, ability to maintain airway protection

Cervical Auscultation

• Screening Tool

• Auditory assessment ofrespiration/swallow, changes duringfeeding

• Make inferences about the pharyngealphase

• Reliability/Validity questionable

• Therapist dependent– Reynolds, et al., 2002



Ultrasonography

• Use to assess suckingbehavior and oral transittimes in both breast-fedand bottle-fed infants

• Non-invasive

• Not used extensively byclinicians in clinicalpractice

– Miller & Kang, 2007

Scintigraphy

• Radionuclide isotope inbuccal cavity

• Indicates aspiration inlungs

• Scanning done at intervalsover a 2 hour period

• Questionable: materialaspirated duringswallowing of saliva orduring a reflux event

• Not a “true” evaluation ofswallowing function



Dye Testing

• Dye added to feeds

• Trached patients– can monitor presence of

dye via tracheal suctioning

• Issues with reliability andvalidity– Use of dye contraindicated

in medically fragile patients

– Evidence questionable asto from above or below insome cases

– More research is needed

Signs of Swallowing Dysfunction

• Coughing, choking while feeding

• Noisy, wet respiration associatedwith feeding

• Color changes

• Physiologic signs:– apneic spells, bradycardia, increased

respiratory rate

• Evidence in tracheotomy tube

• Unexplained respiratory illnesses– Consider patient’s diagnosis (Newman,

et al., 2001)



When to Use Swallow Study

Consider:

• Medical history

• Overall development

– Motor skills (whole bodyand oral-NNS, NS)

– State

– Results of feedingevaluation

• Made in consultationwith team

Video Swallow Study (VSS)Goals

• Obtain dynamic images during swallowing:

– oral phase and transit

– pharyngeal response

– upper esophageal function

• Focus on airway protection capability duringswallowing

• Identify problems:

– Why do they occur and at what point

• Obtain holistic view of suck-swallow-respirationcoordination



Ensuring Success

Preparation is key!

• Positioning

– Fluoroscope table is tilted vertically

– Use optimal positioning for infant, based oninformation from clinical assessment

• Time the VSS for the “right” time

– State and hunger

• Be ready with feeder and equipment

• Establish a collaborative plan with the radiologistto execute the study



Observations During VSS

• Barium via selected nipple or syringe

Analyze sucking response, in terms of:

• Rate, strength, and rhythm

• Even, uneven, slow, in bursts

• Loss of formula

• Other difficulties

Monitoring During VSS

• Monitor physiologic state during feeding

Know the normal baseline!

• Work with team to monitor:– Heart rate, respiratory rate, and effort

• Note any changes

– Oxygen saturation• Note initial saturation and document any changes



Typical Interventions During VSS

• Altering Position– Neutral head position, watch for extension and flexion

• Pacing– Certain number suck-swallows, impose pause

• Changing viscosity– Altering fluid thickness to slow rate of flow, facilitate organization

of airway protection prior to swallowing

• Nipple change– Alter flow rate

• Clearing “dry” swallows– To assist with hypopharyngeal clearance in between nutritive

swallows

Fatigue Effect

• Assess suck-swallow-breathe synchrony

– initially, during, and at end of feeding

• Obtain images of initial sucking bursts andpauses

• Ask radiologist for interval fluoroscopy imagesas the infant continues to feed

– Allows assessment of fatigue effect (e.g., if infant tiresas feeding progresses and has difficulty withmaintenance of airway protection)

– Helpful information for intervention planning



Scoring the Infant VSS

• Evaluation of overall suck-swallow-breathecomponent

• Document:

– Premature spillage

– Episodes of laryngeal penetration

– Episodes of laryngeal aspiration

– Infant responses:

• Clearing response, no protective response

Strengths and Limitations of theInfant Video Swallow Study

Strengths:

• Overall look at all phases

– Detailed analysis oforopharyngeal andpharyngoesophageal phase

• Anatomical and physiologicabnormalities

• Assess protective reactions

• Determine effectiveness ofcompensatory strategies

– Flexibility to try strategies toimprove feeding/swallowingfunction: i.e. differentpositions, alter flow rate,different viscosities

Limitations:

• Brief sample of feeding in alimited time

• Addition of barium (taste)

• Effects of radiation

• Requires ability to ingestsufficient amounts



Possible Findings on VSS

• Oral transfer problems resulting in poor timing ofairway protection and swallowing

• Reduced strength of oropharyngeal andpharyngeal musculature

• Incomplete airway closure during swallowingresulting in penetration into airway

• Aspiration: material in airway with reaction

• Silent aspiration: material into airway with noprotective response

Assessing Poor AirwayProtection

• Before the swallow:

– Poor oral phase collection/delivery

– Delayed initiation/sensory

• During the swallow:

– Incomplete closure or airway protection

• Poor coordination of SSB

– Anatomic issues

– Function/strength



Aspiration

• After the swallow

– Aspiration of persistentresidue secondary to poorpharyngealsqueeze/peristalsis

– Failure of the UES to relax(e.g., cricopharyngealachalasia)

– Poor sensory awarenessof residual material

Objective SwallowingAssessment: VSS



Video: Infant Swallow

Video: Infant Swallow



Question: Infant Swallow

Five to six sucks per swallow

Variable pattern, but a tendency toward1-2 sucks per swallow

No appreciable pattern, the infantseems disorganized

None of the above

1. The pattern of sucks can best bedescribed as:

Five to six sucks per swallow

Variable pattern, but a tendency toward1-2 sucks per swallow

No appreciable pattern, the infantseems disorganized

None of the above

1. The pattern of sucks can best bedescribed as:





Two episodes that cleared

One large episode of aspiration

Three small episodes of aspiration

Deep penetration but noaspiration

2. How many episodes of aspirationoccurred?


Two episodes that cleared

One large episode of aspiration

Three small episodes of aspiration

Deep penetration but noaspiration

2. How many episodes of aspirationoccurred?



Video: Infant Swallow #2




Question: Infant Swallow #2

Disorganized with no real rhythm established

Unorganized initially, with only slightly betterorganization as the swallow sequences continued

Smooth and efficient anterior posterior tongue motion,overall a coordinated 1:1 suck-swallow pattern

Coordinated pattern with basically two-three suckcompressions per swallow

How would you describe the suck-swallowpattern in clip #2?


Disorganized with no real rhythm established

Unorganized initially, with only slightly betterorganization as the swallow sequences continued

Smooth and efficient anterior posterior tongue motion,overall a coordinated 1:1 suck-swallow pattern

Coordinated pattern with basically two-three suckcompressions per swallow

How would you describe the suck-swallowpattern in clip #2?



Analysis: Infant Swallow #2

• More compressionsprior to swallow

• Changes to typicalsuck, swallow,breath pattern






Consistent

Unable to be fully visualized

Incomplete

None of the above

In video clip # 3, palatal contact with theposterior pharyngeal wall is:




Consistent

Unable to be fully visualized

Incomplete

None of the above

In video clip # 3, palatal contact with theposterior pharyngeal wall is:

Role in the NICU



Pediatric FEES

• Transnasal passageof endoscope to viewpharyngeal andlaryngeal structures

• Assessment of abilityto protect airway

• Collaborative exam

• Conduct feedingportion as with VSS

Equipment

• Nasopharyngoscope

• Light source

• Recording equipment

– Camera

– Recording device• Video

• Digital



Scope and Anesthetic

• Scopes sizes:– 2.2, 3.5, 3.7, 4.0 mm

– 2.2 most common forNICU

• Topical anesthesia:– 1:1 mixture of

oxymetazoline and 2%pontocaine spray

– Not used in the NICU

– Can use viscous lidocaineon the scope

(Willging & Miller, 2007. PediatricFEES Conference, Cincinnati

Children’s)

Strengths and Limitations ofFEES

Advantages

• Allows assessment of secretionmanagement ability

• Clear view of structures andfunction

• May assist with seeing tissueirritation secondary to reflux

• Assessment of sensation

• No radiation

• Can be done at the bedside

• Possible to do duringbreastfeeding

• Overall assessment of ability toprotect airway from secretions andfeeds

Disadvantages

• Invasive procedure, athough mostinfants adapt quickly anddemonstrate functional skills

• May be difficult for infants with asensitive gag reflex

• Contraindication – choanalatresia, tongue base prolapse

• Presence of scope may limitwillingness to eat during exam

• Difficult to assess chainswallowing – loss of view

(FEES in the NICU, Pediatric FEESConference - Willging, Miller & Clonan,

2007)



Structural Changes with Age

Hypopharynx

Pharyngeal wall

PyriformSinus

Pharyngoepiglotticfold

Vocal cord

Arytenoid

Epiglottis



Detecting Secretions and IdentifyingEvents During the Exam

• Food color contraindicated

– Increased gut permeability

• Betacarotene

– 50 mg capsules mixed with water, heated

• Aquadex

– Opague color advantage



FEES Findings

• Directly view secretions

– Rate: secretion management, oral phase andfunction, pharyngeal response, swallowdynamics, protective reaction

• No time limit to compensatory strategies

Secretion Management

• Presence of spontaneous clearingswallows

• Pooling within the laryngeal vestibule

• Evidence of leakage into the subglottis

• Response to secretions:

– Normal spontaneous swallows to clear

– Ineffective attempts to clear

– No attempt to clear



Video: Prone PositioningDuring FEES





• Could you detect acoordinated suckpattern?

• Did you recognizethe internalstructures?

Video: FEES



Video: FEES

Video: FEES

• Do you think theunilateral vocal foldparalysis had animpact on theinfant’s ability tofeed?



Parameter VSS FEES

Velopharyngeal closure good excellent

Vocal cord mobility and closure Good/fair excellent

Laryngeal elevation excellent good

Oral phase excellent Fair

Pharyngeal squeeze good excellent

Pooling of secretions poor excellent

Premature spillage excellent excellent

Penetration good excellent

Aspiration excellent good (loss of view)

Residue excellent excellent

Comparing VSS and FEES(Willging & Miller, Pediatric FEES Course 2007)

Section V: Summary

• Videofluoroscopy and endoscopy areinstrumental assessments available whichboth provide important informationregarding anatomy and function key tosafe swallowing

• Defining safety of swallowing is key todevelopment of an appropriateintervention plan by the SLP



Speech PathologyIntervention in the NICU

Section VI: Objectives

• Evidence based practice

• Recognize goodevidence

• Efficacy of specificclinical interventions

– What Exists

– Ongoing Research



ASHA PositionStatement

Evidence-Based Practice inCommunication Disorders, ASHA,2005

• “SLPs should incorporate theprinciples of evidence-based practicein clinical decision making to providehigh quality clinical care”

See Additional Resources


Resources

Evidence Based Practice (EBP)

“Evidence-based clinician”uses clinical expertiseand the best availableexternal evidence

Coyle and Leslie,Perspectives, December

2006 (15:4)



Searching for Evidence

• EBSCO Host: searches numerous databases

• Ovid: searches certain bibliographical databases

• PubMed: http://www.ncbi.nlm.gov/entrez/query

• Medline Plus: designed for consumers, indexes web pages, portal to info

• Medline: professionals

• Eric: educational journals

• Cochrane Database of Systematic Reviews: experts, constant process,systematic reviews

• Scopus: in-depth reviews

Types of Research

• Qualitative

– Collecting data

– Survey research, case reports, caseseries

• Quantitative

– Test hypothesis

– Clinical trials

– Correlation: relationship among 2 ormore variables

– Casual-comparative: identify possiblecauses for variations between groups



Meta-Analysis

• Analysis of findings frommultiple studies on a topic

– Effect and outcomes can becompared

– Provides a more powerfulestimate of true treatmenteffect

– Example: The CochraneCollaboration

Treatment Plan

• Establishing short and long term goalstoward realistic outcomes using bestevidence available and clinical judgment

• What’s available and pertinent to the SLP?

– Effects of some selected feeding interventions



Non-Nutritive Sucking (NNS)

What effect does non-nutritivestimulation have?

• Measel & Anderson, 1979

– Earlier readiness for bottle feeds

• Schwartz et al., 1987 (meta analysis results)

– Decreased time to nipple feeding (NNS duringgavage feeds)

– Decreased length of hospital stay

Effect of NNS

• Pickler et al., 1996

– Decreased heart rate, improved oxygen saturationand behavioral state, and improved duration of firstnutritive sucking burst

• Fucile et al., 2002

– Faster transition from tube to oral feeds, increasedvolume of oral intake, but no reduce length of stay

• Pickler and Reyna, 2004

– NNS prior to oral feed did not affect suckingcharacteristics, behavioral state, or feeding efficiency



Effect of NNS

• Lau and Kusnierczyk, 2001

– No conclusive evidence that NNS facilitatesdevelopment of NS

• McCain, 1995

– Decreased behavioral state changes duringfeeding

– Increased quiet awake state during feeds

– No change in heart rate between NNS/control

Systematic Review of NNS

• Pinelli & Symington, 2005

– No significant associations with weight gain,improved increased energy or digestion ofenteral feeds

– Consistent trend of decreased hospital lengthof stay

– No negative outcomes of intervention wereidentified



Introduction of Oral Feeds

What is the best way to present oralfeeds? Standard care or cue-based?

• McCain, et al., 2001

– Semi-demand feeding protocol

– Faster transition to oral feeds

– Did not compromise weight gain

Cue-Based Oral Feeding

• Oral feeding based on clinical cues ofinfant readiness

– Achieve and maintain appropriate state,physiologic readiness, etc.

• Kirk and Alder, 2007

– Earlier achievement of full oral feeding



Cue-Based Oral Feeding

• Evidence-based guideline (McCain, 2003)

– Based on:

• Behavioral organization, rhythmic suck-swallow-breathe pattern, cardiorespiratory regulation inhealthy preterm infants

• Used “semi-demand” feeding method

• Non-nutritive sucking to promote “awake” behavior,use of behavioral assessment to identify readinessfor oral feeds, systematic observation of infantbehavior cues to regulate frequency, length, andvolume of oral feeds

• Earlier discharge

Nipples and Flow Rates

Does the choice of nipple affect feedingperformance?

• Lau and Schanler, 1990

– Comparison of unrestricted milk flow via standard nipple and use ofspecialized nipple with self-paced flow

– Measured feeding efficiency (ml/minute)

– Concluded bottle feeding can be enhanced with self-paced system

• Scheel, Schanler, and Lau, 2005

– Comparison of 3 different nipples in healthy VLBW infants

– Infants modified sucking to maintain rate of milk transfer appropriate toSSB pattern

– Conclusion: focus on suck-swallow-breathe coordination, not typeof nipple



Oral Support and Facilitation

What is the evidence to support the useof oral facilitation techniques?

• Widely used

• Very little supporting evidence

• Einarsson-Backes et al., 1994

– Increase return to pre-feeding oxygen saturation

• Hill, 2000

– No interference with cardiopulmonary function

Oral Stimulation

Does oral stimulation accelerate transitionfrom tube feeding to oral feeding?

• Fucile, Gisel, and Lau, 2002

– N = 32, pre-term infants (26-29 weeksgestational age)

– Oral stimulation x 15 minutes, experimentalgroup, sham in control group

– Accelerated transition to oral feeds inexperimental group



Pacing

Is there evidence that using pacing as afeeding strategy is beneficial?

• Laws-Morstatt et al., 2003

– Significant decrease in bradycardia episodesduring oral feeds

– More efficient sucking patterns at discharge

Need for Pacing Intervals in BPD

• Gewolb & Vice, 2006

– Apneic swallows frequency increased

– Decreased rhythmic coordination ofswallowing and respiration during feeding



Thickening Fluids

Is there evidence to support use ofthickened fluid as a feeding strategy?

• No efficacy studies as yet

• Clinical judgment

Thickening Liquids

Formula selection, concentration, and deliveryare all dependent on many medical and

nutritional issues

• Consult the NICU team

• Carefully evaluate the nutritional implications of eachthickening method, the infant’s needs, and the feasibilityof the family’s ability to obtain and prepare the product

CAUTION



Commercial Thickeners

• Corn starch based

– add calories but noother nutrients

– Advantage• Easy to use

– Limitations• Continuous thickening

• Diarrhea

• Skews nutrient ratios

• Xanthan gum based

– adds no nutrients

– Advantages:• Easy to use

• Always a consistentthickness

• Flavorless

– Limitation:• *Availability

Electrical Stimulation

Does electrical stimulation assist withimproving swallowing function in

infants?

• No empirical evidence currently

• Research studies currently underway



Oral Feeding Experience

Does early introduction of oral feedingaccelerate transition time to full oral feeding?

• Simpson, Schanlder, and Lau, 2002

– Decreased time to oral feeds

– Progress in maturation of sucking characteristics

• Pickler, Best, Reyna, Gutcher, Wetzel, 2006

– Sucking activity (# sucks, sucks/burst, sucks/minute)predicted by morbidity, maturity, feeding experience,and pre-feeding state

Developmental Care

What is the efficacy of developmental care?

• Symington and Pinelli, 2006– Short term growth, decreased respiratory support, decreased

length of stay, improved neurodevelopmental outcomes up to 24months of age

• More research is needed!– Which aspects of developmental care are most effective?

– What are the long term neurodevelopmental outcomes of infantsreceiving developmental care?



Multi-Center Trial Studying Effects ofIndividualized Developmental Care

• Als, et al., 2003

– Sample of very low birth weight infants (<1250grams, <28 weeks), N = 92

– Outcome measures: medical,neurodevelopmental, and family function

– Effects noted:

• Shorter duration of parenteral feeds , decreasedtime to transition to oral feeds, decreased time inNICU, enhanced autonomic, motor, state,attention, and self-regulatory functioning, loweredfamily stress

Additional Developmental CareStudies

• Symington & Pinelli, 2006

– 36 studies

– Reviewed four categories of developmentalcare

• Positioning

• Clustering of nursery care activities– no randomized trial were found

• Modification of external stimuli

• Individualized developmental care



Conclusions of DevelopmentalCare Studies

• Difficulties identifying intervention effects

• Overall,

– Evidence for limited benefit

– no major harmful effects

Need additional studies on short andlong term outcomes

Comprehensive Follow-Up Care

What do follow-upstudies of high risk

(VLBW) infants show?

• Increased risk ofrespiratory, nutritional,neurologic, anddevelopmental problems

• Longer term outcomestudies underway



Developing anEvidence Base

• Summary of evidence related tooutcomes of treatment

– Roles of Speech-LanguagePathologists in the NeonatalIntensive Care Unit: TechnicalReport

See Additional Resources

– Sheppard & Fletcher, 2007


Resources

Predicting Success

What does the research show the predictorsare for success in oral feeding?

• Vice and Gewolb, 2008– Developmentally regulated

• Howe et al., 2007– OM skills, feeding techniques, feeding practice

• Pickler et al, 2006– Relationship between number of sucks in first nutritive suck burst

& feeding outcomes

• Mizuno and Ueda, 2005– Successful transition to oral feeding does appear to be a

predictor of developmental outcome



Example Treatment Goals

• Long Term:

– To demonstrate appropriate state to support nutritiveinput

• Short Term:

– Transition to state to support nutritive input followingcare, use of gentle arousal techniques, positionchanges, gentle stimulation

– Demonstrate ability to maintain state supportive toparticipate in nutritive activity

– Maintain organization for duration of nutritivestimulation


• Long Term Goals:

– To encourage infant seeking stimulation, rooting, and sucking

• Short Term Goals:

– Accept tactile sensory input to peri-oral area

– Accept tactile sensory input to the peri-oral and intraoral area

– Accept non-nutritive peri and oral input via pacifier, pt.’s hands/fingers, therapist’sgloved finger

– Demonstrate rooting in response to tactile input

– Display open mouth to tactile input

– Demonstrate ability to cup and move tongue anteriorly during non-nutritive sucking

– Display ability to approximate lips on nipple during non-nutritive sucking

– Increase ability to depress jaw to generate negative pressure during non-nutritivesucking

– Display prompt sucking initiation in response to nipple placement on tongue

– Demonstrate appropriate sucking burst length

– Maintain sucking strength

– Demonstrate sucking on pacifier with tastes of formula/breast milk without difficulty




• Long Term:

– To demonstrate emerging oral feeding skills

• Short Term:

– Demonstrate a prompt rooting response to tactile input peri-orally

– Respond with lip closure to intraoral nipple placement

– Demonstrate adequate lip rounding on the nipple

– Demonstrate lingual groove around nipple

– Display prompt sucking initiation in response to nipple placement on tongue

– Demonstrate ability to transition from non-nutritive suck to nutritive suck withintroduction of liquid (using graded jaw depression and elevation).

– Display acceptance of small measured bolus/volumes presented in coordinationwith suck of liquid with syringe and free nipple

– Show ability to extract and accept bolus from nipple without clinical signs of beingoverwhelmed for X ml. (1.5ml/min, 30ml – 20min, 9ml/5min.)

– Display ability to coordinate respiration with suck and swallow with oral intake withuse of external pacing every X sucks for X ml.

– Demonstrate increased coordination of respiration with suck and swallow with oralintake for X sucks with self pacing

Section VI: Summary

• There is evidence to support feedinginterventions

• Nutritive sucking and feeding behaviors areemerging as predictors of developmentaloutcomes

• Write measurable treatment goals that supportprogression of nonnutritive and nutritive skills;stay current in knowledge and utilization ofevidence based interventions



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