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Date Established: April 30, 2004
Date Reviewed: March 2009
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1. To provide guidelines for family, staff and physicians for the introduction and management of oral feeding for high-risk infants. 2. To create positive feeding experiences while assisting infants to achieve full oral feeding and to attempt to prevent the development of oral aversive behaviors.
1. 2. 3. 4. Feeding is an active social interaction between caregiver and infant. Development of oral feeding follows stages that can be identified.166,172 Stages are used to plan physiologically appropriate feeding experiences.172 Movement within and between stages may be bi-directional.
PRINCIPLES OF FEEDING ASSESSMENT
1. Continuous assessment of infant state and responses before, during and after non nutritive sucking (NNS) as well as nutritive sucking (NS), is essential. 146, 152, 154,166 2. Providing interventions that are contingent on infant responses is needed to achieve specific goals within each stage. 76, 152, 156 3. Reassessment of oral feeding process and plans should occur when: 3.1. Engagement/readiness cues are present and if positive signs persist: • Identifiable hunger cues • Increased/enhanced quiet alert state • Stable physiologic responses 3.2. Disengagement/distress cues are present and if distress signs persist: • Significant changes in heart rate (bradycardia, tachycardia) • O2 saturation outside normal limits • Color changes (pallor, cyanosis, mottled) • Significant changes in respiratory status (rate, grunting, nasal flaring, retractions, apnea) • Loss of postural tone • Loss of state 3.3. Feeding skills improve: • Improved suck/swallow/breathe (SSB) coordination • Satiety cues
CHILD HEALTH CLINICAL PRACTICE GUIDELINES
Date Established: April 30, 2004
Date Reviewed: March 2009
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POINTS OF EMPHASIS
1. Most premature infants will be able to feed by mouth without difficulty as they approach term gestation. 2. Gestational age and severity of illness may play a role in how long an individual infant remains in any one stage. 3. There is a wide range in ability at various gestational ages. For example a healthy preterm infant at 33 weeks adjusted age may be able to achieve total oral feedings while a 44 week adjusted age infant with chronic lung disease may not.
OVERVIEW OF THE ORAL FEEDING PRACTICE GUIDELINE: Non-oral stages Pre-oral Stimulation Stage Non-nutritive Sucking Stage Nutritive Sucking Stages Stage I: Minimal oral intake (<10% oral) Stage II: Moderate oral intake (10 to <80% oral) Stage III: Full oral intake (> 80% oral)
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Appendix I: Definitions Appendix II: Development of Premature Infant Feeding Behavior Appendix III: Parameters for Feeding Assessment
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128. 76. 78. 36.127. 36. motor & state regulation with or without stimulation 78. 33 • Sustained touch • Kisses by family Support the mother in initiating and maintaining lactation 11. 52. 129. 128. 148 None to very weak oral reflexes (transient) 66 None to very weak non-nutritive skills 8. 76. 66. 185 Tube feeding only (Refer to Policy: 2-G-1 Gastric Tubes) WHEN TO REFER Refer to LC when mother: • Has difficulty establishing/ maintaining lactation • Experiences complications as a result of pumping • Has difficulty in accessing breast pump • Refer to OT when infant: Fails to progress or has extreme hypersensitivity to oral touching NB: first consider gestational age and severity of illness CHILD HEALTH . 78 INFANT CHARACTERISTICS Responds adversely to handling Poor physiologic. 127. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 3 of 25 STAGES OF NEONATAL FEEDING Pre-Oral Stimulation Stage GOALS Minimize negative oral stimulation8.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. 41 (See: Booklet: Breastfeeding Your Preterm Baby) Discuss with parents realistic expectations for initiation and progression of feeding 61. 129 Promote behavioral organization Establish and maintain mother’s milk supply 0 % oral intake Skin-to-skin care (Kangaroo care©) Positive experiences to the facial area as tolerated by infant. 66. 79 Not managing secretions (Neurological infants) 66 INTERVENTIONS Use developmental care interventions to facilitate midline position and flexion which promotes hand to mouth experience and behavioral organization 78. 52.
attempt to provide external pacing Transition to Pairing NNS and Tube Feeding: • WHEN TO REFER • Stable with handling and able to maintain physiologic. flat or bulb shaped pacifiers).g. refer to OT when infant: • Is evasive or refusing NNS. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 4 of 25 Non-Nutritive Sucking Stage GOALS INFANT CHARACTERISTICS Promote positive oral stimulation and NNS 66 INTERVENTIONS Provide positive facial experiences and NNS: • Infant’s fingers: position to support hand to mouth contact to allow the infant to suck when needed171 • Pumped breast: allows infant to nuzzle and practice sucking.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30.g. neurological impairment) • Fails to progress from this stage Refer to Home Nutrition Support Service. OT. 171 (no orthodontic. never force a nipple into the infant’s mouth Note: If baby has difficulty sucking and breathing. and Neonatal Transition Team (NTT) or Pediatric Home Care when: • Infant is to be discharged home on any amount of tube feeding • Consider placing a warmed drop of milk on the infant’s lip to promote the infant to bring their tongue forward to lick the milk Once infant demonstrates coordination of NNS (breathing and sucking). • Skin-to-skin care (Kangaroo care©) • Soother/ pacifier: standard shaped nipples are recommended 18. all above methods of NNS can be combined with tube feeding (e. gavage feeding while nuzzling at breast) CHILD HEALTH . 66. chronic lung disease. motor and state stability with NNS interventions148 Oral reflexes present or emerging Demonstrates licking and rooting By the end of this stage the infant will be able to demonstrate NNS by: • Establishing and maintaining latch • Rhythmical sucking bursts • Coordinating sucking and breathing Refer to LC when: There is a concern with mother’s milk supply Support the establishment and maintenance of mother’s milk supply 0 % oral intake Refer to OT: After first considering gestational age and severity of illness. or having difficulty coordinating sucking and breathing (e.
171 Skin-to-skin care (Kangaroo care©) a. and cue for readiness.152.Congestion or noisy breathing during feeding . 167 . 52. elicit rooting reflex Note: Pauses need to be > length of sucking burst to allow adequate recovery Emergent but not sustained coordination of SSB • Beginning to self pace • Licking/ Rooting/ Mouthing • Resting RR <80 with no respiratory distress cues 24 Disengagement/ Distress Cues: • Easily becomes physiological unstable • Pooling of bolus • Aspiration • SSB becomes disorganized • CHILD HEALTH .Gurgling sounds in pharynx. 66. and cue for readiness . 90. . 40.155 . allow infant to breath. remove nipple from mouth. External pacing – to aid or prevent disorganized SSB 7. mastitis) Refer to OT when: (NB: first consider gestational age and severity of illness) • Infant is at high risk for dysphagia (e. Feedings should not be pushed 45.Infants capable of limited self-pacing: gently roll infant forward (bottle in the mouth) until milk is out of nipple.147. 170 Good NNS. 109. 148. 28. 76 (<10% oral intake within a 24 hour period) WHEN TO REFER Refer to LC when: • Mother’s milk supply is a concern • Unable to achieve latch • Infant is consistently frustrated at breast • Complications present (e. 164.c. 78. .152 Aid infant to awake state a. symptoms include: . 97. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 5 of 25 Nutritive Sucking Stage I: Minimal Oral Intake CRITICAL STAGE GOALS Oral practice only Quality and ambiance is more important than quantity taken 228 Experience is positive for infant and caregiver Infant is able to take small amounts of feeding orally in a controlled setting 8. 27. reorganize. 24.121.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30.Good NNS but INFANT CHARACTERISTICS Infants who are breastfed may exhibit better O2 saturations than infants who are bottle fed.134. 169. 146.g. emergent but no sustained SSB coordination Oral Intake < 10% daily volume Positive Readiness Cues: • Manages secretions 24.Infant not able to self-pace: Allow the infant to suck 3-4 times on the milk filled nipple. 28.Coughing during feeding.173 Therapeutic tasting – drop milk onto soother from 1 ml syringe 1 drop at a time.g. reorganize. Allow infant to breath. 58. neurological impairment) 13.166 INTERVENTIONS Minimize distracting stimuli 109. 66 • Maintains a quiet/alert state 25.c. cracked nipples. Intervene to prevent distress. break suction. 168 Infants ~32 weeks adjusted age may begin to demonstrate readiness cues and be able to achieve this stage of nutritive sucking 100. If infant does not open mouth spontaneously. 134.
173 • Refer to Home Nutrition Support Service. • Do not jiggle or turn nipple to stimulate NS. or latch 31. 56. try NNS (mom’s finger. try placing infant on a partially pumped breast 85 If infant behavior is disorganized at breast. 40. smell. 93 to help organize infant state and skills • Place a drop of milk on the lip before feeding to help the infant organize for oral feeding • Use low flow single-hole nipple 21.163. 80.g. this practice is contraindicated 152.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING • • • • • Date Established: April 30. OT and NTT or Pediatric Home Care when: • Infant is to be discharged home on any amount of tube feeding CHILD HEALTH . once organized try placing back on breast Pair tube feeding with nuzzling at breast Refer to Pamphlet “Breastfeeding Your Premature or Sick Infant” • refuses NS Difficulty managing secretions (Aspiration may be silent) • • • • • • Persistent feeding induced apnea and bradycardia Poor or unsustained latch i. 44 Breastfeeding: Nuzzle at breast: encourages infant to root. taste. pacifier). 97.64. 74. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 6 of 25 Fatigues easily (falls asleep) Difficulty initiating feeding Head bobbing Loss of postural tone Loss of state 42.e. lick. touch. side lying157 on pillow with head elevated • Begin all feedings with 1-2 minutes NNS 32. e.172 (losing liquid is OK to allow the infant to adjust volume). • Do not allow the infant to become distressed. infant fist. an excessive wide jaw excursion Failure to progress from this stage Bottle Feeding: Check for excessive milk flow: release pressure or change nipple before feeding • Swaddle to promote organized behavior152 Provide postural stability147. If infant has difficulty with strong milk ejection reflex. 89.
27. the infant should be alert. and audible swallowing for several minutes 41. 146. consider test weighing as this is the only accurate way to determine intake 11. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 7 of 25 Nutritive Sucking Stage II: Moderate Oral Intake GOALS To ease the transition to full oral feeding by supporting endurance. actively sucking. 66. 72 • If tube in place. 169 Improved endurance but not enough to maintain full oral feeding Immature state control – unable to maintain quiet alert state throughout entire feeding 25 Consistent self. sustained bursts of nutritive sucking. NNS may help with state control and SSB coordination 148 Feedings should not be pushed. 173.pacing may or may not be present A positive breastfeeding experience is defined as: an infant who demonstrates a good latch. skills and physiologic stability Quality and ambiance is still more important than quantity taken (10% to <80% of oral feedings in a 24 hour period) INFANT CHARACTERISTICS INTERVENTIONS Identifiable readiness cues: • Hand to mouth.c. make up the difference within a 24 hour period • Consider concentrating milk to decrease volume required WHEN TO REFER Refer to LC when: Poor latch evident Infant falls asleep at breast • Poor milk transfer suspected • Considering test weighing • Considering use of nipple shield 142 • • Refer to OT when: NB: first consider gestational age and severity of illness 38 • Poor unsustained latch evident • Flooding present • Good NNS but poor NS • Signs of dysphagia • Persistent feeding induced apnea and Bradycardia • Failure to progress from this stage CHILD HEALTH .CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. and coordinating their SSB. 76 Watch O2 10. 52. 52. When a breastfeeding infant becomes more consistent with positive breastfeeding experiences. rooting • Increased motor activity prior to feeding The infant may demonstrate readiness to feed at some feedings throughout the day. 66. 143 Aid infant to awake state a. pacing. 87 and if the infant desaturates consider replacing with a #5 tube or removing the OG/NG tube for the feeding 63. but not necessarily all the feedings166 Functional to good SSB 28. if infant does not demonstrate readiness to continue feeding or the infant demonstrates disengagement cues. remainder of feeding should be tube fed: 24.12. 31.19 Watch for distress/ disengagement cues closely and assess infant’s readiness to continue feeding. gavage remainder of feeding • If tube not in place.
40 Note: Infants may develop physiological instability if pushed at this stage and require ongoing monitoring of saturation and heart rate External and self.pacing may still be indicated. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 8 of 25 Infants who demonstrate an ability to take ≥ 30% of required volume and ≥ 1.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. 41 Nutritive Sucking Stage II interventions may be further matched to the percentage oral intake as follows: Stage IIA: 10% to <25% oral vs tube • Maximum 5-10 minute oral feeding time (breast or bottle) • Oral practice only when cueing. OT . likely 1-2 times/day • Assess whether baby needs nonpumped or pumped breast for breastfeeding • NNS &/or therapeutic tasting with tube feeds Infant is to be discharged home on any amount of tube feeding CHILD HEALTH . and NTT or Pediatric Home Care when: • • Removing baby from breast during milk ejection reflex • Allowing baby to reorganize before placing back on breast Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding 42. External Pacing for breastfed infants may be necessary for mothers with strong milk ejection reflex: Strategies include: • Having mother pump breast a little before feeding 85 Refer to Home Nutrition Support Service.5ml during the first 5 minutes of feeding may attain oral feeding earlier than others. and if infant has chronic lung disease157. particularly in the first few sucks of a feeding.
determine TFI range to allow flexibility in amount of tube feeding top up needed • Assess need for indwelling vs intermittent NG/OG CHILD HEALTH . aid to awake state ac • Occasional full bottle taken Stage IIC: 50% to <80% oral vs tube • Maximum 30 minute oral feeding time • Offer BF/B opportunities every time infant cues • May or may not need supplementation after BF/B. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 9 of 25 Stage IIB: 25% to <50% oral vs tube • Typically >10 minute oral feeding time • BF/B opportunities dependent on infant cues.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30.
152.160 If infant demonstrates disengagement cues. 41 Before discharge. 112. 28.136. the infant should be transitioned to the nipple and feeding regime that parents are planning to use at home. 134.149.71 Encourage breastfeeding mothers to spend long blocks of time in nursery to facilitate cue-base feeding.118. 66 Endurance to maintain nutritional intake to support growth Demonstrates clear hunger cues: • Hand to mouth. 73. 52. 169 Refer to OT when: Infant discharged on total oral feeding but feeding skills are suspect 38: • SSB incoordination • Poor endurance • Prolonged feedings > 45 minutes • Neurological impairment CHILD HEALTH . If the infant does not tolerate this nipple. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 10 of 25 Nutritive Sucking Stage III: Full Oral Feeding (≥80% oral feedings in a 24 hour period) GOALS INFANT CHARACTERISTICS INTERVENTIONS Full oral feeding that supports growth Feeding experience is positive to infant and caregiver Sustains SSB throughout the feeding 24 .150.73 This will enable matching of the infant’s skills to the nipple to be used. straight nipple is recommended. and to room in for 48 hours before discharge 42. intervals between feedings may vary greatly throughout day 11. then the hospital supplied low flow nipple should be sent home 24.147. 66 Ideally infant should spend >3 days in stage III pre-discharge Most infants by 37-42 weeks adjusted age should be able to achieve Stage III of nutritive sucking 100.156. A commercial single hole. delay feeding until infant cues again Consider no top-up if infant consumes >80% of feed Consider oxygen saturation monitoring for 24 hours during all states including feeding (especially infants with chronic lung disease) 10.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. rooting • Increased motor activity • Wakes to feed Demonstrates satiation cues: Slips off nipple at end of feeding • Falls asleep at end of feeding • WHEN TO REFER Refer to LC when: • Poor latch evident • Poor milk transfer suspected • Poor weight gain • Poor milk supply Continue side lying and external pacing as required Transition to cue base feeding before discharge.31. 31.
Nutritive Sucking (NS): 24.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. reorganize and cue for readiness. and provide time for the infant to clear the bolus from the mouth or throat. purpose is as a state regulatory mechanism and to satisfy sucking desire. Some infants require the nipple to be removed from the mouth because the nipple remaining in the mouth will continue to stimulate a sucking reflex 52. the caregiver is pacing for the infant before distress cues are noted. numerous sucks (approx. the infant will not swallow and take a breath. 76. If infant does not open mouth spontaneously. attempt to elicit rooting reflex. 6 –8) can be taken before a swallow. or will be sucking air on the empty nipple. to occur safely and efficiently. External Pacing is done in 2 ways 52. sucking pressure consists of compression and suction. attempt to elicit rooting reflex. Continue oral feeding only if infant demonstrates readiness cues. 126. Allow the infant to resume effective breathing. and cue for readiness before rolling back to fill the nipple with milk again. Non-nutritive sucking (NNS): 24. this pattern is complex and significantly more challenging than non-nutritive sucking. 126 • If infant is capable of limited self-pacing (swallows and breathes during pauses): Gently and slowly roll infant forward with the bottle in the mouth until the milk is out of the nipple. If infant does not open mouth spontaneously. Gastroesophageal Reflux (GER): a return or backward flow of gastric contents into the esophagus. twenty-six muscles and six cranial nerves must be coordinated for the pharyngeal swallow itself. 171 repetitive sucking bursts and pauses in the absence of nutrient flow. Allow the infant to suck 3-4 times on the milk filled nipple. 66.161 . This will support respiration by promoting deep breathing. because the infant needs to accumulate a large enough secretion bolus before a swallow is triggered. 66 occurs during active sucking for the purpose of nourishment. As a result. 66. then break suction and remove nipple from mouth and allow the infant to effectively breath. the premature infant pattern usually begins with single sucks with long or irregular pauses. to decrease fatigue. In this circumstance. to facilitate organization and rhythmicity.145. reorganize. Verbalize infant’s cues for readiness to parents. • If infant demonstrates no self-pacing: Then removal of the bottle for external pacing may be necessary. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 11 of 25 APPENDIX 1: DEFINITIONS External Pacing (imposed breaks) 52. This allows the infant the choice to resume feeding. 66.caregiver assists the infant in appropriately interspersing breaths during sucking bursts. 149. mature rate is one CHILD HEALTH . a mature NNS rate is 2 sucks per second. Milk Ejection Reflex ( MER): another term for let down or the strong release of milk generally occurring at the beginning of a feeding which may also occur several times during the feeding.
Tube Feeding: Nutritional intake by oral gastric.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. • Breastfeeding: . strength of suck is reflected in the resistance to removing the nipple and the rate of flow. nasal jejunal or gastrostomy tube. 66. Oral Feeding. split second coordination between sucking.in the mature pattern.164. Rhythmicity is the hallmark of normal feeding and is a reflection of smooth. Suck/Swallow/Breathing Coordination (SSB): 24. Immaturity or abnormality in any of these functions can have a profound effect on the other component and on the infant’s feeding ability. swallowing and breathing.nutritional intake by breastfeeding. 76. cup feeding or bottle feeding. nasal gastric.169 Safe feeding requires precise coordination of processes that provide airway maintenance for breathing and airway protection during swallowing. sucking bursts are longer at the beginning of the feeding and become shorter with longer pauses over the course of the feeding. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 12 of 25 suck per second. the return of bubbles into the bottle is a reflection of the liquid flow. CHILD HEALTH . Suck: Swallow Ratio is 1:1 but at the end of the feeding or with older infants may increase to 2:1(rate dependent on flow rate and size of oral cavity).rate of sucking and suck: swallow ratio is variable and dependent on rate of milk flow • Bottle feeding: . Assessment of SSB involves careful assessment of each of the components individually as well as the coordination and organization of all the components together Supplement Feeding: Feeding the infant via a mode other than the mother’s chosen feeding goal-this may account for minimal amount of feed up to a complete feeding (100%).
Sucking bursts are related to the flow of milk. higher milk flow requires more mature sucking patterns.suck sucking bursts of ~ 3. 159. 153.75. DEVELOPMENT OF PREMATURE INFANT FEEDING BEHAVIOR Breastfeeding 31. Immature Mixed Mature • Licking predominates • Some rooting evident • Obvious consistent rooting • Little rooting evident • Repeated short sucking • Deep latch maintained bursts of ~ 6-15 sucks • Shallow latch or • Repeated long sucking difficulty maintaining bursts of ~ 15-30 sucks • Swallowing beginning to latch be integrated into • Swallow audible sucking burst • Occasional short • Pattern of bursts . 134. 47. 151. 41. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 13 of 25 APPENDIX II. 97. 143.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. 168 It is important to be aware of mother’s milk supply as only non nutritive sucking will be observed if supply is very low.• ~ 6-10 minutes of swallow breath or suck 5 sucks suck swallow breath nutritive sucking • Pattern of burst is ~1• > 11 minutes of sucking 5 sucks pause and breath • < 5 minutes of nutritive sucking Bottle Feeding 6. 164 Immature • Mixed • Mature Rhythmic alteration of suction and expression/compression Rate increases ~ 65/min Suck of consistently high amplitude Swallow consistently paired with suck > 90% of sucks organized into bursts Pauses more regular and short 10-40 sucks/burst • • • • • • Predominantly expression/compression rather than suction usually ~ 2-3/second If suction is present it is of low amplitude Pattern is irregular or arrhythmic Expression/suction is not paired with swallow < 50% of expressions/sucks are organized into bursts <10 sucks per burst when burst present Breathing not consistently integrated into expression and swallow • • • • • • • Predominantly expression/compression Expression/compression pattern rhythmic usually ~ 1/second (55/min) Alteration of suction/expression emerging but arrhythmic Expression/suction inconsistently paired with swallow 50-90% of expressions/sucks organized into bursts Pauses irregular and generally long 10-20 sucks per burst • • • • • • CHILD HEALTH .50. 100.
Coughing and choking are frequent. Infants may be disorganized throughout the feeding or may begin organized and suddenly become disorganized. Pattern is rhythmic but pauses are frequent and long compared to the bursts. Baby often has a strong. CHILD HEALTH . The infant may terminate sucking to recover during the pause. 3.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. 165. The baby has difficulty with pacing SSB. Duration of bursts and pauses vary considerably and there is an uncoordinated pattern of breathing and swallowing153. cyanosis or bradycardia. Disorganized Sucking: Characterized by very disorganized and uneven sucking pattern. neurological deficit. This pattern may result in decreased intake due to respiratory compromise and/or swallowing dysfunction. Short Sucking Bursts: Infant only takes 1-3 sucks before pausing to breathe. rapid suck but may have difficulty initiating breathing even after the nipple has been removed. the infant becomes apneic with oxygen desaturation. respiratory problems158 or incompatible nipple flow rate. Prolonged Sucking (can lead to feeding induced apnea): Baby has lengthy sucking bursts without inter-dispersing breaths at appropriate intervals. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 14 of 25 Immature Feeding Patterns That May Require Intervention: 24. If unable to terminate sucking independently. 2. Causes: disorganized state and behavior. 66 1.
Prolonged sucking pattern and stretch receptors (sensory receptors) in pharynx stimulated by large bolus . 66. • Respiratory rate is individual and depends on the infant’s ability to compensate for the reduction in ventilation imposed by feeding. • Bradycardia: A drop in heart rate below 90 or 100 BPM. 66. Retractions Chin tugging. Shallow catch breaths.Aspiration. • For infants with respiratory compromise. 52. Nasal flaring/blanching. Respiratory rates>80 breaths/min.Micro aspiration of food or by reflux (chemoreceptors) 2. <65 to 70 breaths per minute is a conservative guideline for initiating feeding. • Signs of respiratory distress: Tachypnea = >60 breaths per min. indicate that work of breathing is too great and non-oral feeding is recommended until respiratory work during feeding is reduced. during pauses and prolonged recovery to baseline. Heart Rate 6. bradycardia is a significant and possibly life threatening event. Neck extension/arching O2 desaturation CHILD HEALTH . a resting RR (when awake). 173 • Respiratory rate should be evaluated at the beginning. Respiratory Status 24. vagally mediated laryngospasm . Increases in 10 bpm during feeding are not uncommon. When observed with feeding. This indicates work of feeding may be excessive. Common causes include: . Larger increases may indicate that demands of feeding are excessive. mid and post-feeding and time required to return to baseline should be measured. PARAMETERS FOR FEEDING ASSESSMENT 1.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30.Poor positioning during feeding . 24. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 15 of 25 APPENDIX III. even small increases in heart rate can indicate great physiologic stress. structural anomalies.Presence of nasogastric tubes (touch-pressure receptors) or . • Increase RR leads to increase risk of incoordination of SSB and increase risk of aspiration.173 • Tachycardia: If baseline heart rate is elevated or heart rate dramatically increases and remains elevated for prolonged time. However if an infant has a high baseline heart rate.
oxygen saturation levels usually remain higher and exhibit less fluctuation than during bottle feeding. Desaturation may be an isolated event and seen with out significant observable change e. 66. 126 10. Barium is used to image pharyngeal structures and function.162 Refer to Guideline: 2-P-3 Pulse Oximetry in Neonates. 2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 16 of 25 3.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. 173 6. no change in color. 70. and breathing. 66. 4. 66. 40. During the study. Videofluoroscopic Swallowing Study (VFSS) is a radiographic study that evaluates the status and safety of the pharyngeal swallow. 24. 173 CHILD HEALTH . 24 Sometimes aspiration occurs with fatigue towards the middle or end of a feeding and is referred to fatigue aspiration. Sudden dips may be associated with apneic or bradycardic episodes. and bolus size) are attempted to determine if swallowing can be improved. Oxygen Saturation • Term and preterm infants experience slight but measurable oxygen desaturation with bottle feeding (dips with continuous sucking & return to baseline during intermittent sucking). 126 Aspiration can be silent (no coughing present).g. treatment techniques (altering the texture. Aspiration can be descending (during feeding) or ascending (during gastroesophageal reflux). temperature. During breastfeeding. 131. theses reductions can be significant. 24. “wet” upper airway sounds after individual swallows or increasing noisiness over course of feeding • Multiple Swallows to clear single bolus • Apnea during swallowing • History of frequent upper-respiratory infections or pneumonias 5. 134. whereas a gradual decline may indicate inadequate respiratory support for feeding. However for compromised infants with borderline saturations. Clinical Indications of Swallowing Dysfunction (risk for aspiration) 66 • Choking during swallowing • Inability to handle own oral secretions • Noisy. 70. 87. swallowing. Aspiration can result from a primary swallowing dysfunction or from incoordination between sucking. It can only be confirmed with a videofluoroscopic swallow study (VFSS).
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2004 Date Reviewed: March 2009 Reference: Page: 2-0-2 25 of 25 DISCLAIMER All content in this policy and/or procedure is © copyright. All rights reserved. CHILD HEALTH . or omissions in the information in this policy and/or procedure. Calgary Health Region.CHILD HEALTH CLINICAL PRACTICE GUIDELINES Subject/Title: ORAL FEEDING Date Established: April 30. was created expressly for use by Calgary Health Region staff and persons acting on behalf of the Calgary Health Region for guiding actions and decisions taken on behalf of the Calgary Health Region. or for any inaccuracies. errors. and as amended from time to time. Any modification and/or adoption of this policy and/or procedure are done so at the risk of the adopting organization. This information. The Calgary Health Region accepts no responsibility for any modification and/or redistribution and is not liable in any way for any actions taken by individuals based on the information herein.
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