eating in “sinc” national and one … · eating in “sinc”: oral feeding on cpap and beyond...

Eating in “SINC”: Oral Feeding on CPAP and Beyond Stacey Dalgleish, MN, NNP

Canadian Association of Neonatal Nurses – ONE Day of Education

Monday, April 13, 2015

9:15 a.m. – 10:00 a.m. 1

Eating in “SINC”

Oral Feeding on CPAP and Beyond

Winnipeg, April 2015

A Quality Improvement Project

Calgary Zone NICUs

Presenter Disclosure� Stacey Dalgleish, MN, NNP

� Alberta Health Services

� No conflicts

� No potential conflicts of interest

2




9:15 a.m. – 10:00 a.m. 2

Presentation Objectives

•Describe eating as a developmental task.

•Review relationship between eating and breathing.

•Define “SINC” as a QI construct to safely guide the initiation and advancement of oral feeding.

•Illustrate examples of neonates fed safely using “SINC” strategies.

•Share outcome data from a “SINC” cohort3

Calgary Zone

� 1.1 million

� referral area southern Alberta

5 NICUs•123 beds•650 nurses•28 Neonatologists

…at least that many opinions

4




9:15 a.m. – 10:00 a.m. 3

Calgary Status 2012

�

�

�

�

�

�

� No Auditing

� Safety concerns� Oral feeding while on CPAP

� Developmental concerns� Missing opportunities for feeding

skill acquisition

� Long term burden of oral aversion� No local data

5

Optimal Lung Practices� Prolonged CPAP to ensure FRC

� Historical culture to withhold oral feeding on CPAP� Advancing technology, increasing knowledge

� Feedback regarding delayed feeders

� Rapid PDSA Cycles (Spring 2012)� ? Remove CPAP for feeding practice

� ? High Flow NP

� ?Discontinue CPAP at 36 weeks

� All unsuccessful: Loss of FRC, no endurance, delayed feeding success

6




9:15 a.m. – 10:00 a.m. 4

Baby G. 27 weeks in 2012Feeding pattern 37-39 weeks CGA (99 feeds)

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1 3 5 7 9 111315171921232527293133353739414345474951535557596163656769717375777981838587899193959799

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37 weeks

CPAP +6 0.21-0.24

38 weeks

6 lpm HF, 0.28

39 weeks

5 lpm HF, 0.28

7

Quality Improvement Question?

� Can we help babies born at <32 weeks to breathe and eat?

1. Physiologic stability

2. Demonstrate cues of readiness to feed

3. Require time and/or support for optimal lung development

� Thousands of new alveoli and neuronal connections being built every day!!

8




9:15 a.m. – 10:00 a.m. 5

“And” is better than “Or”

� Breathing…… optimal lung development

� AND

� Eating…… food is pleasant and satisfying

Optimal lung = endurance and capacity to eat

9

Evidence� Oral sensory deprivation/overload

� “Skill” acquisition – building neural pathways� Immaturity alone alters the typical path to learning feeding skills

� Oral aversion

� CPAP and risk of aspiration

� Variable flow CPAP (fluidic flip)

10




9:15 a.m. – 10:00 a.m. 6

Too Much OR Too Little� There can be oral sensory deprivation OR overload

with learning to eat

• No opportunity to suck or taste

• Forced opportunity to suck or taste

• Overwhelmed by situation

11

Fragile Feeders� Premature infants < 32 weeks

� Immature

� Medically fragile

� Appreciate individual developmental progression and medical

co-morbidities

� Volume is not the only goal of feeding

12




9:15 a.m. – 10:00 a.m. 7

Eating Organization Develops

in an Orderly Fashion

� Infant ventilation stops during swallowing

� Eating may over-ride respiratory chemical control

� Neuronal mapping� Clin Perinat, 2011 (Browne and Ross)

� Preterm infants show progression of oral-motor

development between 30 and 45 weeks

� Robust NNS is not predictive of ability to manage fluid

� Poor sucking pressures, frequencies, duration and efficiency

13

Eating = Pleasure� Developmental vulnerability

� Eating is predictable and pleasurable, without stress

� Establishing learned experiences

� Affecting ability and desire to eat

� Eating skill acquisition is best achieved by:

� Gently offering feeds with frequency

� Cues for feeding and stopping

� Caregiver contributing to safety and success

� Nursing Research, 2007, Howe, et al.

� Neonatal Intensive Care, 2012. Shaker.

� Nursing Research, 2012, Thoyre.

� Clin Perinat, 2011, Browne, Ross.

14




9:15 a.m. – 10:00 a.m. 8

Early and Frequent Feeding

Practice

• Howe, et al. Nursing Research, (2007)

• Offered on basis of cardio-respiratory and behavioral responses

• Sooner to fully orally fed

• Diminished LOS

15

NICU Eating Care Map

NNS

Breast

Eating

16




9:15 a.m. – 10:00 a.m. 9

Irony of Breast Feeding� Breast milk is MOST desired nutrition

� Breast feeding was non-quantifiable

� Bottle feeding was “easier”

� Worries about supplementation

� “Breastfeeding Paradox”

� LIFT and EPIPAGE cohorts

17

Long Term consequences• Feeding difficulties associated with language delay in

preterm infants• J Peds, 2013 (Adams Chapman et al.)

• 18-22 month Bayley

• 1477 preterm infants, < 26 weeks

• < 1 % of preterm infants required supplemental tube feeds at time of NICU discharge.

• Advances in Neonatal Care, 2007 (Kirkby, et al.)

• 10-80% of parents report problems feeding NICU graduates in the first 24 months

• J Paeds and Child Health, 2002 (Cerro et al.)

• Archives of Dis (fetal), 2003 (Wood et al.)

18




9:15 a.m. – 10:00 a.m. 10

Burden of Oral Aversion� Oral aversion may present:

• In NICU

• At end of reflexive sucking

• At introduction of solids

� Babies are not free from this morbidity until 1 year of life

� Burden of oral aversion� Non-standardized definition

� Rates of 10-70%

� Neurodevelopmental delay, BPD

� ? standardized definition, referral process, or approach to NICU graduate feeding difficulties

19

“Sufficient” Eaters vs

“Skilled” Eaters

� Poor feeding outcomes increase as gestational age

decreases

• <600 gram neonates followed to 3 years of age

� 62% had continued eating problems

• Food as reward, coaxing, food refusal

• Poor weight gain, vomiting, chronic diarrhea

� 29% had gastrostomy tubes

� J Paed Child Health, 2007 (Cerro, et al)

• Sufficient rather than skilled feeders

• JOGNN, 2007 (Thoyre et al.)

20




9:15 a.m. – 10:00 a.m. 11

Literature Support � Wealth of emerging literature

� Introduction and advancement of oral feeds (Browne and Ross 2011, McCain et al 2012, Shaker 2010, Ross and Philbin 2011, White and Parnell 2013)

� LOS

� Paucity of research supporting or refuting practice of

oral feeding on CPAP

21

Variable flow CPAP

22




9:15 a.m. – 10:00 a.m. 12

Variable flow CPAP

23

CPAP and Canadian Lambs� NNS and CPAP

� Nutritive sucking and CPAP� Esophageal multichannel intraluminal

impedance pH monitoring: CPAP +6

� Measured with impedance for safe swallowing and GER during bottling

� Multiple studies supported safety of practice

� Praud and associates

� Journal of applied physiology, 2005, 2012

� Journal of pediatric gastroenterology and nutrition, 2013

24




9:15 a.m. – 10:00 a.m. 13

Preterm babies can breast feed

� Nyqvist

� 1999 – early human development

� 2008 – Acata Paediatr

� 2013 – J Human Lact

� From 29 weeks onward

25

To Remember….� No arbitrary feeding schedules or expectations

� Bottle 1, gavage 2

� Obligate suck as reflex

� Volitional = choice

� Cue based

� Cues for Engagement and DIS-engagement

� No coax, prod, encourage, badger etc etc etc

� More breast feeding focus

26




9:15 a.m. – 10:00 a.m. 14

“Eating in SINC”� Therapeutic Tasting on CPAP (July 2012)

� Pilot at FMC

� Implemented by NNPs for “Fragile Feeders” (still on CPAP at 32 weeks)

� Following principles of the Oral Feeding Protocol…

� NNS

� Then small volume feeding progression on CPAP

� Maximum feeding times and volumes defined

� Infant must prove skill and endurance before advancing to

larger volume or longer time

� *Zonal confusion when babies transferred from FMC

27

Safe Individualized Nipple

Feeding Competence

� “Feeding in SINC” algorithm –multi-disciplinary collaboration

� Sub-group of Oral Feeding Committee� Zonal educational roll out June 2013

� QI project began July 2013� Super-users identified

� Pod talks

� Site visits

� Audit tools developed/revised

� Collaboration with consultants re: follow-up/long-term outcome evaluations

28




9:15 a.m. – 10:00 a.m. 15

Urban Myths� “This will delay babies’ discharge”

� “Feeding on CPAP is not safe”

� “If we don’t push them, we will miss the baby’s feeding window”

� “Parents are unhappy with the slow progression”

� “This will take autonomy away from experienced nurses”

� “Babies should be allowed to nipple feed as long as they want to suck – it’s cruel to stop them”

29

How?� Baseline audit

� Multi-disciplinary team

� Literature review

� Expert opinion� Sherbrooke, Quebec

� Scandinavia

� Pilot project on the NP team

� Fragile neonates cue for feeding and have opportunity to “taste” at breast or with drops offered during NNS with a pacifier

30




9:15 a.m. – 10:00 a.m. 16

A Case Over Time

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The Tale Continues

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35-36…

To 5lpm HF

32




9:15 a.m. – 10:00 a.m. 17

This could go either way…..

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39-40 wks

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“I can get this kid to eat…”

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9:15 a.m. – 10:00 a.m. 18

It went badly….at 45 weeks,

baby transferred to peds

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44-45 wks

35

Quality Eating

Cue Based

� Feeding is relationship based

� Positive experience

� The baby is learning to feed and skills are emerging

� Learning to eat is a developmental skill focusing on the baby

Volume Based

� Feeding is a competitive sport

� Intake is most important

� The baby is a “good feeder” or a “poor feeder”

� Feeding the baby is about who can “get the volume in”

36




9:15 a.m. – 10:00 a.m. 19

“Competence”?

� No decompensation:

� Increased apnea/bradys

� Need for increased respiratory support

� *Deterioration often subtle at first

Infant must prove competence

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"Decompensation"

0.21

2 lpm

0.23-0.25

2 lpm

0.25

2 lpm

3 lpm

0.21

0.233 lpm

0.21

2 lpm

0.24

2 lpm

0.21

2 lpm

37

No disengagement:

� LOW tolerance for stopping the feed –

� “No” means “NO!”

� Feeding experiences must be positive� Building neural connections

� Goal is to hard-wire food + pleasure vs food + discomfort/fear.

� Infant does not have to prove disengagement

38




9:15 a.m. – 10:00 a.m. 20

39

Stage A - K� A: NNS

� B: Maximum 5% volume

� Maximum 5 minutes

� B-C: Drops with a soother

� D: Open nipple with drops

� E-K: Closed bottle

� Breast feeding at every stage

� Max volume and time

� Notes re endurance, distress

40




9:15 a.m. – 10:00 a.m. 21

Safety First

41

Breast is Best!

42




9:15 a.m. – 10:00 a.m. 22

Breastfeeding

� Included at EVERY stage!

� Hopefully first oral experience

� If cueing, baby can (should) go to breast every time

� Requires conversation/management of pumping

� “Baby should breastfeed at an APPROPRIATELY

pumped breast”

� Careful assessment of infant at breast (swallowing,

flooding, etc)

� *If mom reports milk transfer, assume baby took max

oral volume for that feeding

43

SINC Project

� Control population 2012� Born < 32 weeks

� Calgary Oral Feeding Guideline

� Inconsistent application

� SINC population 2013/2014� Born at < 32 weeks defined as fragile feeders

� Follow the SINC algorithm

� Volume and time protected

� Cues for engagement and disengagement

� No change in respiratory management guidelines

44




9:15 a.m. – 10:00 a.m. 23

Advance or Not?� Emphasis on quality of feedings, not quantity

� Increased number of (positive) feeding opportunities correlated to earlier full nipple feeding

� Slow, conservative approach in early stages creates strong basic skills that may allow more rapid advancement later – opposite is also true

� Consider feeding and respiratory pattern over past few days

� Negative trend? � Return to previous stage until stability is recovered

� *Smaller increases allow earlier, less dramatic response

� Physician/NNP orders feeding stage after multidisciplinary discussion during daily rounds

45

“Caution Events”� Vaccinations

� Eye exam

� Tub bath

� Procedures

� GERD

� Site transfers (prepare the parents!)

� Consider the baby’s planned/ recent “workload” prior to

each feeding opportunity

46




9:15 a.m. – 10:00 a.m. 24

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Oral feeds over 14 days

Eye

“Caution Events”

47

Auditing1. Compliance with algorithm

2. Gestational age at introduction of oral feeds

3. Gestational age at full oral feeds

4. Gestational age at discharge home

5. Rates of oral aversion

� Retrospective comparison with 2012 cohort

� Plus:

� Safety

� Impact on other feeding issues

48




9:15 a.m. – 10:00 a.m. 25

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Case 2

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Case 3

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9:15 a.m. – 10:00 a.m. 26

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Case 5

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A Better Way…

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34-35 wks

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9:15 a.m. – 10:00 a.m. 27

Making Progress

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38-39 wks

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40 weeks, baby discharged home, fully

orally fed, on room air

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9:15 a.m. – 10:00 a.m. 28

0

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CPAP +5, 0.21

CPAP +6, 0.22

CPAP +6, 0.21***********

CPAP+5, 0.21************

1 lpm, 0.21*********************

RA***************

****

CPAP +4, 0.21******* 1 lpm, 0.21

**************

Baby S. 24 weeks in 2013

55

Baby H (25 weeks)

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32-33 weeks

CPAP +4,

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CPAP +4, 0.21

56




9:15 a.m. – 10:00 a.m. 29

Making Progress: Baby H

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36-37 weeks

CPAP +4, 0.21

HF 4lpm, 0.21

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1 lpm, 0.21HF 4lpm, 0.21

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40 weeks, Fully Orally Fed

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58




9:15 a.m. – 10:00 a.m. 30

Baby T. 29 1/7 weeks

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32 wks: RA

**********

33 wks: 2 lpm, 0.21

***************

36 wks: RA

Demand feeds

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CPAP +7, 0.29

CPAP +7, 0.25

CPAP +6, 0.21

***

CPAP +4, 0.21*

CPAP +4, 0.21

***

RA

******

RA

*****

****

RA

******

*****

RA

******

****** RA

*****

*****

RA

******

RA

*****

RA

*****

*****

Baby B. 24 5/7 weeks

CPAP +7, 0.27

60




9:15 a.m. – 10:00 a.m. 31

A closer look…Baby B.

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CPAP +7, 0.29

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CPAP +7, 0.25 CPAP +6, 0.21

61

Baby B. cont

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36-37 weeks

CPAP +4, 0.21

CPAP +4, 0.21

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38-39 weeks

RA

62




9:15 a.m. – 10:00 a.m. 32

Baby B. cont

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40-41 weeks

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42-43 weeks

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Baby B. Home at 45 4/7 weeks,

demand feeds

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44-45 weeks

64




9:15 a.m. – 10:00 a.m. 33

Case Study: Baby S Born 30/6 1800gDate:

Age (Weeks) /1 32 /2 /3 /4 /5 /6

Stage A-B

Resp support RA RA RA RA RA

Total # feeds 8 8 8 8 8

Total # oral 1 offer 1 offer 0 0 1 offer

# Br feeds 0 0 0

Vol/feed - total 24 mL /60 27 34 /60

po vol/feed

(feed time)

Refuse/Time/

Distress/Slept

through

0 x7, 1.0 0 x2, 0.5, 0 x5 0 x5, 1.0, 0 x2

Events: Vacc, ROP,

Proc, Other vaccines

Date:

Age (Weeks) 33 /1 /2 /3 /4 /5 /6

Stage B B B-C skipped D - E E - F F F

Resp support RA RA RA RA RA RA RA

Total # feeds 8 8 8 8 8 8 8

Total # oral 4 offers ~6 at max 8 at max 8 0 at max 0 at max 0 at max

# Br feeds 0 0 0 0 0 0 0

Vol/feed - total 31 /60 31 /30 31 31 33 34 34

po vol/feed

(feed time)

Refuse/Time/

Distress/Slept

through

0 x4, 1, 1.5 x3 1.5, 0 x2, 1.5 x5 3.1 x3, 3 x4, 3.1 6 x86, 7i, 8i, 5 x2ijp, 9

x37 x2, 9 x4, 5ij, 8 8, 5, 9 x6

Events: Vacc, ROP,

Proc, Other B=5% = 1.6mL C=10% = 3.1 mL

D=15% = 4.7 E=

20% = 6.2 F=30% = 9.9

65

Baby S cont.Date:

Age (Weeks) 34 /1 /2 /3 /4 /5 /6

Stage F -G G G G G G G-H


Total # feeds 8 8 8 8 8 8 8

Total # oral 5 at F max 0 at max 0 at max 0 at max 5 at max 5 at max 4 at new max

# Br feeds 0 1 1 1 2 1 0

Vol/feed - total 38 40 41 43 43 44

po vol/feed

(feed time)

Refuse/Time/

Distress/Slept

through

9, 5i, 9, 11 x512 x7 (with Brx1),

105p, 5j, 6j, 12 x2,

Br +fullG, 12 x2

12 x2, 9 4ip, 12 Br

+fullG, 12 x2

12, 15, 17 x2,

Br +gav, 10, 17,

Br +fullG

15, 18, 15, Br +gav,

17 x2, 4ij, 17

17 x3, 22 x3, 14ij,

22

Events: Vacc, ROP,

Proc, Other G=40% = 15.2 G=17 H=50% = 22

Date:

Age (Weeks) 35 /1 /2 /3 /4 /5 /6

Stage H-I I I-J J-K


Total # feeds 8 8 8 8 8 8 8

Total # oral 5 at new max 7 at max 4 at max 5 at max 4 at new max 7 at max

# Br feeds 1 1 1 2 2 1 2

Vol/feed - total 45 47 48 50

po vol/feed

(feed time)

Refuse/Time/

Distress/Slept

through

22, 23, 22, 27, Br

+gav, 27 x3

27 x2, 17ij, 27,

Br+gav, 27 x3

28 x2, 17ijx2,

Br+fullG, 17ij,

18ij, 28

29 x2, 17ij, 15ij,

Br+overG, 20ij,

Br+overG, 28

28, 29 x3, Br+bigG,

36, Br+bigG, 36

36 x2, 32, 36 x3,

Br+bigG, 36

36, 37 x2, 49, Br

+5Bij, 50, Br+15B,

20, 60

Events: Vacc, ROP,

Proc, Other I=60%=27 I=28 J=75%=36mL gavage d/c

66




9:15 a.m. – 10:00 a.m. 34

Baby S – to discharge

Date:

Age (Weeks) 36 /1 /2 /3 /4 /5 /6

Stage K

Resp support RA RA RA

Total # feeds 8 8 8

Total # oral

# Br feeds 2 2 1

Vol/feed - total

po vol/feed

(feed time)

Refuse/Time/

Distress/Slept

through

43, 30, 55, 40,

Br+20, 8i, Br, 60

55, 50, 55 x2,

Br+15G, 55, 60,

Br+40B

45, 60, Br,

Br+60

Events: Vacc, ROP,

Proc, Other d/c home

Discharged 36 2/7, RA, EBM/SimAdv

67

SINC Project Results� Discharged on gavage

� Discharged on home oxygen

� LOS

� Time of first feeding

� Time of first breast feeding

� Amount of breast feeding at discharge

68




9:15 a.m. – 10:00 a.m. 35

Gestation at First Breastfeed

28

29

30

31

32

33

34

35

36

37

38

23-24 weeks 25 weeks 26 weeks 27 weeks 28 weeks 29 weeks 30 weeks 31 weeks

Co

mp

lete

d w

eeks

2012

2013

69

Gestation at First Oral Feed

31

32

33

34

35


Co

mp

lete

d w

eeks

2012

2013

70




9:15 a.m. – 10:00 a.m. 36

Average Number of breastfeeds, last 7 days

prior to discharge home

0

2

4

6

8

10

12


2012

2013

71

Gestational age at Full Feeds

32

33

34

35

36

37

38

39

40

41

42


Co

mp

lete

d w

eeks

2012

2013

72




9:15 a.m. – 10:00 a.m. 37

Infants Discharged Home with Feeds

per Gavage

0

1

2

3

4

5

6

7

Jan-Jun 2012 Jul-Dec 2013

73

Calgary Zone Home O2

74




9:15 a.m. – 10:00 a.m. 38

Median Age to Discharge Open Lung 2012 vs Open Lung + SINC 2013

32

34

36

38

40

42

44

23 (n=0)(n=1)

24 (n=0)(n=12)

25 (n=5)(n=7)

26 (n=12)(n=7)

27 (n=5)(n=12)

28 (n=8)(n=19)

29 (n=15)(n=22)

30 (n=18)(n=16)

31 (n=29)(n=33)

Gesta

tio

n a

t D

isch

arg

e (

weeks)

Median Gestation atDischarge 2012(n=92)

Median Gestation atDischarge (SINC)2013 (n=129)

75

No Safety Concerns to Date� Babies stay on CPAP to allow optimal lung development

� Babies SAFELY cue for small volumes until consistently capable and then advance slowly

� Breastfeeding is the preferable mode for all oral feeding experiences

� Parents become more engaged with infant feeding, and have reported self-confidence with feeding

� As with all QI projects, close auditing for safety, efficacy and unintended consequences

76




9:15 a.m. – 10:00 a.m. 39

Next Steps� Follow to 1 year for feeding difficulties

� Physiologic studies underway

� Stability during all modes of careful eating

77

Conclusions

� Early eating while on CPAP is safe

� With protocolized co-regulated techniques and strategies

� SINC provided a standardized feed advancement � Calgary zone NICUs

� Fragile feeders

� Long term follow up will provide further information about outcomes

78




9:15 a.m. – 10:00 a.m. 40

The Team� Stacey Dalgleish

� [email protected]

� Linda Kostecky

� Noreen Blachly

� Jammey Kerik, Susan Charron, Marj Bickell (FMC)

� Jeanne Scotland, Ann Smith (RGH)

� Dallas Baumler, Kyla Lavery (SHC)

� Kirenza Holland, Darlene MacDonald (PLC)

� Deborah Clark (Neo Lead)

� Super User RNs, Nursing Admin (all sites)79

eating in “sinc” national and one … · eating in “sinc”: oral feeding on cpap and beyond...

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