Key issues in supporting transition from tube to bottle feeding

Gillian KennedyConsultant Speech and Language

TherapistNIDCAP Trainer in trainingNeonatal UnitUniversity College London HospitalLondon.

gillian.kennedy@uclh.nhs.uk

.......por lo tanto

-Baby

-Maternal

-System(hospital /

social)

Key issues in supporting transition from tube to bottle feeding

Early input to redress negative peri-oral stimuli

Negative• Intubation• Suction• CPAP• Feeding tubes

Positive– Skin to skin / kangaroo –

mother care– PositiveTouch

Bond 1997

Influence of tube feeding

OGT

NGT

•Rate of flow•Contact with baby•Position of baby

Strategies to promote oral feeding have included:

Early introduction of oral feeds Oral stimulation programmes

Boiron et al 2007

Fucile et al 2002

Barlow 2009

31 weeks vs. 33-34 weeks ga Simpson et al 2002

Specific feeding techniques e.g. cheek and jaw support

Eishema 1991

Quantative outcome measures related to..

• Volume • length of feed• Speed of transfer from

tube oral feeding– e.g.

Entire prescribed volume taken within 20 mins without adverse effects......

Usually defined as apnoeic +/-bradycardic episodes

Influence of individualised care..based in NIDCAP approach Als 1982

Shift in feeding outcome focus from..

Quantative

Qualitative

Als Synactive Theory of Development

• Physiological• Motor• State• Attention / interaction

• Self regulatory

Focussing on the feeding experience for the baby

• Baby viewed as an active participant

• Co-regulation from the parent / carer to:– Facilitate and support

the baby’s own efforts– identify and respond to

the baby’s signals of sensitivity

Feeding readiness behavioursWhite-Traut et al 2005

Thoyre et al 2005• Alert – baby demonstrates the

ability to focus attention on feeding

• Rooting– Neurodevelopmental readiness

Shaker 1996

• Tongue organised to receive nipple

• Body posture orientates to midline – arms forward to assist

• > 90 % baseline oxygen saturation level in quiet state and in preparation period.

34-36 week infants

• Feeding issues for late preterm infants:

Bottle and Breast fed

Dodrill et al 2005

Meier et al 2007

Babies with Chronic Lung Disease• Anticipated maturational patterns of

suckle and swallow rhythms do not occur.

• ?does the absence of stable rhythms at 35 weeks predict subsequent feeding and neurological problems

Gewolb et al 2001

• > incidence in gastro-intestinal issues Jadcherla et al 2010

• > incidence of feeding difficultiesHawdon et al 2000

Modifications to introduction of oral intake for bottle fed babies weaned from long term CPAP

• EBM used for initial trialMizuno & Ueda 2002

• Elevated side-lying position used

Positioning is important because:

• Cranio-cervical posture and pharyngeal airway stability are interconnected

• Premature infant lacks the éxoskeleton’ and strong physiological flexor of the term infant.

Bosma 1972• Feeding success strongly

influenced by the feeders body mechanics

Jones et al 2002

Positioning

Elevated side lying

• Conserves energy• Affords baby more control

over feed• Facilitates infant using

self-regulatory strategies• Enables safer clearance of

oral residue• Allows feeder to feel

respiration

Pilot study investigating the elevated side-lying position Clark et al 2007

• Improved oxygen saturation levels……..when infants fed in elevated side-lying versus semi-upright

p < 0.001Trend • Quicker return to baseline of heart- rate

Further research presently underway