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Understanding and treating Feeding Problems in Infants with Special Medical Needs

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Title: Understanding and treating Feeding Problems in Infants with Special Medical Needs


1
Understanding and treating Feeding Problems in
Infants with Special Medical Needs
  • Kathleen Borowitz, MS, CCC-SLP
  • University of Virginia Health System

2
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3
Infant Feeding Issues
  • Increased survival rate
  • Earlier discharge with more complex medical issues
  • Ever increasing need for early intervention
    services

4
Prematurity
5
Prematurity
  • NICU is an abnormal infant environment
  • Inconsistent and aberrant sensory input
  • Disrupts parent-child bonding

6
Common Issues with Prematurity
HEAD
7
Common Issues with Prematurity
  • Intraventricular Hemmorrhage (IVH)
  • Bleeding in the brain due to fragile vessels
  • Diagnosed by ultrasound
  • Prevented by controlling blood pressure
  • Can cause brain damage and/or hydrocephalus

8
Impact on FeedingHead
  • Brain Function
  • IVH/Hydrocephalus
  • Cognitive development
  • Muscular tone and coordination
  • Sensory processing
  • Oral aversion/defensiveness

9
Common Issues with Prematurity
  • CHEST

10
Common Issues with Prematurity
  • Apnea
  • Pauses in breathing for gt20 seconds
  • Due to immaturity in the area of the brain that
    controls the drive to breathe
  • Occurs in nearly all babies 30 weeks
  • Treated by monitoring /stimulation and medication

11
Common Issues with Prematurity
  • Bradycardia
  • Abnormal slowing of the heart rate
  • Due to low oxygen levels or apnea

12
Common Issues with Prematurity
  • Bronchopulmonary Dysplasia (BPD)
  • Oxygen requirement at 36 weeks
  • Damage or scarring of the lungs
  • immature lungs
  • treatments for breathing
  • infections or pneumonia
  • Milder form is Chronic Lung Disease (CLD)

13
Common Issues with Prematurity
  • Treatment for BPD/CLD
  • Steroids
  • Diuretics
  • Bronchodilators
  • Ventilators/Tracheostomys

14
Respiratory Problems
  • Tracheo-esophagel fistula (TEF)
  • Connection between the trachea and esophagus
  • Tracheomalacia
  • Weakness/floppiness of the tracheal walls
  • Airway stenosis
  • Narrowing of airway
  • Pierre Robin Sequence

15
Respiratory ProblemsTreatment
  • TEF
  • surgery
  • Tracheomalacia
  • time/growth
  • CPAP
  • tracheotomy
  • Airway stenosis
  • laser surgery
  • tracheotomy
  • Pierre Robin Sequence
  • Positioning
  • Tongue lip adhesion
  • tracheotomy

16
Respiratory ProblemsTreatment
  • Continuous positive airway pressure (CPAP)
  • Ventilator
  • Tracheostomy

17
Respiratory Treatment CPAP
  • Introduces positive airway pressure into nasal
    passages
  • Prevents collapse of upper airway

18
Respiratory TreatmentIntubation
19
Respiratory Treatment Intubation
20
Respiratory TreatmentTrach
  • Higher risk for aspiration
  • Type/size of trach tube affects swallow
  • Decreased ability to smell

21
Respiratory TreatmentTrach
22
Congenital Cardiac Defects
  • Most common congenital malformations in newborns
    (1 of live births)
  • Occur when the heart or blood vessels near the
    heart dont develop normally before birth
  • Most defects either obstruct blood flow in the
    heart or vessels or cause blood to flow through
    the heart in an abnormal pattern

23
HEART
  • Right
  • receives used blood via superior and inferior
    vena cava
  • R atrium through tricuspid valve to R ventricle
  • Through pulmonary valve and pulmonary artery to
    lungs
  • Left
  • O2 rich blood returns through pulmonary veins to
    L atrium
  • Through mitral valve to L ventricle which pumps
    blood through aortic valve and out aorta to body

24
Congenital Cardiac Defects
  • Defects causing too much blood to pass through
    the lungs
  • allow oxygen-rich blood that should be traveling
    to the body to re-circulate through the lungs
  • causes increased pressure and stress in the lungs

www.healthsystem.virginia.edu/uvahealth/peds_cardi
ac
25
Congenital Cardiac Defects
  • Defects causing too little blood to pass through
    the lungs
  • allow blood that has not been to the lungs to
    pick up oxygen (and, therefore, is oxygen-poor)
    to travel to the body.
  • body does not receive enough oxygen with these
    defects causing cyanosis

26
Congenital Cardiac Defects
  • Defects causing too little blood to travel to the
    body
  • underdeveloped chambers of the heart
  • blockages in blood vessels that prevent proper
    amount of blood circulation

27
Respiratory TreatmentECMO
  • ExtraCorporeal Membrane
  • Oxygenation
  • The use of an artificial lung located outside
    the body that puts oxygen into the blood and then
    carries it to the body tissues

28
Respiratory TreatmentECMO
  • Frequent Uses of ECMO
  • Newborn respiratory failure
  • Severe heart failure
  • Extra support after heart surgery
  • Bridge to heart transplant

29
Respiratory TreatmentECMO
  • Risks /Complications with ECMO
  • Bleeding from surgical site
  • IVH
  • Renal failure

30
Respiratory TreatmentECMO
31
Impact on FeedingChest
  • Respiration/Cardiac Function
  • CLD/RDS/Congenital Cardiac Defect
  • Endurance
  • Swallow safety
  • Appetite
  • Reflux
  • Coordination/Organization
  • Oral aversion/defensiveness

32
Common Issues with Prematurity
  • STOMACH

33
Common Issues with Prematurity
  • Necrotizing Entercolitis (NEC)
  • Most common intestinal condition (1-5 NICU)
  • Low birth weight highest risk
  • Necrosis of parts of the intestine due to
    immaturity, infection and/or poor blood flow

34
Common Issues with Prematurity
  • Treatment for NEC
  • Medical
  • Antibiotics
  • Bowel rest (no enteral feeds)
  • Frequent x-rays
  • Surgical
  • Removal of diseased section of intestine
  • Ostomy

35
GI Conditions
  • Short bowel syndrome
  • Gastroschisis
  • Esophageal artresia
  • Surgery
  • Lengthy hospital stay
  • NPO for extended periods
  • Abnormal digestive tract

36
GI Conditions
  • Short Bowel Syndrome
  • Absence of 50 of small intestine
  • Inability to absorb nutrients normally
  • Rapid transit through GI tract
  • Most common causes
  • NEC
  • Mid-gut volvulus
  • Intestinal atresias

37
GI Conditions
  • Short Bowel Syndrome
  • Symptoms
  • Chronic diarrhea
  • Abdominal cramps/gas
  • Chronic diaper rash
  • Poor weight gain
  • May be TPN dependent
  • May require long-term tube feeds

38
GI Conditions
  • Gastroschisis
  • Herniation or displacement of the intestines
    through the abdominal wall
  • Infant born with intestines exposed
  • Viewer discretion is advised

39
Gastroschesis
40
Gastroschisis
  • Treatment
  • Intestines surgically replaced in the abdomen and
    outer defect closed
  • May require sequential surgeries to complete
  • TPN required

41
Esophageal Atresia
  • Upper esophagus ends blindly and does not connect
    with lower esophagus/stomach
  • TEF
  • Marked narrowing of esophagus

42
Esophageal Atresia
  • Treatment
  • Requires surgery
  • Prolonged period of TPN dependence
  • Life-long esophageal motility problems

43
Impact on FeedingStomach
  • NEC/Gastroschesis/Short Bowel Syndrome/TEF/Esopha
    geal Atresia
  • Physical inability to swallow or absorb nutrition
  • Aversion due to pain
  • Sensory processing
  • Oral aversion/defensiveness

44
GIFeeding Issues
  • Long-term tube dependence
  • Lack of hunger
  • Nausea
  • Abdominal pain
  • Tolerance of only small feeds
  • Inconsistent response to feeding trials
  • Oral defensiveness

45
Evaluation
46
Evaluation
  • Appearance
  • Facial symmetry
  • Unusual features
  • Movement of extremities
  • Tone
  • Auditory and visual responses

47
Evaluation
  • Oral reflexes
  • Root
  • Transverse tongue
  • Non-nutritive suck
  • Protective gag, cough
  • Voicing

48
Evaluation
  • Method of nutrition
  • Oral/non-oral/combination
  • Enteral/parenteral/combination
  • Sleep/wake cycles
  • Hunger/satiety cues

49
Common Abbreviations for non-oral feeds
  • NGT nasogastric tube
  • OGT orogastric tube
  • GT gastrostomy tube (surgically placed)
  • PEG percutanious endoscopic gastrostomy
    (placed by endoscope)
  • TPN total parenteral nutrition

50
Evaluation
  • Hunger
  • Continuous/bolus
  • Compress feeds or move to bolus
  • Feeding schedule
  • PO with NGT supplement

51
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52
Evaluation
  • Response to Feeding
  • Root/latch
  • Initiate suck
  • Coordinated, sustained suck
  • Detect swallows
  • Changes in O2 sats, RR, HR
  • Signs of distress

53
Evaluation
  • Signs of distress
  • Nares flaring
  • Neck extension
  • Arms out
  • Head bobbing
  • Increased respiratory rate
  • Decreased O2 saturation

54
Evaluation
  • Interventions
  • Change in nipple type/flow rate
  • Change in position
  • External pacing
  • External organization

55
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56
Evaluation
  • Swallow Safety
  • Cervical auscultation
  • Video Fluoroscopic study of swallowing (VFSS)
  • Fiberoptic endoscopic evaluation of swallow (FEES
    )
  • Blue dye test for trach(MEBD)

57
EvaluationSwallow Safety
  • VFSS
  • No age restriction
  • Must be accepting at least small amount by mouth
    before study
  • Significant radiation exposure
  • Shows how and when aspiration occurs
  • Allows evaluation of intervention techniques

58
EvaluationSwallow Safety
  • FEES
  • No age restriction
  • Invasive
  • No radiation exposure
  • Allows view of vocal cords and function
  • Less information as to how and when aspiration
    occurs

59
Case Study
  • 7 week old female of Vietnamese decent with
    Trisomy 21, s/p duodenal web repair and awaiting
    VSD repair
  • Initial evaluation
  • sleepy, hypoactive reflexes, no non-nutritive
    suck
  • Post-surgery
  • more awake, rapid gag, tongue thrusting

60
Case Study ITrisomy 21
  • Characteristics
  • Cognitive /developmental delay
  • Generalized hypotonia
  • High incidence of cardiac defects
  • Wide, thick tongue
  • Feeding
  • Poor lip seal
  • Disorganization
  • Wide jaw excursion

61
Case Study IIntervention
  • Organization
  • Semi-upright position
  • Full support with blanket rolls
  • Slow introduction of oral stimulation
  • Nipple off bottle
  • Establish non-nutritive suck
  • Introduce tastes
  • Limit flow

62
Case Study II
  • 2 week old term infant with esophageal atresia,
    NPO for at least 6 more weeks to allow
    growth/closer proximity of 2 parts of esophagus.
    Oral tube in place to drain secretions from upper
    portion of esophagus
  • Evaluation
  • No oral aversion
  • non-nutritive suck
  • swallows detected

63
Case Study IIIntervention
  • Permission to offer trace tastes by nipple to
    establish and maintain suck-swallow
  • Establish sustained suck on nipple off bottle
  • Trace tastes on nipple 5 minutes x2/day
  • Goal easier transition to oral feeding once
    esophagus repaired

64
Case Study III
  • 2 day old 36 week EGA transferred to NICU due to
    PRS. OGT in place, frequent O2 desats.
  • Evaluation
  • Micrognathia
  • Central U-shaped cleft palate
  • Small, retracted tongue
  • Positional airway obstruction

65
Case Study IIIPierre Robin Sequence
  • Micrognathia
  • Cleft palate
  • Tongue obstructs airway

66
Case Study IIIIntervention
  • Request OGT be moved to NGT
  • Establish stable O2 sats and forward tongue
    position in side lying
  • Establish suck with nipple from cleft palate
    bottle
  • Feedings in side lying with Haberman feeder

67
Cleft Palate Bottles
Mead-Johnson
Haberman
Pigeon
68
Case Study IV
  • 4 year old w/HLHS, s/p 3 cardiac surgeries. H/O
    poor feeding as infant, NGT dependent w/eventual
    G-tube placement. Now w/no oral intake.
  • Parent-child issues early in life
  • Vulnerable child syndrome
  • Previous feeding clinic evaluation/treatment

69
Case Study IV
  • Evaluation
  • Language and articulation WFL
  • Good oral control
  • Tolerates tactile and olfactory input from foods
  • Licks/sucks certain solids
  • Drinks certain liquids w/o difficulty

70
Case Study IVIntervention
  • Hold one tube feeding to allow hunger
  • Establish tastes of smooth foods (no crumbs)
  • Tactile input to teeth, gums, tongue
  • Tooth brushing program
  • Salty/crunchy foods
  • Graham crackers
  • Chips
  • Cheese puffs

71
Summary
  • Consider how medical condition and treatment
    affect
  • Endurance
  • Breathing
  • Hunger
  • Pain
  • Sensory integration

72
Summary
  • Brain Function
  • Cognitive development
  • Muscular tone and coordination
  • Sensory processing
  • Oral aversion/defensiveness
  • Respiration/Cardiac Function
  • Endurance
  • Swallow safety
  • Appetite
  • Reflux
  • Coordination/Organization
  • Oral aversion/defensiveness

73
Summary
  • Gastrointestinal
  • Physical inability to swallow or absorb nutrition
  • Aversion due to pain
  • Sensory processing
  • Oral aversion/defensiveness

74
Summary
  • Set appropriate goals
  • Suck before suck-swallow
  • Limit feeding trial times
  • Limit intake
  • Ensure safety
  • Quality over quantity

75
Resources
  • www.healthsystem.virginia.edu/uvahealth/peds_cardi
    ac
  • www.healthsystem.virginia.edu/uvahealth/adult_pedi
    atrics/reflux.cfm
  • www.healthsystem.virginia.edu/internet/pediatrics/
    patients/KCRCFeedingProgram.cfm

76
Kathleen Borowitz, MS, CCC-SLPUniversity of
Virginia Health SystemTherapy Services434.924.82
45kcb8t_at_virginia.edu
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