Title: Understanding and treating Feeding Problems in Infants with Special Medical Needs
1Understanding and treating Feeding Problems in
Infants with Special Medical Needs
- Kathleen Borowitz, MS, CCC-SLP
- University of Virginia Health System
2(No Transcript)
3Infant Feeding Issues
- Increased survival rate
- Earlier discharge with more complex medical issues
- Ever increasing need for early intervention
services -
4Prematurity
5Prematurity
- NICU is an abnormal infant environment
- Inconsistent and aberrant sensory input
- Disrupts parent-child bonding
6Common Issues with Prematurity
HEAD
7Common 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
8Impact on FeedingHead
- Brain Function
- IVH/Hydrocephalus
- Cognitive development
- Muscular tone and coordination
- Sensory processing
- Oral aversion/defensiveness
9Common Issues with Prematurity
10Common 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
11Common Issues with Prematurity
- Bradycardia
- Abnormal slowing of the heart rate
- Due to low oxygen levels or apnea
12Common 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)
13Common Issues with Prematurity
- Treatment for BPD/CLD
- Steroids
- Diuretics
- Bronchodilators
- Ventilators/Tracheostomys
14Respiratory 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
15Respiratory ProblemsTreatment
- TEF
- surgery
- Tracheomalacia
- time/growth
- CPAP
- tracheotomy
- Airway stenosis
- laser surgery
- tracheotomy
- Pierre Robin Sequence
- Positioning
- Tongue lip adhesion
- tracheotomy
16Respiratory ProblemsTreatment
- Continuous positive airway pressure (CPAP)
- Ventilator
- Tracheostomy
17Respiratory Treatment CPAP
- Introduces positive airway pressure into nasal
passages - Prevents collapse of upper airway
18Respiratory TreatmentIntubation
19Respiratory Treatment Intubation
20Respiratory TreatmentTrach
- Higher risk for aspiration
- Type/size of trach tube affects swallow
- Decreased ability to smell
21Respiratory TreatmentTrach
22Congenital 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
23HEART
- 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
24Congenital 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
25Congenital 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
26Congenital 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
27Respiratory 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 -
28Respiratory TreatmentECMO
- Frequent Uses of ECMO
- Newborn respiratory failure
- Severe heart failure
- Extra support after heart surgery
- Bridge to heart transplant
29Respiratory TreatmentECMO
- Risks /Complications with ECMO
- Bleeding from surgical site
- IVH
- Renal failure
30Respiratory TreatmentECMO
31Impact on FeedingChest
- Respiration/Cardiac Function
- CLD/RDS/Congenital Cardiac Defect
- Endurance
- Swallow safety
- Appetite
- Reflux
- Coordination/Organization
- Oral aversion/defensiveness
32Common Issues with Prematurity
33Common 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
34Common Issues with Prematurity
- Treatment for NEC
- Medical
- Antibiotics
- Bowel rest (no enteral feeds)
- Frequent x-rays
- Surgical
- Removal of diseased section of intestine
- Ostomy
35GI Conditions
- Short bowel syndrome
- Gastroschisis
- Esophageal artresia
- Surgery
- Lengthy hospital stay
- NPO for extended periods
- Abnormal digestive tract
36GI 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
37GI 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
38GI Conditions
- Gastroschisis
- Herniation or displacement of the intestines
through the abdominal wall - Infant born with intestines exposed
- Viewer discretion is advised
39Gastroschesis
40Gastroschisis
- Treatment
- Intestines surgically replaced in the abdomen and
outer defect closed - May require sequential surgeries to complete
- TPN required
41Esophageal Atresia
- Upper esophagus ends blindly and does not connect
with lower esophagus/stomach - TEF
- Marked narrowing of esophagus
42Esophageal Atresia
- Treatment
- Requires surgery
- Prolonged period of TPN dependence
- Life-long esophageal motility problems
43Impact 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
44GIFeeding Issues
- Long-term tube dependence
- Lack of hunger
- Nausea
- Abdominal pain
- Tolerance of only small feeds
- Inconsistent response to feeding trials
- Oral defensiveness
45Evaluation
46Evaluation
- Appearance
- Facial symmetry
- Unusual features
- Movement of extremities
- Tone
- Auditory and visual responses
47Evaluation
- Oral reflexes
- Root
- Transverse tongue
- Non-nutritive suck
- Protective gag, cough
- Voicing
48Evaluation
- Method of nutrition
- Oral/non-oral/combination
- Enteral/parenteral/combination
- Sleep/wake cycles
- Hunger/satiety cues
49Common 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
50Evaluation
- Hunger
- Continuous/bolus
- Compress feeds or move to bolus
- Feeding schedule
- PO with NGT supplement
51(No Transcript)
52Evaluation
- Response to Feeding
- Root/latch
- Initiate suck
- Coordinated, sustained suck
- Detect swallows
- Changes in O2 sats, RR, HR
- Signs of distress
53Evaluation
- Signs of distress
- Nares flaring
- Neck extension
- Arms out
- Head bobbing
- Increased respiratory rate
- Decreased O2 saturation
54Evaluation
- Interventions
- Change in nipple type/flow rate
- Change in position
- External pacing
- External organization
55(No Transcript)
56Evaluation
- Swallow Safety
- Cervical auscultation
- Video Fluoroscopic study of swallowing (VFSS)
- Fiberoptic endoscopic evaluation of swallow (FEES
) - Blue dye test for trach(MEBD)
57EvaluationSwallow 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
58EvaluationSwallow 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
59Case 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
60Case 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
61Case 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
62Case 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
63Case 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
64Case 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
65Case Study IIIPierre Robin Sequence
- Micrognathia
- Cleft palate
- Tongue obstructs airway
66Case 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
67Cleft Palate Bottles
Mead-Johnson
Haberman
Pigeon
68Case 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
69Case 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
70Case 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
71Summary
- Consider how medical condition and treatment
affect - Endurance
- Breathing
- Hunger
- Pain
- Sensory integration
72Summary
- 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
73Summary
- Gastrointestinal
- Physical inability to swallow or absorb nutrition
- Aversion due to pain
- Sensory processing
- Oral aversion/defensiveness
74Summary
- Set appropriate goals
- Suck before suck-swallow
- Limit feeding trial times
- Limit intake
- Ensure safety
- Quality over quantity
75Resources
- 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
76Kathleen Borowitz, MS, CCC-SLPUniversity of
Virginia Health SystemTherapy Services434.924.82
45kcb8t_at_virginia.edu