©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding Changes in the NICU Karen Smith, NNP.

©2013 Children's Mercy. All Rights Reserved. 09/13

Feeding Changes in the NICUFeeding Changes in the NICU

Karen Smith, NNP


How did this come about?How did this come about?• I attended “The Fetus and the Newborn”

conference in 2011 • The breakout session: Feeding the

Preterm Infant: Infant Driven Feeding sparked an interest

• Presented it to the Neonatologists here• Mich Hardy was an integral part and

“cheerleader” of getting this going at CMH


Hospital ParticipationHospital Participation

• Several Neonatologists liked the idea and wanted developed and implemented at CMH

• The program has also been implemented at Truman and SMMC


In the past, what constituted a In the past, what constituted a successful feeding?successful feeding?

A. an empty bottle

B. the infant being tired afterwards

C. was dependent on the nurse’s schedule

D. A & C

an empty bottle

the in

fant being ti

red aft...

was dependent o

n the n...

A & C

0% 0%0%0%


Medical Model of FeedingMedical Model of FeedingHistorically, successfully feeding the preterm infant meant:•was clock, schedule and staff driven•involves the physician ordering feeds at intervals such as twice a day or every other feed. •based on gestational and chronological age.•“getting in” a certain volume resulting in an empty bottle.•Often resulted in a lot of manipulation of the bottle or infant during the feed, regardless of the infant’s behaviors.

Ludwig & Waitzman 2007


QuestionQuestion

• For a Developmental Appropriate feeding, how is the infant fed?

• A. when the infant is mature enough

• B. takes into account the baby’s readiness cues and behaviors

• C. when the doctor says to PO feed the baby

• D. A & B


Developmental ModelDevelopmental Model

• Assesses autonomic, motor, and state stability

• Assesses feeding readiness cues and behaviors

• Considers infant driven times and volumes

• Takes into account infant’s maturity vs. gestational age

• The infant takes an active role and the caregiver a passive role


Developmental Model of FeedingDevelopmental Model of Feeding

• Eliminates force feedings!!• Individualized and tailored to each infant.• Provides a natural progression to full PO.• Provides an objective tool for different caregivers.• Improves communication between the care team

members and parents as to how the infant is feeding.


Prepping for the big dayPrepping for the big day

• All infants may kangaroo care when

> 1200 grams and clinically stable.

• Pacifiers dipped in breastmilk for soothing.

• Initiate oral feeds based on cues as early as 32 weeks PMA, regardless of feeding volumes.


When should a baby be When should a baby be considered for PO feedings?considered for PO feedings?

A. At 34 weeks

B. When the MD or NNP says to do it

C. By using a feeding assessment tool to assess a baby’s readiness

At 34 w

eeks

When th

e MD or N

NP say..

.

By using a

feeding a

sse...

0% 0%0%


Feeding Assessment ToolFeeding Assessment Tool• Recommend to begin using tool at 33

weeks. When using the tool, score the baby prior to feed to assess whether you are going to have the baby breastfeed, bottle or NG feed.

• Eliminates the MD or NNP ordering “X number” of PO feeds a day. Allows the nurse to determine how many PO feeds the baby does based on the score.

• Eliminates the MD or NNP asking why the baby was not fed the prior day, the score can be looked up.


Feeding Assessment ScoringFeeding Assessment Scoring

• Can be used for bottle OR breastfeeding infants

• Appropriate for infants >33 weeks• This tool assesses:• Autonomic stability• Interest• Hunger behaviors• State• Motor skills & tone• Is an objective tool so can be used by

different caregivers but still attain the same result


Feeding “Readiness” Feeding “Readiness” Scoring- Low Score is good!Scoring- Low Score is good!

• 1- drowsy, alert or fussy prior to care; demonstrates feeding cues rooting and/or hands to mouth/takes pacifier; good tone.

• 2- drowsy or alert once handled, some rooting or takes pacifier; adequate tone.

DO NOT FEED FOR THE FOLLOWING SCORES:• 3- briefly alert with cares, no hunger cues; no change in tone.• 4- sleeping throughout care, no hunger cues; no change in tone.• 5- needs increased O2 with cares; apneic and/or bradycardic with

cares; tachypneic or has increased WOB over baseline with cares.• If infant is >35 weeks and is consistently scoring 3,4,5- OT consult

may be needed.


Should a baby be considered for a PO feeding Should a baby be considered for a PO feeding when they are:when they are:

Briefly alert, drowsy and showing no changes in Briefly alert, drowsy and showing no changes in tone?tone?

A. Yes

B. No

Yes No

0%0%


Feeding “Quality” ScoringFeeding “Quality” Scoring• 1- strong, coordinated suck/swallow/breathe pattern

throughout feed.• 2- strong coordinated suck initially, but tires with

progression.• 3-. consistent suck, but difficulty coordinating swallow,

has some loss of fluid, difficulty pacing; benefits from external pacing

• 4- consistent suck, but difficulty coordinating swallow, has some loss of fluid, difficulty pacing; benefits from external pacing and/or inconsistent suck, demonstrates little to no rhythm; may need rest breaks.

• 5- unable to coordinate suck/swallow/breathe pattern despite pacing; may have A/B/Ds or significant loss of fluid, may have significant loss of fluid.


An infant is exhibiting a consistent suck, but difficulty An infant is exhibiting a consistent suck, but difficulty coordinating swallow, has some loss of fluid, difficulty coordinating swallow, has some loss of fluid, difficulty

pacing; benefits from external pacingpacing; benefits from external pacingYou would score him a You would score him a

A. 1

B. 2

C. 3

D. 4

1 2 3 4

0% 0%0%0%


Quality of breastfeedQuality of breastfeedCheck mark box as to:Check mark box as to:

A. Good latch, good swallowing

B. Good latch, minimal swallowing noted

C. No latch, but good rooting around

D. Kangaroo care

Good latch

, good sw

allo...

Good latch

, minim

al swa...

No latch

, but g

ood rootin...

Kangaro

o care

0% 0%0%0%


Supports Used (use only if needed, Supports Used (use only if needed, and may select more than one)and may select more than one)

• Pacing needed• Increased O2 need• Jaw support• Oral stimulation• Pacing needed • Thickener consistency • Cheek support• Enfamil nipple• Similac nipple• Other nipple (nuk, cross cut, etc)

Pacing with bottle tipping forces the infant to take breaths and decreases the risk of aspiration


Feeding position best for Feeding position best for starting a preemie to PO feedstarting a preemie to PO feed

A. elevated sidelying

B. upright

C. reclined

D. sidelying

elevated si

delying

upright

reclined

sidelyi

ng

0% 0%0%0%


Feeding PositionsFeeding Positions

Sidelying: 0 degrees

breastfeeding positionplace infant on their side on your legs, feet to your stomach for supportsafest position: prevents bolus from passively falling to back of pharynx,

slowing flow and promoting active swallowing. Also assists with pacing Elevated Sidelying:

45 degreestransition from sidelying to elevated sidelying

Upright:60-80 degrees elevation

The reason reclined is not used in preterm infants for feedings is because there is a high risk for aspiration. However, it can be used in term infants as it is good interaction time.


Feeding Scoring: Where is it in Feeding Scoring: Where is it in Cerner?Cerner?


Questions?Questions?


Enteral Feeding GuidelinesEnteral Feeding Guidelines

These guidelines were developed by the Nutrition Committee, comprised of Neonatologist, NNPs, Nutritionists, Lactation Consultants, pharmacists, RNs.

This has been a working project for the VON Collaborative that we were a part of in 2011-2012.

Located in “Helpful Hints” on the Scope. Left tab “PHYSICIANS” then click on helpful hints or put in search bar ICN Helpful Hints.



Goals 1. Encourage safe, standardized feeding advancement within team to enhance growth outcomes of ICN infants. 2. Begin minimal enteral feeds by DOL 3, unless contraindications exists, to improve feeding tolerance, prevent gut atrophy, facilitate GI maturation, and shorten time to full enteral feeds. 3. Advocate use of human milk as definitive first choice for feeds. 4. Provide guidelines for holding feeds in assessment of feeding intolerance.



Feeding Initiation • Mother’s breast milk (MBM) is feeding of choice. Lactation consultations occur upon admission or as mother is available • Begin breast milk feeds with unfortified breast milk • For infants <2 kg requiring infant formula - 24 kcal/oz preterm infant formula • For infants >2 kg requiring infant formula - 22 kcal/oz Neosure Expert Care (standard concentration)



Bolus versus Continuous Feeds • Bolus feeds are preferred method of delivery in preterm infants with healthy GI tracts • Continuous feeds may be necessary for ELBW infants or those with short bowel syndrome or severe GE reflux with poor weight gain

Oral Feeds • All infants may kangaroo care when > 1200 grams and clinically stable • Initiate oral feeds based on cues as early as 33 weeks PMA, regardless of feeding volumes



• Osmolarity of breastmilk 260mOsmol/kg• Osmolarity of SSC 24 cal 280mOsmol/kg• Osmolarity of BM with HMF 24 cal 385mOsmol/kg

• For infants <2kg use 24 cal formula or BM• For infants >2kg use regular formula or BM


Which has the higher Which has the higher osmolarity?osmolarity?

A. Breastmilk

B. Preterm formula, 24 calorie

C. Breastmilk with HMF

Breastmilk

Preterm fo

rmula, 2

4 calorie

Breastmilk

with

HMF

0% 0%0%


Breast Milk Fortification • Begin HMF fortification step-wise to 24 kcal/oz when infant tolerating

>80 ml/kg/d enteral feeds • For infants < 2kg - utilize HMF


What feeding volume would you What feeding volume would you start for a 31 5/7 week, 1200 gram start for a 31 5/7 week, 1200 gram

infant?infant?A. 20ml/kg/day

B. 40ml/kg/day

C. 10ml/kg/day

20ml/kg/

day

40ml/kg/

day

10ml/kg/

day

0% 0%0%


How would you start feeding an How would you start feeding an infant who is 33 weeks, 2.4kg?infant who is 33 weeks, 2.4kg?

A. 20mlkg/day

B. 30ml/kg/day

C. 40ml/kg/day

20mlkg/day

30ml/kg/

day

40ml/kg/

day

0% 0%0%


Residual AlgorithmResidual Algorithm

• To standardize care for most residual instances• To decrease the number of calls the providers

receive about residuals and what to do• To try to alleviate instances (mostly on night shift)

of baby becoming NPO due to residuals that the primary team was trying to work through

• After research, residuals were not shown to directly correlate with NEC


Residual AlgorithmResidual Algorithm


Feeding and ResidualsFeeding and Residuals

Questions?

©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding Changes in the NICU Karen Smith, NNP.

Documents

Transcript of ©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding Changes in the NICU Karen Smith, NNP.