EATING IN “SINC” - · PDF fileFollowing principles of the Oral Feeding ... Stage F...
Transcript of EATING IN “SINC” - · PDF fileFollowing principles of the Oral Feeding ... Stage F...
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 1
EATING
IN “SINC”
A Quality Improvement Project
Calgary Zone NICUs
CALGARY STATUS 2012
�
�
�
�
� Safety concerns
� oral feeding while on CPAP
� Developmental concerns
� missing opportunities for
feeding skill acquisition
� Long term burden of oral
aversion
� No local data
2
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 2
“AND” IS BETTER THAN “OR”
� Breathing…… optimal lung development
� AND
� Eating…… food is pleasant and satisfying
Optimal lung = endurance and capacity to eat
Eating and Breathing are co-dependent
actions
3
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!!
4
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 3
EVIDENCE
� 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
� “Skill” acquisition = building neural pathways� Immaturity alone alters the typical path to developing
feeding skills
5
LONG TERM CONSEQUENCES
• Feeding difficulties are 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.) 6
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 4
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 difficulties7
EATING ORGANIZATION DEVELOPS
IN AN ORDERLY FASHION
• Stable non-nutritive sucking may not be identified until 32-34 weeks (or it may be earlier)
• Poor sucking pressures, frequencies, duration and efficiency
• Preterm infants show progression of oral-motor development between 30 and 45 weeks
• Robust NNS is not predictive of ability to manage fluid
• Infant ventilation stops during swallowing
• Eating may over-ride respiratory chemical control
• External pacing, skill for the feeder
• Orienting to own mother’s scent and breast milk
• More stable vital signs, improved brain growth
• Early nuzzling
• Organization of arousal
• Lifelong importance of state organization
• Neuronal mapping
• Clin Perinat, 2011 (Browne and Ross)8
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 5
NICU EATING CARE MAP
NNS
Breast
Eatin
g
9
“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.)
10
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 6
CANADIAN LAMBS
� NNS and CPAP
� Nutritive sucking and CPAP
� Praud and associates
� Journal of applied physiology, 2005, 2012
� Journal of pediatric gastroenterology and nutrition,
2013
11
PRETERM BABIES CAN BREAST FEED
� Nyqvist
� 1999 – early human development
� 2008 – Acata Paediatr
� 2013 – J Human Lact
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Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 7
SINC: BREATHING & EATING
� Safe Individualized Nipple Feeding Competency
1. < 32 weeks at birth
2. Required CPAP for optimal lung development.
3. Demonstrates cues of readiness to feed
4. Physiologic stability
Fragile feeders audit
13
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
14
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.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
QUALITY EATING
� 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
� 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”
Cue Based Volume Based
16
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 9
EATING = PLEASURE
� No arbitrary feeding schedules or expectations
� Obligate suck as reflex
� Volitional = choice
� Cue based
� Cues for Engagement and DIS-engagement
� More breast feeding focus
17
“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 while on
CPAP
� Maximum feeding times and volumes defined
� Infant must prove skill and endurance before
advancing to larger volume or longer time18
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 10
THE ALGORITHM V.15
19
“COMPETENCE”?
� No decompensation: � Increased apnea/bradys
� Need for increased respiratory support
� *Deterioration often subtle at first
• Infant must prove competence
0
2
4
6
8
10
12
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55
Volu
me (mLs)
"Decompensation"
0.21
2 lpm
0.23-0.25
2 lpm
0.25
2 lpm
3 lpm
0.21
0.23
3
0.21
2 lpm
0.24
2 lpm
0.21
2 lpm
20
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 11
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
21
BREASTFEEDING
� Included at EVERY stage: First oral experience should be at breast
� If cueing, baby can/should go to breast every time the mom is present and the baby is cueing
� Requires conversation/coaching/management of pumping
� “Baby should breastfeed at an APPROPRIATELY pumped breast”
� Careful assessment of infant while at breast (swallowing, flooding, etc)� *If mom reports milk transfer, assume baby took max oral volume for that
feeding
� This means: Subtract the max SINC stage oral volume from the gavage feed
� Stage F or greater with milk transfer – decrease the gavage top-up by 50% or more
22
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 12
“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
� Implications for planning SINC stage advancements/ allowance for regression
23
0
5
10
15
20
25
30
1 4 7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
Volu
me (mLs)
Oral feeds over 14 days
Eye
“Caution Events”
24
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 13
SINC PROJECT
� Control population 2012� Born < 32 weeks
� Calgary Oral Feeding Guideline
� Inconsistent application
� SINC population 2013
� 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 25
AUDITING
We review every feed on every baby from first oral feed to discharge home.
1. Compliance with algorithm - Need for conversation/ education?
2. Gestational age:• at introduction of oral feeds
• at full oral feeds
• at discharge home
3. Breastfeeding patterns
4. Rates of oral aversion � Retrospective comparison with Open Lung cohort
� Plus: � Safety
� Impact on other feeding/health/development issues26
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 14
BASELINE FEEDING PATTERN
(2012)
0
10
20
30
40
50
60
1
17
33
49
65
81
97
113
129
145
161
177
193
209
225
241
257
273
289
305
321
337
353
369
385
401
417
433
449
465
481
497
513
529
545
561
577
593
609
625
641
657
673
689
Volu
me per feed (mLs)
Baby M: 33 - 45 weeks CGA
27
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
mL
of
fee
d
Baby S. Born at 24 weeks
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
28
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 15
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
29
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
Completed w
eeks
2012
2013
30
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 16
GESTATION AT FIRST ORAL FEED
31
32
33
34
35
23-24 weeks 25 weeks 26 weeks 27 weeks 28 weeks 29 weeks 30 weeks 31 weeks
Completed w
eeks
2012
2013
31
AVERAGE NUMBER OF BREASTFEEDS, LAST
7 DAYS PRIOR TO DISCHARGE HOME
0
2
4
6
8
10
12
23-24 weeks 25 weeks 26 weeks 27 weeks 28 weeks 29 weeks 30 weeks 31 weeks
2012
2013
32
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 17
GESTATIONAL AGE AT FULL FEEDS
32
33
34
35
36
37
38
39
40
41
42
23-24 weeks 25 weeks 26 weeks 27 weeks 28 weeks 29 weeks 30 weeks 31 weeks
Completed w
eeks
2012
2013
33
INFANTS DISCHARGED HOME WITH
FEEDS PER GAVAGE
0
1
2
3
4
5
6
7
Jan-Jun 2012 Jul-Dec 2013
34
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 18
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
tion at Discharge (weeks)
Median Gestation at
Discharge 2012
(n=92)
Median Gestation at
Discharge (SINC)
2013 (n=129)
35
NO SAFETY CONCERNS TO DATE
� Babies stay on CPAP to allow optimal lung development
� Babies SAFELY “train” with 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
� Enormous national interest (CNN)36
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 19
NEXT STEPS
� Follow to 1 year for feeding difficulties
� Physiologic studies underway
� Stability during all modes of careful eating
37
CHART AUDIT
0
5
10
15
20
25
30
35
40
1 5 9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97
101
105
109
113
117
121
125
129
133
137
141
145
149
153
157
161
165
Volu
me (mLs)
Oral feeds over 21 days
Case 5
38
Eating in “SINC” Stacey Dalgleish, NP
Canadian Association of Neonatal Nurses – ONE Day of Education
Monday, October 6, 2014
3:05 p.m. – 4:05 p.m. 20
THE TEAM
� Stacey Dalgleish (Team Lead)
� Noreen Blachly
� Linda Kostecky
� Jammey Kerik, Susan Charron (FMC)
� Jeanne Scotland, Ann Smith (RGH)
� Dallas Baumler (SHC)
� Kirenza Holland, Darlene MacDonald (PLC)
� Deborah Clark (Neo Lead)
� Super User RNs, Nursing Admin (all sites)
� Donna Dressler-Mund (consultant)
� Karen Lasby (NTT consultant) 39