A  Collabora)ve  Approach  To  Infant  Feeding  In  The  NICU:

Occupa&onal  Therapists,  Speech  Therapists,  and  Lacta&on  Specialists  Working  As  A  Team  

 Jada  Wright  Nichols,  MS,  OTR/L,  CLC  

Blossom  Health  and  Maternal  Wellness  

The  Journey

The  Journey

The  Journey

The  Journey

The  Journey

We  Will • Compare  and  contrast  the  scope,  roles,  and  specialty  areas  of  occupa@onal  therapy,  speech  therapy,  lacta@on  consul@ng  • Iden@fy  limita@ons  in  parent  educa@on  concerning  infant  feeding  in  the  NICU  • Iden@fy  3  way  to  increase  communica@on  among  the  infant  feeding  team  • Describe  4  race-­‐based  dispari@es  in  the  NICU  related  to  infant  feeding  

Occupa)onal  Therapy •  The  assessment  and  treatment  to  develop,  recover,  or  maintain  the  daily  living  skills  (occupa@ons)  of  individuals  with  physical,  cogni@ve,  or  psychological  challenges.  

• Client-­‐centered  focus    

• Adapt  the  environment  • Modify  the  task  •  Teach  a  skill  •  Educate  the  client  and  caregivers    

Occupa)onal  Therapy  in  the  NICU

• Physical  and  Cogni@ve  Development  • Posi@oning  • Appropriate  Elicita@on  and  Integra@on  of  reflexes  • Head  Control  • Sensory  Processing  

Occupa)ons  of  a  Neonate • Thrive:  breathe,  eat,  grow  • Fight  infec@on  • Process  the  sensory  environment  • Receive  care  • Interact  with  others:  family,  medical  staff  

Speech-­‐Language  Pathology • Communica@on  • Cogni@on  • Feeding    • Swallowing  

Speech  Therapy  in  the  NICU • Dysphagia  • Oral-­‐Motor  Control  • Suck-­‐Swallow-­‐Breathe  Reflex  Coordina@on  

Neonatal  Therapist  Does  Not • Rehab  the  infant  • Give  the  babies  a  workout  • Divide  a  600  gram  baby  into  body  parts  • OT  hands  or  sensory  issues  • PT  legs  and  feet  • ST  mouth  

Neonatal  Therapist • Maximizes  Developmental  Outcomes  • Supports  infant  mental  health  • Facilitates  family  interac@on  • Provides  direct  care  and/  or  consulta@on  

NICU  Therapy  is  Vital •  Facilitates  brain  development  in  sick  and  preterm  infants,  even  those  without  bleeds  •  Altered  neurobehavior  in  infants  less  than  30  weeks,  Pineda  et  al  •  Varia@ons  in  stress  responses  and  self-­‐regulatory  behaviors,  Grenier  et  al  •  Neuroprotec@on  in  the  preterm  infant,  McGrath  et  al  

•  Babies  need  to  learn  to  move,  and  need  to  move  to  learn  •  Flexion  •  Midline  orienta@on  •  Posterior  pelvic  @lt  •  Hands  to  face  •  Facilita@ng  normal  skills  into  a  developing  body,  in  an  abnormal  environment      

Therapy  Facilitated  Brain  Development

•  Significant  brain  growth  in  the  last  8  weeks    •  Final  6  weeks,  significant  change  in  func@on  and  structure  •  Sleep  pa_erns,  posi@ons  during  sleep,  quality  of  sleep  • Posi@oning  influences  development  

•  Decreases  stress  response  •  Enhances  infant’s  ability  to  self-­‐soothe  and  interact  with  environment  •  Meets  infant’s  needs  for  containment,  while  also  allowing  movement  

•  Incurs  posi@ve  and  nega@ve  effects  of  environmental  experiences  •  Sensory  integra@on  •  Sensory  overload  •  Benefits  of  touch,  especially  skin  to  skin  •  Stress  of  being  away  out  of  the  womb  and  away  from  mother  

Neuroprotec)on • Posi@oning  impacts  development  of  brain  pathways  • Posi@oning  impacts  postural  development  • Posi@oning  impacts  motor  organiza@on  • Posi@oning  impacts  sensory  development  

Mon@rosso  et  al,  found  that  the  greater  the  use  of  developmental  care  prac@ces,  the  be_er  neurobehavioral  stability  and  neuromatura@on    Therapists  are  uniquely  trained  in  the  understanding  of  how  neurobehavioral  expecta@ons  are  influenced  by  posi@on  to  support  brain  development,  across  the  life  span      

Physiological  Stability • Decreasing  stress  pa_erns,  especially  in  preterm  infants  •  Least  amount  of  stress  in  prone,  prone  nested,  and  side-­‐lie  nested,  Grenier  •  Stress  related  to  decreased  oxygen  levels  in  small  or  sick  infants,  Harrison  et  al  •  Promo@ng  flexion  pa_erns  through  boundaries  helps  infants  to  engage  and  self-­‐soothe  •  Controlled  exposure  to  sensory  s@mula@on  

 

•  Suppor@ng  the  respiratory  system,  including  diaphragm  and  lung  func@on  •  Decreasing  the  impact  of  gravity  on  lung  func@on  

•  Supports  the  diges@ve  system  by  decreasing  reflux  

Prone  Benefits   • Increased  @dal  volume  • Improved  diaphragm  func@on  • Improved  thoraco-­‐abnominal  coordina@on  • Improved  ability  to  oxygenate  • Decreased  oxygen  desatura@ons  • Improved  quality  of  sleep  resul@ng  in  energy  conserva@on  • Decreased  FiO2  needs    • Weaning  ven@lator  secngs  

Feeding  in  the  NICU • May  be  OT  or  ST  based,  PT  may  provide  if  confident  &  competent  •  Facilitate  infant  directed  feeding,  rather  than  caregiver  directed  (feeding  a  rock)  •  Elicit  primary  reflexes  necessary  for  ea@ng  •  Facilitate  and  support  head  and  hand  posi@ons  for  feeding    • Monitor  early  (and  late)  hunger  cues  •  Iden@fying  stress,  overs@mula@on,  and  sa@a@on  cues  •  Involving  nursing  and  FAMILY  

Feeding  Challenges  in  the  NICU • When  is  an  MBS  required  • Coughing,  choking,  apnea,  bradycardia  during  feedings  

• When  to  adjust  milk  consistency  • When  to  supplement  calories  or  nutrients    • Iden@fying  the  appropriate  flow  nipple  • Helping  (mul@ple)  caregivers  to  feel  confident  in  feeding  the  infant    

 

Neonatal  Therapists  Need  Help!

Human  Milk  in  the  NICU!!! •  Species  specific  •  Gesta@onal  age  specific  •  Decreased  risk  of  sepsis  •  Decreased  risk  of  meningi@s  •  Decreased  risk  of  infec@ons,  in  general  •  Fewer  diges@ve  challenges  •  Fewer  incidents  of  necro@zing  enterocoli@s  (NEC)  

•  Exclusively  formula  fed  babies  are  6  to  10  @mes  mores  likely  to  contract  it  

•  Moms  who  begin  breasheeding  in  the  NICU  con@nue  longer  than  moms  of      full-­‐term  babies  aier  discharge  

•  Long  term  immunological  and  developmental  benefits    

Lacta)on  Consultant  in  the  NICU • Prepares  for  successful  nursing,  even  if  infant  cannot  go  to  breast  • Helps  mother  to  ini@ate  pumping  and/  or  breasheeding  • Creates  a  plan  for  baby’s  feeding  •  Troubleshoots  and  resolves  issues  ini@a@ng  the  plan  (especially  if  the  infant  is  at  the  breast)  • Resolves  issues  related  to  latch,  supply,  pain,  engorgement,  infec@on  •  Explores  ways  to  posi@on  infant  at  the  breast  for  comfort  and  efficiency  • Develops  a  discharge  plan  for  con@nuing  to  nurse  at  home  

Booby  Traps  in  the  NICU  Best  For  Babes

• Not  being  informed  of  the  importance  of  breasheeding  a  preterm  baby  •  Emphasis  on  breastmilk,  but  not  breastfeeding  • Belief  that  preterm  or  sick  babies  are  incapable  of  breasheeding  effec@vely  • Not  being  given  the  opportunity  to  perform  skin  to  skin  •  Lack  of  access  to  lacta@on  support  • Poor  help  of  establishing  milk  supply  •  Lack  of  access  to  donor  milk  • Poor  post  discharge  support  

Addi)onal  Barriers  to  BreasOeeding  in  the  NICU • Physical  or  emo@onal  state  of  the  mother  • Proximity  of  mother  to  infant  •  Frequency  of  NICU  visits  •  Educa@onal  level  •  Educa@on  on  breasheeding  and  human  milk  • Readiness  to  breasheed  • Accessibility  to  a  pump  •  Family  support  • Community  support  

AND  More  Barriers  to  BreasOeeding  in  the  NICU •  Lack  of  exposure  to  breasheeding  •  Lack  of  guidance  from  hospital  staff  •  Lack  of  available  hospital  resources  •  Limited  ability  for  follow-­‐up  at  bedside  or  at  home  •  Increased  accessibility  to  formula  • Decreased  accessibility  to  nursing  supplies  • Return  to  work  

Collabora)on  Is  Vital

Create  A  Dream  Feeding  Team • Neonatal  Therapists  • OT,  PT,  ST  

• Lacta@on  Consultants  • Already  a  rela@vely  diverse  field  

• NICU  Nurses  • Nutri@on  Specialists*    

Integra)ve  Training  and  Service  Provision •  Segmented  services  may  confuse  and  overwhelm  the  parents  •  Every  service  provider  cannot  do  everything  •  Every  service  provider  CAN  reinforce  what  another  provider  offers  

•  Posi@oning  •  Sensory  Processing  

•  Environmental:  noise,  lights,  touch  (frequency,  quality)  •  Swaddling,  nes@ng  

•  Elicita@on  of  Reflexes  •  Oral  Anomalies  

•  Clei  lip  or  palate  •  Tied  lip  or  tongue  

•  Oral  Motor  Control  and  S@mula@on  •  Oral  care  with  human  milk    

Transi)ons • Feeding  tubes,  spoons,  and  cups  to  breast  (or  bo_le)  • Isola@on  to  room  air  • An@bio@cs  • Rooming  in  • Home    

Race  Based  Dispari)es • Healthy  People  2020  • Highest  rates  of  formula  supplementa@on  before  2  days  of  life  •  Infant  mortality    • Poverty  •  Lack  of  connec@on  with  lacta@on  professionals    

Collabora)on  and  Consulta)on • Play  to  the  strengths  of  each  team  member,  but  do  not  disengage  

•  Feeding  •  Posi@oning  •  Sensory  Processing  •  Breasheeding  

• No  Team  “Leader”  •  Facilitator  •  Any  team  member  may  have  a  more  prominent  role  at  any@me,  depending  on  the  infant’s  needs    

Collabora)on  and  Consulta)on • Respect  all  professionals  on  the  team,  no  hierarchy  • Be  transparent  about  theories,  professional  prac@ces,  and  frames  of  reference  • Be  willing  to  learn  new  informa@on,  or  old  informa@on  that  you’ve  never  heard  • Use  evidence  to  guide  prac@ce  

•  Nipple  shields,  pacifiers,  ar@ficial  milk,  bo_les        • Be  agreeable  in  determining  the  best  plan  of  care  for  the  infant  • Conduct  regularly  and  frequently  scheduled  mee@ngs  

•  Team  rounding  •  Scholarly  ar@cle  review  •  Current  and/  or  community  event  

Collabora)on  and  Consulta)on • Debunk  NICU  and  Breasheeding  myths  • Discharge  to  early  interven@on  services  •  Secure  lacta@on  consultant  home  visit  •  Establish  and  facilitate  support  and  developmental  play  groups  • Provide  community  resources  

•  Physicians,  support  groups,  play  groups,  delivery  services,  nutri@on  services  

Thank  You!

jada@blossomom.com  www.blossomom.com  

 Blossom  Health    

And    Maternal  Wellness  

 myblossomom  

   

References  and  Resources •  Progress  in  Increasing  Breasheeding  and  Reducing  Racial/  Ethnic  Differences-­‐  2000-­‐2008  Births  Weekly,  February  8,  2013/  62(05);77-­‐80.    

 •  Occupa@onal  Therapy  and  Breasheeding  Promo@on:  Our  Role  in  Societal  Health  

•  Jennifer  S.  Pitonyak  American  Journal  of  Occupa@onal  Therapy,  May/June  2014,  Vol.  68,  e90-­‐e96.  doi:10.5014/ajot.2014.009746  

 •  Racial  and  Ethnic  Dispari@es  in  Breasheeding.  Jones  KM1,  Power  ML,  Queenan  JT,  Schulkin  J.  Breasheeding  Medicine.  2015  Apr  1.    

 •  The  Speech-­‐Language  Pathologist  and  the  Lacta@on  Consultant:  The  Baby's  Feeding  Dream  Team,  Kara  Fletcher  &  Barbara  Ash,  ASHA  Leader,  February  8,  2005.  

 

Resources  and  References •  Breasheeding  Among  Minority  Women:  Moving  From  Risk  Factors  to  Interven@ons,  Champan,  DJ,  Perez-­‐Escamilla,  R.,  Yale  School  of  Public  Health  

•  Respiratory  Func@on  in  Late  Preterm  Infants  Delivered  at  33-­‐36  Weeks  of  Gesta@on  Cindy  McEvoy,  MD,  MCR,  Sridevi  Venigalla,  MD,  Diane  Schilling,  RRT,  Nakia  Clay,  BA,  Patricia  Spitale,  MD,  Thuan  Nguyen,  PhD!  Division  of  Neonatology,  Department  of  Pediatrics,  Oregon  Health  and  Science  University,  Portland,  OR  Published  Online:  November  08,  2012  

•  Pa_erns  of  Altered  Neurobehavior  in  Preterm  Infants  within  the  Neonatal  Intensive  Care  Unit,  Roberta  G.  Pineda,  PhD,  OTR/L,  Tiong  Han  Tjoeng,  MD,  MPH,  Claudine  Vavasseur,  MD,  Hiroyuki  Kidokoro,  MD,  Jeffrey  J.  Neil,  MD,  PhD,  Terrie  Inder,  MD,  PhD!  Published  Online:  October  02,  2012  

 

•  Neuroprotec@on  in  the  Preterm  Infant:  Further  Understanding  of  the  Short-­‐  and  Long-­‐term  Implica@ons  for  Brain  Development,  Jacqueline  M.  McGrath,  PhD,  RN,  FNAP,,  Sharon  Cone,  PhD(c),  RNC,  NNP-­‐BC,  Haifa  A.  Samra,  PhD,  RN