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Preterm oral feeding – beyond reflexes
Nicole Kaufmann, ICBCLC, Logopädie, Ostschweizer Kinderspital
Tuesday, Jan. 21, 2020 · 12:10 p.m. · 27m 23s
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um i will admit it's very disconcerting standing up in front of you here um and it took me a
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while to figure out where i was invited to speak to you about it i realised i had this amazing opportunity
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for all speech language there as to share how we approach our infant feeding and um
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maybe you can also see how we incorporate some of the research thing to what we do every day
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but probably most importantly also i wanna share what we as if eating team here in
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some government um at the children's hospital so just some highlights of what we really focus on
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preterm infant feeding
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to get us started just to get a little bit of an overview
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really or um in the world of pediatrics this page uh and eating disorders
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we're talking about prayer prevalence numbers anywhere between twenty and probably eighty
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percent wherever what we're talking about them for talking about congenital heart disease
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um numbers are showing is that those are about about twenty percent of those children are
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gonna have feeding disorders if we're looking at your muscular children that's gonna be much higher
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up to eighty ninety percent and those are the kids that we really see in
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our outpatient clinics um part of the high risk group or the preterm infants um
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i'm getting really clearly your numbers on what preterm
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infant kind of problems that they have in this nation
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and feeding disorders are at times difficult um most studies sort of come up with
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that word about ten percent for the entire population of returns
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um the lower the gestation age we're gonna be around somewhere between twenty four and twenty eight percent
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where did these kids go that's one of the main reasons but the i do my job um
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but at your study which were all of you will know um did one study that looked at all they're not all the
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to remember twenty five weeks at six years and they still haven't
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two to five times higher rates of eating disorders at six years
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um most outcome studies and then the feeling it's no different really they're looking at outcomes
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two years and we're back about that when you ever usually around that twenty five percent more
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and having some difficulties um the i always find it really difficult to find
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'em outcome studies preterm cats um and johnson did do one where they hear it
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um fulltime counterparts to their late three terms and they still had about five percent higher rate of
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in our own clinic here in some gallon um in the feeding disorder
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clinic we see about eighteen percent or preterm a lot of those early preterm
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i looked at school work thousand and thirteen about over under thirty two
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weeks and we had about eight percent that were really showed up have
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still with feeding anticipation
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but to move on from there
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um when i started almost twenty years ago um really the focus for therapist was on looking at this
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well the reflex saves well though what does that
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mean then we sort of transition into um oral patter
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time of differentiating on trips i continued of sucking what are the patterns
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what are we expecting for term babies what are we expecting for the preacher
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um assassins like the new email or or more assessment really came out of that came up in
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the late nineties which we started to use we're still using it that really look good timing job function
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um and the thought this was volume
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um how quickly can we get how much volume into these children to get in the door
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i'm really looking at one thirty
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sort of resulted and um preterm infants it might
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like correctly being terms where features on basically meaning they had been stuck on what
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happened was that we had a lot of model t.'s with really flow high flow rate
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we're starting to hear a lot of issues with letting
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'em aspirations kind iterations work issues that we were looking at
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probably their best standpoint we were doing a lot of or facial my facial there
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be we were compensating for that means that we were compensating for that me things that
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to get more into world pressure going for these gets in and um when i certainly when i started um it
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was the discussion how many i'm acting is a pretty hard with these preacher big had during their feeds that was
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preterm babies
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so um i think
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okay we've come a long way and i think there was hopefully upon along with that a little bit intervening practised
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with various different models of here that we're using now um however
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we're gonna call them they're sort of looking at developmental family integrated here
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i'm in a therapist world really within the developmental scope of crackers were
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program here and i think within the last couple of years really focusing
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on okay how can we integrate trauma informed knowledge that we have now into
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into into our work as well um i just picked one study form ultimate philips or better said just
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there um picture of they published um an article which they call seven or measures
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of departmental thing we integrated here and one of those things up i think your trash
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so these are things that really we're trying to do
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on a daily basis as well we um
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parents out feeding starts of skin to skin
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that early issue that we really want to look at after that breastfeeding
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we had time as well as we can to really establish some breast feeding before
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started maybe on the bottom of working spend rest
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human overeating you will talk about much more than you know more about than i do
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um and then sort of are are really is that whole issue if you base defeating
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you may speeding is philosophically us a volume driven feeding
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quality of feeds her little bit less concerned at least the beginning
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on what how what kind of boggles the baby is taking orally
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um he lays is also
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right to defeating you'll find that in the literature really we're looking at those developmental milestones
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stability in stress and how's that trial communicating these this with us and how can we um
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address those issues doing features well so doing defeating really lovely getting agent disengagement use
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and if the um across feet across meetings and what is the child individually letting us know
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from a learning standpoint certainly world experiences we
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all understand motivation if we're having a negative experience
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if he were when we're going to do anything where lot less likely to continue wanna do that if we have a lot
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of positive world experiences are more motivated to keep going and that's
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that's as well so that's something we wanna consider with our baby
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how many into patients excavations how many sections have that had all
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those things are gonna influence having approach that choral area in for them
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for us we've sort of switched
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patterns you said there there's the nurses counting stock swallows
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but we've sort of progress integrating that really into the press
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and that's really sort of my favour are um the part that really trying
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to work on a possible for us to get on on board with that
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so quick overview or most of you will notice anyway but development of those three tasks of socks
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well and breath i'm needing to be poured mated
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for that really feeling that's still fascinates me that
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preterm infants are learning that one of the
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simple complex dangerous scale burning if you'd like wait
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i'm an image were neurological system were all their sources subsystems don't really work at it
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um we know um whatever number we really want but all over preterm infant
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are sucking and swallowing they'd have hacked this and that there is
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some recognition of motor patterns of what they're doing with that ah um
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study while her many people start feeling we're looking at thirty two to thirty four weeks cement somewhere in there
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i think it's really important to understand babies can't feed at that age
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what we're expecting them to do is have with models wells
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about every two weeks so they're not gonna aspirated every single time
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at thirty four weeks what we expect them to have the support nation of socks well we'll see
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the rest integration of brett happened after that their studies that say um
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but i think we'll really get around thirty five weeks i think we're somewhere in
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that thirty six week period with the really starting to learn how to do that
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but actual feeding probably actually later
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so this is my favourite slide i like this slide i teach this to parents i teach this to um nurses
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gonna try to um but there's a just a shell
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pattern of development for integrating breath into this sucks well
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and immaturity at the store over right and then it starts
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mind relating the respiratory pattern in other words suck swallow replaces bruce
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and that not a great place to be for preterm infant
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so because of that that's why we're
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seeing decreased inspiration time um respiratory frequency
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that's decreased mine ventilation is last title one they just can't get that reference every
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ah what we're saying is the simplest how are you there
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simplest pattern is like we do when we learn any motor task we separate tasks sex acts stock
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at the very beginning they're probably gonna take a break then follow take
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another break figure out your logically what we need to do and we start
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that's sort of that first pattern around thirty two weeks that we're saying after that
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we get that thirty four weeks when we're like oh i'm thirty four thirty five
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suck swallow suck swallow sex lulls that's well that's
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where you see nurses yelling and telling them really
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because they forget to brave they tend to do stuff
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oh runs and forget that they need to be breathing
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and then as time progresses we have stuck swallow wrestles well the rest as well though right
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preterm infants we'll still hang on an area of compensating their
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breath they're gonna do some catch everything at the end um
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and this is still i think most children that we see on are going
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to some variation of the s. throughout their stay in the nick you order sorry
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'cause as soon as they're some sort of stress comes into it
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hadn't r. o. p. exam are um there were three you are um
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three in terms of getting some lot uh they're gonna think i i might
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be able to do this yesterday but today i'm stressed and i'm gonna do this
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and i think that's one of those things that really that nursing care means that there is
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we're we're
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that gets differently than depending on where they are
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so the media it's my first one is that yes
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but of registration
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yeah
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lovely oh
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hi
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so what we know is that breastfeeding baby stand have more
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organised patterns when they're feeling probably just 'cause there'll be more relaxed
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um oldfield meet so no meets the needs to know everything of that
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um i also understand that there's improve ventilation there and that that whole pattern
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better um the idea behind it probably is that there's not a consistent flow of mail even
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um if you're using a shield and that with a variation in in build flow
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hits can sort of it that better than on the bottle so our next one
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quite as well but we go
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hell getting on the plane
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so again model
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well
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well
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possible
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huh
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yeah
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tell his integration of breath is a lot harder
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okay
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last yeah well
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if you're looking carefully stress size
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sure
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ah thing
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well nothing
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what
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and now everything
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ah
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and then
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so really separating those tasks that he should might be integrating art
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yeah okay
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so what we look yeah um and these are really the things that we're working on with
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nurses were looking at it with parents as well when they're feeding their children we consider catcher reading to be
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part of the course that's okay we're happy for them to do catch up reading any
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kind of nasal flaring um use of accessory respiratory muscles to deepen that right we don't
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or any changes of task hadn't like we were looking at before we really want nurses
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and parents to be aware of that and then see how we can adapt to that
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um one thing i'm working on right now and lactation as well
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as working with versus and hands to start listening more what they
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so are we hearing gulping gurgling any kind of fluid in any part of the airway
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um to be aware of that to note that and to be able to figure out what we need to do from there
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to that i just wanna share with you um the literature each other it's called bell rang
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which is a great premature inspiration it sounds a little
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bit like striker but it's not it's premature opening of
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the air right before the swallow is finished and the second one is what what's called run thing
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um and that's really up for long expiration period so listen to those
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that you know the bottle
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yeah i i i highly
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i found there
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so the yelping we usually look at a lower rate the granting we stop beating falls stop
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those hit that amount of work reading for that amount of fluid that they're taking isn't worth it
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and we need to really address should they be feeding what else is going on so if we're hearing renting it
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with our in our clinic it's an absolute stopped you
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then acne braveheart yeah that's um again really i'm really
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we shouldn't be seeing it um yes feeling isn't aerobics for
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so we expect it gets to go below about five percent below baseline when they're feeling
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but anything about that studies from lower and defeating flop room
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have really shown that anything that goes below five percent of their baseline their meeting so much energy
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to catch up afterwards that a lot of the feed that they've taken in in the nutrition but ah
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they're losing that so they can't really be gaining weight so that's something to also certainly consider
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another thing that really irritates me is when nurses tell me is
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doing really well great discreet you just need a little bit of oxygen
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that to me doesn't make sense unless or d. p. d. n. y. u. need oxygen defeat
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if everything else is going great and something else is going on and we need to look at that again
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what always makes me there is it is what time should be children be expected to be full or like that
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um i think one study from joining from two thousand and fifteen is it
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correlates pretty well with what we do when their description of how they've even having progress
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and they looked at eighty four it's under thirty two weeks gestation
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and they had about a thirty six point seven week for being on full oral feats meaning the first
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time they took their full volume in twenty four hours um and i was thinking was the markets don't go
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but but i think what's important is the range um i'd love to see thirty three week um but fifty
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three weeks yeah we see some that really don't do until forty forty two forty three that they really or meeting
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um the other studies most studies that sort of
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look at 'em post menstrual age for full world feeds
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what i find is that there is really important also to share with parents is that
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for every call morbidity that the child has we're gonna add me on to that
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and that's the major ones are small or just station h. b. p. d. neck any kind
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of surgery um the studies that found him to be really interesting every new room sensory issue
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so that they're really interesting um one of the things i've
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learned is always meet studies very carefully and what it was excluded
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and they all these studies always exclude um any kind of congenital genetic disorder
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and children that the discharge when gosh these are true feelings so really top was
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already number so that helps means that there was a sort of equate we're really going
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so to finish up um where are we and we're we're gonna go off um as far as i'm concerned i think
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respiration is gonna be a continue the key to looking at
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other defeating oh i'm i'm look i'm waiting for the research
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suggestions uh to look at what digestion actually does much more to the progression
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of eating and not just i'm feeding intolerance but really what happens afterwards as well
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we're gonna keep going is feeding isn't about little task i'm sure much more practised
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the breast how we can we really make sure p. terms or going there well
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discharging with and enjoy each oops i'm hearing some cologne we do some of that
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the question of controlling them and checking up on them see how they're doing that sort of a system
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from a technical standpoint i think slow low rate nipples small
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bowl the size i think that sort of standard at this point
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he's saying is a technique for regulation cool regulation there's starting to get
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um a little bit more acceptance i think something we certainly do um
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past couple years there's been a lot published on
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elevated sideline positioning i think the um evidence is gonna
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become better for that um we have some about just basic long volume get the reading
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that we have in that position that's better there's um some anecdotal things that i've heard
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how it's we're i'm looking into it that are also thinking that probably subplot pressure for
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actual swallow was better inside line so those are things that we can look out for
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um the big discussion certainly in the therapy world when we're looking at preterm infant feeding
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our continues to be or facial stimulation there seems to be two groups
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and it happens to be the group that does a lot of breastfeeding don't do a lot of or facial stimulation
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countries that haven't really low breastfeeding rates paid a lot of
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or facial stimulation but again most of the studies end up being
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the child to rank work are my argument often is is
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the greek word they swallow or but did we differentiate that
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the topic he will never go to a conference with their best looking at getting that
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it doesn't that discuss do we or do we not feel don't see happen i flow
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um i think the probably the definitive answer is
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not there yet um some of you might go on the
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study was published and buy for our where they start um
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they actually made her stop the study because children were just ask
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reading so much in comparison to that and i don't think happy so
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who knows answer the news topic that's come up with really looking at temperature feats
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i'm not taking um what we know from pediatrics in it
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don't it's frasier and looking at if we're having preterm infants
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that need some extra help really should we be feeding them fees orally
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at body temperature or just a little bit low how their sensory
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um process so that i think they're probably gonna show up soon
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and with that um i hope i just was able to give you a little bit of in in of insight
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of what we try to do um to over twenty five years
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we ended up pretty well and and help with the parents and with them we had
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some other feeding experiences and when it so
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we had some positive outcomes yet very much ha
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ah
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in some not need one for that very interesting speech in the insides and i think especially that
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most of us we i'm walking owning on me q. s. packets and of
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course nutrition but the aspect of eating which could show very nicely so what
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so where to a lot of us no thanks a
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lot for it inside since each questions from atari um
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not me i'm working but shortly command on the question
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how parents especially the mum ah i'm only eighteen to well
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well uh difficulties in feeding because in most
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mums more looking on quantity so justin no so
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according to experience how difficult is it to on yet but um um how to have a child
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often very because i think we have the system focus on volume
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so i think if we um focus from the beginning of nursing
00:25:00
care if in round we also asked how good she noticed how much
00:25:07
that makes a real difference um i think parents especially moms come
00:25:11
absolute experts they can take it when they're reading when they're not
00:25:15
is it a good day is it that day but i ended the
00:25:17
day still it's volume because bottom means way and we need them going on
00:25:22
um and i think often what we're trying to do is just
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set the basis of prevention of eating disorders um we have in this
00:25:34
and just try to show them that there's other aspects that well especially when we get like toes and they all liked those
00:25:41
of their feeding 'em ability that we can take yep but look we've talked about the breath or in
00:25:47
integrating breath better that all these better means nothing on a bad day for mom but we just keep going on
00:25:58
e. e. o. c.
00:26:10
yeah
00:26:33
um or gastric tube i don't like it it's gonna change sensory issues um
00:26:40
i know there's a couple of clinics that i know from colleagues that do exactly what you what you
00:26:44
do and they have really good experience with that i have no experience with that um i think there's
00:26:50
i wish all tubes could be little tiny return to its so at least there's a little bit less um
00:26:57
but there's certain feats that just won't go through that and i get get that there's practical aspect of that um
00:27:03
but i agree with you i think we see that i'm older children that they feed their
00:27:07
swallow it's safer and better without the two band and i think that we need to consider that
00:27:15
the questions
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The milk gap: Contextualizing Human Milk Banking and Informal Milk Sharing Practices and Perceptions in Switzerland
Jacqueline Barin, CHUV
Jan. 21, 2020 · 2:45 p.m.
An unexpected and severe complication due to a presumed umbilical venous catheterisation
Markus Hahn, PICU/NICU
Jan. 21, 2020 · 2:47 p.m.
170 views
Severe refractory status epilepticus in a neonate
Claudia Beck, Pediatric and Neonatal Intensive Care Unit, Children’s Hospital of Eastern Switzerland
Jan. 21, 2020 · 2:51 p.m.
105 views
The Red Code: improving patient safety by implementing a new call procedure for emergency life-threatening caesarean section in a non tertiary center
Anne-Sophie Morel, Hôpital de Nyon-GHOL
Jan. 21, 2020 · 2:54 p.m.
Ductus venosus atresia leading to severe hydrops fetalis in a very preterm infant
Sven-Eric Baller, Clinic of Neonatology, University Hospital Zurich
Jan. 21, 2020 · 2:59 p.m.
312 views
Neonatal transport in Switzerland:
Tanja Leemann, University Children’s Hospital Zurich
Jan. 21, 2020 · 3:02 p.m.
103 views
Perinatal Stroke and Placenta Pathology
Francisca Barcos, Service de Néonatologie, Hôpitaux Universitaires de Genève (HUG)
Jan. 21, 2020 · 3:06 p.m.
159 views
Correlation of bilirubin levels with the quality of General Movements in moderate preterms – a retrospective study
David Graßmugg, Medical University of Graz
Jan. 21, 2020 · 3:10 p.m.
192 views
Implementation of multidisciplinary In-House Resuscitation Training at Triemli Spital Zürich
Hanna Seewald, Paediatric Department, Stadtspital Triemli, ZH
Jan. 21, 2020 · 3:13 p.m.
Use of Donor Breast Milk at LMU München Perinatal Centre : Experiences and Results
Julia Kappeler, München (DE)
Jan. 21, 2020 · 3:38 p.m.
Milkbanks in Switzerland
Andreas Malzacher, St. Gallen
Jan. 21, 2020 · 3:59 p.m.
103 views
Feeding in late and moderately preterm infants : risks and benefits in the short and long-term
Nicholas D. Embleton, United Kingdom
Jan. 21, 2020 · 4:22 p.m.
235 views
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