5/29/2015

Feeding Expectations in Children with Congenital Cardiac Disease

Disclosures We have no relevant financial relationships to disclose. disclose

Amy L. Delaney, PhD, CCC-SLP Katherine Frontier, MS, CCC-SLP, C/NDT

© Children’s Specialty Group. All rights reserved.

© Children’s Specialty Group. All rights reserved.

Objectives

Known Feeding Outcomes: Tube vs. Oral •Children at 24 months of age:

1. Describe feeding progression in children with congenital cardiac disease 2. Identify typical feeding difficulties in children with congenital cardiac disease 3. Understand common treatment strategies used in infants and children

•25% feeding tube dependent •22% feeding difficulties (only 4% of these had tube)

•Predictors of feeding g outcomes

•feeding difficulties during first hospital stay •multiple surgeries (duration of ventilation, LOS, need for diuretics) •neurologic abnormalities during first hospital stay •genetic syndromes (e.g., 22q11 deletion; Down syndrome) •neurodevelopmental outcomes Mauer et al, 2011; Mussatto et al, 2014 

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Unknown Feeding Outcomes ALL CHILDREN Who When What How long Interventions Compensations Progression Development

30% tube  dependent

• Feeding milestones • Feeding progression • Efficiency/Tolerance • Growth • Quality of feedings “HOW”

70% tube  independent

• Feeding milestones • Feeding progression • Efficiency/Tolerance • Growth • Quality of feedings “HOW”

The Family •Weight gain most salient stressor •Concern with time and energy spent tube feeding •Frustration due to imbalance between parental expectations and child’s abilities •Increased parental stress and child’s resistance to eating than non-cardiac feeding clinic patients Hill et al., 2014; Mauer et al, 2011; Medoff-Cooper & Ravishankar, 2013 © Children’s Specialty Group. All rights reserved.

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Retrospective study on 176 children followed in developmental clinic: 6 to 24 months of age (Delaney & Mussatto)

Stopped / Acquired t b 15% tube

Never tube fed 65%

Always tube fed 20%

Feeding Efficiency dependent on volume and rate nutrition is consumed

4 time points: •Diet •Mealtime structure •Textures eaten •Oral supplements •Type of tube feeding •Growth •Development •Therapy

Temporal Physiologic &  Bolus Flow Measures

Respiration

Frequency / Periodicity  SUCK

SWALLOW

BREATHE

Always s+ Acquired = 27% tube dependent 24 mo age © Children’s Specialty Group. All rights reserved.

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Non-nutritive vs. Nutritive Sucking Non-nutritive sucking: 2 sucks per second  Decreased demands on coordination, breathing, strength, swallowing  Helps to organize and reset the “system”  Used when fatigued

– 6 to 12 months of age

 Highly complex coordination of sucking, swallowing, breathing

– Liquids

6 and 7 months: Smooth puree

Examples within texture

Oral feeding skills

Smooth and thin purees (no lumps)

Infant rice cereal, Stage 1  baby  foods, Homemade blended foods

Inconsistently opens mouth for  spoon; attempt to close lips on  spoon

Smooth and thicker purees (no lumps)

Stage 2 baby foods; Increased volume and variety of  flavors purees

More consistent mouth opening  and lip closure on spoon

Gerber puffs;  graham crackers; dry cereal

Pick up solids and bring to mouth;  Attempts to bite pieces; Early up‐ down chewing (munch)

Stage 3 baby food dinner;  Yogurt with fruit pieces; cottage cheese

Efficient skills for spoon feeding;  tongue mashing pieces

Easily dissolvable solids  (early finger foods)

10 and 11 months: Textured puree  and  Diced solids

Textured purees (with lumps)

Diced solids

12 to 18 months: Toddler foods

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Food Texture

8 and 9 months: Easily dissolvable solids

Toddler foods

Canned fruit; cooked vegetables; soft  Improved chewing; moves food to  cheese; deli meat side with tongue

Soft table foods in bite‐sized pieces

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solids

– Increased oral control and coordination

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Recommended Age of  Introduction

Transitional feeding period

Nutritive sucking: 1 suck per second

Biting and chewing skills more  efficient

Expertise of speech-language pathologist  Extensive knowledge of anatomy/physiology of feeding and swallowing mechanism  Determine developmentally appropriate, safe and efficient feeding plan to maximize oral feeding potential © Children’s Specialty Group. All rights reserved.

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Preoperative oral feeding in ductal dependent neonates

Intolerance

Endurance

Breathing

Willis, et al, 2008 Journal of Pediatrics Willis, et al, 2008 Journal of Pediatrics

Feeding  di Difficulties

Safety

• Little agreement in the literature • Enteral feeding in prostaglandin dependent neonates – 33/34 exhibited normal feeding tolerance

Efficiency

• Risks considered with pre-op feeding – NEC – Umbilical artery catheters – Prostaglandins – Low cardiac output 2014 National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) Feeding work group - https://jcchqi.org

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Variability in the Preoperative Management of Infants with HLHS

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When feeding infants pre-operatively, how do we feed? 100%

n=29

80% 60% 40%

90%

76%

66%

20% 0%

Johnson, B.A., et al, Pediatric Cardiology 2008 © Children’s Specialty Group. All rights reserved.

"Our center allows pre‐op  "Our center utilizes tube  "When we feed pre‐op,  neonates to feed by  feeding pre‐op" we consider breast  mouth" feeding" NPC‐QIC feeding work group © Children’s Specialty Group. All rights reserved.

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SLP involvement, pre-operative ductal dependent lesions

Why do we feed patients preoperatively? • • • •

Goal is to promote positive practice Bedside assessment of non-nutritive sucking Assessment of vocal quality Establish pre-operative feeding guidelines

– Absence of resp. stress, HR, minimal gradient between SaO2 and renal NIRS, duration of PO trials

• Parent education – expectations

NPC-QIC Feeding work group – https://jcchqi.org © Children’s Specialty Group. All rights reserved.

© Children’s Specialty Group. All rights reserved.

Post-operative feeding

Ongoing Balancing Act

• Feeds initiated by medical team • Feeding assessment for ALL infants by speech p p pathologist g – Advantage of dedicated team of SLP’s • Longevity, expertise, knowledge of lesions • Understanding of feeding progression • Management of family expectations © Children’s Specialty Group. All rights reserved.

SLP/OT/PT

• • • • •

Positive feeding experience Oral skill development Sensory integration Safety and efficiency Coaching caregivers Discharge home

Nutrition/Medical

• Medical management of multi-systems • Growth and nutrition • Tolerance © Children’s Specialty Group. All rights reserved.

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Feeding & Swallowing Assessment • Oral-Motor organization

Prolonged NPO or altered feeding status • Mouth cares • Avoid oral aversion

 Rooting and searches for nipple  Non-nutritive sucking pattern w/pacifier  Suck, swallow, breathe synchrony

• Motor

 Orients body posture to midline with arms forward

• Swallowing

 Clinical signs of dysphagia  Determine need for airway evaluation  Determine if instrumental assessment is warranted

– Maintain positive input – Pacifier – Infant toys – Varied textures

• May skip some feeding stages

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Hierarchy of Intervention

• VFI

Flow  Management •Tactile: •Chin support •Cheek support pp •NNS •Taste •Proprioceptive •Swaddle /Physical pressure •Rocking •Bouncing •Swaying

•Manage efficiency with flow  rate •Chin support •Cheek support •Position change •Change nipple or bottle

Input

Vocal Fold Immobility and Aspiration – 8 to 52%

•Remove nipple from mouth  for “x” period of time •Remove nipple and give  pp g pacifier/NNS •Discontinue feeding •Duration of feeding

Pause/Stop  feeding

• Aspiration – up to 50%

• Recovery of VFI – 24% of cardiac patients – Median 4.3 mo (0.4-38.7 mo) Jabbour et al, 2014; Dewan et al, 2012; Medoff‐Cooper & Ravishankar, 2013; Skinner et al, 2005

© Children’s Specialty Group. All rights reserved.

© Children’s Specialty Group. All rights reserved.

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5/29/2015

Summary • Feeding milestones are often delayed or altered •Must preserve integrity of feeding skills and experience p •Oral feeding potential varies over time •Tube feedings afford skill development •Must consider the quality of feeding when determine success •Rely on your Team © Children’s Specialty Group. All rights reserved.

Acknowledgements Funding •Mend A Heart Foundation •CTSI •Herma Heart Center •American Heart Association © Children’s Specialty Group. All rights reserved.

Contact Information Amy L. Delaney, PhD, CCC-SLP [email protected]

Katherine Frontier, MS, CCC-SLP, C/NDT [email protected]

414-266-6676

414-266-2056

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