Understanding Feeding Difficulties in NICU Neonates: An Approach to Evaluation & Management 2016 Workshop on Perinatal Practice Strategies hosted by the AAP Section on Neonatal Perinatal Medicine April 8-10, 2016 Scottsdale, Arizona

Sudarshan R. Jadcherla, MD, FRCPI, DCH, AGAF Professor of Pediatrics Associate Division Chief of Neonatology, Academics Divisions of Neonatology, Pediatric Gastroenterology and Nutrition Director, The Neonatal and Infant Feeding Disorders Program Principal Investigator, Innovative Research on Feeding Disorders Program ………………..……………………………………………………………………………………………………………………………………..

Disclosures

 Research funded by National Institutes of Health Grants ‐ 2 R01 DK 068158 ‐ 2 P01 DK 068051  No conflicts of interest to declare.

Learning Objectives 1) Physiological and Pathophysiological Basis of Feeding Difficulty & Assessment 2) Definition and Symptoms of Feeding Difficulty 3) Expectations and Milestones to Target Management Strategies: 4) Building Institutional Feeding Team 5) SIMPLE Feeding Strategy 6) Preventing Gastrostomy and Post-Gastrostomy Rehabilitation

Objectives 1) Physiological and Pathophysiological Basis of Feeding Difficulty & Assessment 2) Definition and Symptoms of Feeding Difficulty 3) Expectations and Milestones to Target Management Strategies: 4) Building Institutional Feeding Team 5) SIMPLE Feeding Strategy 6) Preventing Gastrostomy and Post-Gastrostomy Rehabilitation

Neonatal Feeding Difficulties

CRYING

A disruption to the ability to move food or liquid bolus from the mouth through the pharynx and esophagus into the stomach safely and efficiently

Rommel et. al. JPGN (2003) Jadcherla et. al. JPGN (2009)

Prevalence of Feeding Problems in NICU  26% premies have feeding problems; 31% of < 1 yr olds with BPD have

airway and digestive concerns

Mercado-Deane et al. Pediatr Radiol 2001

 20- 80% premies with neurological issues have feeding concerns Field et al. J Paediatr Child Health 2003 Rommel et al. JPGN 2003

 3.5% of all newborns had feeding problems, 3-fold more if born < 37 wks,

and 7-fold more if born VLBW

Motion et al. Ambulatory Child Health 2001

 Infants < 28 wks GA have significant oral feeding delays and prolonged

LOS vs. infants > 28 wks GA; majority of healthy premies achieved oral feeding skills by 36-38 wks PMA

Jadcherla et al. J Perinatol 2009

Integrated Aerodigestive System Functions Varies Cardiac

Heart, Arteries, Veins

CNS Foregut

Airway

C1, C2, C3, C4, CN V, CN VII, CN IX, CN X, CN XI, CN XII RLN, SLN

Larynx, Trachea, Lungs, Diaphragm, Intercostal muscles

Oral Cavity, Pharynx, Upper Esophageal Sphincter, Esophageal Body, Lower Esophageal Sphincter, Stomach

Challenges on Aerodigestive Systems at Birth Cardiac Anatomical Defects DZ & Interventions Immaturity Heart, Arteries, Veins

CNS Airway Anatomical Defects DZ & Interventions Immaturity

Larynx, Trachea, Lungs, Diaphragm, Intercostal muscles

Anatomical Defects DZ & Interventions Immaturity

Foregut

C1, C2, C3, C4, CN VII, CN IX, CN X, CN XI, CN XII RLN, SLN

Anatomical Defects DZ & Interventions Immaturity

Oral Cavity, Pharynx, Upper Esophageal Sphincter, Esophageal Body, Lower Esophageal Sphincter, Stomach

Changing Pathophysiology Tube Feeding

Transition (Tube + Oral)

Oral Feeding

 Immature GI motility

 Oro-facial anomalies

 Delayed gastric emptying

 Hunger-Satiety

 Inadequate integration of gut-airway-brain interactions

 Structural anomalies

 Inadequate integration of gut-airway-brain interactions

 Inflammation

 Volume-Viscosity-TasteDensity  Prior experiences

http://www.aboutkidshealth.ca/BCWomens/EN/Resource Centres/PrematureBabies/UnderstandingDiagnosis/Prem aturityandPain/Pages/Assessing-Pain-in-the-NICU.aspx

http://www.mamashealth.com/preem ie/feeding.asp

http://preemies.about.com/od/parenti ngyourpreemie/a/preemiefeeding.htm

Changing Pathophysiology and Effects on Learning to Eat Process

Jadcherla. Am J Clin Nutr (2016)

Assessment Methods Structure Function Magnitude of Problem Mechanisms to Target

Radiological Evaluation Methods Upper Gastrointestinal Series (UGI) Assists in evaluating aerodigestive tract anomalies  Growths  Hiatal Hernia  Inflammation  Scars/strictures  GERD (not definitive)  Malrotation

GER

Hiatal Hernia

Malrotation

VFSS

Pharyngo-Esophageal Motility Methods Pharyngo-esophageal manometry  Evaluates muscle function during swallowing by utilizing pressure sensors

Water Perfusion

• • •

9 Pressure Channels Better for Sphincter Evaluation Dependent on gravity

Solid State

• • •

25 Pressure Channels Contour as and conventional plots Impedance (Clearance)

Clouse, Berseth, Shaker, Mittal, Kahrilas, Pandolfino, Rommel, Omari, Jadcherla

Assessment Methods to Define GERD pH/Impedance Detects absence/presence of GERD in 24 hours  Physical- Gas/Liquid/Mixed  Chemical- Acid/Non-Acid  Height of refluxate

Z1 Z2 Z3

Z1

Z4

Z2 Z3

Z5 pH

Z6

Z4 Z5 Z6 pH

Jadcherla et al. Pediatr Res (2011), Jadcherla et al. Am J Gastroenterol (2008)

Comparison of methods to evaluate neonatal dysphagia Evaluation Method

Pros

Cons

Clinical evaluation (RN, NNP,  NEONATOLOGIST)

Bedside Able to use the infant’s PO/positioning

Incomplete examination of the swallowing phases

VFSS (SLP, RADIOLOGIST)

Oral, pharyngeal, and upper esophageal phases Observe laryngeal closure during multiple,  consecutive swallows

Radiation exposure Barium may alter taste Wide variability in diagnosis/treatment

FEES (ENT)

Structural abnormalities of pharynx and larynx Assesses sensory response Completed at bedside, can use infant position

Endoscope placement Incomplete examination of the pharyngeal phase Unable to assess oral and pharyngeal phases

UGI (RADIOLOGIST)

Detects anatomical abnormalities in the upper  GI tract

Unable to screen for GER events Requires radiation exposure

Distal esophageal pH monitoring  (GI)

Acid GER detection only Automated analysis 

Feeds alter pH Non‐acid GER and height of refluxate undetectable

pH‐multichannel intraluminal  impedance (GI)

GER characteristics: Physical, chemical, spatial

Analysis cumbersome, semi‐automated and labor  intensive

Basal and adaptive esophageal  manometry  (GI)

Mechanistic sensory‐motor evaluation of  esophageal peristaltic reflexes

Not commonly available, labor intensive Clinical correlation needed Lacks sensitivity/specificity Adapted from Jadcherla. Am J Clin Nutr (2016) 

Objectives 1) Physiological and Pathophysiological Basis of Feeding Difficulty & Assessment 2) Definition and Symptoms of Feeding Difficulty 3) Expectations and Milestones to Target Management Strategies: 4) Building Institutional Feeding Team 5) SIMPLE Feeding Strategy 6) Preventing Gastrostomy and Post-Gastrostomy Rehabilitation

Safe Breathing and Feeding Guidelines for Hospital Discharge Term Infants

High Risk Infants

 Stable vitals for 12 hours preceding discharge  At least 2 successful feedings  Appropriate latching and swallowing  (breastfeeding) and/or suck‐swallow‐breathe  coordination (bottle feeding)



Competent feeding by breast or bottle without  cardiorespiratory compromise



Documentation of physiologically mature and stable  cardiorespiratory function for a sufficient duration



Assessment of nutritional risks, with dietary modification when  necessary



Feeding, either by breast, bottle, or alternative technique,  including    formula preparation when necessary

Benitz et al. AAP Policy Statement. Pediatrics, 2015

Bell et. al. Committee on Fetus and Newborn Revised Policy. Pediatrics, 2012

http://www.whattoexpect.com/first-year/photo-gallery/tips-forbottle-feeding-problems.aspx

http://www.mamashealth.com/preemie/feeding.asp

Essentials of Safe Swallowing Requirements Self‐ regulation Airway  Protection Coordination of  suck‐swallow‐breathe‐ peristalsis Sensory and motor integration Maintenance of alertness

Signs, Symptoms & Pathophysiological basis Tube Feeding ‐ Gastric residual  abnormalities ‐ Emesis ‐ Poor growth

http://www.aboutkidshealth.ca/BCWomens/EN/Resource Centres/PrematureBabies/UnderstandingDiagnosis/Prem aturityandPain/Pages/Assessing-Pain-in-the-NICU.aspx

Transitioning

Oral Feeding

‐ ‐ ‐ ‐ ‐

‐ ‐ ‐ ‐ ‐

Lack of cues Coughing/ Aspiration Fatigue Early satiety Poor growth

http://www.mamashealth.com/preem ie/feeding.asp

Increased respiratory effort Inadequate volume intake Coughing/Aspiration Aversion Poor growth

http://preemies.about.com/od/parenti ngyourpreemie/a/preemiefeeding.htm

Objectives 1) Physiological and Pathophysiological Basis of Feeding Difficulty & Assessment 2) Definition and Symptoms of Feeding Difficulty 3) Expectations and Milestones to Target Management Strategies: 4) Building Institutional Feeding Team 5) SIMPLE Feeding Strategy 6) Preventing Gastrostomy and Post-Gastrostomy Rehabilitation

Expected Pattern of Normal Feeding  Milestones in Premature Infants

NCH Feeding Enhancement  Program Milestones for Infants 23‐ 32 wks GA: • Start trophic feeds ≤ DOL 3;  continue for 3‐10 days

Persistence

• Begin progressing enteral feeds  by 20 ml/kg/day increments • Target full enteral feeds achieved  by ≤ DOL 14‐28 • Initiation of first oral feed by ≤  34 wks PMA

Postnatal Timeline Trophic Feeds

Trophic  Feeds End/  Enteral  Feeds begin

Full  Enteral  Feeds  Achieved

Maintain  Full Enteral  Feeds &  begin Cue  based  Feeds

Patience

1st Oral  Feed

Full Oral  Feeds  Achieved

Discharge

• Full oral feeds achieved by 36‐38  wks PMA Jadcherla et al. J Perinatology (2010) Jadcherla et al. JPEN (2015)

Infant and Feeding process systems interactions have complex dynamics Process

Infant Brain

Airway

Signals

Gut

Feeding

Knowledge

NICU Providers

Mom

Objectives 1) Physiological and Pathophysiological Basis of Feeding Difficulty & Assessment 2) Definition and Symptoms of Feeding Difficulty 3) Expectations and Milestones to Target Management Strategies: 4) Building Institutional Feeding Team 5) SIMPLE Feeding Strategy 6) Preventing Gastrostomy and Post-Gastrostomy Rehabilitation

Modifying the Approach to Infant Feeding Problems

Feeding the NICU  Infant

Our Vision In NICU infants, we envision enhancing feeding quality outcomes through individualized innovative translational initiatives, education and perseverant feeding team-work

“Things do not happen. Things are made to happen.” - John F. Kennedy

Our Mission In NICU infants, we will develop:  Multidisciplinary active collaborative feeding management practice models  Acceleration of feeding milestones and lower LOS  Educational tools to share knowledge with parents and providers  Innovative strategies to transform dysfunctional feeding patterns and  enhance feeding quality “There is nothing like Success or Failure. Everything is an experience. Some are good and some are bad. With effort, we can convert bad to good” -Coach Gerry Hammond

Our Story Our first steps towards a successful program: - Identify an interdisciplinary core group - Identify key outcome drivers and specific aims - Define how we would monitor compliance and measure success

Developing Focus Groups 1. 2. 3. 4. 5. 6.

Rounds Readiness Tube Feed Initiation & Maintenance Order Sets/Definitions/Documentation Cue Based Feeding Initiation & Maintenance Drug Utilization and Monitoring Provider/Parent Education

1. Practice Improvement 2. Education-CME/CEU 3. Gastrostomy Tube 4. Drug Utilization 5. Cue Based Feeding

Objectives 1) Physiological and Pathophysiological Basis of Feeding Difficulty & Assessment 2) Definition and Symptoms of Feeding Difficulty 3) Expectations and Milestones to Target Management Strategies: 4) Building Institutional Feeding Team 5) SIMPLE Feeding Strategy 6) Preventing Gastrostomy and Post-Gastrostomy Rehabilitation

The SIMPLE Approach In addition to those infants seen through Specific feeding consults (reactive), we developed a QI program to accelerate the feeding milestones of all other eligible NICU infants (proactive).

Simplified Individualized Milestone-targeted Pragmatic Longitudinal Educational Jadcherla et al. JPEN (2015)

Aims and Methods Gestational Age 23-32 Weeks

Design Changes & Interventions

PMA at admission ≤ 34 Weeks

Key Drivers Provider education and participation

Specific Aim 1) Prevent Feeding Failure by 38 wks PMA 2) Decrease LOS from 96 days to 86 days over a 12 month program

Parent education and involvement Multi-disciplinary collaboration Simplified feeding program Inadequate Database Compliance to the program

Jadcherla et al. JPEN 2015

Enhance multidisciplinary Rounds Provide educational resources Ensure concepts reinforcement Parent learning resources Clarify expectations vs. reality Weekly feeding updates to parents Feeding rounds Education Discuss Science Modify feeding protocols Develop focused guideline Personalized approach Develop acceptable database Verification of data Weekly feeding rounds Follow-up & updates Core group meetings

Inclusions and Exclusions: Baseline & FEP Inclusion Criteria

Exclusion Criteria

 Gestational Age 23-32 Weeks

 Develop ≥ grade 3 IVH

 PMA at admission ≤ 34 Weeks

 Develop NEC stage ≥ 3 (surgical), recurrent NEC of any stage

 All patients discharged to home

or died  Transfers not included in outcomes

 Congenital, metabolic, or genetic anomalies recognized later  GI anomalies recognized later  Any surgery (other than PDA); this includes neurosurgery, GI surgery, urological surgery  Transferred before full feeds, as we cannot follow further milestones

Feeding Milestone Targets: Definitions  1st Trophic Feed: Feed received at ≤ DOL 3  Duration of trophic feeds (10-20 ml/kg/d) for: 3-10 days  Increments in feeds after trophic feeds @ 20 ml/kg/d  Gavage Feeds of at least 120 ml/kg/d (by ≤ 14 - 28 d)  1st Oral Feed ≤ 34 wk PMA  Oral Feeds of at least 120 ml/kg/d at 36-38 wks PMA

Jadcherla et al. J Perinatology (2010) Jadcherla et al. JPEN (2015)

Execution of Simple Feeding Strategy Impacts Neonatal Feeding Milestones Characteristic Trophic feeding duration, days  Time to enteral feeds‐120, days  Time from oral feeding onset to oral feeds‐120, days  Time from oral feeds‐120 to ad lib feeds at discharge, days   Weight velocity, g/day Overall Length of stay, days

Baseline  (N = 92) 14.8 ± 10.3  16.3 ± 15.4 

Program  (N = 92) 7.6 ± 8.1 11.4 ± 10.4

13.2 ± 16.7 

19.5 ± 15.3