Feeding the NICU Infant: Individualizing Support to Maximize Long Term Success Erin Sundseth Ross, MA, CCC-SLP

Pacifiers Ideally should match the infant’s bottle nipple Ideally should match the infant’s bottle nipple –Similar shape –Similar size

Characteristics of Bottle Nipples Material Material Shape Shape Size Size Flow Rate Flow Rate

Material Silicone Clear Clear Firm feel Firm feel Less likely to collapse Less likely to collapsePlastic Tan colored Tan colored More variability in feel More variability in feel More likely to collapse More likely to collapse Tends to have a taste, should be rinsed prior to use Tends to have a taste, should be rinsed prior to use

Shape Straight Straight –Need more tongue cupping –More difficult to draw tongue back into pharynx –More predictable in flow –More difficult to collapse Orthodontic Orthodontic –Useful when infant has a flatter tongue –Easier for infant to draw tongue back to pharynx –Less predictable in flow –Easier to collapse –Larger surface area

Size Needs to be matched to the oral cavity of infant Needs to be matched to the oral cavity of infant Should facilitate the infant’s use of entire oral cavity Should facilitate the infant’s use of entire oral cavity Should not occlude airway Should not occlude airway Should be supportive of bolus transfer and facilitate safe swallow Should be supportive of bolus transfer and facilitate safe swallow

Flow Rate Preemie nipples tend to flow more quickly. Preemie nipples tend to flow more quickly. Cross cut nipples are less predictable. Cross cut nipples are less predictable. Silicone nipples tend to flow more slowly. Silicone nipples tend to flow more slowly. Variable flow nipples should be used with caution – the slowest rate on a variable flow nipple is faster than most fast flow straight nipples. Variable flow nipples should be used with caution – the slowest rate on a variable flow nipple is faster than most fast flow straight nipples. Flow rate should be matched to what the infant can safely take, without cardio respiratory compromise Flow rate should be matched to what the infant can safely take, without cardio respiratory compromise NEVER enlarge nipples manually. NEVER enlarge nipples manually.

Eishima, et al., 1991 Term infants Term infants Evaluated tongue, lip movements Evaluated tongue, lip movements 3 similar nipples 3 similar nipples –No hole –Single hole, regular size –Large hole

Tongue shape in response to varying nipple flows “In the case of the nipple with a large hole, the tongue did not surround the nipple and so was either flow or irregular in shape and did not work to squeeze out the milk…” “In the case of the nipple with a large hole, the tongue did not surround the nipple and so was either flow or irregular in shape and did not work to squeeze out the milk…” The tongue showed the lowest amplitude of movement with the nipple that had a large hole. The tongue showed the lowest amplitude of movement with the nipple that had a large hole. “If nipples with the same size hole were used in the long term, the development of the sucking movements would be influenced. For example, if a nipple with a large hole was repeatedly given, the movements of the tongue, lips, jaws, cheeks, and throat would become laze.” “If nipples with the same size hole were used in the long term, the development of the sucking movements would be influenced. For example, if a nipple with a large hole was repeatedly given, the movements of the tongue, lips, jaws, cheeks, and throat would become laze.” Eishima, 1991

“Infants actively adapt to a varying environment.” “Infants actively adapt to a varying environment.” “Infants engage in trial and error and show complicated responses in order to adapt to different conditions, which means that it is possible that they can distinguish the differences.” “Infants engage in trial and error and show complicated responses in order to adapt to different conditions, which means that it is possible that they can distinguish the differences.” Eishima, 1991

Pros and Cons Bionix Controlled-Flow Baby Feeder Pros Pros –Very effective with infants who need substantial flow restriction –Assists infant in achieving a coordinated sucking, swallowing, and breathing rhythm Cons Cons –Difficult to clean –Expensive 12 Complete Baby Feeders $ Complete Baby Feeders $299.99

Cleft Palate and Craniofacial Disorders

Cleft Palate Inability to create suction Inability to create suction Typically normal rhythm of suck/swallow and breathe, once established Typically normal rhythm of suck/swallow and breathe, once established May also neurological involvement May also neurological involvement

Support for feeding: Infant has control over the sucking bursts, respiratory component (unless needs assistance) Infant has control over the sucking bursts, respiratory component (unless needs assistance) Feeder and infant has control over fluid transfer Feeder and infant has control over fluid transfer

Special bottle systems Haberman Haberman Mead Johnson Cleft Palate Nurser Mead Johnson Cleft Palate Nurser Pidgeon nipple Pidgeon nipple

Mead Johnson Cleft Palate Nurser Can use any standard nipple Can use any standard nipple Usually do not use the nipple that comes with it, because: Usually do not use the nipple that comes with it, because: –X cut –Unpredictable

Pidgeon Nipple Available through Children’s Medical Ventures Available through Children’s Medical Ventures Designed with a “firm” and “soft” sided nipple Designed with a “firm” and “soft” sided nipple

Remember…. There is no “perfect” bottle; There is no “perfect” bottle; Medically fragile babies need an assessment to determine the best system for that baby; Medically fragile babies need an assessment to determine the best system for that baby; Some babies are able to adapt to a bottle system; Some babies are able to adapt to a bottle system; Many babies need the bottle system to be specific to their needs Many babies need the bottle system to be specific to their needs

What to do??? Know the pros/cons of each method; Know the pros/cons of each method; Individualize to the needs of the baby: Individualize to the needs of the baby: –Respiratory –Gastric –Pain/Discomfort –Behavioral cues