1. Practicalities of feeding cardiac babies Sucking Feeds and Solids Material prepared by Terry Wackrow August 2010

2. An effective feeding plan considers:  SAFETY - the feeding plan should support and maintain the child’s health  OPTIMAL NUTRITION - this is essential as the feeding process is high energy output  FARSIGHTED - the implications of current treatment on future feeding and oral functions must be considered

3. Feeding impacted by: [Chart adapted from: Factors that may affect feeding the child with neurological impairment (Reilly et al in Southall, A and Schwartz, A (eds)(2000) Feeding problems in Children: a practical guide. Oxford. Radcliffe Medical Press p154) ] FEEDING Oromotor / pharyngeal function Motor control Posture Communication Developmental levels Cognitive level Drugs GOR Constipation Neurological Issues Cardiac Issues Vision Hearing Tactile Fear Behaviour: Social factors Aversive experiences Fatigue; Endurance State Maintenance

4. Cardiac specific feeding issues  Infants and children with cardiac difficulties frequently have feeding difficulties that result in failure to thrive  Poor endurance, fatigue and high nutritional needs are key limiting factors

5.  Associated problem areas  inco-ordination of swallowing  poor oral feeding skills  increased respiratory effort Which can lead to increased risk factors for aspiration

6.  Ongoing difficulty with suck /swallow / breathe synchrony  can be throughout a feed  can develop during a feed  often related to endurance and fatigue problems

7.  Persistent stress signs during sucking feeds have a huge impact on feeding skills  increased sweating  colour change  changes in state  increased respiratory effort  persistent feed related desaturations  coughing and /or choking  increased heart rate during feeds

8.  Use a syringe with caution: introduce fluid slowly and allow baby time to swallow

9.  If a baby is refusing to feed, look in the baby’s mouth  Check for thrush  Look for signs of teething thrush teething

10. Breast Feeding  Breast Feeding is the GOLD STANDARD  Breast feeding support is from the Lactation Consultant  If there are oro-motor difficulties or queries regarding swallow safety, the SLT becomes involved

11. Bottle Feeding  Bottle feeding, like all feeding, is a learned process  There are always two parties involved: it is a feeding DYAD  Communication within that dyad is essential  Feed to early cues  A baby gets stressed with feeds for a reason  All feeds should be enjoyable for both parties

12. Check state of teat:  These teats need to be replaced  Split x-cut  Deteriorated teat texture Troubleshooting with bottle feeds

13.  Check technique  Teat part empty taking in air  Poorly supported  Bottle weight on mouth

14.  Look for bubble movement in the teat

15.  Check for anterior loss

16.  Chin support can assist when baby fatigues

17.  Utilise neonatal reflexes that support feeding eg palmar grasp flexed position

18. Introducing solids

19.  Textures and viscosity relating to swallow safety is SLT responsibility  Calorie intake, volumes, dietary restrictions are dietician responsibility  Cultural considerations around food and drink should be known and implemented by all involved with the child

20. NOTE  Ice-cream and jelly both class as liquids so are NOT suitable if a child has swallow safety issues with liquid

21.  Some cardiac babies start solids before 6 mths  The dietician must agree  If initial NG insertion not just for nutrition support, SLT should review swallow before solids started  If a baby is tube fed, it is fine to introduce solids if cueing appropriately First solids

22.  Spoon feeding:  Mouth open anticipating  Spoon presented horizontally  Tongue down  Encourage removal of food by upper lip  Residue on face not scraped off

23. Self feeding  When a baby is reaching for the spoon – give him one too  Mess and self feeding go together and are a vital sensory experience

24.  Finger foods are developmentally important  These need to be appropriate and safe

25.  Texture choices for finger foods are helpful to develop tolerances and preferences

26. Seating for solids: spoon and fingers  A child needs to be stable and well supported for meals  Avoid feeding seated on caregiver’s lap: the feeder cannot see the child’s face if it has difficulty  Seating supported in a highchair, a tumbleform chair or car seat are safer choices

27.  Tumbleform chair  ALWAYS fasten straps  use at angle set by therapist  never leave unattended  Highchair – use rolled up towels or nappies for side support

28. Safety first for every meal or drink  FOCUS on the task in hand  LOOK AT POSITIONING how is the head positioned? is the trunk supported? is the baby swaddled?  CHECK texture temperature viscosity – as per SLT directions

29. Any questions, contact the SLTs