1. ©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding Changes in the NICU Karen Smith, NNP

2. ©2013 Children's Mercy. All Rights Reserved. 09/13 2 How did this come about? I attended “The Fetus and the Newborn” conference in 2011 The breakout session: Feeding the Preterm Infant: Infant Driven Feeding sparked an interest Presented it to the Neonatologists here Mich Hardy was an integral part and “cheerleader” of getting this going at CMH

3. ©2013 Children's Mercy. All Rights Reserved. 09/13 3 Hospital Participation Several Neonatologists liked the idea and wanted developed and implemented at CMH The program has also been implemented at Truman and SMMC

4. ©2013 Children's Mercy. All Rights Reserved. 09/13 In the past, what constituted a successful feeding? A.an empty bottle B.the infant being tired afterwards C.was dependent on the nurse’s schedule D. A & C

5. ©2013 Children's Mercy. All Rights Reserved. 09/13 Medical Model of Feeding Historically, successfully feeding the preterm infant meant: was clock, schedule and staff driven involves the physician ordering feeds at intervals such as twice a day or every other feed. based on gestational and chronological age. “getting in” a certain volume resulting in an empty bottle. Often resulted in a lot of manipulation of the bottle or infant during the feed, regardless of the infant’s behaviors. Ludwig & Waitzman 2007

6. ©2013 Children's Mercy. All Rights Reserved. 09/13 6 Question For a Developmental Appropriate feeding, how is the infant fed? A. when the infant is mature enough B. takes into account the baby’s readiness cues and behaviors C. when the doctor says to PO feed the baby D. A & B

7. ©2013 Children's Mercy. All Rights Reserved. 09/13 Developmental Model Assesses autonomic, motor, and state stability Assesses feeding readiness cues and behaviors Considers infant driven times and volumes Takes into account infant’s maturity vs. gestational age The infant takes an active role and the caregiver a passive role

8. ©2013 Children's Mercy. All Rights Reserved. 09/13 8 Developmental Model of Feeding Eliminates force feedings!! Individualized and tailored to each infant. Provides a natural progression to full PO. Provides an objective tool for different caregivers. Improves communication between the care team members and parents as to how the infant is feeding.

9. ©2013 Children's Mercy. All Rights Reserved. 09/13 9 Prepping for the big day All infants may kangaroo care when > 1200 grams and clinically stable. Pacifiers dipped in breastmilk for soothing. Initiate oral feeds based on cues as early as 32 weeks PMA, regardless of feeding volumes.

10. ©2013 Children's Mercy. All Rights Reserved. 09/13 When should a baby be considered for PO feedings? A.At 34 weeks B.When the MD or NNP says to do it C.By using a feeding assessment tool to assess a baby’s readiness

11. ©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding Assessment Tool Recommend to begin using tool at 33 weeks. When using the tool, score the baby prior to feed to assess whether you are going to have the baby breastfeed, bottle or NG feed. Eliminates the MD or NNP ordering “X number” of PO feeds a day. Allows the nurse to determine how many PO feeds the baby does based on the score. Eliminates the MD or NNP asking why the baby was not fed the prior day, the score can be looked up.

12. ©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding Assessment Scoring Can be used for bottle OR breastfeeding infants Appropriate for infants >33 weeks This tool assesses: Autonomic stability Interest Hunger behaviors State Motor skills & tone Is an objective tool so can be used by different caregivers but still attain the same result

13. ©2013 Children's Mercy. All Rights Reserved. 09/13 13 Feeding “Readiness” Scoring- Low Score is good! 1- drowsy, alert or fussy prior to care; demonstrates feeding cues rooting and/or hands to mouth/takes pacifier; good tone. 2- drowsy or alert once handled, some rooting or takes pacifier; adequate tone. DO NOT FEED FOR THE FOLLOWING SCORES: 3- briefly alert with cares, no hunger cues; no change in tone. 4- sleeping throughout care, no hunger cues; no change in tone. 5- needs increased O2 with cares; apneic and/or bradycardic with cares; tachypneic or has increased WOB over baseline with cares. If infant is >35 weeks and is consistently scoring 3,4,5- OT consult may be needed.

14. ©2013 Children's Mercy. All Rights Reserved. 09/13 Should a baby be considered for a PO feeding when they are: Briefly alert, drowsy and showing no changes in tone? A.Yes B.No

15. ©2013 Children's Mercy. All Rights Reserved. 09/13 15 Feeding “Quality” Scoring 1- strong, coordinated suck/swallow/breathe pattern throughout feed. 2- strong coordinated suck initially, but tires with progression. 3-. consistent suck, but difficulty coordinating swallow, has some loss of fluid, difficulty pacing; benefits from external pacing 4- consistent suck, but difficulty coordinating swallow, has some loss of fluid, difficulty pacing; benefits from external pacing and/or inconsistent suck, demonstrates little to no rhythm; may need rest breaks. 5- unable to coordinate suck/swallow/breathe pattern despite pacing; may have A/B/Ds or significant loss of fluid, may have significant loss of fluid.

16. ©2013 Children's Mercy. All Rights Reserved. 09/13 An infant is exhibiting a consistent suck, but difficulty coordinating swallow, has some loss of fluid, difficulty pacing; benefits from external pacing You would score him a A.1 B.2 C.3 D.4

17. ©2013 Children's Mercy. All Rights Reserved. 09/13 Quality of breastfeed Check mark box as to: A.Good latch, good swallowing B.Good latch, minimal swallowing noted C.No latch, but good rooting around D.Kangaroo care

18. ©2013 Children's Mercy. All Rights Reserved. 09/13 Supports Used (use only if needed, and may select more than one) Pacing needed Increased O2 need Jaw support Oral stimulation Pacing needed Thickener consistency Cheek support Enfamil nipple Similac nipple Other nipple (nuk, cross cut, etc) Pacing with bottle tipping forces the infant to take breaths and decreases the risk of aspiration

19. ©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding position best for starting a preemie to PO feed A.elevated sidelying B.upright C.reclined D.sidelying

20. ©2013 Children's Mercy. All Rights Reserved. 09/13 20 Feeding Positions Sidelying: 0 degrees breastfeeding position place infant on their side on your legs, feet to your stomach for support safest position: prevents bolus from passively falling to back of pharynx, slowing flow and promoting active swallowing. Also assists with pacing Elevated Sidelying: 45 degrees transition from sidelying to elevated sidelying Upright: 60-80 degrees elevation The reason reclined is not used in preterm infants for feedings is because there is a high risk for aspiration. However, it can be used in term infants as it is good interaction time.

21. ©2013 Children's Mercy. All Rights Reserved. 09/13 21 Feeding Scoring: Where is it in Cerner?

22. ©2013 Children's Mercy. All Rights Reserved. 09/13 Questions?

23. Enteral Feeding Guidelines These guidelines were developed by the Nutrition Committee, comprised of Neonatologist, NNPs, Nutritionists, Lactation Consultants, pharmacists, RNs. This has been a working project for the VON Collaborative that we were a part of in 2011-2012. Located in “Helpful Hints” on the Scope. Left tab “PHYSICIANS” then click on helpful hints or put in search bar ICN Helpful Hints.

24. ©2013 Children's Mercy. All Rights Reserved. 09/13 Enteral Feeding Guidelines Goals 1. Encourage safe, standardized feeding advancement within team to enhance growth outcomes of ICN infants. 2. Begin minimal enteral feeds by DOL 3, unless contraindications exists, to improve feeding tolerance, prevent gut atrophy, facilitate GI maturation, and shorten time to full enteral feeds. 3. Advocate use of human milk as definitive first choice for feeds. 4. Provide guidelines for holding feeds in assessment of feeding intolerance.

25. ©2013 Children's Mercy. All Rights Reserved. 09/13 Enteral Feeding Guidelines Feeding Initiation Mother’s breast milk (MBM) is feeding of choice. Lactation consultations occur upon admission or as mother is available Begin breast milk feeds with unfortified breast milk For infants <2 kg requiring infant formula - 24 kcal/oz preterm infant formula For infants >2 kg requiring infant formula - 22 kcal/oz Neosure Expert Care (standard concentration)

26. ©2013 Children's Mercy. All Rights Reserved. 09/13 Enteral Feeding Guidelines Bolus versus Continuous Feeds Bolus feeds are preferred method of delivery in preterm infants with healthy GI tracts Continuous feeds may be necessary for ELBW infants or those with short bowel syndrome or severe GE reflux with poor weight gain Oral Feeds All infants may kangaroo care when > 1200 grams and clinically stable Initiate oral feeds based on cues as early as 33 weeks PMA, regardless of feeding volumes

27. ©2013 Children's Mercy. All Rights Reserved. 09/13 27 Enteral Feeding Guidelines Osmolarity of breastmilk 260mOsmol/kg Osmolarity of SSC 24 cal 280mOsmol/kg Osmolarity of BM with HMF 24 cal 385mOsmol/kg For infants <2kg use 24 cal formula or BM For infants >2kg use regular formula or BM

28. ©2013 Children's Mercy. All Rights Reserved. 09/13 Which has the higher osmolarity? A.Breastmilk B.Preterm formula, 24 calorie C.Breastmilk with HMF

29. ©2013 Children's Mercy. All Rights Reserved. 09/13 Breast Milk Fortification Begin HMF fortification step-wise to 24 kcal/oz when infant tolerating >80 ml/kg/d enteral feeds For infants < 2kg - utilize HMF

30. ©2013 Children's Mercy. All Rights Reserved. 09/13 What feeding volume would you start for a 31 5/7 week, 1200 gram infant? A.20ml/kg/day B.40ml/kg/day C.10ml/kg/day

31. ©2013 Children's Mercy. All Rights Reserved. 09/13 How would you start feeding an infant who is 33 weeks, 2.4kg? A.20mlkg/day B.30ml/kg/day C.40ml/kg/day

32. ©2013 Children's Mercy. All Rights Reserved. 09/13 32 Residual Algorithm To standardize care for most residual instances To decrease the number of calls the providers receive about residuals and what to do To try to alleviate instances (mostly on night shift) of baby becoming NPO due to residuals that the primary team was trying to work through After research, residuals were not shown to directly correlate with NEC

33. ©2013 Children's Mercy. All Rights Reserved. 09/13 Residual Algorithm

34. ©2013 Children's Mercy. All Rights Reserved. 09/13 Feeding and Residuals Questions?