NICU care : Neonatal feeding assessment

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Nutrition is the essential and critical part of health and development in every stages of life. From neonate to geriatric population, every one needs adequate and sufficient amount of nutrition for healthy development of body.

Neonates with preterm birth, extremely low or low birth weight, respiratory problems,  traumatic brain injury, heart diseases faces significant difficulties and challenges like growth failure, less than optimal neurodevelopment, feeding and breathing difficulty, little body fat, poor body tone etc.

In this post we will focus on the preterm /premature or low birth weight (LBW) neonates with feeding difficulty and its assessment. Feeding problems are common in preterm infants. These infants often appears to regress in feeding skills or might develop new feeding problems after hospital discharge.

To begin with, feeding is an act of supplying food and nourishment. For a newborn neonate or infant, the global public health recommends exclusively breastfeed for the first 6 months of life to achieve optimal growth, development and health. Growing preterm infants needs about 110-120 kcal/kg/day and 3.5 to 4 g/kg/day of protein for proper development. Premature or LBW neonates or infants feeding is a complex procedure. It should be specially understood and learned by mothers and caregivers. It needs to be demonstrated on mothers by a trained therapists. Occupational therapist and Physiotherapist plays an important role in neonatal care and rehabilitation.

During feeding procedure, in premature neonates, the surrounding environmental conditions, mother's handling and neonates or infants response status should be supportive and appropriate. Monitoring of feeding through direct observation as well as caregivers reports of feeding situation at home is essential to good follow-up care. 

In assessment of feeding performance in premature neonates or in infants following points should be observed, evaluated and documented to understand neonate's current status, progress and to decide intervention plan. Following points are :

1. Consciousness state and State control
2. Stress level
3. Response to Tactile inputs
4. Feeding Position and Postural alignment of  neonate or infant
5. Oro-Motor structure, function and control
6. Physiological Control
7. Sucking, Swallowing and Breathing parameters
8. Coordination of sucking-swallowing-breathing pattern
9. Feeding Interaction between mother and its baby

Lets see each points in detail :

1) Consciousness state or State control : 

• States of consciousness in neonates range from deep sleep to active (light) sleep to drowsy to awake ( alert or fussy) state to crying state.
• The optimal state for feeding is an awake, alert, or active state, although some infants can feed adequately in  a drowsy state.
• Note infant's state before, during and after feeding. It is essential to bring infant to an appropriate state before feed.  

Fig : Deep sleep state (It needs to be protected)

Fig : Quite Awake state ( best time to interact with your baby)

Fig : Crying state (Stress cues)

2) Stress level :

• Feeding process places many demands on infants. Demands may be internal (increased respiratory function and digestive function or GER) or external (oral tactile experience, variation of ambient temperature or noise or light, feeding related stress of liquid flow).
• If demands are beyond infant's adaptive capacity then behaviours in form of infant's stress cues are observed. 
• State and attentional stress cues like irritability, crying, drowsy, alertness, hyperalert, staring. 
• Motoric stress cues like flaccidity, hypertonia, hyperextension of leg, finger splaying, arching backwards, facial grimacing.
  
• Autonomic stress cues : moderate signs includes sighting, yawning, hiccuping, sweating, yawning. Major signs includes coughing, spitting up, gagging, chocking, colour change cyanosis, respiratory pause, irregular respiration etc.

3) Response to tactile inputs: 

• Neonates or infants expression to oral stimulus includes oral reflexes which are either adaptive (rooting reflex or sucking reflex) or protective (cough and gag) depending upon infants level of hunger or state of alertness.
• If cough occurs during sucking and swallowing it may indicates material crossing near or entering airway. If cough occurs after feeding then it indicates that food or material is ascending into pharynx from gastroesophageal reflux (GER).
• Behavioural response to tactile inputs : infant accommodates to a wide variety of tactile stimuli during feeding. Tactile inputs can be from within the mouth, touch of feeder's hand on infant's face or touch  pressure of being held in hand. Preterm infants may perceive tactile inputs as stressful. Early NICU experience may have negative and aversive stimuli to oro-facial area due to orogastric tube.
• Preterm infants may not have been able to engage in normal pleasurable oral exploration because of motor structure and function immaturity or delay or intubation or lack of experience.

4) Feeding Position and Postural alignment of  neonate or infant :

• Optimal position of feeding for neonates or infants is characterized by orientation around midline, semi-flexed head-neck and spine posture, semi-flexed hip and knee, upright positioning with light support under the chin (if cup or spoon feeding).
• Feeding infants in the side-lying position may improve tongue position, particularly if marked tongue retraction is present.
• Infant's feeding position is important for good attachment, latching and successful breastfeeding. Breastfeeding position should be such that it gives extra support for neck and head. Following are the safest position for premature/ preterm neonates or infants namely Laid-back position, football hold position and Cross-cradle hold position.

Fig : Breastfeeding positions for preterm babies

• Premature or preterm infants with hypertonia may attend abnormal postures like backward arching or extended neck during feeds. The infants may be using neck extension to maintain airway flow for breathing. On the other hand, hypotonic infants have poor neck and trunk control leading to inability to sustain semi-flexed position during feeds. These abnormal postures causes difficulty to attain optimal feeding position.

5) Oro-Motor structure, function and control:

• Assessment of specific structures and function of oral cavity, its musculature is done when infant suck the examiner's gloved little finger in form of  non-nutritive sucking. The Neonatal Oral Motor Assessment scale (NOMAS) can be used for taking decision about feeding advances in newborns, including tube feeding in premature infants. During assessment the therapist will analyse about infant's suck strength, suck-swallow ratio, initial position of tongue pre-feed, tone of the oral musculature, changes in breathing rate and pattern, sustainability of feeding ability, stress cues etc.

Fig : Premature or preterm neonates in NICU care.

Fig : Full term infant 

• Rooting reflex and sucking reflex are essential for infants to initiate and sustain the whole feeding process. Rooting reflex usually starts to develop at around 28 to 30 weeks of gestation. Sucking reflex usually doesn't start until 32nd weeks of pregnancy and is fully developed by about 36 weeks of pregnancy. Premature infants may have weak or immature sucking ability due to preterm birth. Assess for rooting and sucking reflex before feeds.
• Wide variety of oro-motor difficulties are observed in these preterm or LBW infants. Full-term infants are born with substantial amount of subcutaneous fat and well defined buccal fat pads. These buccal fat pads develop by the end of pregnancy when the other fat is developing on the baby's body. These oral fat pads helps to keep the cheeks against the gums and attain sufficient intraoral pressure for feeding. The tongue fills the oral cavity and is in physical contact with all the surfaces of oral cavity. Full-term infants also have good body flexor tone which is necessary for appropriate feeding posture.
• In contrast, premature infants have less muscle bulk, poorly developed tendon and ligament structure as well as less body fat. Buccal fat pads are also not well developed. There is decreased opposition of tongue to the surface of oral cavity and reduced flexor tone with neck in extended position.
• Appropriate tongue position is also important to enhance feeding. Look for tongue tip elevation, tongue retraction, tongue protrusion (seen in infant's with hypotonic or on endotracheal tube feeds), excessive jaw excursion (hypotonia) and jaw clenching (hypertonia) . All these oro-motor difficulties prevent successful tongue contact or latching to nipple,  compromise lip seal. Protruded tongue may compress the nipple with little suction force generated.

6) Physiological Control : 

• The infants will have and show physiological responses to the work of feeding. If the infant is not able to show or attain appropriate responses to any activity then stress reactions, physiological changes and poor endurance may result. 
• To assess physiological control, during feeding, specific parameters like heart rate, respiratory rate and blood oxygen saturation levels should be evaluated at baseline, during feeding and after feeding.
• Heart rate parameter : full-term infants normal heart rate is 120 to 140 beats per minute. Rise of 10 beats per minute during feeding is normal. But larger increase indicates that feeding is placing excessive demands. Bradycardia (rate below 100 beats per minute) may be observed in high risk infant during feeding and is life threatening. Bradycardia might occur after oxygen desaturation or suspected reflux (GER) event or change in position or triggered stretch receptors within pharynx due to large bolus or due to nasogastric tube irritation.

• Respiratory rate (RR) parameter : full-term infants normal RR is 30 to 60 breaths per minutes. During bottle feeding the RR is low while infants is actively sucking. The RR is higher during pause. 
• In infants with respiratory compromise RR can be significantly elevated to maintain homeostasis. These infant may not be able to tolerate suppression in respiration that occurs in early part of feeding i.e. during sucking. The infant may fatigue easily or may be at a risk of aspiration or may try to gasp for air.
• If RR is above 80 breaths per minute during pause, it often  indicates the work of feeding is too great for infant. This may lead to significant oxygen desaturation in preterm infant with respiratory compromise. Assess for colour change/  central cyanosis of lips or tongue which indicates reduced arterial oxygen saturation due to abnormality in heart or lung functioning.
• Poor endurance may result in infant terminating feeding before taking required volume and shows poor weight gain. Endurance is a reflection of infant's work to maintain homeostasis, infant's cardiopulmonary reserve and capacity to sustain energy for other activities like feeding.
  

7) Sucking, Swallowing and Breathing parameters : 

• Problem in any one process or lack of coordination between process can have a profound effect of infant's feeding ability. Within pharynx, breathing and feeding shares a common space. This dual role of pharynx underlie the difficulties which is observed in premature infants when sucking, swallowing and breathing is not well coordinated during feeding process.
• Sucking : sucking involves the rhythmic movements of tongue and jaw with support from the lips and cheeks which creates changes in pressure that causes the liquid to flow out of nipple. Sucking is comprised of two types of the pressure namely positive pressure (compression) and negative pressure (suction).   
• Non-nutritive sucking is where a baby sucks without receiving any nutrition. NNS can be given in form of pacifier. NNS by infants in form of licking finger is a sign of feeding cues. Non-nutritive sucking (NNS) occurs in a highly organized, repetitive pattern of bursts and pauses with high ratio of sucks per swallow (6 to 8 : 1) and 1 to 4 swallow per burst. This suck-swallow burst count is assessed using gloved little finger by placing it in infant's oral cavity over the tongue.

Fig : Non- nutritive sucking (to soothe themselves)

• Nutritive sucking occurs during active feeding and has a more complex pattern than NNS. Preterm infants often have fewer or shorter bursts of nutritive sucking. The suck-swallow ratio is usually 1:1, but may increase towards the end of the feeding.

Fig : Nutritive sucking

• The strength of the infant's suck is reflected in both the resistance to pulling the nipple out or gloved finger out ( in cases of NNS) of infant's mouth and rate of liquid flow. Lower the sucking rate and lower the suck-swallow ratio, the faster the milk flow. When differences are noted in the quality of sucking between nutritive sucking and NNS it is suggestive of problems with some aspects of suck-swallow-breath coordination.
• Swallowing : Coughing or choking can indicate that liquid is impinging on the airway. Aspiration can result from primary swallowing dysfunction or from lack of coordination between suck-swallow-breath pattern. Aspiration can be descending (during feeding) or ascending (in case of GER). History of upper respiratory tract infection or pneumonia may be indication that "silent' aspiration is taking place.
• Clinical assessment of swallowing function : to assess ability to handle bolus or secretion,  presence of noise or wet sounding during and after feeding. To assess the need for multiple swallows to clear a single bolus. The most comprehensive evaluation of swallowing occurs radiologically during videofluoroscopic swallowing study or modified barium swallow.
  
• Breathing : infants with compromised respiratory function may be unable to make sufficient adjustments to accommodate the work of feeding. Breathing assessment should be done before, during and after feeding.
• Assessment of respiratory efforts : increased respiratory efforts are indicated by retraction at neck, trunk or rib-cage, head bobbing, grunting or forced exhalation.
• Assessment of changes in respiratory pattern : observe when there are excessive pauses or irregularities in breathing pattern during feeding. Respiratory pause of longer period (more than 15 seconds) and if associated with cyanosis or pallor or bradycardia are considered pathological.
• Assessment of sounds of respiration : noises heard during any part of respiratory cycle may indicate airway obstruction or alteration in airway patency.

8) Coordination of sucking-swallowing-breathing pattern : 

• This is assessed by listening to the ratio of sucks to swallow and observe the timing and adequacy of respiratory efforts during sucking bursts.
• Normal recovery in all respiratory parameters occur during the sucking pause. Infants with organized sucking patterns (mature or immature) that can coordinate sucks and swallows with breathing are generally safe feeders when behavioral cues are respected. 
• Instead of having the 1:1:1 or 2:1:1 suck-swallow-breathe coordination seen in term babies, infants with an immature sucking pattern often cluster three to five sucks together while holding their breath, swallow the accumulated bolus, then cluster several rapid recovery breaths.

• In healthy preterm infants as young as 32 ½ weeks, this pattern is slower and not as efficient as mature sucking, but it may appear organized, as sucks and swallows alternate with breathing in a coordinated manner. Breath-holding during sucking is believed to be related to the infant's instinct to protect the airway from penetration by the liquid bolus (Hunter, Lee, & Altimier, 2014)
• Transitional or disorganized feeding patterns are common in preterm or ill NICU infants learning to orally feeding. These infants have difficulty coordinating sucks and swallows with breathing, and benefit from caregiver interventions such as slow-flow nipples, spoon feeds and pacing to ensure breaks for breathing (Hunter, Lee & Altimier, 2014).

9) Feeding Interaction between mother and its baby : 

• Due to the critical condition of premature or preterm neonates with LBW they are immediately shifted to NICU care unit. In NICU, infants are provided with artificial womb like environmental feel because premature or preterm newborns are not ready to face the normal, harsh environmental conditions.
• Preterm infants and their families are at a risk of problems in feeding interactions due to prolonged periods of hospitalization and other factors.
• According to WHO, skin-to-skin contact between mother and infant should be given shortly after birth. This helps to initiate early breastfeeding and receive the colostrum or "first milk" which is rich in protective factors. But in case of premature or preterm neonates, they are shifted to NICU care and kept in incubators where they are deprived of this skin-to-skin contact and these infants are given expressed breastmilk of the mother by spoons, katori or small cups (in India).
• Feeding observation and assessment of how caregiver or mother and infant work together during feeding. It is both infant's and caregiver's or mother's  responsibilities to provide feedback and cues related to feeding progress.
• Caregiver's or mother's responsibilities includes to recognise and respond to infant's cues, soothe distressed infant, communicate with infant by showing positive feelings and warmth and enhance infant's physical and cognitive growth through positive touch, movements and by talking to them. Delay stimulating or responding until infant's shows signs of readiness while feeding or other activities.
• Neonates or infant's responsibilities includes :

a) Sending clear cues to mother or caregiver : display readiness cues and tension at the beginning of feeding followed by decrease in tension or stress cues once feeding starts. Having period of alertness during feeding. Respond by showing cues to mother for break or rest during feeding and other activities i.e. infant may try to avoid the activity or show fluctuations in vital parameters or show stress cues. Infant should show decrease in stress cues after putting on kangaroo mother care. Child should show signs of positive growth and proper nutritional support like weight gain, improved sucking strength, improved coping ability, appropriate tone development and decrease in fluctuations of parameters during any activity.

b) Showing positive response to caregiver's or mother's attempt to communicate or interact. Stop crying when mother attempts to soothe the neonate or infant. Infant should attempt to look towards the direction of mother's voice and face while talking. Neonate or infant should show sucking response and may make feeding sounds during feeding process.

"Babies are like little suns that, in a magical way, bring warmth, happiness and light into our lives."

Fig : Infant and mother interaction

Thankyou for reading!!!

(Dr. Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe)