Promoting Pre-Feeding Skills: Development and Implementation of an Oral Motor Protocol and Clinical Guidelines in a Level IV NICU

Intro: Oral feeding is often the last discharge criterion for preterm infants in the NICU and a leading cause of extended hospital stay. Preterm infants lack motor practice they would receive in utero when swallowing amniotic fluid and have underdeveloped physiological systems and oral structures, delaying feeding skills. Standardized pre-feeding oral motor protocols that include stimulation of oral structures and sucking on pacifiers have been shown to improve feeding efficiency, decrease transition time to full oral feeding, and decrease length of stay. Purpose: The purpose of this doctoral capstone project was to update the clinical guidelines on oral motor interventions in the University of Minnesota Masonic Children’s Hospital (UMMCH) NICU to improve the neurodevelopmental outcomes of premature infants by targeting oral motor skills through a new protocol to enhance breastfeeding and bottle feeding. Approach: Following an extensive literature review on best oral motor practices, the occupational therapists participated in a survey and focus group, were trained to implement the new protocol, and completed a follow-up survey to assess the utility of the protocol and updated clinical guidelines. Infant oral motor outcomes were also analyzed. Outcomes: All therapists reported feeling satisfied with the guidelines and confident in implementing the protocol and modifying it with intubated infants. Therapists also reported improved patient outcomes, including secretion management and swallowing, arousal levels, tolerance to stimulation and oral interest, and bottling skills. Short-term infant outcomes during the protocol include high percentages of good secretion management, activated swallowing, and latching to a pacifier. Recommendations: UMMCH NICU should continue to implement the protocol with infants of appropriate gestational age, utilize the clinical guidelines to train new therapists, provide additional training on the protocol as needed, continue quality improve cycle and adjust guidelines appropriately based on new evidence, provide parent education on protocol, and distribute modified nursing guidelines to further promote positive oral input for premature infants in the NICU

Training Clinical Judgment Skills for Interpreting Feeding Behavior in Preterm Infants: A Comparison of Video and In Vivo Simulation

Health and feeding outcomes for preterm infants depend upon healthcare providers’ ability to recognize non-verbal signs of distress during bottle-feeding. Methods of training future providers’ to interpret feeding behavior in preterm infants are unclear. This study used a pre-test/post-test design to compare the effects of in- vivo simulation and video-simulation training on students’ knowledge of feeding abnormalities, clinical judgment, and documentation accuracy. Fifty-two graduate level speech-language pathology students were assigned to the in-vivo (N= 27) or video-simulation (N= 25) group. Results revealed that both methods proved beneficial for increasing knowledge and clinical judgment skills. Participants trained using video-simulation training documented a greater number of distress signs. The use of patient simulators to train graduate level speech-language pathology students to use correct clinical judgment for managing abnormal feeding behavior is efficacious

An investigation of the flow rates of disposable bottle teats used to feed preterm and medically fragile infants in neonatal units across the UK in comparison with flow rates of commercially available bottle teats

Aims and Objectives: For preterm and medically fragile infants, learning to feed orally is challenging. There are many contributing factors that can support the development of oral feeding. The flow rate of a teat can influence feeding success in the bottle-fed infant and, if not supportive, can cause physiological instability during feeding. The flow rate of teats used in a selection of neonatal units in the United Kingdom (UK) was tested to determine their flow rate, which was then compared to the flow rate of commercially available teats. Design and Methods: Flow rate of teats used in several neonatal units across the UK were tested by attaching a teat to a breast pump and measuring the output of milk after 1 min. These values were compared to the flow rates of commercially available teats. The hypothesis was that hospital disposable teats might have a considerably higher flow rate, and a higher rate of variability, than commercially available teats. Results and Conclusions: The results identified that there were differing flow rates as well as a wide variation of flow rates for both hospital disposable and commercial teats. Hospital disposable teats had flow rates ranging from 8.5 mL/min to 23.3 mL/min, and commercial teats had a range of 4.2 mL/min to 31.3 mL/min. Measurement of variability in flow rate identified a moderate mean flow rate for hospital disposable teats (CoV = 0.1), with a low mean variability in flow rate for commercial teats (CoV = 0.07). Applicability of this data to a clinical context is discussed

Effectiveness of high-fidelity human patient simulation in learning to manage medically-complex infants

Survival of preterm and medically-complex infants has dramatically increased over the past thirty years due to significant advances in medical care and technology, however the developmental costs of survival are substantial. Comprehensive care of premature babies is critical and there is a need for more neonatal therapists, including speech-language pathologists (SLPs), with the knowledge and confidence to provide that care. Students in graduate SLP programs often receive little clinical experience or dedicated coursework in pediatric feeding and swallowing, especially with medically-complex infants. However, hands-on and experiential learning can support the development of the necessary foundational knowledge and confidence of students entering into the profession. High-fidelity human patient simulation can provide this experience with high-risk patients in a risk-free learning environment. This investigation examined the effect of high-fidelity human patient simulation on student knowledge of and confidence with managing physiologic stability of medically-fragile infants. A sequential, two-phase, embedded mixed methods design was employed. Two cohorts of graduate SLP students participated; the control group (Fall 2017; n = 28) and experimental group (Summer 2018; n = 24) both completed required coursework in pediatric dysphagia. All students completed all requirements of the course and also completed assessment measures at three time points: 1) prior to any didactic instruction, 2) following coursework, and 3) following the intervention. The intervention was either a written case study (control group) or a high-fidelity human patient simulation using the Super Tory® manikin (experimental group). Both conditions used the same case scenario developed by expert SLPs. Rigorous quantitative and qualitative analyses were conducted to examine student knowledge and confidence, as well as perceptions of learning in simulation (experimental group only). All students improved knowledge performance from pretest to posttest, and there was no significant difference between groups in knowledge at the posttest. There were significant differences between the control and experimental groups on confidence, particularly at the third timepoint. Following the simulation, the experimental group reported higher confidence than the control group with skills requiring hands-on experience. Findings of this investigation support integration of high-fidelity simulation into the SLP graduate curriculum to supplement and complement didactic and clinical training

Utilizing Simulation for Family Member Caregivers of NICU Infants: A Pilot Project

According to the World Health Organization (WHO), there are approximately 15 million babies born prematurely every year. Family members of premature infants in the Neonatal Intensive Care Units (NICU) are overwhelmed and lack confidence with basic skills to care for their newborn. Simulation is an education modality used for adult learners that utilizes a hands-on method for education and allows application of knowledge and skill development in a safe environment. Although clinicians are frequently trained utilizing simulation, there is limited information on its use among family members and caregivers. The purpose of this DNP Project was to explore use of simulation to teach family members of NICU patients’ basic skills to care for their newborn. Data collection included demographics, a pre- and post- training survey and a post-training follow up survey 2-3 weeks after discharge home. The goal was to improve health outcomes for the neonates by giving their family members a hands-on experience with a human infant simulator. Participants were instructed how to safely handle the infant, understand the importance of temperature management and what to do as the infant’s temperature varies. The response to the training was positive and parents felt more comfortable going home after having some practice with the manikin. Keywords: premature newborn, infant, infant, simulation, training, caregiver, self- care, education, simulator, maniki

Home and community based parenting support programmes and interventions: report of Workpackage 2 of the DataPrev project

The last decade has witnessed an increasing interest in the promotion of mental health and wellbeing because of its importance for health and social functioning at the individual level and for the social and economic wellbeing of societies. Recent research from a range of disciplines has highlighted the importance of the quality of the parent-child relationships and parenting on children‟s emotional and social development, and on adult mental health and wellbeing. Intervention studies involving children of all age groups have shown that if parenting can be influenced for the better outcomes can be changed. The DataPrev project was funded by the 6th Framework of the European Community Research Programme under Policy-Orientated Research with the aim of establishing a database of evidence-based programmes in Europe that promote mental health and wellbeing and prevent mental illness throughout the life course. This is the report of the Workpackage 2 describing the international evidence base on programmes to support parenting, including home and community based programmes

What are the needs and challenges of breastfed medically complex infants and children in the paediatric setting?

Breastfeeding is known to provide optimal nutrition and immunological support to young children. There are many systems in place to facilitate and protect breastfeeding, such as policies, training programs and specialist practitioners employed within certain settings. However, the support and training are weighted towards the initiation of breastfeeding in healthy newborns, as well as supporting the preterm population. Paediatric settings do not have the same investment in training, policy, or staffing. Within paediatrics, different breastfeeding challenges exist, meaning that not only do staff often not have a baseline level of breastfeeding knowledge, but they also require more nuanced training to effectively support families to overcome difficulties. There is a paucity of research on this subpopulation, especially within the UK, therefore a systematic review was conducted and used to focus the research studies on the identified gaps. Two studies were conducted to identify the knowledge and skills of professionals, and the experiences of mothers breastfeeding their medically complex child in the paediatric setting. The first study was a national survey of 409 multidisciplinary healthcare and allied health professionals working in paediatrics. The second study recruited 30 mothers of children who had been inpatients on paediatric wards or paediatric intensive care units and explored their challenges, barriers and views using semi-structured interviews. The research found that many paediatric professionals have significant gaps in their knowledge and skills, reported several obstacles in terms of unsupportive ward cultures, and identified that current breastfeeding training does not meet the needs of these professionals working to support sick breastfed children in hospital. Furthermore, while some mothers are strongly motivated to breastfeed their sick child, they encounter a range of institutional, clinical and environmental barriers to breastfeeding. The findings suggest that nuanced paediatric-focused breastfeeding training along with a focus on providing family-centred, compassionate care and supportive environments is clinically justified to support families to reach their personal feeding goals and optimise health outcomes for children

Oral and respiratory control for preterm feeding

Purpose of review—Feeding competency is a frequent and serious challenge to the neonatal intensive care unit survivors and to the physician–provider–parent teams. The urgency of effective assessment and intervention techniques is obviated to promote safe swallow, as attainment of oral feeding for the preterm infant/newborn is one of the prerequisites for hospital discharge. If left unresolved, feeding problems may persist into early childhood and may require management by pediatric gastroenterologists and feeding therapists. This review highlights studies aimed at understanding the motor control and development of nonnutritive and nutritive suck, swallow, and coordination with respiration in preterm populations. Recent findings—Functional linkages between suck–swallow and swallow–respiration manifest transitional forms during late gestation and can be delayed or modified by sensory experience and/ or disease processes. Moreover, brainstem central pattern generator (CPG) networks and their neuromuscular targets attain functional status at different rates, which ultimately influences crosssystem interactions among individual CPGs. Entrainment of trigeminal primary afferents to activate the suck CPG is one example of a clinical intervention to prime cross-system interactions among ororhythmic pattern generating networks in the preterm and term infants. Summary—The genesis of within-system CPG control for rate and amplitude scaling matures differentially for suck, mastication, swallow, and respiration. Cross-system interactions among these CPGs represent targets of opportunity for new interventions that optimize experience-dependent mechanisms to promote robust ororhythmic patterning and safe swallows among preterm infants

Automatic Nonnutritive Suck Waveform Discrimination and Feature Extraction in Preterm Infants

Background and Objective: +e emergence of the nonnutritive suck (NNS) pattern in preterm infants reflects the integrity of the brain and is used by clinicians in the neonatal intensive care unit (NICU) to assess feeding readiness and oromotor development. A critical need exists for an integrated software platform that provides NNS signal preprocessing, adaptive waveform discrimination, feature detection, and batch processing of big data sets across multiple NICU sites. +us, the goal was to develop and describe a crossplatform graphical user interface (GUI) and terminal application known as NeoNNS for single and batch file time series and frequency-domain analyses of NNS compression pressure waveforms using analysis parameters derived from previous research on NNS dynamics. Methods. NeoNNS was implemented with Python and the Tkinter GUI package. +e NNS signal-processing pipeline included a low-pass filter, asymmetric regression baseline correction, NNS peak detection, and NNS burst classification. Data visualizations and parametric analyses included time- and frequency-domain view, NNS spatiotemporal index view, and feature cluster analysis to model oral feeding readiness. Results. 568 suck assessment files sampled from 30 extremely preterm infants were processed in the batch mode (\u3c50 minutes) to generate time- and frequency-domain analyses of infant NNS pressure waveform data. NNS cycle discrimination and NNS burst classification yield quantification of NNS waveform features as a function of postmenstrual age. Hierarchical cluster analysis (based on the Tsfresh python package and NeoNNS) revealed the capability to label NNS records for feeding readiness. Conclusions. NeoNNS provides a versatile software platform to rapidly quantify the dynamics of NNS development in time and frequency domains at cribside over repeated sessions for an individual baby or among large numbers of preterm infants at multiple hospital sites to support big data analytics. +e hierarchical cluster feature analysis facilitates modeling of feeding readiness based on quantitative features of the NNS compression pressure waveform