Improving Feeding Outcomes: Challenges in the NICU

Transcription

1 Improving Feeding Outcomes: Challenges in the NICU Sudarshan R. Jadcherla, MD, FRCPI, DCH, AGAF Professor, Department of Pediatrics The Ohio State University College of Medicine Divisions of Neonatology, Pediatric Gastroenterology, & Nutrition Director, The Neonatal and Infant Feeding Disorders Program, Principal Investigator, Innovative Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children s Hospital, Columbus, Ohio, USA

2 Objectives 1. Describe the development and maturational timeline of swallowing and feeding milestones 2. Recognize risk factors for feeding delays 3. Identify potential mechanisms with feeding milestones 4. Discuss multidisciplinary feeding management approach

3 Background Birth rate of ~4 million/year (USA Vital Statistics, 29) Prematurity (~12%); 5, infants/yr are born prematurely (March of Dimes, 29) Appropriate Feeding and Nutrition methods in premature infants lead to better growth and development; but hard to achieve in utero growth and developmental standards (Tsang, Thureen, Schanler, Abrams, Valentine, Jadcherla) Inadequate feeding and nutrition methods run the risk of significant morbidity (Jadcherla) Feeding provides Nutrition, Nutrition maintains growth, Growth provides hope for developmental milestones

4 Objective-I Describe the development and maturational timeline of swallowing and feeding milestones

5 What is a milestone? Date: 1662 a milepost a significant point in development a point in a chain of events at which an important change occurs, a turning point in ones life Source: Merriam-Webster

6 Evolution of Normal Feeding Milestones: New born Nursery setting 12 (11-14) weeks Embryonic life Swallowing of amniotic fluid 2 (18-24) weeks Involuntary sucking movements 32 (3-34) weeks Purposeful sucking if born prematurely (pacifier/feeds) 34 (32-38) weeks Sucking-swallowingbreathing coordination 4-6 months Solids Langman Embryology; Illingworth (Normal Child)

7 Evolution of feeding milestones: NICU premature infant setting Prematurity, Neuromotor deficits, Foregut problems, or Cardio-respiratory disease Total parenteral nutrition Gastric readiness: 1 st Feed (Gavage) Efficient gastric emptying: Full gavage feeds Preparatory sucking/purposeful sucking skills (pacifier/feeds) Oro-motor coordination with breathing: 1 st Feed (PO) Efficient Oro-motor coordination: Full PO feeds (PO) Tubes Solids Tubes

8 To determine feeding milestones in premature infants: Retrospective study (MCW/CHW) Demographic characteristics Morbidity characteristics Feeding milestones at: 1 st and maximum gavage feed 1 st and maximum nipple feed Lengths of stay All infants were under the care of academic group of Neonatologists and consensus Feeding guidelines were followed Jadcherla et al. J Perinatology 21

9 Demographic Characteristics based on GA Characteristics < 28. wks wks wks (N=35) (N=59) (N=81) Gestational age a, wks 26 ± 1 (26) * 3 ± 1 (3.7) 33 ± 1 (33) Birth weight a, g 815 ± 22 (76)* 1412±346(137) 198 ± 46 (186) Median APGAR Score at 1 min b 4 (1-8) * 7 (2-9) 7 (1-1) Median APGAR Score at 5 min b 7 (1-9) * 8 (5-9) 8 (3-1) a Values are shown as mean ± SD (median); B Value are shown as median (range); * P <.5 vs wks; P <.5 vs wks. Jadcherla et al. J Perinatology 21

10 Feeding Milestones Characteristics < 28. wks wks wks (N=35) (N=59) (N=81) PMA at maximal gavage feedings, wks 34 ± 5 (32) N=34 33 ± 2 (33) N=5 35 ± 2.5 (34) N=33 PMA at maximal oral feedings, 37 ± 2 (37) * 35 ± 1.5 (35) 35 ± 1 (35) wks N=18 N=43 N=7 Values are mean ± SD(median); * P <.5 vs wks; P <.5 vs wks. Jadcherla et al. J Perinatology 21

11 Feeding status at discharge P=.3 P=.1 P=.1 Jadcherla et al. J Perinatology 21

12 Length of hospital stay P=.1 P=.1 P=.1 3 Length of hospitalization, days <28 wks wks wks Jadcherla et al. J Perinatology 21

13 Duration of gavage feeding P=.1 P=.1 P= Gavage feeding time, days <28 wks wks wks Jadcherla et al. J Perinatology 21

14 Objective II Recognize confounding factors for feeding delays

15 Duration of ventilation P=.1 P=.1 P=NS 1 8 Ventilation, days <28 wks wks wks Jadcherla et al. J Perinatology 21

16 Duration of CPAP P=.1 P=.1 P=NS 7 6 Duration of CPAP, days <28 wks wks wks Jadcherla et al. J Perinatology 21

17 Morbidity Characteristics based on GA Acute Characteristics < 28. wks (N=35) wks (N=59) wks (N=81) Surfactant 33 (94) * 31 (53) 31 (38) Antenatal Steroids 19 (54) 3 (51) 38 (47) Postnatal Steroids 22 (63) * 6 (1) 4 (5) Hypotension 26 (74) * 16 (27) 6 (7) Indomethacin 13 (37) * 3 (5) 5 (6) PDA surgery 11 (31) * 1 (2) () Chronic BPD 11 (31) * 2 (3) 1(1) GER 11 (31) 9 (15) 13 (16) IVH 8 (23) * 3 (5) 3 (4) Positive blood culture 17 (49) * 16 (27) 7 (9) Caffeine 32 (91) * 36 (61) 16 (2) Values are shown as # (%); * P <.5 vs wks; P <.5 vs wks. Jadcherla et al. J Perinatology 21

18 Relationship between acute and chronic morbidity parameters vs. maximal oral feeding (N=175) Morbidity/Intervention Variable Unadjusted OR (CI) P value Adjusted* OR (CI) P value Gestational age, wks 1.25 (1.11, 1.4) (1., 1.44).5 Hypotension.33 (.16,.67).3.97 (.36, 2.59).95 Caffeine.7 (.36, 1.4) (1.4, 8.91).4 PDA.3 (.9, 1.) (.27, 4.59).89 GER.43 (.19,.96).4.59 (.24, 1.48).26 Ventilation.16 (.6,.42).2.27 (.8,.88).3 NCPAP.35 (.17,.74).6.77 (.28, 2.13).62 Positive blood culture.22 (.1,.46).1.36 (.14,.89).3 *Adjusted for all variables displayed in the table. Interpretation: If the patient s gestational age is older by 1 week, then this patient will have 1.25 times chance to get successful maximal oral feeding based on GA alone, however, if all other co-existing conditions remain same, then the chance to achieve this milestone is 1.2 times. Similarly, if the patient is on ventilation, then this patient will only have.16 times chance to get successful maximal oral feeding compared to patients without ventilation, and.27 times chance to get successful maximal oral feeding if all other co-existing condition remain same. Jadcherla et al. J Perinatology 21

19 Relationship between acute and chronic morbidity parameters on PMA at maximal gavage (N=118) and maximal oral feeding milestones (N=131) Morbidity/Intervention PMA at maximal gavage P value PMA at maximal oral P value Variable feeding* (Adj. R 2 =.55) β ± SEM feeding * (Adj. R 2 =.58) β ± SEM Gestational age.66 ± ±.11.1 Hypotension.35 ± ±.49.1 Caffeine -.62 ± ± PDA.36 ± ± GER 1.45 ± ±.47.5 Duration of ventilation.12 ± ±.2.1 Duration of NCPAP.1 ± ±.2.1 Positive blood culture 1.5 ± ± * Adjusted for all variables displayed in the table. Interpretation: Presence of GER will delay maximal gavage feedings and by 1.45 weeks and maximal oral feedings by.95 wks respectively. If the patient was on ventilation 1 more days, this patient will achieve maximal gavage feedings and maximal oral feedings by 1.2 weeks later. Jadcherla et al. J Perinatology 21

20 Summary of Objective-I & II Duration of Gavage feeds is an indicator of Gastric readiness and gastric emptying, intestinal clearance Initial oral feeds and full nipple feeds are indicators of oromotor readiness and oromotor efficiency Co-morbidities impact acquisition of feeding milestones Prolonged LOS is related to the degree of immaturity Jadcherla et al. J Perinatology 21

21 Speculations Chronic hypoxemia, narcotic usage, and CNS and ENS insults are hypothesized to contribute to feeding difficulty Delays in achieving maximum gavage feeds may suggest foregut dysmotility Delays in achieving maximum nippling feeds may suggest aero-digestive (airway-oromotor-pharyngealesophageal) concerns These findings support involvement of brain-foregut-airway interactions

22 Objective-III II. Identify potential mechanisms involved with feeding milestones Infant Process Brain Signals Knowledge Airway Gut Feeding NICU Providers Mom

23 Neural pathways regulating aero-digestive functions. Mittal RK. N Engl J Med 1997 HThal SCN Thal Cortical Esophagus and airways share similar innervation by the Vagus Afferent and efferent neuronal pathways modulate sensorymotor function

24 Gut Rhythms, Cycles, Clocks Gut rhythms (ultradian rhythms): esophageal, antral, duodenal, colonic contractile frequency Gastric acid secretion and Gastric emptying Sleep and circadian rhythms Inter-digestive migrating motility cycles Hunger and satiety cycles Gut enzyme expression and crypt-villus axis Central clock genes expressed in supra-chiasmatic nucleus Peripheral clock genes expressed in myenteric plexus Hoogerwerf WA. Current Gastroenterology Reports 26

25 Enteric Neuromuscular System or Second Brain or Peripheral rhythm generator Bolus Reflexes Short and Long segmental Conditioned, Voluntary or Involuntary Anterograde or Retrograde Modulators of ENS (Second Brain) Stimulus - Receptor - Afferents - Ganglia - Efferents - Muscles Bolus as a Stimulus Physical, Chemical, Spatio-temporal, Flow, Volume, Osmolarity Mucosa Afferent Nerve + ACH SP M Efferent Nerve - VIP - NO Receptors Enteric ganglia Circular Muscle Longitudinal Muscle

26 Gastro-intestinal motility sequences TERM Gastro-intestinal motility differs between premature and full term neonates in fasting and fed states Premies have immature gastroduodenal motility GI motility matures with growth, and impaired in neonatal feeding problems Berseth et al. J Pediatr 1989 Jadcherla et al. Pediatrics 1995 II I PRETERM I I I MMC

27 Primary peristalsis vs. Secondary peristalsis 3 M-Eso-Inf. Rib-Cage Secondary Peristalsis (ADAPTIVE) Esophageal infusion Primary Peristalsis (BASAL) Deglutition Apnea Abdomen Catheter Pharynx SUM EMG Diaphragm Stomach LES 1 Pharynx 1 UES 1 P-Eso 1 M-Eso 1 D-Eso 1 LES 1 Stomach mmhg UES Contraction LES relaxation SP PP UES relaxation LES relaxation Jadcherla et al. J Pediatr 23; 26; 27

28 Adaptive pharyngeal reflexes vs. dose responses 3 Px-Inf. Rib-Cage.1 ml.3 ml.5 ml EMG Catheter Pharynx LES Diaphragm Stomach 1 Pharynx 1 UES 1 P-Eso 1 M-Eso 1 D-Eso 1 LES 1 Stomach mmhg Single RPS 1 s Multiple RPS Multiple RPS 1 s 1 s Jadcherla et. al JPediatr 27

29 Nutritive Suck: Oral Feeding Challenge Test (Jadcherla et al. JPGN 29) Px-Inf. 3 3 M-Eso-Inf. Respiration Slow Flow, 142/26/1 Regular Respiration Medium Flow 15/44/1 Regular Respiration Fast Flow 17/9513/77 149/88148/96 Erratic Respiration EMG Pharyn x UES P-Eso M-Eso D-Eso LES Stomac h Propagated Swallow Propagated Swallow Decreased Suck : Swallow Ratio Propagated Swallow 1 S 1 S 1 S

30 Gut motility sequences at an oral feeding session Study 1, 51 wks PMA, 3.8 Kg Study 2, 6 wks PMA, 4.7 Kg Respiration Catheter Pharynx EMG Diaphragm Stomach LES 1 Pharynx UES P-Eso M-Eso D-Eso LES Stomach mmhg Irregular Swallow Irregular Swallow Suck 5 s 1 s Well Coordinated Swallow Suck Domino heart transplant, severe GERD, multiple ALTE requiring intubation Same infant on full PO feeds

31 Objective IV: Discuss multidisciplinary feeding management approach CRYING OG, NG OG, NG G tube G tube J tube J tube TPN TPN The future will be better tomorrow." George W. Bush We need to Change. Barack Obama

32 Related to feeding in NICU infants, what would you like to see being discussed? 9% Very Important 14% Very Important 31% 6% Somewhat Important Neutral Somewhat Important 86% Nursing Education Parent Education Collected responses: 131

33 During focused feeding rounds, what would you like to see being discussed? 2% 1% Very Important Somewhat Important 89% Neutral Development of an Individualized Feeding Plan Collected responses: 131

34 Feeding Rounds Primary Care Team: Improved communications, Monitoring compliance, Better practice Result: Better outcomes with lesser cost Neonatal Feeding Program/QI: Catalyst for solving feeding problem through state of the art methods Result: decreased LOS, feeding success, monitor feeding failures, improve growth and development Parents: Increased participation and understanding, acceptance of therapies, satisfaction of feeding their infants Radiology and GI: Adopting uniform practice, procedures, Diagnosis, follow up Connecting the dots

35 Feeding Milestones Defined 1 st Trophic Feed: Feed received at DOL 3 Duration of trophic feeds (1-2 ml/kg/d) for: 7-14 days (< 28 wk GA), 3-1 days ( 28 wk GA) Increments in feeds after trophic 2 ml/kg/d Full Gavage Feeds of at least 12 ml/kg/d (by d) 1 st Oral Feed 34 wk PMA Full Oral Feeds of at least 12 ml/kg/d at wks PMA

36 Feeding Process in the NICU Infant Discharge Trophic Feeds Trophic Feeds End/ Enteral Feeds Begin Full Enteral Feeds Achieved Full Enteral Feeds Maintained/ Cue based Feeds Begin 1 st Oral Feed Taken Full Oral Feeds Achieved

37 Length of Stay comparisons LOS Baseline Vs. Feeding Program 3 25 Baseline Feeding Rounds Feeding Program 2 Days Baseline Ave LOS 94 Days Program Ave LOS 66 Days

38 Complex feeding problem needs complex Individualized multidisciplinary approach Dysphagia Arching Individualized Strategy Cough or Choking spells Frequent Spit ups ALTE Irritability Failure of medical therapy Referral to Neonatal Feeding Disorders Program Anatomical evaluation Comprehensive medical evaluation Occupational Therapy evaluation Dietetic evaluation Psychologist advice Extended pharyngo-esophageal evaluation during a feeding cycle under manometry guidance Feeding success Feeding failure Compliance Follow up Review Individualized innovative Management care plan Personalized guided care plan Volume & caloric regulation Growth monitoring Occupational Therapy Hunger manipulation Operant Conditioning methods Manipulation of gut motility cycles Postural Therapy Pharmacological treatment Outcomes at discharge Jadcherla et al. JPGN 29

39 Feeding Outcomes among Infants referred for Gastrostomy At Evaluation N=1 At Discharge N=1 82% 18% 34% 15% 51% PO with P =.1 PO P =.1 symptoms Tube Tube+PO No PO By 1 year age, 2 patients lost follow up and 9 died; thus, data from 89 patients are shown. Feeding outcomes are significantly different after study evaluation and management. Jadcherla et al. Gastroenterology 29 A

40 Savings in health care $$$ Health care costs for children with feeding tubes at discharge: $18, per infant over 5 yrs (Piazza et al 24) In our study, if we avoided 51 Gastrostomy tubes at discharge, we may have saved about $ 9,1, over 5 years. This is an under-estimation. Improved Feeding Related Quality Of Life in Infants (FRQOLI) has unmeasured benefits. Jadcherla et al. Gastroenterology 29 A

41 The future. Preemie feeding a Preemie Thank You..

42 Acknowledgement National Institutes of Health (NIDDK) Grants Nationwide Children s Hospital and The Research Institute NICU Nursing and The Feeding Enhancement Program Champions NICU Parents