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Oral Feeding for Infants and Children Receiving Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Respiratory Supports: A Survey of Practice

Abstract

To investigate oral-feeding practices for infants and children receiving nasal continuous positive airway pressure (nCPAP) and high-flow nasal cannula (HFNC) respiratory support. A survey was sent to Neonatal (NICU) and Paediatric Intensive Care Units (PICU) in Australia and New Zealand to explore feeding practices for infants/children receiving nCPAP and HFNC, including criteria for commencing/recommencing oral feeding, frequency of oral feeding, strategies to assist oral feeding, assessment tools, reasons for not orally feeding, existence of written guidelines and staff opinion regarding feeding safety. Seventy-seven individual survey responses were analysed from 49 units from 38 hospitals. Most units (53%) reported that infants/children are ‘never or rarely’ fed orally on nCPAP compared with 21% on HFNC. 2% of units ‘often’ feed infants on nCPAP whilst 38% ‘often’ feed on HFNC. Oral feeding on HFNC is more likely to occur in a NICU (100% sometimes/often) than a PICU (55% sometimes/often) setting. Only 4% of infants are often fed orally on nCPAP versus 54% on HFNC in NICUs. Eighty percent of all units reported they do not have a written policy or guideline that includes feeding recommendations for infants/children receiving non-invasive respiratory supports. Oral feeding for infants and children receiving nCPAP and HFNC is occurring in NICU and PICUs in Australia and NZ. There is varied opinion regarding the safety of oral feeding on nCPAP and HFNC. Further research is recommended, including studies with instrumental assessment of swallow safety and investigation of short and long-term feeding outcomes, to guide clinicians in this area of practice.

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References

  1. 1.

    Roberts CL, Badgery-Parker T, Algert CS, Bowen JR, Nassar N. Trends in use of neonatal CPAP: a population-based study. BMC Pediatr. 2011;11:89. https://doi.org/10.1186/1471-2431-11-89.

  2. 2.

    Wilkinson D, Andersen C, O’Donnell CP, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2016;2:CD006405. https://doi.org/10.1002/14651858.cd006405.pub3.

  3. 3.

    Coletti KD, Bagdure DN, Walker LK, Remy KE, Custer JW. High-flow nasal cannula utilization in pediatric critical care. Respir Care. 2017;62(8):1023–9. https://doi.org/10.4187/respcare.05153.

  4. 4.

    Milesi C, Essouri S, Pouyau R, Liet JM, Afanetti M, Portefaix A, Baleine J, Durand S, Combes C, Douillard A, Cambonie G, Groupe Francophone de Reanimation et d’Urgences P. High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study). Intensive Care Med. 2017;43(2):209–16. https://doi.org/10.1007/s00134-016-4617-8.

  5. 5.

    Dalgleish SR, Kostecky LL, Blachly N. Eating in “SINC”: safe individualized nipple-feeding competence, a quality improvement project to explore infant-driven oral feeding for very premature infants requiring noninvasive respiratory support. Neonatal Netw. 2016;35(4):217–27. https://doi.org/10.1891/0730-0832.35.4.217.

  6. 6.

    Shetty S, Hunt K, Douthwaite A, Athanasiou M, Hickey A, Greenough A. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 2016;101(5):F408–11. https://doi.org/10.1136/archdischild-2015-309683.

  7. 7.

    Leder SB, Siner JM, Bizzarro MJ, McGinley BM, Lefton-Greif MA. Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia. 2016;31(2):154–9. https://doi.org/10.1007/s00455-015-9669-3.

  8. 8.

    Ferrara L, Bidiwala A, Sher I, Pirzada M, Barlev D, Islam S, Rosenfeld W, Crowley CC, Hanna N. Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates. J Perinatol. 2017;37(4):398–403. https://doi.org/10.1038/jp.2016.229.

  9. 9.

    Jadcherla SR, Bhandari V. “Pressure” to feed the preterm newborn: associated with “positive” outcomes? Pediatr Res. 2017;82(6):899–900. https://doi.org/10.1038/pr.2017.198.

  10. 10.

    Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol. 2012;47(4):321–37. https://doi.org/10.1002/ppul.21576.

  11. 11.

    Davis NL, Liu A, Rhein L. Feeding immaturity in preterm neonates: risk factors for oropharyngeal aspiration and timing of maturation. J Pediatr Gastroenterol Nutr. 2013;57(6):735–40. https://doi.org/10.1097/MPG.0b013e3182a9392d.

  12. 12.

    Khoshoo V, Edell D. Previously healthy infants may have increased risk of aspiration during respiratory syncytial viral bronchiolitis. Pediatrics. 1999;104(6):1389–90.

  13. 13.

    Dodrill P, Gosa M, Thoyre S, Shaker C, Pados B, Park J, DePalma N, Hirst K, Larson K, Perez J, Hernandez K. FIRST, DO NO HARM: a response to “oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula”. Dysphagia. 2016;31(6):781–2. https://doi.org/10.1007/s00455-016-9722-x.

  14. 14.

    Bizzarro MJ, Lefton-Greif MA, McGinley BM, Siner JM. FIRST, “KNOW” HARM: response to Letter to the Editor. Dysphagia. 2016;31(6):783–5. https://doi.org/10.1007/s00455-016-9748-0.

  15. 15.

    Slain KN, Martinez-Schlurmann N, Shein SL, Stormorken A. Nutrition and high-flow nasal cannula respiratory support in children with bronchiolitis. Hosp Pediatr. 2017;7(5):256–62. https://doi.org/10.1542/hpeds.2016-0194.

  16. 16.

    Leroue MK, Good RJ, Skillman HE, Czaja AS. Enteral nutrition practices in critically ill children requiring noninvasive positive pressure ventilation. Pediatr Crit Care Med. 2017;18(12):1093–8. https://doi.org/10.1097/PCC.0000000000001302.

  17. 17.

    Hanin M, Nuthakki S, Malkar MB, Jadcherla SR. Safety and efficacy of oral feeding in infants with BPD on nasal CPAP. Dysphagia. 2015;30(2):121–7. https://doi.org/10.1007/s00455-014-9586-x.

  18. 18.

    Jadcherla SR, Hasenstab KA, Sitaram S, Clouse BJ, Slaughter JL, Shaker R. Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants. Am J Physiol Gastrointest Liver Physiol. 2016;310(11):G1006–14. https://doi.org/10.1152/ajpgi.00307.2015.

  19. 19.

    Samson N, Nadeau C, Vincent L, Cantin D, Praud JP. Effects of nasal continuous positive airway pressure and high-flow nasal cannula on sucking, swallowing, and breathing during bottle-feeding in lambs. Front Pediatr. 2017;5:296. https://doi.org/10.3389/fped.2017.00296.

  20. 20.

    Samson N, Michaud A, Othman R, Nadeau C, Nault S, Cantin D, Sage M, Catelin C, Praud JP. Nasal continuous positive airway pressure influences bottle-feeding in preterm lambs. Pediatr Res. 2017;82(6):926–33. https://doi.org/10.1038/pr.2017.162.

  21. 21.

    Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care. 2003;15(3):261–6.

  22. 22.

    Bennett C, Khangura S, Brehaut JC, Graham ID, Moher D, Potter BK, Grimshaw JM. Reporting guidelines for survey research: an analysis of published guidance and reporting practices. PLoS Med. 2010;8(8):e1001069. https://doi.org/10.1371/journal.pmed.1001069.

  23. 23.

    Ludwig S, Waitzman K. Changing feeding documentation to reflect infant-driven feeding practice. Newborn Infant Nurs Rev. 2007;7(3):155–60.

  24. 24.

    Wolf L, Glass R. Feeding and swallowing disorders in infancy: assessment and management psychological corporation. Indianapolis: PRO-ED; 1992.

  25. 25.

    Philbin MK, Ross ES. The SOFFI Reference Guide: text, algorithms, and appendices: a manualized method for quality bottle-feedings. J Perinat Neonatal Nurs. 2011;25(4):360–80. https://doi.org/10.1097/JPN.0b013e31823529da.

  26. 26.

    Schibler A, Pham TM, Dunster KR, Foster K, Barlow A, Gibbons K, Hough JL. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847–52. https://doi.org/10.1007/s00134-011-2177-5.

  27. 27.

    Oymar K, Skjerven HO, Mikalsen IB. Acute bronchiolitis in infants, a review. Scand J Trauma Resusc Emerg Med. 2014;22:23. https://doi.org/10.1186/1757-7241-22-23.

  28. 28.

    Jones MW, Morgan E, Shelton JE. Dysphagia and oral feeding problems in the premature infant. Neonat Netw. 2002;21(2):51–7.

  29. 29.

    Ross ES, Philbin MK. Supporting oral feeding in fragile infants: an evidence-based method for quality bottle-feedings of preterm, ill, and fragile infants. J Perinat Neonatal Nurs. 2011;25(4):349–57. https://doi.org/10.1097/jpn.0b013e318234ac7a quiz 358-349.

  30. 30.

    Weir K, McMahon S, Barry L, Masters IB, Chang AB. Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children. Eur Respir J. 2009;33(3):604–11. https://doi.org/10.1183/09031936.00090308.

  31. 31.

    Arvedson JC. Management of pediatric dysphagia. Otolaryngol Clin N Am. 1998;31(3):453–76.

  32. 32.

    Clark LKG, Pring T, Hird M. Improving bottle feeding in preterm infants: investigating the elevated side-lying position. Infant. 2007;3(4):154–8.

  33. 33.

    Park J, Thoyre S, Knafl GJ, Hodges EA, Nix WB. Efficacy of semielevated side-lying positioning during bottle-feeding of very preterm infants: a pilot study. J Perinat Neonatal Nurs. 2014;28(1):69–79. https://doi.org/10.1097/JPN.0000000000000004.

  34. 34.

    Parke RL, Eccleston ML, McGuinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care. 2011;56(8):1151–5. https://doi.org/10.4187/respcare.01106.

  35. 35.

    Wilkinson DJ, Andersen CC, Smith K, Holberton J. Pharyngeal pressure with high-flow nasal cannulae in premature infants. J Perinatol. 2008;28(1):42–7. https://doi.org/10.1038/sj.jp.7211879.

  36. 36.

    Shaker CS. Cue-based feeding in the NICU: using the infant’s communication as a guide. Neonat Netw. 2013;32(6):404–8. https://doi.org/10.1891/0730-0832.32.6.404.

  37. 37.

    Davidson E, Hinton D, Ryan-Wenger N, Jadcherla S. Quality improvement study of effectiveness of cue-based feeding in infants with bronchopulmonary dysplasia in the neonatal intensive care unit.[Erratum appears in J Obstet Gynecol Neonatal Nurs. 2014 Jul-Aug;43(4):539]. J Obstet Gynecol Neonatal. 2013;42(6):629–40. https://doi.org/10.1111/1552-6909.12257.

  38. 38.

    Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–30.

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Acknowledgements

We would like to thank the following: The respondents for taking time to complete the survey. Professor Sharon Mickan for her support in providing an Allied Health Research Clinical Backfill Grant (AC). Melissa Lawrie, Director of Speech Pathology, GCUH for her ongoing support and commitment to research.

Author information

Correspondence to Angie Canning.

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Appendix: Survey

Appendix: Survey

Section 1. Consent

*Q1. I consent to be part of this research study entitled Survey of Feeding Practices for Infants and Children Receiving Nasal Continuous-Positive Airway Pressure (nCPAP) or High Flow Nasal Cannula (HFNC) Respiratory Supports

  • Yes

  • No

Section 2. Demographics

*Q2. What country do you live in?

  • Australia

  • New Zealand

  • Ireland

  • United Kingdom

  • Other (please specify):

Q3. What is the name of your hospital or facility? (This information will remain confidential and will not be reported)

Q4. What is the name of your unit? (This information will remain confidential and will not be reported. If you work in more than one unit, please indicate only one unit for the purpose of this survey. You are welcome to complete another survey regarding your other work unit/s, if you wish).

*Q5. How is your unit classified?

  • Neonatal Intensive Care Unit (NICU) only

  • Special Care Unit (SCN) only

  • NICU and SCN (located together)

  • Paediatric Intensive Care Unit (PICU)

  • Paediatric Inpatient Unit

  • PICU and NICU (located together)

  • Other (please specify):

*Q6. What is your role?

  • Nursing Unit Manager (NUM)

  • Speech Pathologist (SP)/Speech and Language Therapist (SLT)

  • Neonatologist

  • PICU Consultant

  • Other (please specify):

*Q7. What age group does your unit provide services to? (Please tick all that apply):

  • Preterm infants (< 37 weeks gestational age)

  • Neonates (0 to 1 month of age)

  • Infants (1 to 12 months of age)

  • Preschool age (1 to 5 years of age)

  • School age (> 5 to < 18 years of age)

Q8. How many beds/cots in your unit?

Section 3. Nasal Continuous-Positive Airway Pressure (nCPAP)

*Q9. Is nasal continuous-positive airway pressure (nCPAP) * used in your unit?

  • Yes

  • No-skip to Q17

The following questions relate to the care of infants and children who receive nCPAP in your unit.

*Q10. Which nutrition therapy/routes of nutrition are used with infants and children receiving nCPAP in your unit? (Please tick all that apply)

  • Parenteral nutrition

  • Orogastric-continuous

  • Orogastric-bolus

  • Nasogastric-continuous

  • Nasogastric-bolus

  • Oral feeding

  • Other (please specify):

*Q11. Are infants/children who receive nCPAP fed orally?

  • Often

  • Sometimes

  • Rarely

  • Never

*Q12. Oral feeding methods for infants receiving nCPAP (please tick all that apply):

  • Breast feeding

  • Bottle feeding

  • Infant cup

  • Syringe

  • Cup (sipper/straw/open cup)

  • Solids

  • Other (please specify):

*Q13. Are there any restrictions to food textures or fluid consistencies provided to infants/children receiving nCPAP?

  • No

  • Yes (please specify):

*Q14. Please indicate which fluid consistencies and food textures are allowed to infants/children receiving nCPAP in your unit:

  • Thin fluids

  • Thickened fluids

  • Purees

  • Lumpy mashed foods

  • Minced and moist foods

  • Chewable foods

  • All of the above

*Q15. What strategies are employed while the infant/child receiving nCPAP is feeding orally? (please tick all that apply)

  • Volume limited feeds

  • Time limited feeds

  • Monitoring of physiological stability

  • Respiratory support is reduced

  • Specific criteria for respiratory stability is required (eg. respiratory rate)

  • Specified pressure (cmH2O)

  • Monitoring for clinical signs of aspiration

  • Positioning modifications

  • Therapeutic tastes

  • Specific feeding equipment (eg. type of teat)

  • None

  • Other (please specify)

*Q16. Who provides the oral feeds to the infants/children receiving nCPAP? (please tick all that apply):

  • Parents/carers

  • Nursing staff

  • Speech pathologist/therapist

  • Occupational therapist

  • Other (please specify):

Section 4. High Flow Nasal Cannula (HFNC)

*Q17. Is high flow nasal cannula (HFNC) respiratory support * used in your unit?

  • Yes

  • No-skip to Q26

The following questions related to the care of infants and children receiving high flow nasal cannula (HFNC) respiratory support in your unit:

*Q18. How does your unit define high flow?

  • 1 or more litres per minute (> 1 L/min)

  • 2 or more litres per minute (> 2 L/min)

  • Litres per kilogram (L/kg)

  • Unsure

  • Other (please specify):

*Q19. Which nutrition support therapy/routes of nutrition are used with infants/children receiving HFNC in your unit (please tick all that apply):

  • Parental nutrition

  • Orogastric-continuous

  • Orogastric-bolus

  • Nasogastric-continuous

  • Nasogastric-bolus

  • Oral feeding

  • Other (please specify)

*Q20. Are infants/children who are receiving HFNC fed orally?

  • Often

  • Sometimes

  • Rarely

  • Never

*Q21. Oral feeding methods for infants/children receiving HFNC (please tick all that apply):

  • Breast feeding

  • Bottle feeding

  • Infant cup

  • Syringe

  • Cup (sipper/straw/open cup)

  • Solids

  • Other (please specify)

*Q22. Are there any restrictions to food textures or fluid consistencies provided to infants/children receiving HFNC?

  • Yes

  • No

*Q23. Please indicate which food textures and fluid consistencies are allowed to infants/children receiving HFNC in your unit (please tick all that apply):

  • Thin fluids

  • Thickened fluids

  • Purees

  • Lumpy mashed foods

  • Minced and moist foods

  • Chewable foods

  • All of the above

*Q24. What specific strategies are employed while the infant/child receiving HFNC is feeding orally (please tick all that apply):

  • Volume limited feeds

  • Time limited feeds

  • Monitoring of physiological stability

  • Respiratory support is reduced

  • Specific criteria for respiratory stability is required (eg. respiratory rate)

  • Specific litres per minute (L/min) or litres per kilogram (L/kg)

  • Monitoring for clinical signs of aspiration

  • Positioning modifications

  • Therapeutic tastes

  • Specific feeding equipment (eg. type of teat)

  • None

  • Other (please specify):

*Q25. Who provides the oral feeds to the infants/children receiving HFNC? (please tick all that apply):

  • Parents/carers

  • Nursing staff

  • Speech Pathologist/Therapist

  • Occupational Therapist

  • Other (please specify):

Section 5 No oral feeding on nCPAP

*Q26. If you replied no to the question ‘Are infants/children who are receiving nCPAP in your unit fed orally?’, please tells us why (tick all that apply):

  • Medical team do not allow

  • Aspiration risk is unclear

  • Infants are too young to commence oral feeding

  • Not applicable

  • Other (please specify):

Section 6. No oral feeding on HFNC

*Q27. If you replied no to the question ‘Are infants/children who are receiving HFNC in your unit fed orally?’, please tell us why (tick all that apply):

  • Medical team do not allow

  • Aspiration risk is unclear

  • Infants are too young to commence oral feeding

  • Not applicable

  • Other (please specify):

Section 7. Feeding Management

*Q28. Who decides when oral feeding is commenced/recommenced for infants/children in your unit? (Please tick all that apply):

  • Medical officer

  • Nursing staff

  • Speech Pathologist/Therapist

  • Occupational Therapist

  • Parent/carer

  • Team decision

  • Other (please specify):

*Q29. What are the criteria/tools used to assess infant/child readiness for oral feeding? (Please tick all that apply):

  • Age

  • Weight

  • No longer on nCPAP

  • No longer on HFNC

  • Cardiorespiratory stability

  • Resolution/improvement of current illness

  • Observation of feeding readiness cues

  • Specific flow rate (L/min, L/kg, cmH2O)

  • Workplace guidelines

  • Oral feeding readiness tool (please specify details below)

  • Other (please specify):

*Q30. Does your unit have a written policy or guideline that includes feeding method recommendations for infants/children receiving non-invasive respiratory supports (nCPAP, HFNC, LFNC)?

  • Yes

  • No

Q31. If you answered yes to the above question, can you please share this document with us?( Not for distribution, for our information only)

Please upload your document here.

*Q32. Are specialist feeding assessment and intervention services provided in your unit?

  • No

  • Yes

  • How many days per week?

*Q33. Who provides specialist feeding assessment and intervention services in your unit?

  • Speech Pathologist/Therapist

  • Occupational Therapist

  • Other (please specify):

*Q34. Is the feeding therapist referred infants/children who are receiving nCPAP to assess oral feeding readiness and safety?

  • Yes

  • No

  • Not applicable

Q35. Is the feeding therapist referred infants/children who are receiving HFNC to assess oral feeding readiness and safety?

  • Yes

  • No

  • Not applicable

Q36. Are formal or informal oral feeding evaluation tools used in your unit to assess oral sensorimotor, feeding and swallowing function/competence?

  • No

  • Yes (please specify):

Q37. Is instrumental evaluation of the swallow used to assess swallow safety for infants/children in your unit?

  • No

  • Yes (please tick all that apply):

  • Videofluoroscopic swallow study (VFSS) or modified barium swallow (MBS)

  • Fiberoptic endoscopic evaluation of swallowing (FEES)

  • Pharyngeal manometry

  • Cervical auscultation

  • Pulse oximetry

  • Other (please specify):

Q38. What indicators are used to determine if the infant/child is not tolerating an oral feed? (Please tick all that apply):

  • Decrease in physiological stability

  • Behavioural cues

  • Clinical signs of aspiration or laryngeal penetration

  • Changes in state

  • Organisation of sucking, swallowing and breathing

  • None

  • Other (please specify):

*Q39. In your unit, are there any differences of opinion between staff regarding feeding practices for infants/children receiving nCPAP or HFNC?

  • No

  • Yes (please elaborate):

Thank you for taking the time to complete this survey.

Q40. Please let us know your name, phone number and email address, if agreeable.

This information is for follow-up/further enquiries only (if required).

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Canning, A., Fairhurst, R., Chauhan, M. et al. Oral Feeding for Infants and Children Receiving Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Respiratory Supports: A Survey of Practice. Dysphagia (2019). https://doi.org/10.1007/s00455-019-10047-4

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Keywords

  • Infants
  • Children
  • Oral feeding
  • Swallowing
  • nCPAP
  • HFNC