UPMC Newborn Medicine Program Neonatal Feeding Program: A Multidisciplinary Approach to Improving Long-Term Outcomes

Feeding issues can be a common occurrence in neonatal intensive care unit (NICU) patients. Premature or severely premature infants can suffer from developmental delays that can lead to feeding and swallowing issues. Infants with certain neurological disorders, muscle-impairing conditions, or congenital heart lesions all can experience difficulties with self-feeding or delays in reaching feeding ability milestones.

Infants in the NICU also can have a number of repeated negative oral experiences as a consequence of their treatments. Repeated intubations, oral suctioning, and even mouth care critical for their health and well-being can cause issues with feeding that must be overcome through the therapy process to develop more positive associations with activities occurring in and around the oral cavity.

In the past, neonatal feeding approaches were largely volume-driven, the success of an infant’s feeding capabilities or progress gauged on meeting volume targets for ingesting nourishment. However, as the evidence has evolved, volume-driven feeding approaches have been shown to provide suboptimal patient care. In some cases, this approach, in essence, leads to force-feeding the infant outside of their abilities or current developmental possibilities, potentially causing a range of acute physical and psychological impacts and even long-term consequences.

The multidisciplinary feeding program within the UPMC Newborn Medicine program and its NICUs has evolved its approach to one based largely on the concepts of infant-driven or cue-based feeding. It also is multidisciplinary, bringing together physicians, nursing, occupational therapy, speech-language pathology, and other disciplines to tackle the challenges associated with feeding difficulties in fragile NICU patients.

Members of the team, including Arcangela Lattari Balest, MD, a neonatologist and feeding specialist, and Sheryl Rosen, MA, CCC-SLP, dysphagia lead in the program, helped to spearhead many of the changes and evolution of feeding practices for NICU babies at UPMC. Occupational therapy colleagues Kelly Fill, MOT, OTR/L, and Nicole Klasmier, CScD, OTR/L, were instrumental in championing the transition to infant-driven feeding approaches, and their combined collaborative efforts during the last several years have reshaped the approach to infant feeding in the UPMC Newborn Medicine Program.

“We began the transition to infant-driven feeding protocols almost five years ago,” says Dr. Balest. Kelly and Nicole were instrumental in championing this approach within our newborn medicine program and working to bring these changes to fruition. In 2020 they presented data on outcomes from the first three years of our infant-driven feeding approach in a poster at the annual conference of the National Association of Neonatal Therapists.”

Infant-Driven Feeding

Infant-driven feeding relies on taking cues and paying close attention to the behaviors, actions, and responses to feeding that infants present. Aversions or difficulties that are not addressed or even exacerbated by forcing a one-size-fits-all approach to feeding neonates can lead to long-term or life-time difficulties with feeding and swallowing.

“We take a much more developmental and cautious approach to bringing NICU babies along in the feeding process. While being able to take in sufficient volume is ultimately what will help the baby go home, from a neurodevelopmental and neuroprotective perspective, focusing only on increasing volume without accounting for patient-specific circumstances can lead to real issues,” says Ms. Rosen.  “A more nuanced approach to feeding, one based on taking cues from the baby regarding their abilities, is the paradigm we have adopted and implemented with much success.”

The NICU Feeding Task Force

The NICU Feeding Task Force was formed in 2018. It consists of a multidisciplinary group of clinicians whose focus is on improving communications and functioning in the NICU relative to feeding protocols. The task force meets once a month to discuss broad issues related to feeding within the NICU. Nursing, therapy, and neonatology collaborate to tackle challenges and advocate for changes to protocols or quality improvement ideas that can lead to improved outcomes and better communication across caregiver teams.

“Dr. Balest has been an amazing resource for the NICU and the therapists, working as a bridge and facilitator between the neonatologists and therapy teams for feeding issues and discussions,” says Ms. Rosen.

NICU Feeding Rounds

In mid-2020, weekly NICU feeding rounds were established at UPMC Children’s. In Fall 2020, weekly feeding rounds were implemented in the NICU at UPMC Magee-Womens Hospital. Rounds occur each Wednesday for 30-minute sessions. Neonatal clinicians, speech and occupational therapy, and nursing meet to discuss the units' active cases and patients. The rounds afford everyone the opportunity to address patient status and challenges, progress, and changes in care necessary.

“More recently, colleagues from the pediatric otolaryngology division have joined the feeding rounds to lend their expertise to the patient cases and expand the multidisciplinary nature of the group,” says Dr. Balest.

Recent Quality Improvement Programs in Feeding

NG Tube Discharges 

Past protocols for NICU patients needing a nasogastric tube (NG tube) to facilitate feedings or act as a bridge to self-feeding dictated that they could not be discharged home until they could feed normally without the supplemental support of the NG tube. Sending patients home with an NG tube was viewed as too complex and fraught with the potential for complications, such as aspiration or misplacement of the tube during changes. 

That protocol changed in the latter part of 2020 and beginning of 2021 with the first patients with NG tubes discharged to home and cared for by family and very close follow-up support from home nursing services, case management, and the rest of the multidisciplinary members of the NICU feeding program.

"We are targeting this protocol at those cases where the baby is essentially ready to go home, except for the fact that they have the NG tube to support their nutritional needs temporarily. These patients are such that with the close support program we have developed, training for the family, and the attention of home nursing services, they can leave the hospital and continue their convalescence and development in the comforting surroundings of their home,” says Ms. Rosen.

The first two infants discharged to home with NG tubes as part of the new protocol are thriving physically and developmentally in the comfort of their home, achieving good weight gain and continued advancement of their oral skills. One of the infants was able to discontinue using the NG tube less than two weeks after discharge. At the time of discharge, the patient could only feed by mouth approximately 50% of the time.

“Both families of our first two NG tube discharge babies were extremely pleased with the nature and level of support our new program provides, and even more appreciative to have been able to bring their newborns home earlier,” says Dr. Balest.

Testing and Refining Thickening Levels of Liquid Nutrition

A recent quality improvement effort from the feeding program saw testing and changes to the level of thickening agents used in liquid diets while undertaking swallowing studies in infants that aspirate on thin liquids.

Some infants can have difficulties with very thin liquids, requiring a thickening agent (infant cereal) to facilitate swallowing. The feeding program previously used two different levels of thickening agents, but through observation and trial, found that too thick of a mixture also posed swallowing challenges for some patients.

"We have worked out four levels of thickening to use with our patients. The approach gives us a wider range of options to work with or test. It is all about reaching the optimal level of customization for each infant to allow them to be as successful as they can in feeding and swallowing," says Ms. Rosen.