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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

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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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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

Authors and Affiliations

  1. Speech Pathology Department, Gold Coast University Hospital, Gold Coast, Australia

    Angie Canning & Rachael Fairhurst

  2. Newborn Care Unit, Gold Coast University Hospital, Gold Coast, Australia

    Manbir Chauhan

  3. Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia

    Kelly A. Weir

  4. Clinical Governance, Education & Research, Gold Coast University Hospital, Gold Coast, Australia

    Kelly A. Weir

  5. Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD, 4215, Australia

    Angie Canning

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  1. Angie Canning
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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 35, 443–454 (2020). https://doi.org/10.1007/s00455-019-10047-4

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