Columbus, OH - August 2016
The practice of orally feeding babies who have bronchopulmonary dysplasia (BPD), but who do not need a breathing tube, remains controversial. With no breathing tube in the way, it’s possible to introduce liquid to the mouth. But those infants still depend on noninvasive respiratory support, such as nasal continuous positive airway pressure (nCPAP) or nasal cannula.
Many neonatologists do not want to risk increasing respiratory distress because of concern about aspiration or gastroesophageal reflux disease (GERD), potentially caused by oral feeding. Instead, they wait until the babies are breathing room air.
A recent study from clinician-researchers at Nationwide Children’s Hospital, however, has shown that babies on noninvasive respiratory support have adequate aerodigestive reflexes to prevent aspiration, and that concern over increased incidence of GERD is unfounded.
That study, and a complimentary 2015 Nationwide Children’s study showing that controlled oral feedings for infants on nCPAP result in achieving earlier feeding milestones, suggest an overall benefit to early oromotor feeding therapies.
“A positive oral motor nutritive stimulation to babies on minimally invasive respiratory support can help enhance swallowing skills,” says Sudarshan Jadcherla, MD, director of the Neonatal and Infant Feeding Disorders Program and the Neonatal Aerodigestive Pulmonary Program at Nationwide Children’s. “The sooner they learn to eat and are not dependent on a feeding tube, the sooner they can leave the hospital safely.”
Dr. Jadcherla was the lead author of the most recent paper, published in the American Journal of Physiology – Gastrointestinal and Liver Physiology. He was senior author of the 2015 paper, published in Dysphagia.
The recent study prospectively enrolled 38 infants born at approximately 28 weeks gestational age. A total of 28 infants had BPD; nine were on nCPAP and 19 were on nasal cannula. The remaining infants breathed room air, did not have a diagnosis of BPD and were used as a control group. Nasogastric and orogastric tubes were briefly removed and manometry catheters were placed for testing.
Small volumes of sterile water were introduced into the pharynx. Pharyngo-esophageal responses – including upper esophageal sphincter reflexes, pharyngeal contractile waveform recruitment and many others – were recorded and analyzed.
While some differences in upper esophageal sphincter nadir pressures and esophageal body propagation characteristics were found between the infants in the noninvasive respiratory support groups and the room air group, researchers judged those not to be clinically significant.
But similarities in some reflexes, such as upper esophageal sphincter contraction and lower esophageal sphincter relaxation, show that infants on nCPAP and nasal cannula have developed mechanisms to protect against aspiration and reflux.
“We have discovered and quantified these adaptive reflexes, and these reflexes are operational so as to protect the airway,” says Dr. Jadcherla, who is also a professor of Pediatrics at The Ohio State University College of Medicine. ”We need a good clinical trial to say for sure that clinicians should feed babies on nCPAP and nasal cannula, but we now have evidence supporting that conclusion.”
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. American Journal of Physiology – Gastrointestinal and Liver Physiology. 2016 Jun 1; 310(11): G1006-14.
Hanin M, Nuthakki S, Malkar MB, Jadcherla SR. Safety and efficacy of oral feeding in infants with BPD on nasal CPAP. Dysphagia. 2015 Apr; 30(2): 121-7.