Callie is a neonatal therapist who has worked in a level 3 NICU for 10 years. Her unit stocks disposable nipples of varying flow rates. There is a small supply of reusable bottle systems, but they are only available when therapy recommends and brings them to the unit. Callie aims to support her unit in providing positive feeding experiences for babies and families. Yet, as with many NICU roles, she has challenges to her daily workflow. Let’s look at a typical morning for Callie.
Callie’s first patient, William, was born at 30 weeks and is now 35 weeks PMA. Previously, Callie recommended a disposable slow flow nipple for feedings. At care time, William exhibits readiness cues. Callie begins the feeding with the disposable nipple recommended, although the flow appears too fast. Despite other supportive strategies, William continues to have reduced coordination of suck/swallow/breathe. Callie decides it might be the nipple, so she tosses that nipple and grabs another of that same type, only to find that this nipple has no hole in it. She tries a third, which seems to be appropriate, and she proceeds to feed William. As Callie had to return William to his bed each time she got a new nipple, by this time, he no longer has interest in feeding.
The Dreaded Drama: Callie is annoyed that several of the same disposable nipples were used for one feeding, while William did not maintain his alert state as Callie tried to find the ‘right’ nipple. How frustrating for William! If the ‘right’ nipple had been chosen right away, he might have had a more positive feeding! Additional drama included increased time spent and a waste of product.
Callie moves on to baby Francesca, born 28 weeks, now 38 weeks. Yesterday, Francesca exhibited reduced coordination of suck/swallow/breathe with any nipple other than the disposable slowest flow nipple. Callie recommended this nipple, created a bedside feeding plan, and met with parents. Today, she discussed Francesca’s progress with the nurse, who reported they are using a faster flow than recommended because on nights, the nipple seemed ‘way too slow.’ She reports Francesca is doing ‘ok, needing a lot of pacing,’ but that the other slow flow was too slow.
The Dreaded Drama: Callie feels her recommendations aren’t being followed; the nurses feel Speech is overly cautious; and Francesca wonders why these people keep switching flow rates.
Spoiler: The problem isn’t with either staff, but because the nipples are so inconsistent, they DO vary each time.
Callie next sees Caleb, born at 30 weeks, now 39 weeks. Caleb had a video swallow study yesterday, with aspiration on all hospital disposable nipples. The therapist had a reusable bottle system in her office, and Caleb was judged to be safe with this system with a particular slow flow nipple. The bottle was left at the bedside for his night feedings. Today, Callie follows up with Caleb, and Mom is at the bedside. The nurse reports that the bottle ‘disappeared,’ and since Callie was not available, Mom and the night nurse had to use a slow flow disposable. Caleb had reduced coordination of suck/swallow/breathe, even with pacing, and exhibited episodes of coughing and desaturation. The episode did not resolve quickly and scared the mother, who became worried about feeding her son.
The Dreaded Drama: Although Caleb fed safely on the video swallow study with a particular product, the nursing staff did not have access to this product at night. Mom questions Callie that she thought Caleb was safe on a ‘slow flow’ and is confused as to why the hospital doesn’t have the product Caleb needs. She expresses fear about feeding Caleb safely and taking him home. Caleb is also beginning to learn that feeding can be unsafe, and not sure he wants to try again after that last episode.
Poor Callie! She is frustrated with the lack of resources and the inconsistency of these nipples and the disappointment from the parents.
As a neonatal therapist, do you experience these daily dreaded dramas?
Stay tuned next month to learn about a resolution for the Daily Dreaded Drama of the Disposable Nipple.
