Slow flow nipple?

  1. I recently had an upsetting experience at work, and wondered your opinions.

    When bottle feeding, how do you go about choosing a nipple type? For example, for a premature baby, I prefer to try and use a slow flow nipple. For a baby that is breastfeeding at times, I prefer to bottle feed with a slow flow nipple.

    I recently cared for an ex 25 weeker corrected to 42 weeks on 2 liters of oxygen, bottle feeding six times a day when her respiratory rate was less than 70. She had an echo four days prior that showed mild pulmonary hypertension. The night nurse told me the baby spilled milk out of her mouth the entire feed and the feed was a struggle with the baby arching and crying. I decided I wanted to try and feed this baby with a slow flow nipple in an elevated side lying position. However, the baby had a physician order stating only a standard nipple was to be used. When the speech language pathologist arrived, I explained my concerns to her stating I was concerned the baby could be aspirating (since she clearly couldn't handle the milk flow as evidenced by her spilling the milk out the front and sides of her mouth while eating. The SLP stated that if she was spilled the milk out of her mouth, she was not aspirating it. She told me she was more concerned with the baby's pulmonary hypertension being exacerbated due to "having to work harder to get the milk out with the slow flow" than potential aspiration from the standard flow nipple. It should also be shared that this SLP covers the entire adult hospital and RARELY comes into the NICU. I think I have seen her twice now in over four years working in this NICU. She also told me it was a myth that using a slow flow nipple will help a baby transition to breastfeeding in the future.

    I'm curious. What do y'all think? Do y'all use slow flow nipples? Would you have been concerned about aspiration and potential pulmonary hypertension exacerbation? Do you think it's odd to have a physician order stating you cannot use a slow flow nipple? Thank you for your input!
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    Joined: Mar '18; Posts: 1
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    12 Comments

  3. by   Guy in Babyland
    So, she is concerned about PPHN but not worried about the baby not gaining weight due to spilling most of the feed. I would use a cloth diaper or washcloth as a bib. Weigh the cloth diaper/washcloth before the feed and after the feed and record the intake as the net amount.

    If the baby has the potential of causing exacerbation of PPHN due to the choice of nipple, should they be orally fed?
  4. by   itsybitsy
    I'm sorry, but this is so wrong. This is just asking for aversion after aversion.

    "Spilling milk out of her mouth" is anterior loss. It's showing that the baby is not tolerating the flow of the feeding. The feeding is coming out of the nipple too fast, the baby is pushing it out. It's also a sign that that feeding should cease. If it continues, the baby is eventually going to get worn out and aspirate, because it will be too exhausted to push it out any longer.

    Secondly, arching, crying, pushing away from the nipple, falling asleep, etc., with a feeding are also signs that the baby is done eating. That baby is cueing that the feeding is no longer wanted... I wonder why. The faster flow is probably stressing the baby out more, probably exasperating the PPHN.

    This is a 25 weeker, who is 42 weeks, on oxygen, and have mild PPHN. If we are even going to orally feed this kid, it BETTER be slow flow, probably with a thickener.

    ALL of our premature babies are fed with a slow flow nipple, and most term kids are as well, all the way to discharge, and we send parents home with a slow flow bottle and nipple, to continue using. ALL of our premature babies are held in a left-side lying position, elevated. Many of our kids are paced, if it's needed.

    The order needs to be deleted from use. The kid is in the NICU for a reason, and doesn't need to aspirate, in which case they are at higher risk for if they have had any respiratory problems. The few kids that could probably use standard flow nipples are the chorio kids that just need some antibiotics and haven't had any respiratory problems.

    The SLP is not educated on neonatal feedings, obviously. I'd rather not have a kid that has mild PPHN to aspirate, thanks. Slow flow nipple is NOT harder to get out of the nipple, it's to literally SLOW THE FLOW. These kids SHOULD eat slower, so they DON'T aspirate. If the baby is worn out, then the feeding is done. If the baby isn't meeting their full feeds, then you need to tube feed, to meet those requirements. Obviously this is an ongoing problem, seeing as the baby is 42 weeks, in which case, I wouldn't be surprised if the baby needs a button to go home.

    My suggestion - Lobby for a SLP full-time in the NICU that knows what they are talking about.
  5. by   Leader25
    Quote from RNLAC
    I recently had an upsetting experience at work, and wondered your opinions.

    When bottle feeding, how do you go about choosing a nipple type? For example, for a premature baby, I prefer to try and use a slow flow nipple. For a baby that is breastfeeding at times, I prefer to bottle feed with a slow flow nipple.

    I recently cared for an ex 25 weeker corrected to 42 weeks on 2 liters of oxygen, bottle feeding six times a day when her respiratory rate was less than 70. She had an echo four days prior that showed mild pulmonary hypertension. The night nurse told me the baby spilled milk out of her mouth the entire feed and the feed was a struggle with the baby arching and crying. I decided I wanted to try and feed this baby with a slow flow nipple in an elevated side lying position. However, the baby had a physician order stating only a standard nipple was to be used. When the speech language pathologist arrived, I explained my concerns to her stating I was concerned the baby could be aspirating (since she clearly couldn't handle the milk flow as evidenced by her spilling the milk out the front and sides of her mouth while eating. The SLP stated that if she was spilled the milk out of her mouth, she was not aspirating it. She told me she was more concerned with the baby's pulmonary hypertension being exacerbated due to "having to work harder to get the milk out with the slow flow" than potential aspiration from the standard flow nipple. It should also be shared that this SLP covers the entire adult hospital and RARELY comes into the NICU. I think I have seen her twice now in over four years working in this NICU. She also told me it was a myth that using a slow flow nipple will help a baby transition to breastfeeding in the future.

    I'm curious. What do y'all think? Do y'all use slow flow nipples? Would you have been concerned about aspiration and potential pulmonary hypertension exacerbation? Do you think it's odd to have a physician order stating you cannot use a slow flow nipple? Thank you for your input!
    Slo flo nipples are not all that lately the SLP have been using a Dr Brown, premie or regular flo,the use the upright side lying also for some.As far as slo flo being better for future breastfeeding it is no longer thought so based on evidence same goes for Non nutritive sucking,.
    As for the potential of increasing pulmonary hypertension i would follow the MD orders as it is a risk vs benefit,and the pulmonary hypertension being riskier in my own opinion.
  6. by   vintage_RN
    We don't even orally feed any kid on respiratory support...even low flow. We don't even attempt oral feeds until they're completely off and in room air.
  7. by   itsybitsy
    Quote from Leader25
    Slo flo nipples are not all that lately the SLP have been using a Dr Brown, premie or regular flo,the use the upright side lying also for some.As far as slo flo being better for future breastfeeding it is no longer thought so based on evidence same goes for Non nutritive sucking,.
    As for the potential of increasing pulmonary hypertension i would follow the MD orders as it is a risk vs benefit,and the pulmonary hypertension being riskier in my own opinion.
    Slow flow nipples are not all that?? What is that suppose to mean? That they don't work or what? If you're trying to say the practice is being outdated, you're sorely mistaken. Slow flow nipples are very heavily supported by evidence, and continue to be.

    You mention your SLP using a premie Dr. Brown nipple, which is a slower flow nipple than standard.

    So you would follow the MD orders to use a standard flow, because it's risker to use a slow flow than a standard flow in a baby with mild PPHN? What?!? It's risker to slow the flow of milk, than it is to possibly aspirate, stress the baby out, and worsen the PPHN? Where is the thinking that a baby will become stressed by eating from a slow flow nipple?!

    And really, you really should feed every baby left-side down for two reasons. One being that if they are on their side, the milk will not pool in the back of their throat but their cheek, lessening the chance of aspiration. The second reason for specifically left-side down is the anatomy of the stomach. The larger part of the stomach plunges to the left side of the body, meaning that intake will collect at the very bottom of the stomach if left-side down, rather than the flat part of the stomach on the right side. This allows a baby to continue eating without feeling full faster and will reduce reflex. You want them upright as well to reduce reflex.
  8. by   itsybitsy
    Quote from vintage_RN
    We don't even orally feed any kid on respiratory support...even low flow. We don't even attempt oral feeds until they're completely off and in room air.
    We typically don't feed on high flow. We regularly feed on low flow as long as that's the only issue. We don't feed if respirations are greater than 70 breaths/minute.
  9. by   Leader25
    There is more than one way to skin a cat ,so calm down and carry on.
  10. by   Leader25
    That would be my preference but alas others have a different thing to" try out "on these patients.
  11. by   Isabelle49
    I think it is a big problem that this baby spills so much feeding from the mouth. You know it doesn't spill out until the mouth gets too full. This baby is at high risk for aspiration!!! Sounds to me like tube feeding are in order for a while.
  12. by   xObabytiggerr
    @vintage What if the baby isn't ready to come off of oxygen? I find that interesting. In my NICU, if the baby's lungs aren't mature enough to breathe on just RA, they'll go home on like 0.01-0.02L @ 100% NC and able to bottle feed with a slow flow nipple without difficulty.
  13. by   bananas1
    Quote from Leader25
    There is more than one way to skin a cat ,so calm down and carry on.
    Woahhh dude no need to be skinning cats in the process!!!!
  14. by   Miiki
    Quote from bananas1
    Woahhh dude no need to be skinning cats in the process!!!!
    Right!! Way too loud in a NICU!

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