Q & A: Problem-Solving with Catherine

Question: I completed a new eval on a newborn infant, 7 weeks old.  PMH: NAS likely, looks/acts premature, removed from parents at 3 weeks and is in foster home, dehydrated upon custody, limited history.  Intake is great and she is growing/gaining since in foster home.  Last week she started struggling with feeding.  Her tongue tip remains elevated with nipple presentation.  This was present in eval.  Once she drops her tongue and accepts the nipple she will drink very well.  Great suck and coordination.  Jaw opening is limited with nipple stim to lip.  Seems like she is anchoring her tongue to stabilize her jaw.  Is this correct?  If so, what approach is needed to assist with feeding?  And what can foster mother do at home?  Various feeding positions do not assist to extend her trunk.  Stim with soft gum massager does not assist.  Her mouth is very tiny (weighs ~6 lbs.).  Suggestions, please!

Answer: 
Good problem-solving and asking questions!

Given that the infant can actively lower her tongue to the floor of the mouth and establish an effective latch, tongue-palate seal and coordinated sucking pattern, this is likely a compensation (i.e., an adaptive behavior). I see it most often in infants due to  increased work of breathing. Infants will often elevate the tongue tip to the alveolar ridge when the work of breathing creates challenges for suck-swallow-breathe. I suspect the contact/pressure of the tongue tip at the alveolus may help to stabilize the tongue in such a way that it give the feeling of a more open pharyngeal airway. This may sound funny, but one of my favorite neonatologists at my old NICU, who is a marathon runner, told me that when he runs in marathons, he often places his tongue tip at the alveolus to get through the respiratory work during the run. Knowing my great interest in the pathophysiology and co-morbidities of infants with CLD (Chronic Lung Disease,) he postulated the reason as I stated above. It make sense to me (and did to him!) , as we knew we had often seen this behavior co-occur in infants with extra breathing effort during feeding (and at rest too). Though the WOB may be slight, it can interfere with the fine coordination of swallowing and breathing, and infants make adaptations, i.e. use compensatory or adaptive behaviors to “get them through” the feeding or in an attempt to ease stress associated with breathing. Unfortunately , some of the adaptations they use can become maladaptive behaviors if the underlying issue causing the need to adapt is not addressed and rectified.

This would make sense for this infant, given his known/suspected co-morbidities, i.e. being a preterm (which would account for the increase in WOB) and NAS/Neonatal Abstinence Syndrome (which can result in frantic disorganized approach to feeding that leads to an increase in work of breathing).

The “closed jaw” is likely another adaptive behavior — the infant does not actively open her mouth until she is done breathing; when she is  done breathing, she roots, opens her mouth actively and latches. She is communicating by her behavior, as infants do, to you and to mom, and telling you how to help her. So continue to use her rooting reflex to initiate the feeding; if she does not open her mouth and root, then wait  a few  seconds and re-root her; don’t put the nipple in passively or pry her mouth open. She knows how to open her mouth when she wants to, right? 🙂  Just be patient and listen to her:-)

A swaddled elevated sidelying position with her head higher than her hips will help ease WOB and facilitate organization as well. I’d also suggest you consider a controllable flow rate (slow flow rate) as that may indirectly also help the infant manage optimally if there are even subtle breathing issues, likely with his co-morbidities. Dr. Brown’s preemie (slow flow) nipple has worked well with similar infants in my experience.

Take a look at my article “Reading the Feeding” in the ASHA leader archives or you can find it on my website http://www.shaker4swallowingandfeeding.com under the publications tab. It details infant breathing behaviors/cues that guide the feeder to understand what is happening and why.

I hope this is helpful.

Catherine

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