Q & A Time: Problem-Solving with Catherine: Weak Suck

Q & A Time: Problem-Solving with Catherine

Question: I am seeing a newborn at 38 weeks now day of life # 31 baby. Has weak suck. Is able to bring liquid into mouth but no coordination. to swallow. Most liquid pools in mouth and is spit out. Baby tires quickly. Baby has many other health issues including predominant extensor tone, cardiac, chromosomal abnormality-only 50 cases known-life expectancy is very low). I would appreciate any suggestions re: stimulation of swallow, feeding intervention.
Answer:

This certainly appears to be a challenging newborn. From what you describe, there appear to be significant issues for swallowing safety and oral feeding may not be indicated right now.

Many sick infants with such a presentation actually have underlying low tone proximally. Thus the hypotonia that likely exists in the head/neck provides a poor base of support for the trachea and for the swallowing mechanism. It is likely that both the intrinsic and extrinsic tongue muscles are hypotonic. As a result not only will the suck be weak, but the swallow will be affected (decreased BOT for posterior propulsion, decreased pharyngeal compression and motility related to reduced control of the constrictors, etc.). Due to underlying low tone throughout the upper body, it is likely that there are respiratory issues that may result in increased work of breathing, that might compromise timing of the swallow-breathe sequence.

What is his actual diagnosis? What are his pharyngeal reflexes like? Often in such babies those reflexes are unreliable. Does he swallow his saliva? Sounds like it may also pool as does fluid offered. What is his state regulation like? What about work of breathing? What is the status of his airway —is there any auditory suggestion that he is not maintaining it? Not uncommon with such a postural presentation.

Given what we know, I’d suggest a swallow study. It is likely there is a delay in the initiation of the swallow, along with reduced pharyngeal motility and clearing, and the risk for silent aspiration, given what you describe, is high. This information about his swallow will be important to your intervention plan and for the discharge plan, especially since he has already been hospitalized a month.
I’d also recommend to the neo that we limit to gavage feedings only, with swallowing trials (as safety permits) by the SLP. Intervention would include a good postural base (via swaddling and positioning–well-supported side lying may help tremendously; check with OT/PT as needed), work on the intrinsic and extrinsic tongue muscles (via deep pressure input, direct and indirect tapping, direct NDT techniques to the muscle groups of the tongue to improve stability and control); the cheek/lip muscles may benefit from direct input as well, as they are likely also to be hypotonic given what we know. This is not to say that the cheeks/lips need to be active (they are not active in normal infants until 3-4 months of age) but they do provide postural stability for the tongue during young infant feeding. If the pharyngeal responses are diminished, again likely with this presentation, I have found some direct sensory-motor input can be helpful. Depending upon results/impressions from the swallow study, one might consider, after providing the sensory-motor preparation just described, offering trace amounts (single sucks at best) of fluid via a slow flow nipple, which would have been trailed in Radiology (Dr. Brown’s Premie Flow level P or Enfamil slow flow) and observe.
The other issues are of course ethical and quality of life if indeed life expectancy is limited with his diagnosis. So close collaboration with the neos and nurses, and family, regarding safety issues and impact is essential. Volume won’t be the goal if swallowing trials are initiated. He will need some form of tube feeding for his nutrition. Likely this would be an NG if life expectancy is short and prognosis overall is poor, but in some cases a PEG is placed. On-going therapy that may eventually be more monitoring or episodic, is typically provided after discharge.

It’s a rainy day in Florida…

…and cloudy, which is rare. Sort of nice though to just make me want to kick back and relax! The neighborhood children are all back in school and 2014 is more than half gone. What a fast year this has been! My 2015 seminar schedule is almost finalized and I am already looking ahead to 2016.

In 2015 I’ll again be teaching my specialty courses, including “The Early Feeding Skills Assessment Tool: A Guide to Cue-Based feeding in the NICU” in Houston in August, with my colleague and friend, Suzanne Thoyre, PhD, RN. We so enjoy the problem-solving that the nurse and therapist audience experiences watching videos of infants feeding, scoring the EFS and planning infant-guided cue-based feeding care. Michele Clouse, who teaches her course “Tracheostomy and Swallowing: Pediatrics to Adult” will join us in Houston and bring her down to earth hands on approach to trachs that past attendees remark makes such good sense. I’ll also teach my one day “Pediatric Videoswallow Studies” seminar in Houston since that’s been highly requested. Our focus will be on physiology and its impairment in infants and children, not just on aspiration.

You will also find me in Wilmington DE in September 2015 where I’ll offer my newest seminar “The Advanced Clinician in Pediatric Dysphagia”. Its first offering in Dallas this year was so well received, and attended by both seasoned and new clinicians. What the group liked best was the opportunity to go into depth on both hot topics and their own case studies, and share clinical insights. We all waked away with our brains “on fire” from thinking and problem-solving. It’s so important that we have the tools to provide expert consults these days, as that is truly the value we add to our patients’ care. To do that, we need well-honed problem-solving skills to complete a differential of what is going on, consider multiple co-morbidities and a range of interventions. It’s the way we leave an impression with our medical colleagues that leaves them thinking about YOU, “The next time I have a challenging pediatric patient, I want HER/HIS input!”

More to come regarding my 2015 schedule soon….including the West Coast, North Carolina, Dallas and other exciting places. Let me know if you’d like me to consider coming to your hospital in the future.

Have a great weekend!

Catherine

Results, of my newest seminar!

Summer is rapidly moving along and it is hard to believe that back to school is upon us! In less than two weeks I’ll be in Orange California, a favorite venue of mine, to teach my 5 day series. I am excited that this will be the first time we will have NICU nurses attending on day two of my NICU seminar. It will be a great way to frame the “intervention” focus of day 2, and build dialogue and shared reflection.

I wanted to share with all of you what a wonderful group I had at the inaugural offering of my newest seminar, The Advanced Clinician in Pediatric Dysphagia, which was held in Dallas in July! We problem-solved some of the latest challenges in peds/neonatal dysphagia and learned from each other. We used differential diagnosis to sort out the issues and develop clinical strategies incorporating multiple approaches. We watched clips of FEES and videos and discussed so many interesting cases, inpatient, outpatient, schools and home health. The passion in the room was evident and I left with a renewed sense of joy in the work we are blessed to do, and how good it felt to have a forum to appreciate and enhance our critical thinking skills.

Reminds me of a comment by Dr. Susan Mountin, from the Center for teaching and learning, who said: “There is so much noise in our society. Helping people focus, go deeper and create an element of quiet thought is important in every discipline”. That’s what we did.

Next year I plan to hold the seminar again so each of you has the opportunity to experience what we did. I’ll be announcing my 2015 teaching schedule soon.

For now, enjoy our remaining days of summer and spend some time in quiet reflection. Take time to appreciate the awesome work you do and each day we are blessed to do it. And stay in touch!

Catherine