Problem-Solving with Catherine

Question:
Hello!  I work in a children’s hospital with a level 4 NICU.  Our SLPs know that thickening is our last resort, so to speak, in terms of interventions that we provide for these infants (positioning, nipple flow rate, etc.)  Our hospital is currently using rice cereal to thicken feedings if needed based on MBS.  We are exploring GelMix as an option, but this hasn’t been cleared by our Neos or GIs.  Does anyone have any evidence/research to support using a combination of 50/50 breast milk and formula and thickening with rice cereal?  We know that rice is broken down in breast milk, but if we do a 50/50 mix, is that enough for the rice to bind and maintain a thicker consistency?  Do any of you have protocols for those infants with swallow dysfunction in terms of breast-feeding?  Thank you so much for any feedback!!

Answer:

At the end of that post you asked about protocols for “infants with swallowing dysfunction in terms of breastfeeding”.

I am assuming you are asking about infants who are bottle-feeding and breastfeeding and had a swallow study done that showed an impairment or alteration in swallowing physiology with bottle-feeding that resulted in bolus- misdirection and potentially aspiration?

An infant may indeed have an alteration or impairment in his underlying swallowing physiology that will adversely affect the biomechanics of swallowing and lead to bolus mis-direction both toward/into the laryngeal and/or nasopharyngeal airway. In infants of course, who are by nature obligate nasal breathers, the mis-direction and its etiolog(ies) must be carefully considered.

Because of the unique physiology of breastfeeding, it is uncommon that infants will show overt decompensation with breastfeeding but possible. I have found clinically that those infants who decompensate during breastfeeding often have a true alteration or impairment in swallowing physiology. Breastfeeding is actually easier than bottle feeding, even for preemies, so it is possible an infant may not experience an alteration or impairment of swallowing physiology at breast though it was observed in radiology with bottle-feeding. Take a look at the multiple “gold standard’ writings of Paula Meier, Goldfield and Nyqvist regarding the unique physiology of breastfeeding suggesting it is likely most supportive of airway protection for infants.

My clinical experience and reading of the literature has lead me to hypothesize  that those infants whose etiology for impaired swallowing physiology is flow rate and/or coordination of suck-swallow-breathe, in the presence of normal structural integrity of the airway and oral-pharyngeal mechanism, may do quite well with breastfeeding. Breastfeeding optimizes flow rate regulation and provides “windows of opportunity” for breathing so well described by Goldfield; it is this then that likely optimizes bolus control. However when there are issues with structural integrity of the airway (i.e. vocal cord paresis/paralysis, laryngomalacia, tracheomalacia) the “protective nature” of breastfeeding may no longer be realized, if you will.

There is no way to study my hypothesis since we cannot observe breastfeeding under fluoroscopy. However, working closely with pulmonologists, ENTs and neonatologist’s, we have together carefully considered each infant, his co-morbidities and what we know from the science of breastfeeding to inform our decisions about breastfeeding given objective data obtained during bottle-feeding.

I suspect your question, which is a good one, may have been prompted by infants who had a swallow study with the bottle from which “aspiration” findings are being generalized to breastfeeding. I don’t think its that simple, as I hope my thoughts above suggest.
Unfortunately the complexity of the infants we follow requires us to pause at each juncture in the clinical process, and allow ourselves to think in the “gray zone” as I like to call it. Not expecting quick answers but rather allowing reflection, carefully weighing that infant’s history, co-morbidities, clinical and instrumental findings and the evidence-base to complete a solid differential. From there, we dialogue with the team to develop a plan of care and interventions to hopefully minimize risk while optimizing both neuroprotection, skill progression and the infant-mother relationship. It is a challenging balancing act every day for us and so we keep asking questions and learning.

I hope this provides some food for thought and is helpful.

Catherine

Problem-Solving with Catherine

Question: Currently have a 6 y/o pt on an inpatient rehabilitation unit.  She is trach and vent dependent following necrotizing pneumonia.  She is allowed to have cuff deflated 3x/day and can use a pmv while cuff is deflated although she is only tolerating for approximately 30 minutes a day. Getting ready to do an mbs, would you assess pt with cuff down and speaking valve on in addition to cuff inflated?  Do people generally wait until a pt is able to tolerate speaking valve for a certain amount time prior to taking pt to mbs.  Is it always safer for a trach patient to eat/drink with speaking valve inline?  We are having some disagreements on the treatment team.  Thanks for your advice/opinions.

Answer: We don’t know much about her history and other co-morbidities, which might affect next steps and treatment plan. But given what we know: it’s great that she is tolerating cuff deflation and is tolerating the PMV for 30 minutes at a time. While in radiology, I would also observe her with the cuff deflated and the PMV in place. That will give you some objective data about the effect of the PMV on swallowing physiology in comparison to physiology without the PMV in place. Typically in pediatric patients we do often observe better driving force on the bolus and better pharyngeal clearing, likely associated at least in part with restoration of subglottic pressure. Also, the restoration of taste and smell is critical for our pediatric patients to help either normalize or enhance the oral-sensory system, which is such a critical variable in both healthy and medically fragile pediatric patients.

The most recent study I am aware of in Laryngoscope 2013 (Ongkasuwan et al, “The effects of a speaking valve on laryngeal aspiration and penetration in children with tracheostomies”) concluded the PMV did not demonstrate a decrease in laryngeal penetration or aspiration. However, this was small sample with quite varied ages and indications for tracheostomy. Most unfortunately, the study only looked at occurrence of aspiration and penetration. As Bonnie Martin Harris has so wisely stated, aspiration and penetration are neither sufficient nor necessary for a swallowing impairment.

So for this discussion, it reminds us that in radiology with this child it will be important to look beyond the effect of the PMV on just “aspiration” and “penetration”. Consider its effect on her swallowing physiology, and its components, which underlie safe bolus transport.

Let us know what your impressions are, Stephanie, so we can further inform our clinical wisdom.

Catherine

Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders