Problem-Solving with Catherine

Question:

I work with a 4-month old baby with lots of gastro issues on G-tube. He has had a nissen fundo surgery. Originally NPO. I gave mom strategies for oral motor but he has a great suck pattern and no visible oral motor issues. Also gave strategies for environmental modifications while feeding. He is now clear for only puree. I dont know if I should continue seeing him and how to proceed if I do. I have little experience with babies so any or all suggestions are welcome. Thank you!

Answer:

Sounds like a challenging patient. Since you have little experience with infants, this would be a great opportunity to partner with an SLP locally who has treated infants. We don’t know much about this infant except that he is 4 months old. To fully understand what is going on, we need to gather data, including his history, and combine that with what you are seeing to then be able to complete a differential. Some of the history you can gather from the parents, but I would also request records from the referring physician. We would want to know for example: was he born at term, or post-term or was he a preterm infant? What do we know about his birth history? Was he hospitalized in the NICU after birth? If so, how long was he there? What were his medical problems when he was there? Did he require oxygen? Has he had any other surgeries other than the G-Tube/Nissen? Are there still medical problems the doctor is sorting out or following? Why did they place a G-Tube? Did he have a swallow study and what did it tell us about his swallowing physiology? Is he otherwise developing normally for a 4 month old (posture, head control, UE and LE movements/control, swallowing saliva, getting hands to mouth on his own and appreciating that, accepting pacifier, visually alert/engaged and tracking, starting to make sounds?) It may be hard for you to fully assess these developmental parameters, as well as oral-motor integrity, and an extra set of eyes from another SLP will be both helpful and important.

From what you have told us it sounds like reflux is a part of the differential but that alone is unlikely to, though could possibly, lead to the need for G-Tube feedings. It is possible that, given he is to feed only purees, he may have shown alerted or impaired physiology with liquids. The altered or impaired physiology, if identified, should be correlated with an etiology in the swallow study report. Just knowing he “aspirated” won’t guide our differential and plan, as we would want to know what was the nature of the bolus misdirection (to the nasal airway? to the laryngeal airway?) and why the bolus mis-direction occurred, if it did; what they recommended for him at that time. That then drives a plan of care and suggests strategies to specifically address the problems identified.

While some infants do have oral-motor problems that contribute to the need for G-Tube feedings, there can be multiple co-morbdities, or problem areas that contribute. Knowing more about his medical history would help uncover or elucidate these factors, and they are critical to our assessment and treatment plan. They actually form the context in which we interpret our data, i.e., what we observe clinically and what the family tells us about what they see. You mention that he has no visible oral motor issues so then we want to look deeper and broader at other systems that underlie effective feeding, including GI, respiratory, postural, neuro, sensory, for example. Information about his history should guide you toward these suggested domains or away from them.

It is wonderful you reached out to this list serve, but as you can see his presentation and what to do with him is much more complex than can be fully addressed through the list serve. Perhaps use this an opportunity to learn and build your skills, and seek an SLP mentor to work alongside you and guide you.

Not sure if that is possible where you work, but I suspect not or you would have tried sought a colleague’s help.

It takes a clear objective sense of our own limitations and humility to think about not continuing to see a patient for whom we feel unprepared. I think as I read between the lines you are at that juncture and are to be commended for that tough call. Each of has been there and let’s hope we have all been as willing to ask questions and recognize the need to respectfully send the patient to another SLP, whose current skill set is a better match. Were this your infant with feeding/swallowing problems, you would want his therapist to make a decision that is in the infant’s best interest.

I hope that this has been helpful.

Catherine

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