Problem Solving: Infant with Laryngomalacia

QUESTION: I am providing swallowing therapy in a rural EI home.  The PT is a 7 month old male with a history of plagiocephaly, laryngomalacia and glottal surgery.    He demonstrated coughing with feedings and apneic episodes (awake and asleep), prior to surgery with no cyanotic episodes.  When I started treatment, he was 4 months old, post surgery and MBS.

The MBS reported:  Thin liquid-not enough swallows to be diagnostic due to limited latch.   Thickened 1Tbs to 2oz.-consistent, shallow swallows with small volume penetration, which eventually led to silent aspiration.  Suspected aspiration was due to large bolus size as a Level 3 MAM nipple was used.  Thickened 1 to 1 with level 3 nipple-WFL extraction and bolus size, timely swallow initiation, vallecular and pyriform residue observed but PT cleared.

He would not accept the 1-1 thickened feeds at home, so it was decreased 3 to 1 using oatmeal cereal.

The feeding clinic at nearest pediatric hospital recommended introducing plastic juice box and NUK brush to address his oral aversion to the bottle.  In therapy, I instead coached parents to focus on gentle bottle feedings, anticipating readiness to accept bottle and reading the baby’s cues during the feedings and taking breaks when needed, keeping feedings at 15-20 minutes.  This has proved successful.  He takes 3-4 oz at a feeding with 24 plus oz per day.   Mom has been able to return to work and the sitter can also confidently feed him the bottle. He is accepting small amounts of baby food and meltables.  The ENT recently tried to eliminate Zantac but he presented with increase emesis. He is back on the Zantac.  He continues to do best during feedings if he falls asleep with pacifier and then mom presents bottle.  He often reaches for the bottle, smiling and puts in his mouth, but intake is higher and pacing smoother with “sleepy feedings.”  Any thoughts on this????

My other question:  We have decreased thickening to 2.5 Tbs to 4 oz using a new Level 3 nipple.  With the info from the MBS would you decrease thickening further with use of slower flow nipples and how would you structure the decrease?

Thank you for advice in advance!!

 

ANSWER:    I suspect he had a supraglottoplasty which has been correlated in multiple papers in the literature with post-procedure continued impairment in swallowing physiology leading to silent aspiration. Typically, even post-op there continues to be a significant increase in WOB; because we do not know his birth history and early history, it is unclear if there were other co-morbidities whose sequelae may be part of his clinical presentation and therefore need to be a part of the differential.

His respiratory behaviors (both WOB and RR) are missing pieces of the puzzle for me, as these are common areas of challenge with his history. Because infants with LM often have increased WOB and intermittent tachypnea even post-op, I wonder what impact that had on his reluctance during the VFSS to suck (i.e. the need to breathe overrides sucking drive). This can lead to adaptive/compensatory behaviors of not wanting to latch, latching loosely and not transferring milk purposefully. In addition, the flow rate from the MAM, if it was competing with breathing, may have adversely affected the data set.

The information from the instrumental assessment is difficult to understand, because the terminology used in the report is not clear. The usefulness of the data gathered at that VFSS is limited, in that only a MAM nipple was used as they tend to flow faster, and infants S/P supraglottoplasty, if they do PO feed, benefit from optimal flow rate control without the need for thickening (such as a Dr. Browns’ Ultra Preemie or a preemie nipple). In my clinical experience with infants with LM post supraglottoplasty, thickened feedings can themselves create safety issues during a true feeding, related to residue and changes in structural integrity of the airway after surgery. Another consideration is that if we are altering the thickener or level of thickening based only on clinical observations is problematic, especially in the setting of his known silent aspiration. Also, we unfortunately know nothing about the etiology of the airway invasion reported nor if interventions were utilized during the procedure (such as resting and co-regulated pacing) which are crucial interventions for infants with his diagnosis post-op.

I would strongly suggest a repeat instrumental assessment of his physiology by a pediatric trained SLP. The last VFSS appears to have been 3+months ago, and the time from 4 months to 7 months of age, even for the normally- developing infant, is one of great change (structurally and with regards to physiology). It would allow a look at such as a Dr. Browns’ Ultra Preemie or a preemie nipple and use of resting and co-regulated pacing during the procedure. You could then also objectify physiology with the purees and meltables you have started since the last study.

Odd the ENT was planning to d/c the Zantac, as our ENTs typically max-out reflux meds post procedure. This is because it is common for LM and EERD to co-occur, and indeed EERD can cause/exacerbate airway edema and adversely affect laryngeal sensation, which in turn increases the likelihood that events of airway invasion will be silent.

The sleep feeding may indeed be r/t EERD and may also be an attempt to avoid the discomfort or pain associated with eating. Is a pediatric GI doc involved? If his apparent EERD is better managed perhaps the need to sleep fed may be less prominent and he can be guided to be more of an active participant via sensory-motor warm ups prior to feeding. It is likely the plagiocephaly and the torticollis are altering quality of postural/sensory-motor skills (head/neck/shoulder girdle/trunk) , despite perhaps milestones themselves reportedly “approximating” his age level; they may also be altering some of the qualitative aspects of swallowing and feeding, since the head/neck/shoulder girdle/trunk, and even the hips/pelvis, all contribute to form the foundation for feeding and swallowing At his age and with his postural/airway/likely breathing co-morbidities, we need him awake actively learning during feeding , both for better airway protection and for oral-motor learning prerequisite to future skills.

I hope this is helpful. He is quite a complex patient.

Catherine

 

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