Question:

I have completed two VFSSs for infants (1-2 months corrected age) in elevated side lying position who then went on to have FEES completed at a larger children’s hospital. The FEES were completed in upright position. The VFSSs I completed demonstrated functional physiology and no penetration/aspiration; however, the  FEES reports I received documented aspiration and recommended NPO x 3 months. 

 My concerns are the FEES are being completed in a position that the infants aren’t typically being fed in (the literature searches I’ve completed haven’t shown that upright is better).  Parents have also reported to me after the fact that the infants were crying throughout the completion of the FEES.  Lastly, I do have questions about the length of NPO recommendation (e.g. not building on oral feeding skills/experiences for three months and then expecting infants to learn them after the time frame when feeding is driven by reflexes).  As you can imagine, having conflicting results has been tricky to navigate. 

I am interested in your thoughts on an upright feeding position versus side lying feeding position during  instrumental assessment (for Infants under 3-4 months of age).  Any advice you would be willing to share regarding the above scenario would be greatly appreciated as well!

Answer:

Clinically I have consistently found that sidelying is more protective for swallowing and breathing, improves bolus control, and airway protection d/t muscular and gravitational impacts.

This is the most recent published paper/study by colleagues of mine:  Park, J., Pados, B. F., & Thoyre, S. M. (2018). Systematic Review: What Is the Evidence for the Side-Lying Position for Feeding Preterm Infants?. Advances in Neonatal Care, 18(4), 285-294.

FEES is clearly a valuable tool in swallowing diagnostics. Crying during FEES could, however, possibly  adversely affect the swallow-breathe interface, and therefore potentially contribute to an artifact that could alter physiology and lead to inadvertent airway compromise.

When an infant cannot PO feed d/t impaired physiology, we must still maintain the oral-sensory-motor system for future PO feeding. This includes non-nutritive oral-sensory-motor experiences which build components of oral-sensory-motor control combined with those components of motor control that underlie feeding function. Maintaining readiness often includes: offering tiny droplets of EBM preferably, or formula, on a pacifier or on the infant’s hands, or a trace dip of puree on a spoon. These offerings of create sensory load for purposeful swallows that stimulate fast twitch fibers.

This may of course carry some inherent risk, so one must carefully balance the risk for each infant with the benefits for long-term motor learning. Each infant must be considered in the context of his co-morbidities, developmental trajectory and day to day medical stability.

This cannot be approached as a cookbook but rather requires critical reflective thinking and clinical problem-solving to balance protection with learning. These experiences should be done after good oral cares, after postural stability is provided, and when the infant is at his best in terms of RR/WOB, state, postural organization, GI function etc.

The goal is to avoid loss of the multi-system integrated underpinnings for swallow function, avoid onset of disuse atrophy in a developing mechanism, and keep the emerging systems ready for future function.

I hope this is helpful