Problem-Solving: VFSS with former 24 weeker and thickening feedings

Question:

I have a question re: thickening formula in NICU. We don’t do vfss until >40 wks and no other compensations improve bedside feed.

We have a GA 24.6 wks; now 46.3 wks. Failed RA trial yesterday after 5 days of NPO/gavage only after a VFSS that documented laryngeal penetration and aspiration with slow flow in sidelying and upright with thin and nectar thick consistencies, so now NC 1/8L at 100%. Previously was bradying1-2x in a feed, so finally approved for the vfss…and while NPO limited to one Brady or desat a day. Vfss looked best with no penetration or aspiration with honey thick/IDDSI moderately thick. Would you agree with thickening of this infant to work towards safe feeds to go home with NCO2?

Answer:

What is the etiology for the aspiration events? To problem-solve, one must understand the physiology that underlies the bolus mis-direction you observed during the VFSS.

Is possibly GER/EER a part of the differential, as some events when not with PO feeding? Wonder about the effect of EER on laryngeal/tracheal sensation. Guessing that as a 24 weeker CLD may be a factor so both EER and poor swallow -breathe interface are key considerations.

Thickening is, as you know,  a last resort when other interventions are not establishing a safe swallow. Honey thick is rarely being used, both in my experience and as I ask other therapists form across the US and other countries, when I teach my seminars. Honey thick is worrisome in that if the infant requires something so thick to establish a safe swallow “in the moment”, he could during the course of a feeding have a change in position, a change in state, a change in bolus size, a change in sucking strength, a change in breathing pattern) that could easily result in airway invasion. Further, aspiration of honey thick in the developing lung of a former preterm with CLD can create undue pulmonary issues for which the risk-benefit ratio may be quite precarious.

Asking this infant to PO feed and go home a full Po feeder may in the longterm not be a good plan for him, his neuroprotection, his joy in eating and his pulmonary health. Based on what I know about him, which is limited (? other complex co-morbidities than respiratory?), I’d advocate for a GTube and offer readiness interventions (including cautious therapeutic pacifier dips)  to maintain his oral-sensory-motor system for safe return to PO feeing when co-morbidities permit. Often these are infants who, after 1-2 months post discharge, come for a repeat study, and  have established improved respiratory function that allows for the beginning of some safe PO feeding.

I hope this is helpful.

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