Problem-Solving: Aspirating 4 month old

Question: “Asking for a fellow therapist. What would you use to measure the effectiveness of vital stim on a 4 mo old who is aspirating severely due to a discoordinated suck – swallow. Other than using a stethoscope to listen to her lungs or if fluid is entering her stomach, I’m not sure how in a home setting we measure effectiveness. She ate a 3 ounce bottle in 15 minutes when I was there so amount of time doesn’t seem appropriate”

My response:

There can be so many etiologies for why an infant has suck-swallow-breathe incoordination. Depending on the infant’s history (was there prematurity? was she a sick newborn?) and medical co-morbidities (neurologic? respiratory? airway? GI?) as well as developmental co-morbidities (postural control? oral-motor? sensory? ),  the interventions selected will be different and specific to that etiology.

Sometimes it can seem helpful to just “find a tool”, like a NUK brush or a popular bottle or a marketed option, and then use it to “make the feeding better.” But that doesn’t work.

Don’t try to find an answer, ask more questions. Take the time to” look at” and listen to and “feel” the baby when she is feeding so you can figure out why she is “not coordinating”

Slow flow nipples, co-regulated pacing, resting, changes in positioning and guided participation with caregivers can  enhance both intake and quality of feeding, when provided by a  SLP with expertise in infant feeding/swallowing. But only after knowing why you would be using them.
Maybe Vital Stim is not an appropriate intervention, given her history, clinical presentation and your assessment. You need to find out and to ask the questions.

If feeding is new to you, seek out a colleague to work alongside you that you can learn along with. The infants we see today are quite complex for all of us.

It is quite rare  that a tool is the answer — a tool is only useful when preceded by critical thinking about why. Too often, grabbing, for the “tool” is like grabbing for a cookbook —  and its stifles your thinking. Remember cookbooks were made for cooking not for feeding.

Step back, take a deep breath and  look at the baby through new eyes. I bet you will start to answer some of the questions I posed and you will have more questions of your own about what your observations and her behaviors might mean. Then you think some more, ask more questions. Seek out a colleague’s eyes to look along with you. Then think some more with that colleague .

I know you were hoping to have someone just provide a protocol, but I am hoping instead you will let yourself think and live in the “grey zone” as I like to call it  (where answers are not quick and one must be ok with not being sure, not have answers, need to ask more questions, ask “what else” do I need to consider), because that is how one becomes a more skilled clinician.

Also need to think about: why she is aspirating? What is the etiology?

There are multiple possible reasons along the swallow pathway that can lead to maladaptations and bolus mis-direction in the context of her unique history and clinical presentation.

When was the instrumental assessment done? was the infant at her best then? has she changed since then in ways that might affect swallowing/feeding function? is there need or PT and/or OT  or other medical specialists to help sort out the “why”? is she otherwise normally developing?…. I ask all this because, as you know, we don’t treat the problem, we treat the infant.

Without understanding why she aspirated we are likely going to “throw a bunch of  interventions at the problem” and they may be inappropriate, ineffective or ill-advised, given what is really going on and the bigger picture.

I hope this is helpful.

 

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