Problem-Solving: Stridor in preterm infant with trouble breastfeeding

Question:

I am seeing a 5 week old tomorrow morning, born at 35 weeks. I will be looking at fat pads and tethered oral tissues. Mom reports breastfeeding is very painful. Mom just sent a video and I am hearing a lot of stridor.  I am also seeing a very shallow latch. we will explore a Dancer hold tomorrow as well. I attached a video clip.

Thoughts on the stridor?

Answer:

ENT is a very important consult for which to advocate. I have been fortunate over the years to be mentored by some fabulous neonatologists (who love the airway like I do!), RTs, pulmonologists and pediatric ENTs who have kindly allowed me to ask a million questions and who kindly have helped me think about the airway from their perspectives — but very “simplified” so I could start to make sense out of what  I am seeing and hearing clinically.

We don’t know much about history and co-morbidities for this IUGR-appearing infant except she was 35 weeks GA and is now 40 weeks adjusted age. So much possibility for why we are hearing stridor. Knowing more may assist with our problem-solving on the list serve, and as the SLP seeing the infant, inform a initial differential that allows the SLP to advocate from an informed perspective.

The shallow latch may be purposeful to limit flow in order to protect the airway, or it may be due to tethered oral tissues, or it may be purposeful due to the need to prioritize breathing. Or a combination of any of these etiologies.

Is there apparent mandibular hypoplasia that might be leading to an ineffective tongue-palate seal and poorly controlled bolus? That can lead to stridor.

Be thoughtful with a dancer hold as it will inadvertently increase flow rate, which may not be what the infant wants. If when you offer the dancer hold, you hear increased stridor, or infants pulls away or changes facial expression to a “worried” look, or increases breathing rate or effort, the infant will be “telling you” the dancer hold is not helpful for him right now. Infant guided interventions and the infant’s responses always inform our differential.

Stridor may be iatrogenic (post-extubation, post-ECMO, post PDA ligation or repair to the aortic arch, post-emergent or prolonged or repeated intubation, or due to resulting subglottic stenosis, for example),or it may be congenital (r/t a vascular ring, idiopathic occurrence at birth without explanation, laryngomalacia, tracheomalacia or tracheobronchomalacia). It is surprising  how often it can go apparently unnoticed so to speak prior to our noted concerns, despite worrisome or adverse effects on feeding (intake, co-occurring physiologic stress and apparent swallowing safety). I have seen this both in NICU, PCVICU, and with admissions from home to PICU and our pediatric inpatient units at times over the years.

Cannot tell if the stridor is present at rest, as the video starts when infant is already at breast and sucking.

Cannot see if there are suprasternal and/or supraclavicular refractions present at rest or, if they are seen, are they seen during feeding only.

My mentors have taught me that:
Stridor heard frequently at rest suggests a primary airway pathology. Stridor present at rest often will be exacerbated with the aerobic demands of feeding, both at breast and bottle.

Contrast that with stridor that occurs only during feeding. That may suggest either swallow-breathe incoordination, due to  the tendency to inhale after the swallow, or indeed attempts of the airway to close in a protective maneuver due to bolus mis-direction from above and/or below.

The stridor in the video sounded biphasic, suggesting a fixed airway obstruction (subglottic stenosis, paralyzed vocal cord(s)—as the airflow moves past a constant obstruction on inhalation and on exhalation – that leads to the biphasic stridor.

Contrast that with stridor on only one phase of respiration, which is most typically associated with a dynamic airway problem – i.e., laryngomalacia – stridor is typically only inspiratory, as there is collapse on inhalation   or   tracheomalacia  – stridor is typically heard only on expiration. There may of course be a combination of airway problems, best diagnosed by ENT.

Of course we don’t diagnose airway problems as SLPs. My mentors weren’t trying to teach me to do that, but rather to think critically. I  describe what I hear,  in the setting of that infant’s/child’s unique history and comorbidities, and my ENT and neonatology friends tell me that helps them. And it helps me better consider the “whys” that underlie the feeding and swallowing challenges that result.

I hope this is helpful.

Problem-Solving: Balancing ALARA in radiology with data collection

Question

I’m relatively new to conducting pediatric MBS studies. The pediatric MBS is also a relatively new service provided at our facility. The pediatric radiologist seems extremely conservative in how many swallows/seconds he will allow for an MBS study (10 seconds/swallows total). I was trained at another facility and in talking with my peers, this is not enough swallows to get an accurate picture of an infant’s swallowing (especially if also looking at fatigue, position changes, thickeners).
I’ve been looking for research to support the amount of radiation intensity (continuous) and time (around 60 seconds total) that my peers tend to use, however there seems to be minimal literature that specifically addresses this topic.
Can you advise me as to how to advocate for a more complete study, even though this means more radiation exposure?
Thanks

 

Answer:

Rads are the ones who manage and minimize radiation exposure for patients and us too . So his caution is an attempt to protect us.

ALARA – as little as reasonably achievable – is the mantra. Work with the rad from a perspective of recognizing that and finding a common ground for gathering good data but assuring optimal protection (shielding well, time, distance all matter). Have some conversations outside of the “moment in radiology” to problem-solve.

When I teach my pediatric swallow study seminars across the US, I always survey attendees for average exposure times they use as guides, and they are typically <2 minutes for infants , and < 5 minutes for children.

This allow typically for enough data to objectify physiology and interventions usually.

If I need to watch a bit longer to complete my differential, I let the rad know and ask if we can watch just briefly and he knows I really need to see that but that I am careful to watch exposure time.

Our aim is the least dose, so if I use about more time it is only after careful thinking and when it is crucial data that is needed.

Our tech can tell us at any time the exposure time up to that point, so we know how we ear doing as we go along. Tech tells us total exposure time at the end, and I always ask myself is there anything I might have done differently to lessen the exposure time.

Usually there is not but I always try to consider that question so can become a better clinician.

Rads usually pulse the beam, we use 30 frames per second but not every hospital radiology team does. Studies have shown that less frames/sec results in less useful data and 30 fps is optimal.

If the rad pulses the beam, and he starts the beam when you say “on” , and you plan what you are going to observe to objectify physiology, carefully select interventions to objectify so you minimize radiation, then these exposure time guidelines work well.

Feeding off line for fatigue while eating/drinking materials impregnated with barium will not use up that exposure time, just the brief re-imaging post fatigue feeding , to see if there are traces in the airway , larynx, nasal airway, etc. that suggest bolus mis-direction and or residue when infant/child was feeding off line, simulating fatigue factor.

Try this approach and see if it works. It does for me.  I developed it with input from our rads, who problem-solve with us as a team and we learn from each other from a place of mutual respect for the perspectives we each bring. The rads  recognize we too will do all we can to assure safety and focus on  ALARA.

I hope this is helpful.