Question: I was curious if there is any research out there regarding the effects of breastmilk on the lungs if aspirating small amounts? 

We currently have an ex 25 week infant who is now corrected to 40 weeks.  Infant has CLD, currently on LFNC 2.5 LPM 100% Fi02.  Infant is s/p PDA ligation with L vocal cord paresis.  He also had delayed start to feeds due to medical NEC x2.  We started conservative PO trials with him 2 weeks ago-offering 10cc via Dr brown ultra-preemie nipple in R sidelying.  He built stamina and was appropriate for a VFSS this past week.  Results were as expected.  Infant had 2 episodes of gross aspiration- 1 with thin barium via ultra-preemie nipple and 1 with ½ strength nectar thick barium via preemie nipple.  1 was silent and the other resulted in a brady/desat.  However, he demonstrated several consecutive safe swallows during the length of the study.  We decided to allow him to continue to BF on a pumped breast and have been also contemplating allowing him 5cc of straight breastmilk 1-2x/day via ultra-preemie nipple for ongoing practice.  Some of our practitioners would like to allow him these PO bottle trials while others would prefer to keep it at just breast feeding with the pumped breast and allowing some pacifier dips during PG feeds.  I am torn between what would be best for this medical complex infant.  I work frequently with adults as well and have thought about the Frazier Free Water Protocol with some of our patients.  Given that breastmilk seems to be a fairly benign liquid, would it be similar?

Answer:

I know of nothing published but my pulmonologist colleague has told me that she believes EBM is likely tolerated much better by the lungs if aspirated, compared to  formula or thickened formula.

Aspiration is of course especially worrisome, though,  in the setting of CLD and a continued  need for respiratory support, L vocal cord paresis. You dont’ t mention the etiology for the aspiration events but I suspect an altered swallow-breathe interface,  and likely ineffective and/or incomplete airway closure, are probable etiologies.

Because we are not always fortunate to actually witness aspiration during the brief moment in radiology,  when there is indeed gross aspiration, at times silent, it confirms swallowing physiology is impaired.  Based on the data you provided,  I would not PO feed by bottle,  as “practice” as suggested by some practitioners, is not the answer. It is highly likely that resolution of CLD and vocal cord paresis are the answer,  both f which will take time. Pacifier dips of EBM, a GTube and repeat swallow study in 2 months has been a successful plan for our babies who present similarly.

The pacifier dips are like a free water protocol for infants and also perhaps limit the risk while allowing for purposeful swallows. PO feeding silent aspirators, especially those with the history and multiple complex co-morbidities you present, is worrisome to me. “Pratice”, which actually involves recruiting impaired physiology,  would, for me, weigh heavily against this option for this infant. While breastflow is likely more protective than flow from a man-mande rubber nipple, especially in the setting of CLD, breastfeeding may not be more protective  if there is a primary airway problem as you describe.

I hope this is  helpful.