This interesting pediatric patient was sent to me for problem-solving. Thought I’d share, since it is an opportunity to build our clinical reasoning in pediatrics:

Question My patient is almost 9 months old s/p bilateral strokes. Has only breast fed, no bottle feeding experience. Has NGT in place. Head control is an issue but getting better and can maintain in Rifton chair/supported high chair when awake, alert. Currently breast feeding without aspiration related issues, although latch and strength of suck appear to be reduced and mom reports subjective difference. Main issue is moms reduced production of milk at this time, also baby has always been a “grazer” so not a good combo I have tried a dr brown level 1 and used smaller volufeeders; he can’t latch at all and he does not non nutritive on pacifier either. I’ve tried the bottle for over a week at my supervisors recommendation that we should “desensitize him” to the bottle. I am considering using a breast feeding trainer cup such as Mam or NUK simply natural to pursue any bottle feeding route. My understanding is that the neurolearning threshold for transitioning may be pretty tough as this point since sucking isn’t reflexive anymore and he has no prior experience with this skill- but I am open to hearing about others experiences and best practices. He is taking small volumes of purée via spoon and honey bear straw cup. I suspect he may need more time w ngt to build oral motor skills and then wean off ngt. Catherine, can you offer any suggestions for either improving bottle feeding transition ?

Answer: Don’t know a lot about his birth history, developmental history and co-morbidities that would help to problem-solve and to put into context the nature of his feeding/swallowing problems, since they sound like they are part of a bigger picture, as is often the case. I suspect his birth history would inform our differential. Multiple systems can be and often are synactively affected by each other and create a complex puzzle that needs to be solved to guide our plan of care. Wondering why still an NGT at 9 months instead of a GTube, given longstanding poor feeding, to support growth and avoid aversions that can result secondary to prolonged NGT in situ? Sounds like at least hypotonia and reduced postural stability are contributing to poor feeding, and are unlikely to resolve the short term, given apparent neuro comorbidities. Wondering about integrity of saliva swallows. If suck is that poor, swallowing physiology is likely also altered, if not impaired given poor head/neck control. Postural issues described suggest there may also be respiratory considerations. Not sure we can conclude there are no aspiration issues as he is more likely to silently aspirate given hypotonia, if he does invade his airway. Or he may misdirect the bolus toward the nasopharynx and adversely affect his nasal airway patency. Other relevant systems could be airway, respiration and GI co-morbidities that need to be considered in your differential, in the setting of his medical history. That should help guide you to workups to request and what interventions are indicated or might help at this juncture. Not sure about the rationale for the reported need to “desensitize”? Normalizing oral sensitivity sometimes needs to be part of the process but doesn’t sound like it for him, based on what you have mentioned. The latch is not likely refusal from what you have told me but rather altered sucking integrity or perhaps flow rate challenges that result in adaptive behavior that then becomes maladaptive. If the suck is poor, as you describe, a MAM or NUK breastfeeding training cup may not help or may create more challenges. Try to figure out why he is having trouble, first, then consider what interventions might best address that problem. The problem is likely not the feeding utensil but lack of the oral-sensory motor- underpinnings for effective feeding or other factors which I cannot sort out based on what I know thus far. An instrumental assessment of swallowing physiology with the purees and honey bear straw cup you are using with him would help define physiology, and you might also be able to observe some swallows with bottle feeding as well. I hope this is helpful. What a complex little guy.