QUESTION

I have been out of the pediatric feeding and swallowing world for several years now. I had a friend reach out that has a seven-week-old infant with dysphagia. She noticed her baby was having increased strider and apneic spells during breast-feeding. She recently had an MBS completed and was placed on mild nectar thick liquids (she may have been told 1/2 nectar??). They also recommended a Dr. Brown’s bottle with a level two nipple. They recommended she use a specific thickener for breast milk; however, it is currently on back order. Does anyone have different suggestions for how to safely thicken breast milk utilizing a thickener that is approved for infants? Any information is appreciated!

ANSWER:

An easy answer would be to suggest Gel Mix, known to thicken breastmilk.

But a simple answer may not be best.

Because I tend to appreciate the history and co-morbidities to form my data set, and then add clinical data to make recommendations, it is challenging to make a suggestion that I have confidence in, since all thickeners, as you know, are not created equal nor equally suited for every infant nor is aspiration just “aspiration”.

The challenge is suggesting an alternative thickener that wasn’t objectified under fluoroscopy, as that can perhaps create more risk than anticipated. Because the SLP had the opportunity to objectify the impact of that level of thickening and that thickener, and that specific nipple, (as well as others, I suspect), then someone else changing the “prescription” may not be optimal.

Has mother contacted the SLP who did the VFSS for guidance as to optimal alternative plan in the interim, until prescribed thickener is available? That SLP will likely be best able to minimize the risk, given her understanding of the infant’s swallowing physiology, access to full data set and understanding of what would be indeed contraindicated. Not knowing etiology for the aspiration, i.e. pathophysiology, also whether the events were silent, and the etiology for the stridor, and what other interventions appeared to increase the safety margin (versus degrade it) such as co-regulated pacing or resting. I would be remiss to not refer her back to that SLP for next steps.

I am curious if infant has also been a bottle feeder too, prior to the VFSS or if the VFSS as her first PO trial with a bottle; if not, that might an add artifact. Wonder what thickener was suggested. EBM is super thin liquid so often doesn’t require a flow rate as fast as a level 2 for the mild amount of thickener as described. Wonder if EER (extra esophageal reflux) has altered laryngeal/tracheal sensation.

Also take a look at this article from the team at Boston Children’s, which summarizes  the most current evidence-base regarding thickening in pediatrics: Duncan, D. R., Larson, K., & Rosen, R. L. (2019). Clinical Aspects of Thickeners for Pediatric Gastroesophageal Reflux and Oropharyngeal Dysphagia. Current gastroenterology reports, 21(7), 30.

I hope this is helpful.