QUESTION: I am currently seeing a full term baby in our level 2 nursery. She has an inhalation stridor. At times her stridor is quiet & other times very loud. She had a fees completed & the ENT noted a minor laryngomalacia ; he also reported it was so minor that it should not effect feeding but is causing reflux. She is only takes under 7 ml at each feed the rest is through her ng. We have noticed a decrease in her oral feeds last week she as taking over 49% PO & now less then 20%. I suspect shut down. She is being held semi upright & side lying , using Dr Brown preemie nipples & being paces at 4. Which is very conservative. she is also disorganized with her latching. She will latch then suck 2-4 then push the nipple out of her mouth & also some of the breast milk. She does desaturation down to 86 at times during her feeds – hence the strict pacing. We don’t have infant VFSS at our hospital & the ENT did not see her take a bottle during the fees.
I am thinking we should have her transfer her to a NICU to get a VFSS but I honestly don’t know.
ANSWER:
I think you are correct to be concerned. Her behaviors are worrisome, especially given that multiple papers have associated LM with airway invasion in infants. A google scholar search will yield several.
The dynamic adjustments of the airway surrounding the swallow create the perfect storm for airway invasion, often silent, in our little ones with LM. The infant’s behaviors
(“disorganization” that may indeed be purposeful due to not wanting to suck in order to protect herself, limited drive to feed – purposeful – to stop the experience and/or due to the effects of increased WOB, pushing the nipple out likely to stop the flow which may be being mis-directed, desaturations which have been correlated in the research with aspiration in some NICU infants and is potentially suggestive of insufficient depth and frequency of breaths which would be common with LM).
On an interim basis I would consider an ultrapremie nipple to add even more protection by reducing bolus size and affording even more support toward our interim goal of sufficient and timely breaths, as we wait for VFSS. Impact of interventions and their combinations could then be objectified in radiology. More strictly pace her, i.e., single sucks, or 1-2 sucks max to proactively further limit bolus size and hopefully increase coordination for now. If she is pulling off the nipple after at times 2 sucks, she is telling you that even 2 consecutive sucks are beyond her capacity to manage – either related to bolus size delivered and/or need for a breath sooner then every 2 seconds. Perhaps limit PO trials to with you only for now, unless there is no risk for well-intentioned focus on volume by caregivers.
An instrumental assessment will be critical not just to determine if she is aspirating, especially given that radiology is only a moment in time, but more importantly, to objectify her dynamic swallowing physiology, and the impact of interventions. My clinical experience has been that many of our NICU infants with LM, even those without multiple co-morbidities, are silent aspirators.
I find it is not uncommon for ENTs and neonatologists to not connect LM with risk for airway invasion and our results in radiology are often unexpected when we share them. Good critical thinking. Trust your instincts with these little ones and continue to listen to their communication just like you did.
My colleague, Ramya Kumar MS. CCC-SLP, BCS-S, CNT, IBCLC, NTMTC mentioned consideration of trialing alternative side down with elevated sidelying, as she has seen under FEES that infant’s with stridor often have arytenoid prolapse which seems to be more dominant on one side vs the other for some reason. That makes so much sense anatomically. Gravity can surely be a friend or a foe to our little ones.