The impact of Nasal Continuous Positive Airway Pressure (NCPAP) and/or High Flow Nasal Cannulae (HFNC) on swallowing physiology in infants via the swallow-breathe interface is not fully understood. However recent literature is worrisome for increased risk for airway invasion, often silent. It is increasingly common for hospitalized infants to have orders to PO feed while requiring this level of respiratory support. PO feeding is part of the path to discharge.

Some may be otherwise normally developing and recovering from a viral process, yet still present with precarious readiness to return to PO. Some may have a  premorbid history of feeding/swallowing problems, and co-morbidities that place them at an even higher risk. Further research is needed to guide for safe return to oral feeding of infants and children in the PICU with an acute respiratory illness who require NCPAP or HFNC.

In the interim, careful clinical assessment and consideration of risk from multiple perspectives are essential. Conversations with the team that follow will require familiarity with the current literature and dialogue that considers that  infant’s presentation and unique risks. Sometimes, despite our advocacy, there is a decision to proceed with PO feeding. Cautious pacifier dips for purposeful swallows may be followed by brief small PO trials with a slow flow nipple with strict co-regulated pacing to limit the bolus size and support swallow-breathe synchrony, with positioning that optimizes tidal volume. Once there has been some brief motor learning and problem-solving, an instrumental assessment to objectify swallowing physiology under the  current respiratory support would be essential. It is critical that physiology and pathophysiology be our focus in radiology, not just the events of bolus mis-direction in and of themselves that we happen to capture in the short time under fluoroscopy. During the course of a true feeding, intermittent/interval changes in rate and depth of breathing, tidal volume and/or vigor may be a tipping point that leads to silent airway invasion. I don’t know that this is readily understood by all of our medical colleagues.

While my conclusions above differ from those of the authors regarding the potential role of instrumental assessment, the article referenced below is a valuable resource for you:

Raminick, J., & Desai, H. (2020). High Flow Oxygen Therapy and the Pressure to Feed Infants with Acute Respiratory Illness. Perspectives of the ASHA Special Interest Groups, 5(4), 1006-1010.

Abstract

Purpose Infants hospitalized for an acute respiratory illness often require the use of noninvasive respiratory support during the initial stage to improve their breathing. High flow oxygen therapy (HFOT) is becoming a more popular means of noninvasive respiratory support, often used to treat respiratory syncytial virus/bronchiolitis. These infants present with tachypnea and coughing, resulting in difficulties in coordinating sucking and swallowing. However, they are often allowed to feed orally despite having high respiratory rate, increased work of breathing and on HFOT, placing them at risk for aspiration. Feeding therapists who work with these infants have raised concerns that HFOT creates an additional risk factor for swallowing dysfunction, especially with infants who have compromised airways or other comorbidities. There is emerging literature concluding changes in pharyngeal pressures with HFOT, as well as aspiration in preterm neonates who are on nasal continuous positive airway pressure. However, there is no existing research exploring the effect of HFOT on swallowing in infants with acute respiratory illness. This discussion will present findings from literature on HFOT, oral feeding in the acutely ill infant population, and present clinical practice guidelines for safe feeding during critical care admission for acute respiratory illness.

Conclusion Guidelines for safety of oral feeds for infants with acute respiratory illness on HFOT do not exist. However, providers and parents continue to want to provide oral feeds despite clinical signs of respiratory distress and coughing. To address this challenge, we initiated a process change to use clinical bedside evaluation and a “cross-systems approach” to provide recommendations for safer oral feeds while on HFOT as the infant is recovering from illness. Use of standardized feeding evaluation and protocol have improved consistency of practice within our department. However, further research is still necessary to develop clinical practice guidelines for safe oral feeding for infants on HFOT.