QUESTION: I have a little patient that experienced prolonged hypoxia at birth and has been diagnosed with HIE grade 3. This patient is currently on oxygen via Nasal cannula and there is retraction during breathing. Also, notable secretions on the lips and pooling in the oral cavity of these secretions. When I went to assess the suck with my gloved finger, even with oral stimulation, no suck was elicited. This patient is currently on NGT feeds. Would you recommend the use of a pacifier to help with the suck and if so, which pacifier is recommended (I’m not too sure which literature to consult on this so any suggestions are appreciated). The hospital I work at does offer the option for instrumental assessment, but they will only do a barium swallow (not even a modified), so I will suggest this and know the patient will likely be for a PEG long term, but any advice and suggestions would be great 🙂
As a side note, the hospital I work at is very under resourced and we don’t have access to great equipment or specialists like pulmonologists which does limit intervention options.
CATHERINE’S ANSWER:
Sounds like this little one has complex neurological sequelae due to the HIE. The absent suck suggests there is also no active tongue movement for initiating or driving a swallow. I suspect her gag/pharyngeal responses are blunted as well. That affects ability to mobilize secretions/saliva posteriorly, to clear the pharynx and move the saliva away from the laryngeal inlet. This constellation of impairments is due to the overlapping function of the cranial nerves that support suck-swallow-breathe, which also “take a hit” as a group when there is hypoxia or ischemia in the newborn. I suspect infant also has diffuse postural hypotonia which provides a poor base of support for the hyolaryngeal musculature, blade and base of tongue, and muscles of respiration. High risk of ongoing silent aspiration of saliva/secretions due to motor and sensory impairments. Likely unable to generate a cough when needs to. Without a swallow response, we would not take infant for a swallow study as we would likely passively see barium invade her airway. Also we clinically see the behaviors s/o an absent swallow.
The history provided is quite helpful for us to problem solve. The clinical presentation as I understand it, in the setting of the infant’s history and co-morbidities, suggests a very poor prognosis for establishing even safe saliva swallows in the near future. I would recommend work up for a G-Tube and Nissan (as she is also at high risk to aspirate refluxate if there is EER, which is more likely given postural hypotonia). Continued intervention via providing postural stability, offering own hands to face/mouth, facilitating rooting response (which is also likely absent), providing deep pressure input to the biting surfaces, to the intrinsic tongue muscles and base of tongue muscles, f/b functional input with your gloved finger and then standard shaped pacifier to facilitate rhythmical responsive lingual movements. It’s a combination of oral-motor, oral-sensory and neurodevelopmental treatment to support motor learning. Intervention will be based on a thoughtful process and change will be slow, based on what we understand so far about the infant’s back story. The pieces we don’t know about birth history, intra-partum and post-partum infant response, Apgars, how long intubated, progress with state modulation and progress to date neurologically, would all help refine our differential and, I suspect, likely make infant’s prognosis even more worrisome. We offer parents guarded optimism, in that the infant’s story is not written yet and some of our infants amaze us. Early intervention, including ST, PT and OT, and follow through by a supportive family will be key to optimizing progress.