QUESTION: I am currently working with a 3 month She had a TEF repair and has a paralyzed left vocal cord. Her most recent MBSS on 9/15/22 indicated delayed initiation, reduced tongue base retraction, reduced laryngeal sensation and primary concern being uncoordinated SSB. She has a PEG tube, and they recommended slightly thickened breast milk via Dr. Brown’s Level 1 and PO intake to be limited to 2 practice feeds daily up to 60 mls. Practice feeds have been going really well, per data her Mom is taking at home, she is slowly increasing volume, reducing the time it takes to consume practice feeds and feeds have been pleasurable with interventions (elevated side lying on right side, external pacing ever 4-5 sucks and thickening breastmilk). Mom also indicates she seems very fussy when the bottle is removed, as she would like to keep eating. Should I ask the medical team about offering oral feeds for a certain length of time (15 minutes) at each tube feeding time if she is showing readiness and as long as she maintains homeostasis and whatever she doesn’t take orally, provide through the tube. She did aspirate thin breast milk her last two swallow studies.

CATHERINE’S ANSWER: Sounds very risky for airway invasion given impaired swallowing physiology in the setting of her co-morbidities. Do we know that in the VFSS thickened EBM was objectified as to its effects? EBM is super thin so when we thicken it slightly and use a Level 1 Dr Brown’s, it seems like that might be too fast flow to minimize air swallowing and bolus misdirection, in the setting of a L VCP and her pathophysiology. What thickener was objectified during the study? Did the radiologist look at upper esophageal function with thickened EBM during the study? How did the swallowing physiology look with the thickening – safe? precarious but no witnessed airway invasion? penetration without aspiration? Thickening may create increased challenges for resistance to bolus flow through the anastomotic site. When as the last UGI/esophagram to objectify whether there is a narrowing? When as she last dilated? Our surgeons typically dilate about every two weeks through the first two years of life. based on what I understand at this point, I would recommend not PO feed until these pieces are sorted out but continue to offer pacifier dips for purposeful swallows to keep her oral-sensory-motor system primed for return to PO.