Problem-Solving with Catherine: Infant with “Failed” Swallow Study

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Question: I am looking for research on aspiration and breastfeeding as well as breastmilk from a bottle. I have a 3-month-old that failed swallow study with even honey thick and hospital recommended thin breastmilk in bottle. I am more comfortable with breastfeeding, that gives more control than with bottle feeding. Thoughts?

Catherine’s Answer: Aspiration isn’t just aspiration…the “why”, i.e., understanding the pathophysiology of the swallow, in the setting of the infant’s co-morbidities is essential to determine the best plan for that unique infant. Otherwise, we do the same thing with all infants who “aspirate” and that would not make sense and would be unethical. It’s possible you don’t have that data, although the SLP conducting the VFSS should provide that so you can target your interventions. “Thickening” isn’t a plan for intervention, it’s a step along the way, to buy time for improvement. If you aren’t getting that data from the facility who does your swallow studies, I’d refer elsewhere. A result that says there was “aspiration” is essentially useless as a treating clinician. It’s like the pediatrician telling a mother in his office “yes your child is sick”, and then sending her on her way. useless really. Depending on the data set, your plan of care can vary. A healthy normally developing newborn with the same presentation in radiology is very different than a former preterm infant for example, who has CLD and a paralyzed vocal cord. Also agree that honey level thick (to use non-IDDSI terminology) likely increases risk to invade the airway –if the physiology of the swallow is that impaired, then the likelihood of aspirating honey thick is quite high during the course of a true feeding. Have you contacted the evaluating SLP with parent’s permission to better understand her recommendations and rationale? That might be a place to start too. Lots to unpack here. We also know we cannot extrapolate (from results in radiology of bottle feeding) to assume we understand swallowing physiology at the breast. That is not possible. FEES is our closest source of information, and even so, we cannot fully observe the full dynamic swallow pathway due to “white out”; we can however infer some useful data from FEES pre-swallow and post-swallow information to help guide our interventions. Some missing pieces would help problem-solve this little one. Also, no intervention can be considered in isolation — there is a risk-benefit ratio for each patient that we must consider when selecting interventions. Depending on the etiology and co-morbidities, breastfeeding may indeed be protective, under some conditions more than others.

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