Problem-Solving with Catherine: “What Else” to Consider in a Differential

Pegalis Erickson Medical


My friend was induced at 37 weeks due to concerns for gestational HTN. She had a maternal fever and leukocytosis during labor and received ampicillin. She had a vaginal birth with baby’s initial APGAR of 6 followed by 8 and 9. After birth, her baby received phototherapy for ~8 hours for jaundice and was then discharged shortly after.

Pediatrician at follow up appointment noted a “squeaky” cry and diagnosed him with laryngomalacia as well as an anterior tongue tie. He had a frenectomy done at 1 week by ENT. ENT also noted a lip tie and recommended re-assessment in 1 month.

He exhibits a “low tongue posture” and sometimes an open mouth posture when sleeping. He is gaining weight but has difficulty with establishing and maintaining latch, especially on left breast. He tends to use a “biting” pattern rather than a sucking pattern, which seems to be impacting efficiency with intake. My friend has been using cross cradle and football positions to optimize latch. He has been unable to latch in laid back position. Stridor? (“squeaking” noises) during breast feeding on the left breast > right. Baby is also exhibiting occasional episodes of apnea when coughing on secretions and is coughing with burping intermittently, which pediatrician attributed to GERD. Frequent gas and spit up. Poor sleeping during the day unless on parent’s chest of in semi reclined position. He is currently 3 weeks, 3 days old.

Her questions are:

  1. How can she help him improve his latch, especially on the left?
  2. How can she help him to reduce stridor (“squeaking” noise) during feeding, especially on the left?
  3. Are there any exercises to help him improve lingual strength and tongue to palate elevation?
  4. Any tips on reflux management without using medications?


Catherine’s Answer:

His early medical history sounds fairly unremarkable with the exception of the “squeaky voice. I find pediatricians not uncommonly “diagnose” laryngomalacia when they hear “stridor” but there can be many etiologies for stridulous voice in an infant, and its presentation (e.g., heard only during feeding, vs. heard also at rest). It is true as the pediatrician stated that the stridor may also be a by-product of responsive protective closure to EER/LPR events.

Did ENT scope the infant, and did he/she then diagnose the infant with laryngomalacia? Did ENT report seeing any erythema or suggestion of reddening of the larynx (which may suggest ongoing EER/LPR?) If so, not uncommon then for ENT to recommend some meds. Meds have been reported to reduce inflammation and irritation to tissues and restore laryngeal sensation, in some infants. I suspect ENT did not see evidence of EER/LPR, because you mentioned only the TOTs. Did the ENT clip to release the tongue tie or laser? Laser tends to have a better result. Wonder if the “low tongue posture” may be a posterior tongue tie that was missed? Or may have other etiology. The clinical behaviors you report are c/w sequelae from a posterior tongue tie as one possible etiology. The limited ROM of the upper lip (due to tethering) can also impact the entire oral-motor and hyo-laryngeal muscular network that underpins feeding/swallowing, and create the challenges being observed. Research and clinical observation have suggested a correlation between posterior tongue tie and EER/LPR (air is ingested with each suck-swallow d/t an ineffective seal with the nipple); this can be recruited at breast or bottle.

Tethered oral tissues can often co-occur with mandibular hypoplasia, and in such circumstances, if the tethering is released, it can provoke glossoptosis and airway obstruction. This reinforces the importance of always focusing on the bigger picture perspective, using thoughtful reflection and not signal reacting to a single finding, without considering the context, when we complete a differential.

What to do is not fully clear due to multiple pieces that seem to be contributing our differential (TOTs, EER/LPR, potential influence of airway/laryngeal integrity, possible mandibular hypoplasia). A clinical swallowing and feeding evaluation by a pediatric SLP with experience with complex infants is the place to start. With clinical observations there will be more questions and paths to discovery of what to do.

I hesitate to suggest strategies without understanding what is causing what, as it like shooting in the dark. The stridor may resolve with management of EER/LPR, once we understand its etiology. Ineffective tongue-palate seal and air swallowing may be reduced by release of a posterior tongue tie. There may not be a clear indication of need for lingual strengthening base on what we know so far, but there may, pending the SLP assessment. The “whys” behind each of the concerns so thoughtfully articulated need to be peeled apart to find the “what to do/interventions” that best meet this infant’s needs without a generic response about interventions “to try”. In the interim I’d be happy to talk with your friend about some possible interval inventions that might ease the feeding process. She’s lucky to have you in her corner.

For infants presenting like our little one above, my IBCLC colleagues sometimes trial a nipple shield, bodywork, craniosacral and myofascial interventions in addition to positional changes to impact the altered fascia and postural mechanism. Although it’s not optimal, if intake and weight gain become concerns with breastfeeding challenges, consideration of interim supplemental bottle-feeding has been successful via a Dr. Brown’s controllable flow nipple (a similar as possible to the controllable breast flow), adding in the blue valve (to avert energy depletion given what sounds like infant’s predominant compression-only sucking pattern). Lots of moving parts for this infant’s bigger picture that will benefit from a skilled pediatric SLP’s eye.

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