QUESTION: Reading through some old posts and some conference notes about therapy feeding small volumes po even after aspiration is observed on an MBSS. Obviously, these recommendations are baby specific based on a wealth of information re: gestational age, medical status, and specifics observed during MBSS. At our hospital, we traditionally see aspiration on a study and pt becomes completely tube fed. I am getting a lot of questions about a current baby who I (in conjunction with medical team) am allowing 5-10 ml thickened feeds 1-2x/day with therapy or family only. Pt takes very quickly with no signs of stress. Can you please comment below to provide if you ever allow po feeds after observing aspiration on a swallow study?

CATHERINE’S ANSWER:  There are so many pieces to this complex question, as you know. No answer fits every infant, as you know. The plan for one patient may be very different for the other— with the same radiological presentation. “Aspiration” in and of itself is not enough to establish a plan of care with any data set as well. We need to consider the infant’s unique co-morbidities, nature of the pathophysiology, objective data under fluoro regarding response to intervention strategies (and the risk-benefit ratio, how precarious the resulting impact was), nature of the airway invasion witnessed (silent versus symptomatic), subsystem function across motor/sensory/airway/GI/respiratory, tolerance for pulmonary compromise, feeding/swallowing history and skill progression, overall health status, and the feeding “environment” (caregivers, risk factors in predictability and adherence to safety guidelines). Focusing on the pathophysiology observed is I think key, versus focusing on aspiration. Then we next focus on the objective data regarding interventions and your confidence in them to avert airway invasion (versus still yielding a precarious swallow during mealtime). For some infants, a combination of interventions (nipple change, position change, infant-guided co-regulated pacing, and, as a last resort, thickening) may yield safe swallows and promote positive motor learning. We hope to leave the radiology suite with useful data to assist us with avoiding airway invasion. That may suggest for example a period of only pacifier dips for the infant (for purposeful swallows without the risk incurred with PO feeding) — this would be on an interim basis while we support and maintain the oral-sensory-motor system and motor learning for eventual return to PO feeding when the risk-benefit ratio yields more confidence (with resolution or amelioration of some co-morbidities and/or improvement in swallowing physiology and/or system underpinnings). We know from multiple research papers that the risk for silent airway invasion is quite high in the NICU population, and often those we take to radiology have the most complex co-morbidities that escalates their risk for alterations in swallowing physiology, even when there is not witnessed aspiration during the study. If there was silent airway invasion during the study, those with a setting of complex co-morbidities (especially respiratory) are the most worrisome to me and are most in need of caution and protection. Practice really doesn’t make perfect; practice makes permanent. PO feeding with impaired physiology, even for 5-10 mls, while using maladaptive patterns, would be unlikely to yield beneficial motor learning, and may at some level, result in stress that adversely affects neuroprotection via the amygdala. We don’t know that yet through research, but from what I have learned thus far, it is very possible. Our critical thinking and the evidence-base must guide us to make the safest plan, and each infant’s risk-benefit profile must be carefully considered in concert with the team.