QUESTION: What is the typical time for follow-up VFSS for discharged NICU baby who is on thickened feedings? Our team has been recommending 6 to 8 weeks following VFSS. We are finding that there is some improvement at 6 weeks but not enough to change formula thickness.

CATHERINE’S ANSWER:

Because I find every infant is unique, we don’t utilize an arbitrary time frame, but instead determine that with the gestalt of each patient, and then discuss with the team.

Considerations I use include: infant’s history and co-occurring comorbidities, etiology(ies), nature of pathophysiology, how precarious swallowing appears even with thickening, complexity of interventions required to establish safe swallow, anticipated compliance with interventions post-discharge.

For example, a former 24 weeker with slowly resolving CLD, discharged on oxygen with laryngomalacia with the same swallowing pathophysiology as an infant born at 37 weeks IDM would most likely have a repeat VFSS earlier and have post-discharge surveillance more frequently. Ideally, we want to allow enough time for resolution of the etiology or the factors that underpin the swallowing pathophysiology, but not too much time —so that too must be tempered with risk-benefit of prolonged thickening, radiation exposure and how safety may change overtime, both for the better or the worse, depending on the infant and the bigger picture. It’s the art and science of what we do.

In re-assessing potential changes in swallowing physiology in the repeat VFSS, we may not be able to wean thickening based on new data. The data we gather will hopefully better guide interventions that would be occurring aside from thickening, and allow us to objectify potential new interventions and their impact. Re-objectifying physiology in a VFSS allows us to gather objective data on the impact of weaning thickener on physiology itself,  avoiding a narrow focus on only aspiration. It should help optimize the risk-benefit ratio inherent in our clinical decision-making, especially for our most fragile feeders.

Rather than having an arbitrary time frame, consider recommendations that are patient specific based on the domains above. As I always like to say, “in the NICU, co-morbidities matter”.  That applies to this question as well. So perhaps collect data for the team that may yield “co-morbidity-based” time frames that could be your soft “guidelines” — with the understanding that the final recommendation will be infant-specific.  Again, it’s the art and science of what we do and part of the value we bring to the NICU team.

If I were to average the data over many years of practice, I suspect the repeat studies post-discharge from the NICU tend to be between 6-8 weeks post discharge. I hope this provides some food for thought.