QUESTION: What slow flow sippy cups do you recommend?

CATHERINE’S FOLLOW-UP: Can you tell us more about the patient for who you are selecting the sippy cup? Since the cup is to be a therapeutic tool for the child, understanding the bigger picture is essential for targeting a cup that might be a potentially safe intervention.

THERAPSIST’S RESPONSE: Still on bottle, over 18 months, Down Syndrome dx. Silent aspiration across thin, 1/2 nectar, nectar so thickening not effective. Not a candidate for NMES due to pacemaker. Can extract from a straw but spits instead of swallowing. What are your slow flow sippy cup recommendations for him?

CATHERINE’S FOLLOW-UP: The question about any feeding tool (in this case, a slow flow sippy cup) cannot (or should not ??) reasonably be answered in isolation, i.e., outside the context of that patient, with the unique history, co-morbidities and data that provide the bigger picture, since no two children are alike. With the history provided (DS, with known silent aspiration) the question takes on new meaning. But the information from the swallow study that we know so far isn’t really helping to determine next steps by telling us only that “there was aspiration” —it’s like a doctor saying to a Mother who brings her child in for being sick, and is told by the doctor “Your child is sick, so we have to do what a sick child needs” and sending the Mother on her way–useless by itself. Please tell me more about this child’s bigger picture…when was the most recent swallow study? What did it tell us about swallow physiology and pathophysiology – i.e., why the aspiration occurred? What interventions were objectified in radiology? What were the responses to interventions trialed in terms of their impact on the pathophysiology (i.e., to suggest how they affect improve safety with that level of thickening)? Did they objectify purees or straw drinking during the VFSS with any specific utensils?

From multiple papers, we know that this population is at high risk for pharyngeal dysphagia and airway invasion—In this study —Jackson, A., Maybee, J., Moran, M. K., Wolter-Warmerdam, K., & Hickey, F. (2016). Clinical characteristics of dysphagia in children with Down syndrome. Dysphagia, 31, 663-671—-Of the 61 patients who aspirated, 90.2 % (n = 55) did so silently with no cough or overt clinical symptoms.so the objective data learned in radiology should help to protect the airway –especially since our clinical impressions can often be inaccurate according to research about clinical assessments. Given what we know about this child already —related to the precarious nature of his swallow, we would need to very cautious clinically and be sure to use what objective data we already have to guide us. It’s possible you did not get any more detail in the swallow study report, and that has tied your hands. If so, then perhaps follow-up with parent permission with the evaluating SLP at the hospital for that needed data. This child is quite complex, and it’s good that you are asking about options and suggestions. I suspect there must be some form of augmentative feeding available — so take time to think this through to minimize risks for him, and for you as well, in this process. Always here to problem-solve further.