Problem-Solving: Bradycardia in the NICU

Question:

We currently have a former 33 week twin, now 36 and 4 weeks who frequently demonstrates bradycardia events but only during feeding attempts. He does not drop is oxygen saturation at all, in fact this almost always remains at 100% during feeding. His drop in heart rate is usually brief but this is usually after being stimulated. He wakes up consistently for feeding, shows appropriate feeding readiness cues, has a very strong non nutritive suck pattern. With bottle feeding attempts he demonstrates a very poor suck/swallow/breath sequence. He was initially on the ultra preemie nipple to slow the flow down to assist with coordination, however would demonstrate a very fast rate of suck, inefficient with fluid expression with suspected oral pooling in the posterior oral cavity prior to swallow. We have trialed a preemie nipple but without much change in his pattern with the goal of trying to achieve a more functional suck to swallow ratio. I do feel his swallow response is delayed post suck and inconsistent throughout the feed depending on alertness. Could these frequent bradycardia events be a vagal response? As a result of aspiration? Any positioning or flow rate recommendations to trial instead? You can very much tell when he is going to drop his heart rate during a feeding, and usually with re-positioning, taking a break from the feeding it can be prevented but I’m still curious as to a possible etiology for this. He is still currently on caffeine due to these frequent events. Any insight appreciated.

Answer:

This is a challenging clinical presentation to problem-solve but not an uncommon one in the NICU.

Can you tell us any more about the infant’s history  and co-morbidities (especially respiratory, neurologic, GI, postural/sensory-motor?) is he otherwise progressing as one would expect of a former 33 weeker now 36+ weeks PMA?

Bradycardia events during PO feeding can occur at 36 weeks PMA but such are not typical of preemies at that age and are unlikely therefore to be “a variant” of prematurity itself. Some bradycardic events during PO occur without co-occurring desaturation, especially if the bradycardic events are not prolonged. However, the provoking of a bradycardia when the infant  PO feeds  is worrisome none the less. Bradycardia in NICU infants during PO was correlated with aspiration in a study/paper by Neina Ferguson in 2015.

When I think about a differential as to about what co-morbidities might provoke such episodes at 36+ weeks, what comes to mind includes : GI (e.g., EER/LPR), respiratory (swallow-breathe incoordination leading to uncoupling of the swallow -breathe interface secondary to increased WOB, intermittent tachypnea). Both may present a pathway to airway invasion. In addition, alterations in neural integrity (which can occur in a former 33 weeker but are less likely to be the sources of provocation than the other two possibilities I mentioned). There can also be caregiver artifact (i.e., not recognizing and/or responding to infant’s physiological communication and/or swallowing behaviors from moment to moment , to contingently titrate interventions to avert decompensation; using  a flow rate that is too fast, well-intentioned prodding). The last possibility, caregiver artifact, seems unlikely given that he is having these events with you, not only with, for example, parents or staff. But some added interventions might help; more on that later.

Your clinical description suggests a prolonged sucking pattern, likely in the setting of increased WOB and intermittent tachypnea. An increase in WOB may be [resent at baseline or can be recruited (or exacerbated)  by a strong continuous sucking effort, without timely and sufficient breaths. This can lead to the need for an urgent breath, even with flow rate control via Dr. Brown’s premie or ultrapremie nipples. Bolus sizes beyond the infant’s capacity can then perhaps “overwhelm” the required dynamic adjustments of his airway that need to surround the swallow. This may lead to a clinical impression of a delay in onset of post-swallow breath (due to the infant’s attempt to prolonged airway closure as a means to protect the airway). Along the swallow pathway, the infant may attempt adaptations that, unfortunately, create resulting maladaptations that lead to further risk for laryngeal penetration and/or aspiration.

In my clinical experience, bradycardia during PO at 36 weeks PMA, even with interventions in place, is most often correlated with airway invasion. A vagal response can indeed result in bradycardia but is often seen as a maturational variant, again unlikely at 36 weeks PMA. Polyvagal Theory, which is quite complex, postulates and describes the fragile nature of CN X function related to prematurity.

When fluid approaches the airway of a preterm infant, there is a reflex that is supposed to be elicited to close the airway; however, its timeliness, consistency of provocation and effectiveness are not well understood. Caffeine prescribed to stimulate HR as you describe can have the unintended sequelae of increasing EER//LPR, so EER/LPR could still be part of the differential too.

Without knowing any more about the infant’s history and co-morbidities, I would suggest you continue to contingently rest the infant, use controlled flow rate to limit bolus size, and, if you have not trialed it yet, use elongated swaddled sidelying (to optimize tidal volume and respiratory reserves). Then incorporate contingent co-regulated pacing based on the infants communication and swallowing behaviors. If,  with these interventions, you cannot avert the events described, I would instrumentally assess swallowing physiology to help elucidate the etiology(ies) for the events, and the effect of further titrated interventions (frequency of pacing, flow rate). Unfortunately, some of our preterms who have adverse overt events during PO feeding are also observed to silently invade their airway under fluoroscopy.

I hope this is helpful.

Follow-up Question:

What does WOB stand for?

Follow-up Answer:

Sorry for the acronym. I hear the term (and see it in real life) so often in the NICU and PICU that it is just part of my vocabulary.

WOB stands for “work of breathing”, which often adult RNs refer to as shortness of breath (SOB). In the preterm population, increased WOB refers to the extra muscular effort utilized to “move air” or to compensate for the difficulty moving air. It may include during feeding typically chin tugging, shoulder girdle hiking, nasal flaring/blanching, and retractions (pharyngeal, suprasternal, supraclavicular). This “work”, combined with an elevated shallow respiratory rate, can render the  swallow-breathe interface precarious. When you work out at your max effort on a treadmill, you would (or should!) recruit all of these compensatory behaviors to get you through the task (your workout). That’s one of the reasons why even skilled athletes rarely if ever drink from their water bottle at high levels of aerobic activity/demand.

Preterm infants have musculoskeletal immaturity, and so they often have to resort to working harder to move air, even at rest. So they often start with an already increased level of respiratory effort at baseline. Because PO  feeding is their “aerobic exercise” (their heart and lungs work harder during PO feeding) they unfortunately often need to further increase their WOB to accommodate. This creates risk for airway invasion and requires the caregiver to have watchful vigilance during PO feeding. The caregiver needs to carefully watch for changes in WOB and related swallowing behaviors that may suggest swallowing and breathing are becoming uncoupled, and carefully titrate interventions to support the underpinnings for coordination.

Thanks for asking for clarification.

Research: Feeding outcomes in former preterms in the first 7 months of life

Click on this secure  link: Hill et la (2020) Bottle Feeding preterm Infant first 7 months of life

Those of you in Early Intervention and in the NICU will find this new paper just published a valuable addition to your research base for practice.

Hill, R. R., Park, J., & Pados, B. F. (2020). Bottle-Feeding Challenges in Preterm-Born Infants in the First 7 Months of Life. Global Pediatric Health7, 2333794X20952688

It reinforces some of the key factors that may lead to enduring feeding problems after the NICU. It may be helpful for your neonatology team, as its findings suggests that watchful vigilance both in the NICU by the SLP, and indeed after discharge by our colleagues in Early Intervention,  should be a part of the plan of care for our at risk infants and their families. Perhaps this early provision of infant-guided support may in the long run avoid the onset of feeding aversions that can arise from stressful feeding experiences.

Quoting their conclusions:

Very preterm infants (i.e., those born <32 weeks GA at birth) had significantly more symptoms of problematic bottle-feeding than infants born full-term, moderately preterm or late preterm. Factors such as BPD (Chronic Lung Disease), GER, and congenital anomalies of the face, mouth and gastrointestinal tract were significant contributors. Early difficulty with breastfeeding was also a risk factor for later difficulties with bottle-feeding. There was improvement in symptoms with increasing age, which is likely reflection of improvement of medical factors and infant maturation. These findings support the need for frequent assessment of feeding in preterm-born infants after NICU discharge and provides clinicians with information regarding particular medical factors that place infant at risk for feeding difficulty beyond the NICU. The identification of infants who are struggling with bottle-feeding may facilitate interventions within the primary care setting or referral to feeding experts to improve longer outcomes and decrease the likelihood of negative sequelae that could persist into late childhood.

 

 

Research: Videofluoroscopic swallow-study outcomes among infants with tracheotomies

While problem-solving a recent NICU infant I was following with a tracheotomy, I incorporated this information from a study done through Nemours Childrens Hospital in DE. It was presented as a poster session at the ASHA convention, and has not been published to my knowledge. The study was well-done, the findings are informative and can help guide our care of infants in the NICU who require tracheostomy. Contact the authors for more information. I am quoting below from the poster presented.

Videofluoroscopic swallow-study outcomes among infants with tracheotomies                        Jeannine Hoch, MA, CCC-SLP; Michele Morrow, MS, CCC-SLP; Heather Keskeny, MA, CCC-SLP; Aaron Chidekel, MD   

Due to advances in technology, tracheotomy tube-placement is becoming increasingly common during the first year of life.

Infants with tracheotomy are at risk for developing feeding and swallowing problems: There is a paucity of descriptive information regarding dysphagia for infants following tracheotomy. Lack of available research leaves many clinicians feeling unprepared to provide services for pediatric tracheotomy patients.

Infant feeding patterns may also be impacted by environmental and associated medical conditions such as: Gastroesophageal reflux, Low birth-weight, Bronchopulmonary dysplasia, Long-term nasogastric tube-feedings, disruption of parent–infant interaction due to long-term hospitalization

Goals of their study:

  • Based on reports from videofluoroscopic swallowing studies, what are the swallow characteristics of infants with tracheotomies?
  • What percentage of patients required enteral feedings via nasogastric and/or gastrostomy tube-feedings?
  • Are trends present between swallow dysfunction, underlying medical conditions (gastroesophageal reflux, premature birth, nature of illness necessitating tracheotomy tube placement), and the need for enteral feedings?

A Retrospective study

  • Subjects (n = 27) whose Tracheotomy-tube placement by 4 months of age with mechanical ventilation  – Males (n = 16), Females (n = 11) – Exclusion criteria included grade III or IV IVH or presence of severe neurodevelopmental delays that preclude initiation of oral feeding
  • Data collection:  Medical history, Results of initial videofluoroscopic swallow-study, Results of serial follow-up studies when applicable

Data analysis

  • Trends may exist between initial swallow-study findings and reason for tracheotomy-tube placement:
    • Airway issues (n = 10): delayed swallow-initiation (80%), laryngeal penetration (80%), aspiration (50%), residue following swallows (50%), and nasopharyngeal reflux (50%)
    • Respiratory distress with BPD (n = 17): delayed swallow-initiation (53%), laryngeal penetration (71%), aspiration (29%), residue following swallows (47%), and nasopharyngeal reflux (41%)
  • Among patients who underwent G-tube placement (n = 17):
    • Less than half (47%) had documented aspiration on their initial swallow-study.
    • Majority (94%) had documented reflux.
  • Among patients who underwent follow-up swallow studies (n = 17):
    • Laryngeal penetration tended to persist (n = 6) more frequently than it resolved (n = 4).
    • Aspiration tended to resolve (n = 5) more frequently than it persisted (n = 2).
  • Report of oral motor-impairment (n = 12, 44%) and oral phase-impairment (n=17, 63%) was common.
  • All of the patients (n = 27) achieved at least partial or therapeutic oral-feedings as noted on recommendations from their final swallow-study.

 

Problem-Solving: Onset of severe oral aversion in the NICU

Question:

I currently have an infant who has low tone with severe oral aversion impacting P.O feeding. The infant was previous a great feeder but needed to be intubated. Since then, the nursing staff reported poor feeding skills, and I noted poor tolerance of positive tactile stimuli to her checks and non-nutritive sucking for calming. I was wondering if you have any strategies to improve the tolerance of oral stimuli when an infant has an aversion combined with low tone.

Answer:

Will share some thoughts and also some questions. My mind starts right away asking questions to help me start a “differential” as one of neonatology colleagues taught me many years ago. I am so grateful that she took the time to help me problem-solve in a way that physicians are taught. It has really helped me dialogue with the neonatologists.

What is the etiology for the hypotonia? Is this a former preterm or a sick newborn and what are the co-morbidities that would lead to the need for interval intubation? The bigger picture is likely relevant to sorting this out. Why was she recently intubated? It is uncommon for brief interval intubation to completely “change” the oral sensory system. Maybe it isn’t the intubation that is causal but co-occurring events such as the pressure to “get back to PO” ?  or co-morbidity-related? Could this be r/t well-intentioned pushing to feed post extubation? How is she being fed now? “PO all” attempts despite adverse responses? Depending on how volume driven versus infant-guided your unit is, that may be adding fuel to the fire. Are they still trying to PO? I wonder if any of her maladaptive behaviors started as adaptive behaviors (i.e., not wanting to PO d/t breathing too fast at that moment, flow rate too fast, fluid moving toward the airway) unbeknownst to the caregiver feeding her…? Infants do things for a reason as you know and it is often physiologic, so looking from that perspective always informs us.

I wonder if being a “great feeder” for the nurses was a volume-related commentary versus one reflecting quality of feeding? maybe there have been qualitative issues all along that were not apparent.

If she is currently PO, I’d want to just be present when RN feeds and learn along with the infant and nurse about the feeding relationship with the caregiver to help inform your differential. May need a true break from PO, such that for now PO only with a therapist (to reset her sensory system and then attempt to progress back to infant-guided positive PO feeding from a better baseline of oral-sensory readiness).

Will she accept her own hands to face in a swaddled side lying position, ensuring WOB is not problematic? I’d start there as it’s likely tolerated best, and you can facilitate firm deep pressure (versus light touch, which may be processed as more averse). Look at her big picture as the foundational data set. Then listen to the infant. She can likely tell us the “why” or at least lead us in the right direction.

Hope this helps.

Catherine

Research: Challenges to eating, swallowing, and aerodigestive functions in infants

Jadcherla, S. R. (2019). Challenges to eating, swallowing, and aerodigestive functions in infants: a burning platform that needs attention! The Journal of pediatrics211, 7-9.

Always insightful and leading-edge, Dr. Jadcherla at Nationwide Children’s clearly identifies major focus points  in our journey toward supporting independent functional feeding for all of our pediatric patients. Follow his research in those key areas. Read the entire paper on Google Scholar.

Quoting from the article:

“…only when we understand the causal and ameliorating mechanisms of eating, swallowing, and aerodigestive dysfunctions, and the cause for practice and process variation, will we then be able to modify strategies for appropriate diagnostic, therapeutic, and rehabilitative approaches to ensure safe feeding during and beyond ICU stay, lest, we run the risk of over- or underutilization of gastrostomy procedures. In the end, we seek to restore the most fundamental of human behaviors, safe eating”

 

Quoting from the article:

“Summary of 10 Ps That Require Careful Attention to Disrupt the Rising Prevalence of Pediatric Dysphagia

 (1) Physiology of eating, swallowing, and aerodigestive functions in the context of the developing infant must be better understood. Maturational variability and rapid growth during early infancy offer a unique opportunity to improve eating patterns in premature infants.

 (2) Pathophysiology of the mechanisms of pediatric dysphagia also requires careful study so as to provide pathophysiology-guided clinical care.

 (3) Patient characteristics are variable in any given scenario of feeding difficulties, and attention to the risk factors is key because modification of risk factors can improve outcomes.

 (4) Parent involvement and anticipatory guidance for dealing with eating difficulties, swallowing, and aerodigestive morbidities must be undertaken from early on, so that appropriate and timely interventions can be addressed.

 (5) Providers in the healthcare system may be unaware of the factors that influence infant feeding, and physicians may wholly delegate this area to occupational therapists or speech language pathologists. Newer data over the last 2 decades has emerged, and the pace of rapid translation from discovery to implementation will be enhanced when silos of expertise are eliminated and knowledge, attitudes, and skills are reexamined.

 (6) Procedures performed in the diagnosis of pediatric dysphagia need standardization, with careful reevaluation of indications and contraindications in the context of the fragile ICU infant. Diagnostic delays lead to delays in timely interventions during critical windows of opportunities.

 (7) Precision medicine is possible only when the underlying mechanisms are understood and targeted with innovative approaches at the bedside of the infant in the ICU.

 (8) Personalization of diagnostic, therapeutic, and rehabilitative approaches in the context of the infant’s condition, maturity, disease, and functional skills is important.

 (9) Pragmatism in approaches coupled with humanism is needed particularly with developing longitudinal follow-up of feeding milestones. Clinically meaningful outcomes such as independent feeding must be a functional goal”

Enjoy this fabulous read!

Pediatric Feeding Disorder (PFD): “More than a symptom, pediatric feeding disorder is its own diagnosis”

Feeding Matters (feedingmatters.org) is the first organization in the world serving kids with pediatric feeding disorder (PFD) developed by mothers and guided by an interdisciplinary team, of professionals across communities to improve the system of care for children with pediatric feeding disorder. Founded in 2006 by mothers of infants and children with persistent all-encompassing feeding problems, it has partnered in the latest developments to advance the research and treatment of pediatric feeding disorder.

Their efforts have now made possible an amazing milestone in the evolution of accessing support for infants and children with feeding problems, and their families.

The U.S. Centers for Disease Control and Prevention (CDC) has officially approved Pediatric Feeding Disorder (PFD) as a diagnostic code (R code) to the International Classification of Disease edition (ICD-11) in October 20201.

This creates a stand-alone diagnosis and definition for PFD to provide common diagnostic criteria to ensure early and accurate diagnosis among clinicians when assessing children with feeding difficulties.

For so many years, pediatric therapists  have been ​advocating little patient by little patient to bring recognition of the need for this stand-alone diagnosis. I remember starting out back in the late 70s when we had no advocacy group like Feeding Matters and the team of experts assembled  to articulate the need and open the doors for so many infants and children in a timely comprehensive way. Mothers especially were often left to feel that “failure to be able to feed” your child was like “failure to be a mother, as one of the founding mothers of Feeding Matters told me years ago.

All of the pediatric clinicians in the trenches, like me,  thank the professional team for the diligence to see this through. And we thank the founding mothers of Feeding Matters who had the courage to advocate and persist in their search for a change, despite such arduous odds.

This successful effort has the potential to change the trajectory of the lives of many infants and children, and their families. We are blessed to be a part of it!

Click on this link for a free download of the seminal article DOI: 10.1097/MPG.0000000000002188).

Click on this link for the Feeding Matters press release:

https://www.feedingmatters.org/pfd-advocacy-in-action-pfd-as-a-stand-alone-diagnosis/?fbclid=IwAR2BAhqXNYGxlMyIz2tB7U19DXH8bb5YfnhlE_Qv0NHbg1P1Qy0HgNMnKUo

Research: Effects of Additives for Reflux Management and Dysphagia Management

This manuscript  was released in 2019. It  is a compelling read about potential adverse effects of cereal thickeners (rice versus oatmeal) added to formula, and adding medications to formula, and their impact on osmolality. Alteration of ready-to-feed preterm formulas may significantly increase osmolality and have unintended consequences (feeding intolerance, pain, prolonged GI transit, bacterial overgrowth).

The AAP has advocated against the use of thickening agents for high risk preterms under 44 weeks PMA. In the NICU and with infants after discharge in general, we always need to take pause prior to thickening feedings for infants with dysphagia, and do so after other interventions are offered (change in nipple flow rate, position, use of pacing strategies). For many infants, implementing these strategies will support safe swallowing. This manuscript adds to our understanding of the importance of considering risk-benefit ratio in all that we do.

The salient findings from this study are:
1) Cereal thickening amounts and agents added to ready-to-feed liquid preterm formulas impact osmolality and can cross the limits of AAP safety thresholds. Specifically, the thickening agent increases osmolality, and oatmeal contributed to greater osmolality compared with rice on an equi-volume basis. 2) Commonly used vitamin and electrolyte supplements added to ready-to-feed preterm formula can remarkably increase osmolality

They conclude: 1) When thickening is still a strong consideration for Dysphagia/GER management, the ready-to-feed thickened formulas may be a safer alternative as the mixture is more homogeneous and has been vigorously tested, and passes FDA regulations including osmolality thresholds. Other alternative treatment strategies may include modifications to nipple flow or feeding volume, pacing while feeding, or appropriate positioning of the infant during feeding.  2) mixing medications in the entire volume of feed, or dividing doses across multiple feeding sessions mixed with feeds to decrease the osmolality as much as possible.

I am attaching this manuscript as it will be a good discussion point with our medical teams in the NICU, with pediatricians and GI specialists, and for those of us who follow infants in the community.

I hope this informs your practice.​

Here is a link to this article. 

Problem-Solving: SLP completing NGT feedings in NICU

QUESTION

Do you as the SLP drop NG feeds when finishing oral feeds and/or treatment sessions instead of the RN? Does your department or hospital have any guidelines for this?

ANSWER

It is understandable that our NICU nurses can get very busy these days with greater numbers of infants to care for, conflicting patient needs at the same time, and time sensitive interventions. While we are there to lend a hand to a change diaper prior to out treatment, warm the formula/milk etc., it sounds as if you are in a situation where what you are being asked to do is making you uncomfortable. Understandably so, from what you have told us. Our tendency to help out if asked is commendable but must be thoughtfully weighed for its risk-benefit ratio to the patient, the hospital, and of course, to us.

In the NICU, placing an NGT, and/or offering that remaining portion of a PO feeding which requires delivery via an NGT feeds are neither without potential risk for adverse events. NICU RNs are required to meet competencies to complete these medical interventions, and trained mentorship, give it is in their scope of practice. Adult RNs who “float” to NICU to help in crisis situations, require competencies as well.

These procedures also are, to my knowledge, not within the scope of practice of the SLP, either by ASHA standards nor by typical hospital job descriptions. Doing so, because of its high risk problem-prone nature in neonates (provoking emesis, provoking bradycardia and/or apnea, co-occurring EER event, incorrect placement  if “dropping NGT – by which I think you are meaning “placing an NGT”. Even delivering the remaining volume in an NGT that is indwelling may lead to an adverse unanticipated event and place the SLP at risk. Working outside our scope of practice may open us up to serious liability issues.

I suggest you take this question/situation to your rehab leader and request input from NICU leadership, and hospital Risk Management. Proactively considering every action we undertake, and its risk (for the infant, for you, for the hospital), is essential in the environment of neonatal intensive care.

I commend you for thoughtfully pursuing this request made to you.

I hope this is helpful.

Problem-Solving: Silent Deep Laryngeal Penetration

QUESTION:

I am a graduate student in my medical externship and I’m trying my best to understand this:

It’s my understanding that the internal branch of the recurrent laryngeal nerve mediates sensation below the vocal folds and mediates a cough reflex. This is why we’d expect a cough if material is sensed below the level of the vocal folds in a pt with an intact cough response. If material gets below the vocal folds and no cough is produced, we call that silent aspiration.

It’s my understanding that the superior branch of the laryngeal nerve mediates sensation above the vocal folds and an expected response to material above the level of the vocal folds is a swallow.

What about material sitting on top of the vocal folds (level 5 of the pen-asp scale)? Is that expected to elicit a cough or a swallow?

If material sitting on top of the vocal folds is considered penetration (because it did not go below the vocal folds) and is expected to elicit a cough, wouldn’t that mean that there is such a thing as silent penetration?

DR. JAMES COYLE’S ANSWER:

Good for you in accurately describing the sensory innervation of the larynx. 

In a healthy state the stimulus of foreign material on the vocal folds should elicit a response of some sort.  However, people who frequently exhibit laryngeal penetration, people who smoke, and people with other conditions that desensitize the mucosal receptors’ or the sensory system’s response to irritation can lead to the need for a higher threshold of stimulation to elicit a response (attenuated response).  So that is why the distinction is important.  “Silent” laryngeal penetration to this level (PAS 5) would be unlikely in a person with intact laryngeal sensation while more likely in these other situations.

Also, it is perfectly normal for material (thin liquid especially) to just barely enter the vestibule and then spontaneously be ejected to the pharynx during laryngeal closure (PAS 2).  So if you wanted to use these terms I suggest including the depth of penetration in the descriptions (as the PAS scores include).  For instance, “silent deep laryngeal penetration” is different from “silent shallow laryngeal penetration” as explained above.

 

CATHERINE’ S FOLLOW-UP COMMENT:

Thank you, Dr. Coyle, as always for your input that informs our practice, whether in pediatrics or adult populations.

This paper below may be of interest to you. While it was published in 2000, it was a study well-done from the team Children’s of Colorado. It remains foundational in the world of pediatric dysphagia. In the setting of particular co-morbidities, especially CLD in our littlest ones, such understanding becomes critical in developing an algorithm for each infant that helps peel apart the likely impact of physiology on risk to invade the airway, not just in the moment in radiology, but in the course of a true feeding,

Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia, 15(3), 153-158.

Abstract: This study describes the incidence of laryngeal penetration in 125 dysphagic children ranging in age from 7 days to 19 years who were seen over a 6-month period at The Children’s Hospital in Denver, Colorado. Laryngeal penetration was identified in 60% of the study group, with 31% demonstrating deep laryngeal penetration. Of the children exhibiting deep laryngeal penetration, 85% aspirated, suggesting a strong correlation between these two events. It was noted that children exhibiting deep laryngeal penetration often began to aspirate further into their feedings. Use of extended feedings during videofluoroscopy is discussed as a diagnostic strategy in the presence of deep laryngeal penetration.

I hope this is helpful in your key learnings.
Keep up the critical thinking!

 

Research: Clinical Swallowing Assessment Across the Lifespan

I wanted to share this just published paper by our SLP colleagues about the clinical swallow evaluation, which shares critical insights that will inform everyone’s practice, from pediatrics to adult.

Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment Across the Life Span: The Clinical Swallow Evaluation. American Journal of Speech-Language Pathology29(2S), 919-933.

 

The final paragraph will make you want to read it right now:
“Specific guidelines for carrying out a clinical feeding and swallowing evaluation require systematic decision making with considerations for high degree of variability within and across adult and pediatric patient populations. The CSE is not only a useful tool but a critical one. As aptly noted, “it is critical that the CSE not be relegated to the status of a screening tool. It is far too powerful” (Rosenbek et al., 2004). The CSE is often the first complete physical assessment of swallowing function for a patient where critical information is gathered and should not be overlooked. A thorough CSE extends beyond watching someone eat and drink; it is a multidimensional assessment. While reliability of individual measures remains questionable, the experienced clinician can make important judgments regarding patient safety that will help chart the course of care for individuals needing additional assessment and, possibly, intervention. Employing a standardized CSE tool after sufficient training will further enhance clinical decision making. As instrumental examinations are more costly, more invasive, and less available, the CSE can also serve to chart progress, or lack of progress, over time when it is conducted methodically and consistently.”

I hope you will enjoy this read as much as I did, and share it with your students.

Problem-Solving: Impact of High Narrow Palate in the Setting of Tethered Oral Tissues

QUESTION: Infant  diagnosed with a tongue tie at birth. He is now 9 months old. We never clipped his tie, and he is still going strong with breastfeeding .

At birth, told the he has a very high arched palate. My pediatrician brushed it off saying it was fine. The ENT we took him to for the tie also pretty much brushed it off. Same thing. If he was feeding fine, he was probably fine. But when I look into his mouth now, I am shocked by how high his palate is. I have tried to read up and research it, and I have learned that the tongue is responsible for flattening out the palate (so it makes sense that a tongue tie would inhibit this). He is getting to the speaking age, it’s made me question if he really could end up having some speech issues. It seems logical that it would be nearly impossible for him to make palatal sounds when the time comes if he can’t even get his tongue close, but I can’t really find anything out there that gives me guidance.

My questions:
* Does a tongue tie with a high arched palate likely lead to more speech issues than a tongue tie?
* Is there anything to suggest that if I released it now, it would help with palate development? (or is there a point where releasing it would or would not make a difference?)

ANSWER:

Sounds like your little guy is doing well.

A good resource for you would be Lori Overland and Robyn Merkel-Walsh, both SLPs and accessible via ASHA Community. There latest publication is an invaluable resource regarding the potential broad reaching effects on the dynamic oral-motor and oral-sensory synergies that underpin swallowing and speech sound development.

Functional Assessment and Remediation of Tethered Oral Tissues (TOTs) 2018

The dynamic systems are integrated in utero as early as 17 weeks of life, when the fetus has fully formed the aerodigestive system as the fetus swallows amniotic fluid. This sensory- motor learning lays down the motor mapping for feeding in the delivery room with skill and integrity. Alterations, be they structural and/or muscular, likely impact this motor learning and can, even in subtle ways, create differences in how muscle groups function and provide the “forces” , if you will, that then may impact boney relationships, and vice versa. The forces that are brought to bear in utero on the palate do indeed help to shape it in utero.

Infants can learn to compensate with feeding but may also learn maladaptive patterns that yield functional feeding with qualitative differences, especially as more complex oral-motor skills need to emerge for refined chewing. Those qualitative differences may influence motor learning for speech. You are likely already having wonderful opportunities at 9 months to listen for the range of vowel sounds, articulatory contacts during his babbling and sound play and imitation to give you some insights, as to evolution of speech sound learning. As more complex speech sound integration is required for connected speech, you’ll gather more data.

In my practice as an acute care pediatric SLP, and an outpatient pediatric SLP for many years prior, I have worked with many infants and children with apparent tethered oral tissues with various functional presentations. Meaning, some can get by functionally and run under the radar. Others have more overt and sometimes more subtle alterations in function. My background in neurodevelopmental treatment (NDT) in pediatrics really opened my eye to the dynamic systems approach to the postural mechanism, including the oral-motor/oral-pharyngeal components, and the potential far reaching effects of tethered tissue anywhere along the human body.

I hope this is helpful

Problem-Solving: Where to Begin with Former Preemie with Multiple Complex Co-Morbidities

QUESTION

I’m looking for some insight on where to begin with this case:
The child’s age : 4 Months (Preemie Baby – 35 Weeks, will be 5 months June 26th from day he was born)
Aspiration pneumonia, G-Tube and Nissen Fundoplication, nothing by mouth

Issues with swallowing – risk of saliva entering to lungs – can’t give him pacifier, reflux, and unknown genetic abnormality/corpus callosum.

Any help would be appreciated!

ANSWER
Sounds like he is a late preterm  who is going to be 5 months soon, and would then be not quite 4 months adjusted age.​ The neurologic co-morbidities (likely absent corpus callosum) suggest at least part of the etiology for the abnormal swallowing and likely; altered oral-pharyngeal reflexes that underpin feeding. There may be other components of his history that might further inform a differential to guide a plan of care. I would suspect there might have been a VFSS early on in the NICU unless he was so neurologically devastated that the team determined a VFSS would not change his management and proceeded with a G-Tube/Nissen; or if he did not swallow his saliva, we would likely not do a VFSS.

To start problem-solving, it will be helpful to understand what you see clinically, especially related to postural and oral-pharyngeal tone, oral-pharyngeal reflexes, interest in own hands to face/ mouth, need for suctioning and response to suctioning, any spontaneous swallows observed, any ENT consult results.

Very challenging patient with multiple complex issues that are likely to be enduring and progress likely to be slow.

I hope this is helpful.

Research: Behavioral Epigenetics and Oral Feeding Skills in Preterms

For my NICU colleagues,

Many years ago when I started in the NICU in 1985 we were just beginning to understand the importance of developmentally-supportive care, “brain care” , to lay the foundation for early and future function across all developmental domains, including feeding.

How far we have come and yet how much we still need to understand. The feeding “environment”, that is, the gestalt of “experience” in which the preterm infant is supported from the first day of life, has implications every step of the way, that are often not appreciated or fully understood.

This just published paper by some well-respected researchers looks at how early-life cumulative stress exposure may influence evolution of oral feeding skills in preterm infants. We are just beginning to scratch the surface about the multiple underpinnings for safe and successful feeding for preterm infants. It reminds me of my favorite phrase, “In the NICU, every experience matters, especially when it comes to feeding.”

Griffith, T., White-Traut, R., & Janusek, L. W. (2020). A Behavioral Epigenetics Model to Predict Oral Feeding Skills in Preterm Infants. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses.

“The proposed conceptual model  is guided by the Preterm Behavioral Epigenetics framework, which theorizes that prenatal and early postnatal adverse events (ie, cumulative stress exposure) influence preterm infant phenotypes (eg, HPA axis regulation of cortisol reactivity and neurobehavioral development) through epigenetic modifications. Our conceptual model posits that early-life cumulative stress exposure, reflected by DNA methylation of glucocorticoid-related genes and altered cortisol reactivity, may disrupt neurobehavioral development critical for achievement of oral feeding skills. In other words, the conceptual model represents the idea that cumulative stress exposure (prenatally and postnatally) may change the epigenetic information, resulting in changes in  oral feeding skills.

The emerging field of Preterm Behavioral Epigenetics emphasizes how early-life stress exposure can imprint epigenetic mechanisms during sensitive neuroplastic periods and disrupt attainment of neurobehavioral

Untimely introduction of oral feeding when infants demonstrate inadequate or complete lack of oral feeding skills may lead to negative imprints during the sensitive neuroplastic developmental period. Such negative imprints influence future feeding behaviors and may predispose to lifelong susceptibility to feeding problems, eating disorders, obesity, and/or metabolic disease.”

Amazing. I hope this informs your practice as it has mine.

Covid-19 Update July 26,2020

Our remaining seminars in Phoenix AZ and Greenwich CT have unfortunately been cancelled due to Covid-19. We are rescheduling them in 2021. I hope that you and your loved ones are healthy and safe during this difficult and uncertain time. My goal is to assure that you receive the highest quality continuing education that you trust us to provide. The safety and health of our community – our course participants and faculty– are my top priority.

I am also working on some new CEU offerings in a live virtual environment.

Watch for updates on my website or sign up for postings in order to receive future updates.

Please, as always, reach out  with any questions. Thank you for being part of our community and choosing Shaker Seminars for your professional development.

I look forward to learning along with you soon!

Problem-Solving: Intervention with NICU Infants Who Are Vent Dependent

QUESTION

Can you share feeding protocols when asked to work with infants on a ventilator in the NICU. Specifically, patients that are expected to go home on a home ventilator.

CATHERINE’S ANSWER

These indeed are often our most fragile NICU infants. Each one is typically unique, so I always start with understanding that infant’s unique co-morbidities that led to the need for long-term ventilation. For example,   PPHN, CLD, CHD, congenital malformations, neuromuscular disorders, and structural airway alterations, or multiple complex co-occurring co-morbidities, which then create an even higher risk for the infant to, at some point, safely tolerate oral feeding. This then is the foundation for determining timing and nature of intervention, as we consider relevant factors for feeding readiness/oral-sensory-motor treatment to support the prerequisite skills for future PO feeding.

Multiple factors need to be considered such as: level and mode of respiratory support in the setting of that infant’s respiratory history, the prerequisite  oral-motor integrity, ability to swallow saliva, oral-sensory processing, non-nutritive sucking, as well as physiologic stability during  interventions utilized to support these prerequisites, if they are emerging. Once these prerequisites are established, I would likely be considering appropriateness of, and tolerance for,  an in line valve like the PMV to establish flow into the upper airway  that promotes restoration of taste, smell and subglottic pressure, which most optimally underpins swallowing; at this juncture, working closely with ENT/Pulmonology and the respiratory therapist is essential.

For those infants with readiness skills for whom a PMV is contraindicated (per diagnosis and/or airway status and/or clinical status), I would perhaps offer a cautious pacifier dips for purposeful swallows — because, without a PMV in line, there won’t be the taste or smell or subglottic pressure so critical for an infant who has no previous motor learning with suck-swallow-breathe and bolus control; I would offer this motor learning experience via very limited pacifier dips with SLP to allow some interval sensory-motor learning in preparation a swallow study very early on in the therapeutic process to objectify swallowing physiology.

For those infants with readiness skills, and who are appropriate for and tolerate a PMV (with MD approval), considerations may include: pacifier dips with PMV in line, limited trace PO via ultra preemie nipple (for interval sensory-motor learning in preparation a swallow study very early on in the therapeutic process to objectify swallowing physiology). I prefer an NICU infant’s first PO feeding not be in radiology if possible, recognizing safety concerns; but some interval motor learning is likely important to reduce artifacts. This must be carefully and cautiously balanced with that infant’s risk for, and ability tolerate airway invasion, especially from a pulmonary perspective.

In my 35 years in the NICU, I have never seen one of our trach/vent infants go home as a full safe PO feeder. Often in some NICUs, the challenge may be having the entire team on board about risk, prerequisites, silent aspiration, that it isn’t just about “aspiration” (but rather the dynamic impact of altered or impaired swallowing physiology),  in the setting of the complex co-morbidities these fragile infants have.

You will notice as you read my thoughts above, they aren’t a protocol as much as a scaffolding I use, when I unpeel the layers as I go along, learn from the infant, combine that with his history and ask more questions. I hope this is helpful.

COMMENTARY FROM KRISTIN KING at PASSY MUIR

First, thank you, Catherine Shaker for such a well-thought out response as always. I learn something new each time I read a response from you.

I am only responding to the question about cuff deflation and cuff deflation with use of a PMV. All that I provide here is somewhat contingent on following the information that  Catherine Shaker’s response provides. I realize much of this will be known if you work with patients on a vent, but I do not want to miss an important aspect.

Typically, I do not recommend a cuff deflation trial prior to PMV use or swallowing assessment. If with cuff deflation and airway assessment, it is determined that the airway is patent, and all other factors being appropriate, then I would trial a PMV shortly after cuff deflation. Ideally, for swallowing/feeding, a child could use a PMV to restore various physiologic functions (such as subglottic pressure), but it may not be necessary in some cases. In considering cuff deflation and a trial of cuff deflation, an inflated cuff is used to “seal” the airway allowing all airflow to be to and from the ventilator. PEEP (positive end-expiratory pressure) is provided via the vent because with an open tracheostomy there can be a loss of PEEP/decreased pressure in the lungs. PEEP assists with keeping the alveoli open for good gas exchange and oxygenation. If the ventilator is not properly adjusted, having an open tracheostomy tube with deflated cuff may cause loss of PEEP and de-recruitment of the lungs. Now, this is all in relation to infants/children who have a cuffed trach tube with ventilation. Infants/children are frequently ventilated with cuffless trach tubes and that is a different situation.

The loss of PEEP and de-recruitment with cuff deflation has been shown in research on adults (Sutt et al, 2016, 2017, Critical Care); unfortunately, we do not have much research on infants and children. Having a cuff deflation trial may actually cause a person (no matter the age) to have difficulty maintaining good lung recruitment and PEEP, if the trach tube is left open.

Trialing a PMV assists with maintaining lung recruitment and PEEP. The potential impacts and need for a closed system are illustrated in a case presentation in the 2018 pediatric issue of Aerodigestive Health presented by an RT and the issues they had transitioning a 10-year old child from the vent and use of a PMV to trach collar without a PMV (for the cuff deflation/trach collar trial). While this case presentation is with an older child, the concepts with cuff deflation still apply. Restoring more physiological PEEP with use of the PMV sooner will assist with overall respiratory function (the Sutt research even showed improved diaphragmatic use).

As to the swallowing/MBS assessment, ideally, the cuff would be deflated and a PMV available for trial. I recommend testing with and without the Valve and with and without cuff deflation, if at all possible and with considerations for exposure. Lastly, this is all contingent on the cuff being properly managed/inflated.

Hope this helps some. It is a little bit different slant than the initial question.

FOLLOWUP RESONSE FROM CATHERINE

Thank you, Kristin, for sharing this wonderful issue that informs everyone’s practice with this population, and for the helpful response. Laura Brooks wrote an article in a previous edition of Passy-Muir’s Aerodigestive Health that was also specific to trach and vent dependent infants and children in intensive care which is very helpful. All issues can be found at www.passymuir.com/resources .

I agree that if an in-line PMV trial is indicated, partnering with RT and trialing cuff deflation immediately prior to attempting the in line PMV,  is best for these little ones, who also can readily experience physiologic stress and anxiety when a cuff is deflated even extremely slowly. They, like the ten year old in the article, require so much patience and thoughtful progression of interventions. It is worrisome to me that the complexity of the swallow-breathe interface for neonates in the setting of a trach is not always appreciated by all members of the team. In those situations, these infants can readily decompensate,  and then both neuroprotection and airway protection are often adversely affected.

On a side note, in radiology I have typically seen improved swallowing physiology with the PMV in place for these complex neonates. I suspect part of that is that most were not PO feeding prior to their trach (due to complex co-morbidities), and so they often have no previous “motor learning” with PO feeding to “fall back on” to “guide them” when and if they start to PO feed. When a tolerated PMV restores the fundamental underpinnings for swallowing,  it seems to make all the difference for these fragile neonates.

Thanks again for your insights too , Kristin. So appreciated.