Question:

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.

Question:

I have not seen this family yet, but here are their concerns. They didn’t specify the babies’ current age but I’m guessing a couple of weeks out from being discharged at 44 weeks so their corrected age would only be about 6 weeks. Would love any guidance in how to best support this family!

“Twins born 25w, used to take 100ml per feed in NICU when they were 36weeks – 44weeks. Their feed has been declining since discharge at 44 weeks. Recently 30-70ml per feed, only hitting 50-70% of daily total volume goal. Both would get fussy/mad often during feed and fall asleep a lot. We have already changed the formula a couple times as suggested by our pediatrician, but they don’t seem to behave too differently. We use fortified breast milk 24 calories per oz with the formula. Started with Neosure (used in the NICU), tried Enfacare for a few days, and changed to Nutramigen for the last two weeks.”

Catherine’s Answer:

We don’t know much about history but hearing that they are former 25 weekers suggests strongly to me that there is a high risk for respiratory sequelae, which may be why they are disengaging during feeding; it is likely purposeful and adaptive behavior. There may be GI issues that could be related to many possibilities—such as gulping leading to air ingestion, tethered oral tissues that create air ingestion with each suck – both possibilities could provoke GI discomfort.  Parents may have increased the nipple flow rate since being home (to increase intake) which may be actually reducing their available breaths and leading to depletion of reserves and making intake worse. It’s all about the aerobic demands of feeding and the co-morbidities that underpin function. And it is also possible the intake noted in NICU was due to well-intentioned volume-driven feeding, sadly, and maybe now parents – hopefully- aren’t “pushing them”. When you evaluate the infants, be watchful for infant communication (physiologic and behavioral stress signs), how parents feed (flow rate, position, consideration of state, their response, or lack of response to infant disengagement, how developmentally supportive the feeding experience is – or is it volume-driven, what they describe would be a “good feeding” (i.e., bottle empty, awake at the end, stays awake, seems to like it). May experience tells me that volume-driven feeding combined with respiratory fatigue may be what’s going on. Parents will then need gentle (and the “whys” behind your suggestions) to unwind that volume-driven approach and move to infant-guided feeding (more manageable/slower flowrate, swaddled elevated sidelying, contingent resting, contingent co-regulated pacing). Close contact with the pediatrician will be essential. Re-admissions due to FTT post NICU discharge are high in this group, who often present as fragile feeders in the NICU and after discharge too. There is also a high risk for silent and symptomatic aspiration in this group, which may also be a part of the bigger picture adversely affecting feeding.

Join me for multiple advanced clinical learning opportunities! Clinically relevant, rooted in evidence-based practice and critical thinking. Immediately applicable. Enjoy a welcoming environment that fosters interaction and learning along with each other. Remaining 2023 locations: Indianapolis, Baltimore, Yonkers NY, and Boston.

• Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
• NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
• Pediatric Swallowing and Feeding: The Essentials
• Pediatric Video Swallow Studies: From Physiology to Analysis
• The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU and 

What you colleagues are saying: “This was the first “advanced” course I’ve attended that did not waste time reviewing “beginner” info. Most advanced courses do not provide functional therapy ideas or go into such high-level detail and with different evidence-based approaches in such a dynamic way” Anita, SLP

“Real time clinical problem-solving and how I can take pieces from a variety of approaches and individualize them for the infants and children I treat. Loved the group discussion and the up-to-date research”. Stephanie, OTR 

Question:

I have a 4-year-old who unfortunately has demonstrated significantly violent behavior with parents’ attempts to wean him. He has been significantly impacted on a structural level by prolonged use, negatively impacting both speech and feeding. My gut tells me it needs to be addressed by pediatric psychology.

Catherine’s Answer:

There are likely multiple factors contributing as this is atypical for an otherwise normally- developing four-year-old. What else do you know about his history and co-morbidities? That gestalt will likely offer some key insights that may be relevant.

It is possible the structural differences you observe are a consequence of prolonged pacifier use, but the structural differences may also be co-occurring. Meaning that the structural differences may be separate from the impact of a pacifier and unrelated in their etiology. Or they may indeed be solely due to prolonged pacifier use or exacerbated by it. Understanding any history or co-morbidities that are a part of his “bigger picture” would help peel that apart. As Barb so thoughtfully suggested, there may be reasons from a sensory motor perspective that pacifier use serves “a purpose” for him, meets a “need’ on a sensory level, as our kids at all ages do things for a reason. That may provoke the unbridled response reported when the “answer” to his “need” is taken away. Or it may be a learned behavioral response established in the child-parent relationship.

Without knowing his history and co-morbidities, it is challenging to problem-solve but with what I understand, there is a need for the expertise of pediatric SLP related to feeding and speech. Prolonged pacifier use can alter the oral-motor synergies/components that underpin chewing, swallowing and speech production. I’d suggest a consult by a pediatric OT skilled in sensory integration. The OT will also assess overall sensory motor control/processing, which may be the part of the underlying need that pacifier use is serving and determine if a PT consult is warranted.

At his age there may be a learned behavior and interaction pattern with parents, both related to pacifier use and beyond, that would benefit from the additional expertise of a pediatric psychologist.

Then the three professionals can together problem-solve and develop a plan of care with family involvement that addresses the “why” (postural, sensory-motor, oral-motor, “behavioral”) and a systematic approach to providing, in other ways, what his sensory system needs or “is craving” That may include SLP support for oral-sensory-motor treatment to normalize his oral-sensory system, and promote carryover of that intervention in ways that are more socially acceptable (and more developmentally supportive) than a pacifier, and OT for sensory integration that is perhaps more of a global need for this child than apparent on first glance.

I hope this is helpful.

2023 Locations: Miami, Indianapolis, Baltimore, Yonkers NY and Boston

Join me for an exceptional learning opportunity!

• Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Issues
• NICU Swallowing and Feeding: In the Nursery and After Discharge in EI
• Pediatric Swallowing and Feeding: The Essentials
• Pediatric Video Swallow Studies: From Physiology to Analysis 
• The Early Feeding Skills Assessment Tool: A Guide to Cue based Feeding in the NICU 

What your colleagues are saying….  ” It’s nice to know that even experienced therapists don’t have all the answers and need to problem solve and dialogue with others. I liked Catherine’s discussion “system-based thinking” when trying to differentially diagnose the reason why something might be happening. Loved the increased confidence this course gave me! It filled in lots of gaps.”  Violet, SLP

For those of you working with infants with CHD, this is a great resource which includes a primer on CHD pathophysiology and nutrition needs. These infants are among our most fragile feeders, at risk for aversions and failure to thrive. The more we understand normal and altered structure/function of the heart, and the impact on nutritional needs and feeding, the more informed our clinical reasoning and our engagement with the team will be. So essential to supporting infants and families in both acute care and after discharge in early intervention. Here is the secure link from Nutricia Learning Centers:

roundtable journal discussions overview (nutricialearningcenter.com)

Join your colleagues in Baltimore, MD in August for advanced clinical learning opportunities with Catherine Shaker and Dr. Suzanne Thoyre!

• August 29-30: The Early Feeding Skills Assessment Tool (EFS): A Guide to Cue-Based Feeding in the NICU and EI
• August 31: Pediatric Videofluoroscopic Swallow Studies: Physiology to Analysis
• Sept 1-2: Advanced Infant/Pediatric Dysphagia: Problem-solving Complex Patients and Practice Challenges

In the Cue Based seminar, Dr Thoyre and I will guide the group in higher level conversations about complex feeding challenges in the NICU and after discharge, watching and scoring videos of neonates feeding and problem-solving next steps. In the Pediatric Swallow Studies seminar, discuss unique components of the swallow pathway across the pediatric age span, and then peel apart the pathophysiology and its implications.  In the Advanced Dysphagia seminar, focus on critical thinking for decision-making, problem-solving and interventions for our neonatal through school aged patients.  A great venue to share ways of navigating the practice challenges that each of us faces on a daily basis. Walk away feeling renewed. I hope to see you in 2023!

Question:

I am currently searching the literature on the impact of adenoid hypertrophy on pediatric dysphagia. I welcome, and appreciate any recent contributions to the field, ideally with objective findings from VFSS. Thank you in advance.

Catherine’s Answer:

Our ENTs tell me that they commonly see nasal congestion, mouth breathing and LPR (laryngopharyngeal reflux) in those infants/children who present with adenoid hypertrophy, and it often presents as tonsillaradenoid hypertrophy. It becomes most worrisome to them when it provokes OSA and/or chronic cough and there is associated clinical presentation of dysphagia. To their knowledge and mine, no one has published about this diagnosis related to objective data from VFSS but my impressions in radiology include nasopharyngeal narrowing, swallow-breathe incoordination leading to retrograde flow into the nasopharynx, which appeared due to the adverse effect of the obstructed nasal airflow on breathing, and, for 2 of them, incidental findings of LPR were witnessed during the VFSS. Post adenoidectomy follow-up VFSS results with infants who had isolated adenoid hypertrophy (without other co-morbidities) noted greater improvement in the integrity of swallowing physiology post-op than those with other associated co-morbidities (craniofacial anomalies, Down Syndrome, hypotonia).

I suspect the setting or “bigger picture” when there is tonsillaradenoid hypertrophy (or adenoid hypertrophy) is likely to be a critical factor for our index of suspicion, and for the nature of our radiological data. I also suspect that if the adenoid hypertrophy provoked significant mouth breathing, that could readily alter the anterior seal on the bolus, and there might also be a pathway for laryngeal airway invasion due the need for urgent breaths during dynamic swallowing. The co-occurring LPR might also lead to diminished laryngeal sensation which has been shown to be a risk factor for airway invasion as well. Partnership with ENT is so valuable at all ages for our pediatric patients, for optimal outcomes.