Research Corner: Best Practices in VFSS

Wanted to share this recent publication on best practice for swallow studies,  which brings to practicing clinicians both the state of the science and best practices from leading researchers.

Martin-Harris, B., Canon, C. L., Bonilha, H. S., Murray, J., Davidson, K., & Lefton-Greif, M. A. (2020). Best Practices in Modified Barium Swallow Studies. American Journal of Speech-Language Pathology29 (2 Suppl), 1078.

Abstract:

Purpose: The modified barium swallow study (MBSS) is a widely used videofluoroscopic evaluation of the functional anatomy and physiology of swallowing that permits visualization of bolus flow throughout the upper aerodigestive tract in real time. The information gained from the examination is critical for identifying and distinguishing the type and severity of swallowing impairment, determining the safety of oral intake, testing the effect of evidence-based frontline interventions, and formulating oral intake recommendations and treatment planning. The goal of this review article is to provide the state of the science and best practices related to MBSS.

Method: State of the science and best practices for MBSS are reviewed from the perspectives of speech-language pathologists (SLPs) and radiologists who clinically practice and conduct research in this area. Current quandaries and emerging clinical and research trends are also considered.

Results: This document provides an overview of the MBSS and standards for conducting, interpreting, and reporting the exam; the SLPs’ and radiologist’s perspectives on standardization of the exam; radiation exposure; technical parameters for recording and reviewing the exam; the importance of an interdisciplinary approach with engaged radiologists and SLPs; and special considerations for examinations in children.

Conclusions: The MBSS is the primary swallowing examination that permits visualization of bolus flow and swallowing movement throughout the upper aerodigestive tract in real time. The clinical validity of the study has been established when conducted using reproducible and validated protocols and metrics applied according to best practices to provide accurate and reliable information necessary to direct treatment planning and limit radiation exposure. Standards and quandaries discussed in this review article, as well as references, provide a basis for understanding the current best practices for MBSS.

Click here to view/download from NIH Best Practices in Modified Barium Swallow Studies (nih.gov)

 

Research Corner: Critical Thinking Skills

Many of you know about Dysphagia Café, a wonderful resource for SLPs. The attached link will take you to an article just posted there by  Ed Byce, M.Ed. CCC-SLP and  Angela Van Sickle, PhD, CCC-SLP on critical thinking. Such foundational information to put our knowledge into action as we problem-solve patients across the age span and co-morbidities. Filled with clinical references, it reinforces the importance of being life long learners and is a must read.

A quote from their conclusions:
The good news is that the progress of gaining knowledge can be measured incrementally, one bit of information at a time. Now the proverbial ball is in your court. Take some time to set goals for learning. Will it be one article a week? Two per month? Will it be starting a journal club to review the information with colleagues? Perhaps it will be developing a robust data collection system? There are many possibilities, but it is worth the journey because patients are counting on you! 

 I think it’s so easy to look for a cookbook or an algorithm, and it gives us a sense of security. It is perhaps a false sense of security, given our complex patients,  each of whom is unique in terms of history, co-morbidities and clinical progression. Each needs a unique algorithm. As the authors so eloquently explain, problem-solving always requires a deeper dive, filled with knowledge but also with questions that help us complete our differential. This article really should be a must read for graduate students,  to reinforce that living in  the “gray zone”,  as  like to call it,  i.e., stepping back and pausing, not expecting yourself to have all the answers or a quick answer,  is ok.  And it is not only ok, but also essential. It underpins critical reflective thinking,  and best supports effective patient care, no matter what the age or co-morbidities.

Building a Knowledge Base to Improve Critical Thinking Skills – Dysphagia Cafe  

 

Research Corner: An Overview of Tracheostomy Tubes and Mechanical Ventilation Management

Barnes, G., & Toms, N. (2021). An Overview of Tracheostomy Tubes and Mechanical Ventilation Management for the Speech-Language Pathologist. Perspectives of the ASHA Special Interest Groups, 1-12.

This is a wonderful addition to our working knowledge base about tracheostomy. While it is focused on the adult population, it provides quite useful information and clinical reasoning to inform the practice of pediatric therapists.

 Authors’ conclusion:

 SLPs are a vital part of the clinical team for patients with tracheostomies and on ventilators. New SLPs or SLPs new to this population may not have an adequate knowledge base to become an effective part of the clinical team. This clinical focus article, although not all inclusive, is an overview of respiratory considerations, disease processes, medical considerations, and complexities that effect the overall prognosis of tracheotomy and ventilator patients. Basic explanations of tracheostomy tubes, ventilation, and weaning have been provided as well to familiarize SLPs to the terminology. Overall assessment of the patientsmedical conditions, respiratory status, oral condition, speaking valve tolerance, voicing ability, secretion management, swallowing ability, and interventions are outlined to give the SLPs a comprehensive picture of these complex patients. A working knowledge in these areas is crucial for SLPs to become effective members of the clinical team involved in facilitating the patientsrecovery. It is highly recommended that this clinical focus article be a starting  point and encourage SLPs new to this population to further their knowledge base with education courses, hands-on training, and review of current literature related to tracheostomy and ventilated patients.

Research Corner: Vocal Fold Movement and Silent Aspiration after Congenital Heart Surgery

This is a wonderful addition to our evidence base related to the potential impact of the need for heart surgery on airway protection in our infant population. Combined with the documented increased risk for R vocal fold motion impairment post ECMO in this same population, it can aid us we advocate for our involvement in safe progression to PO for this vulnerable infants.

Citation: Narawane, A., Rappazzo, C., Hawney, J., Clason, H., Roddy, D. J., & Ongkasuwan, J. (2021). Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. The Laryngoscope.

Abstract

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.

Methods

This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.

Results

Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.

Conclusion

Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

This will inform your pediatric practice whether in the inpatient or community pediatric setting.

Research: Disruptions in the development of feeding for infants with congenital heart disease

Jones CE, Desai H, Fogel JL, et al  (2020). Disruptions in the development of feeding for infants with congenital heart disease. Cardiology in the Young, 1-8

This just published manuscript is a valuable resource for therapists supporting feeding/swallowing for infants with CHD.  The authors include in the-trenches pediatric therapists from leading programs across the US. It will inform your practice,  whether you are in the hospital, Early Intervention  or community programs that support these complex infants.

The introduction:

Congenital heart disease (CHD) is the most common birth defect for infants born in the United
States, with approximately 36,000 affected infants born annually. While mortality rates for
children with CHD have significantly declined, there is a growing population of individuals with
CHD living into adulthood prompting the need to optimize long-term development and quality
of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental
challenges and feeding difficulties. Feeding challenges carry profound implications for the quality
of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional
bonding with parents and other caregivers. Oral feeding challenges in children with CHD
are often the result of medical complications, delayed transition to oral feeding, reduced stamina,
oral feeding refusal, developmental delay, and consequences of the overwhelming intensive
care unit (ICU) environment. This article aims to characterize the disruptions in feeding
development for infants with CHD and describe neurodevelopmental factors that may contribute
to short- and long-term oral feeding difficulties. 

They discuss the impact of: cardiac physiology, necrotizing enterocolitis, gastroesophageal reflux, timing of cardiac surgical interventions, sedation and medication, chylous pleural effusion, respiratory support, neurodevelopment, genetic syndromes, a noxious feeding environment, nerve paralysis/paresis, and dysphagia. They then discuss the consequences of these feeding challenges, including: nutritional interference, breastfeeding difficulty, tube feeding, oral aversion, and finally long-term feeding outcomes.

 

Supporting Feeding for Infants with Cleft Lip/Palate

Congratulations to Brenda Fetter, SLP  from Childrens’ Mercy in Kansas City for joint authorship on a wonderful new publication.

Kaye A, Huff H, Fetter B, Thaete K (2020) Cleft Lip and Palate Newborn Care and Feeding: A Primer for Bedside Nursing Providers. Int J Nurs Health Care, 2 Volume 03; Issue 07

Contributions from a  plastic surgeon and pediatric dietician make it a unique offering. Witten as a primer for bedside nursing providers working with newborns with cleft lip and palate, it provides excellent information for  all of us to consider for informing our practice with this infant population.

While each of us may have a slightly different slant on intervention approaches based on our unique clinical experiences, it provides a solid compendium of information to inform our practice.

 

Click on this  secure link for the open access article:  Kaye et al (2020) cleft palate primer for RNs

The Science of Breastfeeding

The science and physiology of breastfeeding has always been a great interest of mine. Partnering with IBCLCs early on taught me so much. They instilled in me a desire to learn and understand the critical implications for our bottle-feeding practice with infants, especially with my work supporting preterm infants and their mothers in the NICU. The works of Paula Meier (regarding the infant-controlled flow rate at the breast — -once mother pumps through letdown—and how it reminds us then to offer a slow  controlled flow from a man-made rubber nipple, to minimize adaptation required and optimize safety). The works of Nyqvist about successful breastfeeding experiences as early as 29 weeks PMA (I suspect likely related to controlled flow rate that absolutely best supports breathing stability for suck-swallow-breathe synchrony). With every mother in our NICU that I am blessed to work with via consult regarding bottle-feeding, if mother is pumping, I advocate for early nuzzling, early breastfeeding, and share the research (in a simple way) about flow rate, how breastfeeding is actually easier than bottle feeding for preterm infants, and that breastfeeding always facilitates progression of bottle feeding skills  (in my experience). The infant-guided nature of breastfeeding that supports the “dance” between mother and infant is at the heart of trust, communication and trauma-informed neuroprotective care.

Too often I hear well-intentioned caregivers in the NICU tell mothers that breastfeeding is harder for preemies, and I see the sadness come over the mother. I am always so grateful to be there to gently reinforce what the evidence tells us and encourage our mothers on behalf of our infants.

I can’t imagine working with bottle-feeding infants without understanding the science and physiology of breastfeeding. In every course I teach we carve out time to discuss the science and physiology of breastfeeding and how we can best support bottle-feeding experiences that facilitate continued successful breastfeeding.

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.

 

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!

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. 

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.

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.

Latest research on the effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants

Dumpa, V., Kamity, R., Ferrara, L., Akerman, M., & Hanna, N. (2020). The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants. Journal of Perinatology, 1-7.

Louisa Ferrara, PhD SLP contributes to the science that underpins our growing understanding of the potential risks of asking preterm infants to PO feed while they continue to require NCPAP. This information will inform your practice in the NICU and can promote needed discussion among members of the NICU interdisciplinary team

Objective To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants.

Design In this retrospective pre–post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation).

Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP.

Results Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1.

Conclusions:  Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.

Research Corner and Commentary about Article in the ASHA Leader on Thickening in the NICU

This is an excellent article just published by our colleagues at Boston Childrens and will inform your practice.

Duncan DR, Larson K, Rosen RL(2019) Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia.
Current gastroenterology reports.  https://doi.org/10.1007/s11894-019-0697-2

Abstract
The purpose of this review is to discuss current knowledge and recent findings regarding clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. We review evidence for thickener efficacy, discuss types of thickeners, practical considerations when using various thickeners, and risks and benefits of thickener use in pediatrics. Recent Findings: Thickeners are effective in decreasing regurgitation and improving swallowing mechanics and can often be used
empirically for the treatment of infants and young children. Adverse effects have been reported, but with careful consideration of
appropriate thickener types, desired thickening consistency, and follow-up in collaboration with feeding specialists, most patients have symptomatic improvements. Summary Thickeners are typically well tolerated and with few side effects, but close follow-up is needed to make sure patients tolerate thickeners and have adequate symptom improvement.

On a related note, I feel compelled to address a recent article in The ASHA Leader “From My Perspective: Overuse of Thickeners in the NICU.”

The article, I believe, while certainly written with the best of intentions, has the potential to set back the progress SLPs have made delineating a critical well-respected evidence-based role in the NICU and, left unaddressed, could do harm.

I am concerned that  SLPs (both adult and pediatric)  who are unfamiliar with the work of NICU SLPs may, after reading the above mentioned article in The ASHA Leader, have an inaccurate the impression about our practice. The article appears to make assumptions, and appears to question the clinical reasoning that underpins decisions made every day, with deliberate consideration for short and long-term implications and for best practice.

Many of the assumptions made by the author  are not consistent with both my practice in large level IV  NICUs for the last 35 years, nor the practice of most other NICU SLPs I have met as I teach across the US about NICU intervention. While there may indeed be variability in the knowledge and practice of some NICU providers (Madhoun, et al 2015),  the AAP recommends caution with thickeners in preterm infants, and this is typically the overriding consideration for all interventions prescribed in the NICU. First, do no harm. 

The author’s statement that “thickeners are a long-term solution” is not consistent with typical NICU practice. Thickeners are used only as the last resort in the NICU (Gosa, 2015) —- after trialing changing feeding position, slowing nipple flow rate, utilizing contingent  co-regulated pacing to support the swallow-breathe interface and assure timely and sufficient breaths.  Even then, thickening may not be the safest solution for a specific  infant and can  present untoward sequelae ( higher risk to aspirate after the swallow, concerns of digestive immaturity, malabsorption, NEC, etc.) Most NICUs rarely use thickeners today to the extent that they were used in the past, and if thickeners are, it is viewed as short term. In dialogue with the medical team, there is typically careful interdisciplinary deliberation of the risk benefit ratio. If indicated, there is typically the contingent use of interventions to minimize the risk, and support both oral-motor learning and motor learning, and avoid maladaptations that may result.

Each NICU infant’s  developmental progression, respiratory, GI and neuro history and co-morbidities must be considered, as well as the nature of the pathophysiology objectified in radiology.  When the author states that “failing a swallow study” is a reason to thicken, it suggests the author considers a swallow study as a “pass-fail procedure”.  Rather than a pass-fail procedure, an instrumental assessment is viewed with the NICU population, as an analysis of swallowing physiology, its alteration or impairment, and its implications for that unique infant in the setting of his unique presentation/data set.  Like with other populations for whom SLPs provide services, a neonate does not need to penetrate or aspirate to have a swallowing impairment that may lead to airway invasion. As a result, the level of analysis that is required, and the essential caution as to prescribed interventions, is well understood by those of us working with this high risk fragile population in the NICU. Thickening may be contraindicated based on data obtained in radiology.

The author asks  “What if the baby can’t suck?” and then states that “all babies have a suck reflex”. Unfortunately, this is inaccurate. It is not uncommon that a sick newborn or some preterm infants with significant neurologic co-morbidities may not have a sucking reflex, or the suck lacks the integrity to feed orally. If  indeed this is the clinical presentation, thickeners would be contraindicated. Our  interventions for motor learning would go in a completely different direction, both in the NICU and after discharge.

In addition, the assumptions about the interventions described in the article for use with post NICU infants (e.g., bottle feeding thin liquid  to avoid maladaptive feeding patterns, use of glycerin swabs, ice chips, and anterior controlled placement of thin water) are worrisome and may mislead the reader as to the interventions most typically indicated for an infant just discharged from a neonatal intensive care unit. The infant post-NICU is often still quite immature overall, and interventions such as those suggested may both present undue risk to the airway and be poorly tolerated from a sensory and GI perspective. Indeed, safety of progressing the diet to thin liquids, if previously contraindicated, would best be considered for the NICU graduate in the setting of objective data regarding physiology in radiology. Many NICU graduates continue to have medical issues post discharge that can make airway invasion a compelling risk to both their pulmonary and overall health. 


Cichero, J A  et al (2013). Thickened milk for the management of feeding and swallowing issues in infants: a call for interdisciplinary professional guidelines. Journal of Human Lactation, 29(2), 132-135.

Duncan DR, Larson K, Davidson K, May K, Rahbar R, Rosen RL.(2019) Feeding interventions are associated with improved outcomes in
children with laryngeal penetration. J Pediatr Gastroenterol Nutr. 68(2):218–224.

Goldfield, EC  et al (2013) Preterm infant swallowing of thin and nectar-thick liquids: changes in lingual-palatal coordination and relation to bolus transit. Dysphagia 28, 234e244.

Gosa, MM & Corkins, M R(2015). Necrotizing enterocolitis and the use of thickened liquids for infants with dysphagia. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(2), 44-49.

Madhoun, LL et al (2015). Feed-thickening practices in NICUs in the current era: Variability in prescription and implementation patterns. Journal of Neonatal Nursing, 21(6), 255-262.

I appreciate the opportunity to share the perspective of an NICU SLP and hope this has been helpful.