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1. Problem solving question with a kiddo with reflux.

   Previous 35w5d baby spent 24 hours in the NICU for low blood sugars and high bilirubin and low body temp. He needed to be on a warmer for 2 hours. He did not need lights or other intervention other than feeding for blood sugars and bilirubin.

   Feeding difficulties from the beginning but progressively worsening reflux that correlated with stridor. His last MBSS showed better coordination with thins and less prespill to valleculae and pyriforms on avent anti colic with level 2 nipple compared to slightly thick on level 3. Increasing prespill to valleculae and pyriforms with 2 episodes of penetration above the cords with slightly thick. Recommendation for reflux is usually thickening feeds but his OP swallow wasn’t as coordinated on thickened feeds. How can we manage reflux and not have poor OP swallow function? He has an appointment with an aerodigestive clinic but was hoping to implement something sooner as he is very uncomfortable and colicky.

   Reply

   • This is a great case study, Shauna and a complex infant. Thanks for reaching out. I am going to post it on my website so others can learn too, with all deidentified.

     Sounds like he was a late preterm. I have lots of questions to help me understand what the relevant factors might be.

     What is the PMA (adjusted age) now? When was he discharged from the NICU? How long has he been with you in OP? Are there any other diagnoses/co-morbidities we know about so far?  

     How is weight gain and stooling?

     When is the aerodigestive workup?

     Was reflux a presumptive diagnosis or based on objective data? Is he being treated pharmacologically or non-pharmacologically for reflux?

     Was there stridor only at rest? Or also with PO?

     How do we know the stridor is provoked by reflux? It could be, in an attempt to close the airway to “stop” the refluxate from entering, or it could be an inspiratory stridor associated with co-occurring airway invasion, or it could be due to problems with structural integrity of the larynx, or a combination of each of these.

     Did he have a scope by ENT at the bedside to determine etiology for stridor? Without that, we are guessing about the “why”. It could provide excellent data re whether EER/LPR is the reason for stridor and/or airway lack of integrity. Reflux could also be adversely affecting laryngeal sensation and further compromising swallowing safety. But we cannot guess at that and then formulate a plan for optimizing safe feeding.

     Was the study during NICU stay or after discharge? Your calling it an “OP swallow” suggest it was after d/c from NICU…? What was the feeding plan at discharge home? i.e., no PO, PO with NGT backup or? When was that swallow study (i.e., how long ago?)

     During the VFSS: Was there pacing offered? Avent nipples tend to run fast and could be increasing aerophagia (exacerbating reflux) …? It would likely be too fast a flow with thin to use a level 2 – that increased flow rate may have predisposed such a young infant to mis-direct the bolus. Did they then try a slower flow rate such as a Dr. Brown’s preemie or ultra preemie – we often use those with preterms to optimize swallowing safety. Thickening only as last resort after those nipple options trialed if indicated.

     Normal NB infant swallowing physiology is to actively drive the bolus into valleculae,  but the premature entry to the pyriforms is not a normal variant and suggests a delay in swallow initiation – the question is why – and could be figured out by seeing the swallow study. Could be there was reflux in or coming up the esophageal body and neural messaging “told the infant” to “pause the bolus” and maladaptation occurred (laryngeal penetration). Could be there was increased WOB, typical of late preterms, and that caused swallow-breathe incoordination that led to LP. Could be that there are airway problems causing the stridor (especially if it is heard at non-feeding times) that alters timing of the swallow -breathe interface.

     What was used to thicken? Rice? Oats? The increase in loss of bolus control is likely related to the higher flow rate nipple, one would think or if the thickener was not binding or mixed well..? or was EBM? Were the LPs shallow/midway to the vocal cords or deep to the level of the cords? In either case, the LPs are worrisome given the bigger picture, but especially if they were to the level of the true vocal cords (deep).

     That suggest that there is a very high risk of events of silent and/or symptomatic aspiration during the course of a true feeding based on research findings and my experience as well.

     Does the infant have a means of alternate or augmentative nutrition, or all PO? PO feeding without the aerodigestive data seems risky, both based on “precarious”/limited data from the VFSS, limited information about impact of interventions and etiology for swallowing pathophysiology, unclear etiology(ies) for the stridor and potential for airway invasion. His apparent discomfort and colicky behavior could be response to airway invasion, and not reflux.

     Look forward to further information to help me problem-solve.

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