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.

Research Corner: Aspiration and Dysphagia in the Neonatal Patient

Raol, N., Schrepfer, T., & Hartnick, C. (2018). Aspiration and Dysphagia in the Neonatal Patient. Clinics in perinatology, 45(4), 645-660.

Quote:

There are 3 major types of aspiration: anterograde (occurring before, during, and after the swallow), retrograde (as occurs with gastroesophageal reflux), and silent aspiration (no accompanying symptoms). Aspiration has the potential to cause permanent damage to the developing lungs of infants and children. Aspiration in children includes oral feeds and secretions (direct aspiration) and reflux contents (indirect aspiration). Pulmonary aspiration is present in one-half of pediatric patients with unexplained or refractory respiratory symptoms, such as cough. It can cause recurrent respiratory illness, pneumonia, and lung damage, requiring frequent hospitalizations.6 Etiologies of dysphagia and aspiration can be divided broadly into 5 categories:  Anatomic abnormalities (ie, craniofacial anomalies, laryngotracheoesophageal clefts, laryngomalacia);  Neurologic abnormalities (ie, intrauterine stroke, posterior fossa malformations, neuromuscular disorders);  Cardiopulmonary disease affecting the suck–swallow–breathe pattern (ie, bronchopulmonary dysplasia, cardiac disease, infection);  Gastrointestinal etiology (ie, reflux); and  Other/unknown.

The diagnosis and management of dysphagia and aspiration in neonates represent a significant challenge for physicians, with management requiring long-term medical supervision and attention. Without intervention, the patient may develop recurrent illness, inadequate nutrition, and the need for supplemental nutrition that, if continued for an extended period of time, may result in oral aversion and refusal behaviors. Successful management begins with a thorough evaluation with a complete history and physical examination and appropriate imaging studies to identify the etiology and potential targets for intervention.

Neonatal dysphagia and aspiration can be difficult to treat. Multiple etiologies can be responsible for feeding and swallowing issues, including prematurity, structural abnormalities, neurologic delay, infectious etiology, and reflux. Identifying the etiology will help to guide management. Multidisciplinary team management, including otolaryngology, neonatologists, speech-language pathologists is necessary to achieve optimal short and long-term outcomes in these patients.

Research Corner: Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity

Tracy, M. K., & Berkelhamer, S. K. (2019). Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity. Pediatric annals, 48(4), e148-e153.

Abstract

Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in premature infants who require mechanical ventilation and oxygen therapy. Despite advances in neonatal care resulting in improved survival and decreased morbidity, limited progress has been made in reducing rates of BPD. Therapeutic options to protect the vulnerable developing lung are limited as are strategies to treat lung injury, resulting in ongoing concerns for long-term pulmonary morbidity after preterm birth. Lung protective strategies and optimal nutrition are recognized to improve pulmonary outcomes. However, characterization of late outcomes is challenged by rapid advances in neonatal care. As a result, current adult survivors reflect outdated medical practices. Although neonatal pulmonary disease tends to improve with growth, compromised respiratory health has been documented in young adult survivors of BPD. With improved survival of premature infants but limited progress in reducing rates of disease, BPD represents a growing burden on health care systems.

Comments from Catherine: This provides an excellent summary of pathophysiology, ventilation modes and outcomes for this fragile group of preterms who often have feeding and swallowing problems related to their Chronic Lung Disease and its sequealae.

Research Corner: Nonpharmacological and Pharmacological Measures in Neonates with Neonatal Abstinence Syndrome

Magyar, Hannah R.; Metzger, Laura D.; and Schrage, Ariel N., “Systematic Review: The Effects of Nonpharmacological and Pharmacological Measures in Neonates with Neonatal Abstinence Syndrome” (2019). Williams Honors College, Honors Research Projects. 889. https://ideaexchange.uakron.edu/honors_research_projects/889

Abstract

With the increasing incidence of drug addiction among pregnant women, neonatal abstinence syndrome (NAS) has become a significant problem in the United States and has led to increased hospital costs, longer lengths of stay, and more serious health problems in neonates. This systematic review will explore the evidence about outcome differences for neonates with NAS that receive breastfeeding, rooming-in, and acupuncture in addition to pharmacological agents when compared to infants only receiving pharmacological agents. Twenty-one articles, retrieved from the databases PubMed and CINAHL and published between the years 2000-2017, were described in an integrated review, analyzed with critical appraisal, and synthesized for this systematic review. In general, researchers have found that breastfeeding, rooming-in, and acupuncture have positive effects of decreasing the need for pharmacological treatment, NAS symptoms, hospital costs, and length of hospital stay for infants with NAS when used in conjunction with pharmacologic agents.

Research Corner: VFSS and Frame Rate

For those  of you not on the ASHA List Serve, I am sharing a post regarding a recent publication about frame rate for Pediatric Videofluroscopic Swallow Studies. The post was written by Heather Bonilha, PhD,  who is  a speech-language pathologist and medical researcher who specializes in voice and swallowing disorders. For over 15 years, she has been studying the impact of temporal resolution (ex. frame rate) on diagnostic accuracy and treatment recommendations with a specific focus on MBSSs. We are so grateful for contributions, and for her post, which infomrs our practice.

The recently published article is:  Layly, J., Marmouset, F., Chassagnon, G., Bertrand, P., Sirinelli, D., Cottier, J. P., & Morel, B. (2019). Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies? Dysphagia. doi:10.1007/s00455-019-10027-8

To quote from her post:

 I am reaching out to the SIG13 forum to express my concerns related to a very recently published article: Layly, J., Marmouset, F., Chassagnon, G., Bertrand, P., Sirinelli, D., Cottier, J. P., & Morel, B. (2019). Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies? Dysphagia. doi:10.1007/s00455-019-10027-8 I’ve never made a post like this but am compelled based on my concern for quality patient care to post this one. I want to informally point out some information that clinicians and researchers should consider when evaluating the merits of the article referenced above. 

Points to consider when evaluating the merit and clinical implications of the research article “Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies?”:

The most significant point is that one can not notice a difference in something that isn’t there. When studying the impact of technical parameters of MBSS, one must use cases where the phenomenon (penetration / aspiration in this case) exists. If the patient doesn’t penetrate/ aspirate at 30 frames per second (fps) there is not a possibility to find it at 15fps, falsely leading to a result of agreement in diagnostic accuracy between 30 & 15 fps. Thus, any study of pulse rate / frame rate must be limited to that in which a phenomenon (penetration/aspiration, reduced laryngeal elevation, delayed initiation of pharyngeal swallow etc.) is detectable at 30fps. Therefore, of the 190 swallows studied in the above referenced article only 46 are pertinent to addressing the research question. By including all 190 swallows, the results of the study are significantly biased towards revealing no differences between 15 and 30fps.

Next, it is necessary to consider more than penetration/aspiration when determining whether technical factors influence diagnostic accuracy. Our treatments have a goal of reducing penetration/aspiration, but we do that by modifying swallowing physiology (not assessed by, for instance, by the penetration-aspiration scale (PAS)). Strong clinical implications regarding the suitability of using 15 vs 30fps must consider more than just PAS. The authors correctly state in the discussion that “15 fps may be adequate to record aspiration and penetration in children; however, more subtle biomechanical and kinematic phenomena may be missed at the slower sampling frequency due to the rapidity of the physiological swallowing components.”

The technique used to down sample the 30fps recording to 15fps does not allow the raters to be blinded to the higher versus lower frame rates as the higher frame rates (30 fps) will be twice as long as the 15fps swallows. There is a statement that using the 15fps recordings did not change the treatment plan for the patients. However, impact on treatment plan was not a variable in the research study and no data related to treatment plans / recommendations were presented.

There is a statement that using 15fps instead of 30fps is “an efficient way to reduce the ionizing radiation exposition in children”. However, radiation exposure, and more importantly, radiation risk, was not assessed in the study.

For these reasons, I strongly recommend a careful evaluation of the research methods and conclusions of the article “Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies?” I will be formally writing a Letter to the Editor of Dysphagia; however, that is a lengthier process and I felt that the potential clinical ramifications dictated a more immediate response. Therefore, before the formal Letter to the Editor can be published, I hope that clinicians are encouraged to read the published article with critical appraisal prior to incorporating it in their evidence-based clinical practice.

Please feel free to contact me off-line at bonilhah@musc.edu regarding this. Sincerely,

Heather Bonilha  

Bonilha, H.S., Blair, J., Carnes, B., Huda, W., McGrattan, K., Humphries, K., Michaels, Y., Martin-Harris, B. (2013). Preliminary investigation of the effect of pulse rate on judgments of swallowing impairment and treatment recommendations. Dysphagia, 28(4): 528-538. [PMID: 23559454] [PMCID: PMC3762944]

Bonilha, H.S., Huda, W., Wilmskoetter, J., Martin-Harris, B., Tipnis, S.V. (2019). Radiation risks to adult patients undergoing Modified Barium Swallow Studies. Dysphagia. [PMID: 30830303] [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Tipnis, S.V., Martin-Harris, B., Huda, W. (2019). Relationships between Dose Area Product, radiation exposure time and projection in adult Modified Barium Swallow Studies. American Journal of Speech-Language Pathology. [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Tipnis, S.V., Martin-Harris, B., Huda, W. (2018). Estimating thyroid doses in Modified Barium Swallow Studies. Health Physics, 115(3): 360-368. [PMID: 30045116] [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Martin-Harris, B., Tipnis, S.V., Huda, W. (2017). Effective dose per unit kerma area product conversion factors in adults undergoing Modified Barium Swallow Studies. Radiation Protection Dosimetry, 16:1-9. [PMID: 28204745] [PMCID: PMC5927331]

Bonilha, H.S., Humphries, K., Blair, J., Hill, E., McGrattan, K., Carnes, B., Huda, W., Martin-Harris, B. (2013). Radiation exposure time during MBSS: Influence of swallowing impairment severity, medical diagnosis, clinician experience, and standardized protocol use. Dysphagia, 28(1): 77-85. PMID: 22692431

Martin-Harris, B., Carson, K.A., Pinto, J.M., Lefton-Greif, M.A. (2019). BaByVFSSImP© A novel measurement tool for videofluoroscopic assessment of swallowing impairment in bottle-fed babies: establishing a standard. Dysphagia. [PMID 30955137]

Lefton-Greif, M.A., Arvedson, J.C. (2016). Pediatric feeding/swallowing: yesterday, today and tomorrow. Semin Speech Lang 37:298-309. [PMID 27701706]

Arvedson, J.C., Lefton-Greif, M.A. (2017). Instrumental assessment of pediatric dysphagia. Semin Speech Lang 38:135-146. [PMID 28324903]

Problem-Solving: NICU Safety Concern

Question: I work in a NICU and am having difficulty with one of the Neonatologists. He changes nipple flow rates to see if volume will improve despite detailed documentation from therapists and nurses related to poor feeding quality, liquid loss, disengagement, occasional coughing and wet breathing with the faster flow nipple. Orders are changed requiring caregivers to use the faster nipple basically tying their hands behind their back regarding following the infants lead. I still use the slower nipple regardless and try to educate. Last time this happened, we spoke to the ‘head physician’ and were told that although my services were consulted, it’s is the physician’s decision to make. The question I want to throw out is…. In this case, is it expected that I sign off as the recommendations are not followed after education and discussions? Do I stay on to provide quality oral experiences 3-5 feedings per week, only? Not sure what the expectation is at this point.

Answer: This is unfortunately a more common situation than one might think. As I travel to teach about the NICU across the US and beyond, all too often this is a topic of discussion, as many SLPs who are part of NICU teams experience such a dilemma. Volume driven feeding in the NICU continues to be a challenge to neuroprotection and swallowing safety, and creates not only concerns for airway invasion but also learned aversions and maladaptive behaviors. The push to “get babies out”, lack of awareness and/or understanding of current research, combined with old habits of “getting it in”, combine to make our work in the NICU both challenging, at times disheartening and at times exhausting. Continuing to bring the research, using each consult as an opportunity to dialogue and letting the medical team “think along with you” about physiology, medical co-morbidities in the NICU and their relationship to feeding/swallowing, using guided participation with nurses and partnering with RNs who “get it” continue to be ways we can articulate our value. But in these situations as you describe, there is no clear answer. One option is to sign off, but then we cannot even advocate to protect the infant, support parent learning and reconsideration of their infant’s communication, identify onset of resulting aversions, or try to optimize safety with interventions. And we often cannot continue the dialogue about that infant and his response to the faster flow that may continue to go unrecognized by well-intentioned caregivers. And we lose an opportunity to turn the tide. I recognize it is a high and strong tide, one I have been dealing with since 1985 when I first set foot in a neonatal intensive care unit. Our resilience matters for the preterm and sick term infants in our care in the NICU, and their futures. Working in the NICU is indeed a step at a time each day, and requires much of those who choose to be there. The changes one can see over time keep us going and we support each other to have the courage and confidence to do so. I hope this helps

Problem-Solving: 9 month old with poor feeding and NGT

This interesting pediatric patient was sent to me for problem-solving. Thought I’d share, since it is an opportunity to build our clinical reasoning in pediatrics:

Question My patient is almost 9 months old s/p bilateral strokes. Has only breast fed, no bottle feeding experience. Has NGT in place. Head control is an issue but getting better and can maintain in Rifton chair/supported high chair when awake, alert. Currently breast feeding without aspiration related issues, although latch and strength of suck appear to be reduced and mom reports subjective difference. Main issue is moms reduced production of milk at this time, also baby has always been a “grazer” so not a good combo I have tried a dr brown level 1 and used smaller volufeeders; he can’t latch at all and he does not non nutritive on pacifier either. I’ve tried the bottle for over a week at my supervisors recommendation that we should “desensitize him” to the bottle. I am considering using a breast feeding trainer cup such as Mam or NUK simply natural to pursue any bottle feeding route. My understanding is that the neurolearning threshold for transitioning may be pretty tough as this point since sucking isn’t reflexive anymore and he has no prior experience with this skill- but I am open to hearing about others experiences and best practices. He is taking small volumes of purée via spoon and honey bear straw cup. I suspect he may need more time w ngt to build oral motor skills and then wean off ngt. Catherine, can you offer any suggestions for either improving bottle feeding transition ?

Answer: Don’t know a lot about his birth history, developmental history and co-morbidities that would help to problem-solve and to put into context the nature of his feeding/swallowing problems, since they sound like they are part of a bigger picture, as is often the case. I suspect his birth history would inform our differential. Multiple systems can be and often are synactively affected by each other and create a complex puzzle that needs to be solved to guide our plan of care. Wondering why still an NGT at 9 months instead of a GTube, given longstanding poor feeding, to support growth and avoid aversions that can result secondary to prolonged NGT in situ? Sounds like at least hypotonia and reduced postural stability are contributing to poor feeding, and are unlikely to resolve the short term, given apparent neuro comorbidities. Wondering about integrity of saliva swallows. If suck is that poor, swallowing physiology is likely also altered, if not impaired given poor head/neck control. Postural issues described suggest there may also be respiratory considerations. Not sure we can conclude there are no aspiration issues as he is more likely to silently aspirate given hypotonia, if he does invade his airway. Or he may misdirect the bolus toward the nasopharynx and adversely affect his nasal airway patency. Other relevant systems could be airway, respiration and GI co-morbidities that need to be considered in your differential, in the setting of his medical history. That should help guide you to workups to request and what interventions are indicated or might help at this juncture. Not sure about the rationale for the reported need to “desensitize”? Normalizing oral sensitivity sometimes needs to be part of the process but doesn’t sound like it for him, based on what you have mentioned. The latch is not likely refusal from what you have told me but rather altered sucking integrity or perhaps flow rate challenges that result in adaptive behavior that then becomes maladaptive. If the suck is poor, as you describe, a MAM or NUK breastfeeding training cup may not help or may create more challenges. Try to figure out why he is having trouble, first, then consider what interventions might best address that problem. The problem is likely not the feeding utensil but lack of the oral-sensory motor- underpinnings for effective feeding or other factors which I cannot sort out based on what I know thus far. An instrumental assessment of swallowing physiology with the purees and honey bear straw cup you are using with him would help define physiology, and you might also be able to observe some swallows with bottle feeding as well. I hope this is helpful. What a complex little guy.

Problem- Solving: Milk drop intervention for feeding readiness

Barbara O’Rourke, NICU RN, read my post on pacifier dips in the NICU, and is sharing the infant-guided neuroprotective “milk drop intervention” being used in her intensive care unit, and its positive outcomes. Thank  you, Barbara! 

Three years ago, our NICU launched an approved IRB research project of giving milk drops to our infants. The project was initiated due to an increase in our VLBW and LBW of oral aversion and the inability to take full oral feedings at 40-44 weeks CGA. We sought the guidance of our medical team, who requested that the project focus on 23 week to 33+6 week gestational age at birth infants. Although our only hypothesis was that “the infants who received milk drops would have a shorter length of stay (LOS) than infants who did not”, we also assessed and collected data for our knowledge regarding their HR, RR, oxygenation, color, state, tone, respiratory support, and response to the milk drops. The intervention would start at 3 days of age, and the infants were to be given normal bedside care except after they had been nested in, we would give a droplet or two of milk – if the infant licked their lips we would offer a swab or pacifier – if the infant accepted we would give more – a droplet at a time – based on the infant’s cues. The swab or pacifier remained in place as the droplets were given. The volume was limited by gestational age, and just like a feeding, sometimes the infants would not respond, however most of the time the infant did respond. As they matured they would often awaken before cares, sucking their fingers, looking around, and “waiting” for their milk drops. The process often took 10-15 minutes as we paced the infant allowing the infant to guide us. We only gave milk drops with cares or gavage feedings as oral attempts were considered the oral enjoyment for that set of cares. 100 subject infants were matched with 100 control infants who were discharged from our NICU before the study began. The data of the one 23 week infant in the project was pulled since the infant was transferred to another facility. The remaining 99 subject infants were matched only on gender and gestational age at birth with control infants. The average LOS for the subject group was 44.11 days versus the control group 49.30 days. The most significant difference in LOS being seen in the infants 24-30weeks. When costs were assessed, it saved our unit over $660,000.00 on these 99 infants. Our medical team requested the milk drop intervention become a standard of care for all infants in our NICU. The nurses document the infant’s response to milk drops in EPIC with the therapists and neonatologists often including the infant’s response to milk drops when they are assessing for oral feeding readiness. It is not unusual for our VLBW and LBW infants to go home at 35-36 weeks, some exclusively breastfeeding.

Problem-Solving: Pacifier Dips in the NICU

Question:

As ST/OT therapists, we have been doing feeding readiness and oral stimulation via pacifier dips for infant with controlled volumes, comfort during cares, etc….  Some of us do them as pacifier dips: milk in a medicine cup/medela bottle lid and some of do a mixture of the pacifier dips along with having the infant actively suck, offering 1 drip via a 1cc syringe.

The question has come up: Is there a standardization across the board regarding how and when to do pacifier dips/syringe drips?  The concerns with syringe drips, is that the bolus may be larger than with dips.  Another concern that I have is with oral organization, removing the pacifier multiple times makes the infant relatch and reorganize.  Versus allowing an infant to suck and offering syringe drips with time in between, allows infant to remain orally organized.

Is there a standardization? What do you guys practice?  Any research out there regarding the benefits?

Answer:

Pacifier dips can provide the opportunity for purposeful swallows that create the motor maps for swallowing in the course of a PO feeding. Supportive elongated swaddled sidelying, careful titration of bolus size, support for the swallow-breathe interface and physiologic stability all become essential components of our intervention that support infant-guided learning as co-morbidities permit.

Once the infant is tolerating a dry pacifier with physiologic stability utilizing co-regulated pacing, I use my gloved finger to place a tiny droplet of EBM or formula on the tip of the pacifier, and then offer it using the infant’s rooting response, when engagement, GI comfort, WOB and RR permit.

Re-latching in a supportive context can allow for prolonged resting to focus on respiratory reserves in between offerings, with when one is first introducing pacifier dips. This is especially true for infants for whom respiratory or airway co-morbidities are part of the differential. After resting, recruiting the root-to-latch sequence again, followed by onset of non-nutritive sucking promotes the motor mapping required for PO feeding.

Then one can begin to allow the pacifier to remain in the oral cavity, when infant is ready for that added aerobic workload. With the pacifier in the infant’s mouth, I can wait until WOB and RR look optimal, then deliver successive tiny droplets on the pacifier hub (I do it with my gloved finger to assure it is only a droplet). With each droplet I would be providing imposed breaths  to assure they are timely and sufficient, via use of contingent co-regulated pacing. Use of deep tactile cues at the cheek corner or at the anterior alveolus during imposed pauses creates the sensory-motor learning for future PO feeding.

I am not aware of standardization. I think it is more about being thoughtful and informed about why this intervention can help, what to consider and how to support both neuroprotection and safety, as we progress through this important step toward PO feeding in the NICU. The infant’s communication should always guide us.

So much goes into planning and executing this intervention, though it can appear quite simple. I hope this is helpful

 

Problem-Solving: Advocacy for SLP staffing in the NICU

Question: I am seeking your help as we fight for increased SLP staffing in our Neonatal Intensive Care Unit.  Do you have  any resources to justify more staffing and resources?

Answer: There is little to no data about NICU SLP services out there , and we always have to build the relationships that create respect for the value we add. This takes much time collaborating, thinking along with our medical and nursing colleagues, and building that open mind with each infant with whom we work, one by one.  As a former  Rehab leader, I found that was my only way to over time build the recognition of the need for our services , i.e our value to the infants, their families and the team. This then generated the referrals that needed to be seen.  Then when MDs were not happy if referrals were delayed due to inadequate staffing,  leadership could relook at budget to allow us  to allocate more staff.  Now, as a front line NICU staff person, I continue to build relationships and then let my leader take the next steps.

I have found it very successful  to utilize a co-morbidity-based approach to advocating for feeding needs   —  See: Edney, S. K., Jones, S., & Boaden, E. (2018). Screening for feeding difficulties in the neonatal unit: Sensitivity and specificity of gestational age vs. medical history. Journal of Neonatal Nursing.

The only article I know of looking at utilization in the NICU was this one  —- Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in developmental disabilities, 64, 108-117.

I hope this is helpful.

Problem-Solving: Variability in Breastfeeding Success

Question: A colleague reached out to me regarding her 3-week-old baby. She has some successful breastfeeding feedings and some that are not. Pediatrician suspects posterior tongue tie. Would that be possible if many feedings are perfectly successful?

Answer:

Feeding and swallowing are both dynamic systems, with multiple and varying influences from moment to moment and from feeding to feeding. Completing  a differential about what is causing the reported variation in feeding, and what may be the contributing the etiology(ies),  is a complex endeavor, to which many of the responses thus far have alluded. It is important to remember that multiple systems contribute to feeding/swallowing skill and the interplay, i.e., synactive relationships, amongst those systems, must be peeled apart .

None of the  systems that underlie function for nutritional intake exists in isolation. These systems include: cardio-respiratory, neurologic, neuromotor, sensory, sensory-motor/postural , airway, gastrointestinal, and oral-sensory/oral-motor, as well as the feeding “environment” (such as mother’s milk supply, milk flow rate, the caregiver’s perception of her role as a feeder and her experience, position utilized, and for bottle fed babies – nipple choice, as well as response to apparent infant stress and communication throughout the feeding). In addition, how the caregiver defines “successful” can be enlightening (e.g., volume, amount of stress observed, how soon infant disengages, feeding with or without apparent incoordination). Sometimes, infant behaviors interpreted as leading to an  “unsuccessful” feeding may be purposeful on the infant’s part to protect his airway or to signal stress (i.e., use of a compression-only sucking pattern, no longer rooting, letting go of the latch, loose latch). Sometimes what can look  like an oral-motor problem may be the infant being “smart”. It is important to ask that question. Again, think of dynamic systems theory.

You can see how if we, unfortunately, view one system as the focal point and don’t consider the bigger picture of  the context  of the other relevant systems for that particular infant, our differential about the problems observed will be sorely lacking, and our plan of care, therefore, ineffective. From this informed perspective, the SLP can present impressions and recommend further consults and diagnostic workups  thoughtfully to the physician.

An evaluation by a skilled pediatric therapist who looks at all the systems that underlie function, and their interaction, in the setting of the infant’s history, will best help to answer the “why” that can then guide the infant toward more consistency “successful ” feeding  —-  which to me, means infant-guided pleasurable safe feeding with an engaged infant and a caregiver who provides contingent responses to infant communication during feeding.

I hope this is helpful.

 

Research Corner: Non-nutritive sucking in the preterm infant

Pineda, R., Dewey, K., Jacobsen, A., & Smith, J. (2018). Non-Nutritive Sucking in the Preterm Infant. American journal of perinatology.

Objective To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

Study Design Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA. Oral feeding was assessed at 38 weeks PMA.

Results There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = –1.4) was related to feeding success at 38 weeks PMA.

Conclusion Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Commentary from Catherine:  Co-morbidities matter in every facet of the preterm infant’s development and skill progression. The emergence of non-nutritive sucking, its quality, and its interface with swallowing and breathing,  is clearly affected by the nature of and interaction among the infant’s co-morbidities. Take time to carefully consider this in your assessments and ongoing interventions with our  ones in  the NICU. Remember, sucking does not occur in isolation –  it is part of a dynamic interactive system.

 

 

 

 

Research Corner: Characteristics of children at risk of aspiration pneumonia

Pavithran, J., Puthiyottil, I. V., Narayan, M., Vidhyadharan, S., Menon, J. R., & Iyer, S. (2018). Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia. The Laryngoscope.

Methods: A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS).

 Results: Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88).

Conclusion: Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies.

 

Problem-Solving: Aspiration of EBM

Question: I was curious if there is any research out there regarding the effects of breastmilk on the lungs if aspirating small amounts? 

We currently have an ex 25 week infant who is now corrected to 40 weeks.  Infant has CLD, currently on LFNC 2.5 LPM 100% Fi02.  Infant is s/p PDA ligation with L vocal cord paresis.  He also had delayed start to feeds due to medical NEC x2.  We started conservative PO trials with him 2 weeks ago-offering 10cc via Dr brown ultra-preemie nipple in R sidelying.  He built stamina and was appropriate for a VFSS this past week.  Results were as expected.  Infant had 2 episodes of gross aspiration- 1 with thin barium via ultra-preemie nipple and 1 with ½ strength nectar thick barium via preemie nipple.  1 was silent and the other resulted in a brady/desat.  However, he demonstrated several consecutive safe swallows during the length of the study.  We decided to allow him to continue to BF on a pumped breast and have been also contemplating allowing him 5cc of straight breastmilk 1-2x/day via ultra-preemie nipple for ongoing practice.  Some of our practitioners would like to allow him these PO bottle trials while others would prefer to keep it at just breast feeding with the pumped breast and allowing some pacifier dips during PG feeds.  I am torn between what would be best for this medical complex infant.  I work frequently with adults as well and have thought about the Frazier Free Water Protocol with some of our patients.  Given that breastmilk seems to be a fairly benign liquid, would it be similar?

Answer:

I know of nothing published but my pulmonologist colleague has told me that she believes EBM is likely tolerated much better by the lungs if aspirated, compared to  formula or thickened formula.

Aspiration is of course especially worrisome, though,  in the setting of CLD and a continued  need for respiratory support, L vocal cord paresis. You dont’ t mention the etiology for the aspiration events but I suspect an altered swallow-breathe interface,  and likely ineffective and/or incomplete airway closure, are probable etiologies.

Because we are not always fortunate to actually witness aspiration during the brief moment in radiology,  when there is indeed gross aspiration, at times silent, it confirms swallowing physiology is impaired.  Based on the data you provided,  I would not PO feed by bottle,  as “practice” as suggested by some practitioners, is not the answer. It is highly likely that resolution of CLD and vocal cord paresis are the answer,  both f which will take time. Pacifier dips of EBM, a GTube and repeat swallow study in 2 months has been a successful plan for our babies who present similarly.

The pacifier dips are like a free water protocol for infants and also perhaps limit the risk while allowing for purposeful swallows. PO feeding silent aspirators, especially those with the history and multiple complex co-morbidities you present, is worrisome to me. “Pratice”, which actually involves recruiting impaired physiology,  would, for me, weigh heavily against this option for this infant. While breastflow is likely more protective than flow from a man-mande rubber nipple, especially in the setting of CLD, breastfeeding may not be more protective  if there is a primary airway problem as you describe.

I hope this is  helpful.

Problem-Solving: Stridor in preterm infant with trouble breastfeeding

Question:

I am seeing a 5 week old tomorrow morning, born at 35 weeks. I will be looking at fat pads and tethered oral tissues. Mom reports breastfeeding is very painful. Mom just sent a video and I am hearing a lot of stridor.  I am also seeing a very shallow latch. we will explore a Dancer hold tomorrow as well. I attached a video clip.

Thoughts on the stridor?

Answer:

ENT is a very important consult for which to advocate. I have been fortunate over the years to be mentored by some fabulous neonatologists (who love the airway like I do!), RTs, pulmonologists and pediatric ENTs who have kindly allowed me to ask a million questions and who kindly have helped me think about the airway from their perspectives — but very “simplified” so I could start to make sense out of what  I am seeing and hearing clinically.

We don’t know much about history and co-morbidities for this IUGR-appearing infant except she was 35 weeks GA and is now 40 weeks adjusted age. So much possibility for why we are hearing stridor. Knowing more may assist with our problem-solving on the list serve, and as the SLP seeing the infant, inform a initial differential that allows the SLP to advocate from an informed perspective.

The shallow latch may be purposeful to limit flow in order to protect the airway, or it may be due to tethered oral tissues, or it may be purposeful due to the need to prioritize breathing. Or a combination of any of these etiologies.

Is there apparent mandibular hypoplasia that might be leading to an ineffective tongue-palate seal and poorly controlled bolus? That can lead to stridor.

Be thoughtful with a dancer hold as it will inadvertently increase flow rate, which may not be what the infant wants. If when you offer the dancer hold, you hear increased stridor, or infants pulls away or changes facial expression to a “worried” look, or increases breathing rate or effort, the infant will be “telling you” the dancer hold is not helpful for him right now. Infant guided interventions and the infant’s responses always inform our differential.

Stridor may be iatrogenic (post-extubation, post-ECMO, post PDA ligation or repair to the aortic arch, post-emergent or prolonged or repeated intubation, or due to resulting subglottic stenosis, for example),or it may be congenital (r/t a vascular ring, idiopathic occurrence at birth without explanation, laryngomalacia, tracheomalacia or tracheobronchomalacia). It is surprising  how often it can go apparently unnoticed so to speak prior to our noted concerns, despite worrisome or adverse effects on feeding (intake, co-occurring physiologic stress and apparent swallowing safety). I have seen this both in NICU, PCVICU, and with admissions from home to PICU and our pediatric inpatient units at times over the years.

Cannot tell if the stridor is present at rest, as the video starts when infant is already at breast and sucking.

Cannot see if there are suprasternal and/or supraclavicular refractions present at rest or, if they are seen, are they seen during feeding only.

My mentors have taught me that:
Stridor heard frequently at rest suggests a primary airway pathology. Stridor present at rest often will be exacerbated with the aerobic demands of feeding, both at breast and bottle.

Contrast that with stridor that occurs only during feeding. That may suggest either swallow-breathe incoordination, due to  the tendency to inhale after the swallow, or indeed attempts of the airway to close in a protective maneuver due to bolus mis-direction from above and/or below.

The stridor in the video sounded biphasic, suggesting a fixed airway obstruction (subglottic stenosis, paralyzed vocal cord(s)—as the airflow moves past a constant obstruction on inhalation and on exhalation – that leads to the biphasic stridor.

Contrast that with stridor on only one phase of respiration, which is most typically associated with a dynamic airway problem – i.e., laryngomalacia – stridor is typically only inspiratory, as there is collapse on inhalation   or   tracheomalacia  – stridor is typically heard only on expiration. There may of course be a combination of airway problems, best diagnosed by ENT.

Of course we don’t diagnose airway problems as SLPs. My mentors weren’t trying to teach me to do that, but rather to think critically. I  describe what I hear,  in the setting of that infant’s/child’s unique history and comorbidities, and my ENT and neonatology friends tell me that helps them. And it helps me better consider the “whys” that underlie the feeding and swallowing challenges that result.

I hope this is helpful.