Heading to ASHA Convention and Speaking at Meet The Masters!

It has been a fulfilling year travelling the US, meeting colleagues with a similar passion for “all things feeding and swallowing”. While I love teaching, I also love learning from the therapists I meet and making lasting friendships as well. We each have so much to share and I never stop learning .

It is a beautiful sunny day in Orlando, and I am going to the ASHA Convention for three days of learning and networking and catching up with old finds and past mentors. I am especially excited to be an invited speaker at the annual Bracco “Meet the Masters” presentation dedicated to the latest information on videofluoroscopic swallow studies. I’ll be speaking about “Big Considerations for Tiny Feeders – Navigating the VFSS in the Neonatal Intensive Care Unit (NICU).” And then on Saturday, I’ll be speaking on “The Role of Semi-Elevated Swaddled Sidelying in Neuroprotective Feeding” followed by “Providing Infant-Guided Co-Regulated Feeding Starts with Assessment of Feeding Skills” with my colleague, Dr. Suzanne Thoyre.

In the meantime, I am busy finalizing my 2020 schedule. I’ll see you coast to coast, and offering:

Pediatric Swallowing and Feeding: The Essentials – 13 hours -2 days

Pediatric Videofluoroscopic Swallow Studies – 6.5 hours – 1 day

NICU Swallowing and Feeding – in the Nursery and after Discharge – 13.5 hours – 2 days

The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding – 13 hours – 2 days

NEW Advanced Infant/Pediatric Feeding and Swallowing: Complex Patients, Effective Solutions – 13 hours – 2 days

I will see you in:

Nashville – May                                                                    

Houston – June, including The Cue base Feeding seminar and a 2-day Advanced Infant/Pediatric Feeding and Swallowing Seminar                                                                                       

Orange County CA – July

Chicago area – August

Phoenix – September

Greenwich CT – October

Watch for details soon on my website or sing up for my blog to get an automatic notice when the schedule posts.

I am grateful for many blessings and wish you each a Happy Thanksgiving.

Problem-Solving: Sensory Normalization with Rubinstein-Taybi Syndrome

Question:

I recently started treating a 2-year-old little girl with Rubinstein-Taybi syndrome in outpatient feeding therapy. She has had a G-tube since she was 1 month old and has barely eaten PO. I am just trying to get her to take PO to get her to a VFSS, as the last VFSS she had, she aspirated after the swallow due to residuals in pyriforms. No cough response at the time. She is literally so averse to even a dry spoon touching her lips, she tightens her lips and turns her head no matter how many times I do it in an attempt to desensitize her. The one time I touched a dipped spoon to her lips, she had a moderate-severe gag response. And the amount of vanilla pudding in the bowl of the spoon was so minimal, I couldn’t really lessen it….we just went back to a dry spoon. I’ve tried the Honey Bear straw, I’ve tried a spoon with cold water, Dum Dum lollipops….no luck. I’m really at a loss. We’ve had 4 sessions so far and no progress…and even possibly a regression, as she now won’t even sit in the high chair for more than 10 minutes without getting restless, reaching out, wanting to play and/or sit on parents laps. She has no verbal communication, only whining and reaching arms out. She can identify some things but it’s inconsistent. However, I know her receptive language and memory are her strengths. Any suggestions/feedback/advice is greatly appreciated! I need all the help I can get with this little one.

Answer:

Normalizing her sensory-motor/postural system (through partnering with a sensory integration trained OT) and normalizing her oral-sensory system will be a critical first step. PO feeding skills are built on a well integrated sensory system, often a key area of need for children with this diagnosis.

A swallow study likely isn’t a next step for her until she is accepting well graded positive oral sensory input. There is likely some level of swallowing impairment that won’t be fully understood until the sensory system is normalized, which will allow her to then begin to accept trace tastes of purée to eventually support an instrumental assessment of swallowing physiology.

Her progress will be slow due to her underlying diagnosis and a sensory system that has been impaired since birth. These systems are complex, require heavy neuro underpinning and require new sensory- motor maps be created in the brain through child-guided well graded sensory motor learning. Co therapy with an OT focused on sensory treatment with SI intervention would be a great facilitator. Parents can learn along with you about the need to think of small steps “toward” eventual PO but that is not the immediate goal due to the many little steps of learning required before she is truly ready to eat/drink orally.

Problem-Solving: Former Preterm with Beckwith Wiedemann Syndrome

Question:

I have a 34 week premature infant with Atrial flutter and Atrial septal defect that I just started seeing who has Beckwith Wiedeman Syndrome. The pediatrician recommended solid food feedings due to not taking his formula consistently. Mom only gives him baby food at night and he eats about half a container but seems to enjoy it. He had a MBS since he was receiving thickened formula with oatmeal on 6/5/19. He was clear for thin liquids via Avent level 1. He got frustrated with nipple so SLP in outpatient ok’d him to use Avent level 2. According to his MBS, he had oral transport/lingual motion impairment and oral residue. His swallow response is impaired at level of pyriforms, laryngeal elevation and anterior hyoid excursion are also impaired. At rest, child’s tongue protrudes and when he sucks on the bottle and when spoon feedings are tried, he has a tongue thrust. Coughing is noted during bottle and spoon feedings and when the bottle is pulled out of his mouth every 2-3 sips to help him breathe, he seems to have difficulty latching onto the bottle. I’ve tried palpating gently under his chin and noticed his tongue recessed into his mouth for a brief time, and have tried a ‘j scoop’ with the spoon when fed him. I just wonder what other treatments you would recommend I try since his doctor wants to try therapy before surgical treatment of macroglossia.

Answer:

Sounds like he is a former 34 weeker who you are following in the community. What is his adjusted age now?

Being a former preemie, as opposed to a former full term infant, adds some other challenges to his BWS that might be playing a role, such a respiratory co-morbidities. Sounds as though he was sent home from the NICU as a full oral feeder, but quality may not have been part of the assessment for readiness to be a full PO feeder, rather volume was.

What looks like tongue thrust may actually be the tongue moving forward with onset of motion, due to the lack of space in the oral cavity for his enlarged tongue as it moves posteriorly and an adaptive response on the part of the infant to maintain his upper airway.

Sounds like he was sent home without any respiratory support to assist with airway maintenance. Many infants with BWS require trachs to assure a consistent patent upper airway. Even so, some who manage to be discharged without airway support can readily destabilize a fragile upper airway with the act of swallowing during feeding. The need for the base of tongue to retract, and the large thickened blade to move posteriorly as part of the swallow, can actually “create” a sense of further airway obstruction with the act of swallowing. In addition, the thickened blade with intrinsic tongue muscles that lack thinning and cupping can create challenges with bolus control orally.

The macroglossia also can alter mandibular alignment, leading to subluxation. It also inhibits a closed mouth posture, which can work against establishing the necessary anterior seal on the bolus to help drive the swallow.

Often behaviors during feeding may be related to the struggle during feeding to manage the bolus and maintain the upper airway, and can lead to adaptive behaviors, which then create maladaptive feeding behaviors and long-term struggles with eating/drinking.

Sounds like with Avent 1 flow in radiology there was a delay in swallow initiation with premature entry to the pyriforms. It is likely the bolus is poorly managed due to the adverse effects of BWS noted above, so it would be important to objectify the effect of the change/increase in flow rate with Avent 2 on his swallowing physiology, as his physiology sounds precarious. The coughing with spoon and bottle suggest fluid has approached or entered his airway.

Even if he there was no witnessed aspiration or laryngeal penetration during the VFSS (which is a moment in time), he is at high risk for airway invasion and onset of aversions due to the struggle to feed. Most events of aspiration are silent in the infant population,  and he is also giving us some signs, so he is likely more worrisome.

I think the doctor’s well-intentioned goal of wanting him to PO feed before surgery may have been made without his understanding of the impact of BWS on swallowing physiology and the swallow-breathe interface, and may be counter productive and perhaps not safe for this former preemie. Muscular and structural restrictions such as those with BWS often require us to take a step back and look at the co-morbidities and their overriding influence on swallowing physiology not just on intake, which is at times challenging for our medical colleagues.

Problem-Solving: Late Preterm with Sequelae from Mandibular Hypoplasia

Question:

I am presently working with an 8 month old who is s/p cleft palate repair, x 1 month. She is an ex 35 weeker with a trach and PEG tube. Her list of problems/diagnoses: Pierre Robin Sequence, Peter’s anomaly, ASD, Stankiewitcz-Isidor Syndrome, retrognathia, and micrognathia. Currently, she eagerly accepts the pacifier and bottle. We are using Dr. Brown’s level 1 with the valve but this flow seems a little fast and are trying the Newborn level. However, her tongue pulls back and therefore is not wrapping around the nipple for traction. She gets approximately 10-15ml in 30 min only due to compression. Any time that I attempt to put a gloved finger on top of her tongue to work on drawing it forward she gags. At best she reluctantly allows my gloved finger with formula just to the tip of her tongue. Any recs? Also, what resources/books do you recommend for infants/children with cleft palate?

Answer:

I think right now the cleft is the last important factor and is likely not contributing to what you are seeing with PO attempts. Her complex co-morbidities make a her a fragile feeder,  I would think, with high risk of silent airway invasion. The muscular and structural restrictions to the mandible, and therefore, to the tongue (glossoptosis) associated with the Pierre Robin and Peter’s Anomaly, likely lead to adaptive behaviors in an attempt to protect the airway. That then leads to the maladaptive behaviors you are seeing. My guess is her trach was placed  to establish an airway (not for long-term ventilation), so without a PMV (which she cannot wear due her airway obstruction), she also has no taste, no smell and has no subglottic pressure for airway protection. I would not PO with what I know, but rather, work on readiness non-nutritively right now. ENT would be very helpful  to guide your plan of care by assessing growth and readiness for decannulation in the future.

Problem-Solving: Initiating PO Feeding in the NICU

Question:

My colleagues and I have been discussing the age at which to start bottle feedings. I realize it will depend on the child’s development, their history, their stress level, and rooting behavior. But in writing a policy for the NICU for cue Based Feeding I was hoping for a starting age. We’ve said 33 weeks or greater. I have a NICU manager who is pushing for 32 weeks, and a neonatologist who wants to stay away from a defining age. Currently we have “CBF to begin 33 weeks or later. Any infant younger than 33 weeks to be assessed by speech therapist first.” But that last statement has yet to be approved. And I was hoping to have literature to back the age. Any feedback is much appreciated.

Answer:

The question about when NICU infants initiate PO feeding is of course multi-factorial, so PMA (post-menstrual age) is just one factor. Unfortunately, while it puts us in “the ballpark”, it has little value in and of itself. The PMA has significance, I like to say, in the context of the infant’s co-morbidities and history. Considering only PMA without regard for co-morbidities and history can lead to first PO feedings that are physiologically stressful, adversely affect neuroprotection and set the stage for feeding early onset refusals as a result, as you know. Some infants at a particular age, for example, 37 weeks PMA may not be ready/appropriate to PO, often due to the sequalae from their co-morbidities and history.

As I teach across the US regarding NICU feeding/swallowing practice, the earliest I have heard PO feeding being initiated is 31 weeks PMA. This has typically been a healthy preterm stable on unassisted RA and with a clean history; but even then, readiness of requisite subsystems, such as postural/head/neck control and state modulation, may not be available for that infant, and the suck-swallow-breathe interface is likely quite precarious. Asking the infant to feed 9 weeks prior to his due date would be worrisome. The push to “get infants out” and the desire to “get infants home” has created undue pressure on the infants, staff and in-turn on families to “get it in”.

Perhaps that is why the neonatologist is suggesting avoiding a defining age and is looking instead, hopefully, at a more global assessment of the infant. Alternatively, he/she may be leaving the door open to push harder unfortunately . Carrie Anne’s reference should be helpful but unfortunately Dr. Pickler often has a focus on “practicing” PO as a benefit and the pathway to good outcomes. While some in the NICU think “practice makes perfect” when it comes to feeding, unfortunately, when feeding attempts are ill-timed or are not truly supportive, then “practice”  only makes “permanent”   the emotional overlay and activation of the HP axis/cortisol release associated with physiologic stress in preterms, that likely co-occurs with trying to feed and struggle. Contrast that with an infant-guided feeding approach , truly cue-based PO feeding, that focuses on the experience and neuroprotection, versus intake.

Individualized readiness using multiple factors, one of those factors being PMA, is ideal an most supportive of neuroprotection. I am not aware of any research that has specifically determined “the age” to start, as so many variables indeed must be taken into account as I referenced above. That would be a hard study to do and do well. My thought is that 33-34 weeks PMA is likely most typical across the US based on feedback I solicit in every city I teach. If you can help to build criteria that encompass not only age (PMA), but a more comprehensive look at the infant, then perhaps there will be room purposefully built in to individualize and assess that unique infant’s readiness in the setting of his co-morbidities and history.

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.