Supporting Feeding for Infants with Cleft Lip/Palate

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

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

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

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

 

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

The Science of Breastfeeding

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

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

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

Problem-Solving: Thickening Breastmilk Post Swallow Study

QUESTION

I have been out of the pediatric feeding and swallowing world for several years now. I had a friend reach out that has a seven-week-old infant with dysphagia. She noticed her baby was having increased strider and apneic spells during breast-feeding. She recently had an MBS completed and was placed on mild nectar thick liquids (she may have been told 1/2 nectar??). They also recommended a Dr. Brown’s bottle with a level two nipple. They recommended she use a specific thickener for breast milk; however, it is currently on back order. Does anyone have different suggestions for how to safely thicken breast milk utilizing a thickener that is approved for infants? Any information is appreciated!

ANSWER:

An easy answer would be to suggest Gel Mix, known to thicken breastmilk.

But a simple answer may not be best.

Because I tend to appreciate the history and co-morbidities to form my data set, and then add clinical data to make recommendations, it is challenging to make a suggestion that I have confidence in, since all thickeners, as you know, are not created equal nor equally suited for every infant nor is aspiration just “aspiration”.

The challenge is suggesting an alternative thickener that wasn’t objectified under fluoroscopy, as that can perhaps create more risk than anticipated. Because the SLP had the opportunity to objectify the impact of that level of thickening and that thickener, and that specific nipple, (as well as others, I suspect), then someone else changing the “prescription” may not be optimal.

Has mother contacted the SLP who did the VFSS for guidance as to optimal alternative plan in the interim, until prescribed thickener is available? That SLP will likely be best able to minimize the risk, given her understanding of the infant’s swallowing physiology, access to full data set and understanding of what would be indeed contraindicated. Not knowing etiology for the aspiration, i.e. pathophysiology, also whether the events were silent, and the etiology for the stridor, and what other interventions appeared to increase the safety margin (versus degrade it) such as co-regulated pacing or resting. I would be remiss to not refer her back to that SLP for next steps.

I am curious if infant has also been a bottle feeder too, prior to the VFSS or if the VFSS as her first PO trial with a bottle; if not, that might an add artifact. Wonder what thickener was suggested. EBM is super thin liquid so often doesn’t require a flow rate as fast as a level 2 for the mild amount of thickener as described. Wonder if EER (extra esophageal reflux) has altered laryngeal/tracheal sensation.

Also take a look at this article from the team at Boston Children’s, which summarizes  the most current evidence-base regarding thickening in pediatrics: Duncan, D. R., Larson, K., & Rosen, R. L. (2019). Clinical Aspects of Thickeners for Pediatric Gastroesophageal Reflux and Oropharyngeal Dysphagia. Current gastroenterology reports, 21(7), 30.

I hope this is helpful.

Research: Feeding outcomes in former preterms in the first 7 months of life

Click on this secure  link: Hill et la (2020) Bottle Feeding preterm Infant first 7 months of life

Those of you in Early Intervention and in the NICU will find this new paper just published a valuable addition to your research base for practice.

Hill, R. R., Park, J., & Pados, B. F. (2020). Bottle-Feeding Challenges in Preterm-Born Infants in the First 7 Months of Life. Global Pediatric Health7, 2333794X20952688

It reinforces some of the key factors that may lead to enduring feeding problems after the NICU. It may be helpful for your neonatology team, as its findings suggests that watchful vigilance both in the NICU by the SLP, and indeed after discharge by our colleagues in Early Intervention,  should be a part of the plan of care for our at risk infants and their families. Perhaps this early provision of infant-guided support may in the long run avoid the onset of feeding aversions that can arise from stressful feeding experiences.

Quoting their conclusions:

Very preterm infants (i.e., those born <32 weeks GA at birth) had significantly more symptoms of problematic bottle-feeding than infants born full-term, moderately preterm or late preterm. Factors such as BPD (Chronic Lung Disease), GER, and congenital anomalies of the face, mouth and gastrointestinal tract were significant contributors. Early difficulty with breastfeeding was also a risk factor for later difficulties with bottle-feeding. There was improvement in symptoms with increasing age, which is likely reflection of improvement of medical factors and infant maturation. These findings support the need for frequent assessment of feeding in preterm-born infants after NICU discharge and provides clinicians with information regarding particular medical factors that place infant at risk for feeding difficulty beyond the NICU. The identification of infants who are struggling with bottle-feeding may facilitate interventions within the primary care setting or referral to feeding experts to improve longer outcomes and decrease the likelihood of negative sequelae that could persist into late childhood.

 

 

Research: Videofluoroscopic swallow-study outcomes among infants with tracheotomies

While problem-solving a recent NICU infant I was following with a tracheotomy, I incorporated this information from a study done through Nemours Childrens Hospital in DE. It was presented as a poster session at the ASHA convention, and has not been published to my knowledge. The study was well-done, the findings are informative and can help guide our care of infants in the NICU who require tracheostomy. Contact the authors for more information. I am quoting below from the poster presented.

Videofluoroscopic swallow-study outcomes among infants with tracheotomies                        Jeannine Hoch, MA, CCC-SLP; Michele Morrow, MS, CCC-SLP; Heather Keskeny, MA, CCC-SLP; Aaron Chidekel, MD   

Due to advances in technology, tracheotomy tube-placement is becoming increasingly common during the first year of life.

Infants with tracheotomy are at risk for developing feeding and swallowing problems: There is a paucity of descriptive information regarding dysphagia for infants following tracheotomy. Lack of available research leaves many clinicians feeling unprepared to provide services for pediatric tracheotomy patients.

Infant feeding patterns may also be impacted by environmental and associated medical conditions such as: Gastroesophageal reflux, Low birth-weight, Bronchopulmonary dysplasia, Long-term nasogastric tube-feedings, disruption of parent–infant interaction due to long-term hospitalization

Goals of their study:

  • Based on reports from videofluoroscopic swallowing studies, what are the swallow characteristics of infants with tracheotomies?
  • What percentage of patients required enteral feedings via nasogastric and/or gastrostomy tube-feedings?
  • Are trends present between swallow dysfunction, underlying medical conditions (gastroesophageal reflux, premature birth, nature of illness necessitating tracheotomy tube placement), and the need for enteral feedings?

A Retrospective study

  • Subjects (n = 27) whose Tracheotomy-tube placement by 4 months of age with mechanical ventilation  – Males (n = 16), Females (n = 11) – Exclusion criteria included grade III or IV IVH or presence of severe neurodevelopmental delays that preclude initiation of oral feeding
  • Data collection:  Medical history, Results of initial videofluoroscopic swallow-study, Results of serial follow-up studies when applicable

Data analysis

  • Trends may exist between initial swallow-study findings and reason for tracheotomy-tube placement:
    • Airway issues (n = 10): delayed swallow-initiation (80%), laryngeal penetration (80%), aspiration (50%), residue following swallows (50%), and nasopharyngeal reflux (50%)
    • Respiratory distress with BPD (n = 17): delayed swallow-initiation (53%), laryngeal penetration (71%), aspiration (29%), residue following swallows (47%), and nasopharyngeal reflux (41%)
  • Among patients who underwent G-tube placement (n = 17):
    • Less than half (47%) had documented aspiration on their initial swallow-study.
    • Majority (94%) had documented reflux.
  • Among patients who underwent follow-up swallow studies (n = 17):
    • Laryngeal penetration tended to persist (n = 6) more frequently than it resolved (n = 4).
    • Aspiration tended to resolve (n = 5) more frequently than it persisted (n = 2).
  • Report of oral motor-impairment (n = 12, 44%) and oral phase-impairment (n=17, 63%) was common.
  • All of the patients (n = 27) achieved at least partial or therapeutic oral-feedings as noted on recommendations from their final swallow-study.

 

Problem-Solving: Onset of severe oral aversion in the NICU

Question:

I currently have an infant who has low tone with severe oral aversion impacting P.O feeding. The infant was previous a great feeder but needed to be intubated. Since then, the nursing staff reported poor feeding skills, and I noted poor tolerance of positive tactile stimuli to her checks and non-nutritive sucking for calming. I was wondering if you have any strategies to improve the tolerance of oral stimuli when an infant has an aversion combined with low tone.

Answer:

Will share some thoughts and also some questions. My mind starts right away asking questions to help me start a “differential” as one of neonatology colleagues taught me many years ago. I am so grateful that she took the time to help me problem-solve in a way that physicians are taught. It has really helped me dialogue with the neonatologists.

What is the etiology for the hypotonia? Is this a former preterm or a sick newborn and what are the co-morbidities that would lead to the need for interval intubation? The bigger picture is likely relevant to sorting this out. Why was she recently intubated? It is uncommon for brief interval intubation to completely “change” the oral sensory system. Maybe it isn’t the intubation that is causal but co-occurring events such as the pressure to “get back to PO” ?  or co-morbidity-related? Could this be r/t well-intentioned pushing to feed post extubation? How is she being fed now? “PO all” attempts despite adverse responses? Depending on how volume driven versus infant-guided your unit is, that may be adding fuel to the fire. Are they still trying to PO? I wonder if any of her maladaptive behaviors started as adaptive behaviors (i.e., not wanting to PO d/t breathing too fast at that moment, flow rate too fast, fluid moving toward the airway) unbeknownst to the caregiver feeding her…? Infants do things for a reason as you know and it is often physiologic, so looking from that perspective always informs us.

I wonder if being a “great feeder” for the nurses was a volume-related commentary versus one reflecting quality of feeding? maybe there have been qualitative issues all along that were not apparent.

If she is currently PO, I’d want to just be present when RN feeds and learn along with the infant and nurse about the feeding relationship with the caregiver to help inform your differential. May need a true break from PO, such that for now PO only with a therapist (to reset her sensory system and then attempt to progress back to infant-guided positive PO feeding from a better baseline of oral-sensory readiness).

Will she accept her own hands to face in a swaddled side lying position, ensuring WOB is not problematic? I’d start there as it’s likely tolerated best, and you can facilitate firm deep pressure (versus light touch, which may be processed as more averse). Look at her big picture as the foundational data set. Then listen to the infant. She can likely tell us the “why” or at least lead us in the right direction.

Hope this helps.

Catherine

Research: Challenges to eating, swallowing, and aerodigestive functions in infants

Jadcherla, S. R. (2019). Challenges to eating, swallowing, and aerodigestive functions in infants: a burning platform that needs attention! The Journal of pediatrics211, 7-9.

Always insightful and leading-edge, Dr. Jadcherla at Nationwide Children’s clearly identifies major focus points  in our journey toward supporting independent functional feeding for all of our pediatric patients. Follow his research in those key areas. Read the entire paper on Google Scholar.

Quoting from the article:

“…only when we understand the causal and ameliorating mechanisms of eating, swallowing, and aerodigestive dysfunctions, and the cause for practice and process variation, will we then be able to modify strategies for appropriate diagnostic, therapeutic, and rehabilitative approaches to ensure safe feeding during and beyond ICU stay, lest, we run the risk of over- or underutilization of gastrostomy procedures. In the end, we seek to restore the most fundamental of human behaviors, safe eating”

 

Quoting from the article:

“Summary of 10 Ps That Require Careful Attention to Disrupt the Rising Prevalence of Pediatric Dysphagia

 (1) Physiology of eating, swallowing, and aerodigestive functions in the context of the developing infant must be better understood. Maturational variability and rapid growth during early infancy offer a unique opportunity to improve eating patterns in premature infants.

 (2) Pathophysiology of the mechanisms of pediatric dysphagia also requires careful study so as to provide pathophysiology-guided clinical care.

 (3) Patient characteristics are variable in any given scenario of feeding difficulties, and attention to the risk factors is key because modification of risk factors can improve outcomes.

 (4) Parent involvement and anticipatory guidance for dealing with eating difficulties, swallowing, and aerodigestive morbidities must be undertaken from early on, so that appropriate and timely interventions can be addressed.

 (5) Providers in the healthcare system may be unaware of the factors that influence infant feeding, and physicians may wholly delegate this area to occupational therapists or speech language pathologists. Newer data over the last 2 decades has emerged, and the pace of rapid translation from discovery to implementation will be enhanced when silos of expertise are eliminated and knowledge, attitudes, and skills are reexamined.

 (6) Procedures performed in the diagnosis of pediatric dysphagia need standardization, with careful reevaluation of indications and contraindications in the context of the fragile ICU infant. Diagnostic delays lead to delays in timely interventions during critical windows of opportunities.

 (7) Precision medicine is possible only when the underlying mechanisms are understood and targeted with innovative approaches at the bedside of the infant in the ICU.

 (8) Personalization of diagnostic, therapeutic, and rehabilitative approaches in the context of the infant’s condition, maturity, disease, and functional skills is important.

 (9) Pragmatism in approaches coupled with humanism is needed particularly with developing longitudinal follow-up of feeding milestones. Clinically meaningful outcomes such as independent feeding must be a functional goal”

Enjoy this fabulous read!

Pediatric Feeding Disorder (PFD): “More than a symptom, pediatric feeding disorder is its own diagnosis”

Feeding Matters (feedingmatters.org) is the first organization in the world serving kids with pediatric feeding disorder (PFD) developed by mothers and guided by an interdisciplinary team, of professionals across communities to improve the system of care for children with pediatric feeding disorder. Founded in 2006 by mothers of infants and children with persistent all-encompassing feeding problems, it has partnered in the latest developments to advance the research and treatment of pediatric feeding disorder.

Their efforts have now made possible an amazing milestone in the evolution of accessing support for infants and children with feeding problems, and their families.

The U.S. Centers for Disease Control and Prevention (CDC) has officially approved Pediatric Feeding Disorder (PFD) as a diagnostic code (R code) to the International Classification of Disease edition (ICD-11) in October 20201.

This creates a stand-alone diagnosis and definition for PFD to provide common diagnostic criteria to ensure early and accurate diagnosis among clinicians when assessing children with feeding difficulties.

For so many years, pediatric therapists  have been ​advocating little patient by little patient to bring recognition of the need for this stand-alone diagnosis. I remember starting out back in the late 70s when we had no advocacy group like Feeding Matters and the team of experts assembled  to articulate the need and open the doors for so many infants and children in a timely comprehensive way. Mothers especially were often left to feel that “failure to be able to feed” your child was like “failure to be a mother, as one of the founding mothers of Feeding Matters told me years ago.

All of the pediatric clinicians in the trenches, like me,  thank the professional team for the diligence to see this through. And we thank the founding mothers of Feeding Matters who had the courage to advocate and persist in their search for a change, despite such arduous odds.

This successful effort has the potential to change the trajectory of the lives of many infants and children, and their families. We are blessed to be a part of it!

Click on this link for a free download of the seminal article DOI: 10.1097/MPG.0000000000002188).

Click on this link for the Feeding Matters press release:

https://www.feedingmatters.org/pfd-advocacy-in-action-pfd-as-a-stand-alone-diagnosis/?fbclid=IwAR2BAhqXNYGxlMyIz2tB7U19DXH8bb5YfnhlE_Qv0NHbg1P1Qy0HgNMnKUo

Research: Effects of Additives for Reflux Management and Dysphagia Management

This manuscript  was released in 2019. It  is a compelling read about potential adverse effects of cereal thickeners (rice versus oatmeal) added to formula, and adding medications to formula, and their impact on osmolality. Alteration of ready-to-feed preterm formulas may significantly increase osmolality and have unintended consequences (feeding intolerance, pain, prolonged GI transit, bacterial overgrowth).

The AAP has advocated against the use of thickening agents for high risk preterms under 44 weeks PMA. In the NICU and with infants after discharge in general, we always need to take pause prior to thickening feedings for infants with dysphagia, and do so after other interventions are offered (change in nipple flow rate, position, use of pacing strategies). For many infants, implementing these strategies will support safe swallowing. This manuscript adds to our understanding of the importance of considering risk-benefit ratio in all that we do.

The salient findings from this study are:
1) Cereal thickening amounts and agents added to ready-to-feed liquid preterm formulas impact osmolality and can cross the limits of AAP safety thresholds. Specifically, the thickening agent increases osmolality, and oatmeal contributed to greater osmolality compared with rice on an equi-volume basis. 2) Commonly used vitamin and electrolyte supplements added to ready-to-feed preterm formula can remarkably increase osmolality

They conclude: 1) When thickening is still a strong consideration for Dysphagia/GER management, the ready-to-feed thickened formulas may be a safer alternative as the mixture is more homogeneous and has been vigorously tested, and passes FDA regulations including osmolality thresholds. Other alternative treatment strategies may include modifications to nipple flow or feeding volume, pacing while feeding, or appropriate positioning of the infant during feeding.  2) mixing medications in the entire volume of feed, or dividing doses across multiple feeding sessions mixed with feeds to decrease the osmolality as much as possible.

I am attaching this manuscript as it will be a good discussion point with our medical teams in the NICU, with pediatricians and GI specialists, and for those of us who follow infants in the community.

I hope this informs your practice.​

Here is a link to this article. 

Problem-Solving: SLP completing NGT feedings in NICU

QUESTION

Do you as the SLP drop NG feeds when finishing oral feeds and/or treatment sessions instead of the RN? Does your department or hospital have any guidelines for this?

ANSWER

It is understandable that our NICU nurses can get very busy these days with greater numbers of infants to care for, conflicting patient needs at the same time, and time sensitive interventions. While we are there to lend a hand to a change diaper prior to out treatment, warm the formula/milk etc., it sounds as if you are in a situation where what you are being asked to do is making you uncomfortable. Understandably so, from what you have told us. Our tendency to help out if asked is commendable but must be thoughtfully weighed for its risk-benefit ratio to the patient, the hospital, and of course, to us.

In the NICU, placing an NGT, and/or offering that remaining portion of a PO feeding which requires delivery via an NGT feeds are neither without potential risk for adverse events. NICU RNs are required to meet competencies to complete these medical interventions, and trained mentorship, give it is in their scope of practice. Adult RNs who “float” to NICU to help in crisis situations, require competencies as well.

These procedures also are, to my knowledge, not within the scope of practice of the SLP, either by ASHA standards nor by typical hospital job descriptions. Doing so, because of its high risk problem-prone nature in neonates (provoking emesis, provoking bradycardia and/or apnea, co-occurring EER event, incorrect placement  if “dropping NGT – by which I think you are meaning “placing an NGT”. Even delivering the remaining volume in an NGT that is indwelling may lead to an adverse unanticipated event and place the SLP at risk. Working outside our scope of practice may open us up to serious liability issues.

I suggest you take this question/situation to your rehab leader and request input from NICU leadership, and hospital Risk Management. Proactively considering every action we undertake, and its risk (for the infant, for you, for the hospital), is essential in the environment of neonatal intensive care.

I commend you for thoughtfully pursuing this request made to you.

I hope this is helpful.

Problem-Solving: Silent Deep Laryngeal Penetration

QUESTION:

I am a graduate student in my medical externship and I’m trying my best to understand this:

It’s my understanding that the internal branch of the recurrent laryngeal nerve mediates sensation below the vocal folds and mediates a cough reflex. This is why we’d expect a cough if material is sensed below the level of the vocal folds in a pt with an intact cough response. If material gets below the vocal folds and no cough is produced, we call that silent aspiration.

It’s my understanding that the superior branch of the laryngeal nerve mediates sensation above the vocal folds and an expected response to material above the level of the vocal folds is a swallow.

What about material sitting on top of the vocal folds (level 5 of the pen-asp scale)? Is that expected to elicit a cough or a swallow?

If material sitting on top of the vocal folds is considered penetration (because it did not go below the vocal folds) and is expected to elicit a cough, wouldn’t that mean that there is such a thing as silent penetration?

DR. JAMES COYLE’S ANSWER:

Good for you in accurately describing the sensory innervation of the larynx. 

In a healthy state the stimulus of foreign material on the vocal folds should elicit a response of some sort.  However, people who frequently exhibit laryngeal penetration, people who smoke, and people with other conditions that desensitize the mucosal receptors’ or the sensory system’s response to irritation can lead to the need for a higher threshold of stimulation to elicit a response (attenuated response).  So that is why the distinction is important.  “Silent” laryngeal penetration to this level (PAS 5) would be unlikely in a person with intact laryngeal sensation while more likely in these other situations.

Also, it is perfectly normal for material (thin liquid especially) to just barely enter the vestibule and then spontaneously be ejected to the pharynx during laryngeal closure (PAS 2).  So if you wanted to use these terms I suggest including the depth of penetration in the descriptions (as the PAS scores include).  For instance, “silent deep laryngeal penetration” is different from “silent shallow laryngeal penetration” as explained above.

 

CATHERINE’ S FOLLOW-UP COMMENT:

Thank you, Dr. Coyle, as always for your input that informs our practice, whether in pediatrics or adult populations.

This paper below may be of interest to you. While it was published in 2000, it was a study well-done from the team Children’s of Colorado. It remains foundational in the world of pediatric dysphagia. In the setting of particular co-morbidities, especially CLD in our littlest ones, such understanding becomes critical in developing an algorithm for each infant that helps peel apart the likely impact of physiology on risk to invade the airway, not just in the moment in radiology, but in the course of a true feeding,

Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia, 15(3), 153-158.

Abstract: This study describes the incidence of laryngeal penetration in 125 dysphagic children ranging in age from 7 days to 19 years who were seen over a 6-month period at The Children’s Hospital in Denver, Colorado. Laryngeal penetration was identified in 60% of the study group, with 31% demonstrating deep laryngeal penetration. Of the children exhibiting deep laryngeal penetration, 85% aspirated, suggesting a strong correlation between these two events. It was noted that children exhibiting deep laryngeal penetration often began to aspirate further into their feedings. Use of extended feedings during videofluoroscopy is discussed as a diagnostic strategy in the presence of deep laryngeal penetration.

I hope this is helpful in your key learnings.
Keep up the critical thinking!

 

Research: Clinical Swallowing Assessment Across the Lifespan

I wanted to share this just published paper by our SLP colleagues about the clinical swallow evaluation, which shares critical insights that will inform everyone’s practice, from pediatrics to adult.

Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment Across the Life Span: The Clinical Swallow Evaluation. American Journal of Speech-Language Pathology29(2S), 919-933.

 

The final paragraph will make you want to read it right now:
“Specific guidelines for carrying out a clinical feeding and swallowing evaluation require systematic decision making with considerations for high degree of variability within and across adult and pediatric patient populations. The CSE is not only a useful tool but a critical one. As aptly noted, “it is critical that the CSE not be relegated to the status of a screening tool. It is far too powerful” (Rosenbek et al., 2004). The CSE is often the first complete physical assessment of swallowing function for a patient where critical information is gathered and should not be overlooked. A thorough CSE extends beyond watching someone eat and drink; it is a multidimensional assessment. While reliability of individual measures remains questionable, the experienced clinician can make important judgments regarding patient safety that will help chart the course of care for individuals needing additional assessment and, possibly, intervention. Employing a standardized CSE tool after sufficient training will further enhance clinical decision making. As instrumental examinations are more costly, more invasive, and less available, the CSE can also serve to chart progress, or lack of progress, over time when it is conducted methodically and consistently.”

I hope you will enjoy this read as much as I did, and share it with your students.

Problem-Solving: Impact of High Narrow Palate in the Setting of Tethered Oral Tissues

QUESTION: Infant  diagnosed with a tongue tie at birth. He is now 9 months old. We never clipped his tie, and he is still going strong with breastfeeding .

At birth, told the he has a very high arched palate. My pediatrician brushed it off saying it was fine. The ENT we took him to for the tie also pretty much brushed it off. Same thing. If he was feeding fine, he was probably fine. But when I look into his mouth now, I am shocked by how high his palate is. I have tried to read up and research it, and I have learned that the tongue is responsible for flattening out the palate (so it makes sense that a tongue tie would inhibit this). He is getting to the speaking age, it’s made me question if he really could end up having some speech issues. It seems logical that it would be nearly impossible for him to make palatal sounds when the time comes if he can’t even get his tongue close, but I can’t really find anything out there that gives me guidance.

My questions:
* Does a tongue tie with a high arched palate likely lead to more speech issues than a tongue tie?
* Is there anything to suggest that if I released it now, it would help with palate development? (or is there a point where releasing it would or would not make a difference?)

ANSWER:

Sounds like your little guy is doing well.

A good resource for you would be Lori Overland and Robyn Merkel-Walsh, both SLPs and accessible via ASHA Community. There latest publication is an invaluable resource regarding the potential broad reaching effects on the dynamic oral-motor and oral-sensory synergies that underpin swallowing and speech sound development.

Functional Assessment and Remediation of Tethered Oral Tissues (TOTs) 2018

The dynamic systems are integrated in utero as early as 17 weeks of life, when the fetus has fully formed the aerodigestive system as the fetus swallows amniotic fluid. This sensory- motor learning lays down the motor mapping for feeding in the delivery room with skill and integrity. Alterations, be they structural and/or muscular, likely impact this motor learning and can, even in subtle ways, create differences in how muscle groups function and provide the “forces” , if you will, that then may impact boney relationships, and vice versa. The forces that are brought to bear in utero on the palate do indeed help to shape it in utero.

Infants can learn to compensate with feeding but may also learn maladaptive patterns that yield functional feeding with qualitative differences, especially as more complex oral-motor skills need to emerge for refined chewing. Those qualitative differences may influence motor learning for speech. You are likely already having wonderful opportunities at 9 months to listen for the range of vowel sounds, articulatory contacts during his babbling and sound play and imitation to give you some insights, as to evolution of speech sound learning. As more complex speech sound integration is required for connected speech, you’ll gather more data.

In my practice as an acute care pediatric SLP, and an outpatient pediatric SLP for many years prior, I have worked with many infants and children with apparent tethered oral tissues with various functional presentations. Meaning, some can get by functionally and run under the radar. Others have more overt and sometimes more subtle alterations in function. My background in neurodevelopmental treatment (NDT) in pediatrics really opened my eye to the dynamic systems approach to the postural mechanism, including the oral-motor/oral-pharyngeal components, and the potential far reaching effects of tethered tissue anywhere along the human body.

I hope this is helpful

Problem-Solving: Where to Begin with Former Preemie with Multiple Complex Co-Morbidities

QUESTION

I’m looking for some insight on where to begin with this case:
The child’s age : 4 Months (Preemie Baby – 35 Weeks, will be 5 months June 26th from day he was born)
Aspiration pneumonia, G-Tube and Nissen Fundoplication, nothing by mouth

Issues with swallowing – risk of saliva entering to lungs – can’t give him pacifier, reflux, and unknown genetic abnormality/corpus callosum.

Any help would be appreciated!

ANSWER
Sounds like he is a late preterm  who is going to be 5 months soon, and would then be not quite 4 months adjusted age.​ The neurologic co-morbidities (likely absent corpus callosum) suggest at least part of the etiology for the abnormal swallowing and likely; altered oral-pharyngeal reflexes that underpin feeding. There may be other components of his history that might further inform a differential to guide a plan of care. I would suspect there might have been a VFSS early on in the NICU unless he was so neurologically devastated that the team determined a VFSS would not change his management and proceeded with a G-Tube/Nissen; or if he did not swallow his saliva, we would likely not do a VFSS.

To start problem-solving, it will be helpful to understand what you see clinically, especially related to postural and oral-pharyngeal tone, oral-pharyngeal reflexes, interest in own hands to face/ mouth, need for suctioning and response to suctioning, any spontaneous swallows observed, any ENT consult results.

Very challenging patient with multiple complex issues that are likely to be enduring and progress likely to be slow.

I hope this is helpful.

Research: Behavioral Epigenetics and Oral Feeding Skills in Preterms

For my NICU colleagues,

Many years ago when I started in the NICU in 1985 we were just beginning to understand the importance of developmentally-supportive care, “brain care” , to lay the foundation for early and future function across all developmental domains, including feeding.

How far we have come and yet how much we still need to understand. The feeding “environment”, that is, the gestalt of “experience” in which the preterm infant is supported from the first day of life, has implications every step of the way, that are often not appreciated or fully understood.

This just published paper by some well-respected researchers looks at how early-life cumulative stress exposure may influence evolution of oral feeding skills in preterm infants. We are just beginning to scratch the surface about the multiple underpinnings for safe and successful feeding for preterm infants. It reminds me of my favorite phrase, “In the NICU, every experience matters, especially when it comes to feeding.”

Griffith, T., White-Traut, R., & Janusek, L. W. (2020). A Behavioral Epigenetics Model to Predict Oral Feeding Skills in Preterm Infants. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses.

“The proposed conceptual model  is guided by the Preterm Behavioral Epigenetics framework, which theorizes that prenatal and early postnatal adverse events (ie, cumulative stress exposure) influence preterm infant phenotypes (eg, HPA axis regulation of cortisol reactivity and neurobehavioral development) through epigenetic modifications. Our conceptual model posits that early-life cumulative stress exposure, reflected by DNA methylation of glucocorticoid-related genes and altered cortisol reactivity, may disrupt neurobehavioral development critical for achievement of oral feeding skills. In other words, the conceptual model represents the idea that cumulative stress exposure (prenatally and postnatally) may change the epigenetic information, resulting in changes in  oral feeding skills.

The emerging field of Preterm Behavioral Epigenetics emphasizes how early-life stress exposure can imprint epigenetic mechanisms during sensitive neuroplastic periods and disrupt attainment of neurobehavioral

Untimely introduction of oral feeding when infants demonstrate inadequate or complete lack of oral feeding skills may lead to negative imprints during the sensitive neuroplastic developmental period. Such negative imprints influence future feeding behaviors and may predispose to lifelong susceptibility to feeding problems, eating disorders, obesity, and/or metabolic disease.”

Amazing. I hope this informs your practice as it has mine.