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.

Covid-19 Update July 26,2020

Our remaining seminars in Phoenix AZ and Greenwich CT have unfortunately been cancelled due to Covid-19. We are rescheduling them in 2021. I hope that you and your loved ones are healthy and safe during this difficult and uncertain time. My goal is to assure that you receive the highest quality continuing education that you trust us to provide. The safety and health of our community – our course participants and faculty– are my top priority.

I am also working on some new CEU offerings in a live virtual environment.

Watch for updates on my website or sign up for postings in order to receive future updates.

Please, as always, reach out  with any questions. Thank you for being part of our community and choosing Shaker Seminars for your professional development.

I look forward to learning along with you soon!

Problem-Solving: Intervention with NICU Infants Who Are Vent Dependent

QUESTION

Can you share feeding protocols when asked to work with infants on a ventilator in the NICU. Specifically, patients that are expected to go home on a home ventilator.

CATHERINE’S ANSWER

These indeed are often our most fragile NICU infants. Each one is typically unique, so I always start with understanding that infant’s unique co-morbidities that led to the need for long-term ventilation. For example,   PPHN, CLD, CHD, congenital malformations, neuromuscular disorders, and structural airway alterations, or multiple complex co-occurring co-morbidities, which then create an even higher risk for the infant to, at some point, safely tolerate oral feeding. This then is the foundation for determining timing and nature of intervention, as we consider relevant factors for feeding readiness/oral-sensory-motor treatment to support the prerequisite skills for future PO feeding.

Multiple factors need to be considered such as: level and mode of respiratory support in the setting of that infant’s respiratory history, the prerequisite  oral-motor integrity, ability to swallow saliva, oral-sensory processing, non-nutritive sucking, as well as physiologic stability during  interventions utilized to support these prerequisites, if they are emerging. Once these prerequisites are established, I would likely be considering appropriateness of, and tolerance for,  an in line valve like the PMV to establish flow into the upper airway  that promotes restoration of taste, smell and subglottic pressure, which most optimally underpins swallowing; at this juncture, working closely with ENT/Pulmonology and the respiratory therapist is essential.

For those infants with readiness skills for whom a PMV is contraindicated (per diagnosis and/or airway status and/or clinical status), I would perhaps offer a cautious pacifier dips for purposeful swallows — because, without a PMV in line, there won’t be the taste or smell or subglottic pressure so critical for an infant who has no previous motor learning with suck-swallow-breathe and bolus control; I would offer this motor learning experience via very limited pacifier dips with SLP to allow some interval sensory-motor learning in preparation a swallow study very early on in the therapeutic process to objectify swallowing physiology.

For those infants with readiness skills, and who are appropriate for and tolerate a PMV (with MD approval), considerations may include: pacifier dips with PMV in line, limited trace PO via ultra preemie nipple (for interval sensory-motor learning in preparation a swallow study very early on in the therapeutic process to objectify swallowing physiology). I prefer an NICU infant’s first PO feeding not be in radiology if possible, recognizing safety concerns; but some interval motor learning is likely important to reduce artifacts. This must be carefully and cautiously balanced with that infant’s risk for, and ability tolerate airway invasion, especially from a pulmonary perspective.

In my 35 years in the NICU, I have never seen one of our trach/vent infants go home as a full safe PO feeder. Often in some NICUs, the challenge may be having the entire team on board about risk, prerequisites, silent aspiration, that it isn’t just about “aspiration” (but rather the dynamic impact of altered or impaired swallowing physiology),  in the setting of the complex co-morbidities these fragile infants have.

You will notice as you read my thoughts above, they aren’t a protocol as much as a scaffolding I use, when I unpeel the layers as I go along, learn from the infant, combine that with his history and ask more questions. I hope this is helpful.

COMMENTARY FROM KRISTIN KING at PASSY MUIR

First, thank you, Catherine Shaker for such a well-thought out response as always. I learn something new each time I read a response from you.

I am only responding to the question about cuff deflation and cuff deflation with use of a PMV. All that I provide here is somewhat contingent on following the information that  Catherine Shaker’s response provides. I realize much of this will be known if you work with patients on a vent, but I do not want to miss an important aspect.

Typically, I do not recommend a cuff deflation trial prior to PMV use or swallowing assessment. If with cuff deflation and airway assessment, it is determined that the airway is patent, and all other factors being appropriate, then I would trial a PMV shortly after cuff deflation. Ideally, for swallowing/feeding, a child could use a PMV to restore various physiologic functions (such as subglottic pressure), but it may not be necessary in some cases. In considering cuff deflation and a trial of cuff deflation, an inflated cuff is used to “seal” the airway allowing all airflow to be to and from the ventilator. PEEP (positive end-expiratory pressure) is provided via the vent because with an open tracheostomy there can be a loss of PEEP/decreased pressure in the lungs. PEEP assists with keeping the alveoli open for good gas exchange and oxygenation. If the ventilator is not properly adjusted, having an open tracheostomy tube with deflated cuff may cause loss of PEEP and de-recruitment of the lungs. Now, this is all in relation to infants/children who have a cuffed trach tube with ventilation. Infants/children are frequently ventilated with cuffless trach tubes and that is a different situation.

The loss of PEEP and de-recruitment with cuff deflation has been shown in research on adults (Sutt et al, 2016, 2017, Critical Care); unfortunately, we do not have much research on infants and children. Having a cuff deflation trial may actually cause a person (no matter the age) to have difficulty maintaining good lung recruitment and PEEP, if the trach tube is left open.

Trialing a PMV assists with maintaining lung recruitment and PEEP. The potential impacts and need for a closed system are illustrated in a case presentation in the 2018 pediatric issue of Aerodigestive Health presented by an RT and the issues they had transitioning a 10-year old child from the vent and use of a PMV to trach collar without a PMV (for the cuff deflation/trach collar trial). While this case presentation is with an older child, the concepts with cuff deflation still apply. Restoring more physiological PEEP with use of the PMV sooner will assist with overall respiratory function (the Sutt research even showed improved diaphragmatic use).

As to the swallowing/MBS assessment, ideally, the cuff would be deflated and a PMV available for trial. I recommend testing with and without the Valve and with and without cuff deflation, if at all possible and with considerations for exposure. Lastly, this is all contingent on the cuff being properly managed/inflated.

Hope this helps some. It is a little bit different slant than the initial question.

FOLLOWUP RESONSE FROM CATHERINE

Thank you, Kristin, for sharing this wonderful issue that informs everyone’s practice with this population, and for the helpful response. Laura Brooks wrote an article in a previous edition of Passy-Muir’s Aerodigestive Health that was also specific to trach and vent dependent infants and children in intensive care which is very helpful. All issues can be found at www.passymuir.com/resources .

I agree that if an in-line PMV trial is indicated, partnering with RT and trialing cuff deflation immediately prior to attempting the in line PMV,  is best for these little ones, who also can readily experience physiologic stress and anxiety when a cuff is deflated even extremely slowly. They, like the ten year old in the article, require so much patience and thoughtful progression of interventions. It is worrisome to me that the complexity of the swallow-breathe interface for neonates in the setting of a trach is not always appreciated by all members of the team. In those situations, these infants can readily decompensate,  and then both neuroprotection and airway protection are often adversely affected.

On a side note, in radiology I have typically seen improved swallowing physiology with the PMV in place for these complex neonates. I suspect part of that is that most were not PO feeding prior to their trach (due to complex co-morbidities), and so they often have no previous “motor learning” with PO feeding to “fall back on” to “guide them” when and if they start to PO feed. When a tolerated PMV restores the fundamental underpinnings for swallowing,  it seems to make all the difference for these fragile neonates.

Thanks again for your insights too , Kristin. So appreciated.

 

Problem-Solving: Open Mouth Posture in 9 year old

Question

I have a 9 year old girl on my caseload with an open mouth posture  She presents with normal cognitive abilities and is compliant towards sustaining a closed mouth posture .  However, the day is long and memory is short.  Therefore, I would like to provide her with strategies to remind herself during the day in order to maintain this position    Any suggestions are welcome

 

Answer

The biggest question for me is why, what else could be going on? I would look to solve the etiology before trialing treatments that may not be applicable given what the etiology actually s.

Oral-motor problems can exist in and of themselves but, in my experience,  they are part of a bigger picture that must be considered. Considering the potential impact of the postural mechanism, the sensory system and the feeding/swallowing pathway in its entirety, often helps to solve a clinical puzzle such as the one you pose.

Some questions I have to help problem-solve:

Does she and/or do  parents report this is new onset behavior? Was it observed in infancy? Is it longstanding? If not, what prompted the referral  at age 9?

Are there any past co-morbidities from which  this may be part of the sequelae? These may be from birth, or alterations along her developmental trajectory that may not be so obvious now. You will need to ask parents and look beyond the obvious. If there are past co-morbidities, for example if there is even mild postural hypotonia in infancy, the sequelae we would see at 9 may be more subtle but affect function as you report.

Does she appear otherwise grossly normally developing in her sensory, gross-motor, and fine-motor and perceptual motor skills? I ask because I have learned from some fabulous OTs that sensory integration skills that underlie all these systems and can lead to what can look like “isolated” aberrations but are not.

An open mouth posture may be compensatory/purposeful (i.e., it is being used for a purpose, and does not reflect  a “mandibular” or muscle problem in and of itself) OR  it may be pathologic (related to alteration in the muscle synergies that stabilize and provide the dynamic synergies for suprahyoid/infrahyoid function)  OR it could be purely habitual which is very unlikely, given what you have told us.

Is her breathing quiet or is there some audible turbulence in airflow whether on inhalation or exhalation, suggestive of potential obstruction to/alteration in nasal airflow?

When she establishes a closed mouth posture, does that maneuver provoke any changes in her work of breathing (i.e., breathing effort) or her RR?

Tell us about her oral-motor skills, both for speech/conversation and during eating/drinking. Do you see the full ROM and strength and coordination that underpin both those functional skills? Is her voice or swallow altered in ways that are suggestive of tonsillar or adenoidal hypertrophy?

What about her saliva swallows? If the open mouth posture is predominant, she would likely have anterior loss of saliva bolus. Does she actually establish an anterior seal at the moment of the swallow and is it effective? Does she have other sensory challenges that may not be readily apparent but might be a part of the differential.

I would request an ENT consult to assure integrity of the nasopharyngeal airway, rule out any other structural etiologies and assure patent nasal airway, while you are sorting out the pieces that are or are not in your clinical differential.

Its ok to be in the “gray” zone for a while and not have the answers right away,  and take time for reflective thinking to sort this out. I suspect it is not that simple, but more comple.x

Problem-Solving: Seating Devices for Pediatric Swallow Studies

QUESTION

Can you recommend a chair model to use for pediatric infant and child video swallow studies and teen swallow studies?

ANSWER

Some general considerations:

If you need to use a C-arm (versus standard x-ray table), it may limit ease of access for certain seating devices and may limit establishing required view (i.e. child’s travel chair/wheel chair may seat the child too low to allow the desired view/image).

If the standard x-ray table is used, travel chair may be too wide with a tray in place to fit; yet if we take the tray off so chair fits in the narrow space, we change the postural stability typically available for PO feeding, and then may create an artifact in the data set.

Some very helpful seating devices go off the market randomly and we are left searching for a replacement

Need to consider if plan is to objectify typical position or optimal.

So problem-solving always a key, as is thinking outside the box.

I really like the MAMA Chair — Multiple Articulation, Multiple Adaptation chair, as Joan mentioned above. Flexible for different ages and levels of postural control and optional supports, hip-pelvic angles, has a footplate for optimal stability, which sounds not so important, but it is. Ever go out for a drink and end up on a bar stool with no rungs? You don’t stay long! Foot stability transfers throughout the entire postural mechanism and can affect swallowing/feeding skill. Just wish it had a tray to provide upper body stability via weightbearing, as that really can make a difference for some children too. We usually create something with very firm towel rolls to simulate a weight bearing surface. It is well worth the investment.

Some options for infants: Tumbleforms infant seat, infant seat/car seat, MAMA chair, swaddled sidelying on a wedge. Tumbleforms may create too rounded of a hip-pelvic angle if there is any postural instability, and that can adversely affect oral-motor swallowing function or generate maladaptive patterns.

Some options for toddlers: Secure larger Tumbleforms seat on Hausted chair( same caveat above applies), MAMA Chair, Special Tomato MPS seat , Hi Low Tomato Seat

Some options for children: same as above but may also be able to sit in regular chair (pending sensory-motor skills),  Rifton toileting chair with a cushion insert, Transmotion chair, Snug Seat Tiger High Low chair.

I hope this is helpful.

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

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

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

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

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

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

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

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

Pursuing Certification in Lactation

My colleague Mary Lou Sorey, MS/CCC-SLP, IBCLC is a guest columnist. She has provided services in pediatrics and specifically in the NICU for many years at University of Mississippi Medical Center. Her post provides some very helpful answers to a frequently posed question: “What is the best way to pursue certification in the field of lactation in lactation?” Her thoughtful comments follow.

As a certified SLP and IBCLC (International Board-Certified Lactation Consultant) now practicing in a Level IV NICU, I have often been asked by my colleagues about pursuing certification in the field of lactation. Most want to know how to go about obtaining this additional certification, as well as if I have found it to be beneficial in my practice.

I have found the certification to be helpful, and the education most fascinating! I have used this education/certification in various ways over the years. On occasion, I have been allowed to initiate first feedings with preemie babies at the breast when MD allows, and hopefully this will become more prevalent in our unit with ongoing education regarding the benefits of this practice. We have lactation consultants in our hospital that follow the moms who deliver here, so I am typically not directly involved with those moms. I do, however, ask all of my patient’s moms who are providing EBM for their babies about pumping, make suggestions for increasing milk supply, and troubleshoot problems that may warrant further referral to our lactation consultants. This has been especially helpful for the moms who didn’t deliver at our hospital and don’t have one of our lactation consultants following them. 

There are several different lactation certifications that one can pursue, i.e. Certified Lactation Educator (CLE), Certified Lactation Consultant (CLC), Certified Breastfeeding Counselor (CBC), or International Board-Certified Lactation Consultant (IBCLC), each with its own set of educational and/or clinical requirements.

The one I am most familiar with is the IBCLC offered through the IBLCE (International Board of Lactation Consultant Examiners). The IBLCE offers three different certification pathways from which to choose but requires all candidates to complete 14 health science courses (either as an IBLCE Recognized Health Care Professional OR complete coursework in each subject) and 90 hours of lactation education. The IBCLC exam is required for certification, which is maintained by submitting continuing education hours (called CERPS) after the first 5 years, and by retaking the board exam every 10 years from date of certification. Specific information for each pathway can be found at https://iblce.org.

Here are some excellent resources for obtaining more information and education for those who are interested in pursuing certification in the various areas of lactation.

Problem-Solving Bradycardia during PO in the NICU

Question:

We currently have a former 33 week twin, now 36 and 4 weeks who frequently demonstrates bradycardia events but only during feeding attempts. He does not drop is oxygen saturation at all, in fact this almost always remains at 100% during feeding. His drop in heart rate is usually brief but this is usually after being stimulated. He wakes up consistently for feeding, shows appropriate feeding readiness cues, has a very strong non nutritive suck pattern. With bottle feeding attempts he demonstrates a very poor suck/swallow/breath sequence. He was initially on the ultra preemie nipple to slow the flow down to assist with coordination, however would demonstrate a very fast rate of suck, inefficient with fluid expression with suspected oral pooling in the posterior oral cavity prior to swallow. We have trialed a preemie nipple but without much change in his pattern with the goal of trying to achieve a more functional suck to swallow ratio. I do feel his swallow response is delayed post suck and inconsistent throughout the feed depending on alertness. Could these frequent bradycardia events be a vagal response? As a result of aspiration? Any positioning or flow rate recommendations to trial instead? You can very much tell when he is going to drop his heart rate during a feeding, and usually with re-positioning, taking a break from the feeding it can be prevented but I’m still curious as to a possible etiology for this. He is still currently on caffeine due to these frequent events. Any insight appreciated.

Catherine’s Answer

This is a challenging clinical presentation to problem-solve but not an uncommon one in the NICU. Can you tell us any more about the infant’s history and co-morbidities (especially respiratory, neurologic, GI, postural/sensory-motor?) is he otherwise progressing as one would expect of a former 33 weeker now 36+ weeks PMA?

Bradycardia events during PO feeding can occur at 36 weeks PMA but such are not typical of preemies at that age and are unlikely therefore to be “a variant” of prematurity itself. Some bradycardic events during PO occur without co-occurring desaturation, especially if the bradycardic events are not prolonged. However, the provoking of a bradycardia when the infant PO feeds is worrisome none the less. Bradycardia in NICU infants during PO was correlated with aspiration in a study/paper by Neina Ferguson in 2015.

When I think about a differential as to about what co-morbidities might provoke such episodes at 36+ weeks, what comes to mind includes : GI (e.g., EER/LPR), respiratory (swallow-breathe incoordination leading to uncoupling of the swallow -breathe interface secondary to increased WOB, intermittent tachypnea). Both may present a pathway to airway invasion. In addition, alterations in neural integrity (which can occur in a former 33 weeker but are less likely to be the sources of provocation than the other two possibilities I mentioned). There can also be caregiver artifact (i.e., not recognizing and/or responding to infant’s physiological communication and/or swallowing behaviors from moment to moment , to contingently titrate interventions to avert decompensation; using a flow rate that is too fast, well-intentioned prodding). The last possibility, caregiver artifact, seems unlikely given that he is having these events with you, not only with, for example, parents or staff. But some added interventions might help; more on that later.

Your clinical description suggests a prolonged sucking pattern, likely in the setting of increased WOB and intermittent tachypnea. An increase in WOB may be [resent at baseline or can be recruited (or exacerbated) by a strong continuous sucking effort, without timely and sufficient breaths. This can lead to the need for an urgent breath, even with flow rate control via Dr. Brown’s premie or ultrapremie nipples. Bolus sizes beyond the infant’s capacity can then perhaps “overwhelm” the required dynamic adjustments of his airway that need to surround the swallow. This may lead to a clinical impression of a delay in onset of post-swallow breath (due to the infant’s attempt to prolonged airway closure as a means to protect the airway). Along the swallow pathway, the infant may attempt adaptations that, unfortunately, create resulting maladaptations that lead to further risk for laryngeal penetration and/or aspiration.

In my clinical experience, bradycardia during PO at 36 weeks PMA, even with interventions in place, is most often correlated with airway invasion. A vagal response can indeed result in bradycardia but is often seen as a maturational variant, again unlikely at 36 weeks PMA. Polyvagal Theory, which is quite complex, postulates and describes the fragile nature of CN X function related to prematurity.

When fluid approaches the airway of a preterm infant, there is a reflex that is supposed to be elicited to close the airway; however, its timeliness, consistency of provocation and effectiveness are not well understood. Caffeine prescribed to stimulate HR as you describe can have the unintended sequelae of increasing EER//LPR, so EER/LPR could still be part of the differential too.

Without knowing any more about the infant’s history and co-morbidities, I would suggest you continue to contingently rest the infant, use controlled flow rate to limit bolus size, and, if you have not trialed it yet, use elongated swaddled sidelying (to optimize tidal volume and respiratory reserves). Then incorporate contingent co-regulated pacing based on the infants communication and swallowing behaviors.

If, with these interventions, you cannot avert the events described, I would instrumentally assess swallowing physiology to help elucidate the etiology(ies) for the events, and the effect of further titrated interventions (frequency of pacing, flow rate). Unfortunately, some of our preterms who have adverse overt events during PO feeding are also observed to silently invade their airway under fluoroscopy.

I hope this is helpful.

Problem-Solving: Fluoro Time for Neonates

Question:

At the hospitals that I work at we have outdated machines that only capture video swallow studies at 6 frames per second. Are the restrictions the same for fluoro time (I think it’s about 2 min recommended fluoro time at 30 frames per second for peds and neos)?

Catherine’s Answer:

The low frame rate will of course limit the objectification of swallowing physiology, unfortunately, and sometimes can lead to the need for increased exposure time. Multiple citations by Heather Bonilha Shaw would be helpful as you advocate, along with your radiologists, for equipment that provides 30 fps.  Given your situation, ALARA (as low as reasonably achievable) should remain your guide. That said, as I teach across the US and survey attends at my swallow study seminars, is most typical that with neonates, the aim is the least amount necessary but less than 2 minutes; with pediatric patients, less than 5 minutes. Of course, co-morbidities, compliance, previous exposure to x-ray/radiation, and clinical impressions about physiology as your go along in the study, all must be considered.

Our tech tracks the exposure time as we go along, the rad and I are very aware, and at each juncture I am asking myself “have I objectified physiology sufficiently? Do I need more time?” and if so I am very thoughtful about continuing or not. if I need a few more swallows to better elucidate physiology or complete a differential, or to objectify the likely positive impact of an intervention, I usually discuss it with the rad and we agree on further time based on a determined required need. Most infant studies are less than 2 minutes exposure and most of our pediatric patients less than 3 minutes, at 30 fps.

At the end of each study, I think always ask myself, ” is there anything I could have done differently to reduce exposure time?” Maybe not but it keeps my always trying to do better for my little patients. Heather is on the ASHA list serve, and, I am sure, can add her always appreciated thoughts. Her recent commentary (see list serve archives) on a paper suggesting 15 fps in pediatrics so eloquently explained issues even in 15 fps for our population that may also be useful in helping to make the case for equipment that provides 30 fps.

Problem-Solving: Respiratory rates in neonates

Question:
Hot topic and in need of evidence based research regarding bottle feeding the premature infant (or term infant) with tachypnea.

What is everyone’s practice?  No PO feeding if respiratory rate above 60? 70?  Would appreciate research articles and your hospitals guidelines!

Catherine’s answer:

To my knowledge, there is no research to guide practice but rather the it is often neonatologist training,  preference and the extent to which intake is a key driver in a particular NICU. Neina Ferguson published an informative paper in 2015 about preterm infants in  the NICU that correlated tachypnea during PO with subsequent aspiration in radiology.

Ferguson, N. F., Estis, J., Evans, K., Dagenais, P. A., & VanHangehan, J. (2015). A retrospective examination of prandial aspiration in preterm infants. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(4), 162-174.

The paper did not look at impact on physiology in detail, but I clinically see in the NICU population that tachypnea can alter physiology without witnessed aspiration or penetration under fluoroscopy, and thereby create risk for airway invasion.

Some neos write orders to PO if infant is “comfortably tachypneic”, RR under 70.  “Comfortably tachypneic” is a almost parodical , in that tachypnea is rarely co-occurring with a comfortable looking infant, rather infants who are tachypneic may often be  exhibiting other signs of physiologic stress (e.g., nasal flaring/blanching, suprasternal and/or supraclavicular retractions, chin tugging). Increasing RR leads to more shallow insufficient respirations. The need to breathe often and rapidly will create challenges in the swallow-breathe interface, and cause breathing and swallowing to uncouple. It takes a second to complete the pharyngeal swallow, so then a RR over 60 clearly increases risk for airway invasion.

Respiratory Rate, my RT mentors tell me, doesn’t exist in isolation but is rather a part of a bigger picture. Much like, they say, level of respiratory support required does not exist in isolation. It’s each infant’s bigger picture that guides us.

As we advocate and make determinations of relative risk with PO feeding for our preterm infants, we really must look at each infant in the setting of his unique history and co-morbidities and their unique attendant sequelae. An infant post HIE just weaned or HHFNC will require a different algorithm than the former 24 weeker with CLD, contrasted with the term infant who is s/p TEF/EA repair. And, as Dr Coyle says, that is ok. One algorithm won’t work for every patient and it shouldn’t. All of my examples are infant who often have risks for airway invasion but the nuances of each infant will likely yield a slightly different profile from which to problem-solve, with the team.

That is the challenge of our work in the NICU. To look at each infant as a unique patient, and,  in the setting of what we know about him, and what we see clinically, make a well-thought out educated plan to minimize risk, articulate those risks as best we can to the team, establish interventions that optimize safety and assess their impact on an ongoing basis.

In the NICU , we are required to  live in the grey zone…no easy questions and there are no easy answers, more questions than answers, constantly thinking and re-thinking.  Just keep “listening” to each infant Tara, like you are doing, and especially partner with RTs and a neonatologist that respects the complexity of feeding and swallowing so they can think along with you.

Problem-Solving: Vocal Cord Paralysis and Sidelying

Question:

Does anyone know of any research articles regarding the effectiveness of putting an infant with a left vocal fold paralysis in a sidelying position for bottle feeds? Also, what are your thoughts about performing an MBS or FEES prior to initiation of PO feeds?

Answer:

To my knowledge there are no randomized controlled trials or research studies regarding this intervention. The pediatric ENTs who took me under their wing early on in my career suggested it and theoretically it made sense to me. While its proposed purpose (i.ie, placing infant with a left vocal cord paralysis R side down for PO feeing) is to utilize gravity to assist by passively bringing the paralyzed cord to midline, it is unlikely that can simulate true effective closure as one would observe in the setting of normal vocal cord motility.

In addition, if there are other co-occurring co-morbidities that adversely affect airway, postural or swallowing function, those most also be considered in the differential. However, combined with other interventions such as controlling flow rate, co-regulated pacing and resting, we have consistently seen improved dynamic swallowing objectified under fluoroscopy in radiology. That clinical wisdom is a level of evidence base that has helped to guide my practice.

There is also a high risk for a paralyzed R vocal cord post ECMO, so many of our cardiac infants and select preterms who require ECMO. Similarly, I have both clinically and instrumentally observed a left side down position in the setting of a R vocal cord paralysis to be a useful intervention to trial.

Once again, need to consider all co-morbidities that maybe relevant to guide us. I prefer that infants not have their first PO feeding experience in radiology. It doesn’t allow me to complete a cautious limited clinical examination of PO feeding prior to the instrumental, during which time I can begin to formulate a differential regarding the full picture (i.e., potential effects of respiration, state, and other co-morbidities on the infant’s feeding/swallowing function in the context of the infant’s history. Also, during that first feeding, when sensory-motor maps are being established and recruited, they must be on the x-ray table or in an infant seat. That said, we recognize that high risk for airway invasion in the setting of both L and/or R vocal cord motility issues. If clinically indicated, I prefer at least 1-2 very small brief PO feeding experiences with me while I trial the interventions and allow the infant to experience sensory-motor learning under optimal conditions. This can be as little as 5 mls. Because we recognize that swallowing physiology needs to be objectified to guide management for such an infant, an instrumental assessment would then follow. FEES would clearly inform our differential, and a VFSS would provide insight into the dynamic swallow pathway. I hope this is helpful.

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.