Problem-Solving: Reflux Medication Administration in the Setting of Aspiration

Question

I have an ex-preemie (now adjusted 40 weeks) being worked up for laryngeal cleft – aspirated thins on swallow study even with Dr. Brown Ultra Preemie, but is doing ok with mildly thick liquids for PO; however, he is also on Prevacid and the nurses are mentioning he’s sounding congested when they administer the med (likely aspirating med as it’s not mildly thick consistency).  I typically add other meds to a little bit of the thickened formula to solve this issue; however, Prevacid has to be given on an empty stomach so mixing with formula doesn’t seem to be a good option.  Any suggestion on how to thicken a med that has to be given on an empty stomach?  Also he’s an ex-31 week preemie with a history of r/o NEC, so Simply Thick is not an option

Answer

The onset of congestion with the meds administered unthickened is potentially more worrisome in some ways than aspirating the feeding, from a pulmonary perspective.

You don’t indicate the aspiration was silent in radiology, but he may be at risk for occasions of silent aspiration, given that EER/LPR may be part of the differential and alter laryngeal/tracheal sensation. His potential respiratory issues as a former 31 weeker may add further risk, in the setting of the possible laryngeal cleft. It is possible the audible congestion, especially if it is heard “in synch” with inhalation/exhalation after administration of meds,  reflects airway invasion.

As I understand the limited history above, it sounds like there is no NGT access or they’d be using that for meds. As we consider the relative the risk-benefit ratio for this infant with his clinical presentation, then the risk for airway invasion of the med being offered unthickened is likely going to outweigh the benefit of delivery of the unaltered Prevacid to the gut prior to PO.

Most of the time, while 30″ prior to feeding is recommended for Prevacid administration, the nurses often give the GI meds just prior to feeding to avoid waking the infant earlier. So, it’s unclear to what extent most NICU infants can really take advantage of the time period prior to PO that likely affects positive impact of Prevacid. If the nurse is indeed waking him early to PO, I think the risk-benefit ratio for this infant that I described above still should be considered.

Since you have objectified an apparently approved thickener deemed safe if radiology for swallowing/feeding, I would use perhaps 5mls of that to offer the Prevacid before PO. Is that a perfect solution? No, but it is likely most protective of pulmonary function at this time, based on what we know. In related conversations with our pulmonologists and GI docs, this is the kind of critical thinking have heard them model and that I am fortunate to be exposed to.

His top priority seems right now to be airway protection at this point in the workup, based on data gathered. Reflux may indeed be part of the differential for management, and potentially contributing to his aspiration, but it may have to be a secondary priority at this time, for now.

Perhaps have a conversation with the MDs about their thoughts on the risk-benefit ratio for this infant. Physicians are used to living “in the gray zone” and weighing risk-benefit ratio, so it will be a familiar approach for them, and open the door for collaboration.

 

Problem-Solving: Laryngeal Penetration during Pediatric VFSS

QUESTION:

Some of the SLP’s completing VFSS in the pediatric population are making recommendations solely on penetration. If the child penetrates they assume they will aspirate (due to gravity) and downgrade them to the thickest liquid they don’t penetrate or aspirate with. The reports I have received have not mentioned whether the infant attempts to cough or clear the penetration. I frequently complete fees with the adult population, but my experience is more limited with the pediatric/infant population. Adults will penetrate and clear independently with additional swallows or throat clear/cough to remove the penetration before they aspirate. I’ve also seen flash penetration in adult VFSS does that happen with infants?. I would love some opinions to help guide my practice.

ANSWER:

Infants and children aren’t little adults in so many ways, especially when it comes to swallowing. I’ll share some of the concepts that have influenced my practice and are part of my passion when I teach my seminar about pediatric/neonatal swallow studies.

One of them is that laryngeal penetration, when witnessed,  doesn’t exist in a vacuum. Dr. Coyle has taught us that the significance of penetration, even in the adult population, is on a sliding scale. I love that. He is always so descriptive. I think he means that we have to make decisions on a case-by-case basis, by combining all available information, there is no one size fits all analysis and plan. Then we develop a management algorithm for that patient, with unique co-morbidities, risk factors, history and so on. Each infant/child is unique in birth history, feeding history, postural, sensory-motor, aerodigestive, neurologic status and caregiver attributes. Combined, they all can affect not only what we might witness in radiology but how the infant/child may respond, compensate, or  be affected, and from moment to moment. For example, for our infants, their respiratory co-morbidities will increase the risk for airway invasion, especially under the “right conditions” (i.e., interval change in sucking rate or strength, change in RR or WOB, caregiver artifact). Data analysis in radiology must consider the unique algorithm best for that infant/child based on the available data and understanding of the implications in that context/setting. An otherwise normal infant/child would very likely have a different algorithm after radiology.

Our data set in radiology is limited in so many ways. We must look at the data gathered and focus on the physiology; impressions may be tenuous. We cannot focus on just the events of bolus mis-direction in and of themselves.  A swallow study really is only a moment in time. Bonnie Martin Harris has told us that “aspiration or penetration is neither sufficient nor necessary for a swallowing impairment”. Dr Coyle describes the swallow study as an analysis of how and why the abnormal bolus flow occurred. The alterations in or impairment of physiology, and why that infant/child penetrated,  must influence our critical thinking, and must inform our plan.

All events of laryngeal penetration are not alike in children, and that influences our analysis as well. Their frequency and depth, in the setting of the co-morbidities and age and pulmonary health, are important factors. Friedman and Frazier (2000) found that of those infants/children with witnessed deep laryngeal penetration, 85% went on to aspirate when the swallow study was extended. This correlation between deep laryngeal penetration and aspiration is an important consideration in our “bigger picture” analysis with infants and children. Duncan et al (2019) concluded that laryngeal penetration may be indicative of aspiration risk in children less than 2 years of age. It is also associated with negative clinical outcomes (Gurberg et al, 2015, and Duncan et al, 2019). Duncan’s group concluded that “Any finding of LP in a symptomatic child should be considered clinically significant and a change in management should be considered”.
Another consideration and a key one is what we understand about the evolution of swallowing physiology from infancy toward adulthood. It is closely intertwined with, and highly influenced by, evolving structural relationships of the head/neck, development of maturing postural control and the musculoskeletal network that underlies hyolaryngeal function. At different points along that developmental trajectory, the components of swallowing physiology that guide bolus flow evolve in synch with a gradually more adultlike postural mechanism. Along the way there is: encephalization, sensory-motor learning, skeletal changes, and growth of the larynx. (Ruark, 2002; Gosa, 2013, Riley et al, 2019) At various times along this continuum, physiology is evolving and thus the need for all the considerations I have mentioned about above. This evolution truly is delicate ballet and can be precarious at times. Normal infants and children adapt, and this evolution happens behind the scenes, unnoticed, giving the sense that it happens effortlessly. Not so for the infants and children who land at our doorstep whether in in radiology, early intervention, the outpatient clinic, or our children’s hospital.

Unfortunately, due to adverse effects of radiation exposure, we don’t have data across a wide range of normal infants/children to delineate the variation in pediatric swallowing physiology that may represent normal variation. So, we must peel apart the layers thoughtfully and carefully as each piece of data is obtained.

Perhaps have some dialogue with the SLPs you mention who have sent you reports, so you can learn along with them. Thickening is not always the best intervention either in adult or pediatric dysphagia, and at times may indeed create more risk. That said, some still see thickening as the go-to intervention and yet there may be other or better alternatives for a particular infant/child. There may not be. Have a conversation with that therapist about her/his impressions, rationale, and selection of interventions, and review the study together if possible. That would help build your own understanding of the unique considerations specific to the infants and children you may be following and will build a relationship for future collaboration.  As therapists, we often need to live in the gray zone, as I like to call it, where questions are more common than answers and the answer is rarely straight forward, but that is also the pathway to being a lifelong learner.

I hope this is helpful. Thanks for reaching out.

Duncan, D. R., Larson, K., Davidson, K., May, K., Rahbar, R., & Rosen, R. L. (2019). Feeding interventions are associated with improved outcomes in children with laryngeal penetration. Journal of pediatric gastroenterology and nutrition68(2), 218-224.

Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia15(3), 153-158.

Gosa, M. (2013). Infant Airway Protection Mechanisms During Swallowing. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)22(4), 156-160.

Gurberg, J., Birnbaum, R., & Daniel, S. J. (2015). Laryngeal penetration on videofluoroscopic swallowing study is associated with increased pneumonia in children. International journal of pediatric otorhinolaryngology79(11), 1827-1830.

Riley, A., Miles, A., & Steele, C. M. (2019). An exploratory study of hyoid visibility, position, and swallowing-related displacement in a pediatric population. Dysphagia34(2), 248-256.

Ruark, J. L., McCullough, G. H., Peters, R. L., & Moore, C. A. (2002). Bolus consistency and swallowing in children and adults. Dysphagia17(1), 24-33.

 

 

 

Research Corner: Vocal Fold Movement and Silent Aspiration after Congenital Heart Surgery

This is a wonderful addition to our evidence base related to the potential impact of the need for heart surgery on airway protection in our infant population. Combined with the documented increased risk for R vocal fold motion impairment post ECMO in this same population, it can aid us we advocate for our involvement in safe progression to PO for this vulnerable infants.

Citation: Narawane, A., Rappazzo, C., Hawney, J., Clason, H., Roddy, D. J., & Ongkasuwan, J. (2021). Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. The Laryngoscope.

Abstract

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.

Methods

This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.

Results

Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.

Conclusion

Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

This will inform your pediatric practice whether in the inpatient or community pediatric setting.

Problem-Solving: Duration of utilizing side lying positioning for feeding

QUESTION:

I haven’t found anything specific in the literature, but I cannot think of a rationale for ceasing a sidelying at 4 months of age.  I heard this at a course. I nursed all 4 of my own children until they were around 1 year of age, which means that they were in  sidelying (each side) during feedings for 1 year.  I also find that if a baby with an intact sensory system has the drive to resist a side lying feeding position,  then they are likely no longer in need of that protective positioning.  I did read the abstract to the systematic review that was done by Park, Pados and Thoyre, but since I didn’t have access to the full article, I can’t swear that a timeline was not referenced, but it wasn’t suggested in the abstract.  If the parent is capable and the baby accepts, I will have the parents feed from both sides if they are capable and steady and the baby will accept it, being mindful of vision development and head shape.  I am curious to know your thoughts on the matter.

ANSWER:

For me it is all infant-guided. I let the infant tell us. There is no arbitrary age for anything really, it is based on developmental readiness for a change, less need for a support.  I suggest parents trial a more typical feeding position when infant has been home for a month or so and has been feeding without stress in a sidelying position.  If the infant feeds as well in the new position as he did in sidelying, then the infant is telling you he is ready for the new position. If he does not feed as well in the new position, he is telling you he is not quite ready for a change and still wants that developmental support provided by sidelying.

An exception would be if the sidelying position with specific  L or R side  down was prescribed post swallow study or post-ECMO or post-PDA ligation. Then the change should coincide with therapist guidance and, if indicated based on etiology,  a repeat instrumental assessment of swallowing physiology.

Problem-Solving: Ten Year Old with Cerebral Palsy

QUESTION:
I am a young clinician with a patient that has recently had a follow up swallow study that showed poorer results than original swallow study in absence of change in medical status.

Patient is male, 10 with CP. I’ve seen him for feeding and social/emotional communication around mealtimes due to intense frustration. Recently he got a swallow study that shows aspiration for thin and half nectar by straw and sippy cup due to volume. Nectar showed no a/p. Silent aspiration on 5/20 swallows. He eats all solids and had no a/p on previous and most recent MBSS.

Recommendation following swallow study was to use Thick It to nectar consistency. Also to use Vital Stim.

I’m looking for input on next steps in the home health setting. Is it worth it to discuss Frazier Free Water protocol with Mom? One consideration is he had a croup attack 2 months ago unexpectedly.

ANSWER: 

So glad you reached out. Lots of thoughts and questions as I read your post. Know that the questions and “thinking out loud’ are part of my clinical problem-solving, to sort out relevant considerations and complete differential as I go along. Just lots of questions and weighing of possibilities to start with. Usually, children with complex co-morbidities have multiple relevant components to their care to sort out.

“Poorer results than the original study” in this child’s situation, based on what we you have shared, could be the result of several possibilities.

Not sure how long ago the previous study was or the results, but the previous study may be part of the relevant picture: the analysis of that study might not have incorporated all the data or a bigger picture so the “results’ were precarious; the study was short or data was tenuous and conclusions were therefore tenuous; the etiology for the whatever adverse events were seen was not clear (or not made clear in the report) and perhaps, if it were,  would have given more information that might make sense now with newer data; physiology was not described, which would have provided more data than just what events of aspiration or laryngeal penetration were witnessed – remember Bonnie Martin Harris has told us that “aspiration or penetration is neither sufficient or necessary for a swallowing impairment”, so physiology becomes the key in our analysis; the study is always a moment in time and so we may not witness events that are indeed occurring during true meals.

A second relevant factor to consider is his neuromotor problems with a diagnosis of CP. While CP is not progressive, increasingly complex functional skills (including feeding) can sometimes look worse and become more challenging as time goes on, due to the demands on an already altered sensory-motor system to integrate for increasingly complex tasks over time.

A third relevant factor to consider as you reflect, is that children with CP often have related co-morbidities. We don’t know what his are from your description, but they can often include respiratory and GI, whose integrity may wax and wane, and therefore be fluid in their influence, pending for example the season of the year (e.g., winter can bring more respiratory challenges, spring can bring allergy-like factors in to play) , growth spurts, minimal changes in diet content that may seem at first glance as minimal, changes in activity. This can lead to subtle respiratory changes, subtle GI changes,  that in a dynamic system like the swallow, can influence function from moment to moment. The croup, which may have been part of an URI provoked by airway invasion from above or below, is worrisome.

Can you connect with the SLP who did the study and perhaps look at it together? It might suggest some added interventions that were or were not objectified, though likely were, such as: rate of intake, bolus size, cup utilized (there are so many and some work better for some children for safety), pacing, self-drinking versus fluids offered by caregivers, position and support/stability offered to optimize proximal and distal stability (seating device and support for the procedure can alter physiology in a good way or an adverse way).

Regarding a free water protocol, is he staying hydrated with the thickened liquids? Is he willing to drink them? Has his fluid intake gone down since thickening was started? Does he receive good oral care on a regular basis? What has his pulmonary health been like over time? can family carry it  over safely? Doesn’t sound indicated with what we know.

I hope this was helpful to get you thinking. It’s ok to live in the gray zone and not know these answers. Just thinking about them is part of the problem-solving process.

Problem-Solving: Two year old with Neuroblastoma and G-Tube

QUESTION:

I work with a child who is  two years old, and was diagnosed in October 2020 with neuroblastoma. She is fed through both a g-tube and by mouth minimally. Generally healthy. She completed chemotherapy at in April 2021. She began immunotherapy and will receive treatments one week per month (M,W,F).

Mom reports there was a never a concern for a true “swallow disorder” in regard to risk for pneumonia or ever a need for an instrumental swallow study. Mom reports that after her child was diagnosed with Neuroblastoma, the medical team considered an SLP to evaluate her swallowing due to an oral pocketing, lack of appetite and coughing concern; however, she was seen 1-2x by the inpatient SLP who deemed her “OK” and “fine” to eat, and “no need for instrumental”.

Per mom report, she was told that the feeding issue was behavioral/sensory, and that for nutritional / hydrational reasons, she received an NG tube, then a G-Tube was placed (end of November). Mom reports that she was told that her child can technically come off the G-Tube but since she wasn’t eating enough eating enough, it will remain placed.

Mom reports that now her child is being fed mostly through GTube and “not much” orally; reports approximately  2 spoons yogurt, OR 10 cheerios, OR dry cereal, nibble 1 bite of noodle, 1 bite of a freeze pop; mom reports that when she sees her siblings eat, she desires it, yet once given, she will throw it away.

I saw the child today; she ate 3 spoons of chocolate yogurt with no problem, 1/2 chip with functional oral skills and no overt issues. Mom then brought her favorite food: chickpeas (spicy flavor), the child ate about 10 pieces, then picked the last piece out of her mouth, gagged, burped, and proceeded to vomit a large amount of orange secretions. Given a sip of water, she began coughing.

When questioned, mom reports that this happens often with certain foods (“even the non-spicy chickpeas“), however they don’t always see it because she “hardly eats”. I recommended perhaps a GI consult and/or follow up with hospital SLP to consider instrumental exam.

 

ANSWER:

It is challenging when the infant’s/child’s history is provided solely by the parents. They may recall information incorrectly, forget critical details that would assist you, misinterpret what was said or what transpired, or perhaps have focused only on part of what they heard that might have been more readily understood or accepted at that time. On the inpatient side, especially after a critical diagnosis of neuroblastoma, the aftershock and the stages of grief set in for parents. They have told me it is like a fog sets in, it’s hard to remember what you heard, and it’s scary. During that time, information processing is very much affected by the stage of grieving they are in, the acuity of infant’s child’s medical situation, the early progress during inpatient stay and the multitude of consultants that come in and out of their daily lives, as they stay at the hospital, who touch them and their child each day. I see it first had as I am in the room with a family and an infant/child, a physician comes in to examine and update their differential and the talks with the family. Or the team does morning Rounds. It can be overwhelming for parents but intended to be so helpful. Everyone is typically thoughtful, and share a lot of crucial information, answer questions, listen. One parent might not be there due to being at work for example and gets the information second hand from a family member. After the physician leaves, the reprocessing often begins as the parent wonders aloud and then “digests” what actually transpired or what they heard through weary ears. Add this to the critical decisions made by the team and asked of the families when they are under emotional stress. I wonder sometimes how the families get up each day and come back so kind, so thoughtful, and so caring, yet completely drained so much of the time.  It is within this context that they then store and late recall for you on the community/OP side, the important information.

It is possible that the SLP did have concerns about swallowing safety, which would be likely given the diagnosis. The SLP may indeed have expressed this concern, and the team decided otherwise, which can happen.  The parent may have found the SLP’s concern about swallowing surprising and kindly with respect disregarded it. It is hard for parents with a sick child to think now even eating and drinking m might also be a problem and the child might “lose” that as well. Sounds like interim pleasure feeding trials might have been recommended or perhaps there was a plan to complete an instrumental assessment, and, for multiple reasons, it was cancelled and there was a plan to follow-up with OP study. Possibly mucositis r/t chemo was apart of the decision. So many possibilities. This is not to say that as inpatient SLPs we don’t look back and say “hmm, I wish I would have…”  or “I wonder if I had…”  That is a part of doing your best to minimize risk and improving one’s practice, thoughtfully reflecting on how we can do better. Without that SLPs input, we just don’t know what unfolded.

Perhaps ask Mother for a release of records for SLP services during IP stay and get her authorization to contact the SLP staff directly and speak with the SLP who cared for this child, to get that SLPs perspective and objective data. That will hopefully bridge the gap for Mother and for the child and for your planning your next steps.

Thanks for reaching out. We are all part of a big team that continues beyond the walls of the hospital, to support each other.

Research: Disruptions in the development of feeding for infants with congenital heart disease

Jones CE, Desai H, Fogel JL, et al  (2020). Disruptions in the development of feeding for infants with congenital heart disease. Cardiology in the Young, 1-8

This just published manuscript is a valuable resource for therapists supporting feeding/swallowing for infants with CHD.  The authors include in the-trenches pediatric therapists from leading programs across the US. It will inform your practice,  whether you are in the hospital, Early Intervention  or community programs that support these complex infants.

The introduction:

Congenital heart disease (CHD) is the most common birth defect for infants born in the United
States, with approximately 36,000 affected infants born annually. While mortality rates for
children with CHD have significantly declined, there is a growing population of individuals with
CHD living into adulthood prompting the need to optimize long-term development and quality
of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental
challenges and feeding difficulties. Feeding challenges carry profound implications for the quality
of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional
bonding with parents and other caregivers. Oral feeding challenges in children with CHD
are often the result of medical complications, delayed transition to oral feeding, reduced stamina,
oral feeding refusal, developmental delay, and consequences of the overwhelming intensive
care unit (ICU) environment. This article aims to characterize the disruptions in feeding
development for infants with CHD and describe neurodevelopmental factors that may contribute
to short- and long-term oral feeding difficulties. 

They discuss the impact of: cardiac physiology, necrotizing enterocolitis, gastroesophageal reflux, timing of cardiac surgical interventions, sedation and medication, chylous pleural effusion, respiratory support, neurodevelopment, genetic syndromes, a noxious feeding environment, nerve paralysis/paresis, and dysphagia. They then discuss the consequences of these feeding challenges, including: nutritional interference, breastfeeding difficulty, tube feeding, oral aversion, and finally long-term feeding outcomes.

 

Problem-Solving: A Feeding “Window” for NICU Infants?

QUESTION:

There is this idea of a feeding “window” for the infants in our NICU, where PO trials ideally need to happen within this “window” or there could be longer-term feeding issues.  This idea is perpetuated by nurses, physicians, and our developmental care specialist but as an SLP I am not only puzzled but can’t find any research refuting or supporting it. I think the way in which its used by other staff is that this “window” exists around 40-43 weeks and that it is important that if PO hasn’t already happened, that trials at least need to happen during this timeframe.

Does anyone have any research for or against this “window”? Or know the origin of this idea?

ANSWER:

Unfortunately, today many of our preterm infants are being asked to feed much earlier/younger and that can readily cause more stress, unless the approach is infant-guided and not volume-driven. Today, the pressure to get infants out of the NICU often drives many care decisions, especially when it comes to PO feeding.

It’s not uncommon for neonatologists to assume that there is a window within which our preterms must “experience” PO feeding or they will “miss that critical window and never learn”. There needs to be reconsideration of that paradigm to consider instead, individualized readiness to PO. This is why.

That well-intentioned paradigm is based on writings from Gesell back in the 60s that talked about a “critical window” for learning to eat. Those times were different in many ways,  as was the population being described. NICUs were just being developed, there were no therapists as part of the neonatal team, as the need for therapy support, much less feeding support, was not well understood. Many NICU infants did not survive or did so back then with enduring developmental concerns. NICU  infants, though they weren’t asked to PO feed as early back then, they eventfully were PO fed. Prior to initiating  PO, the infants did not have developmental support for the system-based underpinnings to support that future PO feeding and avert maladaptive sensory, sensory-motor and oral-motor patterns that often evolved. At that same time community in Early Intervention, and even in the early 80s when I first started out, we rarely saw former  preemies who had survived the NICU until they were often 4 or 5 years old. Can you even imagine? And they came with horrific stories back then, and complex maladaptive behaviors. The fragile marginal subsystems that underpinned PO feeding had been dormant all that time, and the infants developed maladaptations from motor learning environments that were not therapeutic;  but the nurses in the NICU had done the best they could without therapeutic collaboration/insights, and then parents, after discharge, did the best they could without support of therapists. You can see how “not missing a window” might have been seen as the key, to avert such outcomes, when actually, it was the need to provide the right kind of environment to nurture the prerequisites, individualize care, and then further support emerging PO skills. That was then. This is now.

Today with the advent of neonatal interdisciplinary teams that include PT/OT and ST, we can better support readiness by maintaining those systems for future PO when co-morbidities safely permit. “Readiness” that is not determined based on an arbitrary date or age, but infant-guided readiness based on clinical signs/behaviors in the context of that unique infant’s GA (age at birth) and history/co-morbidities. That is the gestalt  that, when considered thoughtfully,  can set the stage for success, or, if not considered, create the perfect storm for risk. That gestalt benefits from neonatal care that is neuro-protective and promotes positive overcomes and recognizes safety issues inherent with some co-morbidities and clinical presentations that should suggest caution.

Concern for  “missing that critical window” has led perhaps to team decisions to PO with “let’s see what happens” or “let’s let him practice”. But as a thoughtful  nurse once said tome, “why do we ask them to PO when they are not ready? Practice doesn’t make perfect. Practice makes permanent.” I, of course, hugged her!

The concept that preterms must “experience” PO feeding or they will “miss that critical window and never learn” has led to the well-intentioned “pushing PO” and orders to PO on CPAP and HFNC. Many of our former preterms can learn to feed orally at later ages, once weaned in the level of respiratory support, and from my experience, do so with less stress and more safely. Amaizu (2008) reported that gestational age at birth (GA)  influences the ex utero development of oral feeding skills more than PMA (post-menstrual age) at which PO is started. So the age, i.e., PMA (post-menstrual age) at which you start to offer PO is not the key to focus on. It is the bigger picture, which means individualizing readiness considerations.

Advocating for safety for these infants is a critical one for SLPs in the NICU (and PICU). Current NICU technology has advanced to the point that more infants are surviving and yet many are requiring extended periods of CPAP and HFNC. Many extremely preterm infants in our NICU with CLD at post-term (41 weeks PMA +) remain dependent on CPAP or HFNC.  Sadly, this is often the group that gets the most “pressure” to feed and go home.  Does the team ask them to PO feed to not “miss a critical window”? Or does the team maintain their readiness with therapy support, to optimize safety and neuroprotection, by individualizing readiness?

Good collaborative conversations about the benefits of ST being involved to maintain a positive oral-sensory environment, promoting the oral-sensory-motor components that are the underpinnings for future PO feeding, beginning early to foreshadow for parents the swallowing, breathing and postural skills needed, and helping families also support those components, versus attempting PO feeding when the infant is struggling with respiratory stability. Clearly, medical co-morbidities predispose an infant in the NICU to PO feeding problems. Multiple papers have studied that. Those infants with the greatest respiratory comorbidities, often those born < 28 weeks’ gestation and BW < 1000 grams, are most likely to require prolonged NIPPV, CPAP and/or HFNC at those post-menstrual ages when PO feeding is typically attempted. Sick newborns may also present similar issues, secondary to their co-morbidities

If the infant has such respiratory needs that he requires CPAP, or a HFNC, one must ask if PO feeding is really a priority for that infant at that time. The ability to reconfigure the pharynx from a respiratory tract and back to an alimentary tract with precise timing and coordination surrounding each swallow is a concern. When we look objectively in radiology during an instrumental assessment of swallowing physiology, even infants with CLD stable on RA have altered or impaired swallowing physiology as a direct result of their CLD. The bolus mis-direction and resulting aspiration we often observe is typically silent. The need for an “urgent breath” often can predispose an infant with increased work of breathing to silently mis-direct the bolus into the airway during the swallow. The ability of the infant to close the glottis against the driving force of the respiratory support, while breathing with increased effort or with an increased respiratory rate, which effectively creates air hunger, and yet still maintain glottic closure throughout the duration of the swallow, would likely be precarious. Given the infant’s likelihood of baseline tachypnea and increased WOB, the dynamic adjustments of the airway surrounding the swallow are likely to be disrupted and create uncoupling of swallowing and breathing. Indeed, infants for whom we do not necessarily witness aspiration during a dynamic swallow study may indeed show alterations in swallowing physiology that may predispose them to airway invasion under “the right conditions” during PO feeding (changes in nipple flow, changes in position, changes in respiratory support or work of breathing at that moment, for example). The fact that NICU  infants “eat” and “are fed” and “transferred volume” does not equate to “safe or neuroprotective feeding”. Ferrara and colleagues (2017, 2020) and Ferguson (2015) have contributed greatly to our understanding of this risk.

We must of course remember the physiologic stress likely to occur when the infant experiences “feeding” when the infant is not “ready”. It is highly possible the stress of trying to breathe and coordinate a swallow may lay down neural pathways that move the infant away from wanting to eat, by wiring those sensory-motor pathways that lead to current and/or future maladaptive feeding behaviors. We know that studies looking at stress in preterms have shown an association with adverse changes in brain structure on MRIs.

In the NICU seminars I teach, this dilemma is always part of our problem-solving discussions. After 35 years as an NICU SLP,  I so appreciate and always advocate for our key role in dialoguing  with the team, problem-solving and focusing on safety and neuroprotection as the essential part of this practice issue which confronts every neonatal team.

I hope this is helpful.

Catherine

 

Amaizu, N., Shulman, R. J., Schanler, R. J., & Lau, C. (2008). Maturation of oral feeding skills in preterm infants. Acta Paediatrica97(1), 61-67.

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 Perinatology40(6), 909-915.

Ferguson, N. F., Estis, J., Evans, K., Dagenais, P. A., & VanHangehan, J. (2015). A Retrospective Examination of Prandial Aspiration in Preterm Infants. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(4), 162-174.

Ferrara, L., Bidiwala, A., Sher, I., Pirzada, M., Barlev, D., Islam, S., … & Hanna, N. (2017). Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates. Journal of Perinatology37(4), 398.

 

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!