Problem-Solving with Catherine

Question:

I work with a 4-month old baby with lots of gastro issues on G-tube. He has had a nissen fundo surgery. Originally NPO. I gave mom strategies for oral motor but he has a great suck pattern and no visible oral motor issues. Also gave strategies for environmental modifications while feeding. He is now clear for only puree. I dont know if I should continue seeing him and how to proceed if I do. I have little experience with babies so any or all suggestions are welcome. Thank you!

Answer:

Sounds like a challenging patient. Since you have little experience with infants, this would be a great opportunity to partner with an SLP locally who has treated infants. We don’t know much about this infant except that he is 4 months old. To fully understand what is going on, we need to gather data, including his history, and combine that with what you are seeing to then be able to complete a differential. Some of the history you can gather from the parents, but I would also request records from the referring physician. We would want to know for example: was he born at term, or post-term or was he a preterm infant? What do we know about his birth history? Was he hospitalized in the NICU after birth? If so, how long was he there? What were his medical problems when he was there? Did he require oxygen? Has he had any other surgeries other than the G-Tube/Nissen? Are there still medical problems the doctor is sorting out or following? Why did they place a G-Tube? Did he have a swallow study and what did it tell us about his swallowing physiology? Is he otherwise developing normally for a 4 month old (posture, head control, UE and LE movements/control, swallowing saliva, getting hands to mouth on his own and appreciating that, accepting pacifier, visually alert/engaged and tracking, starting to make sounds?) It may be hard for you to fully assess these developmental parameters, as well as oral-motor integrity, and an extra set of eyes from another SLP will be both helpful and important.

From what you have told us it sounds like reflux is a part of the differential but that alone is unlikely to, though could possibly, lead to the need for G-Tube feedings. It is possible that, given he is to feed only purees, he may have shown alerted or impaired physiology with liquids. The altered or impaired physiology, if identified, should be correlated with an etiology in the swallow study report. Just knowing he “aspirated” won’t guide our differential and plan, as we would want to know what was the nature of the bolus misdirection (to the nasal airway? to the laryngeal airway?) and why the bolus mis-direction occurred, if it did; what they recommended for him at that time. That then drives a plan of care and suggests strategies to specifically address the problems identified.

While some infants do have oral-motor problems that contribute to the need for G-Tube feedings, there can be multiple co-morbdities, or problem areas that contribute. Knowing more about his medical history would help uncover or elucidate these factors, and they are critical to our assessment and treatment plan. They actually form the context in which we interpret our data, i.e., what we observe clinically and what the family tells us about what they see. You mention that he has no visible oral motor issues so then we want to look deeper and broader at other systems that underlie effective feeding, including GI, respiratory, postural, neuro, sensory, for example. Information about his history should guide you toward these suggested domains or away from them.

It is wonderful you reached out to this list serve, but as you can see his presentation and what to do with him is much more complex than can be fully addressed through the list serve. Perhaps use this an opportunity to learn and build your skills, and seek an SLP mentor to work alongside you and guide you.

Not sure if that is possible where you work, but I suspect not or you would have tried sought a colleague’s help.

It takes a clear objective sense of our own limitations and humility to think about not continuing to see a patient for whom we feel unprepared. I think as I read between the lines you are at that juncture and are to be commended for that tough call. Each of has been there and let’s hope we have all been as willing to ask questions and recognize the need to respectfully send the patient to another SLP, whose current skill set is a better match. Were this your infant with feeding/swallowing problems, you would want his therapist to make a decision that is in the infant’s best interest.

I hope that this has been helpful.

Catherine

Problem-Solving with Catherine

Question: I need help brainstorming possible etiologies for chronic vomiting/regurgitation with a 3 year old.

Medical hx is significant for 36 week prematurity, hypoplastic left heart syndrome now s/p Fontan on 6/16. On 6/18, pt w/new onset left side weakness; imaging found hypoxic injury and watershed infarct. PMH also significant for submucosal cleft palate and GT dependence. Chart review revealed ongoing ST to address feeding issues from infancy, including oral aversion and decreased oral motor development, both now resolved. Parents report pt is interested in PO feeding and will put all textures in his mouth but chews them and pockets rather than swallowing because he is afraid of vomiting. Assessment revealed mild OM weakness but adequate lingual lateralization and chewing skills. Initial PO trials were with preferred foods (smooth puree and water via straw). After very small volumes (less than a teaspoon of each), pt regurgitated the food/liquid which subsequently expelled everything else he had “eaten” via GT up to 2.5 hours earlier. The gag did not happen until after pt had safely swallowed on both trials (separate events with puree and liquid). Parents report that this happens several times a day and that pt also vomits without PO intake (just GT feeds) but that is less common. Pt has had several MBSS which revealed functional pharyngeal skills (oral skills were lacking in one but that was some time ago). The only UGI pt has had was when he was an infant, as part of the work up for GT but they presented contrast via NGT and only viewed stomach and beyond. Therefore, today, I asked for an esophagram to rule out structural or functional issues in the upper GI sections. This test was negative.

These parents are so frustrated and don’t know why their son is vomiting all the time. What I witnessed did not appear to be related to sensory/behavioral (texture aversion) or swallow dysfunction. I was wondering about UES dysfunction or esophageal pouch/diverticulum but the radiologist did not see evidence of those today. Any suggestions??

Answer:
There may be a variety of GI issues to consider as part of the differential. You don’ t mention if he also received a Nissen at the time in infancy when his G-Tube was placed; if so this may be part of the puzzle, especially considering the vomiting after G-Tube feedings. His diagnosis of HLHS and multiple surgeries, and subsequent post-cardiac surgery GI complications are quite common, as Shaunda suggested. The lower branch of the vagus can wreak havoc with many of our babies and children post-op. Given his history and pre-morbid feeding challenges (oral aversion, oral-motor problems), there may now be an exacerbation of those premorbid challenges. Given that he must have had some kind of post-op event on or prior to 6/18 that resulted in a documented hypoxic injury and watershed infarct, I wonder if there may also be some alterations in pharyngeal and/or upper esophageal function that may be also part of the etiology. What I mean is that even though there is a strong case for GI issues as a part of your differential, there are apparent recent neuro ones too that, along the swallow pathway, may alter both pharyngeal and upper esophageal (especially UES) swallow function. You mentioned he has had several swallow studies but has there been once since the onset of left sided weakness and the watershed infarct and cardiac repair? This would be a great opportunity to objectify both pharyngeal and upper esophageal swallowing physiology with at least the puree and liquid he clinically appeared to swallow well. His complex history and the recent post-op event suggest to me the need for a current instrumental assessment. Because the UGI is a moment in time, and that his is such a complex presentation, a test result such as a “negative UGI” may not tell the whole story. Perhaps during the swallow study, you may also capture an incidental finding related to GI function, and given the focus on dynamic swallowing in the swallow study (versus what they may focus on in an UGI), you may be able to gather needed data about both pharyngeal and upper esophageal function. The combination of his multiple co-morbidities, and their interaction, is likely quite complex, and the data from a swallow study may help inform the entire team’s perspectives.
Catherine

Indwelling NG Tubes

In community-based early intervention, children/infants with indwelling NGTs (nasogastric tubes) may come to us for services. They may have struggled for extended periods of time learning to PO feed while having NGTs for months. By the time we see them, there may already be onset of early aversive behaviors set in motion. Our job then is often to then unwind the negative learning. I recognize as I travel the US teaching that discharge to home on indwelling NG tubes is getting more common, including bridled NGTs and I am concerned. In my experience, those infants/children for whom this is a consideration clearly require the interdisciplinary perspective which the attached paper advocates.

A common concern as pediatric therapists is the potential impact of indwelling NGTs on the oral-sensory -motor system, both in the short term and the long-term. This perspective is shaped by those infants/children whom we follow after the decision is made and often present with sequelae from a well-intentioned plan. The challenge is always the risk-benefit ratio for each individual infant/child. This paper does a good job of articulating the importance of looking at the bigger picture. That is it can help the team, especially related to co-morbidities, to better profile those infants/children whose feeding issues are likely to truly be “short-term” versus thus whose medical history and co-morbidities suggest a more enduring feeding/swallowing problem. I hope this article informs your team’s practice.

NG-tube vs. G-tube

Problem-Solving with Catherine

Question:

What are your thoughts therapeutic taste trials? We are a level 3b NICU. And
have many babies with multiple medical complexities. We are beginning a
therapeutic taste trial protocol for babies who are over 32 weeks PMA, have
a nonnutritive suck, and physiological stability. The idea behind this is
practice swallowing for babies who are yet able to bottle feed due to a
number of factors but mostly babies who are on too much oxygen support (1.5
liters of hi Flow or greater)

I have some concerns especially regarding babies who are post PDA ligation
and we are receiving “encouragement” from physicians to begin this protocol
on babies on bubble CPAP. My obvious concerns with PDA ligation is the
incidence of paresis to left vocal fold and CPAP from my understanding
maintains positive pressure for open airway which worries me for poor airway
protection/open airway during the swallow. The bolus give is .05ml-.2 ml
increments. Also what are your thoughts on using sterilized water vs
breastmilk/formula? we seem to be giving them less than what they get from
“oral care”. Any help will be greatly appreciated!

Answer:

I think this could be supportive provided the therapist drives the plan
(once the consult is ordered), and that careful attention is given to
physiologic stability and infant engagement during all oral-sensory-motor
experiences and with pacifier dips. I would in general not be offering
“nipple” delivered boluses at 32 weeks PMA; however, even at 33-34 weeks
PMA, each infant’s unique history, co-morbidities postural control and
current level of support needed, as well as baseline WOB and RR would all
together best determine relative risk and how to best proceed. Many positive
experiences for readiness can be part of therapeutic interventions prior to
offering a nipple for PO feeding.

Infants s/p PDA ligation are highly at risk d/t the typical respiratory
sequelae associated with having required a ligation. A scope by ENT has been
advocated in some recent papers (search Google Scholar) suggesting many
infants are asymptomatic post-PDA ligation surgery despite having true vocal
cord motility sequelae and therefore scoping should be considered to assess
the airway integrity.

I think MBM is always better than sterile water or formula – more sensory
load than sterile water and a more normal oral-sensory-motor experience. No
one has studied it to my knowledge but I suspect that if traces of MBM are
micro aspirated, perhaps the lungs will better tolerate MBM than formula.

I hope this is helpful.

Catherine

Problem Solving with Catherine

Question:
I have not yet personally seen this baby (he’s 2-3 months old), but got some background info from our NICU ST. I’m trying to brainstorm before he sees me for a follow up appointment. Baby had VFSS in NICU and was safe on thickened formula (nectar, I believe) with baby oatmeal. Baby never took off with feeding while in the NICU and was d/c with NG and doing 1-2 bottles/day. As baby has been home he’s having painful constipation issues and thickened feeds have stopped. Baby is to have follow up with GI, but will end up seeing me before them.
He’s coming back as an outpatient for a repeat VFSS. Now, in a perfect world he’ll pass without thickener… but if not, I’m wondering what my options are for thickening feeds? Has anyone thickened for infants with something other than baby oatmeal/rice cereal? Is there another option besides cereal and NG tube?

Answer:
Late responding to this thread. You may have already seen this infant for the repeat VFSS by now. We don’t know much about his history except that he was in NICU, which leaves a wide potential for possible co-morbidities that would be important to your differential in radiology. The GI discomfort you mention makes EER/GER a possible co-mrobidities but there are likely others that you will want to both peel apart and consider together “synactively” to better understand his dynamic swallow and its function during feeding given what you find out about his feeding “environment”, i.e., how he is fed, bottle used, his clinical presentation while he feeds and post-feeding behaviors

Hopefully you were able to get more information about why he was placed on nectar thick liquids post-NICU VFSS – the etiology for the apparent bolus mis-direction should guide you in the follow up study and help you problem-solve as well as look at optimal interventions to address that etiology –sometimes thickening is viewed as a solution but it is not, as you know. As Suzanne Evans Morris said years ago, it is merely a step along the way to improved swallowing. When the VFSS analysis and synthesis of information informs our understanding of the infant’s physiology, we can then develop a plan of care to address both the etiology as well as an interim plan to optimize safety.

We try both in the NICU and with infants either post-NICU, or who were never in NICU, to avoid thickening whenever possible. Because toady we have so many flow controlled nipple options, we are much more able in radiology to find a nipple flow rate combined with co-regulated pacing that optimizes bolus size and enhances timing of the suck-swallow-breathe sequence. There aren’t many options to thicken for infants. Our GI docs have concern for grain allergy in infants, increased constipation, and other MD specialist often have their own concerns (altering of caloric density and nutrients, electrolyte balance, free water etc.) Gel Mix is a newer carob bean based thickening product developed by a GI doc that some hospitals are using for some post-term infants. You can find more information on the internet or by talking to its developer. It is often helpful to partner with the attending, in this case likely a pediatrician, to ask, if thickening appears to be the least problematic option, what would he prefer his patient receive. As many previous list serve threads have expressed, the answers for each patient must be individualized, be the product of a team’s perspectives, and its effects be assessed in an on-going manner. It is challenging to live in the “gray” zone where the answers are not black and white nor are they immediately clear, but require deliberate and reflective thinking. Each of us in radiology is faced daily with this dilemma, and I think it makes us better clinicians at the end of the day. Our physician colleagues have always considered risk-benefit ratios for their patients regarding multiple options, and we can do no less, considering all levels of evidence and family/team input.

I hope this is helpful. Keep us posted on what the repeat VFSS suggested.

Catherine

Article Review: High Flow Cannulae

Article Review

Leder SB, Siner JM, Bizzarro MJ, McGinley BM, Lefton-Greif MA.

Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia 2016, 31;154-159.

article available through Google Scholar

I am quite concerned by the conclusions of Leder et al regarding safety of oral feeding for preterm infants requiring CPAP.

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. Our team has had 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 underpinning’s 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 clearly 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 co-morbidities, often those born < 28 weeks’ gestation and BW < 1000 grams, are most likely to require CPAP and/or HFNC at those post-menstrual ages when PO feeding is often 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. This is quite concerning given the conclusion from Leder et al’s study does not even mention this possibility. In the adult population in the most recent information I have seen (Garon et al, 2009 Journal of Neuroscience Nursing) reported that of 2000 adults studied with a variety of co-morbid conditions, including COPD, 54.5% of those who aspirated did so silently. Should the potential for silent aspiration not at least be mentioned? The data I have collected thus far for NICU infants suggests strongly to me that even the data from Arvedson et al in 1994 likely underestimated the tendency for infants to silently aspirate. In addition, her study population was not only less involved from a respiratory perspective back in 1994 than the population we see today, but it also was a population composed of not just infants. 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. Without objective data on the impact of CPAP or HFNC on swallowing physiology we cannot conclude that feeding under these conditions is “safe”. Indeed, infants for whom we do not necessarily capture aspiration during a dynamic swallow study may indeed show alterations in swallowing physiology that may indeed predispose them to aspiration under “the right conditions” during PO feeding (changes in nipple flow, changes in position, changes in respiratory support for example) so it isn’t even just about aspiration but the potential impact of CPAP and HFNC on swallowing physiology. The fact that the infants “ate” and “were fed” and “transferred volume” does not equate to “safe feeding”. Leder et al’s conclusions don’t unfortunately take this into account.

We must of course consider as well the physiologic stress likely to occur when the infant experiences “feeding” under such circumstances. It is highly possible the stress of trying to breathe and coordinate a swallow may actually 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.

My colleague, Dr. Suzanne Thoyre, a neonatal nurse feeding researcher, raised some excellent questions about the study design some of which I will try to share in my own words, as she is not a part of our list serve

What did Leder et al deem for inclusion criteria that would be “stable respiratory status” and “Cardio-respiratory stability”? Typically, infants requiring CPAP or HFNC have both increased WOB and increased RR. RR may appear artificially low when rates are captured by a monitor for example that does not sense shallow rapid breaths. Was WOB a consideration? This is a key component of infant clinical assessment of breathing in preparation for attempting as well as during PO feeding. Excessive WOB even in the presence of a less elevated RR can alter timing of swallowing and breathing and often lead to silent bolus mis-direction in the NICU population, much as it might in adults with respiratory work. It is common that infants requiring even low flow oxygen cannot feed without a co-occurring increase in their work of breathing. Two of my OT colleagues in NICUs out East who each observed MD-directed RNs feeding infants on CPAP and HFNC reported seeing significant increase in WOB, RR and signs of behavioral stress.

How was successful oral feeding measured? Did they collect physiologic and behavioral data that demonstrated no indicators of stress, change in oxygen saturation, change in HR, change in respiratory status? The tool they used to measure this needs to be provided. If the feeder simply filled out a checklist, it would be important to know how those observers were trained, how all of these parameters were described and what definitions were used for change in these parameters.
Are the infants in the study on CPAP and HFNC truly being PO fed at 32 weeks PMA? Or is the term “corrected GA” being used incorrectly? I ask because typically even healthy preterms without co-morbidities stable in RA are not being fed PO in most NICUs, with some rare exception. This needs clarification and perhaps makes the conclusions even more concerning.

Unfortunately, Leder et al’s paper will reinforce an incorrect not uncommon assumption. Many neonatologists incorrectly assume that there is a window within which our preterms must “experience” PO feeding or they will “miss that critical window and never learn”. So despite co-morbidities and often respiratory needs that are paramount, infants are being asked to feed. 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. Early intervention now in NICUs to support readiness, neonatal care that is neuro-protective and promotes positive overcomes, and recognition of safety issues inherent in the complex task of PO feeding even when weaned from CPAP and HFNC clearly call for reconsideration of that paradigm, which, perhaps to a large part, underlies the thinking that leads to “pushing PO” and orders to PO on CPAP and HFNC. Many of our former preterms do learn to feed orally at later ages, once weaned, and from my experience do so with much less stress and much more safely.

The dialogue needs to continue and we need measures of oral feeding that go beyond intake, and methods of assessment that actually capture critical variables, including objective assessment of physiology.

I hope this is helpful.

Problem-Solving with Catherine

Question:
I’ve been seeing a 15-month old female pt. for feeding therapy for almost one year (coming up on annual). She’s diagnosed with microcephaly & pharyngeal dysphagia. She came to me on a 5.0 oz. honey thick soy formula diet after a swallow study revealed aspiration.

She’s always sick (snotty, congested, had CDIFF 2x) and presents with a snorty quality when eating. ENT reports clear, but narrow canals. She’s been cleared by GI, passed thyroid testing, had genetic testing revealing no abnormalities, and PCP not too concerned for her development. Therapy tools & techniques have included facial and oral massage, flavored gloves, Z vibe, Nuk brush, flat maroon spoons, chewy tubes for chewing, trialing different temperatures & flavors, etc. She clears spoon adequately, doesn’t lose food, sits upright in a high chair, and gains weight appropriately.

She’s transitioned from thickened milk–to thickened stage 1 & 2 foods–to non-thickened stage 1 & 2 foods (cleared by Dr and follow up swallow study revealed aspiration on liquids only). And we are stuck here. There were two instances when mom forgot to pack food so she was given stage 3 lasagna bc ironically, that’s all I had at the clinic. She tolerated the chunks and ate the food w/ no problem. She never did this at home for mom or ever again for me. One time, in preparation for her 1st birthday, we tried sneaking tiny pieces of cupcakes in her food. She tolerated this and even ate bites of it without baby food altogether by the end of the session! She never did eat it again. Lately she’s taking 1-2 containers of 4.0 oz. stage 2 baby food during her sessions lasting 30-60 minutes. Once a solid (tiny cereal piece, yogurt meltable, chunks in stage 3 food) of any kind enters her mouth, she’s choking, crying, and trying to get it out. She’s not into the oral motor stuff anymore. She turns her head away, she just wants to eat. Help! Where should I go next with my re-eval as far as testing, other referrals (allergy?) and new goals?

Answer:
Sounds like a complex child. Her microcephaly is likely a clear influence on her skill progression and at least part of the reason for her feeding/swallowing difficulties. As Heidi suggested, her sensory-motor system is likely not going to process information in the typical way, and that may be the underlying reason for her variability in skills and her dysphagia. From the information so far, I don’t know anything about her early history which often helps to sort out what might be going on and why. It helps to now she aspirated but that is so limiting in helping us understand the bigger picture. Sometimes swallow study reports unfortunately only tell us aspiration occurred. If we could understand why the events occurred, what the child’s response was, and what specifically then might improve physiology, it allows our therapy approach to be more directed.

The always getting sick and congestion may sequelae of dysphagia and/or reflux. If there is a delay in swallow initiation, some of the bolus may be inadvertently mis-directed in to the nasopharynx and create the sound you hear. She may have more chronic congestion because refluxed material is entering the hypopharynx, some of it is being swallowed down but some “hangs up” along the

pharyngeal or nasopharyngeal wall.
Sounds like you have utilized many of the typical therapy tools to enhance function and she’s made progress. Her inconsistent ability to manage texture change may indeed be sensory-motor and/or trouble preparing and managing (i.e., fully chewing, reforming a bolus and effectively swallowing the bolus. Again, not knowing the etiology for and timing of for the current liquid aspiration reported, that remains a missing piece of our problem-solving puzzle that might help us better understand her challenges with her solid diet as well. Sometimes children with microcephaly may have diminished sensory registration throughout the entire oral-pharyngeal system that can at any moment alter processing of information along the swallow pathway. This places her at risk of mis-interpreting sensory data as she east/drinks, so she will bear watchful, vigilance during meals to monitor rate of eating and bolus size. The food chaining Heidi referenced might indeed be helpful and you can incorporate continued work on further improving oral-motor integrity as you go along. Given her microcephaly, the quality of her oral-motor skills may be a continued issue, although they may be functional. The clarity and variety of her spontaneous speech/sounds and her imitative skills may provide some indirect insights for you.

Perhaps you can talk with the therapist who did the study to find out more about physiology and have her suggest next steps, since she has seen the child clinically. I would also find out more about the reported liquid aspiration, so you know what you can be working on to enhance her liquid swallows, with the goal of eventually not needing thickening as safety permits. While we may need to thicken liquids for some children when there are no alternatives, our goal as you know id to work on the underlying components of the swallow that will support safe tolerance of less thickened and hopefully eventually unthickened liquids. Also is she in OT and PT? She may benefit from sensory integration and sensory motor treatment that may actually further support your progress with her.

I hope this is helpful. You are asking such good questions and she is making progress. Keep up the good work!

Problem-Solving with Catherine

Question: I work in EI, in a primary-service provider, parent-coaching model doing home visits, and am considering taking courses to get an Infant/Toddler Mental Health certificate. Since strong relationships really provide the foundation for so many early communication foundations, I think this would be a beneficial area in which to learn more, but would love some feedback/input from other SLPs in the EI world.

Answer: I agree that the parent-infant relationship is best used to guide and inform our SLP practice, whether it’s supporting early communication in EI, or indeed in the NICU, while supporting the early communication that takes place first through the feeding relationship. Feeding isn’t a task of course, it is, when it is at its best, relationship-based.

As an NICU SLP, this is the heart of my daily practice as I empower parents to understand their infant’s communication during feeding, and let the infant guide them in providing a positive safe feeding experience. I call this “infant-guided” feeding. It fits so well with the concept of infant mental health, I thought I would share it with you.

Interaction between infant and parent is the mechanism through which the infant’s development ultimately occurs. Feeding is not solely a task of nutritional intake, but also has many social correlates in infancy and throughout the lifespan. Interaction during infant feeding aids the development of social interaction, communication and being responsive to others among both parents and the infant. Parents of healthy term infants regulate the environment and any stressful events for the infant through bonding and attachment. This “dance of attachment” between parents and the infant creates a blueprint for the infant’s future well-being, including brain development, nervous system regulation, ability to manage stress and sense of security. In the NICU, however, parents may experience the loss of their own homeostasis due to the stress of having a preterm infant. Parental anxiety, depression, and the sense of a loss of autonomy are common. The dissonance between the parents’ expectations and the reality of parenting an infant born early is often particularly stressful. Parents may perceive themselves as outsiders in the NICU and there may be difficulties for parents in developing relationships with their infant and staff. Therefore, empowering parents in the NICU is very important.

Research has shown that the ability to feed well is closely related to the caregiver’s ability to understand and sensitively respond to the infant’s physiology and behavioral communication. Depending on the perspective of the professional caregiver, however, feeding may be viewed as either supporting the infant in a positive learning opportunity or as emptying the bottle. Infant cues of stress may not be recognized by professional caregivers who remain focused on “getting it in” the infant. They may feed past the infant’s communicative “stop signs” in an effort to assure volume is ingested, using well-intentioned strategies that actually result in stress for the infant and often, incoordination. These volume-driven strategies, may include: increasing the flow rate to empty the bottle, which can cause the infant to “fight the flow” to breathe; prodding the infant, which takes away the infant’s active sensory-motor control over feeding, and delivers unanticipated flow into the infant’s oral cavity and/or pharynx; putting the infant’s head back to use gravity to help empty the bottle, which increases risk for bolus misdirection and airway compromise; unswaddling the infant to “keep him awake”, which actually takes away critical postural support for the swallowing mechanism. The infant may be expected to continue feeding, despite subtle signs of physiologic instability, behaviors that suggest swallowing and breathing are starting to uncouple, for example: drooling, gulping, nasal flaring and blanching, the lack of a regular series of deep breaths, chin tugging, and changes in eye gaze pattern. Communicative signs of disengagement may not be given meaning. These signs may include pushing the nipple out, pulling off the nipple, no active rooting or sucking, arching, shutting down/inability to re-alert, or purposeful use of a weak suck on the infant’s part to signal a preference for return to only pacifier sucking. If the role model provided for parents is volume-driven, parents may see their role as emptying the bottle or “getting it in” the infant. They may not correlate feeding behaviors with co-occurring physiologic instability, may not identify adverse events as problematic, and may not recognize and respond to infant “stop signs” during feeding. They may learn to view feeding a something they do “to their infant” not “with their infant “. Reducing stress for the infant promotes neuroprotection and reducing stress empowers the parents.

Parents observe and learn they can communicate back and forth with their infant during feeding, and that this conversation allows their infant to guide them. This co-regulated approach to feeding recognizes the impact of the caregiver on the infant’s experience of feeding and views the infant as a co-regulatory partner with his own agenda and emerging feeding skills. This co-regulation between parent and preterm becomes the foundation for strong parent-infant attachment and is formed most often during feeding experiences in the NICU. When the unique behavior of an infant is understood as a communicative attempt, and parents know how to respond to it effectively, feeding is both more successful and less stressful, and the attachment relationship tends to strengthen, while parental anxiety tends to diminish. Infant-guided feeding early on is the foundation for a strong parent-child-relationship that supports long-term positive outcomes a cross so many domains.

I hope this is helpful to embracing infant-guided feeding as a critical component of infant mental health. As you are able to incorporate this perspective into your work, both infants and caregivers benefit.

Catherine
Catherine S. Shaker, MS/CCC-SLP, BCS-S
http://www.Shaker4SwallowingandFeeding.com

Problem-Solving with Catherine…

QUESTION:
My niece, on 2/4/16, birthed by c-section a 5#1oz boy with perfect latch and sucking but is labeled a preemie as his due date was 3/7
My grandson was born 5 weeks pre-term, 5#3oz and had a weak suck and labeled preemie.  Required facilitation for increasing sucking strength and became an efficient breast feeder after a month.
Is a preemie determined by the amount of weeks gestation or maturity at birth?
The new boy is doing everything a newborn does…good latching, sucking, eliminating, etc….
I have worked with some infants and young ones with gtubes, but haven’t thought about this question when a “preemie” has developed and appropriate feeding skills since I have never seen a preemie with good sucking!
Anyone?
Thank you…
ANSWER:
I can see how this might seem confusing to you. One of the babies was 36 weeks gestation, which means he is a late preterm infant. The other was 35 weeks gestation, and he is also considered a late preterm infant.

GA (gestational age) is a way of classifying preterms, and can give us insight into potential risk for developmental challenges and potential for associated medical issues. The lower the GA (infant may be as early as 23 weeks), the more likely for both associated medical co-morbidities and the more likely there will be feeding difficulties. The research profiles this correlation, which is most compelling for those infants born at or under 28 weeks GA.

Your little guys are both late preterms so in a group profiled with less risk overall but none the less, some risk d/t been born, in this case, 4-5 weeks early. Every day in the womb is one more day for intrauterine sensory-motor learning to occur, and so even a week longer inside mom can make an amazing difference in how the infant presents and progresses. In addition, other factors come to bear on the infant’s progression to feeding, including components of mom’s own pregnancy and medical issues during that time, the quality of the new infant’s transition to extrauterine life in the delivery room, whether he was delivered at a hospital that is experienced in delivering preterms, whether he was transported to an NICU after birth or was born at a hospital with its own NICU, for example.

Being even “only” 4-5 weeks early of course affects messaging from the brain to the muscles, timeliness of airway opening/closing, and also integrity of musculoskeletal movement, each to a varying degree for each preterm, as each one is unique in his presentation. For late preterms, there is an increased risk for hypoglycemia and hyperbilirubinemia, increased WOB, and intermittent tachypnea.  Each of these can affect drive to feed and coordination of breathing with swallowing, and the drive to suck (i.e., because breathing takes precedence). Sometimes reduced drive to feed (d/t respiratory issues common to late preterms) can be mistakenly perceived as poor sucking, when most topically the suck is fine and the infant is choosing to suck less (or less strongly) so he can focus on breathing.

In addition, there is also the influence of the hospital staff on the infant’s feeding environment, i.e., is the hospital staff volume-driven or infant-guided in their feeding approach? That “approach” is the lens through which the staff then interprets, or misinterprets, infant feeding behavior to families, and then in turn teaches families how to feed their infant,  either in a volume driven way (“he has a poor suck, give him help to suck”) or “he has less drive (due to perhaps hyperbilirubernemia and hypoglycemia and/or just being early) and has increased breathing effort, so we need to re-alert him, rest him intermittently during feeding, offer co-regulated pacing based on his communication and slow the flow rate so he does not fight the flow to breathe.” So the quality of the feeding experience is a part of the picture too.

So many factors go into the feeding experience for each preterm infant. I hope this helps make sense of the multiple reasons for the apparent variability you report. Glad to hear they are both doing well now.

Shaker Seminars Finalized for 2016!

February is already flying! Hard to believe that in a little over three months will be back on the road again. This time away to refresh, relax and refocus is a blessing that I always look forward to. I’ll be traveling coast to coast in 2016 and I hope our paths cross this year. Maybe I will see you at NANT in April and watch for my webinar for Dr. Browns’ coming in March. After that, I’ll see you in Chicago, Atlanta, New York City, Denver, San Jose and San Antonio!

So many of you have asked……and here it is!

You can now download my finalized 2016 brochure! Go to the Brochure TAB on my website.
Registration is open and on-site locations are posted under the Lodging/Directions TAB.

BTW, are there other seminar topics you would like me to consider for 2017? Send an email to pediatricseminars@gmail.com.

See you down the road!

Catherine

Problem-Solving with Catherine

I recently received an email with questions from an experienced SLP posed by the neonatologists at her large level IV NICU regarding swallow studies. There are of course no black and white answers, and the evidence-base is lacking, we know, but thought I’d share my comments/perspectives.

Her questions follow. My responses are in italics:

” A lot of concern has come to light regarding how we perform MBSS.  The physicians feel it is not a fair assessment given altered positioning, transport to the fluoroscopy suite which may negatively impact regulation and physiology of these infants, and strategies used.  The swallow study is only a moment in time and looks at physiology not just aspiration (or bolus mis-direction), so, given that, the data we can extrapolate during an instrumental assessment may be more useful, than they realize, to help complete a differential and develop a plan of care. 

Would you mind answering the following:

1. Do you always assess in sidelying?  If semi-reclined, do you start that way and transition into sidelying routinely or if you feel this position may change outcomes? If swaddled elevated sidelying is the typical positon the infant is fed in, yes; if not, I would look at typical position, and then determine if objectifying sidelying as a helpful intervention is indeed justified by the added exposure, based on physiology observed, co-morbidities and interventions trialed.

  2. Do you feed for a certain time frame or percentage of the volume that infant consumes bedside, prior to the study To build in a fatigue factor, I would observe briefly under fluoroscopy at the start of feeding and then feed off line with periodic imaging as indicated for that infant’s differential and based on what is typical for him. That way we see physiology at the start and then intermittently to objectify impact of fatigue on physiology over time.

3. Are there parameters for duration between studies if you note significant clinical improvements during bedside feeds? I typically image as infrequently as possible. If we are not chasing the ‘aspiration” event but rather assessing physiology in radiology, my sense is we then focus on and ask ourselves what component(s) of the etiology (or etiologies) observed on the previous study may have changed in the interim. And if the etiology or etiologies have not resolved, why radiate the infant again with little potential for change in physiology? Too many MDs want us to keep repeating studies to “look for aspiration” and therefore if we “just do one more study” maybe we won’t capture aspiration, right? And then we don’t “capture aspiration” in that moment, and someone concludes incorrectly, therefore, that the infant “passes”, is “safe to feed”, is “cleared to eat”?? That is the thinking I believe that incorrectly follows when the procedure is inadvertently presented as such or viewed as such. That is not the best use of the procedure nor in the infant’s best interest when we look at the “cost ” long-term of added radiation (which we know the AAP is quiet concerned about, especially with infants). The type of “revised” thinking that I am advocating for is often out of the box for many of our neonatologists, but I find that once we have this level of critical reflective thinking and dialogue with neonatologists, then they better understand the role of physiology (normal versus altered versus impaired) and the judicious use of video fluoroscopic swallowing studies in the NICU. They too can learn to look beyond aspiration if we guide them. But it starts with us and these conversations. The dynamic nature of swallowing in the context of the infant’s co-morbidities must always ground us and guide our clinical reasoning.

I hope this is helpful to my NICU colleagues!

Catherine

http://www.Shaker4SwallowingandFeeding.com

Happy Holidays…

I am pleased to post my 2016 brochure that many of you have been asking for. My teaching will take me across the US and hopefully close to where you live. Only one location is still in the works, which is California in September 2016. A few details pending, which I hope will be sorted out very soon. Do you work in California and think your facility might be a back-up option? If so, thanks for emailing me.

As 2015 draws to a close, I count my many blessings, including the opportunity to share my passion for swallowing and feeding with you and your colleagues.
Through teaching, my website, list serve contributions and the thought-provoking emails we exchange regarding challenging patients and the evidence-base, I hope I have inspired you and your passion. May the New Year be especially good to each of you, and I hope our paths cross in 2016.

Merry Christmas and happy holidays!
Catherine