[Dysphagia] thickening breast milk

[SuzMorris at aol.com (SuzMorris@aol.com)]

In a message dated 7/8/04 12:42:29 PM, MICHAEL@email.chop.edu writes:
> 
> <<The question at hand is... in situations (albeit rare) where thickening 
breast milk IS necessary given the situation (and assuming all other issues HAVE 
been addressed adequately).. WHAT is suggested to be used??

Anybody? anybody?>>


What a feast for thought this discussion is!   I'd like to join Staci in the 
highly practical question.   What if we really do need to use a thickener for 
children under 12 months of age?   There is definitely a diagnostic and 
therapy progression that needs to be followed much more rigorously by professionals. 
  This includes the diagnostic questions related to causation of the 
aspiration or reflux, frequency of occurrence, amount aspirated,and the child's 
overall health.   We need to be particularly aware of vulnerabilities in the immune, 
gastrointestinal and respiratory systems.    These factors are critical in 
deciding an initial direction (which we will fine-tune) for each infant.    

One factor that has not been mentioned in this discussion is the preference 
of the infant.   Many parents will tell you that their baby did not begin to 
suck and swallow enough formula or breast milk to thrive until thickening was 
added.   In a sense, the infant is telling us that he/she is more comfortable or 
able to sustain a suck-swallow-breathe pattern more efficiently.   Thickening 
can contribute to better coordination of sucking because it is heavier and 
gives more sensory input, and the fluid moves more slowly.    Some infants who 
aspirate on thin liquids probably do so because the liquid rapidly moves out of 
control during the oral phase.   When there is more input and a more slowly 
moving fluid, coordination often is improved and the risk of aspiration is 
greatly reduced or eliminated.    Babies also seem to vary a great deal in their 
comfort level and acceptance of aspiration during the swallow.   With silent 
aspiration some infants will act as though there is no problem at all and will 
continue to take the bottle or breast;   others drink enough to take the edge 
off of their hunger and then refuse to take more because they are 
uncomfortable.   When there is laryngeal penetration accompanied by coughing and choking 
(with or without aspiration) many infants will refuse to eat.   Thickening the 
liquid to a level that reduces aspiration or choking can result in more 
vigorous oral feeding as well as more comfortable bonding between the parent and 
infant during feeding.

So in my mind we have an extremely practical question that asks us to choose 
the least invasive or least risky alternative for the baby.    The first 
choice will always a noninvasive choice such as exploration of positioning, pacing 
of the feeding, varying feeding equipment and other alternatives that do not 
involve adding anything to the formula.   

But when these alternatives are not effective, especially if the baby is not 
taking in enough formula or is vomiting up most of what is consumed, the 
choice is often between continuing oral feeding and tube feeding.   There are 
definitely situations where a gastrostomy/tube feeding is the best choice. But 
there are indeed children who with a simple modification of judicious thickening, 
can maintain oral feeding with appropriate nutrition and calories. 

Using cereal to thicken feedings for infants under 6 months of age certainly 
does not acknowledge what we know about gastrointestinal immaturity with a 
resulting risk of increased allergies when infants are given foods other than 
breast milk or formula before 4-6 months.   This may be a very high risk 
situation for some children, but minimal for others.    Probably the majority of 
people on this listserv were given cereals and pureed foods during their first 2 
months. [I did a longitudinal filmed study of 6 typically developing infants 
between 1974-77.   The 4 bottle-fed infants were all given rice cereal by 1 month 
and the pediatrician of one infant recommended rice cereal at 10 days of age 
to help her sleep through the night!   The 2 breast fed infants were given 
rice cereal at 3 and 5 months.]   Certainly rice cereal for most infants doesn't 
offer as high a risk factor as a feeding tube or some medications.

In asking what specific thickener choices we make, it is highly situational 
for the infant and family.    The benefits of breast milk far outweigh the 
benefit of shifting to formula in order to thicken with rice cereal.   Since rice 
cereal won't thicken breast milk, we may need to consider a different 
thickener. . . even a commercial thickener.    With infants older than 4-6 months, I 
have used many pureed fruits or a sweeter vegetable such as sweet potato or 
carrot to thicken the formula.   

Babies can change very quickly when an appropriate treatment strategy 
(positioning, pacing, equipment or thickener) is used.   Once an infant is given a 
thickened formula, therapists rarely incorporate the additional treatment 
strategy to gradually reduce the amount of thickening in order to give the baby 
opportunities to develop and use a more efficient suckle-swallow pattern.   It is 
so important to educate therapists in the concept that treatment of an infant 
with a feeding issue is a process?not just a set of isolated steps.   So often 
therapists (and parents) look just at the destination and forget the 
importance of the journey.    So if aspiration or vomiting is reduced by thickening 
this becomes the destination.   The process leading toward happier, more 
comfortable and more efficient feeding is often forgotten.

It would be nice if there were simple answers and comforting if we could say 
that thickening formula isn't healthy or effective for infants and children 
and therefore should not be used when there are feeding and swallowing problems. 
  But there are kids who swallow better and want to eat more when taking 
thicker liquids or thicker foods.   If that is the case and overall nutrition and 
hydration needs are well managed, then using a thickener may be the least 
invasive and least risky procedure we can choose.   The error, in my mind, is 
seeing thickeners as the final solution.   They are simply a way-station that can 
maintain oral feeding for some children while therapy addresses and reduces 
the sensorimotor coordination problems that contributed to the initial 
aspiration or reduced oral intake problem.


Suzanne Evans Morris, Ph.D.
New Visions
1124 Roberts Mountain Rd.
Faber, VA 22938
(434) 361-2285 ext. 5
www.new-vis.com