[Date Prev][Date Next]
[Dysphagia] thickening breast milk
- Subject: [Dysphagia] thickening breast milk
- From: SuzMorris at aol.com (SuzMorris@aol.com)
- Date: Thu Jul 8 21:13:50 2004
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??
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.
1124 Roberts Mountain Rd.
Faber, VA 22938
(434) 361-2285 ext. 5