[Dysphagia] thickening breast milk

[MICHAEL at email.chop.edu (Staci Michael)]

Thank You Suzanne! - I highly doubt that I am the only one who finds that =
in certain occasions thickening may be necessary, and I like the comment =
you made reminding us that thickening is not the end solution, but rather =
a tool towards the end solution which would be "normal" (aka unthickened) =
feedings.  I also appreciate the other comments from everyone inspiring me =
to really look at a case and double check that I have tried everything... =
we all need to do this more often.  So let's switch here and suppose that =
I do not have a specific case to be picked apart, but just a general =
issue, which is what we should be use that is safest, nutritionally sound, =
etc.  I really think as a field we need to reach consensus here!

To review:  for babies under 6 months of age our options are:  rice =
cereal, oatmeal cereal?, commercial thickeners such as Thick It, gel based =
thickeners such as Simply Thick... and for non breast milk babies Enfamil =
AR... so far I am getting feedback regarding not using gel based due to =
possible NEC, but am getting feedback from plenty of therapists currently =
using this.  Can we get some literature here?  Commercial thickeners/corn =
starch based thickeners are typically avoided due to allergies... that =
leaves rice cereal which has its own set of issues, again digestion, =
nipple clogging etc.  and the fact that I have yet to see it actually =
thicken breast milk for any significant period of time. =20

Anyone else seeing my quandry?  Can we somehow gather some literature, =
review pros and cons and come up with what we would feel most appropriate =
for thickening breast milk when necessary?  Because the bottom line is =
that these babies are out there and I have received enough feedback to =
know I am not the only one facing this issue- and these kiddos don't have =
time to wait for us to argue semantics- they are hungry!!! :)

>>> <SuzMorris@aol.com> 07/08/04 11:13PM >>>
In a message dated 7/8/04 12:42:29 PM, MICHAEL@email.chop.edu writes:
>=20
> <<The question at hand is... in situations (albeit rare) where thickening=
=20
breast milk IS necessary given the situation (and assuming all other =
issues HAVE=20
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=20
highly practical question.   What if we really do need to use a thickener =
for=20
children under 12 months of age?   There is definitely a diagnostic and=20
therapy progression that needs to be followed much more rigorously by =
professionals.=20
  This includes the diagnostic questions related to causation of the=20
aspiration or reflux, frequency of occurrence, amount aspirated,and the =
child's=20
overall health.   We need to be particularly aware of vulnerabilities in =
the immune,=20
gastrointestinal and respiratory systems.    These factors are critical =
in=20
deciding an initial direction (which we will fine-tune) for each infant.   =
=20

One factor that has not been mentioned in this discussion is the preference=
=20
of the infant.   Many parents will tell you that their baby did not begin =
to=20
suck and swallow enough formula or breast milk to thrive until thickening =
was=20
added.   In a sense, the infant is telling us that he/she is more =
comfortable or=20
able to sustain a suck-swallow-breathe pattern more efficiently.   =
Thickening=20
can contribute to better coordination of sucking because it is heavier =
and=20
gives more sensory input, and the fluid moves more slowly.    Some infants =
who=20
aspirate on thin liquids probably do so because the liquid rapidly moves =
out of=20
control during the oral phase.   When there is more input and a more =
slowly=20
moving fluid, coordination often is improved and the risk of aspiration =
is=20
greatly reduced or eliminated.    Babies also seem to vary a great deal in =
their=20
comfort level and acceptance of aspiration during the swallow.   With =
silent=20
aspiration some infants will act as though there is no problem at all and =
will=20
continue to take the bottle or breast;   others drink enough to take the =
edge=20
off of their hunger and then refuse to take more because they are=20
uncomfortable.   When there is laryngeal penetration accompanied by =
coughing and choking=20
(with or without aspiration) many infants will refuse to eat.   Thickening =
the=20
liquid to a level that reduces aspiration or choking can result in more=20
vigorous oral feeding as well as more comfortable bonding between the =
parent and=20
infant during feeding.

So in my mind we have an extremely practical question that asks us to =
choose=20
the least invasive or least risky alternative for the baby.    The =
first=20
choice will always a noninvasive choice such as exploration of positioning,=
 pacing=20
of the feeding, varying feeding equipment and other alternatives that do =
not=20
involve adding anything to the formula.  =20

But when these alternatives are not effective, especially if the baby is =
not=20
taking in enough formula or is vomiting up most of what is consumed, =
the=20
choice is often between continuing oral feeding and tube feeding.   There =
are=20
definitely situations where a gastrostomy/tube feeding is the best choice. =
But=20
there are indeed children who with a simple modification of judicious =
thickening,=20
can maintain oral feeding with appropriate nutrition and calories.=20

Using cereal to thicken feedings for infants under 6 months of age =
certainly=20
does not acknowledge what we know about gastrointestinal immaturity with =
a=20
resulting risk of increased allergies when infants are given foods other =
than=20
breast milk or formula before 4-6 months.   This may be a very high =
risk=20
situation for some children, but minimal for others.    Probably the =
majority of=20
people on this listserv were given cereals and pureed foods during their =
first 2=20
months. [I did a longitudinal filmed study of 6 typically developing =
infants=20
between 1974-77.   The 4 bottle-fed infants were all given rice cereal by =
1 month=20
and the pediatrician of one infant recommended rice cereal at 10 days of =
age=20
to help her sleep through the night!   The 2 breast fed infants were =
given=20
rice cereal at 3 and 5 months.]   Certainly rice cereal for most infants =
doesn't=20
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=
=20
for the infant and family.    The benefits of breast milk far outweigh =
the=20
benefit of shifting to formula in order to thicken with rice cereal.   =
Since rice=20
cereal won't thicken breast milk, we may need to consider a different=20
thickener. . . even a commercial thickener.    With infants older than 4-6 =
months, I=20
have used many pureed fruits or a sweeter vegetable such as sweet potato =
or=20
carrot to thicken the formula.  =20

Babies can change very quickly when an appropriate treatment strategy=20
(positioning, pacing, equipment or thickener) is used.   Once an infant is =
given a=20
thickened formula, therapists rarely incorporate the additional =
treatment=20
strategy to gradually reduce the amount of thickening in order to give the =
baby=20
opportunities to develop and use a more efficient suckle-swallow pattern.  =
 It is=20
so important to educate therapists in the concept that treatment of an =
infant=20
with a feeding issue is a process=96not just a set of isolated steps.   So =
often=20
therapists (and parents) look just at the destination and forget the=20
importance of the journey.    So if aspiration or vomiting is reduced by =
thickening=20
this becomes the destination.   The process leading toward happier, =
more=20
comfortable and more efficient feeding is often forgotten.

It would be nice if there were simple answers and comforting if we could =
say=20
that thickening formula isn't healthy or effective for infants and =
children=20
and therefore should not be used when there are feeding and swallowing =
problems.=20
  But there are kids who swallow better and want to eat more when =
taking=20
thicker liquids or thicker foods.   If that is the case and overall =
nutrition and=20
hydration needs are well managed, then using a thickener may be the =
least=20
invasive and least risky procedure we can choose.   The error, in my mind, =
is=20
seeing thickeners as the final solution.   They are simply a way-station =
that can=20
maintain oral feeding for some children while therapy addresses and =
reduces=20
the sensorimotor coordination problems that contributed to the initial=20
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=20