[Dysphagia] Infant question

[susanslp at swfla.rr.com (Susan O'Neill)]

I would like input from the group on the following case.  I am working with
an infant in the NICU who is now 40 weeks post conception, was born at 36
weeks via C-section to a healthy 19 year old mom. Infant weight at birth was
1490 grams and dx was intrauterine growth disorder.  Apgars were 9, 9.
Infant has been stable on room air.  She has had growth and feeding issues.
Gag, root, suck, transverse tongue reflexes are intact.  Suck on pacifier is
vigorous and coordinated.  When nipple feeding is attempted, suck becomes
weaker is poorly coordinated with swallow & breathe. Infant takes
10-22cc/feeding and the rest is gavaged (goal 40cc of 34 cal formula).
Initally nursing was using a standard similac nipple. I noticed lots of oral
loss, increase in respiratory rate with feeding (from 30's to high 50's),
some coughing and sneezing (rare, but present at least once each feeding),
I tried our slowest flow nipple and it wasn't a whole lot better and intake
was less.  I have switched to Haberman on the slowest flow and we no longer
have oral loss or a signif increase in respiratory rate.  Intake remains
quite low (driving the nurse's nuts.they blame it on the nipple) and
coordination of suck-swallow-breathe still not 1:1:1 by a long shot.  I've
tried pacing the baby to get her to swallow more often, since I feel she is
repressing the swallow, and when she finally does swallow, it is too big.
At present, I have recommended an MBS for more information, but
neonatologist is reluctant.  I am concerned she is aspirating some and this
shuts her down.  Even when her state is great (quiet, alert) she'll quit
after 10-20cc and start to gag/refuse to root when offered the nipple.  I
would like to get your ideas on how else I might proceed or if I should
"stay the course" and hope she starts to get it now that we are sticking to
the Habermann (I have the staff's agreement to stick with one nipple for a
week, as they were changing the nipple every shift and I felt we weren't
giving the poor baby a chance to learn and get used to anything).  The
neonatologist says neurologically baby looks good, but I do think there are
some dysmorphic features with this little peanut.  She is getting a
chromosome workup per my observations, but it is still pending.  Thanks in
advance for your time and advice.  Much appreciated.

 

Susan O'Neill, MS, CCC-SLP

NCH Heathcare System