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[Dysphagia] Infant question
I agree that a swallow study is critical for this infant. Her "weaker"
nutritive suck (compared to non-nutritive suck) may indeed be a
purposeful response in an attempt to protect her airway. In addition to
her increase in RR, she may also be demonstrating an overall increase in
"work of breathing"; this would be another "reason" for her to attempt
to limit how much fluid she sucks per sucking burst. The added
intervention of imposing brief breaks from sucking, based on physiologic
and swallowing behaviors, would also be important, both at the bedside
and to observe in radiology. This often can make a significant
difference in suck-swallow-breathe coordination and safety.
Regarding the neo, it may be helpful to share the limited data we have
about silent aspiration in the pediatric population in general. The
literature suggests that silent aspiration is common in children with
dysphagia, with estimates ranging from 70-97% depending upon the age and
the underlying etiology of the dysphagia (Arvedson, Rogers, Buck, Smart
& Msall, 1994; Lefton-Greif et al, 2000; Newman et al, 2001; Sheikh et
al, 2001). I have worked in our Level III NICU for over 21 years, 800
admissions/yr, 1/3 of those under 26 weeks GA. I find that a high
percentage of our NICU babies who have a swallow study do aspirate, and
do so silently. Also perhaps explore with the neo his/her reluctance and
attempt to dialogue. The discussion may aid in his/her understanding for
future swallow study requests.
Catherine
Catherine S. Shaker M.S./CCC-SLP, BRS-S
Manager - NICU/Pediatric Rehabilitation
Wheaton Franciscan Healthcare - St. Joseph
5000 West Chambers Street
Milwaukee, WI 53210
414-447-2797 Phone
414-874-4104 Fax
Catherine.Shaker at wfhc.org
-----Original Message-----
From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com] On
Behalf Of Dailey, Scott
Sent: Friday, December 22, 2006 6:19 AM
To: Susan O'Neill; Dysphagia at b9.com
Subject: Re: [Dysphagia] Infant question
I agree that this infant needs a swallow study. I have seen many, many
infants who stop feeding (gagging, letting it run out of their mouths)
after taking small amounts who are silently aspirating. The cough
reflex is not well developed in an infant so silent aspiration is very
possible. My other thoughts are that this infant was IUGR and most
likely still small and feeding may be taking alot of her energy with not
a lot of reserve built up(fat reserves). My final suggestion, is that
you ask the docs/nurses if a trial of Oxygen via blow by or nasal
cannula can be tried during a couple of feedings to see if that helps
with coordination. We have been surprised by some of our babies when we
try a little oxygen during feedings. Some of our neonatalogists are
reluctant to try it. My rationale is usually that it will be a
temporary thing until we get feeding improved and then wean it.
Scott Dailey, MA, CCC-SLP
Speech-Language Pathologist
University of Iowa Hospitals and Clinics.
________________________________
From: dysphagia-bounces at b9.com on behalf of Susan O'Neill
Sent: Thu 12/14/2006 7:30 PM
To: Dysphagia at b9.com
Subject: [Dysphagia] Infant question
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
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