Evaluating Infant Feeding Difficulties: The Role of FEES & VFSS

[Dr. Gopi Shah]
That's great. Just to set the clinical stage, how do infants with feeding difficulties usually present to you in the hospital? You can, if you want, divide it by, the NICU babies usually present this way because they're so different from the CVICU babies. Then, of course, the PICU babies.

[Olivia Brooks SLP]
They are very different, and it depends on where they're at from a developmental stage as well. Our very young premature babies, 32-33 weeks, they're just having those emerging skills and feeding cues. We're working on strengthening their oral motor functions and providing good positive experiences for them with feeding. A lot of my work revolves around positioning them for feeding well and handling flow rates and helping moms breastfeed. They're typically a little bit slower to feed. They might take a little bit longer. We have a level four NICU, so we see very sick infants as well, babies with tracheostomies, babies that have had prolonged NPO because they've had to be on high levels of respiratory support or they've had GI infections and intolerance. From an ENT perspective, we have your typical noisy breathers. A lot of premature babies sort of have that elongated face. They'll have high, narrow palates. They can be born with all sorts of congenital anomalies as well. We see choanal atresia, pretty severe laryngomalacia from time to time will come up. If they've been intubated, we will see intubation injuries, airway edema, things like that.

For the cardiac ICU, those babies are different. Usually, they're term, so they're not premature, not always, but a lot of times they are. They're recovering from open-heart surgery. What we are most concerned about and what started the whole FEES discussion at our hospital was the protocols that we had around managing those patients, particularly those with aortic arch involvement because of the risk to the recurrent laryngeal nerve there and how we were managing those patients. Those patients will fatigue quickly. They'll have cyanosis. They'll need more time to feed. They might need a lot of support to feed efficiently and safely. They'll also have a lot of comorbidities, too, and respiratory insufficiency, so we work with them a lot. On our PICU, it's a lot of trauma patients or, older patients as well we'll see there, too. That's a little bit of a different beast. That's the gist, I think, for them.

[Dr. Gopi Shah]
When you're getting a call for a consult for one of the kids in the NICU, do you have, in your mind, the same sort of H&P? What kinds of questions do you always ask, whether it's the parent or the bedside nurse? Especially in the NICU, we get a lot of our history from the inpatient nursing team. What are you always asking?

[Olivia Brooks SLP]
I don't know if this is maybe always the best way to do it, but I come at it with a very sort of aerodigestive framework in my mind as I'm going through. I like to get a very clear picture of how each subsystem is working first. I like to start from the top and work my way down. The first thing I do is I go in and I look at the baby. I think that's one of the most important things, honestly, we can do. I want to really lay eyes on that child and look at their tone, look at their state regulation, and listen for things like high-pitched cry. Are they just going from screaming and inconsolable to a deep sleep with no sort of time in between? That's going to tell me a lot about what's happening with their neurofunction.

Then, I'll just work my way down. I'm listening to their breathing sounds. I'm watching their respiratory rate. We're looking for signs of GI difficulties. Are they very grunty, bearing down? They just seem really uncomfortable. They have a lot of flatulence. They're burping everywhere. Trying to tease apart, there's a reason that the physician has consulted me. There's some system that's going awry or could be a multiple set of systems. I like to ask questions around that. Nurses are a great resource because they spend so much time feeding with and working with the babies. They often have them for multiple days in a row. I'll talk to them: how is this baby managing transitions, hands-on time? Are you noticing any noisy breathing? Do you hear a stridor? Does it get worse when they're feeding? Does their breathing get better when they cry? Are we having a lot of vomiting? How are they tolerating NG feeds? A lot of children have to be fed even post-pyloric. Getting a good picture of all of that, I think is really important.

Then another really important piece is the social situation. I want to know how involved parents are, what mom and dad have been able to do. Have they been able to feed their baby? What does that look like? Does mom have certain goals for feeding? Does she want to breastfeed? Does she want a bottle feed? Where we're at with the family situation, what their expectations are. Different levels of care require different expectations, I think, around oral feeding. Has somebody even had a conversation with the straight G2 baby about what the prognosis is for full oral feeds in the next week or two, or however long we think that the child will be with us in the hospital?

I can tend to break it down like that, just to get a good overview of all the aerodigestive systems and try to tease apart where I think the breakdown might be happening. If we need more information through either a FEES or a videofluoroscopy swallow study, then we go from there.

[Dr. Gopi Shah]
I think the point you make about the social situation is so paramount. At least for me, sometimes I don't think I think of it as much as I should, especially when it comes to feeding. I get so fixated on, they've been intubated, and how long were they intubated? Why is there noisy breathing? Yet the parent component, because that's who's going to be feeding the baby and sort of expectations. I think that's such an important point you bring up, Olivia.

[Olivia Brooks SLP]
I'll just add as a therapist, I think we are a little bit better equipped to do that sometimes than the surgeons. We're doing therapy with these patients as well daily. Feeding is a very intimate, dynamic process, and that's not something that I think you as a surgeon, you're always able to capture if you're just coming in and doing an eval, but we really can. We can spend a lot of time. We can spend more time, I think, often than what you might have available, so I encourage you to use your therapist for that.

[Dr. Gopi Shah]
Yes. No, it's huge. It's a huge component of the overall care for the baby and the outcomes. You mentioned looking at the baby, evaluating the breathing and the respiratory rate, grunting, all those things that just by looking. What else is part of your physical exam when you're seeing these babies?

[Olivia Brooks SLP]
I include a full body exam. Again, we do the same thing whenever we're doing the physical exam, starting from head to toe. Some big things I look at are the baby's tone. How are they maintaining their posture in space with gravity? Are they high-tone? Are they very low-tone? Looking for things like torticollis, plagiocephaly. I'll do a full oral mechanism exam and cranial nerve exam to the best that I can. Really evaluating the palate and the gums and the way the tongue is moving. Is it able to lateralize? Does the baby root and gape? Are all those oral reflexes intact? Look down, look for any retractions, move down to the chest. This is, I think, really important, particularly for feeding. Our chest wall development, it's impacted greatly, especially with our premature babies and our cardiac infants who've had their chest open. We look for things like pectus. Because they're laying in bed for prolonged periods of time, they don't get a lot of time sitting up, which a typical baby would, where that helps to pull the ribcage and the lungs a little bit more downward. Even for older infants that have had a prolonged stay, they'll have things like shortened looking rib cages, retractions, and diaphragms.

Oftentimes with our cardiac infants or our infants in the NICU, if they've had gastric surgeries at all, that does happen quite frequently, or they've had chest tubes, or they've had pacer wires, and they've had an incision, I like to look at all that scarring because you can have a lot of banding down and tightness. The scar tissue will just get really adhered to the stomach and the diaphragm, and that can affect the way that they're laying and breathing. I want to make sure if I see anything like that, I'm prepared to do some massage and work some of it out, but also make sure that we have some PT and OT working with these babies.

Move down to the hips, see how our hips are working and moving, because if that's all out of alignment, that really affects their feeding efficiency as well. Then even down to the legs, what is their tone looking like? How is that helping maintain posture for feeding? Just start at the top and really work my way down.

[Olivia Brooks]
Well, I could talk about it forever. I won't though. I think that for the longest time, VFSS was the gold standard, and we still consider that to be the gold standard. Now with FEES becoming more and more popular, there are many people who also think of that as the gold standard. We have two very separate and distinct exams that give us distinct information. I'm actually stealing this from my dysphagia professor, but the platinum standard would be to have access to both, and different babies will do better and participate better for one versus the other.

Age is a big factor. I think FEES works great for young infants who have that reflexive suckle intact and are food-motivated. We can get them hungry. We can take advantage of that suckle reflex and that usually works very, very well. Once they get about five, six, seven, eight months of age, it becomes much harder unless they're very food-motivated because they start to have very big opinions about you having a scope in their nose and eating at the same time. Two, three-year-old children, even worse, I rarely do a FEES in that age unless, again, we have just a very food-motivated, very compliant child, which does happen occasionally. For those children, I tend to lean more towards the videofluoroscopy swallow study because I can make that a little bit less scary, I think.

Otherwise, for our critically ill patients, the FEES is a great option because we don't have to transport them. We're not exposing them to unnecessary radiation. Some children need both. It depends on what I'm seeing clinically that will have me lean towards one side or the other.

On our cardiac ICU, we have a protocol in place that says that after the aortic arch procedures or any infant that had a sternotomy, six weeks of age, those children, they must have some sort of instrumental assessment of swallowing. This is coming from our cardiothoracic surgeons, so that's something that they feel very strongly about. That team, in that unit, really prefers the FEES because taking those patients down to fluoro is, as you can imagine, quite the endeavor. They like to get the airway evaluation at the same time because of the risk of vocal fold impairment. Also, it's very easy because we're feeding the babies in our arms. We can try a lot of positional strategies that we might not have as easy access to down in fluoro. For instance, if we have a left vocal fold paralysis, we would try to feed that baby lying on the right side to see if that helps. With airway protection, we can feed them whatever they're typically eating so we're not having to give them a barium contrast. The team really likes that and they really prefer that. Sometimes though I will have a baby that I'll say, this child has got some aversive behaviors going on. I don't think a FEES is going to work. I would like to go straight to just fluoro and then have the ENTs come and do an airway evaluation if they need that. Sometimes that will still happen. That was our original protocol. Typically on the cardiac ICU, we aim to do a FEES first per the cardiothoracic surgeon's mandate there.

Otherwise, like if I'm in the NICU, it's really what I am seeing. If I am concerned about airway issues and I want to see that as well as the swallow function, then I will attempt the FEES. If I have a baby that from a respiratory reserve perspective, I don't think they'll do well with me including air by using the scope, then we'll opt for the video swallow study. If I'm more worried about esophageal issues and I want to do an esophageal screen, obviously I need fluoro to do that. Some of our patients with strokes, HIE, I need to see what's going on in the mouth with the tongue and how that's moving, then videofluoroscopy is probably a better option for that. It depends on what I want to see, what the skills of the baby are, what the parents' wishes are, and the team as well, what questions they have that maybe I can help answer as well with whatever study I choose to do. Does that answer the question?

[Dr. Gopi Shah]
Yes, it does. I think the way you explained it's super helpful because I think the FEES versus video swallow is always something that I always have to take a second and think about what information, what's the question and what am I looking for? Then, I have to think about what's actually happening in both of the tests to then help me decide what's helpful. I like the points that you make about being able to do an evaluation bedside and not having to transport a baby with the FEES, being able to try different positions bedside.

I wanted to talk to you a little bit more about the inpatient, bedside FEES. You said that this all started with the cardiac babies. Initially, those babies would get a video swallow, an ENT would come and do a scope bedside to look at vocal cord function to the main question. Then, tell me sort of the evolution of, wait a second, why are we sending these babies down to fluoro, can we do this whole bedside?

[Olivia Brooks SLP]
It started with me, I think, getting a little frustrated with that protocol from time to time. As soon as the patient was extubated, that morning, they would be extubated at 9:00 AM and at 9:02, ENT had consented, yes, and poor ENT was running up from the OR to try to scope the patients. They're freshly extubated, probably on BiPAP or something, and the cardiothoracic surgeons are just ready to go at that point. As soon as ENT's evaluation was done, we would have so many conversations around what the findings were.

[Dr. Gopi Shah]
I'm glad you say that because they're never that clear that early on, right?

[Olivia Brooks SLP]
Exactly.

[Dr. Gopi Shah]
There's like, "Oh, can't get the best view? Maybe it's weak."

[Olivia Brooks SLP]
There's so much edema, yes. Then, they would say, if there's a cord out, the cardiothoracic team would really start to then push me off a little bit and say, "Well, we want to see if the vocal fold is going to get better or, you can do like little bits, PO, but let's hold off on the swallow study." Or the opposite would happen, they would say, "Oh, well, the cords are compensating, everything looks good, so you have to do the swallow study like now, today." We just started having these evolving conversations and I tried to make the case that just because a vocal fold is out, that's not a functional swallow assessment. What they need is that: they need a functional swallow assessment and that gives me some good information of some things that I can try when I'm doing my swallow assessment, but I didn't like being told that the baby couldn't eat because of that and vice versa, that the baby could eat because the vocal fold was moving because a lot of those patients without vocal fold paralysis still aspirate. There's a multitude of reasons why that would happen.

It evolved from there. I was feeling frustrated. I don't know if ENT was feeling frustrated, but I think that they might have been because they're having to come up from the OR and I wanted to do this. I had this thought, I said, "I think I can do FEES on these patients and we can maybe set them up for a little bit more success." My hope was that we got better information at a more appropriate time that would help the babies not be rushed to a G-tube or have to have multiple video swallow studies and be exposed to multiple bouts of radiation and have to come up the unit and it's a big thing.

I went to my manager at the time, Dr. Carrie Linnaeus, who's extremely supportive and she sent me to Baylor. They have a neonatal FEES course there with Jenny Reynolds, who's awesome. I did that training and then I came back and I just asked ENT, I said, "Listen, can I practice with you guys?" Because there was nobody at our institution, we have separate competencies for peds and adults. Even though I was competent to scope adults, I was not competent, technically, to scope the infants. I wasn't even sure if it was something that they would tolerate because obviously, the scope would have to be in there a little bit longer. We would have to have them up out of bed, all of these things. I was very, very fortunate that I was supported by my ENT colleagues and they allowed me to tag along and they taught me how to scope the patients. I started off just helping them with their bedside evals that they would get on the cardiac ICU. They would allow me to tag along. The MD was present, she would teach me and I would just do the scoping part. My management was very supportive of that too, because technically that's not something I can bill for because I wasn't doing a functional swallow. I was just practicing, after I had gone to Baylor and practiced there and all of that. I got pretty good at it and we had a set plan that I was going to do so many with them. I kept a rudimentary tally on my post-it note and every time I would go with them, I would just do it. I'm sure there's better ways to do that. Then once I got to our number that we said that they wanted me to do with them, I sent a message to Dr. Bill Collins, who I think has been on your podcast.