Infant Feeding Difficulties: Diagnostic & Therapeutic Interventions

[Dr. Gopi Shah]
When you say instrumental, are you saying video swallow FEES, what are we talking about?

[Ashley Brown]
Yes, so we can do either. With breastfeeding babies, FEES is really, if they are strictly breastfeeding, FEES which is flexible endoscopic evaluation of swallowing, is really our go-to option if they are strictly breastfeeding neonate infant, because we cannot observe breastfeeding during a video fluoroscopic swallow study. Just because they breastfeed does not mean that they will immediately go onto a bottle and do a fluoro. We have gotten referrals for strictly breastfeeding babies, they come in for a video fluoroscopic swallow study, and they want nothing to do with the bottle. Fees is a good option for those strictly breastfeeding babies.

When it comes to the video fluoroscopic swallow study, if they are full bottle feeders, and we're really thinking we'll need to change a lot about flow rate, possibly the viscosity, the consistency, thickening the feed, and we'll maybe have to play around a lot. Fluoro sometimes is our good option there, because there's only so long someone will tolerate a scope in their nose. We can observe a full feed with the FEES because we don't have the constraints of radiation, but there is a certain tolerance level there for sure.

[Dr. Gopi Shah]
As the referring physicians, should we be ordering a video swallow before we send them to you? Should they all, like who should get imaging or workup before they're sent to you, and who should it, and what do you want?

[Ashley Brown]
That can be a little tricky, as I'm sure you know, to figure out. Does this baby need to go for a bedside outpatient evaluation, or does this seem urgent enough that we need a swallow study within the next two days? Maybe some of those clues would be if they really are not gaining weight, they are failing to thrive. We're trying to change the language around that, because saying failure to thrive puts the label on the parents that they're failing to do their job, so we're changing the language around that, but that's the most common way people know it right now.

If there is some sort of respiratory history, that maybe they've been to the ED a few times because baby is having apneic moments, or their breathing isn't right, they've turned colors, maybe we need to do an urgent swallow study at that time. If baby is maybe just a little bit messy when they're eating, they have some reflux type signs, frequent spitting up, vomiting after every feed, then maybe we don't need to go straight to fluoro, and maybe need to think about referrals to some of our other colleagues.

[Dr. Gopi Shah]
Let's get into the instrumentals. I guess first, if you could just explain that when you like a video and when do you prefer a FEES, and which ones, I guess, show you what?

[Ashley Brown]
We'll start with FEES, the flexible endoscopic evaluation of swallowing. I've already mentioned that for strictly breastfeeding babies, that is our good option. We do breastfeeding FEES in office. We've done them over in our acute care side, so that is good because we can get baby on breast, we can scope them, watch them swallow while breastfeeding, because breastfeeding is very different than bottle feeding. There have been a study showing that even though they might aspirate during a bottle feed, they don't necessarily aspirate during breastfeeding. Baby has a little more control when they are breastfeeding than bottle feeding.

That's a good option before we start, especially thinking, let's start taking PO away from this baby. I like FEES for our secretion management kids. If we are concerned that maybe this child baby is in PO, but we feel like they're not managing their secretions, FEES is really the only option and is the best option to look at, do they have copious pharyngeal secretions? Are they aspirating these secretions and not initiating a cough response to help clear those secretions? We know and we've seen from studies that have been put out fairly recently how detrimental aspirating secretions is on lung health.

It seems that it is worse than aspirating food and liquid, if you think about how nasty our mouths are, and aspirating those secretions that have mixed with maybe some bacteria in your mouth. I like the FEES for our kids that are in PO. Maybe they only do a few flavor taste, but we really want to expand on what they can do orally. Maybe give them a therapy plan of they can do a few taste of liquid or puree. I feel like those are good FEES options. I also really like, we don't encounter this as much in pediatrics, especially infant. Our head and neck cancer patients that have had a lot of radiation to that area, do we need to expose them more, you know, with a video fluoro?

FEES would be a good option because often those children, infants who-- and we've had had a few infants who have had some head and neck masses that we have had to take care of, you get a better picture of residue with Fees. Is it unilateral? Is it bilateral? How much is it? You get a better idea of how much residue there is. I like FEES for those patients as well, but FEES is also complementary to video fluoro and vice versa. Video fluoro is complementary to FEES. They don't necessarily are meant to be done alone and one is better than the other.

For our video fluoro, which is where most of our kids would fall, like I've mentioned, if we think we're really going to have to play around with flow rate, consistency, video fluoro really gives us a good picture. They did better if I paced them this many times. Also, with video fluoro, you're getting the full oral picture and esophageal. With FEES, you're only seeing that pharyngeal and laryngeal space, so you are missing the oral and esophageal component.

[Dr. Gopi Shah]
Who are the kids that need the neuromuscular stimulation? Is that just your poor tone kids or is there a criteria?

[Ashley Brown]
Yes, so again it's all about function. We need to know what the deficit is before we treat it. What is the pathophysiology of their swallowing deficit? You can't just come in, do NMES without actually knowing what you're targeting and what the deficit is. It gets a bad rap, a bad name. There's not a ton of pediatric research out about it. When we're talking in terms of NMES, more and more pediatric dysphagia research is coming out, but it definitely lags behind our adult colleagues but that's how most things are in pediatrics, right?

[Dr. Gopi Shah]
Yes.

[Ashley Brown]
With the NMES, it can be that, for lack of a better term, seemingly normal aspirators where we can't quite figure out there's no other comorbidities that we have yet to figure out. We use it, yes, low tone, high tone, some of our CP kids, our situation management kids because NMES essentially the easy way to describe it is you're inducing a muscle contraction. It's like the TENS units you would use on your back or legs. You're inducing a muscle contraction, but it also impacts that surface sensory as well, because they are short electrical pulses.

That's the theory behind it. Does it work for every kid? No, it does not. Do we see some good outcomes? Yes, we do. We need definitely more research on the long-term outcomes. Is this sustainable as soon as the therapy is done? Do they regress? That I think, is where we need more information but you should be very thoughtful in how you use it and recommend it because you need to know the pathophysiology behind their swallow deficit before implementing NMES, because you need to know what to target and not go in blind.

[Dr. Gopi Shah]
Meaning where exactly you're going to, which muscles to stimulate and where you're going to place your electrodes based on what you see in the video swallow or what you physically see?

[Ashley Brown]
Correct. Yes, so with the video swallow or the FEES, there are different electrode configurations that in theory target different muscle groups. You go through training. Everyone who uses it goes through training and you get information and handbooks on these electrode placements target this group of muscles, and this deficit pathophysiology you saw on the swallow study. You have to be very precise about it. It's not for every kid. A lot of our kids we'll try it. We'll get NMES for a little while and we see no progress or benefits that may happen but it's up to that treating therapist to really think through the deficit and what they're targeting.