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BackTable / ENT / Podcast / Transcript #48
Podcast Transcript: Feeding Difficulties in Infants
with Ashley Brown, SLP
We talk with Ashley Brown, SLP about how to approach the infant with feeding difficulties, including common causes and workup, therapeutic options, and the importance of family counseling and education. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Assessing & Addressing Infant Feeding Challenges
(2) Flexible Endoscopic Evaluation of Swallowing (FEES) & Video Fluoroscopy in Evaluating Infant Swallowing
(3) Key Differentiators in Pediatric Dysphagia
(4) Laryngomalacia, Tongue Tie, & Feeding: Focus on Function Over Anatomy
(5) The Role of Reflux in Pediatric Feeding Evaluation
(6) Distinguishing Food Allergies from Dysphagia in Infants
(7) The Implications of Nasal Obstruction on Infant Feeding
(8) Supporting the Child & Family in Feeding Therapy
(9) Neuromuscular Electrical Stimulation in Pediatric Dysphagia: Indications & Implementation
(10) The Emotional Impact of Dysphagia on Pediatric Patients & Families
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[Dr. Gopi Shah]
My name is Gopi Shah, and I'm a pediatric otolaryngologist at UT Southwestern here in Dallas, Texas. I'm so excited for our podcast today. My guest is my colleague and partner, Ashley Brown. Ashley Brown is a pediatric speech-language pathologist here at Children's Health in Dallas. She's an integral part of our complex airway and swallowing team and is truly an expert on pediatric aerodigestive disorders, including dysphagia, swallowing, and voice.
She's a board member for the Society for Ear, Nose, and Throat Advancement in Children, also known as SENTAC. She's on the medical committee for Texas Speech-Language Hearing Association and is board-certified specialist in swallowing and swallowing disorders. She's here to talk to us today about the evaluation and management of the infant with dysphagia. Welcome to the show, Ashley.
[Ashley Brown]
Hi, thanks so much for having me, Gopi.
[Dr. Gopi Shah]
Ashley, tell us a little bit about yourself and your practice.
[Ashley Brown]
I've been here at Children's for 15 years, actually. Dr. Romaine Johnson and I started around the same time, so we've been partners in crime for a while now. I am on the airway management team here at Children's. That's a new program that started, I guess we're coming up on four years now, so it's been a little bit. I staff all clinics within that, aerodigestive, voice, vent clinic, airway clinic, and also go on trach rounds with the team.
[Dr. Gopi Shah]
You have a very busy clinical practice, seeing all kinds of-- yes, that's pretty awesome.
[Ashley Brown]
I also do all the swallow studies for ENT.
[Dr. Gopi Shah]
I see, and that's why I come to you with a thousand questions. Every day there's an inbox message from me. I'm really excited about this topic because I think that whether you're a pediatric otolaryngologist in the aerodigestive, super specialized to the pediatric otolaryngologist like me, who's maybe not a part of that or the general ENT, you're going to have babies that come into clinic that there's some concern about feeding. That's why I thought this would be a great topic.
(1) Assessing & Addressing Infant Feeding Challenges
[Dr. Gopi Shah]
For infants, and again, we're talking about infants under a year, how do they usually present to you when they're feeding difficulties?
[Ashley Brown]
Whether it be in clinic or just a PCP referral from the community to our outpatient clinic, generally the infants present to us because they're a failure to thrive. They're not gaining weight. They are pulling off breast or bottle frequently. Maybe some reports of coughing, watery eyes, red eyes when they're eating, not completing their feeds, super fussy during feeds, refusing is I would say the general referral reasons that we get when it comes to infants.
[Dr. Gopi Shah]
How old are they usually? Are they usually early on, like a couple of weeks, a couple of days, or do some of them present a little bit later on?
[Ashley Brown]
We will get them when they are a few days, maybe a couple of weeks old, all the way up until, like you mentioned, that 12-month-old mark. Probably our youngest patients are seen within our craniofacial weight check clinics that we have, because when those babies are born with cleft lip and palate, they need to get in immediately, see the surgical team and the speech therapist, because they require such specialized feeding systems. Those are probably our youngest patients, but I've done swallow studies on a baby that's about two weeks old.
[Dr. Gopi Shah]
There's quite a range.
[Ashley Brown]
A very large range and within that range, you are looking at rapid developmental changes. A two-week-old infant does not equate a six-month-old infant.
[Dr. Gopi Shah]
When these babies come to you, how do you organize your thought process? Or like what kinds of questions? Are there the same basic handful of questions that you ask and then you tease it apart? How do you look at these and then what kinds of questions are you asking?
[Ashley Brown]
We definitely start with a standard set of questions, probably very similar to questions you would ask in your practice, asking about birth history and then getting into what brought you in today. What are your concerns? Tell me what a feed looks like in terms of quality, quantity, the time it takes the baby to finish. From there, then you start delving into specific questions that apply to that patient but there are definitely a set of standard questions that you start with that give you a good clue of what do I need to ask next.
[Dr. Gopi Shah]
Then what's your exam like?
[Ashley Brown]
With the exam after asking some of those questions, I feel like the whole time we as speech therapists are pretty good at looking at the whole patient. We are very holistic in our approach to any dysphagia, especially infant dysphagia. The whole time we are observing posture, tone, we do tone check, oral motor exam on the baby and not just focusing on the mouth. We're looking at trunk support. We're looking at how did the parents hold the baby during a feed. That's where we start when we delve into the oral exam. Again, we're looking at tone, but also range of motion, integrity of the structure.
[Dr. Gopi Shah]
Then do you watch them feed every time when they're with you?
[Ashley Brown]
Yes, we have instructions when they are scheduled for an appointment that hopefully they are hungry enough. We say for a snack, once you get a baby over a tipping point of so hungry, it works against us a lot of the time that they don't want to eat because they are so mad at that point. Yes, we do ideally observe a feed. Now, we do have some infants that come in that are NPO so that's a different exam but we observe a feed. During the observation of the feed, we are looking at the oral motor skills, the feeding pattern, the swallow pattern. We are looking at are they self-regulating? Are they pacing themselves during the feed? What does the coordination look like in terms of the suck, swallow, breathe pattern?
We know that small infants, they're obligate nasal breathers, so they suck, swallow, breathe, suck, swallow, breathe. If they are not pacing themselves and get into this bad pattern, you know, you're going to choose breathing over eating, and we get into some bad moments then if we're not coordinating the suck, swallow, breathe. You breathe when you should be swallowing. Those are all things that we look at during the feed.
[Dr. Gopi Shah]
How do you know which babies you're like we're going to do some feeding therapy or, hey, we need to do further workup or further imaging or testing?
[Ashley Brown]
So sometimes it's hard to tell is this just strictly a feeding therapy kit or do we need an instrumental because the great majority, if you look at the research, anywhere from 80% to 90% of aspiration is silent. They're not going to give you many cues that they are aspirating. You have to take some other cues from them. Given the comfort level, are they frequently pulling off the bottle? Do they sound a little wet, gurgly? Is there some sort of respiratory history that is the reason they were sent to us? Then that's where we would go for an instrumental.
Sometimes the families get into us and it is just a utensil change of maybe they are overloading baby with a too fast a flow nipple, and we just need to back them down a little bit. Sometimes they just need strategies to pace baby. I think it's always a good idea to start with the bedside and a speech therapist observing a feed so you are not getting into unnecessary exposure to radiation with a fluoro swallow study. Those are some of the clues that we take. Infants don't cough. That's not a-- small infants, that is not a reflex quite yet when they're very small, that that develops over time. That cough is not something you should rely on as a clue that they need an instrumental.
(2) Flexible Endoscopic Evaluation of Swallowing (FEES) & Video Fluoroscopy in Evaluating Infant Swallowing
[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.
(3) Key Differentiators in Pediatric Dysphagia
[Dr. Gopi Shah]
When you're seeing these kids, in your mind, what's your differentials that are like the common dysphagia or things that you're thinking of?
[Ashley Brown]
If you look at some of the research and numbers, anywhere from like 25% to 45% of normally developing children and infants will have some sort of feeding difficulty that is a large number. I'm sure y'all can tell that from your practice that is a large number because it's every day, all day. Sometimes they don't give you any clues as to what is going on and there are these seemingly normal aspirators, and we can't quite figure out a differential there, which is very frustrating. If we think about the most common big picture that we're looking at, oral structure, tongue tie, one of them that we'll start with that's very popular right now to talk about, tone, have they had a HIE, a brain bleed?
Were they born premature? Were they intubated for a long time? What kind of clues could prolong intubation give you? Oral sensitivity being one of them. They were in the hospital for a long time, lots of things taped to their face. You can understand why they don't necessarily want to eat or a bottle coming at their face or is the therapist trying to do exercises with them. They can be very orally defensive. Intubation tube sitting in their mouth for a long time too, affects the shape of the palate, which can affect bottle feeding, not getting that great seal that you need. Are they a cardiac baby? Do they have a cardiac history? Have they had cardiac surgery?
When we think about our cardiac babies, they have a very low kind of energy reserve. Feeding is already an aerobic exercise, and then for our cardiac babies, that especially is true. Maybe they don't want to eat for longer than five minutes, and then when also you're thinking about cardiac history, is there some immobile vocal cord involvement because there was injury to the recurrent laryngeal nerve, which we see often. That is probably primarily what our voice clinic is, is children who have had a history of cardiac surgeries, PDA, ligation.
We're looking at vocal cord immobility. In general, do they have a history of syndrome? You start looking up those syndromes, trisomy 21, probably being our biggest one down syndrome. They're going to have a lot of tone issues there. 22Q, the 11.2 deletion syndrome, so also known as DeGeorge. There's some people label it DeGeorge. They all come with their own set of difficulties that you really need to research what those syndromes look like in terms of feeding. Some other differentials, we definitely get more referrals, especially from swallow studies of a kid who is not making progress in therapy. There may be one of those seemingly normal aspirators. We would like to look for a laryngeal cleft. I think that that is on top of mind with a lot of people now, and we are definitely diagnosing it a lot more, especially over the past 5 to 10 years.
(4) Laryngomalacia, Tongue Tie, & Feeding: Focus on Function Over Anatomy
[Dr. Gopi Shah]
I think, you know, there's such a spectrum, and we tend to think about the cardiac kids and the trisomy 21 kids and the syndromic kids as being the most difficult, but I find that sometimes in our otherwise “healthy” I don't know if nobody can see me, but I have my finger quotes, that sometimes the tongue tie or laryngomalacia kids or that six month old that's always had a little cough when they drink milk and are now finally coming to you, those are to me, can be very difficult as well, just because we know that not all tongue tie is the main issue. Even with that otherwise healthy six-month-old there might be something. Is there any details or ways to help tease those kids in terms of how to help think about etiology or things they might benefit from? How do you look at that group?
[Ashley Brown]
You mentioned laryngomalacia and that also is a large referral population that we have within ENT. If we think about it in terms of also tongue tie, I think sometimes we get stuck on the visual of it, and tongue tie is not about the anatomy. It's about the function. It's not about the visual. It's about the function. When we think about laryngomalacia when you think about it in that term as well, because we'll see notes that say, my laryngomalacia we'll continue to watch, but they're showing all of these signs that their astragalus during feedings is the time the parents notice it the most.
They get a little junky, a little congested. They're not gaining weight. Is that mild laryngomalacia in that baby just enough to throw off that suck, swallow, breathe sequence where in another child they were doing fine with the exact same maybe appearance of the rental tissue? It has to be patient by patient, kid by kid. It cannot be this box that we put them in of you have a tongue tie, therefore you have a feeding difficulty. Or it looks like a mild tongue tie, therefore you won't have a feeding difficulty. That's where best practice would be this multidisciplinary approach to everything. We should not expect our ENT colleagues to know it all about feeding and that's why we're here. We would rather you ask than order all of these exams or just say we'll see you in six months. There's a wide spectrum of how people handle it.
(5) The Role of Reflux in Pediatric Feeding Evaluation
[Dr. Gopi Shah]
Well, good thing I sent you an epic message about once a week then for all my kids that I see.
[Ashely Brown]
We never mind those questions because there are things that we have not thought of that you can offer, and then we might pick one little clue out of the message that you sent that you're like, “Oh, actually this kid probably needs to go to GI. This sounds like they are having some major GI difficulties and let's pull those colleagues in.” If we could see every dysphagia patient in the aerodigestive clinic, that would be wonderful but the bandwidth is not quite there.
[Dr. Gopi Shah]
Let's talk about some of the GI. I feel like I'm always asking, is there any history of reflux spitting up? Tell us a little bit about what you're asking when you're looking for GERD or reflux. Do they need to be actively spitting it up for them to have it? How does that play a role into your feeding evaluation?
[Ashley Brown]
All babies have reflux, right? They have immature guts and they are messy and they spit up. There is silent reflux as well. They are not necessarily going to spit up all the time. Spit up does not mean that it's affecting them in any sort of negative capacity. All babies do it. It again, is really looking at the parents have told me they spit up a lot. They're smacking their lips a lot during a feed, have this sour look on their face. Is it affecting the feed? Is it affecting their growth? Is it affecting a happy, pleasant feed? Are the parents struggling and they're feeding the baby every hour because the baby has started to volume limit because they don't feel good?
The way, unfortunately, babies show you that they don't feel good is crying or not necessarily cooperating the way that they want them to because they cannot tell you how they feel. Looking at those signs of pulling away from the bottle, lots of maybe tummy discomfort, gas, sound like they're maybe swallowing a lot of air, which would then in turn with aerophagia, you get more reflux with that. Is it affecting the feed is what you need to know. Are they stooling like they should? Do they have constipation? They're going to volume limit at that moment. If you have constipation, there's only some place the food, liquid can go and it's going to start to possibly go back up the other way. Again, looking at how is this affecting the feed because do our GI colleagues get a little annoyed with us that sometimes we want to blame reflux all the time?
[Dr. Gopi Shah]
All the time.
[Ashley Brown]
Probably. It's like, you got reflux. Oh, yes. Is there a place? Those are the two things. Yes. They probably do get slightly annoyed with us but if you think of it in terms of is it affecting their feed? Is it affecting the volume? Is it affecting their growth? That's when you start thinking I need to rope in my GI friends because the baby's only job when they're very small is to eat and go to the bathroom. If both of those, either of those are messed up, we need to get our GI colleagues involved as well.
(6) Distinguishing Food Allergies from Dysphagia in Infants
[Dr. Gopi Shah]
In the infancy, how much does something like a food allergy come into play or does and present as dysphagia, does that come at all?
[Ashley Brown]
I mean, I think probably some food sensitivities, maybe some dairy, milk protein sensitivities. A lot of our moms do elimination diets if they're breastfeeding or doing express breast milk. How many babies really have food allergy? I don't think that that is necessarily maybe what we're looking at. It's more because infants are going to be more formula, express breast milk or breast feeding, human milk based. Maybe a milk protein sensitivity, which, again, is where our GI colleagues get involved. Now once they start transitioning to spoon feeding and parents are trying fruits and veggies and we start seeing rashes or some other signs of discomfort, once they start introducing more solid type foods, then that's when we maybe start thinking food allergy. In terms of very small infants that are still just breast or bottle based, you would think more milk protein discomfort type signs when they're eating.
[Dr. Gopi Shah]
Then what about, we've talked about intubation history.
(7) The Implications of Nasal Obstruction on Infant Feeding
[Dr. Gopi Shah]
We've talked about laryngomalacia, craniofacial, but what about just nasal obstruction? How often do you see nasal obstruction in infancy that is enough to cause trouble feeding? They get six to eight colds a year, we say, I feel like that's your main group. Then, of course, you're going to have the history of pyriform aperture or cranial atresia, but those are not common. How often is in the nose and how does that present?
[Ashley Brown]
I don't feel like we have too many families that come to us that everything seems solely based on just a junky nose and they can't eat. Like you mentioned, it's going to be cold based if they go to daycare, maybe just some seasonally based kinds of things. Then it seems to be a fairly simple conversation of talking about nasal saline, those kinds of things to help them with that. If it's just some of that junk, yes, when they are obligate nasal breathers, can it throw off their suck, swallow, breathe pattern? Yes. That's what we just talk about. Let's help baby along with some pacing to help with that coordination sequence.
Cranial atresia, pyriform aperture stenosis, they will, as we have seen, have difficulty with feeding, but generally I feel like they do well with just some strategies. I don't know what you've seen necessarily with your patients that have come through, but most of the time they do very well with some strategies by getting your feeding therapy colleagues involved to help them with some pacing strategies generally helps them through.
[Dr. Gopi Shah]
Yes, I agree. I think that the otherwise healthy kid that catches a cold all the time isn't necessarily going to be the ones having the issues, because you're right, once they're about two months, they're not as much of an obligate nasal breather, and then the colds, that's when they start getting affected more. I mean, I feel like we do see a lot of, in our clinic for four-month-old with nasal, the nose has been clogged since they were born type of picture. Like you said, it's supportive care, lots and lots of saline and going from there and just letting them grow.
I think with the cranial atresia or pyriform stenosis, whether, cranial atresia, if it's bilateral, you're going to have had to repair it and do surgery. Every once in a while, not a lot, not very often might you see an infant with unilateral that has some feeding difficulties with a URI or perhaps they have trisomy 21 or something. There's other factors also playing a role like tone or every time that kid gets sick, there's issues with feeding.
I think that with bilateral cranial atresia or prefrontal stenosis whether you've repaired it or not, there can-- when the nose is getting tighter, if there's re-stenosis or scoring that, feeding is always going to be one of the first things that tends to be affected and nasal flaring, not being able to stay on. Again, those things aren't that common, right? Those pathologies aren't that common but that is always in my mind of, we need to take a look, maybe we need to go back and do something and re-dilate and things like that.
[Ashley Brown]
Yes, I think the babies who've had the most difficulty with feeding when cranial atresia is one of the diagnoses on the table, generally, like you said, have some other comorbidities other than just cranial atresia. There are degrees of obstruction, like you mentioned unilateral versus bilateral, and when you're going to have to get surgically involved, these are not these long-term kids that pop up in our clinic over the years that that's their only history.
[Dr. Gopi Shah]
Yes, you're right, because if it's CHARGE or something else, we're also thinking about a nerve, a vocal cord precess or a cleft or some other, there's stuff that we're thinking about that might also play other roles.
[Ashley Brown]
Right. Yes, CHARGE is a tricky one with a lot of cranial nerve involvement, and that is a difficult diagnosis in terms of feeding as well.
(8) Supporting the Child & Family in Feeding Therapy
[Dr. Gopi Shah]
Yes. In terms of feeding therapy, what happens like when they, “You're going to go see speech pathology, they're going to evaluate you and decide” and now, “How are you doing? You're into feeding therapy, that's great. How are things going?” I don't really know what actually happens though.
[Ashley Brown]
Right. What happens during a session? I will say a very large part of what we do is family counseling and parent support and parent training. These are not adults that come into dysphagia clinic where it's up to them and their partner to navigate. This is a whole family. We have grandparents that come to every appointment with the parents. You are counseling an entire family and you can't forget that the parents are part of your evaluation and part of your therapy plan, because they are the ones that are going to have to implement these strategies at home.
You can't go home with them as much as maybe the families would like you to go home with them and do every feed with them. You have to do a lot of great parent training. That is a very large part of therapy is making sure the parents are comfortable with the strategies, they are continuing the exercises, if that's what you're doing at home, because one or two sessions a week does not necessarily translate to carry over. You've got to train these parents and they are their child's biggest advocate. They are a very large part of the therapy plan but in terms of focusing on the child during therapy, there is a wide range of do they just need a change in nipple flow, like we've talked about, and really just following them for a few sessions to make sure that that strategy worked well for them.
Sometimes these are very long-term therapy patients who need a lot of sensory and motor work. Sensory is a very large part of eating that sometimes I think gets missed and not talked about. Our little friends that like to overstuff their mouths are we looking at a sensory feeding problem that they really need that input where they just shove a bunch in their mouth and look like little chipmunks? You have to think about the sensory as well. They will do maybe some oral motor stretches. Do we have some hypertonia and we really need to work on stretching those lips for good lip rounding?
Do we just by getting in there and maybe doing some sour or cold stimulation, are we increasing that sensory input and working on their sensory system for oral motor but also for swallowing? Then they move on to maybe some more of the complex like facial kinesio taping for also sensory input but for some support we use that a lot for our droolers, our facial management. Kids that need a little help with lip rounding to keep lips closed so that they can't actually swallow their secretions and then all the way on to neuromuscular electrical stimulation.
Some people know it as their brand name, VitalSim, but that is just the company. NMES is the actual therapy. There's a wide range. If you are looking at a infant that has had a long-standing feeding problems, we talked about they are intubated for a long time and are very defensive, you are also just working on them having pleasurable oral experiences and being okay within you getting to the exercises and wanting to take some flavor-taste PO trials.
(9) Neuromuscular Electrical Stimulation in Pediatric Dysphagia: Indications & Implementation
[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.
(10) The Emotional Impact of Dysphagia on Pediatric Patients & Families
[Dr. Gopi Shah]
Well, as we start to wrap things up, do you have any final tips or pros? I mean, these are hard patients and like you said, there's a whole family aspect to that. You're looking at everybody and feeding such an important-- especially for growing and quality of life that is so valued as part of life, if you will. Do you have any other final pearls for us or things that we should be thinking about, or how we can make our practice better or how we should be looking at these kids differently?
[Ashley Brown]
Dysphagia is very difficult. There are days that I wonder why I do this all day, every day, but you get those.
[Dr. Gopi Shah]
It's so hard. It’s so hard.
[Ashley Brown]
It is but you get those small victories and it makes it all worthwhile but it is very difficult because there are probably more times than not, I would have to say is we often had to tell the families I don't know, and I don't know why. I think it's okay to say I don't know. We're so afraid to not have an answer for families and that's why they come to us. They want an answer but so much of it is unknown, and you are there to support them through the journey which means they may be with you for several years, especially in pediatrics.
It's hard to tell a family I don't know. We've put you through therapy, we've done a DLB, we've injected a look you know a deep notch for laryngeal cleft and nothing is working. Sometimes maturation is just our best friend. We definitely see that, that it just takes them a little time developmentally when we're looking at maybe now, they're walking, maybe now they're running, we have better core support, we have better neck control. Sometimes maturation is just our best friend in terms of feeding and swallowing and that's a hard thing to tell a family.
That's a hard thing to admit to yourself that you don't have the answer, but sometimes you're not going to, a lot of times you're not going to in pediatrics. Feeding is very emotional. You think about bringing this baby home and your only job is to keep them alive, and that is to feed them, and it is such a bonding emotional experience for Mom and Dad, especially when me a mom is trying to breastfeed and she's having difficulty with that. You need to remember especially when it comes to breastfeeding evaluations, tongue-tie evaluations that Mom is also your patient, and where a multidisciplinary including lactation and speech really come into play there because maybe baby is doing okay but mom needs help with her supply.
There are mouth and you know nipple mismatches and problems there that your lactation friends can really help you with positioning baby for optimal feeding. Mom is your patient at that moment too, it is not just baby. Like I mentioned when we're thinking tongue-tie we need to think function, just not how it looks, and we'll tell you a lot. These are very difficult evaluations and they can be very frustrating, but I think as long as the families know that you're really trying to help them navigate this very tough part of their life, because it seems like our parents are okay with their kid not walking.
They're okay sometimes even if they're not saying as many words as they like, but feeding is such a family community-based activity, we take such pleasure from eating. Even if the child is not showing the parents that they really have any interest in eating, that's a very hard thing for people who eat okay to connect with because we take such pleasure from eating. We're coming up on Thanksgiving so I mean that is what we base a lot of our celebrations and holidays around, so if you are the family that has that one kid that doesn't get to participate in that that is very difficult.
I think that that is why a lot of us in terms of our feeding therapy colleagues try not to go this NPO route. We try to give the family something because they will say “I just want him to have some icing on his first birthday so I can get that smash cake picture.” Is that something we're really taking away from families because there is a big mental health component around this as well.
[Dr. Gopi Shah]
I think that's a great point. Ashley, thank you so much for taking the time to talk with me today, and more so for just answering all my questions all the time and helping me with these patients. I find them to be truly difficult and wanting to make sure because there's so much at stake that we're doing the right thing. Thank you for being such a resource and my partner in this. I appreciate it.
[Ashley Brown]
Yes, of course. I would always rather be there to answer those questions and make sure the kids get what they need than people trying to blindly walk through this journey with these families for sure.
Podcast Contributors
Ashley Brown, SLP
Ashley Brown, SLP is a pediatric speech language pathologist at Children's Health in Dallas.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2022, February 8). Ep. 48 – Feeding Difficulties in Infants [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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