This is wonderful information, thank you!  I was fortunate enough to attend
the Wolf and Glass Feeding and Swallowing Disorders in Infancy presentation
held in Tucson in '05 and this was an excellent refresher.

I posted more information last night but as of this moment it's not showing
(delayed?).  Wolf & Glass recommended Simply Thick over cereals because the
other thickeners are quickly digested by the breastmilk, returning the milk
to its original thinner consistency.  Have you found this to be the case?
It stands to reason that a food would be healthier than something so high in
complex carbohydrates (fiber) as Simply Thick.  Given that the doctors are
insisting that she use the more expensive gel version ($200/month) of Simply
Thick rather than the powder, which would have been covered by insurance,
these MDs are quite specific in their orders.

Although feeding at the breast was, I'm sure, difficult because of mom's
fire-hydrant milk supply, I suspect that the bottle they used during the
test probably created a very poor representation of what actually happens at
the breast for this baby.  Considering he refused every type of bottle
nipple she tried on him once she was told not to breastfeed, I'm guessing it
was quite traumatic to deal with the bottle during the test, even if he was
sitting upright.

I definitely agree that this baby and mother deserve a second opinion from
someone who sees the bigger picture, so to speak; however this mom is so
high-strung that I don't see her even considering the idea for fear of
offending the doctors who, she believes, saved her baby from imminent
death.  She's also working under the restrictions of her insurance company
to the point of practically having them on her speed dial.  Between the
pressures from her husband, the myriad of health care professionals who are
part of this case, her toddler daughter's special needs, and having to pump
and bottle feed day in and day out, I wouldn't be surprised if she
spontaneously combusted, she's so stressed out (I hesitate to suggest she
talk to her doctor about PPD for fear that would be the staw that broke the
camel's back).

Thank you all again for your brain power and suggestions.  I'm going to call
her today and share this information with her, including the consideration
that his situation might not be as dire as they made it out to be.  After
all, he hadn't so much as a runny nose, let alone any respiratory symptoms
that typically accompany aspiration.  I'll keep you all posted!

Gratefully,


Debbie Gillespie, IBCLC, RLC, LLLL




On Tue, Jul 14, 2009 at 6:44 AM, Kirkwood, Angela
<[log in to unmask]>wrote:

>
>
>
> I am involved with cases of aspiration on a routine basis.  I work in a
> large pediatric hospital in PA, USA with a very large referral area, up
> to 4 hours drive time for some families.  I work with both breastfeeding
> and bottlefeeding babies and do so along with the Speech Language
> Pathologists and Occupational Therapists.  I am fortunate that we have
> grown to work very well together and both SLP's and OT's are more than
> happy to use my lactation expertise when needed.  We also have an
> Airway-Digestive Clinic for our Ear, Nose and Throat doctors one day a
> week.  Some situations seen are laryngomalacia, tracheomalacia,
> subglottic stenosis, laryngeal paralysis, mass removals.  I attend those
> appointments when appropriate, especially lactation related.  There are
> multiple medical and anatomical reasons that an infant would aspirate.
> Aspiration can occur either/or/or both when going down/feeding and when
> coming back up/refluxing.  The test for evaluating aspiration and
> swallow during feeding is called a Video Flouro Swallow Study.  It
> involves radiation so it is limited in time and will ususally be used
> intermittently thorough a feeding to see different stages of the
> feeding.  As the infant fatigues, is a common source of discoordination.
> The radiation will not be continued throughtout the entire feed.  There
> are standards of radiation exposure which is why the Radiologists do not
> routinely perform Swallow Studies during a breastfeed.  I cant say it is
> never done but it really stretches the rules.  The difficulty is trying
> to recreate the breastfeeding experience with a bottle which obviously
> cant be done.  What our SLP's and Radiologists do, is they will usually
> use multiple textures and  many times different flow nipples.  The first
> adjustment when aspiration occurs, is to slow down the pace of suck,
> swallow, breathe.  The infant needs to complete clearing of the liquid
> before the next bolus of liquid is swallowed.  That may be done by
> upright positioning, addressing oversupply and overactive letdown,
> leaning back, even actualy unlatching after every so many swallows
> etc... or a slower flow nipple and external pacing if not fed at breast.
> When those benign interventions are not slowing the pace of feeding,
> adding texture is the next step.  In our facility, we prefer to use an
> infant cereal to thicken rather than the commercial thickeners.  There
> will be a decrease in volume taken by the infant due to the increased
> texture so having the source come from a food not just a corn or
> carbohydrate starch seems to be a better option.  Yes, it is taking away
> important nutrients but it is only done in situations that aspiration is
> occuring.  Not thickening and allowing aspiration can can have
> devastating results.  We make every attempt to slow the pace of the
> feeding with pacing techniques first and then adding as little cereal as
> possible.  I have seen babies with gas and constipation issues, but
> again the devasation of aspiration is a bigger evil.  Some babies will
> tolerate infant oatmeal or barley better than the rice and some
> physicians will order lactulose.  I have not seen rectal stimulation a
> preferred treatment by parents in the long term.  As I mentioned, there
> may be anatomical reasons for the spillage of liquid into the airway and
> rarely, there are situations that only gastric or duodenal feeding are
> safe.  An alternative test is the Fiberoptic Endoscopic Evaluation of
> Swallow (FEES) which is possible with breastfeeding.  It is a thin soft
> tube with a camera that an ENT physician can place from nose, through
> pharynx to the top of the larynx.  This can evaluation spillage while
> feeding but not actually view below that.  It can be one piece of
> evaluation and can be performed during breastfeeding if mother and
> physician are willing.
> Angie Kirkwood RN BSN IBCLC RLC
>
>
>
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