Swallowing disorders in infancy ARE being diagnosed more frequently. They
can result from a lot of factors:  poor bolus organization, problems with
the swallow reflex, abnormalities in the pharyneal protective mechanisms, or
problems with esophageal peristalsis.  When babies present with wet, noisy
breathing (they are literally breathing through aspirated secretions) or
have frequent, severe respiratory problems, swallowing studies with
videofluoroscopic visualization can help identify what the problem is.
There are various treatments, depending on the etiology of the problem.  The
lit describes some infants who are so dysfunctional that they cannot safely
manage their own secretions (saliva) without aspiration.

Some of the treatments for the child who is able to do oral feeding involve
chilling the fluids the child receives or providing chilled semi-solids.
This thermal stimulation seems to improve the speed of the swallowing reflex
in some infants.  Sometimes, if the child can only be safely fed with
non-oral methods, chilled pacifiers can be given to help the baby develop
the swallowing reflex while they do non-nutritive sucking.  Sometimes by
controling the bolus rate, feeds can become less dangerous.  Small, single
boluses, or paced feeding (gen. with a bottle) can help dysfunctional
swallowers begin to organize safe swallowing/breathing patterns.

If the aspiration occurs during  or after the swallow, different positions
and some use of thickening agents may be employed to try to give the infant
a safer experience.  Thickening has become controversial because over time,
the infants can gain well but still be malnourished due to substitution of
carbohydrates (in the thickening agents -- typically cerals) at the expense
of protein intake.  Yet thickening may permit the infant to continue to take
some feeds orally, so clearly, balancing the needs of these dysfunctional
babies is tricky.

While it is interesting to read about these therapies, obviously employing
them without expert supervision is beyond the scope of practice of an LC
unless he/she is licensed as an OT, PT, or Speech Pathologist.  Offering
chilled fluids, for instance, may be dangerous to some infants.

The bottom line is that no one ever said all we would be managing was normal
babies. For a normal baby, the consistency of breastmilk is just fine.  But
we do see some abnormal babies with medical diagnoses, and we have to
understand that there will be different issues to consider in these
populations.  Breastmilk is clearly best for babies, but chronic
microaspiration even of breastmilk is not good for pulmonary status, and is
especially dangerous for the infant who has had lungs damaged by BPD, RSV,
or whatever.  For these babies, aspiration may mean serious medical
compromise.  Secondarily, I have recently worked with two babies with
serious lung conditions.  Their experiences with invasive proceedures and
chronic aspiration have contributed to sensory defensiveness issues and
serious feeding aversions.  The inability to enjoy eating, to fear it
instead, is a terrible experience for baby and for family.  Early protection
and intervention seems prudent to me.

What I hope to live to see is teamwork between the OTs involved with
designing feeding plans and LCs who advocate for delivery of breastmilk.
The goal of therapy should always be a return, if possible, to normal
feeding.  For infants under 6 mo. this is defined as exclusive or near
exclusive breastfeeding.  If that cannot be achieved, it is the delivery of
a normal supply of breast milk via some safe means.

Barbara Wilson-Clay BSEd, IBCLC
Austin Lactation Associates
http://www.lactnews.com

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