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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