Hi Laura,

I feel I must weigh in as well, as this is a huge thorn in my side within my profession and is something that will require published studies to change the current belief system.  We, as speech pathologists are trained solely in bottlefeeding as the norm.  Most SLP's do not have the training or expertise to understand the mechanics of breastfeeding, and how it is so very different from bottlefeeding, unless they have taken a particular interest in BF and sought out the additional training in lactation.  This has come up for me locally and I know is a problem in most settings.  I agree wholeheartedly with what others have said.  There are many concerns with the swallow study and the subsequent recommendations made by the SLP.
1.  It is known that a TT can impact effective and safe feeding from breast and bottle, so why was a study done before attempting a frenotomy first? (i.e. a tongue tie can cause aspiration due to the reduced tongue mobility, cupping of tongue, peristalsis, etc...) 
2.  As was mentioned before, was there a history of pneumonia or other respiratory infections that could be associated with aspiration (eg. aspiration pneumonia)?  
3.  This baby appears to be gaining weight beautifully, and although is fussy at the breast is not outright refusing to nurse.  I question why a swallow study was ordered in the first place. ( It is possible that the Dr. or SLP wanted to glean additional information about oral and pharyngeal phases of swallowing, or wanted to see if something else might be going on with this baby that is causing her problems...but already having a diagnosis of a TT, it is not a rec I most likely would have made at this time, even if I suspected that she was aspirating.)
4.  The results of a swallow study of a baby bottlefeeding cannot be directly translated to what is happening while BF, especially if the baby has never bottlefed before.  The flow, position, and suck would all be quite different, as well as the passive nature of the bottle vs. breast.
5.  As was mentioned, a "chin tuck" is a classic rec made for adults and sometimes for an infant who is aspirating as it may help close off the airway while swallowing.  It is not effective for all situations, and I wonder if it was even tried while the baby was under fluoroscopy to assess its effectiveness.  There are many other positional changes that can be made while breast and bottlefeeding that can improve safety of swallow.  
6.  Thickening can sometimes be helpful for babies who are aspirating, as it can slow the flow, but it should be a last resort when ALL other avenues have been exhausted, especially for a BF baby. And, should not be rec'd for a baby who is healthy and growing on breastmilk alone. Thickening agents, such as rice cereal, as well as commercial products have their own set of risks, and may break down due to the amylase in breastmilk.
7.  There is little to no empirical evidence that aspirating breastmilk is harmless, BUT with the knowledge that we have, it most likely does not harm the baby's lungs, especially in small amounts.  It sounds like the risks of thickening for this baby far outweigh the risks of continuing to BF.

Nina Isaac, MS, CCC-SLP, IBCLC
Speech Pathologist/Lactation Consultant
Tucson, AZ 


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