Feeding Specialist: When Is it Time to See One?
Nancy Fitzgerald Calamusa MA, CCC-SLP (adapted from a post and the comments under the post in this Closed Facebook Group)
Parents should seek the advice of a feeding specialist when there are any concerns regarding how the baby/child is feeding or swallowing. Coughing/choking/eye tearing and audible upper airway congestion during feeding are all clinical signs of dysphagia which should be addressed immediately. Failure to progress through the developmental spectrum of feeding i.e., unable/unwillingly to transition between textures; unable/difficulty transitioning from breast/bottle to other methods of fluid intake; gagging & choking, these are all clinical markers or red flags for feeding &/or swallowing difficulty. Failure to thrive, gain weight & grow is another obvious sign. Prolonged episodic GERD which may result in aversion or refusal to drink &/or eat due to association of pain during these tasks.
In the medical field, we have many people who are good at helping you alleviate a problem and yet very few who know how to recognize and fix/change the problem.
Infantreflux: Please explain about what many mothers/parents describe as trouble swallowing formula “it runs out of baby’s mouth resulting in gagging.” Many parents think/believe this is due to thin viscosity of formula. Thoughts? Is a Swallow Study warranted? Example: “When we gave her straight formula [not elemental] we’d have to use a preemie nipple to slow the flow to give her time to swallow. Does that seem normal/ok?”
Nancy Fitzgerald Calamusa: That is a loaded question. There could be numerous reasons why formula is being expelled. First you want to make sure that the infants suck/suckle is strong & capable to organize fluids; second, you need to assess positioning; type of bottle/nipple vs. flow rate; if breast feeding-latching difficulties; rate of let down; assess for Posterior Tongue tie; is there desaturations of oxygen/heart rate during feeds. Thickening is managing a problem but you need to know where the problem is so you can address it and change it before an aberrant style of sucking/swallowing is habituated.
Infantreflux: Is this determined during Swallow Study? or is Swallow Study strictly looking at mechanics?
Nancy Fitzgerald Calamusa: A GOOD FEEDING therapist is responsible for assessing all of it. However, they must have a strong background in neonatal development and feeding! In the medical field, we have many people who are good at helping you alleviate a problem and yet very few who know how to recognize and fix/change the problem. In this field, it is very difficult for new parents or parents struggling through a stressful event with their child to research “who” they should go to. Typically, one would seek their doctors advice but how does he/she actually KNOW that the therapist is good and not just referring b/c that’s who they have always used? When lecturing new parent groups, one statement that rings true with them is from my own mouth “as parents, you spend more time researching car seats, high chairs, etc, then researching who will be responsible for your child’s therapy!” My suggestion is “due diligence” look for reviews, ask other moms, look for credentials/ expertise; call the therapist and ask if he/she has treated XYZ before, if so, how many, and what were the outcomes? The only time I conduct an MBSS is when I suspect aspiration and when FEES would not be beneficial. Otherwise, We prefer FEES b/c less radiation exposure, can be done in office without lengthy scheduling, and cost effective.
MBSS is an abbreviation for Modified Barium Swallow Study which is a radiological procedure where a “moving x-ray” (videofluoroscopy) captures how an individual consumes and manages food. It assess all three phases of the swallow: (1) Oral Preparatory Phase (2) Oral Transit Phase (3) Pharyngeal while the patient consumes various consistencies and fluids. In some facilities the radiologist will follow the bolus to the esophagus for what is the Phase 4 or the Esophageal Phase.
MBSS does not show anything regarding tolerance with breastfeeding unless they are putting both you & baby under X-ray. The SLP would most likely use EBM via bottle which negates the reason for testing. FEES is a better option but you would need a good SLP & ENT.
FEES is an abbreviation for Fiberoptic Endoscopic Evaluation of Swallow which evaluates only the pharyngeal phase of the swallow. This is achieved by using a small catheter with a camera inserted into the nostril and threaded through the soft palate so that the larynx is visualized. A swallow sequence is recorded. This can quickly determine if someone is aspirating. There are pros and cons to both.
Signs & symptoms of penetration or aspiration are coughing during feeds (not 1 or 2) but coughing as if it went the wrong way; fever (may or may not be present but spikes after aspiration) may have it for days; congestion of the airway &/or chest; cessation of breathing during or after feeds (gasping for air; turning colors); wet-gurgle vocal quality as if liquids are in the throat.
Changing your BF position can often help baby with management but, as always, you should seek professional advice such as an SLP or lactation consultant. Some OTs are trained in swallowing disorders. Pediatricians will refer you for radiological procedures.
Fiberoptic endoscopic evaluation of swallowing successfully performed at Baylor University Medical Center