Thickener Is Not the Answer in the NICU

Abstract

You have accessThe ASHA LeaderFrom My Perspective1 Jun 2019Thickener Is Not the Answer in the NICUUsing thickened formula as a long-term solution impedes infants’ oral and swallow development. SLPs can prevent overuse. Mallory LaBarre MilletMS, CCC-SLP Mallory LaBarre Millet Google Scholar More articles by this author , MS, CCC-SLP https://doi.org/10.1044/leader.FMP.24062019.8 SectionsAboutPDF ToolsAdd to favorites ShareFacebookTwitterLinked In A baby born at 38 weeks has difficulty latching on. After the baby has been breastfeeding for weeks, the primary care physician recommends supplementing with formula. Even after transitioning to bottles, the infant still has trouble latching on. As the infant’s frustration mounts, he displays behaviors that look like refusal. The primary care physician thinks the baby has reflux and recommends medication (to decrease inflammation) and thickened feeds (which settle better in the stomach). When the infant continues to have latching difficulty, the physician recommends stretching or making a larger hole in the nipple of the bottle to increase flow. A second infant, born prematurely due to maternal complications, is discharged from the hospital without difficulties once she is full-term. She ate well in the hospital on thickened formula, introduced because she failed an initial swallow study. At discharge, medical staff showed the parents how to cut the nipple opening to accommodate the formula. The baby progressed well and gained weight. At 5 months, however, she experiences difficulty transitioning off the thickener, so a gastroenterologist refers her to a speech-language pathologist. As a pediatric SLP, I have witnessed a surge in the use of thickened liquids. And, while thickening liquids is necessary in some situations, it should only be the “crutch” SLPs use while rehabilitating the swallow mechanism. Instead, I see many SLPs using it as the solution to pediatric dysphagia. The problems Problem one: Stretching or cutting bottle nipples to “allow” for easier flow negates the purpose of a nipple and decreases development of proper oral mechanism function. With a little pressure on the bottom of the nipple from the tongue, the cut hole opens, releasing the bottle’s contents. The result is a munching pattern of eating, which, in typical development, is seen later in infancy. Why does it matter if we skip several steps to end up where we should be anyway? In my patient population, when I see a “munching” pattern for a bottle “suck,” there has been an associated decrease in buccal and lingual movement and lingual coordination. Having an adequate sucking motor plan is likely important when transitioning to straws and sippy cups. Problem two: Thickening may alter the development of pharyngeal function for swallowing because it allows the infant more time to initiate a swallow (see sources). Routine intake of thickened foods may lead to motor plan development that is not safe for intake of a lower-viscosity liquid, which moves much more quickly (see sources). The scenario is similar to one in which someone lifts a five-pound weight for six months, and then tries to do the same exercise with a 20-pound weight with the same accuracy. The body is not prepared and cannot handle the new load of work. Given any thickness of liquid, a baby develops safe swallow initiation, laryngeal sensitivity and response specific to that thickness level. Months later, during a swallow study with thin liquid, the baby aspirates—much like the example of the premature infant above. No surprise. The baby’s mechanical system encounters something it has not “learned” to handle. To be prepared for thin liquids, you probably need to “train” with thin liquids. As SLPs, we need to help reteach the baby to respond more quickly and efficiently to thin liquids. So we lessen the thickness, and decrease the nipple size, but now we have a new problem—the baby does not know how to suck properly. We can’t continue with thickened liquids forever and we need to teach the baby’s system to tolerate thin liquids as safely and as soon as possible. The solution How can we help to ensure that babies develop sucking and swallowing appropriately? We need to advocate to be included on NICU transition teams, and to reach out to gastroenterologists, pulmonologists and primary care physicians to become integrated in a multidisciplinary team for appropriate referrals for all feeding difficulties. For the baby having difficulty latching, we can begin by assessing motor function (lingual, labial and buccal). The goal is to teach the baby how to properly suck. This process begins mainly with non-nutritive sucking tasks. However, because non-nutritive sucking does not involve the same frequency of swallow initiations, it will likely be beneficial for developing adequate motor planning to incorporate nutritive sucking activities (see sources). An SLP can also address the need for rehabilitating the swallow to develop the skills to swallow thin liquids, as in the second scenario. Depending on the baby’s medical status, I begin introducing stimuli in a hierarchy—glycerin swabs, toothettes, ice chips, controlled anterior placement of thin water—to stimulate sensation and muscle response, with the goal of improving and establishing adequate swallow motor planning. Babies can usually safely absorb small amounts of aspirated plain water, so we can safely complete these exercises to build the responses the baby needs to progress. Once we can establish a functional nutritive sucking pattern, we can then test thin formula safety and progress off thickened feeds. Prevention We can prevent the need for extended amounts of feeding treatment, even for babies who must have thickened feeds or who have a weak suck. If a baby is on thickened feeds, the key is nipple selection. All nipples come in sizes, typically tied to an age range. But the age measurement is meaningless: A level 2 nipple indicates 6 months-plus, but a 2-month old baby on thickened foods may be using a level 2. We tell our caregivers to look at the level or flow rate, not the age listed. X- and Y-cut nipples are specifically created for thickened feeds and allow for a proper suck pattern to develop. And they eliminate the need to modify a nipple that was not meant to accommodate a thicker flow. What if the baby can’t suck? All babies have a suck reflex—they are born doing it (see sources). If the baby has a weak or uncoordinated suck, we can teach strategies and exercises to strengthen the baby’s suck from the beginning. It’s better to intervene early and prevent developmental problems, rather than to undo maladaptive behaviors that prolong the need for aspiration precautions and thickened feeds. The ultimate goal is to rehabilitate the swallow mechanism by improving the motor plan to increase safety and function. SLPs need to advocate to be included in multidisciplinary teams for all feeding difficulties. We can promote our value in early oral motor and swallow interventions, decreasing the long-term need for thickener and the need to undo developmental effects of overuse of thickeners. Sources Feştilă, D., Ghergie, M., Muntean, A., Matiz, D., & Şerbanescu, A. (2014). Suckling and non-nutritive sucking habit: What should we know?.Clujul Medical, 87(1), 11–14. CrossrefGoogle Scholar Goldfield, E., Smith, V., Buonomo, C., Perez, J., & Larson, K. (2013). Preterm infant swallowing of thin and nectar-thick liquids: Changes in lingual-palatal coordination and relation to bolus transit.Dysphagia, 28(2), 234–244. CrossrefGoogle Scholar Lau, C. (2015). Development of suck and swallow mechanisms in infants.Annals of Nutrition and Metabolism, 66(Supp. 5), 7–14. CrossrefGoogle Scholar Newman, R., Vilardell, N., Clave, P., & Speyer, R. (2016). Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: White paper by the European Society for Swallowing Disorders (ESSD).Dysphagia, 31(2), 232–249. CrossrefGoogle Scholar Author Notes Mallory LaBarre Millet, MS, CCC-SLP, works in a pediatric outpatient clinic in Baton Rouge, Louisiana, providing treatment for infant/newborn feeding progressions and functional swallow deficits. She is pursuing Board Certification in Swallowing and Swallowing Disorders. 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