Thickened Feedings for Infants and Children: Moved this to a larger post as I have rocked the world of too many therapists
Posted Oct 19 2008 12:00am
Thickening: For More On Pediatric Dysphagia, See the Cochrane Reviews http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME
Controversial subject! How thick do you go? Don't we as therapists thicken liquids as one of our big guns of feeding therapy?
Here are some of my thoughts. I think thickening is not doing therapy. Now, don't get all crazy yet. It is a COMPENSATORY measure, not TREATMENT of the problem which is swallowing thin liquids. You are moving in the right direction, but not getting to the heart of the problem. It has it's place but you must always worry about aspirating thickened material in the lungs or having thickened feeds come back up and be aspirated as gastric content.
Still reeling? OK, say, I want to go to Cincinnati and you give me a map that takes me to Cleveland. I get there and say, "Hey, I asked to go to Cincinnati" and you say, "Don't worry at least you are in Ohio." Yes the child is eating. But I am not happy with Cleveland. No offense, Cleveland. But I digress, I am glad you are in Ohio, but I want to give you the skills to make it all the way to Cincy.
Now swallowing thin liquid is a life skill we want for all our babies. The earlier we work on building those skills the better. I may work on single drops of thin liquid and continue to work up as slowly as needed. I may use pacifier and Hazelbaker Finger feeder or syringe. We do it in a safe manner with a physician's order and understanding of what we are doing. We use our CCCCC's as speechies adding Common Sense and Compassion to the Certificate of Clinical Competence. If I am dealing with a child with a challenge such as a craniofacial problem or Cerebral Palsy, I am going to use thickened liquid and the best products/positioning and pacing strategies I know to keep the child safe. But I am going to work on the skills to refine them as much as possible. I am going to look hard at nutrition and hydration.
Our position is that we work on thin liquids with a slow flow nipple, paired with positioning modifications (side tilt may work) and external pacing of the feeding before ever considering thickening. Nectar is as thick as I will go for babies, but only after I have worked on skills to handle thin liquids. When I do thicken liquids, I always continue to work on moving to thin over the course of treatment via a Pre-Chaining program and beyond. I monitor every session via cervical auscultation of the swallow. If you are treating infants, don't go thin immediately and hurt the baby, work TOWARD thin as tolerated. If you thicken, don't thicken and walk away and think you got the child there. Keep working, thicken and gradually work down to thin as tolerated. Keep working with a focus on the oral skills you need to develop. Strengthening oral skills, improving bolus formulation and control, working on trigger of the swallow with slightly cool temp liquids may help.
Honey thickened liquids for infants are a huge concern from both a nutritional and oral motor/swallowing perspective. Does a baby have a swallow that is capable of clearing liquid of this consistency over the course of 8-12 daily feedings? Never thicken liquids without a swallow study to show that the baby is safe for this consistency of liquid.
If Honey is Not Recommended, What Then, A Tube? Most parents are very distressed by the thought of a tube. You need to educate the family and help them consider all the pluses and minuses of nasogastric and gastric tubes. Nutrition the first three years of life is vital. Take time, talk to your families, set goals together and help them through these difficult times. If you have a plan it is very helpful to see the progression toward safe oral intake. Most of my patients eat better with a g-tube and they make progress in all areas (sensory, fine and gross motor, sleep, stooling, health). But it is not easy.
So in the meantime, when I have to thicken, what should I use? Simply Thick/Hydra Aid/Thick-It/Thick Em Up or Cereal? If you chose to use Simply Thick it must be whisked, not shaken. There are concerns now regarding the preservative sodium benzoate in this thickener (see articles). We need to know more about this. We do not use Simply Thick in a g-tube for reflux. In our practice, we do not use Thick-It or Thick Em Up with our pediatric population. Cereal is not the answer for reflux. To reduce reflux, cereal must be so thick an infant cannot consume it. We generally use about 1/2 tsp blenderized rice cereal per each ounce of liquid for our babies. With kids, we are very creative about thickening and sometimes come up with our own yummy blends in smoothies and shakes. Many caloric supplements are already at a nectar consistency and so are drinkable yogurts. With kids, I may add carbonation via small amounts of ice cream floats, to work on trigger of the swallow using both carbonation and cold temperature. I may do small cold water trials with lemon juice in tiny amounts. It depends of the needs of the child.
Blenderized rice cereal This is an option if you want to help the child with bolus control and airway protection as you work toward thinner consistencies. This means you put dry cereal in a blender or food processor and pulse it a few seconds to crush the flakes to a fine powder. This will often mix better and not clog the nipple.
What about Air Ingestion? Often air ingestion is a contributing factor to reflux. The Dr. Brown products help reduce air intake significantly. We also like the Parent's Choice nipples (can be used on the Dr Brown bottle too) to help seal the mouth better while feeding. Finding a nipple that provides optimal lip seal for the infant also helps reduce air intake and helps the infant control liquid and swallow more efficiently. The Dr Brown also flows about a beat slower and may also help protect the airway. Laser cut nipples (hole in the nipple is created by laser in the company) and good silicone mean this product is reliable and flow rate is not variable the way puncture cut nipples are.
Never Cut a Nipple-Use Cereal Nipples Instead Never, ever, ever, ever, under any circumstances, slit, cut or enlarge the hole of a nipple. The Dr. Brown Y-cut nipple is your best option as it is made for thickened feedings. You do not have to blenderize cereal when using this product. You may also like to use a Parent's Choice 6+, Gerber silicone fast flow nipple, Dr. Brown Level II or Level III nipple for blenderized cereal feedings.
Be Safe- Do A Swallow Study A swallow study or FEES assessment is required to determine which product is best for the baby or the child you are treating. It is also necessary to repeat the studies as you progressively thin out the feedings. You should limit studies to three a year maximum. Cervical auscultation and observation are very important throughout this process.