Case by Case, Transitioning to Oral Feeds

as published in Pediatric Feeding and Dysphagia Newsletter, October 2007
By Amy Thorpe, M.Ed., CCC/SLP

Background: JC, a 4 month old male, was a term baby born with a tracheo-esophageal fistula (TEF). TEF repair was completed and esophageal dilation was performed 5 times to reduce stricturing. Primary method of nutrition was via G-tube feeds with intermittent attempts of oral feeds as tolerated. Upon evaluation at the bedside, JC demonstrated functional oral motor development and an appropriate non-nutritive suck.  He appeared interested in the bottle and demonstrated a coordinated suck/swallow/breathe ratio during oral feeding. Shortly after oral feeding was initiated, signs and symptoms of distress became apparent characterized by postural arching, color changes and refusal of the bottle. A video fluoroscopic evaluation of swallowing (VFSS) was conducted to assess oral, pharyngeal and esophageal phases of swallowing.

Results of the VFSS revealed functional oral and pharyngeal phases of swallowing with no aspiration or pharyngeal stasis. Esophageal phase of the swallow was abnormal characterized by significant stasis in the distal esophagus above the level of the TEF repair secondary to a narrowing of the esophageal space and delayed esophageal motility. Liquids were noted to pass through the esophageal stricture with a delay.

The patient was observed under fluoroscopy using both a standard flow Enfamil nipple and a slow flow level 1 and 2 on the Bionix Controlled Flow Feeder. Results with the Enfamil standard flow nipple significantly increased the amount of esophageal stasis and patient discomfort was apparent characterized by postural arching and crying. External pacing was required to reduce the amount of bursts to no more than 5-6 per pause in attempts to reduce esophageal stasis. In addition, several minutes were required to clear to stasis. Results with the Bionix Controlled Flow Feeder on level 1 and 2 revealed a significant reduction in esophageal stasis due to the reduced amount of formula being presented during nippling, allowing the infant to continue nippling at a rate of 20-22 bursts per pause without the presence of significant esophageal stasis. The patient was organized and calm during the slow flow rate process. When the flow rate was raised above a level 3, esophageal stasis increased and patient disorganization observed.

Intervention and Outcome: A primary goal for JC was to continue the ability to maintain oral feeding skills and development, maintain esophageal motility and continue exposure to oral feeding without developing aversive feeding responses due to physiologic complications. When the patient was placed on a slow, controlled feeding rate of bolus delivery which did not compromise the integrity of the esophagus, response to oral feeds was positive. JC was able to successfully orally feed 30 ml’s of formula every 3 hours in 10-15 minutes using a level 2 on the Bionix Controlled Flow Feeder daily with supplemental G-tube feedings. Aversive feeding behaviors were not noted during oral feeding attempts with the controlled flow rate.

JC received 3 additional esophageal dilations aiding in reducing the esophageal stricture. As the stricture reduced, the flow rate of the formula was increased on the Controlled Flow Feeder with no aversive behaviors observed.

At the conclusion of esophageal dilation, VFSS was repeated. Results indicated a significant improvement in esophageal motility and a significant reduction in esophageal stasis. JC was able to nipple at a flow rate of 5 on the Controlled Flow Feeder with minimal stasis or disorganized feeding patterns. Over a period of weeks, oral intake was gradually increased and JC was successfully transitioned to a standard flow rate nipple. Currently, tube feeds are not required and JC is taking full oral feeds from a standard flow rate nipple.

Conclusion: Through the gradual and systematic increase of flow rate and amount of bolus presented using the Controlled Flow Feeder, JC was able to maintain oral feeding skills without developing aversive feeding responses. He is currently taking full oral feeds and is beginning to transition to stage 2 foods without difficulty. Parents are thrilled with his progress and he is continues to do well!