[Dysphagia] [asha-div13] first cup

[Catherine.Shaker at wfhc.org (Shaker, Catherine S.)]

In considering cup drinking options for this little guy, it is helpful
to note that a faster flow may actually create more work for him from a
cardiorespiratory perspective. Sounds surprising  I know but I'll try to
briefly explain the physiology :-)
 
The "work of sucking" is often perceived as the critical focus for
infants with cardiac problems.
However, concern for the "work of breathing", in the presence of a high
or fast flow, has been noted in the literature (for example, Google
"O.P. Mathew", a physician whose interests and research are focused on
breathing and swallowing; numerous articles from the 80's and early
90's). 
 
The idea is that not being able to breathe when one wants to/needs to,
due to spending so much time swallowing a faster flow, creates more
cardiorespiratory effort than does the actual "sucking" from a nipple. 
 
That is, the "effort" required to suck has much less of a physiologic
impact than waiting to do the deep breathing that resaturates our blood
with oxygen, and optimizes respiratory stability, for example. Mathew
does a nice job explaining this. 
 
It is a fundamental paradigm change that, when thinking shifts, can have
a dramatic effect on feeding experiences for preterm infants and those
with Chronic Lung Disease, as well as cardiac babies. Physiologic
parameters (such as RR, HR, TCP02, saturations) are more stable with a
controllable flow. That is because the infant can breathe whenever he
needs to, because he is not working against flow. Coordination of suck
swallow-breathe is also typically more synchronous when the flow is
controllable, especially if cardiorespiratory reserves or stability are
suboptimal.
 
The influence of flow rate on cardiorespiratory control is also why
breastfeeding, even for premies who are as young as 31 weeks and less
than three pounds, is less stressful physiologically than bottle
feeding. The infant can control the flow at the breast (through slowing
his sucking rate and reducing his sucking pressure) versus being able to
only "respond to" the flow from a man made nipple. Work by Paula Meier,
recognized as publishing the gold standard literature in breastfeeding,
is quite interesting in this regard.
 
I like Hilda's suggestion for thickened liquids from a cut-out cup, and
I'd add pacing to limit the bolus size based on the baby's physiologic
cues when drinking. If some bottle feedings were to continue, I have
observed a slow flow nipple have a similar positive effect on intake and
cardiorespiratory function (as compared to a high flow/fast flow
nipple).
 
Hope this is helpful! 
Let us know what the baby tells you--he will let you know what works :-)
 
Catherine
Catherine S. Shaker M.S./CCC-SLP, BRS-S 
Board Recognized Specialist, Swallowing Disorders 
NICU/Pediatric Rehabilitation 
Wheaton Franciscan Healthcare - St. Joseph 
5000 West Chambers Street 
Milwaukee, WI  53210 
414-447-2797 Phone 
414-874-4104  Fax 
Catherine.Shaker at wfhc.org 


________________________________

	From: Sarah and Bruce Feder [mailto:sbfeder at earthlink.net] 
	Sent: Tuesday, July 10, 2007 7:43 PM
	To: Division 13 Discussion List
	Subject: [asha-div13] first cup
	
	
	I am working with an 11 month old who is just beginning oral
feeds. He has cardiac issues and sucking a bottle is very tiring for
him.  He was given a cup with a cover and spout without the valve so no
sucking is necessary and he did well.  What cup have any of you used
with success in this situation that does not require sucking (and is not
a 'sippy' cup).  I am thinking of also trying a straw cup, but are there
any other suggestions?
	 
	thanks!
	Sarah


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