Tuesday, November 29, 2011
Okay, so this is not within my field of specialty, but I guess I'm throwing it out there for an chiropractors or SLPs who may have come across a case like this....

A friend of mine has a four month old that has had a difficult few months with management of oral/pharyngeal mucous. Also add onto that fun mix some projectile vomiting, and you've got some worrying symptoms. From the get-go he was breastfed, and he has done great! Consistently gaining weight, not appearing (from maternal observation) to have difficulties with suck/swallow/breath patterns. All seemed pretty normal as far as those areas go. Only other notable information is that he is a frequent feeder at times (1 to 2 hours in between feedings at night for example). Considering he can feed for a longer period of time, and go for longer periods of time in between feedings, it all balances out to a normal, healthy baby.

The mucous began to really be an issue. He began having periods of what was likely a penetration or aspiration of mucous causing some choking spells with difficulty breathing. Yikes! Poor little guy (and parents) weren't happy.

Added info update: The mom has talked to pediatrician who feels his drooling is a normal amount (they unfortunately live in a different state), woohoo! Mainly the issue appears to be overly thick mucous

The pediatrician, (and admittedly me) think perhaps it could be GERD (reflux). Another thought was that it might be due to a slight allergy to dairy products. The mother stops dairy products, AND... there is a significant improvement! Since dairy products can thicken mucous due to fat content, I am curious if this could carry over to breast milk thickness as well. I still have lots to learn about pediatric dysphagia.

Despite the significant improvement, the poor guy is still having choking with periods of apnea. The parents are awesome though, and they didn't give up trying to figure out what was up with their little one's feeding issues! (Add on... significant drooling; poor oral management of mucous) Through a friend that is a chiropractor, they learned that the little one appears to be suffering from a vertebral subluxation. 

Due to the trauma of  birth, vertebrae can become misaligned. If the vertebrae are misaligned, this can cause nerve difficulties and tightening of muscles. From what I read though, the idea of subluxation among chiropractors is not a 100% agreed upon diagnosis due to lack of clinical research evidence. Regardless, this could just be due to the lack of accurate/appropriate research being completed. Not my field to know the answer to that question... either way -- the doctor performed an adjustment on the baby and now it is a waiting game! He believes that this subluxation caused an over tightening of the neck muscles (comparative to whiplash), which may be causing difficulties in managing mucous.

I'm incredibly curious if this will help him out because:
a) I don't want him or his family to have to go through the pain of him having difficulties any more!
b) I'm curious if there are other cases out there which might benefit from chiropractic intervention.

Of course, it is not my place to recommend/refer a client to a chiropractor, but I would love to see if there is more information out there. A quick search of the ASHA journals didn't really turn up anything immediately.

So... we shall see!

Otherwise... next step I'd recommend? Perhaps a barium swallow study to make sure we've got 100% normal anatomy going on there. Course... I'm a Speechie, so of course I'd recommend that! 

:) Here is thinking happy thoughts that they have found a fix! AND.... I welcome any insight from chiropractors or pediatric dysphagia specialists that may have dealt with a situation like this before.

Time to head home and try to put my work out of my mind for at least a little bit. ;)

Update!: thank you for the comment with suggestions! I haven't recommended a swallow study to her yet because he has not had any major respiratory issues that would make me immediately think aspiration. I am guessing most likely penetration, no aspiration. But thickened mucous, difficulty swallowing appropriately... Hmm? Will update as we get more info. It is an "interesting" case (though it feels inappropriate to say that, I think my friend would agree)


Eco Yogini said...

wow that is a new one.
well- since i've just finished leading the local peds dysphagia course, this stuff is fresh on the brain.
i'm wondering how "tightening the neck muscles" really helps in oral management of mucous? I've never heard of this (doesn't mean it doesn't exist).
It could be a variety of things, but i agree with you- a Videofluroscopy is a must to assure no aspiration is occurring. There is also a "nuclear test" (very safe!) that assesses whether any of the mucous has been making it's way into the lungs. If he's not managing his mucous, then how do you think he's managing liquids? Silent aspiration is a risk, even at that young age...

if there is a "feeding team/clinic" at your local hospital, i would refer immediately to the feeding/dysphagia SLP/OT/Dietitian team.... (whatever is common where you are)

very interesting! Sending hopeful thoughts!!

Unknown said...

I commented in the post, but feel like I should respond here, too. I think the main issue is mucous in the pharynx that is overly thick. The idea of allergies makes sense since if the body is trying to fight off an irritant, it can cause some thick sinus drainage. I don't really know much about postnasal drip-type symptoms in an infant though... I think the choking is probably from penetration and the apneic episodes perhaps from laryngospasms after the cough reflex. He has had no signs of respiratory issues that would make me immediatly say "Go get a swallow study!" Yes, he could be having silent aspiration during mealtimes, but since I'm going off verbal info only and no direct observation, I'm going to assume that the pediatrician would pick up if this is a necessary step. We'll see!

Eco Yogini--

I am the owner of the above mentioned cutie pie. The trauma incurred during birth/during his daily life (including flinging his head back involuntarily while we hold him, attempting/learning to roll over and subsequently getting stuck in awkward positions) caused the tight muscle in his neck. That throws off the absorption of calcium and magnesium, which has inevitably led to him not sleeping at night, because his body is trapped in a cycle of not knowing when to sleep, but being exhausted at the same time. Somehow, this is connected to his stomach/diaprahm (we received a lot of information today, and I'm still trying to process it all). His stomach is too high, and his stomach acid is too weak (I believe this all has something to do with the lack of mineral/vitamin absorption, which brings you back to the neck issue), so his stomach is working in over time to break down what he eats, thus making it very easy for milk to flow back up in a silent reflux type of way. The milk goes into his nasal cavity, signaling to his body to create more mucus for protection. Now we're back to the neck. He's got an overabundance of mucus, and instead of draining through proper channels, it goes down his throat, because his neck is too tight to allow proper drainage. *phew*. The dr. told us that the adjustment he did today was one of the most significant he's made because of how tense his neck was. He had some pretty serious loss of range of motion on one side of his head (could look better one way than he could the other). Which, somehow I never noticed, but am not happy that our ped. missed.

Thank you for your insight :-)

Unknown said...

Hehe... And she emerges from anonymity ;) he is so stinkin adorable! What you say makes sense... I wish I could find out more info on it in our swallowing research, but I guess first step is to see about pediatric chiropractors in my area to see if anyone is trained in this. Crazy about the limited neck movements ! I could definitely see how restricted neck muscle movement can lead to difficulty in pharyngeal phase of swallow. :)

Unknown said...

Added note from an SLPeep on Twitter... Might want to consider tracheomalacia as another possibility

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