Breastfeeding Among Infants Who Aspirate
by Anne Eglash MD, IBCLC, FABM
Oropharyngeal aspiration is a fancy term for the food going down 'the wrong way', into the lungs to some degree. Formula fed infants who have swallowing dysfunction and aspirate formula into their lungs have a higher risk of recurrent pneumonia and lung inflammation, although we have no evidence on the effect of aspirating breastmilk into the lungs.
Many lactating parents of infants who demonstrate aspiration have been advised to express their milk, thicken it, and feed it via bottle, or the infants have undergone feeding tube placement. Bottle feeding thickened breastmilk or feeding tube placement has not been proven to be safer than direct breastfeeding in terms of risk of respiratory illness. Breastfeeding has been shown to be very protective of respiratory illness and risk of death from severe infectious illnesses.
The study for today’s CQW is a retrospective chart review of 80 infants seen in a tertiary pediatric aerodigestive center in Boston MA from August 2016 to March 2021 at 1-6 month of age, who were diagnosed with a degree of airway invasion when swallowing via videofluoroscopic swallow study. They were all given clearance to continue direct breastfeeding and/or provide bottles of unthickened breastmilk. The infants were followed for 3 months, for evidence of lung disease such as wheezing, bronchiolitis, croup, or stridor during or after feeding, pneumonia or persistent bacterial bronchitis.
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Breastfeeding is widely recommended as optimal nutrition for infants. However, there are no known publications on the impact of prandial aspiration of breast milk fed infants with dysphagia. The goal of this study was to assess pulmonary outcomes in infants with dysphagia who were given medical clearance for intake of breast milk.
This retrospective cohort study included review of 80 infants examined between August 2016 to March 2021. Patients were evaluated by an interdisciplinary team of providers in a tertiary pediatric aerodigestive center. Patient inclusion criteria included a VFSS with documented aspiration or penetration with thin liquids. Participants met inclusion criteria if given medical clearance for intake of breast milk despite aspiration risk. Pulmonary health was monitored for three months following medical clearance for the consumption of breast milk. Pulmonary illness was defined as development of bronchiolitis, wheezing, unexplained stridor during feeding, croup, pneumonia, or persistent bacterial bronchitis requiring medical intervention.
Forty-three males (54%) and 37 females (46%) enrolled in the study with an age range of 1 month–6 months corrected age. Mean age at initial VFSS was 3.6 months. Twenty-six out of 80 (32.5%) had a report of a mild cough but did not require intervention. Eight out of 80 (10%) received a diagnosis of a pulmonary illness. Seventy-two out of 80 (90%) did not report pulmonary illness.
This pilot study reveals that the majority (90%) of this single institution, small sample size cohort of breast milk fed infants with documented oropharyngeal dysphagia remained healthy despite continued intake of breast milk. Prospective investigation is warranted to follow pulmonary health outcomes longitudinally and a head to head comparative study would be helpful to identify whether there were indeed significant changes to pulmonary health according to differential feeding regimens offered and followed.
This is great news on an important topic! The researchers found that 32.5% of the infants had a mild cough but no significant lung disease that required treatment. Ten percent of the 80 infants were found to have lung disease due to aspiration, and 60% of these infants needed surgery for a laryngeal cleft.
I suspect that breastmilk is likely to be microaspirated into the lungs at some point in a breastfed infant’s life, given how common it is to see babies cough during breastfeeding, especially when they fall asleep while still latched. This may serve to protect lung tissue from disease, given the immune modulating and anti-inflammatory nature of human milk, along with its anti-infective factors.
The authors identified that lack of follow-up after 3 months of their initial videofluoroscopic swallow study (VFSS) may be a limitation of this study.
The authors also shared that this work led to a change in their practice, such that breastfed or human milk fed infants referred to their center are not automatically subjected to a VFSS study if they are otherwise doing well with no evidence of lung disease.