Hi! I also posted this in Ask SLP, but I just noticed there has been no responses there from the expert in a LONG time, so I thought I would post it here as well. I have a question about my 19 month old son. He is about 2 1/2 months post op from a nissen fundoplication and is having swallowing difficulties. We have not been allowed to try to feed Brent orally since early December when we tried to feed him puree, and he got aspiration pneumonia. Although I might mention that before surgery he would not eat either, and has been tubefed since August because of severe damage to his esophagus.
We went on Monday for a swallow study to see if he was aspirating when he tries to eat, and luckily he did not aspirate during the test, and that we could resume trying to get him to eat orally. However, he did have severe gagging, delayed swallowing, double swallowing, that she said was indeed a pattern for him and she may have to document that. I have read a artilce recently ( by Suzanne Evans Morris SLP, New Visions) that stated when there is delayed swallowing, the child may be at high risk of aspirating.
What do you think of this, is it safe to continue to TRY (so far he really shows no interest in eating, and we will not push him) A couple of time he has willingly taken a bite and has had the severe gagging, choking. And what can be done to help him swallow better.
He does have OT, which has been on hold as he has been having an extremely complicated and painful recovery, we have also recently learned that he can reflux past his fundoplication, so we are still dealing with that as well, although it is better. There was also concern that his wrap was too tight, as his surgery was a very difficult procedure for the surgeon(he was in really bad shape in there, everything had to be reconstructed) The barium did indeed fit through the wrap,but I wonder if that means food will go down smoothly as well. As you can expect he does have fear of eating, as he has been in a lot of pain in his little life.
Well thanks in advance for any thoughts you may have.

Hi Jessica:
Apparently I am having posting issues tonight and somehow lost my first post to you…grrrrrr L. Here goes take # 2 …lol! I consider you an “expert” GERDling mom having done this 4 times. I am a feeding specialist and I am happy to give you my 2 cents worth. I do treat head to toe with the exception of speech and language, which is not in my scope of practice. My specialty areas are reflux, dysphagia or feeding difficulties, and modified barium swallow studies. I perform several studies a week with our radiology team.
Let’s talk about Brent. With limited information, I know that he really has not been eating much, if anything orally since August. He has also had significant esophagitis and he is refluxing superior to the Nissen. Up to 30% of patients with Nissen’s have retch syndrome. Persistent retch can loosen the Nissen wrap to the point where patients can reflux to the hypopharynx or even vomit. I have had many patients who have done this. I have also had patient’s whose Nissen’s were done too loosely. I have also had patient’s whose Nissen’s were done too tight. It is rare for surgeons to go back in and “adjust” Nissens. This is only done if the patient is having frequent aspiration/pneumonias.
During a swallow study, a therapist has a limited time to view the oral, pharyngeal, and esophageal swallowing phases without over-radiating a patient. We typically view the very beginning of the feeding and observe them consume only a fraction of what they usually eat. If a patient has a “normal” swallow, he will have a suck-swallow-breathe ratio of 1:1:1. As clinicians, we look for other “red flags” of possible aspiration during this quick test. Signs of an in-coordinated swallow at the beginning of a MBS study include nasopharyngeal reflux (food/liquid going up into the nasal sinus), decreased velar elevation, a delayed swallow, laryngeal penetration, and epiglottal undercoating. Suzanne Morris is absolutely correct! If a patient has a delayed swallow on the first ½ - 1 ounce of intake, imagine what he is doing by the 5-6 ounce. One must also look at the big picture too. This includes health history (i.e. frequent upper respiratory, ear or sinus infections, GERD, asthma, coughing/choking during feedings, sounding increasingly congested post feedings, not WANTING to eat, gagging, and retching). Swallow delay, or food hanging out over the airway for any length of time makes us a little nervous! We do worry about aspiration events that can occur with or without a cough.
Little ones are very smart. If they do not want to eat, they are usually trying to tell us something is wrong. I look at a child’s history first. If they look “too good” at the beginning of a study, I feed them a little more when the fluoro is off so I can look at the swallow with a little fatigue and to see what kind of feeding endurance the child has. The end of a feeding is when I usually “catch” my aspirators. If I don’t, I ALWAYS recommend thickened feedings regardless, especially for a child like Brent who has been non-oral and aversive for so long. I would highly recommend talking to your OT about implementing some fun oral-alerting activities to get Brent back into the swing of things. In addition, I would try smooth, yummy textures such as pudding or yogurt, and dip fake food into these consistencies to model “taking a taste.” Write back if you have questions. I hope this helps J

Robynne