As clinical manager for Diagnostic Radiology at the Brigham, Meghan Hopkins, R.T.(R)(ARRT), and her colleagues had always cared for adult patients. Then, about two years ago, a multidisciplinary team from the Neonatal Intensive Care Unit (NICU) approached them to see if Brigham Radiology could begin performing swallow studies for babies in the unit.
Videofluoroscopic swallow studies are video X-ray exams used to visualize, in real time, what a person’s mouth and throat do when eating or drinking. These studies are an especially important diagnostic tool for NICU babies, who can have trouble swallowing milk or formula correctly but cannot communicate this to a caregiver. Young babies very rarely cough when they aspirate, or inhale, fluid into their lungs.
Until recently, Brigham NICU babies who needed a swallow study — about 10 percent of patients — underwent testing at Boston Children’s Hospital. This process included temporarily discharging the baby from the Brigham and transporting the baby, along with their nurse, their feeding team and often their family, to Boston Children’s. Once completed, the transport and admission process happened again in reverse.
While it was an important and valuable collaboration between the two hospitals, it was time-intensive and came with logistical challenges for Brigham NICU patients and families. Notably, scheduling options were limited to one or two slots per week. Additionally, the two hospitals use different electronic medical record systems, meaning test results were not immediately available to the baby’s care team. As a result, infants who needed swallow studies often stayed three to four days longer in the Brigham NICU than necessary.
“It was amazing to us — and a little shocking — when they told us about the delay in discharge for these babies,” Hopkins said. “Hearing that pulls at your heart. You think, how do we make this happen so that these studies can be done here?”
From Idea to Reality
After many meetings, significant planning and the combined efforts of several teams — including Infection Control, Nursing, Pediatrics, Radiology and the Speech/Swallow/Feeding team from Rehabilitation Services — the Brigham began providing in-house NICU swallow studies in 2022.
These tests are now performed in Fluoroscopy on L1, with dedicated times available for NICU patients every weekday and capacity for up to 10 infant swallow studies per week. The initiative has been nothing short of a “huge success,” said Lorraine Downey Cuddy, MS, CCC-SLP, clinical supervisor for Speech and Swallow.
“We are able to get our babies the swallow studies they need in a more efficient timeframe, which in turn allows the feeding team the opportunity to recommend the safest mode of feeding for one of our most fragile populations,” she said. “We are now also providing better continuity of care. The same feeding specialists who follow our babies in the NICU are also the ones performing the studies, which results in a better overall NICU experience for our families as well.”
As department leaders worked out all the administrative details that needed to be coordinated — billing, coding and so forth — Radiology staff worked with feeding specialists from the BWH and Massachusetts General Hospital to understand how to perform swallow studies correctly and safely on infants.
Most notably, babies are placed in a special seat, similar to a car seat, that appears transparent in imaging while keeping the infant in a safe, supported position during the test. The baby is then fed liquid barium — a safe, sweet liquid that shows up on the X-ray.
Although infant swallow studies are commonly available in children’s hospitals, very few adult hospitals with NICUs offer them to pediatric patients, explained Dodrill, one of two clinical specialists on the NICU Feeding Team along with Katherine Gibson, MS, CCC-SLP, BCS-S, CNT.
“A lot of NICUs in adult hospitals have to send babies by ambulance for these tests,” she said. “We were lucky to have a bridge to Children’s and very appreciative of their partnership, but it’s not the same as having access any day you need it. You can also be more responsive if you’re the clinician who is both caring for the baby and completing the study.”
Having greater flexibility in scheduling means families are more likely to be able to attend the test and ask questions in real time. Additionally, the results are entered directly into the baby’s chart and become immediately available to the full care team.
All of these changes have elevated the experience of patients, families and staff, said Julie Cadogan, MSN, RNC-NIC, CNL, nursing director for the NICU.
“Everyone worked together to figure out how this was going to function safely and effectively,” she said. “We’re so pleased to know patients and families are benefiting from this initiative, which has also streamlined workflows for our nurses.”
An Unexpected Role Reversal
Hopkins witnessed the significance of these changes firsthand — and not only as one of several technologists who underwent special training to conduct these tests on infants. Just a few months after working behind the scenes to help bring the project to fruition, she found herself on the other side of it: as a mother with a baby in the Brigham’s NICU who needed a swallow study.
Her daughter, Aime, was born at 34 weeks gestation via emergency cesarean section after Hopkins experienced severe preeclampsia, a form of persistent and life-threatening high blood pressure that can occur during pregnancy. Baby Aime’s lungs were underdeveloped at birth, which, among other complications, led to feeding challenges during her 57-day stay in the unit.
After about two months in the NICU, Aime’s feeding specialist, Pamela Dodrill, PhD, CCC-SLP, BCS-S, CNT, recommended a video swallow study. That morning, Hopkins texted a Radiology colleague to let her team know they would be coming down to L1 that afternoon for Aime’s test.
“I had been on the clinical side of it before, and now I’m the parent watching my baby swallow barium on the screen. I was so anxious, just waiting for Pamela to give me the thumbs up,” Hopkins remembered. “But I knew it was all going to be OK— and fortunately it was — because we had the best people performing the exam.”
Katy Locke, MHA, R.T.(R)(ARRT), assistant clinical director for Diagnostic Radiology and the Lee Bell Center for Breast Imaging, said the experience of caring for Hopkins and her daughter reaffirmed for the entire 70-person team why this project deserved their time and attention.
“We all know how busy the NICU is, and doing these tests here allows them to discharge patients sooner. Everybody, of course, understood why that mattered, but when it impacted one of our own, it really drove home how important it is that we do this,” Locke said.
Baby Aime, who is now 5 months old, was discharged home this summer and is doing great, her mother said.
“She is such a smiley girl, and her laughter is the best thing ever,” Hopkins said. “We still come into the Brigham for the NICU Follow-up Program, and we recently saw two members of the feeding team. I gave her a bottle right in front of them, and they were so excited to see how big she’s gotten.”
Why Perform Swallow Studies?
Even to a trained professional, it can be difficult to determine if a newborn is aspirating milk or formula simply by observing a feeding session, Dodrill explained.
“Not only are they unable to tell you something doesn’t feel right, but we found in one research study we did with Children’s that only 5 percent of babies under 6 months will cough when they aspirate,” she said. “It’s because they take these tiny sips. Adults take in about 15 milliliters per sip, whereas babies only take 0.1 or 0.2 milliliters per sip. So, it’s not like a whole lot of liquid ends up in their lungs. It’s more like little sprays.”
Feeding specialists will recommend a swallow study when a baby is not progressing as expected, such as failing to wean from oxygen or a feeding tube despite hitting other milestones, Dodrill said.
“It’s often a subtle suspicion that something isn’t right,” she said. “In fact, we find 85 percent of the babies we bring for swallow studies are aspirating, but that doesn’t always mean we have to make them stop eating via breast or bottle. It often just means we have to change something about how they’re eating, such as using a slower-flow nipple, changing positions or thickening the liquid.”