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Sunday, December 9, 2007

Question: Vocal Cord Paralysis and Eating

I know that there are a bunch of you moms out there with experience in this field, so this one is for you:

Yesterday, Sharon was eating a piece of reheated pizza and Hallie expressed a lot of interest in it, and so we thought: what the heck, she's not had anything to eat in a while, why don't we let her experiment with taking a bite and see what happens (and of course we prayed we didn't have to dust off those rusty CPR skills). It went great--it was clear that she knew how to bite (all that practice with book eating really seems to have paid off), and she knew how to chew--definitely up and down and perhaps some rudimentary rotary chewing. She still is lacking her first year molars, but she looked good chewing. And she even figured out how to swallow without panicking (we've always assumed the vomiting up of solids was a fight-or-flight thing kicking in).

That went well and we thought: maybe the issue is that Hallie can't deal with thick purees' texture but is okay on crunchy stuff (there is evidence that this is true of other kids). So we decided to see what she would do with the first real hard food kids often get: biter biscuits (or teething biscuits). We have a full stash of all possible foods you might feed kids who are transitioning to solids (of course we do: whenever she fails to eat I buy new products that she ends up not eating in the hopes that she might be able to eat them). And so I ran to the kitchen and got one and we put her in her high chair in front of a Sesame DVD and let her have at the biter biscuit.

She did great. It took awhile, but she bit off pieces, chewed them, pulled out pieces that were too big, put them back in (sorry about that graphic image) and ended up swallowing them. There was a tiny amount of choking, sputtering, spitting, but nothing disturbing.

Now we were really puffed up, so I decided to pick up some Cheese Puffs (sorry about that bad pun) at Whole Foods (they are NOT as tasty as Cheetos, by the way). We were going to our neighbor's Josh and Nancie's for dinner and thought that it might be nice to use these as a bribe for Hallie to stay in her high chair and let us eat dinner together like real people do.

This worked for a while. She bit, crunched, munched and swallowed. We were thrilled. Our kid was eating something normal. Our kid was eating the same thing that another kid at the table (Ethan) was eating. Wow.

But then the choking started. And with it, the spitting. Which turned into vomiting. And morphed into projectile vomiting.

And so my question for you guys out there is this: is she doing this because food is going down the wrong way because her vocal cord is paralyzed ALMOST but not quite at midline? Is it going to be possible to do something about this if that is the case? Will that something involve a. surgery, b. botox, c. training her once she is old enough to follow our guidance how to handle solid food when choking happens, or d. something else I haven't thought of doing? And what do we do in the meantime? Do we go back to the nasty purees like the feeding clinic wants to do, just feed her Stage 2s because they are safe and we can get them in with minimal distress and they help her get nutrients and calories, or keep trying with the crunchy stuff? We're at a loss here, and kindof sad to have moved so quickly again from elation to dejection in less time than it would take you to chew and swallow ten cheese puffs...


Meg Weaver said...

Firstly, I'm not a mum (or doctor, or anything) so feel free to disregard me. I have, however, read through your archives and have a few thoughts. I think that if Hallie is willing to try something, go with it. She seems like she's good at telling you what works and what doesn't. Cheese puffs are a very different texture than biter biscuits so that may account for the sudden vomiting. I would use the biscuits (and other crunchy things) as a supplement/fun food/big girl reward and count them as bonus calories rather than relying on them for the precious RDAs. Learning to eat a new thing is challenging for anyone, especially in a social environment where there are other distractions.

Slightly related (again, not a doctor or a mom) have you ever considered tummy massages to help with digestion? Massage therapists have some very specific techniques especially to stimulate the stomach and digestive system.

Anne said...
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Anne said...

Not that I am a font of wisdom on this, but Eliza Grace does pretty much the same thing, and does not have a paralyzed vocal cord so I am thinking this is more related to the general "what the heck do I do with this stuff in my mouth" syndrome. She actually does well with the cheese puffs (likes the Wisconsin white cheddar ones best) since I think she feels these are "safe" since they eventually melt if she can't negotiate it around her mouth.

This morning at my Mom's Eliza bit and chewed several fairly large size pieces of toast with butter and, like Halle, got rid of the pieces she couldn't handle. Did the same thing with a Lorna Doone cookie and some gold fish (now there's a healthy diet!). After a while though as she continue to try to "snack" and something happens and she vomits. I think it just takes that one little piece hitting the right spot and then Blam!

So I keep letting her have stuff she is interested in and I keep lots of burp clothes nearby and my CPR skills up to date.

abby said...

It's so odd...Hallie really seems to like food and in this we're lucky because so many micropreemies have such strong food aversions. But something weird happens and things go so wrong. We're really not sure what to do. Purees are usually safe foods and it's so tempting to just serve her those because she won't gag or retch often and can even sometimes make it through a whole meal without even retching (was 4 ounces; she's become less tolerant lately because of our attempts at thicker purees as per the feeding doctor's orders). But once something goes wrong, we end up in a battle with her. This morning a tiny piece of fruit puree (homemade, thicker stuff) got stuck in her throat (windpipe? esophagous? who can say) and she started coughing and retching and making all sorts of grunting noises until she threw it up, along with a bit of milk. Not a major vomiting episode (and we're grateful for this) but still discomforting. Oy. But if all we give her is stage 2 food, she'll never learn to get the hang of things.

Who knew eating was so hard? You just kind of take it for granted and then it turns out that, next to breathing, it's the hardest thing to learn how to do for a goodly number of our kids.

E said...


I'll pass along what Paige's ENT said for what it's worth. Basically at a year old give her foods and liquids that a kid without a paralyzed vocal cord would have. Our ENT said basically Paige would probably develop pneumonia until she adapted. Paige's vocal cord compensated so we never really had to put this to the test, but that's what he said to us on multiple occasions.

Lori said...

So I am clueless about the paralyzed vocal cord issue since we didn't deal with that. But I will say that Aidan will still do this occasionally. He likes food too and as I mentioned to you, the crunchy technique worked GREAT with him. A couple of weeks ago he did what you described on pizza. Did great through literally the *whole* slice, and on the last bite, it just hit the wrong gag area in the back of his mouth and he lost it.

I think what I have decided is that there is still such a huge mental connection for him between having that gag spot hit and vomiting. Sometimes he can control it, but if food kind of "lodges" there he falls into the pattern he knew best for a while. For the most part he actually has figured out how to avoid this gag area in his own mouth, but occasionally he slips up.

As for what to do...only my not so humble opinion of course. We decided at the time (when we were where you are right now) that 3 of his 4 meals would be for nutrition and one would be practice. Any calories he got and kept down were bonus, but it was for practice of feeding. This helped me a lot because it took the pressure off of me for that one meal. At that time we did basically 3 puree meals for nutrition and 1 meal where I tried something new.

Just a thought...good luck!


Ms.Kitty said...

Since dairy from cows = vomit for Hallie, so why not try something of similar texture without cheese? Give the girl a cookie! Glad her first "real" food was pizza, good start! Caramel/chocolate rice cake, maybe?

Anne said...

Apparently pizza eating is contagious.... guess who ate (chewed and swallowed) five bites of pizza? I give up trying to figure this out!

23wktwinsmommy said...

As you know Serena has a paralyzed vocal cord, but to be more helpful I would have to find out the particulars of you mentioned Hallie's is almost midline. We are going back to the ENT next month for a follow-up bronch to see if there is anything that should be done with the vocal cord and the airway issues...narrowing and floppy. She continues to drop her sats in a deep sleep without a little O2.

Even though she is similar to Hallie with respect to her vocal cord and airway, she does not have the eating difficulties that her virtual 23 week friend has. Serena eats everything from very thin purees, to chicken fingers, to spahetti, to biter biscuits, to chips. There has yet to be a consistency she doesn't like, although there have been a few tastes she isn't too fond of. I don't have any wisdom with respect to eating, as we somehow made out with two 23 weekers who love all types of's nothing we *did*.
So I'm not sure about the vocal cord paralysis playing a role, although it certainly could be contributing. However, I do know that EJ has a very sensitive gag reflex and if he gags and begins coughing, he will projectile vomit. Somtimes if we can distract him we can avoid a vomit fest. We usually hear him coughing or gagging and say "hiii Edwin. Heeeey buddy whatcha doing!" really loud and goofy so he "forgets" he is gagging and swallows and goes on eating. This works more than half of the time. I don't know if Hallie is gagging and then throwing up as a result, or if is something more complex related to the texture of the food and her aversion to that texture.
I know Serena really enjoys feeding herself, and we try and give her and EJ every opportunity to pick up food of their trays and put it in their mouths. Serena also enjoys standing by the couch and being fed off my plate if I am eating out in the living room with them as they play. It's just more opportunity to get calories in her. We also do 3 meals a day with chances for snacks in between. (oh yeah how does Hallie do with yogurt? That makes for a great snack or desert.)
Perhaps try pizza again and see how she does? Maybe introduce things relatively slowly and see how she does with that particular texture. Maybe that will help narrow down what she is tolerating and what she isn't.
And if need be, perhaps schedule another bronch and see if things have changed with respect to her airway. I know our ENT thought he'd see improvment as she grew, and I'll be interested to see what he says about her airway next month.
I'll be sure to give you any insight after we see the ENT January 7th.

Nancy said...

I do love when our kids eat a good amount of food, only to vomit it up on the last bite.

I think one of the most difficult stages with Caitlyn was the transition from jarred foods to table foods. It seemed like Caitlyn boycotted the jars and wanted what we were eating. The only problem was that once it was in her mouth, she absolutely could not tolerate it being in there. Which lead to vomiting. Which lead to a hungry child who wouldn't eat anything. Which lead to a really stressed out mom. Vicious circle.

What I discovered what this:

The Baby Safe Feeder. Let me just tell you that this little contraption saved my life I could put chunks of whatever we were eating (within reason) into that thing and she could suck the hell out of it. I never worried about her choking, she only got little bits of the contents, I could introduce her to a varity of tastes and textures, I could live a day without cleaning up a meal presented as puke. All in all, a win win situation.

Once she was able to taste some things using this and kind of get a sense for what they felt like in her mouth, we could move to giving her food without it. Although, that was a long (long) time away from it's introduction.

Another thing I discovered with Caitlyn was that she was so very leary of anything other than crunchy foods. They were safe to her. And in order to keep her eating, that's what we fed her. Is it the ideal way to feed a kid? No. But we were dealing with so much more than just the transition from baby food to table food.

I would really give the feeder a try. If anything, it will give you some piece of mind that when she is self feeding, she can't choke.

And just wait until once she does start eating, and she will only eat hot dogs and chicken nuggets. And it's not because of texture or any other underlying issue. Good times. Good times.

sexy said...