965636

research-article2020
AORXXX10.1177/0003489420965636Annals of Otology, Rhinology & LaryngologyMills et al

Original Article
Annals of Otology, Rhinology & Laryngology

Flexible Endoscopic Evaluation of

1­–13
© The Author(s) 2020
Article reuse guidelines:
Swallowing in Breastfeeding Infants sagepub.com/journals-permissions
DOI: 10.1177/0003489420965636
https://doi.org/10.1177/0003489420965636

With Laryngomalacia: Observed Clinical journals.sagepub.com/home/aor

and Endoscopic Changes With Alteration

of Infant Positioning at the Breast

Nikki Mills, MBChB, FRACS, PhD1,2 , Melissa Keesing, BSLT3,

Donna Geddes, DMU, PhD4, and Seyed Ali Mirjalili, MD, PhD2

Abstract
Objectives: This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of swallowing in
infants with laryngomalacia, to ascertain the impact of infant positioning on airway compromise and fluid dynamics during
breastfeeding. The study aims to identify whether modification of infant positioning at the breast may improve the possibility
of safe, successful breastfeeding in infants with laryngomalacia and concurrent breastfeeding difficulty.
Methods: Twenty-three infants referred for noisy breathing and difficulty feeding were assessed with flexible endoscopic
evaluation of swallowing (FEES) during breastfeeding. All had endoscopically confirmed laryngomalacia. During FEES,
observations were made of clinical signs of airway compromise as well as endoscopically observable anatomical features
and swallowing dynamics during breastfeeding, including tongue base position, view of laryngeal inlet and vocal folds,
dynamic supraglottic soft tissue collapse, timing of milk flow into pyriform fossae/hypopharynx relative to sucking, and
presence of penetration and/or aspiration. If airway and/or swallowing compromise was present, the infant’s initial position
at the breast was altered from supine or semi lateral decubitus position to semi-prone, with a description of the clinical
and endoscopically observable changes that subsequently occurred.
Results: Signs of dynamic airway obstruction and/or compromised airway protection with swallowing were present in 20
of the 23 infants (87%) in their initial supine or semi lateral decubitus position. These 20 infants were repositioned to semi-
prone, with improvement and/or resolution of stridor and an improved ability to maintain latch in all infants. Continued
endoscopic evaluation following positional change was possible in 16 infants, identifying anterior positioning of the tongue
base, reduced dynamic supraglottic tissue collapse, reduced volume of milk flow into pyriform fossae during pauses in
sucking and resolution of penetration and aspiration.
Conclusion: This study has shown how alteration of breastfeeding position to semi-prone may improve dynamic airway
obstruction and reduce aspiration risk in infants with laryngomalacia.

Keywords
breastfeeding, swallowing, laryngomalacia, flexible endoscopic evaluation of swallowing, positioning

Introduction
Infants with noisy breathing are commonly referred to an
otolaryngologist for diagnostic assessment. It is important
to recognize that infants with airway compromise may also
have difficulties feeding,1,2 with breastfeeding being par-
ticularly challenging for infants with any form of airway
compromise.3 Early breastfeeding difficulties may jeopar-
dize effective milk removal at the breast and impact on
establishment of milk supply, which may precipitate an
early transition to bottle feeding. In order to improve the
possibility of safe, successful breastfeeding in this cohort, it
is critical to understand how airway compromise impacts
1
Paediatric Otolaryngology Department, Starship Children’s Hospital,
Auckland, New Zealand
2
Department of Anatomy and Medical Imaging, Faculty of Medical and
Health Sciences, University of Auckland, Auckland, New Zealand
3
Paediatric Speech-Language Therapy Department, Starship Children’s
Hospital, Auckland, New Zealand
4
School of Molecular Sciences, Faculty of Science, University of Western
Australia, Crawley, Western Australia, Australia
Corresponding Author:
Nikki Mills, BHB, MBChB, FRACS, Dip Paeds, IBCLC, PhD, Paediatric
Otolaryngology Department, Starship Children’s Hospital, Park Road,
Grafton, Auckland 1023, Private Bag 92024, Auckland 1142, New
Zealand.
Email: nikki@webrage.co.nz
2 Annals of Otology, Rhinology & Laryngology 00(0)
on swallowing in breastfeeding infants, then to determine
whether there are any potential modifications that may
improve their airway and swallowing dysfunction.
When infant airway and feeding difficulties are present,
a thorough multidisciplinary assessment is essential, with a
range of investigations used to diagnose or exclude a broad
range of potential anatomical and neurological anomalies
that could impact on feeding.4 Awake flexible trans-nasal
endoscopy is a valuable investigation for identifying the
location of upper airway obstruction when an infant has
noisy breathing,5 with laryngomalacia being the most com-
mon endoscopically diagnosed cause of noisy breathing in
infants.6,7 Infants with laryngomalacia classically have
worsening of stridor associated with increased effort of
breathing during feeding, as well as often being reported to
have frequent interruption of feeding caused by coughing
and choking episodes.8 These symptoms raise concern
regarding aspiration possibly occurring in some of these
infants, with acknowledgment that silent aspiration could
be occurring even in the absence of these clinical signs. In
one study of infants with laryngomalacia, 85% had dyspha-
gia, 50% poor weight gain, and 57% penetration and/or
aspiration on videofluoroscopic swallow study (VFSS).9
VFSS is the most commonly utilized instrumental
assessment of infant swallowing when aspiration during
feeding is suspected.10 However, using a bottle in a VFSS to
assess an exclusively breastfeeding infant’s swallow is of
questionable validity, given increasing evidence of differ-
ences between the biomechanics of sucking when compar-
ing breastfeeding and bottle feeding.11-13 Because of
practical challenges in imaging or viewing the breastfeed-
ing swallow, there is still very little known regarding the
differences in the pharyngeal phase of swallowing between
breastfeeding and bottle feeding. There are only 2 published
cine radiographic studies (VFSS or historic equivalent) of
breastfeeding that describe suck-swallow dynamics.11,14
Both are limited by poor image resolution, unnatural posi-
tioning of the mother, and the inability to visualize breast
milk under cine radiography/fluoroscopy. These factors,
together with radiation exposure to the mother and infant,
make VFSS an unsuitable clinical modality for assessment
of the breastfeeding swallow. Magnetic Resonance Imaging
(MRI) is a non-radiating imaging modality that has been
recently used for the first time to capture the breastfeeding
swallow, however, practical issues currently prevent this
from being useful in clinic practice.15
Fibreoptic or Flexible Endoscopic Evaluation of
Swallowing (FEES) requires specialized equipment and
significant expertise and training in both procedural tech-
nique and interpretation of findings, but has been validated
as a safe an appropriate alternative to VFSS.16-19 FEES has
also proven to be an appropriate and safe modality for
assessing the breastfeeding swallow and is able to provide
a dynamic three-dimensional view of pharyngeal and
laryngeal anatomy that can be helpful in the diagnosis of
both airway and swallowing pathology.19-22 However, as
FEES lacks objective measures that are readily available
with VFSS, the understanding of the pharyngeal phase of
the infant swallow remains predominantly based on research
using VFSS viewing bottle feeding.
When aspiration is identified during VFSS, a trial of
modifications is usually undertaken as part of the assess-
ment, to determine if any are effective at improving airway
protection with swallowing. These modifications may
include thickening fluid to slow the speed of bolus transit,
using a slower flow teat, using frequent pauses to “pace”
feeds, reducing bolus volume, or altering temperature to
increase the thermal sensory stimulus.23 Unfortunately, all
these options for modification preclude the possibility of
continued breastfeeding, with no research to date evaluating
any modifications that would support continued feeding
at the breast when aspiration has been diagnosed. For
infants with laryngomalacia severe enough to warrant
surgical intervention, an improvement in feeding difficul-
ties and aspiration has been reported in many patients
post-operatively.24-26 However, as only the most severely
affected infants usually proceed to surgery, for the large
cohort of infants with mild to moderate laryngomalacia,
there are limited strategies for addressing feeding difficul-
ties that would support continued breastfeeding.
There is little research assessing the impact of specific
infant body positioning on infant swallowing. Bottle feed-
ing research has not led to a consensus regarding an “ideal”
feeding position, with research predominantly limited to
premature infants and using physiologic outcome measures
such as oxygen saturation, respiratory rate, heart rate, and
heart rate variability.27-30 Willette et al’s20 study on FEES in
breastfeeding infants in 2015 suggested positional modifi-
cation in 15% of the infants as a strategy to improve feed-
ing, but they did not include any details on how or when this
strategy might be utilized and did not provide evidence for
its use. The positioning of an infant for breastfeeding is well
recognized as being important for achieving maternal com-
fort and efficient milk transfer at the breast, with a variety
of positions existing that accommodate the variability in
both maternal and infant anatomy.31-33 A semi-reclined
maternal position, with the infant semi-prone and their
chest and abdomen flat against the mother’s body, has been
shown to effectively utilize gravity to provide positional
stability for the infant and ensure optimal intra-oral breast
tissue volume.34 This semi-reclined maternal positioning
has also been shown to trigger a wide range of innate
reflexes in the infant that assist with successful rooting,
latching, and sucking33-36 but no studies have described how
this specific positioning impacts the infant’s breathing and
swallowing.
The influence of an infant’s positioning on dynamic air-
way compromise is widely recognized, with the supraglottic
Mills et al
Figure 1. Cradle-hold: infant in supine or semi lateral decubitus position. Mother upright or slightly leaning over infant; infant supine,
with slight lateral tilt into semi lateral decubitus position. Weight of the infant supported by Mother’s hand, arm, and/or pillow.
soft tissue prolapse occurring with laryngomalacia known to
be exacerbated when the infant is supine.9,37 This has been
confirmed radiologically, with posterior displacement of the
tongue base, retroflexion of the epiglottis and narrowing of
the 3-dimensional space of the pharyngeal airway when
imaging is captured in the supine position.38 The impact of
gravity on an infant’s airway is commonly utilized in clinical
practice in infants with Pierre Robin Sequence, with prone
positioning improving the pharyngeal airway by displacing
the tongue base anteriorly.39,40 Takagi et al has reported suc-
cessful feeding of infants with Pierre Robin Sequence and
airway compromise using prone positioning, which was
enabled in the study using a specially modified bottle.41
In spite of the body of knowledge on the importance of
positioning for infants with dynamic airway compromise,
we have not identified any publications specifically
assessing the impact of infant positioning during feeding
in infants with laryngomalacia. Aiming to further under-
standing in this area, this retrospective study uses FEES to
describe the clinical and endoscopically observed changes
occurring with alteration of breastfeeding positioning in a
cohort of infants presenting with laryngomalacia and feed-
ing difficulties.
Methods and Participants
Study Design and Participants
This is a descriptive study of infants with laryngomalacia,
involving a retrospective audit of our clinical practice using
FEES to assess swallowing whilst feeding at the breast and
trialing repositioning of the infant as a modification if signs
of compromised airway and/or swallowing were present.
We reviewed all FEES that assessed breastfeeding of infants
with endoscopically diagnosed laryngomalacia, performed
or directly supervised by the lead author (N.M.) between 1st
September 2016 and 31st October 2019. All infants were
breastfed, with some receiving supplementary calories via a
3
nasogastric tube. All had been referred for feeding difficul-
ties and/or airway compromise (n = 23 infants). All FEES
took place at a tertiary referral pediatric hospital with
approval for this retrospective audit given by the National
Ethics Committee. Patient demographics and medical infor-
mation were retrieved from electronic patient records,
including referral source, primary presenting symptoms, the
presence of a nasogastric tube, oxygen requirement, and
any prior VFSS assessments.
The multidisciplinary FEES team included a pediatric
otolaryngologist with lactation consultant training (N.M.),
at least one pediatric speech-language pathologist (SLP), a
pediatric nurse specialist, and when possible, a lactation
consultant was also present. The FEES were performed in
the outpatient clinic or at bed-side for inpatients. When
compromised breathing and/or swallowing was present dur-
ing breastfeeding, the endoscope was kept in situ to observe
swallowing following modification of latching position, to
determine if altered positioning improved the dynamic air-
way collapse and/or aspiration.
FEES Protocol for Breastfeeding Infants
The infant was positioned on the mother’s lap, with prepa-
ration for the mother to transition as easily as possible to
breastfeed in their usual feeding position without readjust-
ment of clothing or position. All mothers chose which breast
to feed from and started by latching their infant in their
usual breastfeeding position. For all, the initial position of
choice was a cradle hold, with the infant supine or semi-
lateral decubitus and the mother using their arm or a pillow
to support the weight of the infant (Figure 1).
Video and audio recordings were captured of the endo-
scopic procedure using a Storz Telepack with a 1.9 mm flex-
ible fiberoptic endoscope. The endoscope was lubricated
with a small amount of viscous 2% lidocaine and passed
through the side of the infant’s nasal airway closest to the
4 Annals of Otology, Rhinology & Laryngology 00(0)
Figure 2. Use of rubber band to help secure endoscope position at infant nares.
endoscopist or on the same side as the nasogastric tube if
present, to leave the other nostril unimpeded for breathing.
As the endoscope was advanced, observation was made
of the nasal airway, soft palate, pharyngeal, and laryngeal
anatomy. The endoscope was secured in position at the
nares utilizing a rubber band, which was slid down the
endoscope and taped to the dorsum of the infant’s nose
(Figure 2). This is a low-cost technique developed to give
some security to endoscope positioning without the endos-
copist’s hand impeding the mother’s visual and physical
access to her infant for latching. Once the endoscope was
positioned in the pharynx, observations were made of the
infant’s vocal fold movement, dynamic supraglottic tissue
prolapse, pharyngeal constrictor function, and management
of saliva and secretions.
The infant was then allowed or assisted by their mother
to latch, with our nurse specialist aiding in minimizing
endoscope displacement during this maneuver. Once the
infant was latched and sucking established, the breastfeed
was observed endoscopically, noting tongue base position,
dynamic supraglottic soft tissue collapse (and correlation
with audible stridor), dynamics of milk flow into the hypo-
pharynx, the presence of penetration and or aspiration, and
any observable cough response if/when this occurred.
Penetration was defined as milk being seen to enter the
laryngeal inlet prior to swallow initiation and aspiration
diagnosed when milk was visualized passing below the
vocal folds, either before or after swallowing.
Alteration of Infant Positioning
After an initial period of observation of active sucking, if
airway compromise and/or penetration or aspiration were
present, the infant was repositioned at the breast to be
semi-prone, with the mother in a “laid-back” position.
This transition was done by bringing the infant into a side
lying position with their abdomen in close contact with the
mother, then gently reclining the mother to bring the infant
into a semi-prone position (Figure 3). Exact positioning
was modified as needed to adapt to the individual mother
and infants’ anatomy and optimal comfort. The majority of
infants had the axis of their body orientated horizontally,
with a few improving further if positioned more diago-
nally across their mother’s abdomen (with the infant’s feet
lower than their head), maintaining a semi-prone but more
upright position (Figure 4). Repositioning was facilitated
by using a chair that accommodated the mother being
reclined, however, these positional adaptations were still
possible in a standard chair with an upright back (Figure
3). Clinical observation documented any change in the
noise or work of breathing and endoscopic observation
noted any changes to airway dynamics and/or the pharyn-
geal phase of the swallow.
Following completion of the procedure, the video (with
combined audio) recording was reviewed and assessed by
the otolaryngologist and SLP, with the images transferred to
a computer to allow slow motion and frame-by-frame
review. The captured images and videos are also used to
explain findings to the parents.
Detailed Analysis of Captured Imaging
For the purposes of this audit, a detailed descriptive analy-
sis of the endoscopically observed dynamic pharyngeal
anatomy and swallowing was then undertaken (as part of
the primary author’s PhD research). This review focused on
Mills et al 5

Figure 3. Semi-prone positioning. Mother is slightly reclined, infant horizontal (right side lower) but positioned semi prone and held
closely (“tummy-to-tummy”) to mother.

Figure 4. Variations of semi-prone positioning. In all variations, the infant is semi prone and held closely (“tummy to tummy”) with
their mother. Images (A and F) show the infant in horizontal positioning, (B and C) show diagonal positioning, (D) more upright infant
position, (E) infant almost fully prone with the mother lying almost flat (image taken from above infant).

describing general features observable during FEES of the
breastfeeding infant. This included evaluation of tongue
base and epiglottic position, a visual perception of volume
capacity of the pyriform fossae, the view of the glottic inlet
and vocal cords (and relative obscuring of this view by
supraglottic soft tissues), dynamic supraglottic soft tissue
collapse and the timing, and flow of milk visible in the
hypopharynx as temporally related to the infant’s active
sucking, with these observations being presented as a
descriptive summary.
6 Annals of Otology, Rhinology & Laryngology 00(0)

Table 1. Patient Demographics and Clinical Variables.

Demographics and Clinical Number of Infants, Percentage

Variables Variables n = 23 (%)
Gender Male 11 48
Female 12 52
Ethnicity European 13 56
Maori 3 13
Pacific Island 5 22
Asian 2 9
Age, wk Range 1-37
Average 11
Referred by Neonatologist/pediatrician 15 65
Speech-language pathologist 2 9
General practitioner (family doctor) 3 13
Otolaryngologist 2 9
Lactation consultant 1 4
Indication for referral (may Difficulty feeding 23 100
have multiple ~) Noisy breathing (worsened with feeding) 21 91
Coughing/choking/not able to maintain latch 19 83
Concerns regarding aspiration 16 70
Current mode of feeding Exclusive breastfeeding 19 83
Breastfeeding (with nasogastric top-ups) 4 19
Previous VFSS No 22 96
Yes (showing aspiration) 1 4
Supraglottoplasty Prior to FEES 3 13
After FEES 1 4

Results Observations of Swallowing During

Participant Demographics, Comorbidities, and
Endoscopic Diagnoses
Analysis was made of data from 23 infants with laryngo-
malacia who had undergone FEES whilst breastfeeding.
Patient demographics, referrer, indication for referral, and
current feeding mode are outlined in Table 1. Twelve
patients had no known co-morbidities. The other 11 patients
had one or more comorbidities, which included 5 infants
with neurologic diagnoses and/or conditions associated
with low muscle tone, 2 infants with Down Syndrome,
4 with primary congenital cardiac anomalies, 4 who had
been born prematurely (30-35 weeks gestation), and 2 who
had repaired tracheo-esophageal fistulas. Three of the
infants had undergone supraglottoplasty prior to the FEES
but were referred for persistent feeding difficulties. One
infant had significant nocturnal airway compromise associ-
ated with their laryngomalacia and proceeded subsequently
to supraglottoplasty. Five infants were on low flow nasal
prong oxygen with the remainder breathing spontaneously
in room air. All of the infants were exclusively breastfeed-
ing, with 4 receiving supplementary calories via a nasogas-
tric tube. No complications occurred during any of the
FEES procedures.
Breastfeeding
FEES was completed with the mother’s breastfeeding in
their usual latching position, which for all was a cradle or
cross-cradle position with the infant in a supine or semi-
lateral decubitus position, with their weight supported by a
pillow or their mother’s arms. A summary of endoscopic
observations of the breastfeeding infant’s swallow are
detailed in Table 2 and an example of imaging captured
shown in Supplemental Video 1. We include a description
of features of pharyngeal anatomy and the pharyngeal phase
of swallowing that were well visualized endoscopically and
outline aspects that were not easy to view or assess.
Observed Changes Associated With Modified
Latching Position
In 3 infants, there was no clinically or endoscopically
observable compromise of breathing or swallowing during
the assessment and therefore no indication for positional
modification. Twenty infants had compromised breathing
and/or swallowing during breastfeeding with 16 (80%) of
these infants having stridor induced during the feeding with
observable prolapse of supraglottic soft tissues on inspira-
tion, 11 (55%) being unable to maintain their latching
Mills et al 7

Table 2. Endoscopic Observations of the Breastfeeding Swallow During FEES.

Assessment during the

Breastfeeding Swallow
General observations
Diagnosis of penetration
and aspiration
Endoscopic Visualization
•• Sucking movement was visible with an antero-posterior movement of the tongue base and
associated “rocking” movement of the epiglottis
•• The soft palate remained in apposition with the tongue base during sucking
•• The free edge of the soft palate was usually near the vallecula and the tip of the epiglottis gliding
up into the nasopharynx
•• Milk flows into the gravity dependent (lower) pyriform fossa if side lying
•• Milk continued to flow (into the pyriform fossa) during pauses in sucking
•• The volume of milk visible in the pyriform fossa prior to the swallow being initiated varied
throughout the feed in every infant. A larger volume of milk was likely to accumulate in the
pyriform fossa when the infant paused for sequential breaths without sucking or swallowing
•• The milk volume and flow rate were variable during a feed (fastest during milk ejection reflex/es)
and varied significantly between mother and infant dyads
•• Sucking and swallowing patterns varied throughout the feed and appeared very responsive to
visible changes in milk flow
•• Pre-swallow penetration was usually easily visualized and was the most common timing for
penetration/aspiration events seen in our study
•• Penetration (milk passing into the laryngeal inlet) occurring before the swallow was usually well
visualized, but was dependent on endoscope positioning and supraglottic anatomy
•• Aspiration (milk passing through the vocal folds) was more difficult to directly visualize, as
a direct view of the vocal folds was usually intermittent whilst the infant was feeding. With
laryngomalacia, the supraglottic soft tissues often obscured the view of the vocal folds,
particularly when the infant was supine
•• More subtle events required diagnosis on slow motion video review
•• Events (including aspiration) that occur during the swallow are poorly visualized, as a “white-
out” (a brief loss of view) occurs during swallow secondary to pharyngeal constriction
momentarily closing soft tissues over the endoscope lens as the peristaltic movement propels
the liquid bolus through the pharynx
•• Aspirated milk could occasionally be seen expelled from below the vocal folds into the laryngeal
inlet on expiration immediately post swallow
•• Post swallow pharyngeal residue (+/− aspiration of residue) is usually well visualized

position due to airway compromise or choking, and 15
(75%) having endoscopically observed aspiration and/or
penetration (with 10 of these infants having silent events,
with no overt cough response).
Accordingly, 20 infants proceeded to a trial of modified
positioning. In 4 (20%) procedures, the endoscope was dis-
placed during the change in infant positioning, so subse-
quent assessment was made using only clinical observation.
Continued endoscopic assessment following positional
modification was possible in 16 (80%) infants. A summary
of endoscopically observed changes following altered posi-
tioning are described in Table 3, with focus on the perceived
impact on the infant’s airway and on the dynamics of milk
flow as observed in transit through the pharynx.
Impact of Positional Change on Dynamic Airway
Compromise
When the infants were positioned for feeding in a traditional
cradle hold, with a predominantly supine or semi-lateral
decubitus position, the infant’s tongue base was displaced
posteriorly and the epiglottis was generally retroflexed.
This was associated with increased signs of airflow
obstruction (clinically and endoscopically) in 20 of the 23
infants during feeding. In these 20 infants, modification to
semi-prone position led to a reduction or resolution of
audible stridor, with all infants able to maintain their latch
with no coughing or choking. In the 16 infants where con-
tinued endoscopic observation was possible following
positional change, all had reduced dynamic prolapse of
supraglottic tissues. This, together with more anterior
positioning of the tongue base and reduced retroflexion of
the epiglottis, created an improved view of the laryngeal
inlet and vocal folds. Figure 5 and Supplemental Video 2
show imaging captured before and after positional change
to illustrate these changes in 1 infant. The findings of
reduced endoscopically visible signs of dynamic airway
obstruction correlated with the clinically observed reduc-
tion in audible stridor and signs of reduced work of breath-
ing in all patients.
8 Annals of Otology, Rhinology & Laryngology 00(0)

Table 3. Endoscopic Observations: Relative Changes With Infant Positioning During FEES.

Infant Positioning Endoscopic Observations

Supine •• Tongue base displaced posteriorly
•• Reduced volume capacity of pyriform fossae
•• Epiglottis retroflexed (resting position)
•• Compromised view of laryngeal inlet/vocal folds
•• Increased dynamic supraglottic airway collapse (+/− stridor and increased work of breathing)
•• Milk flow visible into pyriform fossae/pharynx when sucking paused (associated with increase in
pre-swallow penetration/aspiration events)
Changes observed: moving •• Tongue base positioned more anteriorly
from supine to semi-prone •• Increased volume capacity in pyriform fossae
•• Epiglottis more upright at rest
•• Improved view of laryngeal inlet/vocal folds
•• Reduced dynamic supraglottic airway collapse (reduced stridor and work of breathing)
•• Less milk visible flowing into pyriform fossae during pauses in sucking (with associated
resolution of pre-swallow penetration/aspiration events)
•• Earlier initiation of swallow (before or as milk enters pyriform fossae)
•• Maintenance of latch (reduced milk flow +/− airway related disruption)
Side lying •• Milk always flows into pharynx via the gravity dependent (lower) pyriform fossa

Figure 5. Endoscopic view of pharynx with infant positioned supine (left image) then semi-prone (right image). Both images captured
during a pause in sucking.
Abbreviations: E, epiglottis; TB, tongue base; PF, pyriform fossae.

Impact of Positional Change on Visible Milk Flow
Into Pharynx
With FEES allowing observation of a full breastfeed, we
were able to identify significant variability in milk flow rates,
infant sucking patterns and the timing of swallowing and
breathing. The flow and volume of milk entering the pyri-
form fossa prior to swallow initiation varied both during a
feed as well as varying between individuals. Our observation
was that all infants had active sucking bursts, interspersed
with pauses of variable duration. In all infants, at times
during the feed, milk would continue to visibly flow and
accumulate in the space of the pyriform fossa during these
pauses in active sucking. During these pauses, the pyriform
fossa would act briefly as a fluid reservoir, with its volume
capacity dependent on its specific dimensions. A swallow
would usually be triggered before the milk filled the capacity
of the pyriform fossa and flowed over the free edge of the
aryepiglottic fold into the laryngeal inlet (Figure 6). Infants
with increased respiratory rate and/or effort of breathing
required more frequent and longer pauses in active sucking.
In this cohort, during these pauses, milk was more likely to
Mills et al
Figure 6. Sequential FEES images: milk filling right pyriform fossa during pause in active sucking. Infant positioned side-lying, with
right side dependent. Images (A-H) show sequential images when sucking was paused during a “breathing break”; showing milk
continuing to flow into the right (gravity dependent) pyriform fossa. Images (D-H) show milk filling right pyriform fossae up to “rim”
of aryepiglotti.
Abbreviations: L, left; R, right; P, posterior (pharyngeal wall).
Black arrow: vocal folds.
Dotted line: epiglottis (anterior).
“overflow” into the laryngeal inlet before a swallow was
triggered, causing pre-swallow penetration or aspiration.
With alteration of infant positioning to semi-prone, 2
changes occurred that appeared to reduce the risk of pre-
swallow aspiration (as summarized in Figure 7). The first
observation was that tongue base position altered with infant
position which, as a consequence, appeared to alter the appar-
ent spatial volume or capacity of the pyriform fossa. With the
soft tissues of the aryepiglottic folds forming the medial wall
of the pyriform fossa, this space forms a natural conduit or
channel on either side of the laryngeal inlet. With alteration
from supine to semi-prone, the infant’s tongue base became
positioned more anteriorly, which in turn altered the position
of the epiglottis and the aryepiglottic folds. This correlated
with apparent widening of the pyriform fossae, thereby
increasing the volume of milk able to be accommodated in
this space without overflow into the laryngeal inlet.
The second observation was that the volume of milk
flowing into the pyriform fossa prior to swallow initiation
was greatest during the milk ejection but was also influ-
enced by infant position. Milk was visible flowing into the
piriform fossa prior to swallow initiation when the infant
was supine, but this was reduced or absent when the infant
was repositioned to semi-prone, correlating with reduced
pre-swallow aspiration risk.
9
Another incidental observation was that if the infant was
tilted into a side-lying position, all milk was diverted into
the lower (gravity dependent) pyriform fossa.
Discussion: Summary of Findings and
Clinical Implications
FEES is a valuable clinical tool that has improved our
understanding of swallowing dynamics when assessing
infants with laryngomalacia who are experiencing difficulty
breastfeeding. Furthermore, FEES has provided endoscopic
evidence for the potential use of infant positioning as a
modifiable variable, by understanding the impact of infant
position on dynamic airway compromise and on fluid
dynamics in the pharyngeal phase of the swallow.
Using FEES, we have identified a number of specific
anatomical and physiological variables associated with a
higher risk of penetration and/or aspiration (Table 4).
Penetration or aspiration occurring before the swallow is
initiated is usually well visualized during FEES, being
the most common timing of airway compromise with swal-
lowing identified in this study. As pre-swallow penetration
and aspiration resolved in all participants following posi-
tional modification, fluid dynamics during the pharyngeal
phase of swallowing during breastfeeding appears to be
10 Annals of Otology, Rhinology & Laryngology 00(0)

Table 4. Variables Associated With Higher Incidence of Pre-swallow Penetration/Aspiration.

Anatomical •• Shallow (or asymmetric) pyriform fossae creating low milk volume capacity
•• Flimsy, short epiglottis (uncommon anatomical variant) with dynamic retroflexion of epiglottis into laryngeal
inlet (loss of epiglottic “barrier” to milk flowing from vallecula into laryngeal inlet)
Physiological •• Fast milk flow (usually associated with milk ejection reflex)
•• Supine positioning (variation of “cradle-hold”). Commonly associated with increased volume of milk visible
in hypopharynx prior to swallow initiation
•• Increased respiratory rate
•• Longer pauses in active sucking and swallowing (particularly when occurring at times of faster milk flow)
•• Absence of cough response to penetration (suggesting sensory impairment)
Dynamic •• Dynamic supraglottic soft tissue prolapse (poor coordination of timing of swallowing and breathing relative
to milk being present in hypopharynx)
•• Increased pharyngeal constrictor tone (when crying, the space of the pyriform fossae is often obliterated
and any milk present easily overflows into the laryngeal inlet)

influenced at least in part by gravity. In the absence of active
sucking, with the infant in a supine position, milk was
observed continuing to flow from the oral cavity into the
pharynx, consistent with this occurring as a passive process,
similar to water flowing “downhill” in a river. In the semi-
prone position, the milk bolus appeared to be more effec-
tively maintained (with gravity) in the oral cavity during
these pauses in sucking, with base of tongue motion required
to actively propel the bolus from the oral cavity “uphill” to
the pharynx. As the continued flow of milk into the pyri-
form fossae during pauses in sucking appears to be a major
factor associated with pre-swallow penetration/aspiration
events (when supine), understanding how this can be modi-
fied with alteration of infant positioning (to semi-prone) is
a significant clinical breakthrough.
The majority (10/15, 67%) of aspiration and penetration
events observed in this study did not stimulate a cough
response, indicating clinical assessment can be hampered
by the absence of this symptom. This is consistent with
other studies of infant aspiration42-47 and confirms consider-
ably higher silent aspiration rates in infants than is reported
in adults.48 The clinical implication is that the absence of
overt clinical signs does not exclude the presence of aspira-
tion in infants with laryngomalacia, thus reliance on clinical
feeding evaluation alone is likely to under diagnose aspira-
tion in breastfeeding infants.
Although awake trans-nasal flexible endoscopy is avail-
able as a diagnostic procedure in many centers for assessing
infants with noisy breathing, breastfeeding FEES is not as
widely available. As a procedure, FEES presents many
practical challenges, requiring specialized equipment, a
multidisciplinary team and a significant time commitment,
as well as having a steep learning curve in both the technical
aspects and interpretation of the captured imaging.
Procedural success is dependent on a well-informed, toler-
ant mother and a compliant infant and even then, acquisi-
tion of adequate views for meaningful analysis is not always
possible. However, in spite of these challenges, detailed
analysis of FEES imaging during breastfeeding has enabled
a clear understanding of the impact of varying infant posi-
tioning on swallow and airway dynamics which has not
been possible with other imaging modalities to date.
It is important to acknowledge that the majority of babies
are able to feed efficiently and safely in a wide range of
latching positions, with no requirement to make positional
adjustments when the mother and infant are breastfeeding
without difficulties. However, if problems with breastfeed-
ing occur, this can be a significant source of stress for a
family49 and the potential loss of breastfeeding can be dev-
astating for new parents, particularly when their motivation
and expectation of breastfeeding their infant has been
high.50 When problems occur, an understanding of potential
causes and actively supporting continued breastfeeding
whenever possible is critical. This FEES-based research
confirms that airway compromise can create increased dif-
ficulty for the infant in coordinating breathing and safe
swallowing during breastfeeding.3 The potential disruption
of feeding caused by airway compromise can be associated
with frequent unlatching and re-latching, potentially con-
tributing to maternal nipple discomfort and trauma and
causing infant distress. This research clarifies the impact of
positional modification on infant breathing and/or swallow-
ing during breastfeeding, therefore in the absence of FEES
availability, it may still be possible to apply the principles of
this research to improve breastfeeding in many infants with
laryngomalacia.
This is one of the largest studies on breastfeeding FEES
and is the first to specifically assess infants with laryngoma-
lacia, a patient cohort recognized to have difficulty breast-
feeding. Although the severity of laryngomalacia in the
participants was not quantified, the group represented a
broad range of symptom severity, with all infants having
symptoms sufficient to warrant referral to a tertiary referral
pediatric hospital for assessment and management.
We acknowledge that this study is descriptive, based on
subjective interpretation of findings and is therefore lacking
objective measures. However, the use of FEES in research
on infant swallowing is hindered by the difficulties in
Mills et al
Figure 7. Summary of impact of gravity on airway and swallow dynamics during breastfeeding.
providing objective measurements from captured videos
and images. In spite of this drawback, FEES is currently the
only instrumental tool available for assessing the pharyn-
geal phase of swallowing in breastfeeding infants. A
descriptive analysis of FEES imaging at present seems to be
the most appropriate starting point for understanding breast-
feeding swallowing dynamics until more sophisticated
technology is available to provide objective measures.
When an infant present with airway and feeding compro-
mise, we highlight the importance of an individualized
assessment of functional anatomy with consideration of
other factors, such as laryngeal sensation, fatigue and
comorbidities that may impact on feeding and airway pro-
tection. Further research is required to assess the impact of
positioning during breastfeeding on infants with other air-
way pathologies, as well the impact on bottle-feeding.
Conclusion
FEES has provided an improved understanding of the breast-
feeding swallow and the impact of infant positioning at the
breast on airway and swallowing dysfunction in infants with
laryngomalacia. We have shown that in a semi-prone posi-
tion, the infant’s tongue base becomes positioned more
anteriorly, with the apparent benefit of reduced dynamic
supraglottic soft tissue collapse, increased volume capacity
of the pyriform fossae and reduced rate and volume of milk
flowing directly into the hypopharynx prior to swallow ini-
tiation. Together, these factors appear to improve dynamic
airway obstruction and enhance the infant’s ability to safely
co-ordinate swallowing and breathing. This research
11
suggests that infant positioning at the breast is a modifiable
variable that may improve the possibility of successful and
safe breastfeeding in infants with laryngomalacia.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: D.G.
received funding from an unrestricted grant from Medela AG,
Baar, Switzerland.
ORCID iD
Nikki Mills https://orcid.org/0000-0003-4214-7521
Supplemental Material
Supplemental material for this article is available online.
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