Bolus Fading to Prepare a Tube-Dependent Child for Video Fluoroscopic Swallow Study: A Case Report

Children with prematurity and complex medical histories are at increased risk for tube dependence, feeding aversion, and aspiration, which can interfere with completing a video fluoroscopic swallow study (VFSS) making it challenging to target broader feeding goals. This case report describes a bolus fading intervention designed to establish consistent oral intake and prepare a tube-dependent child for VFSS. An 18-month-old child born at 26 weeks’ gestation with severe bronchopulmonary dysplasia, a prior failed VFSS, and 100% gastrostomy-tube dependence participated in an intensive interdisciplinary home-based feeding program. A single-case reversal design evaluated a bolus fading treatment that included noncontingent reinforcement and escape extinction (initially), along with procedures to increase mouth clean. Bolus sizes increased systematically from empty spoon to full spoon while the clinician monitored clinical signs of aspiration. Caregiver acceptability was assessed using a questionnaire. Baseline responding showed no acceptance and high inappropriate mealtime behavior. During treatment, acceptance increased, inappropriate mealtime behavior decreased to near zero, and mouth cleans improved after targeted modifications. During the VFSS, the child accepted thin liquids by spoon without inappropriate mealtime behavior, and the hospital speech-language pathologist confirmed safe swallowing. Caregivers indicated high acceptability. Bolus fading effectively prepared a tube-dependent child to participate in the VFSS, making it possible to determine swallow safety and progress toward broader feeding treatment goals. Implications for Impact Statement Our findings highlight how individualized behavioral interventions can make swallow studies more successful for children who struggle with feeding, improving both the assessment process and ultimately treatment outcomes.