Claire Kane Miller

Pediatric laryngopharyngeal sensory testing during flexible endoscopic evaluation of swallowing: feasible and correlative.

Laryngopharyngeal sensory testing can predict aspiration risk in adult patients. Its feasibility and potential role in the evaluation of pediatric swallowing is undetermined. The goals of this study were to determine the feasibility of performing laryngopharyngeal sensory testing in awake pediatric patients and to assess whether the sensory testing results correlated with aspiration during a feeding assessment or correlated with a history of pneumonia. Fiberoptic endoscopic evaluation of swallowing with sensory testing was performed in 100 pediatric patients who were evaluated for feeding and swallowing disorders. The swallowing function parameters evaluated were pooled secretions, laryngeal penetration, and aspiration. The laryngopharyngeal sensory tests were performed by delivering a pressure-controlled and duration-controlled air pulse to the aryepiglottic fold through a flexible laryngoscope to induce the laryngeal adductor response (LAR). The air pulse stimulus ranged in intensity from 3 to 10 mm Hg. The patients tested ranged from 1 month to 24 years of age, with a median age of 2.7 years. Sensory testing was completed in 92% of patients. Patients who had an LAR at less than 4 mm Hg rarely if ever had episodes of laryngeal penetration or aspiration. Those with an LAR at 4 to 10 mm Hg had variable amounts of aspiration and laryngeal penetration. The LAR could not be elicited at the maximum level of intensity (10 mm Hg) in 22 patients, who demonstrated severe laryngeal penetration and/or aspiration. Elevated laryngopharyngeal sensory thresholds correlated positively with previous clinical diagnoses of recurrent pneumonia, neurologic disorders, and gastroesophageal reflux, and correlated positively with findings of pooled secretions, laryngeal penetration, and aspiration. Laryngopharyngeal sensory testing in children is feasible and correlative.

Eosinophilic Esophagitis in Infants and Toddlers

Feeding refusal is often described in conjunction with the diagnosis of eosinophilic esophagitis (EE) in pediatric patients; however, there are little data regarding the specific clinical manifestations and effective management of this condition in very young children. The aim of this study was to evaluate the presentation of EE in infants and toddlers referred to the Interdisciplinary Feeding Team Clinic of a tertiary referral center and to document responses to treatment. Database matching was performed (from January 2000 to June 2003) to identify infants and toddlers diagnosed with EE who had been referred to the Interdisciplinary Feeding Team Clinic. Endoscopic features required for a diagnosis of EE included esophageal mucosal furrowing, erythema, exudates, or decreased vascular markings. Histologic features of EE were more than 24 eosinophils per high-power field (HPF), thickening of basal cell layer, and papillary (rete peg) lengthening or elongation. All study patients were treated with a combination of proton pump inhibitors (PPI) and fluticasone (swallowed). In addition, elemental diet was instituted in those documented to have a food allergy. Treatment success was defined by an improved oral intake, adequate weight gain, and improved endoscopic and histologic findings at 3–6-month followup. A total of 15 subjects [mean age = 19.9 months (SD = 9.7 months)] who fulfilled the entry criteria during the study period were identified. All 15 children had documented endoscopic improvement and 14/15 children had histologic resolution of EE after therapy. In 13 of the 15 children, this translated to clinical improvement as well.

Pediatric fiberoptic endoscopic evaluation of swallowing.

Pediatric dysphagia is the presenting feature of many underlying diagnoses. Between July 1993 and July 1999, 643 fiberoptic endoscopic evaluations of swallowing (FEES) were performed on 568 patients. The median age of the population was 2.5 years (range, 3 days to 21 years). The principal medical and surgical diagnoses of the patients at the time of presentation to the FEES clinic were prospectively recorded: 36% of the patients presented with a diagnosis of structural abnormalities of the upper aerodigestive tract or airway; 26% with neurologic diagnoses; 12% with gastroenterological disorders; 8% with genetic syndromes; 7% with pulmonary dysfunction; 5% with prematurity; 3% with cardiovascular anomalies; and 2% with metabolic problems. The patients were classified according to the following feeding regimens: 9% normally fed; 38% orally fed with limitations; 13% orally fed, but with required supplemental tube feedings; and 40% prohibited from taking nutrition orally. The FEES enabled the following classification of feeding abnormalities: 15% had normal feeding; 56% exhibited behavioral abnormalities, including sensory-based feeding disorders; 15% exhibited structural abnormalities; 16% exhibited neurologic abnormalities; 1.5% exhibited metabolic abnormalities; and 0.5% exhibited cardiorespiratory abnormalities. The unique aspects of pediatric dysphagia are highlighted, and the role of FEES in the workup of this challenging aspect of pediatric otolaryngology is discussed.

Feeding issues and interventions in infants and children with clefts and craniofacial syndromes.

Problems with oral feeding occur in varying degrees in infants born with cleft lip/palate and/or craniofacial syndromes. The extent of clefting is associated with the severity of feeding problems, and if cleft lip/palate occurs in conjunction with a craniofacial syndrome, additional structural, airway, and neuromotor issues may be present. The infants feeding and swallowing skills may be significantly impaired, characterized by inefficient oral feeding skills coupled with poor airway protection ability during swallowing. Inadequate airway protection during swallowing has serious implications for the infants respiratory health as sequelae of chronic aspiration during feeding may include recurrent respiratory illness, pneumonia, and lung damage. Feeding difficulty in nonsyndromic and syndromic cleft lip/palate infants has been documented as source of considerable stress for parents and can have a potential negative effect on the parent-infant bonding process. Therefore, timely identification of feeding problems by the speech pathologist with subsequent intervention and modification in the feeding method is essential, along with provision of early feeding instruction to families. The objective of this article is to review expert opinion and available evidence regarding factors that influence feeding success and efficiency in infants with nonsyndromic and syndromic cleft lip/palate. The types of compensatory strategies or interventions that are effective in alleviation of feeding and swallowing difficulties will be described. Descriptive reports, expert opinion, and available evidence from clinical trials to support the use of feeding interventions in treatment are reviewed.

An Interdisciplinary Team Approach to the Management of Pediatric Feeding and Swallowing Disorders

Children with complex feeding problems frequently are involved with many health care services given the multiple medical and developmental issues impacting on feeding progress. The key to providing well-coordinated clinical services for these patients is to use an interdisciplinary team approach. In this article we describe a model of interdisciplinary team care for medically complex children with chronic feeding, swallowing, nutrition, and growth problems. A description of the functional roles of each of the disciplines represented on the team (nursing, nutrition, speech pathology, occupational therapy, psychology, and gastroenterology) is provided.

Updates on pediatric feeding and swallowing problems.

Purpose of reviewThere is increased recognition in the range of feeding and swallowing problems that occur in conjunction with congenital and acquired pediatric conditions. Differential diagnosis and management of these problems is often not straightforward and requires consideration and collaboration between multiple disciplines that are involved in the care of this special population. This article reviews recent investigations across disciplines regarding the cause and evaluation of pediatric feeding and swallowing issues, intervention efficacy, and available evidence to guide clinical practice. Recent findingsKnowledge of the basis for feeding issues associated with a variety of causes has advanced. Recent investigations of specific feeding and swallowing issues accompanying prematurity, selected diagnoses, and congenital syndromes are described. Significant advancements in the objective analysis of nonnutritive sucking have been made and provide increased understanding of the precursors for transition to oral feeding. Preliminary evidence regarding the effectiveness of selected clinical interventions to treat feeding and swallowing issues is highlighted. SummaryResearch is increasingly available to guide practitioners in evidence-based evaluation and management of pediatric feeding and swallowing issues. These continued advancements increase our understanding of the causes of pediatric dysphagia, the efficacy of treatment, and underscore the opportunities for continued research for best practice in clinical evaluation and management.

Swallowing function after laryngeal cleft repair: More than just fixing the cleft

To evaluate and describe the swallowing function in children after laryngeal cleft repair.

Duration and extent of dysphagia following pediatric airway reconstruction

OBJECTIVE Patients who undergo open airway reconstruction procedures are likely to experience some degree of post-operative dysphagia. This retrospective review describes the duration of post-operative dysphagia and the use of compensatory strategies in a group of 30 pediatric patients. METHODS A retrospective chart review of pediatric patients referred for post-operative swallowing assessment following airway reconstruction during a six-month period was completed. Age, sex, surgical procedure, stent type, co-morbid factors, duration of dysphagia, and use of compensatory dietary modifications and swallowing strategies was summarized and compared. RESULTS Dysphagia was generally of short duration (1-5 days) in patients undergoing single stage procedures with anterior or anterior/posterior grafts. Duration of swallowing difficulty was increased in patients undergoing posterior grafts in combination with T tubes (10-14 days). The longest duration of difficulty (>2 weeks) occurred in patients who had anterior and posterior grafting with T tubes, combined with additional procedures such as vocal fold lateralization, epiglottic petiole repositioning, and/or arytenoidectomy. There was a greater likelihood of oral feeding difficulty post-operatively in patients presenting with pre-operative feeding issues such as oral aversion or specific texture refusal, and the pre-morbid need for supplemental tube feeding to supplement oral intake. Compensatory swallowing strategies were effective in decreasing aspiration associated with swallowing in oral feeders post-operatively, and in facilitating return to baseline swallowing skills. CONCLUSIONS The duration of dysphagia overall was increased in patients undergoing anterior/posterior grafts in conjunction with in-dwelling T tubes, especially when combined with additional procedures. Compensatory strategies to assist with swallowing were found to be effective in the post-operative phase and included the use of a modified supraglottic swallowing sequence to assist with compensatory airway closure during swallowing in conjunction with diet modifications. Post-operative feeding difficulty occurred in patients with pre-existing feeding issues such as oral aversion and/or texture resistance regardless of reconstructive surgical procedure type.

Current research in voice and swallowing outcomes following pediatric airway reconstruction.

Purpose of reviewPathologic airway conditions in pediatric patients include congenital or acquired subglottic stenosis, glottic stenosis, laryngotracheal stenosis, laryngeal webs or atresia, and tracheal lesions. Acute airway management via tracheotomy is often required with later surgical intervention for reconstruction and expansion of the airway. The effect of the surgical interventions used to expand the airway may impact upon the laryngeal functions of phonation and airway protection during swallowing. Overall, the specific outcomes of airway surgery have focused on airway restoration. Outcomes in regard to voice and swallowing parameters have been largely unexplored, though recent reports have begun to emerge that provide some research data specific to both voice and airway protection/swallowing postoperatively. Recent findingsResearch regarding outcomes following laryngotracheal reconstruction over the last year reveals the use of more systematic approaches to collection of voice data and recognition of postoperative dysphagia. There continues to be a dearth of available research regarding longer term swallowing outcomes or treatment of voice disorders in this population. SummaryResearch findings that contribute to the base of knowledge regarding the effectiveness of surgical methodology for establishment of airway patency with preservation of laryngeal functions of voice and swallowing are beginning to accumulate. Increased evidence regarding types of reconstructive approaches and effect on laryngeal functions will assist surgeons and clinicians in designing specific treatment approaches.

Aspiration and Swallowing Dysfunction in Pediatric Patients

Early identification and management of aspiration associated with oral intake will help contribute to the best possible outcome for infants and children who have airway protection issues with swallowing. Though the incidence and prevalence of aspiration specifically related to swallowing dysfunction across medical conditions in the pediatric population is unknown, there is accumulating evidence of swallowing-related aspiration in infants and children with diagnoses that include structural abnormalities of the upper airway, central nervous system abnormalities, and progressive neurological disease. Chronic aspiration is associated with compromised respiratory health, progressive lung disease, bronchiectasis, and respiratory failure; thus, early detection and appropriate management is crucial. Determining the etiology and effect of aspiration is complex, and multiple evaluations are often required. This article will focus on instrumental studies of swallowing physiology used in the diagnosis and management ...