Ish K. Gulati

Upper and lower esophageal sphincter kinetics are modified during maturation: effect of pharyngeal stimulus in premature infants

Background:We hypothesized that changes in proximal and distal esophageal sphincter kinetics evoked upon pharyngeal provocation undergo longitudinal maturation.Methods:Pharyngeal stimulation-induced reflexes were characterized using novel pharyngo-esophageal motility methods in 19 healthy premature neonates, studied at 34.7 ± 0.8 wk (time-1) and 39.3 ± 1.1 wk postmenstrual age (time-2). Graded volumes of air (290 infusions) and sterile water (172 infusions) were infused to define sensory-motor characteristics of upstream (pharyngeal reflexive swallow, PRS) and downstream (pharyngo-lower esophageal sphincter relaxation reflex, PLESRR) esophageal reflexes. Data displayed as mean ± SE.Results:Threshold volumes were similar with air and water for PRS and PLESRR at time-1 and time-2. Multiple PRS responses were noted with water stimulus and were different between the media (time-1 vs. air, P < 0.0001; time-2 vs. air, P = 0.0003). Dose–response relationships for water were significant (P < 0.01 for PRS and PLESRR time-1 and time-2), but not with air.Conclusion:Significantly, the recruitment frequency of PRS and PLESRR increases with maturation, liquid is a superior medium for evoking such swallowing reflexes, and stimulus-response relationships for these reflexes are evident. These changes in aerodigestive protective reflexive activity may indicate differences in modulation of excitatory and inhibitory pathways during longitudinal postnatal maturation.

Pharyngeal stimulus‐induced reflexes are impaired in infants with perinatal asphyxia: Does maturation modify?

Development of pharyngo‐esophageal protective reflexes among infants with hypoxic ischemic encephalopathy (HIE) is unclear. Our aim was to distinguish these reflexes from controls and examine the maturational changes in HIE infants.

Brain Lesions among Orally Fed and Gastrostomy-Fed Dysphagic Preterm Infants: Can Routine Qualitative or Volumetric Quantitative Magnetic Resonance Imaging Predict Feeding Outcomes?

Introduction The usefulness of qualitative or quantitative volumetric magnetic resonance imaging (MRI) in early detection of brain structural changes and prediction of adverse outcomes in neonatal illnesses warrants further investigation. Our aim was to correlate certain brain injuries and the brain volume of feeding-related cortical and subcortical regions with feeding method at discharge among preterm dysphagic infants. Materials and methods Using a retrospective observational study design, we examined MRI data among 43 (22 male; born at 31.5 ± 0.8 week gestation) infants who went home on oral feeding or gastrostomy feeding (G-tube). MRI scans were segmented, and volumes of brainstem, cerebellum, cerebrum, basal ganglia, thalamus, and vermis were quantified, and correlations were made with discharge feeding outcomes. Chi-squared tests were used to evaluate MRI findings vs. feeding outcomes. ANCOVA was performed on the regression model to measure the association of maturity and brain volume between groups. Results Out of 43 infants, 44% were oral-fed and 56% were G-tube fed at hospital discharge (but not at time of the study). There was no relationship between qualitative brain lesions and feeding outcomes. Volumetric analysis revealed that cerebellum was greater (p < 0.05) in G-tube fed infants, whereas cerebrum volume was greater (p < 0.05) in oral-fed infants. Other brain regions did not show volumetric differences between groups. Conclusion This study concludes that neither qualitative nor quantitative volumetric MRI findings correlate with feeding outcomes. Understanding the complexity of swallowing and feeding difficulties in infants warrants a comprehensive and in-depth functional neurological assessment.

Su1170 Relationship Between Discharge Feeding Method and Neuro-Developmental Outcomes At 18-24 Months of Age in Former Preterm Infants

BACKGROUND: Preterm neonates commonly encounter oral feeding difficulties. We have previously shown that a personalized feeding management approach yields improved oral feeding outcomes at NICU discharge. The association of feeding outcome at discharge to long term neuro-developmental outcomes is not known. AIMS: In preterm infants, we characterized and compared aerodigestive and neurodevelopmental (cognitive, communicative, and motor) outcomes at 18-24 months corrected age of successful (full oral at discharge) feeders vs unsuccessful (gastrostomy tube at discharge) feeders. METHODS: Retrospective analysis was performed on 105 preterm infants (<37 weeks gestation) who were referred to the Neonatal and Infant Feeding Disorders program between July 2006 and July 2012, and also had a neuro-developmental evaluation at 18-24 months corrected age. Aerodigestive outcomes included: first oral feed attainment, weight velocity at 36 wks postmenstrual age (PMA), gastrostomy frequency, feeding method at discharge (full oral or g-tube fed), oxygen at 36 wks PMA, duration of ventilation, tracheostomy frequency, and oxygen at discharge. Neuro-developmental outcomes included: composite Bayley Scales of Infant Development (BSID)-III that were comprised of cognitive, communication, and motor scores. BSID-III composite scores were corrected for gestational immaturity. Statistical comparisons were made using Chi-Square, Mann-Whitney U, or t-tests comparing the two groups (full oral vs. g-tube). Data presented as mean ± SD, median (IQR), or %. RESULTS: Subjects (N = 105, 52 male) were born at 27 ± 3 weeks gestational age, weighing 968 ± 428 grams. Clinical characteristics, aerodigestive milestones, and neuro-developmental outcomes of the 105 infants are shown (Table 1). CONCLUSIONS: Inability to attain full oral feeding milestones at discharge is associated with mild cognitive neuro-developmental delays at 1824 months of age, sparing communication and motor outcomes. Delays in aerodigestive milestones and complex interplay of neurologic and behavioral areas controlling feeding and cognitive functions can be contributory. Timely initiation of oro-motor stimulation and oral feeding may provide opportunities for enhanced feeding skills and improvement in neuro-developmental outcomes. *Supported in part by R01 DK068158 (Jadcherla) and P01 DK068051 (Jadcherla/Shaker)

558 Reactivity of Lower Esophageal Sphincter (LES) Upon Pharyngeal Provocation in Infants With Hypoxic Ischemic Encephalopathy (HIE)

The ageing of the population makes elderly-onset inflammatory bowel diseases (IBD) a rising problem. Risk of cancer is unknown in this population. We studied this risk in a populationbased cohort of patients with IBD. Patients and methods: In a French population-based cohort, we identified 841 IBD patients >60 years of age at diagnosis from 1988 to 2006, including 367 Crohns disease (CD) and 472 ulcerative colitis (UC)1. We compared incidence of cancer among patients with IBD with that observed in the French Network of populationbased Cancer Registries (FRANCIM). Only cancers occurring after IBD diagnosis were taken into account. Confidence interval (CI) was estimated assuming a Poisson specific law for rare events. Results were expressed using the standardized ratios of incidence (SIR) and their CI 95%. Results: After a median follow-up of 6 years [2-11], 103 (12.3%) patients with IBD including 42 CD and 61 UC developed a cancer corresponding to a SIR of 1.00 [0.83-1.21]. Eleven patients (1.3%) developed at least 2 cancers.There was no increased risk of colorectal cancer in IBD (SIR=1.06 [0.65-1.72], CD (SIR=1.15 [0.54-2.40] and UC (SIR=0.99 [0.52-1.91] without significant protective role of 5-ASA (HR=0.7 [0.2-2.6]). An increased risk of malignant lymphoproliferative disorders was found in IBD (SIR=2.71 [1.415.20] and in UC (SIR=3.05 [1.37-6.79]) but not in CD (SIR=2.21 [0.71-6.86]). An increased risk of extraintestinal tumors was observed only for the liver in CD (SIR=3.25 [1.04-4.07]). Immunomodulator exposure (n=26) was not associated with an increased risk of cancer (SIR=0.75 [0.43-1.29]) nor with any specific risk including malignant lymphoproliferative disorders (SIR=1.89 [0.26-13.44]). Only 2 patients of this cohort received biotherapy. Conclusions: There is no increased risk for developing intestinal cancer among patients with elderly-onset IBD in this population-based cohort. There is an increased risk of developing malignant lymphoproliferative disorders in UC and an increased risk for developing liver cancer in CD. These data reinforce the peculiarity of elderly-onset IBD as compared with younger age at onset IBD1. 1 Charpentier C et al. Gut 2013