Kara Larson

Preterm Infant Swallowing of Thin and Nectar-Thick Liquids: Changes in Lingual–Palatal Coordination and Relation to Bolus Transit

Tongue–soft palate coordination and bolus head pharyngeal transit were studied by means of postacquisition kinematic analysis of videofluoroscopic swallowing images of ten preterm infants referred from hospital NICUs due to poor oral feeding and suspicion of aspiration. Sequences of coordinated tongue–soft palate movements and bolus transits during swallows of thin-consistency and nectar-thick-consistency barium were digitized, and time series data were used to calculate continuous relative phase, a measure of coordination. During swallows of nectar-thick compared to thin barium, tongue–soft palate coordination was more likely to be antiphase, bolus head pharyngeal transit time was longer, and coordination was significantly correlated with bolus head pharyngeal transit. Analysis of successive swallows indicated that tongue–soft palate coordination variability decreased with nectar-thick but not with thin-consistency barium. Together, the results suggest that slower-moving bolus transits may promote greater opportunity for available sensory information to be used to modulate timing of tongue–soft palate movements so that they are more effective for pumping liquids.

Evaluation and Management of Chronic Aspiration in Children With Normal Upper Airway Anatomy

IMPORTANCE Chronic airway aspiration is a challenging problem for physicians and caregivers and can cause significant pulmonary morbidity in pediatric patients. Our knowledge regarding the causes and optimal management of these patients is in its infancy. OBJECTIVE To review our experience with the evaluation and management of pediatric patients with documented aspiration and normal upper airway anatomy. DESIGN, SETTING, AND PARTICIPANTS In this retrospective medical record review, we studied pediatric patients for airway disorders at a pediatric tertiary referral center who were diagnosed as having aspiration on modified barium swallow study during a 10-year period (June 1, 2002, through September 31, 2012). INTERVENTIONS Direct laryngoscopy and bronchoscopy performed with the patient under general anesthesia. MAIN OUTCOMES AND MEASURES Demographics, comorbidities, management, and swallowing outcomes were analyzed. RESULTS Forty-six patients met the inclusion criteria. The mean age at presentation was 1.56 years, and there was a male to female ratio of approximately 2:1. Eight patients (17%) were syndromic, 16 (35%) had developmental delay, and 12 (26%) had congenital heart disease. Fifteen patients (33%) underwent brain magnetic resonance imaging, and none had a brainstem or posterior fossa lesion that accounted for their aspiration. Patients were subdivided according to the consistency of the fluids that they aspirated: 25 (54%) aspirated thin liquids, 15 (33%) aspirated thickened liquids, and 6 (13%) aspirated purees. Of these patients, 21 (84%), 12 (80%), and 3 (50%) had resolution of their swallowing dysfunction with feeding and swallowing therapy, respectively. A total of 3 patients (7%) required a tracheostomy for their refractory aspiration. CONCLUSIONS AND RELEVANCE We recommend feeding and swallowing therapy for children with normal upper airway anatomy. Brain magnetic resonance imaging should be considered for patients with suspected brainstem or posterior fossa lesion based on neurologic examination findings. Most patients who aspirate thin and thickened liquids will have resolution of their swallowing dysfunction within 1 year of beginning therapy.

Oropharyngeal Dysphagia is Strongly Correlated With Apparent Life-Threatening Events.

Objectives: The aim of the present study was to investigate the prevalence of oropharyngeal dysfunction with resultant aspiration in patients admitted after apparent life-threatening events (ALTE) and to determine whether historical characteristics could predict this oropharyngeal dysphagia and aspiration risk. Methods: We retrospectively reviewed the records of all patients admitted to Boston Childrens Hospital between 2012 and 2015 with a diagnosis of ALTE to determine the frequency of evaluation for oropharyngeal dysphagia using video fluoroscopic swallow studies (VFSS) and clinical feeding evaluations, to determine the prevalence of swallowing dysfunction in subjects admitted after ALTE and to compare presenting historical characteristics to swallow study results. Results: A total of 188 children were admitted with a diagnosis of ALTE of which 29% (n = 55) had an assessment of swallowing by VFSS. Of those who had a VFSS, 73% (n = 40) had evidence of aspiration or penetration on VFSS. Of all of the diagnostic tests ordered on patients with ALTEs, the VFSS had the highest rate of abnormalities of any test ordered. None of the historical characteristics of ALTE predicted which patients were at risk for aspiration. In patients who had both clinical feeding evaluations and VFSS, observed clinical feedings incorrectly identified 26% of patients as having no oropharyngeal dysphagia when in fact aspiration was present on VFSS. Conclusions: Oropharyngeal dysphagia with aspiration is the most common diagnosis identified in infants presenting with ALTEs. The algorithm for ALTE should be revised to include an assessment of VFSS as clinical feeding evaluations are inadequate to assess for aspiration.

FIRST, DO NO HARM: A Response to "Oral Alimentation in Neonatal and Adult Populations Requiring High-Flow Oxygen via Nasal Cannula".

A recent paper [1] has proposed that the use of respiratory support delivered via high-flow nasal cannula (HFNC) does not have a direct impact on the safety of oral (PO, per os) feeding. As a group of NICU clinicians and researchers, we are writing to express our concern about the design and conclusions presented in this study. Specifically, the article does not present sufficient data for the NICU sample studied to support their conclusions in relation to this population (as detailed below). We believe that this could potentially place vulnerable infants at risk of unsafe feeding practices. Within the NICU environment, HFNC is used as an intervention for many infants with pulmonary disease. Common clinical benefits of HFNC support in infants identified in the literature include a ‘CPAP’ effect (i.e., delivering positive pressure that stents open the airway), providing anatomic O2 reservoirs in the pharynx and allowing rinsing of pharyngeal dead space [2, 3]. To swallow safely, the bolus needs to be contained in the oral cavity prior to the swallow, and the laryngeal vestibule needs to close (deglutition apnea) as the bolus moves through the pharynx, to ensure transport to the esophagus and not into the larynx or lower airway. To swallow safely during breastfeeding and bottle feeding, the precise timing of the suck-swallow-breath sequence needs to be maintained over every one of the swallows that occur in quick succession for minutes at a time while the infant is latched and suckling at the breast or bottle. We are not aware of any objective data using instrumental assessment that show that the presence of HFNC does not (a) impair swallow function during infant suckle feeding or (b) increase aspiration risk in NICU infants (many of whom are at heightened risk for aspiration from their underlying lung disease in itself). The Leder et al. paper [1] does not provide any such data but appears to encourage the practice of allowing (at least some) infants who are dependent on HFNC to feed PO. Of note, the authors report that 34 % (17/50) of infants on HFNC were deemed ‘safe’ to PO feed by MD/RN staff (although it appears that all continued to require tube feeds, indicating that they were not fully functional PO feeders, and is not clear how ‘safety’ was monitored). On examination of the information presented, it is apparent that none of the infants included in this study had a direct feeding evaluation (either formal clinical assessment or instrumental assessment) to confirm the safety of PO feeding. The authors report on their initial criteria for determining readiness to consider trying PO feeds, but make no mention of direct feeding evaluation and no & Pamela Dodrill PDodrill@partners.org

Presenting Signs and Symptoms do not Predict Aspiration Risk in Children.

Objectives To determine if any presenting symptoms are associated with aspiration risk, and to evaluate the reliability of clinical feeding evaluation (CFE) in diagnosing aspiration compared with videofluoroscopic swallow study (VFSS). Study design We retrospectively reviewed records of children under 2 years of age who had evaluation for oropharyngeal dysphagia by CFE and VFSS at Boston Childrens Hospital and compared presenting symptoms, symptom timing, and CFE and VFSS results. We investigated the relationship between symptom presence and aspiration using the Fisher exact test and stepwise logistic regression with adjustment for comorbidities. CFE and VFSS results were compared using the McNemar test. Intervals from CFE to VFSS were compared using the Student t test. Results A total of 412 subjects with mean (±SD) age 8.9 ± 6.9 months were evaluated. No symptom, including timing relative to meals, predicted aspiration on VFSS. This lack of association between symptoms and VFSS results persisted even in the adjusted multivariate model. The sensitivity of CFE for predicting aspiration by VFSS was 44%. Patients with a reassuring CFE waited 28.2 ± 8.5 days longer for confirmatory VFSS compared with those with a concerning CFE (P < .05). Conclusions Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE does not have the sensitivity to consistently diagnose aspiration so a VFSS should be performed in persistently symptomatic patients.

Gastroesophageal Reflux Burden, Even in Children That Aspirate, Does Not Increase Pediatric Hospitalization.

Objectives: Gastroesophageal reflux is common but remains a controversial disease to diagnose and treat and little is known about the role of reflux testing in predicting clinical outcomes, particularly in children at risk for extraesophageal reflux complications. The aim of this study was to determine if rates of hospitalization were affected by reflux burden even after adjusting for aspiration risk. Methods: We prospectively recruited, between 2009 and 2014, a cohort of pediatric patients with suspected extraesophageal reflux disease who were referred for reflux testing and underwent both multichannel intraluminal impedance with pH (pH-MII) and modified barium swallow studies. A subset of patients also underwent bronchoalveolar lavage with pepsin analysis. We determined their rates of hospitalization for a minimum of 1 year following pH-MII testing. Results: We prospectively enrolled 116 pediatric patients who presented for care at Boston Childrens Hospital and underwent both pH-MII and modified barium swallow studies. There was no statistically significant relationship between reflux burden measured by pH-MII or bronchoalveolar pepsin and total number of admissions or number of admission nights even after adjusting for aspiration status (P > 0.2). There were no statistically significant relationships between reflux burden by any method and the number or nights of urgent pulmonary admissions before or after adjusting for aspiration risk (P > 0.08). Conclusions: Even in aspirating children, reflux burden did not increase the risk of hospitalization. Based on these results, routine reflux testing cannot be recommended even in aspirating children, because the results do not impact clinically significant outcomes.

A Systematic Process for Weaning Children With Aspiration From Thickened Fluids

Importance Thickening of fluids is a common strategy for feeding patients with oropharyngeal dysphagia but has known risks and should be stopped once it is safe to do so. Weaning children from thickened fluids safely can be challenging, and novel methods are required. Objective To describe the use of a systematic weaning process (SWP) for children who received thickened liquids owing to oropharyngeal dysphagia and identified risk of aspiration. Design, Setting, and Participants Retrospective case series (2010 to 2015) at a tertiary care center of 50 children with documented aspiration by clinical swallowing assessment, airway evaluation, and videofluoroscopic swallow study with at least 4 months of follow-up. All patients were initially receiving thickened fluids. A 10% reduction in thickness was made every 2 weeks based on clinical symptoms. Caregivers progressed to the next incremental level if there were no signs or symptoms of aspiration. Main Outcomes and Measures Number of patients weaned to a thin-fluid diet. Results Of 50 children (32 [64%] male; median [interquartile range] age, 0.7 [1.0] y at presentation and 1.8 [1.3] y at start of wean) using the SWP, 44 (88%) were able to reduce the amount of thickener used. A successful wean from thickened fluids to thin fluids was completed in 39 (78%). The mean (SD) duration of a successful wean was 0.9 (0.6) years. Five patients tolerated a reduction in thickener but not a full wean to thin fluids. For 6 patients, weaning failed and they continued to receive thickened fluids. Of those whose weaning failed, 2 patients developed pneumonia. Of the 39 successfully weaned patients, 14 (36%) experienced a temporary stall but eventually tolerated thin fluids. Only 2 (5%) developed pneumonia while all other successfully weaned patients (n = 37 [95%]) did not experience any substantial respiratory issues. Overall, 46 (92%) of children required 2 or fewer videofluoroscopic swallow study evaluations. Conclusions and Relevance Patients with oropharyngeal dysphagia and aspiration should be gradually weaned off of thickened fluids. The SWP uses small incremental steps to gradually reduce the amount of thickener. Using this method, most children tolerated a reduction in thickeners and a thin-fluid diet. The SWP presents a safe and effective way of gradually returning children to a more normal diet.

How I approach expressing condolences and longitudinal remembering to a family after the death of a child

Bereaved families fear their child being forgotten by those who knew their loved child, including their childs oncology team. Thoughtfully timed, family‐centric condolences shared by pediatric oncology team members have the potential to extend our compassion and kindness toward a family during the darkness of grief. Well‐intended medical teams sometimes feel “at a loss” in terms of what to say to a grieving family and how or when to say it. This paper provides a tangible overview of written or verbal condolence communication in a format that can be personalized to the provider and the patients family.

Association of Proton Pump Inhibitors With Hospitalization Risk in Children With Oropharyngeal Dysphagia

Importance Proton pump inhibitors (PPI) are commonly prescribed to children with oropharyngeal dysphagia and resultant aspiration based on the assumption that these patients are at greater risk for reflux-related lung disease. There is little data to support this approach and the potential risk for increased infections in children treated with PPI may outweigh any potential benefit. Objective The aim of this study was to determine if there is an association between hospitalization risk in pediatric patients with oropharyngeal dysphagia and treatment with PPI. Design, Setting, and Participants We performed a retrospective cohort study to compare the frequency and length of hospitalizations for children who had abnormal results on videofluoroscopic swallow studies that were performed between January 1, 2015, and December 31, 2015, and who were or were not treated with PPI, with follow-up through December 31, 2016. Records were reviewed for children who presented for care at Boston Children’s Hospital, a tertiary referral center. Participants included 293 children 2 years and younger with evidence of aspiration or penetration on videofluoroscopic swallow study. Exposures Groups were compared based on their exposure to PPI treatment. Main Outcomes and Measures The primary outcomes were hospital admission rate and hospital admission nights and these were measured as incident rates. Multivariable analyses were performed to determine predictors of hospitalization risk after adjusting for comorbidities. Kaplan-Meier curves were created to determine the association of PPI prescribing with time until first hospitalization. Results A total of 293 patients with a mean (SD) age of 8.8 (0.4) months and a mean (SD) follow-up time of 18.15 (0.20) months were included in the analysis. Patients treated with PPI had higher admission rates (Incidence rate ratio [IRR], 1.77; 95% CI, 1.16-2.68) and admission nights (IRR, 2.51; 95% CI, 1.36-4.62) even after adjustment for comorbidities. Patients with enteral tubes who were prescribed PPIs were at the highest risk for admission (hazard ratio [HR], 2.31; 95% CI, 1.24-4.31). Conclusions and Relevance Children with aspiration who are treated with PPI have increased risk of hospitalization compared with untreated patients. These results support growing concern about the risks of PPI use in children.