Research Corner: Dysphagia in infants with single ventricle anatomy following stage 1 palliation: Physiologic correlates and response to treatment

Abstract

Background: Deficits in swallowing physiology are a leading morbidity for infants with functional single ventricles and systemic outflow tract obstruction following stage 1 palliation. Despite the high prevalence of this condition, the underlying deficits that cause this post-operative impairment remain poorly understood.

Objective: Identify the physiologic correlates of dysphagia in infants with functional single ventricles and systemic outflow tract obstruction following stage 1 palliative surgery.

Methods: Postoperative fiberoptic laryngoscopies and videofluoroscopic swallow studies (VFSS) were conducted sequentially on infants with functional single ventricles following stage 1 palliative surgery. Infants were dichotomized as having normal or impaired laryngeal function based on laryngoscopy findings. VFSS were evaluated frame-by-frame using a scale that quantifies performance within 11 components of swallowing physiology. Physiologic attributes within each component were categorized as high functioning or low functioning based on their ability to support milk ingestion without bolus airway entry.

Results: Thirty-six infants (25 male) were included in the investigation. Twenty-four underwent the Norwood procedure and twelve underwent the Hybrid procedure. Low function physiologic patterns were observed within multiple swallowing components during the ingestion of thin barium as characterized by 4 sucks per swallow (36%), initiation of pharyngeal swallow below the level of the valleculae (83%), and incomplete late laryngeal vestibular closure (56%) at the height of the swallow. Swallowing deficits contributed to aspiration in 50% of infants. Although nectar thick liquids reduced the rate of aspiration (P 5 .006), aspiration rates remained high (27%). No differences in rates of penetration or aspiration were observed between infants with normal and impaired laryngeal function.

Conclusions: Deficits in swallowing physiology contribute to penetration and aspiration following stage 1 palliation among infants with normal and impaired laryngeal function. Although thickened liquids may improve airway protection for select infants, they may inhibit their ability to extract the bolus and meet nutritional needs.

McGrattan, K. E., McGhee, H., DeToma, A., Hill, E. G., Zyblewski, S. C., LeftonGreif, M., … & MartinHarris, B. (2017). Dysphagia in infants with single ventricle anatomy following stage 1 palliation: Physiologic correlates and response to treatment. Congenital Heart Disease.

Read more…Congenital Heart Disease 2017 (Feb 28 epub)

Research Corner: The prevalence and effects of aspiration among neonates with CHD at the time of discharge

Abstract

Neonates undergoing heart surgery for CHD are at risk for postoperative gastrointestinal complications and aspiration events. There are limited data regarding the prevalence of aspiration after neonatal cardiothoracic surgery; thus, the effects of aspiration events on this patient population are not well understood. This retrospective chart review examined the prevalence and effects of aspiration among neonates who had undergone cardiac surgery at the time of their discharge.

This study examined the prevalence of aspiration among neonates who had undergone cardiac surgery. Demographic data regarding these patients were analysed in order to determine risk factors for postoperative aspiration. Post-discharge feeding routes and therapeutic interventions were extracted to examine the time spent using alternate feeding routes because of aspiration risk or poor caloric intake. Modified barium swallow study results were used to evaluate the effectiveness of the test as a diagnostic tool.

A retrospective study was undertaken of neonates who had undergone heart surgery from July, 2013 to January, 2014. Data describing patient demographics, feeding methods, and follow-up visits were recorded and compared using a χ2 test for goodness of fit and a Kaplan–Meier graph.

The patient population included 62 infants – 36 of whom were male, and 10 who were born with single-ventricle circulation. The median age at surgery was 6 days (interquartile range=4 to 10 days). Modified barium swallow study results showed that 46% of patients (n=29) aspirated or were at risk for aspiration, as indicated by laryngeal penetration. In addition, 48% (n=10) of subjects with a negative barium swallow or no swallow study demonstrated clinical aspiration events. Tube feedings were required by 66% (n=41) of the participants. The median time spent on tube feeds, whether in combination with oral feeds or exclusive use of a nasogastric or gastric tube, was 54 days; 44% (n=27) of patients received tube feedings for more than 120 days. Premature infants were significantly more likely to have aspiration events than infants delivered at full gestational age (OR p=0.002). Infants with single-ventricle circulation spent a longer time on tube feeds (median=95 days) than infants with two-ventricle defects (median=44 days); the type of cardiac defect was independent of prevalence of an aspiration event.

Aspiration is common following neonatal cardiac surgery. The modified barium swallow study is often used to identify aspiration events and to determine an infant’s risk for aspirating. This leads to a high proportion of infants who require tube feedings following neonatal cardiac surgery.

Karsch, E., Irving, S. Y., Aylward, B. S., & Mahle, W. T. (2017). The prevalence and effects of aspiration among neonates at the time of discharge. Cardiology in the Young, 1-7.

 Read more….Cardiol Young 2017 (1-7)

Q & A with Catherine: Supporting PCVICU

Question

Our hospital is working on creating a neurodevelopmental care team to implement in our CVICU. We are thankful to be involved and are working to gather research based evidence for what we do. We need research articles regarding the benefits of:

pacing
side-lying
breastfeeding with cardiac dysfunction (any guidelines you are using?)
vocal cord dysfunction/aspiration following arch advancement/coarcs (any protocols you are using with ENT/VFSS/FEES?)

We have found some articles but would love to hear your thoughts/get additional research to support our cause 🙂

Thank you so much!

Answer

You mention many of the critical areas of consideration when working in the PCVICU (pediatric cardiovascular intensive care unit), as many infants and children with congenital heart disease have feeding/swallowing problems secondary to their cardio-respiratory co-morbidities as well as other associated co-morbidities. This population is at high risk for genetic syndromes, which opens an even wider potential for co-morbid conditions. Post-arch repair increases risk for left VCP and post-ECMO infants in PCVICU are also at risk for right VCP; early scoping by ENT and early ST involvement prior to resuming/initiating PO is essential.

Because many of the feeding/swallowing issues specific to prematurity involve respiratory co-morbidities, much of the literature on preterm infant feeding and NICU intervention will inform your practice in cardiac.

Search the ASHA list serve archive for past posts from many contributors regarding NICU feeding, pediatric cardiac feeding issues and feeding on high flow cannulae for some excellent considerations and references. You will also find applicable information on my website including my publications with extensive bibliographies of pertinent references that address co-regulated pacing, sidelying and other interventions. A literature search will also yield several recent helpful papers (on VCP associated with cardiac repair, benefits of breastfeeding, feeding challenges post cardiac repair etc.), and a search through ASHA will yield pertinent Division 13 CE articles as well as post-convention papers, for example from a presentation by SLPs from Boston Children’s regarding their work and my past NICU-related presentations as well as those of others pertinent to NICU and PCVICU practice.

Working in PCVICU provides an amazing environment for learning from both nurses cardiologists, intensivists and respiratory therapists. I absolutely love it there, although I think the well-intentioned goal of getting these infants/children discharged after surgery can lead to challenges such consistency of feeding approach, following a plan, not focusing on just intake but also positive learning and its impact on long-term feeding outcomes. I found that starting by learning from them, having collegial conversations that enlighten them about our perspectives, the research and our clinical problem-solving, all helped to open doors for professional respect, collaboration and partnership, and for engaging in the difficult conversations with nurses and physicians when  a well-intentioned volume-driven approach becomes the problematic issue. Families are so grateful for the individualized infant-guided and child-guided approach we can share with them, as it allows them to build or rebuild a relationship with their sick child through positive feeding.

You will likely work with your own team to best create pathways and protocols that your team develops, once you have your feet on the ground and have a better understanding of your unique PCVICU population and your team’s preferences and past experiences utilizing therapy services in PCVICU. Once I had a sense of this and had built relationships, I provided an in-service to all PCVICU team members (and am set to repeat it d/t staff turnover) that allowed us to set the stage for their understanding of the unique considerations for return to feeding function, swallowing physiology, critical interventions, safe feeding, avoiding volume driven feeding, the high potential for feeding aversions, and the fragile nature of skills in this population.

Building relationships and bringing data seem to best go hand in hand when we start any new program. How wonderful they have asked you to be a part of their team. Know up front there will be daily struggles, just like in NICU, but they are all worth it at the end of the day. All the best to you in this endeavor!

Catherine

 

 

Research Corner: Feeding Outcomes After the NICU

Abstract:

Optimal growth and successful feeding in the neonatal intensive care unit (NICU) are difficult to achieve, and data indicate premature infants continue to struggle after discharge. The purpose of this systematic review was to identify growth and feeding outcomes in the NICU published within the last 10 years. Available evidence suggests weight-for-age decreases between birth and discharge from the NICU, and continues to lag behind expectations after discharge. Prevalence rates of breastfeeding differ across countries, with declining rates after discharge from the NICU. Interventions focused on increasing breastfeeding rates are effective. Most healthy preterm infants successfully nipple feed at a gestational age ≥ 36 weeks, but infants may be discharged prior to achieving full oral feeding, or eating with poor coordination. Earlier born preterm infants are later at achieving full oral feedings. After discharge, preterm infants are slower to develop eating skills, parental reports of feeding problems are prevalent, and parents introduce solids to their infants earlier than recommended. This review enhances professionals’ understanding of the difficulties of feeding and growth in preterm born infants that are faced by parents.

 

Ross, E. S., & Browne, J. V. (2013). Feeding outcomes in preterm infants after discharge from the neonatal intensive care unit (NICU): A systematic review. Newborn and Infant Nursing Reviews, 13(2), 87-93.

 

Read more…Ross Feeding Outcomes 2013 NAINR

Q & A Time with Catherine

Question: Our department is rolling out a new oral care protocol.  I am “on the fence” about this and I am worried that this practice may create more harm than good.  However, we have lots of little ones on vents, HFNC and many “gut” babies that will be NPO long term.  Many of these kiddos are at very high risk for infection and I think anything that can be done to prevent infection would be extremely beneficial.  I have been asked to assist in developing the protocol and giving input as to how to go about delivering the colostrum w/o inflicting negative stimuli to oral cavity (this was my hesitation w/ the program).  I am thinking perhaps the program should only include kiddos 30+ weeks as they may be more tolerant of oral stimuli. I thought maybe attempting to find a silicone swab of sorts to deliver colostrum via oral massage to gum ridge/buccal cavity may be appropriate.  Any thoughts?   Thank you!

Answer:
The benefits of mother’s milk (MBM) to the mucosa via tiny trace droplets that may promote purposeful swallows and oral-sensory-motor mapping is being considered by many NICUs as an early approach to supporting readiness for infant-guided feeding in the future and to prime the sensory-motor system along with nuzzling at the breast (kangaroo mother care). There is a very tiny “paintbrush” one of the reps has (sorry I cannot recall which) that can support a very gentle limited offering of MBM to the lips or this could be offered via very gentle well-graded touch.

The key is that this should be offered when infant is at his best respiratory wise (both in terms of respiratory support being required and his WOB and RR), he is actively engaged and maintains physiologic stability, and should be offered using infant-guided principles of interaction. Resting the infant and use of co-regulated pacing to assure that respiratory stability is fostered from moment to moment, are essential to support a neuro-protective experience that promotes both safety and positive learning. Some NICU caregivers may need guidance to view this experience in such a light, as opposed to a “task” that one “must complete as a part of cares.”

We recognize that, in the NICU, “practice” is not the key, but what is, is the experience, and how it is both offered and received by the immature emerging neuronal pathways and oral-sensory-motor system. Practice of course, makes permanent the neuronal pathways that are recruited and mapped; it does not in and of itself create the pathways that underlie function or skill; it can unfortunately lead to maladaptive behavior and stress if done as a task and/or offered in a programmed way. So yes, there is potential for this initiative to do more harm than good.

I would avoid “oral-motor work” designed to focus on jaw work or oral-motor skills per se at this juncture as it would be too invasive and not appropriate. You are describing preterms who are both fragile and still many weeks prior to term. Were they not born too soon, they would be fetuses experiencing motor and oral-motor learning in utero; their oral-motor movement patterns would be evolving in the context of the containment provided by the uterus, with hands on their face and in their mouth (and alternating touching the placenta per research). They would be integrating their structurally-intact aero-digestive system by 17 weeks of life, swallowing several ounces of amniotic fluid each day.

Focus on structuring experiences outside of the uterus that most closely align with the ideal sensory-motor environment and help caregivers embrace the critical impact this intervention can have if offered in a neuro-protective infant-guided way.

I hope this is helpful.




Catherine