Research Corner and Commentary about Article in the ASHA Leader on Thickening in the NICU

This is an excellent article just published by our colleagues at Boston Childrens and will inform your practice.

Duncan DR, Larson K, Rosen RL(2019) Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia.
Current gastroenterology reports.  https://doi.org/10.1007/s11894-019-0697-2

Abstract
The purpose of this review is to discuss current knowledge and recent findings regarding clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. We review evidence for thickener efficacy, discuss types of thickeners, practical considerations when using various thickeners, and risks and benefits of thickener use in pediatrics. Recent Findings: Thickeners are effective in decreasing regurgitation and improving swallowing mechanics and can often be used
empirically for the treatment of infants and young children. Adverse effects have been reported, but with careful consideration of
appropriate thickener types, desired thickening consistency, and follow-up in collaboration with feeding specialists, most patients have symptomatic improvements. Summary Thickeners are typically well tolerated and with few side effects, but close follow-up is needed to make sure patients tolerate thickeners and have adequate symptom improvement.

On a related note, I feel compelled to address a recent article in The ASHA Leader “From My Perspective: Overuse of Thickeners in the NICU.”

The article, I believe, while certainly written with the best of intentions, has the potential to set back the progress SLPs have made delineating a critical well-respected evidence-based role in the NICU and, left unaddressed, could do harm.

I am concerned that  SLPs (both adult and pediatric)  who are unfamiliar with the work of NICU SLPs may, after reading the above mentioned article in The ASHA Leader, have an inaccurate the impression about our practice. The article appears to make assumptions, and appears to question the clinical reasoning that underpins decisions made every day, with deliberate consideration for short and long-term implications and for best practice.

Many of the assumptions made by the author  are not consistent with both my practice in large level IV  NICUs for the last 35 years, nor the practice of most other NICU SLPs I have met as I teach across the US about NICU intervention. While there may indeed be variability in the knowledge and practice of some NICU providers (Madhoun, et al 2015),  the AAP recommends caution with thickeners in preterm infants, and this is typically the overriding consideration for all interventions prescribed in the NICU. First, do no harm. 

The author’s statement that “thickeners are a long-term solution” is not consistent with typical NICU practice. Thickeners are used only as the last resort in the NICU (Gosa, 2015) —- after trialing changing feeding position, slowing nipple flow rate, utilizing contingent  co-regulated pacing to support the swallow-breathe interface and assure timely and sufficient breaths.  Even then, thickening may not be the safest solution for a specific  infant and can  present untoward sequelae ( higher risk to aspirate after the swallow, concerns of digestive immaturity, malabsorption, NEC, etc.) Most NICUs rarely use thickeners today to the extent that they were used in the past, and if thickeners are, it is viewed as short term. In dialogue with the medical team, there is typically careful interdisciplinary deliberation of the risk benefit ratio. If indicated, there is typically the contingent use of interventions to minimize the risk, and support both oral-motor learning and motor learning, and avoid maladaptations that may result.

Each NICU infant’s  developmental progression, respiratory, GI and neuro history and co-morbidities must be considered, as well as the nature of the pathophysiology objectified in radiology.  When the author states that “failing a swallow study” is a reason to thicken, it suggests the author considers a swallow study as a “pass-fail procedure”.  Rather than a pass-fail procedure, an instrumental assessment is viewed with the NICU population, as an analysis of swallowing physiology, its alteration or impairment, and its implications for that unique infant in the setting of his unique presentation/data set.  Like with other populations for whom SLPs provide services, a neonate does not need to penetrate or aspirate to have a swallowing impairment that may lead to airway invasion. As a result, the level of analysis that is required, and the essential caution as to prescribed interventions, is well understood by those of us working with this high risk fragile population in the NICU. Thickening may be contraindicated based on data obtained in radiology.

The author asks  “What if the baby can’t suck?” and then states that “all babies have a suck reflex”. Unfortunately, this is inaccurate. It is not uncommon that a sick newborn or some preterm infants with significant neurologic co-morbidities may not have a sucking reflex, or the suck lacks the integrity to feed orally. If  indeed this is the clinical presentation, thickeners would be contraindicated. Our  interventions for motor learning would go in a completely different direction, both in the NICU and after discharge.

In addition, the assumptions about the interventions described in the article for use with post NICU infants (e.g., bottle feeding thin liquid  to avoid maladaptive feeding patterns, use of glycerin swabs, ice chips, and anterior controlled placement of thin water) are worrisome and may mislead the reader as to the interventions most typically indicated for an infant just discharged from a neonatal intensive care unit. The infant post-NICU is often still quite immature overall, and interventions such as those suggested may both present undue risk to the airway and be poorly tolerated from a sensory and GI perspective. Indeed, safety of progressing the diet to thin liquids, if previously contraindicated, would best be considered for the NICU graduate in the setting of objective data regarding physiology in radiology. Many NICU graduates continue to have medical issues post discharge that can make airway invasion a compelling risk to both their pulmonary and overall health. 


Cichero, J A  et al (2013). Thickened milk for the management of feeding and swallowing issues in infants: a call for interdisciplinary professional guidelines. Journal of Human Lactation, 29(2), 132-135.

Duncan DR, Larson K, Davidson K, May K, Rahbar R, Rosen RL.(2019) Feeding interventions are associated with improved outcomes in
children with laryngeal penetration. J Pediatr Gastroenterol Nutr. 68(2):218–224.

Goldfield, EC  et al (2013) Preterm infant swallowing of thin and nectar-thick liquids: changes in lingual-palatal coordination and relation to bolus transit. Dysphagia 28, 234e244.

Gosa, MM & Corkins, M R(2015). Necrotizing enterocolitis and the use of thickened liquids for infants with dysphagia. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(2), 44-49.

Madhoun, LL et al (2015). Feed-thickening practices in NICUs in the current era: Variability in prescription and implementation patterns. Journal of Neonatal Nursing, 21(6), 255-262.

I appreciate the opportunity to share the perspective of an NICU SLP and hope this has been helpful.

Research Corner: Aspiration and Dysphagia in the Neonatal Patient

Raol, N., Schrepfer, T., & Hartnick, C. (2018). Aspiration and Dysphagia in the Neonatal Patient. Clinics in perinatology, 45(4), 645-660.

Quote:

There are 3 major types of aspiration: anterograde (occurring before, during, and after the swallow), retrograde (as occurs with gastroesophageal reflux), and silent aspiration (no accompanying symptoms). Aspiration has the potential to cause permanent damage to the developing lungs of infants and children. Aspiration in children includes oral feeds and secretions (direct aspiration) and reflux contents (indirect aspiration). Pulmonary aspiration is present in one-half of pediatric patients with unexplained or refractory respiratory symptoms, such as cough. It can cause recurrent respiratory illness, pneumonia, and lung damage, requiring frequent hospitalizations.6 Etiologies of dysphagia and aspiration can be divided broadly into 5 categories:  Anatomic abnormalities (ie, craniofacial anomalies, laryngotracheoesophageal clefts, laryngomalacia);  Neurologic abnormalities (ie, intrauterine stroke, posterior fossa malformations, neuromuscular disorders);  Cardiopulmonary disease affecting the suck–swallow–breathe pattern (ie, bronchopulmonary dysplasia, cardiac disease, infection);  Gastrointestinal etiology (ie, reflux); and  Other/unknown.

The diagnosis and management of dysphagia and aspiration in neonates represent a significant challenge for physicians, with management requiring long-term medical supervision and attention. Without intervention, the patient may develop recurrent illness, inadequate nutrition, and the need for supplemental nutrition that, if continued for an extended period of time, may result in oral aversion and refusal behaviors. Successful management begins with a thorough evaluation with a complete history and physical examination and appropriate imaging studies to identify the etiology and potential targets for intervention.

Neonatal dysphagia and aspiration can be difficult to treat. Multiple etiologies can be responsible for feeding and swallowing issues, including prematurity, structural abnormalities, neurologic delay, infectious etiology, and reflux. Identifying the etiology will help to guide management. Multidisciplinary team management, including otolaryngology, neonatologists, speech-language pathologists is necessary to achieve optimal short and long-term outcomes in these patients.

Research Corner: Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity

Tracy, M. K., & Berkelhamer, S. K. (2019). Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity. Pediatric annals, 48(4), e148-e153.

Abstract

Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in premature infants who require mechanical ventilation and oxygen therapy. Despite advances in neonatal care resulting in improved survival and decreased morbidity, limited progress has been made in reducing rates of BPD. Therapeutic options to protect the vulnerable developing lung are limited as are strategies to treat lung injury, resulting in ongoing concerns for long-term pulmonary morbidity after preterm birth. Lung protective strategies and optimal nutrition are recognized to improve pulmonary outcomes. However, characterization of late outcomes is challenged by rapid advances in neonatal care. As a result, current adult survivors reflect outdated medical practices. Although neonatal pulmonary disease tends to improve with growth, compromised respiratory health has been documented in young adult survivors of BPD. With improved survival of premature infants but limited progress in reducing rates of disease, BPD represents a growing burden on health care systems.

Comments from Catherine: This provides an excellent summary of pathophysiology, ventilation modes and outcomes for this fragile group of preterms who often have feeding and swallowing problems related to their Chronic Lung Disease and its sequealae.

Research Corner: Nonpharmacological and Pharmacological Measures in Neonates with Neonatal Abstinence Syndrome

Magyar, Hannah R.; Metzger, Laura D.; and Schrage, Ariel N., “Systematic Review: The Effects of Nonpharmacological and Pharmacological Measures in Neonates with Neonatal Abstinence Syndrome” (2019). Williams Honors College, Honors Research Projects. 889. https://ideaexchange.uakron.edu/honors_research_projects/889

Abstract

With the increasing incidence of drug addiction among pregnant women, neonatal abstinence syndrome (NAS) has become a significant problem in the United States and has led to increased hospital costs, longer lengths of stay, and more serious health problems in neonates. This systematic review will explore the evidence about outcome differences for neonates with NAS that receive breastfeeding, rooming-in, and acupuncture in addition to pharmacological agents when compared to infants only receiving pharmacological agents. Twenty-one articles, retrieved from the databases PubMed and CINAHL and published between the years 2000-2017, were described in an integrated review, analyzed with critical appraisal, and synthesized for this systematic review. In general, researchers have found that breastfeeding, rooming-in, and acupuncture have positive effects of decreasing the need for pharmacological treatment, NAS symptoms, hospital costs, and length of hospital stay for infants with NAS when used in conjunction with pharmacologic agents.

Research Corner: VFSS and Frame Rate

For those  of you not on the ASHA List Serve, I am sharing a post regarding a recent publication about frame rate for Pediatric Videofluroscopic Swallow Studies. The post was written by Heather Bonilha, PhD,  who is  a speech-language pathologist and medical researcher who specializes in voice and swallowing disorders. For over 15 years, she has been studying the impact of temporal resolution (ex. frame rate) on diagnostic accuracy and treatment recommendations with a specific focus on MBSSs. We are so grateful for contributions, and for her post, which infomrs our practice.

The recently published article is:  Layly, J., Marmouset, F., Chassagnon, G., Bertrand, P., Sirinelli, D., Cottier, J. P., & Morel, B. (2019). Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies? Dysphagia. doi:10.1007/s00455-019-10027-8

To quote from her post:

 I am reaching out to the SIG13 forum to express my concerns related to a very recently published article: Layly, J., Marmouset, F., Chassagnon, G., Bertrand, P., Sirinelli, D., Cottier, J. P., & Morel, B. (2019). Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies? Dysphagia. doi:10.1007/s00455-019-10027-8 I’ve never made a post like this but am compelled based on my concern for quality patient care to post this one. I want to informally point out some information that clinicians and researchers should consider when evaluating the merits of the article referenced above. 

Points to consider when evaluating the merit and clinical implications of the research article “Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies?”:

The most significant point is that one can not notice a difference in something that isn’t there. When studying the impact of technical parameters of MBSS, one must use cases where the phenomenon (penetration / aspiration in this case) exists. If the patient doesn’t penetrate/ aspirate at 30 frames per second (fps) there is not a possibility to find it at 15fps, falsely leading to a result of agreement in diagnostic accuracy between 30 & 15 fps. Thus, any study of pulse rate / frame rate must be limited to that in which a phenomenon (penetration/aspiration, reduced laryngeal elevation, delayed initiation of pharyngeal swallow etc.) is detectable at 30fps. Therefore, of the 190 swallows studied in the above referenced article only 46 are pertinent to addressing the research question. By including all 190 swallows, the results of the study are significantly biased towards revealing no differences between 15 and 30fps.

Next, it is necessary to consider more than penetration/aspiration when determining whether technical factors influence diagnostic accuracy. Our treatments have a goal of reducing penetration/aspiration, but we do that by modifying swallowing physiology (not assessed by, for instance, by the penetration-aspiration scale (PAS)). Strong clinical implications regarding the suitability of using 15 vs 30fps must consider more than just PAS. The authors correctly state in the discussion that “15 fps may be adequate to record aspiration and penetration in children; however, more subtle biomechanical and kinematic phenomena may be missed at the slower sampling frequency due to the rapidity of the physiological swallowing components.”

The technique used to down sample the 30fps recording to 15fps does not allow the raters to be blinded to the higher versus lower frame rates as the higher frame rates (30 fps) will be twice as long as the 15fps swallows. There is a statement that using the 15fps recordings did not change the treatment plan for the patients. However, impact on treatment plan was not a variable in the research study and no data related to treatment plans / recommendations were presented.

There is a statement that using 15fps instead of 30fps is “an efficient way to reduce the ionizing radiation exposition in children”. However, radiation exposure, and more importantly, radiation risk, was not assessed in the study.

For these reasons, I strongly recommend a careful evaluation of the research methods and conclusions of the article “Can We Reduce Frame Rate to 15 Images per Second in Pediatric Videofluoroscopic Swallow Studies?” I will be formally writing a Letter to the Editor of Dysphagia; however, that is a lengthier process and I felt that the potential clinical ramifications dictated a more immediate response. Therefore, before the formal Letter to the Editor can be published, I hope that clinicians are encouraged to read the published article with critical appraisal prior to incorporating it in their evidence-based clinical practice.

Please feel free to contact me off-line at bonilhah@musc.edu regarding this. Sincerely,

Heather Bonilha  

Bonilha, H.S., Blair, J., Carnes, B., Huda, W., McGrattan, K., Humphries, K., Michaels, Y., Martin-Harris, B. (2013). Preliminary investigation of the effect of pulse rate on judgments of swallowing impairment and treatment recommendations. Dysphagia, 28(4): 528-538. [PMID: 23559454] [PMCID: PMC3762944]

Bonilha, H.S., Huda, W., Wilmskoetter, J., Martin-Harris, B., Tipnis, S.V. (2019). Radiation risks to adult patients undergoing Modified Barium Swallow Studies. Dysphagia. [PMID: 30830303] [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Tipnis, S.V., Martin-Harris, B., Huda, W. (2019). Relationships between Dose Area Product, radiation exposure time and projection in adult Modified Barium Swallow Studies. American Journal of Speech-Language Pathology. [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Tipnis, S.V., Martin-Harris, B., Huda, W. (2018). Estimating thyroid doses in Modified Barium Swallow Studies. Health Physics, 115(3): 360-368. [PMID: 30045116] [PMC Journal – In Process]

Bonilha, H.S., Wilmskoetter, J., Martin-Harris, B., Tipnis, S.V., Huda, W. (2017). Effective dose per unit kerma area product conversion factors in adults undergoing Modified Barium Swallow Studies. Radiation Protection Dosimetry, 16:1-9. [PMID: 28204745] [PMCID: PMC5927331]

Bonilha, H.S., Humphries, K., Blair, J., Hill, E., McGrattan, K., Carnes, B., Huda, W., Martin-Harris, B. (2013). Radiation exposure time during MBSS: Influence of swallowing impairment severity, medical diagnosis, clinician experience, and standardized protocol use. Dysphagia, 28(1): 77-85. PMID: 22692431

Martin-Harris, B., Carson, K.A., Pinto, J.M., Lefton-Greif, M.A. (2019). BaByVFSSImP© A novel measurement tool for videofluoroscopic assessment of swallowing impairment in bottle-fed babies: establishing a standard. Dysphagia. [PMID 30955137]

Lefton-Greif, M.A., Arvedson, J.C. (2016). Pediatric feeding/swallowing: yesterday, today and tomorrow. Semin Speech Lang 37:298-309. [PMID 27701706]

Arvedson, J.C., Lefton-Greif, M.A. (2017). Instrumental assessment of pediatric dysphagia. Semin Speech Lang 38:135-146. [PMID 28324903]