QUESTION:
Some of the SLP’s completing VFSS in the pediatric population are making recommendations solely on penetration. If the child penetrates they assume they will aspirate (due to gravity) and downgrade them to the thickest liquid they don’t penetrate or aspirate with. The reports I have received have not mentioned whether the infant attempts to cough or clear the penetration. I frequently complete fees with the adult population, but my experience is more limited with the pediatric/infant population. Adults will penetrate and clear independently with additional swallows or throat clear/cough to remove the penetration before they aspirate. I’ve also seen flash penetration in adult VFSS does that happen with infants?. I would love some opinions to help guide my practice.
ANSWER:
Infants and children aren’t little adults in so many ways, especially when it comes to swallowing. I’ll share some of the concepts that have influenced my practice and are part of my passion when I teach my seminar about pediatric/neonatal swallow studies.
One of them is that laryngeal penetration, when witnessed, doesn’t exist in a vacuum. Dr. Coyle has taught us that the significance of penetration, even in the adult population, is on a sliding scale. I love that. He is always so descriptive. I think he means that we have to make decisions on a case-by-case basis, by combining all available information, there is no one size fits all analysis and plan. Then we develop a management algorithm for that patient, with unique co-morbidities, risk factors, history and so on. Each infant/child is unique in birth history, feeding history, postural, sensory-motor, aerodigestive, neurologic status and caregiver attributes. Combined, they all can affect not only what we might witness in radiology but how the infant/child may respond, compensate, or be affected, and from moment to moment. For example, for our infants, their respiratory co-morbidities will increase the risk for airway invasion, especially under the “right conditions” (i.e., interval change in sucking rate or strength, change in RR or WOB, caregiver artifact). Data analysis in radiology must consider the unique algorithm best for that infant/child based on the available data and understanding of the implications in that context/setting. An otherwise normal infant/child would very likely have a different algorithm after radiology.
Our data set in radiology is limited in so many ways. We must look at the data gathered and focus on the physiology; impressions may be tenuous. We cannot focus on just the events of bolus mis-direction in and of themselves. A swallow study really is only a moment in time. Bonnie Martin Harris has told us that “aspiration or penetration is neither sufficient nor necessary for a swallowing impairment”. Dr Coyle describes the swallow study as an analysis of how and why the abnormal bolus flow occurred. The alterations in or impairment of physiology, and why that infant/child penetrated, must influence our critical thinking, and must inform our plan.
All events of laryngeal penetration are not alike in children, and that influences our analysis as well. Their frequency and depth, in the setting of the co-morbidities and age and pulmonary health, are important factors. Friedman and Frazier (2000) found that of those infants/children with witnessed deep laryngeal penetration, 85% went on to aspirate when the swallow study was extended. This correlation between deep laryngeal penetration and aspiration is an important consideration in our “bigger picture” analysis with infants and children. Duncan et al (2019) concluded that laryngeal penetration may be indicative of aspiration risk in children less than 2 years of age. It is also associated with negative clinical outcomes (Gurberg et al, 2015, and Duncan et al, 2019). Duncan’s group concluded that “Any finding of LP in a symptomatic child should be considered clinically significant and a change in management should be considered”.
Another consideration and a key one is what we understand about the evolution of swallowing physiology from infancy toward adulthood. It is closely intertwined with, and highly influenced by, evolving structural relationships of the head/neck, development of maturing postural control and the musculoskeletal network that underlies hyolaryngeal function. At different points along that developmental trajectory, the components of swallowing physiology that guide bolus flow evolve in synch with a gradually more adultlike postural mechanism. Along the way there is: encephalization, sensory-motor learning, skeletal changes, and growth of the larynx. (Ruark, 2002; Gosa, 2013, Riley et al, 2019) At various times along this continuum, physiology is evolving and thus the need for all the considerations I have mentioned about above. This evolution truly is delicate ballet and can be precarious at times. Normal infants and children adapt, and this evolution happens behind the scenes, unnoticed, giving the sense that it happens effortlessly. Not so for the infants and children who land at our doorstep whether in in radiology, early intervention, the outpatient clinic, or our children’s hospital.
Unfortunately, due to adverse effects of radiation exposure, we don’t have data across a wide range of normal infants/children to delineate the variation in pediatric swallowing physiology that may represent normal variation. So, we must peel apart the layers thoughtfully and carefully as each piece of data is obtained.
Perhaps have some dialogue with the SLPs you mention who have sent you reports, so you can learn along with them. Thickening is not always the best intervention either in adult or pediatric dysphagia, and at times may indeed create more risk. That said, some still see thickening as the go-to intervention and yet there may be other or better alternatives for a particular infant/child. There may not be. Have a conversation with that therapist about her/his impressions, rationale, and selection of interventions, and review the study together if possible. That would help build your own understanding of the unique considerations specific to the infants and children you may be following and will build a relationship for future collaboration. As therapists, we often need to live in the gray zone, as I like to call it, where questions are more common than answers and the answer is rarely straight forward, but that is also the pathway to being a lifelong learner.
I hope this is helpful. Thanks for reaching out.
Duncan, D. R., Larson, K., Davidson, K., May, K., Rahbar, R., & Rosen, R. L. (2019). Feeding interventions are associated with improved outcomes in children with laryngeal penetration. Journal of pediatric gastroenterology and nutrition, 68(2), 218-224.
Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia, 15(3), 153-158.
Gosa, M. (2013). Infant Airway Protection Mechanisms During Swallowing. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 22(4), 156-160.
Gurberg, J., Birnbaum, R., & Daniel, S. J. (2015). Laryngeal penetration on videofluoroscopic swallowing study is associated with increased pneumonia in children. International journal of pediatric otorhinolaryngology, 79(11), 1827-1830.
Riley, A., Miles, A., & Steele, C. M. (2019). An exploratory study of hyoid visibility, position, and swallowing-related displacement in a pediatric population. Dysphagia, 34(2), 248-256.
Ruark, J. L., McCullough, G. H., Peters, R. L., & Moore, C. A. (2002). Bolus consistency and swallowing in children and adults. Dysphagia, 17(1), 24-33.