In the neonatal and pediatric population, evidence is still emerging to guide our processes during the instrumental assessment, interpretation and analysis of pathophysiology and subsequent recommendations. Our time in radiology is such a small window, often with limited, and at times tenuous, data. We then need to consider that data in the setting of that infant’s/child’s unique co-morbidities and history, which then give meaning to the data we have collected.
There is no cookbook for pediatric swallow studies; cookbooks were made for cooking, not for instrumental assessments. Knowing potential interventions, but also what interventions would be contraindicated based on pathophysiology/history/co-morbidities is the starting point. What we then recommend may indeed tip that balance between risk-benefit, and in either direction. Optimizing the risk-benefit ratio for the infant/child requires us to utilize critical reflective thinking, with a focus on the nature of the pathophysiology, the biomechanical alteration/impairment, and its implications for that unique infant/child. In drilling down to that infant’s/child’s “story”, we then realize that a plan for baby A with the same objective data from radiology may not be appropriate for baby B.
The nature of the pathophysiology in the neonatal/pediatric population has nuances that reflect the dynamic interaction of the developmental trajectory of motor learning with evolution of the swallow. Superimposed on this, then, are the co-morbidities that increase risk, especially prematurity, CLD, CHD and other diagnoses that adversely affect cardio-respiratory integrity.
The evidence-base in the literature to guide us is emerging and is still in its infancy. Laryngeal Penetration (LP) has been associated with negative clinical outcomes in subsets of the pediatric population, including increased risk for PNA and aspiration (Gurberg et al, 2015). Duncan et al (2020) out of Boston Children s Hospital found in their study that laryngeal penetration is not transient in children < 2 years of age and may be indicative of aspiration risk. In their study, on repeat VFSS: 26% with prior LP had frank aspiration. The authors remarked that “Any finding of LP in a symptomatic child should be considered clinically significant and a change in management should be considered”. That may be a change in position, change in nipple, change in cup, adding a control valve, limiting bolus size, pacing, slow rate of intake, smaller sips, not necessarily thickening.
In such a scenario, thickening is not a solution but may be an interim step along the way to allow time for motor learning by the infant/child and for us to address the underlying pathophysiology. Thickening is not without its own attendant sequalae and is always our last resort in pediatrics. Brooks (2021) looked at potential options for thickening that may be less problematic for and better tolerated by our pediatric population, which can include certain purees, such as fruit or vegetable purees and yogurts.
Duncan et al in 2019 stated that thickened liquids are indicated “When symptoms pose greater risk than negative effects of thickeners”. In their study, intervening when penetrations were observed yielded symptom improvement, and reduced hospitalizations, especially pulmonary–related. Greatest improvement was observed with thickening (91%). Benefits of thickening when indicated via critical thinking can include swallowing safety, increased intake and parent satisfaction (Coon et al, 2016; Duncan et al, 2019, Krummrich et al 2017)
In addition, (Friedman & Frazier, 2000) from Colorado Children’s found a strong correlation between deep laryngeal penetration and subsequent aspiration in pediatric patients. Most often I find these are infants and children with complex co-morbidities, especially cardio- respiratory.
This discussion is a good one for our self-reflection. It reminds us that the dynamic swallow pathway exists only in the context of the infant or child and what their unique “story” is. Our job is to peel apart the layers of the history, co-morbidities, clinical and instrumental findings, the feeding “environment”, family input, and then thoughtfully reflect on the best plan least likely to cause adverse events. The critical thinking required is built upon organizing our thinking around not only what we know, but what we do not know (or fully understand), which remains quite broad in pediatrics. Those questions become flashlights that we shine into the darkness, allowing us to move forward into the uncertain and unknown thoughtfully. As the philosopher Bertrand Russell once remarked, “In all affairs, it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted”. And so it is, I think, with the work that we do. The “answers” have a way of becoming insufficient or obsolete over time. The questions, the intellectual curiosity, must endure for us to make good clinical decisions for our little patients.
Brooks, L., Liao, J., Ford, J., Harmon, S., & Breedveld, V. (2021). Thickened Liquids Using Pureed Foods for Children with Dysphagia: IDDSI and Rheology Measurements. Dysphagia, 1-13.
Coon, E. R., Srivastava, R., Stoddard, G. J., Reilly, S., Maloney, C. G., & Bratton, S. L. (2016). Infant videofluoroscopic swallow study testing, swallowing interventions, and future acute respiratory illness. Hospital pediatrics, 6(12), 707-713.
Duncan, D. R., Larson, K., Davidson, K., May, K., Rahbar, R., & Rosen, R. L. (2020).Feeding interventions are associated with improved outcomes in children with laryngeal penetration. Journal of pediatric gastroenterology and nutrition, 68(2), 218.
Duncan, D. R., Larson, K., & Rosen, R. L. (2019). Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. Current gastroenterology reports, 21(7), 1-9.
Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia, 15(3), 153-158.
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.
Krummrich, P., Kline, B., Krival, K., & Rubin, M. (2017). Parent perception of the impact of using thickened fluids in children with dysphagia. Pediatric Pulmonology, 52(11), 1486-1494.