Research Corner: Congenital Heart Disease and Vocal Fold Immotility

Congratulations to our pediatric colleague, Christine Rappazzo, for this wonderful addition to our evidence base related to the potential impact of the need for heart surgery on airway protection in our infant population. This, combined with the documented increased risk for R vocal fold motion impairment post ECMO in this population, helps us to advocate for our involvement in safe progression to PO for these vulnerable infants.

Citation: Narawane, A., Rappazzo, C., Hawney, J., Clason, H., Roddy, D. J., & Ongkasuwan, J. (2021). Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. The Laryngoscope.

Abstract

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.

Methods

This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.

Results

Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.

Conclusion

Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

This will inform your pediatric practice whether in the inpatient or community pediatric setting.

 

 

 

 

Problem-Solving: 30-month-old with Random Gagging and Altered Swallowing Physiology

QUESTION:

Recently, I completed a MBSs on a 30-month-old child secondary to complaints of vomiting, gagging/choking at random. At age 24 months, child had tonsillectomy/adenoidectomy completed secondary to vomiting/gagging with the hopes this would correct child’s difficulties. MOC reports that this did help some however reports difficulties have not completely resolved. Per MOC, child had pacifier until age of 20 months. At time of MBSs child did consume pureed and thin liquids, they refuse all other bolus consistencies. Child noted to have a high palate arch and slightly narrowing in front of mouth. Delayed swallow to the level of the pyriform sinus was observed, suspect secondary to poor retraction and elevation of tongue to soft palate due to high arch. No penetration or aspiration noted. Appropriate ROM with tongue was observed during attempts at oral facial/motor examination. Per MOC, child is a picky eater, consumes 30oz of milk daily, will pocket food and spit it out and gag on water intermittently.

Based off of how this child presents, I would focus on lingual strengthening, age-appropriate mastication patterns and acceptance of age-appropriate foods. For a child of this age, what would your recommendations be for treatment/tasks to obtain these goals/exercises etc.? I am running into a roadblock per say. From my research and reading, I have found great ideas for older children or adults who follow verbal directives, however due to this child’s age, I am stuck!

ANSWER:

Is the child otherwise normally developing? Is postural /sensory-motor control age-appropriate?  I am asking because sometimes this type of clinical presentation is part of a bigger sensory processing issue or part of a constellation of craniofacial alterations or alterations across developmental domains. That creates a different “bigger picture” from which to problem-solve.

Craniofacial malformations often co-occur with changes in the muscular network that supports those structures. The high arched (and sometimes “tented”) palate can co-occur as part of a genetic syndrome and can co-occur with mandibular hypoplasia. Mandibular hypoplasia alters lingual and supra/infrahyoid muscular ROM and their functional coordination.

Interestingly, I have seen across the age span that, with this clinical presentation you described, it is not uncommon to have co-occurring tethering of oral tissues. I suspect that, if there are TOTs, this may be because the formation of these structures and muscular attachments occurs around the same time in utero. Then their motor sequences are initially mapped in utero through swallowing of amniotic fluid. So, the underpinnings for a well-integrated oral-motor system are underway quite early. Maladaptive networks also start in utero and the foundations for function can then start off in infancy already altered and impact future function that “feeds forward”, as our PT colleagues call it, in motor learning. So, implications unfold overtime.

If there are tethered oral tissues, or related alterations, they can at times be more subtle. These alterations can create challenges for the emergence of motor plans along the swallow pathway, and for bolus control and manipulation. That may also provoke the air swallowing that can lead to the vomiting/emesis you report. We must of course recognize that tethered oral tissues are not always the explanation/etiology, but should be a part of your thoughtful differential, as it could explain the functional limitations you describe. As could altered oral-facial tone, an altered overriding postural network, and/or sensory integration problems, and other possibilities, depending on the unique “bigger picture” for this child. Thinking through that bigger picture will best guide targeted interventions.

A wonderful resource on the neurodevelopmental underpinnings for feeding development is included in Robyn Walsh and Lori Overland’s book on “Functional Assessment and remediation of Tethered Oral Tissues”. Even if TOTs are not part of this child’s etiology(ies), their tutorial included in their book is not just about TOTs but is a foundational must read on functional oral motor development. By two of our wonderful SLP colleagues.

The swallow study would likely reveal any alterations in base of tongue retraction and pressure generation that may be created if tethering were impacting this child’s swallow pathway. For some children, the oral phase appears most altered, but that of course can cause problems down the line such as gagging and “sudden” loss of control which mother describes, which may reflect challenges with coordination during the dynamic swallow (when the need for exquisite motor mapping is required).

The attached article by my colleague Laura Brooks that adds to our understanding of the potential implications of some of the potential alterations. Even though with your patient there was no witnessed airway invasion, there was an alteration in physiology that likely is connected somehow to the functional differences you are seeing. This may take some peeling apart layers of data through a second and third look. Or more. And it may take a while to sort out and trial the interventions that best meet your differential. And that’s ok. It’s complex but you have a good start.

Click here for Laura Brooks article

Practicing at the Top of Your Profession in Feeding/Swallowing

An SLP asked recently, “What resources, articles, courses, etc. did you find helpful when you were first learning infant feeding? I’m looking for something to give me what I really need.”

“My seminars” I told her, “are designed to do just that. When I created them, and as I update them, I always think ‘What do I wish I had known, both research and clinical information, to practice in peds dysphagia when I started out? What is essential to work toward practicing at the top of our professions?’  My NICU and Pediatric as well as Advanced seminars, my Peds/ Neonatal Video Swallow Studies and Cue Based seminars are filled with everything I want to pass along. As I learn from colleagues and attendees at my courses, I weave that in as well. Sometimes I almost run out of time!

I will always offer you a welcoming environment that fosters interaction and learning along with each other.

Click here to download Shaker 2022 On-Site Seminars Brochure

Click here to Register

 

Research: Down Syndrome and Swallowing Pathophysiology

I wanted to share a summation of recent research on prevalence of pathophysiology in infants with Down Syndrome that adds to our evidence-base. It suggests that a high index of suspicion is warranted, and watchful vigilance is required.

Narawane et al (2020) found high prevalence of both oral and pharyngeal dysphagia (89.8% and 72.4% respectively) in infants with Down Syndrome during VFSS. Laryngeal penetration was present in 52% and aspiration in 31.5%, often with thin liquids. When aspiration occurred, it was “silent” in 67.5%.

Jackson et al. (2019) looked at presence of deep laryngeal penetration and/or aspiration (on VFSS or FEES) in infants with Down Syndrome younger than 6 months versus those 6-12 months old. 31.9% of the younger group showed abnormal findings, compared to 51.3% in the older group. CHD and laryngomalacia were identified as risk factors for aspiration.

Stanley et al (2019) looked at 100 infants with Down Syndrome younger than six months via VFSS. 96% showed abnormal results. CHD was not a risk factor in this study, but co-occurring risk factors were desaturation during feeding, airway/respiratory anomalies, being underweight and prematurity.

Jackson et al. (2016) looked at older children with Down Syndrome (mean age of 2.1 years), and found oral motor difficulties in 63.8%, pharyngeal dysphagia in 56.3% and aspiration in 44.2%. Aspiration events were mostly “silent”.

 

References

Narawane, A., Eng, J., Rappazzo, C., Sfeir, J., King, K., Musso, M. F., & Ongkasuwan, J. (2020). Airway protection & patterns of dysphagia in infants with down syndrome: Videofluoroscopic swallow study findings & correlations. International journal of pediatric otorhinolaryngology132, 109908.

Jackson, A., Maybee, J., Wolter‐Warmerdam, K., DeBoer, E., & Hickey, F. (2019). Associations between age, respiratory comorbidities, and dysphagia in infants with down syndrome. Pediatric pulmonology54(11), 1853-1859.

Jackson, A., Maybee, J., Moran, M. K., Wolter-Warmerdam, K., & Hickey, F. (2016). Clinical characteristics of dysphagia in children with Down syndrome. Dysphagia31(5), 663-671.

Stanley, M. A., Shepherd, N., Duvall, N., Jenkinson, S. B., Jalou, H. E., Givan, D. C., … & Roper, R. J. (2019). Clinical identification of feeding and swallowing disorders in 0–6 month old infants with Down syndrome. American Journal of Medical Genetics Part A179(2), 177-182.

 

Significance of Laryngeal Penetration in Pediatrics: Research and Reflection

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 pediatrics6(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 nutrition68(2), 218.

Duncan, D. R., Larson, K., & Rosen, R. L. (2019). Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. Current gastroenterology reports21(7), 1-9.

Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia15(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 otorhinolaryngology79(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 Pulmonology52(11), 1486-1494.

 

 

Research Corner: Swallowing Biomechanics in Infants with Feeding Difficulties

Variability in Swallowing Biomechanics in Infants with Feeding Difficulties: A Videofluoroscopic Analysis by Laura Fuller, Anna Miles, Isuru Dharmarathn, Jacqui Allen1 (2022) Dysphagia – published online March 2022

This just published paper adds to our evidence and understanding about the dynamic infant swallow.

Abstract

Clinicians performing feeding evaluations in infants often report swallow variability or inconsistency as concerning. However, little is known about whether this represents pathological incoordination or normal physiologic variance in a developing child. Our retrospective study explored quantitative videofluoroscopic measures in 50 bottle-fed infants (0–9 months) referred
with feeding concerns. Our research questions were as follows: Is it possible to assess swallow to swallow variability in an infant with feeding concerns, is there variability in pharyngeal timing and displacement in infants referred for videofluoroscopy, and is variability associated with aspiration risk? Measures were taken from a mid-feed, 20-s loop recorded at 30 frames per second. Each swallow within the 20-s loop (n=349 swallows) was analysed using quantitative digital measures of timing, displacement and coordination (Swallowtail™). Two blinded raters measured all swallows with strong inter-rater reliability (ICC .78). Swallow frequency, suck-swallow ratio, residue and aspiration were also rated. Variability in timing and displacement was identified across all infants but did not correlate with aspiration (p>.05). Sixteen infants (32%) aspirated. Across the cohort, swallow frequency varied from 1 to 15 within the 20-s loops; suck-swallow ratios varied from 1:1
to 6:1. Within-infant variability in suck-swallow ratios was associated with higher penetration-aspiration scores (p<.001). In conclusion, pharyngeal timing and displacement variability is present in infants referred with feeding difficulties but does not correlate with aspiration. Suck-swallow ratio variability, however, is an important risk factor for aspiration that can be
observed at bedside without radiation. These objective measures provide insight into infant swallowing biomechanics and deserve further exploration for their clinical applicability.

Research Corner: Developmental Trajectory of Long-term Oral Feeding Problems in ‘Healthy’ Preterm Infants

Robinson, L., Heng, L., & Fucile, S. (2022). Investigating the Developmental Trajectory of Long-term Oral Feeding Problems in ‘Healthy’ Preterm Infants. Developmental Neurorehabilitation, 1-5.

Quote:

Purpose: To investigate the occurrence of oral feeding problems in preterm infants up to one year after hospital discharge

Methods: Thirty-six infants born<34 weeks’ gestation were enrolled in a prospective exploratory      longitudinal pilot study prior to hospital discharge. Parents of eligible infants completed telephone questionnaires at 3, 6, and 12 months corrected gestational age. The occurrence and type of feeding problems; medical problems; and rehabilitation services received were collected.

Results: A total of 26 (72.2%) parents responded, with 11 (42%) identifying feeding problems that developed within the first year of life. Avoidant behavior (including crying, agitated/fussy, and refusing to eat) was the most common feeding problem that occurred.

Conclusion: Feeding problems in ‘healthy’ preterm infants may occur at any point in development within the first year of life. Increased screening after hospitalization is needed for early identification and to make appropriate referrals in a timely manner to prevent and/or reduce the severity of long-term feeding problems

Implications for Practice The findings from this study are clinically significant because many ‘healthy’ preterm infants in particular, those born >29 weeks’ gestation, are often discharged from the hospital without specialized follow-up and are not monitored closely for feeding issues by their primary care provider until the problems become clinically significant. Moreover, feeding is reported as a main concern for families of preterm infants following discharge from the NICU and is a major cause for emergency room visits and hospital readmissions to one year after discharge from the NICU. Hence, given the increased susceptibility of all preterm infants to encounter oral feeding problems beyond hospitalization, parental education and counseling should be provided prior to hospital discharge, and infants should continue to be screened and assessed post-discharge

Research Corner: Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery

Congratulations to our pediatric colleague, Christine Rappazzo,  for this wonderful addition to our evidence base related to the potential impact of the need for heart surgery on airway protection in our infant population. This, combined with the documented increased risk for R vocal fold motion impairment post ECMO in this population, helps us to advocate for our involvement in safe progression to PO for these vulnerable infants.

Citation: Narawane, A., Rappazzo, C., Hawney, J., Clason, H., Roddy, D. J., & Ongkasuwan, J. (2021). Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. The Laryngoscope.

Abstract

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.

Methods

This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.

Results

Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.

Conclusion

Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

This will inform your pediatric practice whether in the inpatient or community pediatric setting.

 

 

Research Corner: High Flow Oxygen Therapy and the Pressure to Feed Infants with Acute Respiratory Illness

The impact of Nasal Continuous Positive Airway Pressure (NCPAP) and/or High Flow Nasal Cannulae (HFNC) on swallowing physiology in infants via the swallow-breathe interface is not fully understood. However recent literature is worrisome for increased risk for airway invasion, often silent. It is increasingly common for hospitalized infants to have orders to PO feed while requiring this level of respiratory support. PO feeding is part of the path to discharge.

Some may be otherwise normally developing and recovering from a viral process, yet still present with precarious readiness to return to PO. Some may have a  premorbid history of feeding/swallowing problems, and co-morbidities that place them at an even higher risk. Further research is needed to guide for safe return to oral feeding of infants and children in the PICU with an acute respiratory illness who require NCPAP or HFNC.

In the interim, careful clinical assessment and consideration of risk from multiple perspectives are essential. Conversations with the team that follow will require familiarity with the current literature and dialogue that considers that  infant’s presentation and unique risks. Sometimes, despite our advocacy, there is a decision to proceed with PO feeding. Cautious pacifier dips for purposeful swallows may be followed by brief small PO trials with a slow flow nipple with strict co-regulated pacing to limit the bolus size and support swallow-breathe synchrony, with positioning that optimizes tidal volume. Once there has been some brief motor learning and problem-solving, an instrumental assessment to objectify swallowing physiology under the  current respiratory support would be essential. It is critical that physiology and pathophysiology be our focus in radiology, not just the events of bolus mis-direction in and of themselves that we happen to capture in the short time under fluoroscopy. During the course of a true feeding, intermittent/interval changes in rate and depth of breathing, tidal volume and/or vigor may be a tipping point that leads to silent airway invasion. I don’t know that this is readily understood by all of our medical colleagues.

While my conclusions above differ from those of the authors regarding the potential role of instrumental assessment, the article referenced below is a valuable resource for you:

Raminick, J., & Desai, H. (2020). High Flow Oxygen Therapy and the Pressure to Feed Infants with Acute Respiratory Illness. Perspectives of the ASHA Special Interest Groups5(4), 1006-1010.

Abstract

Purpose Infants hospitalized for an acute respiratory illness often require the use of noninvasive respiratory support during the initial stage to improve their breathing. High flow oxygen therapy (HFOT) is becoming a more popular means of noninvasive respiratory support, often used to treat respiratory syncytial virus/bronchiolitis. These infants present with tachypnea and coughing, resulting in difficulties in coordinating sucking and swallowing. However, they are often allowed to feed orally despite having high respiratory rate, increased work of breathing and on HFOT, placing them at risk for aspiration. Feeding therapists who work with these infants have raised concerns that HFOT creates an additional risk factor for swallowing dysfunction, especially with infants who have compromised airways or other comorbidities. There is emerging literature concluding changes in pharyngeal pressures with HFOT, as well as aspiration in preterm neonates who are on nasal continuous positive airway pressure. However, there is no existing research exploring the effect of HFOT on swallowing in infants with acute respiratory illness. This discussion will present findings from literature on HFOT, oral feeding in the acutely ill infant population, and present clinical practice guidelines for safe feeding during critical care admission for acute respiratory illness.

Conclusion Guidelines for safety of oral feeds for infants with acute respiratory illness on HFOT do not exist. However, providers and parents continue to want to provide oral feeds despite clinical signs of respiratory distress and coughing. To address this challenge, we initiated a process change to use clinical bedside evaluation and a “cross-systems approach” to provide recommendations for safer oral feeds while on HFOT as the infant is recovering from illness. Use of standardized feeding evaluation and protocol have improved consistency of practice within our department. However, further research is still necessary to develop clinical practice guidelines for safe oral feeding for infants on HFOT.

Research Corner: Infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants

This newly published paper reminds us that, in the NICU, care is best when it is family-centered. Our most vulnerable preterms and their mothers benefit most when compassionate and thoughtful caregivers consider not only the infant’s co-morbidities but also maternal anxiety, stress, and depression, when assessing premature infants’ oral feeding performance. They influence each other, and should guide our approach to supporting the feeding experience.

 

Muir, H., Kidanemariam, M., & Fucile, S. (2021). The Impact of Infant and Maternal Factors on Oral Feeding Performance in Premature Infants. Physical & Occupational Therapy In Pediatrics, 1-7.

Abstract

Aims: To identify infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants.

Method: A retrospective study was performed on 89 premature infants (<34 weeks gestational age) from a tertiary care neonatal intensive care unit (NICU). Infant and maternal factors were concurrently assessed. Infant factors included gestational age, birthweight, continuous positive airway pressure assistance, mechanical ventilation support, and presence of neonatal morbidities including bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and intraventricular hemorrhages (IVH). Maternal factors included maternal age, first born, twin birth, and presence of mental health conditions including anxiety, stress, or depression.

Results: A total of 89 premature infants were included in the sample. A stepwise linear regression model revealed that infants who received mechanical ventilator support and presence of maternal mental health conditions were significantly associated with time to attain FOF.

Conclusions: Results suggest that oral feeding performance is influenced not only by infant’s medical severity denoted by need for ventilator assistance, but also by presence of maternal anxiety, stress, and/or depression.

Details of conclusion: In terms of infant factors, this study revealed that mechanical ventilation support is associated with time to attain FOF. These study results are supported by others who found that infants with a chronic lung disease who require oxygen therapy or prolonged ventilation, are older by post conceptual age, when bottle feeding is initiated. Although the literature indicates that younger gestational age, lower birth weight, and neonatal morbidities such as BPD, IVH, and NEC are associated with longer FOF attainment these factors were not significant in this study. The lack of significance in GA, BW, and neonatal morbidities is likely because both infant and maternal factors were simultaneously assessed in the stepwise linear regression model which may have impacted the significance of these variables on FOF. Stepwise linear regression model essentially does multiple regression a number of times, each time removing the weakest correlated variable. At the end, the variables remaining are those that best explain FOF. Oral feeding consists of infants’ ability to generate and coordinate suck, swallow, and breathe processes. This entails proper functioning of the oral musculoskeletal, cardiorespiratory, and gastrointestinal systems. Taking the above into consideration, the study findings suggest that infants’ respiratory status, defined by need for mechanical ventilation assistance, has a significant effect on FOF, as it is one of the main systems involved in the oral feeding process. With regards to maternal factors, this study found that the presence of a maternal mental health condition, in particular anxiety, stress, or depression, is negatively associated with attainment to FOF, which corroborates a recent study (Park et al., 2016*). They found that increased maternal psychological distress was associated with decreased use of developmentally supportive feeding behaviors. These results suggest that mothers with psychological distress may be less responsive to the infant signals and needs. The literature suggests that maternal mental health conditions are associated with feeding behaviors but does not directly link this factor to delays in FOF as in this study. The study findings bring to light the importance of considering both infant and maternal factors when assessing premature infant’s oral feeding performance. 

*Park, J., Thoyre, S., Estrem, H., Pados, B., Knafl, G., & Brandon, D. (2016). Mothers’ psychological distress and feeding of their preterm infants. American Journal of Maternal Child Nursing, 41(4). Available through Google Scholar

 

Research Corner: Severe IVH and Biorhythms of Feeding

This just published paper by Gewolb and Vice, two well known neonatal feeding researchers, adds to our evidence base about severe IVH as a co-morbidity that can alter feeding progression in neonates 35-42 weeks PMA. As such, it may be an added consideration for consult to neonatal therapists in the NICU.

Gewolb, I. H., Sobowale, B. T., Vice, F. L., Patwardhan, A., Solomonia, N., & Reynolds, E. W. (2021). The Effect of Severe Intraventricular Hemorrhage on the Biorhythms of Feeding in Premature Infants. Frontiers in Pediatrics, 870.

OBJECTIVE: evaluate the underlying rhythms of suck,
swallow, and breath in a low-risk cohort of preterm infants, as
well as in cohorts with severe IVH, BPD, or BPD + IVH, thus
allowing us to determine whether neurological injury alone has
an adverse impact on the rhythms of infant feeding.
We hypothesized that the attainment of rhythmic stability of
suck-suck and suck-swallow dyads would be adversely impacted
in the high-risk preterm groups and that respiratory and
neurological issues might have different effects on the overall
biorhythmic patterns seen.

CONCLUSION
Severe IVH has a negative impact on the biorhythms of suck-suck
and suck-swallow in preterm infants 35–42 weeks PMA. If a
preterm infant with IVH but without BPD at 35–42 weeks PMA
lacks adequate feeding biorhythms, there could be a need for
additional workup to identify possibly undetected neurological
injury. The independent effect of severe IVH on feeding rhythms
suggests that quantitative analysis of feeding may both reflect
and predict neurological sequelae, and perhaps points to a critical
period where intervention may be most efficacious.

I am attaching is as it is open access on Google Scholar  Severe IVH and Feeding (2021)

Research Corner: Best Practices in VFSS

Wanted to share this recent publication on best practice for swallow studies,  which brings to practicing clinicians both the state of the science and best practices from leading researchers.

Martin-Harris, B., Canon, C. L., Bonilha, H. S., Murray, J., Davidson, K., & Lefton-Greif, M. A. (2020). Best Practices in Modified Barium Swallow Studies. American Journal of Speech-Language Pathology29 (2 Suppl), 1078.

Abstract:

Purpose: The modified barium swallow study (MBSS) is a widely used videofluoroscopic evaluation of the functional anatomy and physiology of swallowing that permits visualization of bolus flow throughout the upper aerodigestive tract in real time. The information gained from the examination is critical for identifying and distinguishing the type and severity of swallowing impairment, determining the safety of oral intake, testing the effect of evidence-based frontline interventions, and formulating oral intake recommendations and treatment planning. The goal of this review article is to provide the state of the science and best practices related to MBSS.

Method: State of the science and best practices for MBSS are reviewed from the perspectives of speech-language pathologists (SLPs) and radiologists who clinically practice and conduct research in this area. Current quandaries and emerging clinical and research trends are also considered.

Results: This document provides an overview of the MBSS and standards for conducting, interpreting, and reporting the exam; the SLPs’ and radiologist’s perspectives on standardization of the exam; radiation exposure; technical parameters for recording and reviewing the exam; the importance of an interdisciplinary approach with engaged radiologists and SLPs; and special considerations for examinations in children.

Conclusions: The MBSS is the primary swallowing examination that permits visualization of bolus flow and swallowing movement throughout the upper aerodigestive tract in real time. The clinical validity of the study has been established when conducted using reproducible and validated protocols and metrics applied according to best practices to provide accurate and reliable information necessary to direct treatment planning and limit radiation exposure. Standards and quandaries discussed in this review article, as well as references, provide a basis for understanding the current best practices for MBSS.

Click here to view/download from NIH Best Practices in Modified Barium Swallow Studies (nih.gov)

 

Research Corner: Critical Thinking Skills

Many of you know about Dysphagia Café, a wonderful resource for SLPs. The attached link will take you to an article just posted there by  Ed Byce, M.Ed. CCC-SLP and  Angela Van Sickle, PhD, CCC-SLP on critical thinking. Such foundational information to put our knowledge into action as we problem-solve patients across the age span and co-morbidities. Filled with clinical references, it reinforces the importance of being life long learners and is a must read.

A quote from their conclusions:
The good news is that the progress of gaining knowledge can be measured incrementally, one bit of information at a time. Now the proverbial ball is in your court. Take some time to set goals for learning. Will it be one article a week? Two per month? Will it be starting a journal club to review the information with colleagues? Perhaps it will be developing a robust data collection system? There are many possibilities, but it is worth the journey because patients are counting on you! 

 I think it’s so easy to look for a cookbook or an algorithm, and it gives us a sense of security. It is perhaps a false sense of security, given our complex patients,  each of whom is unique in terms of history, co-morbidities and clinical progression. Each needs a unique algorithm. As the authors so eloquently explain, problem-solving always requires a deeper dive, filled with knowledge but also with questions that help us complete our differential. This article really should be a must read for graduate students,  to reinforce that living in  the “gray zone”,  as  like to call it,  i.e., stepping back and pausing, not expecting yourself to have all the answers or a quick answer,  is ok.  And it is not only ok, but also essential. It underpins critical reflective thinking,  and best supports effective patient care, no matter what the age or co-morbidities.

Building a Knowledge Base to Improve Critical Thinking Skills – Dysphagia Cafe  

 

Research Corner: An Overview of Tracheostomy Tubes and Mechanical Ventilation Management

Barnes, G., & Toms, N. (2021). An Overview of Tracheostomy Tubes and Mechanical Ventilation Management for the Speech-Language Pathologist. Perspectives of the ASHA Special Interest Groups, 1-12.

This is a wonderful addition to our working knowledge base about tracheostomy. While it is focused on the adult population, it provides quite useful information and clinical reasoning to inform the practice of pediatric therapists.

 Authors’ conclusion:

 SLPs are a vital part of the clinical team for patients with tracheostomies and on ventilators. New SLPs or SLPs new to this population may not have an adequate knowledge base to become an effective part of the clinical team. This clinical focus article, although not all inclusive, is an overview of respiratory considerations, disease processes, medical considerations, and complexities that effect the overall prognosis of tracheotomy and ventilator patients. Basic explanations of tracheostomy tubes, ventilation, and weaning have been provided as well to familiarize SLPs to the terminology. Overall assessment of the patientsmedical conditions, respiratory status, oral condition, speaking valve tolerance, voicing ability, secretion management, swallowing ability, and interventions are outlined to give the SLPs a comprehensive picture of these complex patients. A working knowledge in these areas is crucial for SLPs to become effective members of the clinical team involved in facilitating the patientsrecovery. It is highly recommended that this clinical focus article be a starting  point and encourage SLPs new to this population to further their knowledge base with education courses, hands-on training, and review of current literature related to tracheostomy and ventilated patients.