Research: Videofluoroscopic swallow-study outcomes among infants with tracheotomies

While problem-solving a recent NICU infant I was following with a tracheotomy, I incorporated this information from a study done through Nemours Childrens Hospital in DE. It was presented as a poster session at the ASHA convention, and has not been published to my knowledge. The study was well-done, the findings are informative and can help guide our care of infants in the NICU who require tracheostomy. Contact the authors for more information. I am quoting below from the poster presented.

Videofluoroscopic swallow-study outcomes among infants with tracheotomies                        Jeannine Hoch, MA, CCC-SLP; Michele Morrow, MS, CCC-SLP; Heather Keskeny, MA, CCC-SLP; Aaron Chidekel, MD   

Due to advances in technology, tracheotomy tube-placement is becoming increasingly common during the first year of life.

Infants with tracheotomy are at risk for developing feeding and swallowing problems: There is a paucity of descriptive information regarding dysphagia for infants following tracheotomy. Lack of available research leaves many clinicians feeling unprepared to provide services for pediatric tracheotomy patients.

Infant feeding patterns may also be impacted by environmental and associated medical conditions such as: Gastroesophageal reflux, Low birth-weight, Bronchopulmonary dysplasia, Long-term nasogastric tube-feedings, disruption of parent–infant interaction due to long-term hospitalization

Goals of their study:

  • Based on reports from videofluoroscopic swallowing studies, what are the swallow characteristics of infants with tracheotomies?
  • What percentage of patients required enteral feedings via nasogastric and/or gastrostomy tube-feedings?
  • Are trends present between swallow dysfunction, underlying medical conditions (gastroesophageal reflux, premature birth, nature of illness necessitating tracheotomy tube placement), and the need for enteral feedings?

A Retrospective study

  • Subjects (n = 27) whose Tracheotomy-tube placement by 4 months of age with mechanical ventilation  – Males (n = 16), Females (n = 11) – Exclusion criteria included grade III or IV IVH or presence of severe neurodevelopmental delays that preclude initiation of oral feeding
  • Data collection:  Medical history, Results of initial videofluoroscopic swallow-study, Results of serial follow-up studies when applicable

Data analysis

  • Trends may exist between initial swallow-study findings and reason for tracheotomy-tube placement:
    • Airway issues (n = 10): delayed swallow-initiation (80%), laryngeal penetration (80%), aspiration (50%), residue following swallows (50%), and nasopharyngeal reflux (50%)
    • Respiratory distress with BPD (n = 17): delayed swallow-initiation (53%), laryngeal penetration (71%), aspiration (29%), residue following swallows (47%), and nasopharyngeal reflux (41%)
  • Among patients who underwent G-tube placement (n = 17):
    • Less than half (47%) had documented aspiration on their initial swallow-study.
    • Majority (94%) had documented reflux.
  • Among patients who underwent follow-up swallow studies (n = 17):
    • Laryngeal penetration tended to persist (n = 6) more frequently than it resolved (n = 4).
    • Aspiration tended to resolve (n = 5) more frequently than it persisted (n = 2).
  • Report of oral motor-impairment (n = 12, 44%) and oral phase-impairment (n=17, 63%) was common.
  • All of the patients (n = 27) achieved at least partial or therapeutic oral-feedings as noted on recommendations from their final swallow-study.

 

Research: Challenges to eating, swallowing, and aerodigestive functions in infants

Jadcherla, S. R. (2019). Challenges to eating, swallowing, and aerodigestive functions in infants: a burning platform that needs attention! The Journal of pediatrics211, 7-9.

Always insightful and leading-edge, Dr. Jadcherla at Nationwide Children’s clearly identifies major focus points  in our journey toward supporting independent functional feeding for all of our pediatric patients. Follow his research in those key areas. Read the entire paper on Google Scholar.

Quoting from the article:

“…only when we understand the causal and ameliorating mechanisms of eating, swallowing, and aerodigestive dysfunctions, and the cause for practice and process variation, will we then be able to modify strategies for appropriate diagnostic, therapeutic, and rehabilitative approaches to ensure safe feeding during and beyond ICU stay, lest, we run the risk of over- or underutilization of gastrostomy procedures. In the end, we seek to restore the most fundamental of human behaviors, safe eating”

 

Quoting from the article:

“Summary of 10 Ps That Require Careful Attention to Disrupt the Rising Prevalence of Pediatric Dysphagia

 (1) Physiology of eating, swallowing, and aerodigestive functions in the context of the developing infant must be better understood. Maturational variability and rapid growth during early infancy offer a unique opportunity to improve eating patterns in premature infants.

 (2) Pathophysiology of the mechanisms of pediatric dysphagia also requires careful study so as to provide pathophysiology-guided clinical care.

 (3) Patient characteristics are variable in any given scenario of feeding difficulties, and attention to the risk factors is key because modification of risk factors can improve outcomes.

 (4) Parent involvement and anticipatory guidance for dealing with eating difficulties, swallowing, and aerodigestive morbidities must be undertaken from early on, so that appropriate and timely interventions can be addressed.

 (5) Providers in the healthcare system may be unaware of the factors that influence infant feeding, and physicians may wholly delegate this area to occupational therapists or speech language pathologists. Newer data over the last 2 decades has emerged, and the pace of rapid translation from discovery to implementation will be enhanced when silos of expertise are eliminated and knowledge, attitudes, and skills are reexamined.

 (6) Procedures performed in the diagnosis of pediatric dysphagia need standardization, with careful reevaluation of indications and contraindications in the context of the fragile ICU infant. Diagnostic delays lead to delays in timely interventions during critical windows of opportunities.

 (7) Precision medicine is possible only when the underlying mechanisms are understood and targeted with innovative approaches at the bedside of the infant in the ICU.

 (8) Personalization of diagnostic, therapeutic, and rehabilitative approaches in the context of the infant’s condition, maturity, disease, and functional skills is important.

 (9) Pragmatism in approaches coupled with humanism is needed particularly with developing longitudinal follow-up of feeding milestones. Clinically meaningful outcomes such as independent feeding must be a functional goal”

Enjoy this fabulous read!

Research: Effects of Additives for Reflux Management and Dysphagia Management

This manuscript  was released in 2019. It  is a compelling read about potential adverse effects of cereal thickeners (rice versus oatmeal) added to formula, and adding medications to formula, and their impact on osmolality. Alteration of ready-to-feed preterm formulas may significantly increase osmolality and have unintended consequences (feeding intolerance, pain, prolonged GI transit, bacterial overgrowth).

The AAP has advocated against the use of thickening agents for high risk preterms under 44 weeks PMA. In the NICU and with infants after discharge in general, we always need to take pause prior to thickening feedings for infants with dysphagia, and do so after other interventions are offered (change in nipple flow rate, position, use of pacing strategies). For many infants, implementing these strategies will support safe swallowing. This manuscript adds to our understanding of the importance of considering risk-benefit ratio in all that we do.

The salient findings from this study are:
1) Cereal thickening amounts and agents added to ready-to-feed liquid preterm formulas impact osmolality and can cross the limits of AAP safety thresholds. Specifically, the thickening agent increases osmolality, and oatmeal contributed to greater osmolality compared with rice on an equi-volume basis. 2) Commonly used vitamin and electrolyte supplements added to ready-to-feed preterm formula can remarkably increase osmolality

They conclude: 1) When thickening is still a strong consideration for Dysphagia/GER management, the ready-to-feed thickened formulas may be a safer alternative as the mixture is more homogeneous and has been vigorously tested, and passes FDA regulations including osmolality thresholds. Other alternative treatment strategies may include modifications to nipple flow or feeding volume, pacing while feeding, or appropriate positioning of the infant during feeding.  2) mixing medications in the entire volume of feed, or dividing doses across multiple feeding sessions mixed with feeds to decrease the osmolality as much as possible.

I am attaching this manuscript as it will be a good discussion point with our medical teams in the NICU, with pediatricians and GI specialists, and for those of us who follow infants in the community.

I hope this informs your practice.​

Here is a link to this article. 

Research: Clinical Swallowing Assessment Across the Lifespan

I wanted to share this just published paper by our SLP colleagues about the clinical swallow evaluation, which shares critical insights that will inform everyone’s practice, from pediatrics to adult.

Garand, K. L., McCullough, G., Crary, M., Arvedson, J. C., & Dodrill, P. (2020). Assessment Across the Life Span: The Clinical Swallow Evaluation. American Journal of Speech-Language Pathology29(2S), 919-933.

 

The final paragraph will make you want to read it right now:
“Specific guidelines for carrying out a clinical feeding and swallowing evaluation require systematic decision making with considerations for high degree of variability within and across adult and pediatric patient populations. The CSE is not only a useful tool but a critical one. As aptly noted, “it is critical that the CSE not be relegated to the status of a screening tool. It is far too powerful” (Rosenbek et al., 2004). The CSE is often the first complete physical assessment of swallowing function for a patient where critical information is gathered and should not be overlooked. A thorough CSE extends beyond watching someone eat and drink; it is a multidimensional assessment. While reliability of individual measures remains questionable, the experienced clinician can make important judgments regarding patient safety that will help chart the course of care for individuals needing additional assessment and, possibly, intervention. Employing a standardized CSE tool after sufficient training will further enhance clinical decision making. As instrumental examinations are more costly, more invasive, and less available, the CSE can also serve to chart progress, or lack of progress, over time when it is conducted methodically and consistently.”

I hope you will enjoy this read as much as I did, and share it with your students.

Research: Behavioral Epigenetics and Oral Feeding Skills in Preterms

For my NICU colleagues,

Many years ago when I started in the NICU in 1985 we were just beginning to understand the importance of developmentally-supportive care, “brain care” , to lay the foundation for early and future function across all developmental domains, including feeding.

How far we have come and yet how much we still need to understand. The feeding “environment”, that is, the gestalt of “experience” in which the preterm infant is supported from the first day of life, has implications every step of the way, that are often not appreciated or fully understood.

This just published paper by some well-respected researchers looks at how early-life cumulative stress exposure may influence evolution of oral feeding skills in preterm infants. We are just beginning to scratch the surface about the multiple underpinnings for safe and successful feeding for preterm infants. It reminds me of my favorite phrase, “In the NICU, every experience matters, especially when it comes to feeding.”

Griffith, T., White-Traut, R., & Janusek, L. W. (2020). A Behavioral Epigenetics Model to Predict Oral Feeding Skills in Preterm Infants. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses.

“The proposed conceptual model  is guided by the Preterm Behavioral Epigenetics framework, which theorizes that prenatal and early postnatal adverse events (ie, cumulative stress exposure) influence preterm infant phenotypes (eg, HPA axis regulation of cortisol reactivity and neurobehavioral development) through epigenetic modifications. Our conceptual model posits that early-life cumulative stress exposure, reflected by DNA methylation of glucocorticoid-related genes and altered cortisol reactivity, may disrupt neurobehavioral development critical for achievement of oral feeding skills. In other words, the conceptual model represents the idea that cumulative stress exposure (prenatally and postnatally) may change the epigenetic information, resulting in changes in  oral feeding skills.

The emerging field of Preterm Behavioral Epigenetics emphasizes how early-life stress exposure can imprint epigenetic mechanisms during sensitive neuroplastic periods and disrupt attainment of neurobehavioral

Untimely introduction of oral feeding when infants demonstrate inadequate or complete lack of oral feeding skills may lead to negative imprints during the sensitive neuroplastic developmental period. Such negative imprints influence future feeding behaviors and may predispose to lifelong susceptibility to feeding problems, eating disorders, obesity, and/or metabolic disease.”

Amazing. I hope this informs your practice as it has mine.

Latest research on the effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants

Dumpa, V., Kamity, R., Ferrara, L., Akerman, M., & Hanna, N. (2020). The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants. Journal of Perinatology, 1-7.

Louisa Ferrara, PhD SLP contributes to the science that underpins our growing understanding of the potential risks of asking preterm infants to PO feed while they continue to require NCPAP. This information will inform your practice in the NICU and can promote needed discussion among members of the NICU interdisciplinary team

Objective To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants.

Design In this retrospective pre–post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation).

Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP.

Results Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1.

Conclusions:  Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.

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: 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]

Problem-Solving: Advocacy for SLP staffing in the NICU

Question: I am seeking your help as we fight for increased SLP staffing in our Neonatal Intensive Care Unit.  Do you have  any resources to justify more staffing and resources?

Answer: There is little to no data about NICU SLP services out there , and we always have to build the relationships that create respect for the value we add. This takes much time collaborating, thinking along with our medical and nursing colleagues, and building that open mind with each infant with whom we work, one by one.  As a former  Rehab leader, I found that was my only way to over time build the recognition of the need for our services , i.e our value to the infants, their families and the team. This then generated the referrals that needed to be seen.  Then when MDs were not happy if referrals were delayed due to inadequate staffing,  leadership could relook at budget to allow us  to allocate more staff.  Now, as a front line NICU staff person, I continue to build relationships and then let my leader take the next steps.

I have found it very successful  to utilize a co-morbidity-based approach to advocating for feeding needs   —  See: Edney, S. K., Jones, S., & Boaden, E. (2018). Screening for feeding difficulties in the neonatal unit: Sensitivity and specificity of gestational age vs. medical history. Journal of Neonatal Nursing.

The only article I know of looking at utilization in the NICU was this one  —- Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in developmental disabilities, 64, 108-117.

I hope this is helpful.

Research Corner: Non-nutritive sucking in the preterm infant

Pineda, R., Dewey, K., Jacobsen, A., & Smith, J. (2018). Non-Nutritive Sucking in the Preterm Infant. American journal of perinatology.

Objective To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

Study Design Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA. Oral feeding was assessed at 38 weeks PMA.

Results There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = –1.4) was related to feeding success at 38 weeks PMA.

Conclusion Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Commentary from Catherine:  Co-morbidities matter in every facet of the preterm infant’s development and skill progression. The emergence of non-nutritive sucking, its quality, and its interface with swallowing and breathing,  is clearly affected by the nature of and interaction among the infant’s co-morbidities. Take time to carefully consider this in your assessments and ongoing interventions with our  ones in  the NICU. Remember, sucking does not occur in isolation –  it is part of a dynamic interactive system.

 

 

 

 

Research Corner: Characteristics of children at risk of aspiration pneumonia

Pavithran, J., Puthiyottil, I. V., Narayan, M., Vidhyadharan, S., Menon, J. R., & Iyer, S. (2018). Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia. The Laryngoscope.

Methods: A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS).

 Results: Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88).

Conclusion: Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies.

 

Research Corner: Tracheobronchomalacia and CLD in the NICU

Should Neonatologists Rule Out Tracheobronchomalacia in Every Premature Baby With Bronchopulmonary Dysplasia?      Fadous Khalife et al,    J Med Cases. 2019;10(3):72-7   

doi: https://doi.org/10.14740/jmc3259

Commentary from Catherine: This current look at one of the possible adverse effects of prolonged intubation should inform our practice when supporting infants with CLD. Poor coordination and adverse events with PO that may lead to symptomatic or silent airway invasion may have their etiology in TBM. Keep this in your differential as you work with NICU infants who have CLD. Also our kids in PICU who present with persistent airway invasion in the setting of chronic respiratory co-morbidities. A direct laryngoscopy/bronchoscopy by ENT may be something to suggest as you work with your medical team. 

Excerpts:

Bronchopulmonary dysplasia (BPD) is a chronic inflammatory lung disease that affects mainly premature infants; it results from the damage to the immature lungs from mechanical ventilation and prolonged use of oxygen. They suffer from obstructive lung disease.

TBM in children is defined as weakening of the airway wall due to softening of the cartilaginous rings, decreased tone of the airway smooth muscle and collapse. This results in increased airway compliance and reduction of the size of the airway lumen during expiration. The clinical manifestations of malacia vary widely: barking cough, impaired mucous clearance, retractions, dyspnea and prolonged expiratory phase. Children can also have atelectasis and recurrent pneumonia leading sometimes to intubation and difficulty weaning from ventilator support. It may be associated with feeding difficulties.

The acquired type is most commonly associated with prolonged mechanical endotracheal intubation (with more significant effect in premature infants), severe tracheobronchitis and external tracheal compression (double aortic arch, innominate artery compression, vascular rings, left atrial enlargement).

 

 

Join us for The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding

Please plan to join Dr. Suzanne Thoyre and I on October 12-13th,  2019 in Columbus OH at Nationwide Children’s Hospital for a Train-the-Trainer session on  The Early Feeding Skills (EFS) Assessment Tool: A Guide to Cue-Based feeding in the NICU . 

Bring yourself, your colleagues, or your whole feeding team! We are aiming for an interdisciplinary-professional group, putting our heads together to improve feeding experiences for our most vulnerable infants. We hope to see you in Columbus! 

Learn to use the EFS to effectively plan and provide an infant-guided approach to feeding.

Simultaneously learn to train others back home to use the EFS to strengthen your unit’s feeding care. Review current research, the role of experience, dynamic systems theory, and feeding outcomes after NICU. Videotapes with enhanced audio of swallowing and breathing to learn key skill areas of the EFS: respiratory regulation, oral motor and swallowing function, physiologic stability, engagement, and change in coordination patterns of s-s-b as infants develop. Gain confidence scoring early feeding skills as not yet evident, emerging or established. Learn components of an infant-guided, co-regulated approach to feeding and contingent adaptations that make this approach so effective, using the EFS to plan individualized interventions. Receive teaching resources to take back to your unit to train others to use the EFS. As a group, we will network and navigate challenging issues and role-model a collaborative feeding practice.

The EFS provides a means of identifying, for individual preterm infants, areas of strength and areas in which support is required to accomplish safe and effective feeding. All too often during oral feeding, infants experience multiple episodes of oxygen desaturation, increased energy expended in response to stress, and fatigue. Possible negative sequelae of recurring stress are often unnoticed, disregarded, or minimized. Through developmental conceptualization of specific infant feeding skills, the EFS provides an infant-focused framework for planning individualized interventions.In addition, the EFS provides a means for assessing infant readiness to engage in oral feeding and for evaluating infant response to a feeding, including any interventions employed.

Assessment and intervention are integrated functions. As infants are fed and their capacities assessed, caregiver behaviors and assessment foci must be adjusted for the individual infant. If he stops sucking spontaneously only on occasion, for example, the infant probably needs a brief imposed break from sucking to support regulation of breathing and to prevent fatigue and/or physiologic dysregulation. If the infant does not root when his lips are stroked, indicating lack of readiness to feed, the feeder explores reasons for this. If the infant has difficulty coordinating swallowing and breathing, the feeder is more alert to his capacity to manage the bolus of fluid given the frequency of sucks and the duration of sucking bursts. The feeder will want to help prevent abbreviated or missed breaths for the infant, to listen more closely for complete and safe swallowing, and to explore the need for a sidelying feeding position, low-flow nipples, pacing strategies, or more extensive swallowing evaluation by a pediatric therapist. Thorough and ongoing assessment is an essential component of feeding practice, particularly for infants early in their skill development. 

Not only does the EFS provide a pathway for your NICU team to infant-guide feeding , but it also has been shown to have strong psychometric properties for use in research. See:  Thoyre, S. M., Pados, B. F., Shaker, C. S., Fuller, K., & Park, J. (2018). Psychometric Properties of the Early Feeding Skills Assessment Tool. Advances in Neonatal Care, 18(5), E13-E23.