Aspiration and Dysphagia in the Neonatal Patient

Nikhila Raol, Thomas Schrepfer, Christopher Hartnick,

Clinics in Perinatology 45 (2018) 645–660

KEY POINTS

_ Management of neonatal dysphagia and aspiration should involve a multidisciplinary  effort, including neonatologists, otolaryngologists, pulmonologists, gastroenterologists, and speech-language pathologists.

_ Flexible fiberoptic laryngoscopy and a formal swallow evaluation in conjunction with the speech pathologist should be undertaken in any neonatal patient with dysphagia.

_ Babies born before 34 weeks may have dysphagia owing to a developmental delay.

_ Although the otolaryngologist may recommend acid suppression in patients with laryngomalacia, there is a lack of evidence to support use of acid suppression medications in suspected extraesophageal reflux disease.

_ Addressing anatomic/structural causes of aspiration are indicated when present; however, the vast majority are nonanatomic.

Velayutham, P., Irace, A. L., Kawai, K., Dodrill, P., Perez, J., Londahl, M., … & Rahbar, R. (2017). Silent aspiration: Who is at risk?. The Laryngoscope.

Among 1,286 patients who underwent MBS, 440 (34%) demonstrated aspiration. Within the aspiration group, 393 (89%) specifically demonstrated silent aspiration. Thin fluids were silently aspirated in 81% of these patients. Of children aged <6 months, 41% were found to aspirate and, of those, 95% silently aspirated. Median age at which patients demonstrated silent aspiration was 1.1 years. Silent aspiration was documented in 41% of patients with laryngeal cleft, 41% of patients with laryngomalacia, and 54% of patients with unilateral vocal fold paralysis. Laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndrome, and congenital heart disease were all associated with silent aspiration.

Their conclusions: Silent aspiration may be associated with several underlying conditions and is more common than previously described. Caregivers and clinicians should be aware that the absence of cough does not eliminate the possibility of aspiration. Modified barium swallow studies can reveal silent aspiration, which is difficult to detect on clinical feeding evaluation. Modified barium swallow findings can guide feeding therapy and the overall management of aspiration.

Fry, T. J., Marfurt, S., & Wengier, S. (2018). Systematic Review of Quality Improvement Initiatives Related to Cue-Based Feeding in Preterm Infants. Nursing for women’s health.

A nursing team at The Children’s Hospital, OU Medicine, in Oklahoma City, OK examined and synthesized the outcomes of quality improvement (QI) initiatives related to cue-based feeding of preterm infants to facilitate implementation of findings to improve nursing practice.

Their review yielded seven studies related to cue-based feeding of preterm infants. Five studies included multidisciplinary stakeholder teams to assess their respective NICU environments and facilitate project completion. In two studies, feeding “champions” were designated as facilitators. In one study, researchers used a Plan–Do–Study–Act approach and emphasized process over outcome. In six studies, researchers measured hospital length of stay, which decreased in five intervention groups. In three studies, researchers measured infant weight gain, which increased in two intervention groups. In two studies, researchers monitored weight gain velocity, and in five studies, researchers reported earlier attainment of full oral feedings.

They concluded: Weight gain, time to full oral feedings, and hospital length of stay may be improved with the use of cue-based feeding. QI initiatives are a practical means to bring best evidence and multidisciplinary collaboration to the NICU.

New Shaker Publication – “You Got This Mom” – in the American Speech-Language Hearing Association (ASHA) Leader

Feeding is Communication. When we help NICU caregivers  interpret what their preemie is telling them during feeding, we support the parent-infant relationship.

Excerpt: ” What builds confidence is shifting the focus to feeding quality and their relationship with their infant. We get there by helping parents conceptualize feeding as a “conversation” with their infant. Our role as feeding specialists in the neonatal intensive care unit (NICU) is to guide parents to develop this “co-regulation” with their infant—this line of communication that drives feeding, and, ultimately, the parent-infant relationship itself. With our ongoing support, parents can begin to see their relationship with their infant as the foundation for feeding. Intake is then viewed as the byproduct of a quality feeding interaction, not the feeding’s only goal. And so, the parent-infant-relationship begins, through infant-guided feeding.”

Read more ………

Follow the link below to the full article on the ASHA Website.

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These are two wonderful resources to add to your professional library!

Feed Your Baby and Toddler Right: Early eating and drinking skills encourage the best development

Book by Diane Bahr MS CCC-SLP CIMI     Published: 2018

Functional Assessment & Remediation of Tethered Oral Tissues (TOTs)

Book by Robyn Merkel-Walsh and Lori Overland      Published: 2018

I hope you enjoy them as much I have!

Duncan, D. R., Mitchell, P. D., Larson, K., & Rosen, R. L. (2018). Presenting Signs and Symptoms do not Predict Aspiration Risk in Children. The Journal of Pediatrics.

Objectives

To determine if any presenting symptoms are associated with aspiration risk, and to evaluate the reliability of clinical feeding evaluation (CFE) in diagnosing aspiration compared with videofluoroscopic swallow study (VFSS).

Study design

We retrospectively reviewed records of children under 2 years of age who had evaluation for oropharyngeal dysphagia by CFE and VFSS at Boston Children’s Hospital and compared presenting symptoms, symptom timing, and CFE and VFSS results. We investigated the relationship between symptom presence and aspiration using the Fisher exact test and stepwise logistic regression with adjustment for comorbidities. CFE and VFSS results were compared using the McNemar test. Intervals from CFE to VFSS were compared using the Student t test.

Results

A total of 412 subjects with mean (±SD) age 8.9 ± 6.9 months were evaluated. No symptom, including timing relative to meals, predicted aspiration on VFSS. This lack of association between symptoms and VFSS results persisted even in the adjusted multivariate model. The sensitivity of CFE for predicting aspiration by VFSS was 44%. Patients with a reassuring CFE waited 28.2 ± 8.5 days longer for confirmatory VFSS compared with those with a concerning CFE (P < .05).

Conclusions

Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE does not have the sensitivity to consistently diagnose aspiration so a VFSS should be performed in persistently symptomatic patients.

Wanted to update you on a new manuscript about the EFS which I co-authored that is now in press with Advances in Neonatal Care.  Abstract below – Dr. Thoyre and I hope to see it published ahead of print in the next few weeks. We are very excited that the psychometrics of the EFS, demonstrating its reliability and validity, will soon be published. 

Psychometric Properties of the Early Feeding Skills (EFS) Assessment Tool Abstract

 Background: Supporting infants as they develop feeding skills is an essential component of neonatal and pediatric care. Selecting appropriate and supportive interventions begins with thorough assessment of the infant’s skills. The Early Feeding Skills (EFS) tool is a clinician-reported instrument developed to assess the emergence of early feeding skills and identify domains in need of intervention.

Purpose: The purpose of this study was to identify the factor structure of the EFS and test its psychometric properties, including internal consistency reliability and construct validity.

Methods: EFS-trained inter-professional clinicians in three settings scored 142 feeding observations of infants aged 33 to 50 weeks postmenstrual age. Redundant and rarely-endorsed items were removed. Factor-analysis methods clustered items into subscales. Construct validity was examined through the association of the EFS with (1) concurrently scored Infant-Driven Feeding Scale-Quality (IDFS-Q), (2) infant birth risk (gestational age), and (3) maturity (postmenstrual age).

Results: Principal components analysis with varimax rotation supported a 5-factor structure. The total EFS demonstrated good internal consistency reliability (Cronbach’s α = .81). The total EFS score had construct validity with the IDFS-Q (r = -.73; p < .01), and with gestational age of a subsample of premature infants (r = .22; p < .05).

Implications for Practice: As a valid and reliable tool, the EFS can assist the inter-professional feeding team to organize feeding assessment and plan care.

Implications for Research: The strong psychometric properties of the EFS support its use in future research.

Please plan to join Dr. Suzanne Thoyre and I on August 15^thand 16^th for a Train-the-Trainer session on the EFS Tool in Atlanta, GA. 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. 

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

Supporting Optimal Neurodevelopmental Outcomes in Infants and Children with Congenital Heart Disease

Peterson, Jennifer K. “Supporting Optimal Neurodevelopmental Outcomes in Infants and Children with Congenital Heart Disease.” Critical Care Nurse 38, no. 3 (2018): 75-79.

Our fragile infants and children with congenital heart disease are at risk for adverse developmental outcomes across multiple domains, including feeding/swallowing. This just-published article speaks to critical interventions, among them, cue-based feeding.

Abstract:

Improved survival has led to increased recognition of developmental delays in infants and children with congenital heart disease. Risk factors for developmental delays in congenital heart disease survivors may not be modifiable; therefore, it is important that lifesaving, high-technology critical care interventions be combined with nursing interventions that are also developmentally supportive. Implementing developmental care in a pediatric cardiac intensive care unit requires change implementation strategies and widespread support from all levels of health care professionals. This manuscript reviews developmentally supportive interventions such as massage, developmentally supportive positioning, kangaroo care, cue-based feeding, effective pain/anxiety management, and procedural preparation and identifies strategies to implement developmentally supportive interventions in the care of infants and children with congenital heart disease. Improving developmental support for these infants and children at high risk for developmental delay may improve their outcomes and help promote family-centered care.

Read more: https://insights.ovid.com/critical-care-nurse/ccnu/2018/06/000/supporting-optimal-neurodevelopmental-outcomes/11/00003242

Therapy Usage in the NICU

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.

This article by Bobbi Pineda OTR and her colleagues provides valuable information about utilization of therapy services in a large NICU. It provides insight into referral patterns and supports the concept of early and continued therapy services throughout the NICU stay to optimize outcomes. While their findings are not necessarily generalizable to other NICUs, this is the first attempt to gather such data.

It is worrisome to me that for those NICUs in which SLPs support feeding, referrals are often not received until > 36 weeks PMA. By that time, many of our fragile preterms (with complex co-morbidities) have already struggled learning to feed and may be referred at that time for extra support to “fix them”. In NICUs where PT/OT support feeding, they are typically already following the infants when feeding readiness is a focus, so for those infants whose team is likely to require extra support for feeding, it is already in place. My hope is that there will be greater recognition of the importance of early additional feeding support to the team for those preterm infants at the highest risk for enduring feeding problems, as profiled in the literature. The complex nature of their poor feeding often requires a team approach to avoid maladaptive behaviors and airway invasion. More research is needed to explore this concept and articulate infant needs for support related to co-morbidities.

Tube Fed Children: Management, Weaning and Emotional Considerations

Edwards, S., Davis, A. M., Bruce, A., Mousa, H., Lyman, B., Cocjin, J., … & Hyman, P. (2016). Caring for tube-fed children: a review of management, tube weaning, and emotional considerations. Journal of Parenteral and Enteral Nutrition, 40(5), 616-622.

Working with our infants and children who are tube fed can be challenging. This more recent article by a well-respected interdisciplinary team highlights some key perspectives and current data that can inform your therapy practice. Hope you enjoy it as much as I did.

Catherine

Feeding Problems from the Parents’ Perspective

Estrem, H. H., Pados, B. F., Thoyre, S., Knafl, K., McComish, C., & Park, J. (2016). Concept of pediatric feeding problems from the parent perspective. MCN: The American Journal of Maternal/Child Nursing, 41(4), 212-220.

Wanted to share this recent article that so well captures the importance of the family as the most important part of our therapy with their child. As the authors state: “A child and their family have a feeding problem; they experience this journey together. It is more inclusive to consider this issue in the context of the child’s natural environment with the people who are most familiar and invested. A shared conceptualization that families can relate to (without perceived stigma), and that providers could use to classify pediatric feeding problems, would improve potential for early feeding assessment, referral, and for feeding intervention efficacy to last long term.”

Brain Oriented Care in the NICU 

I wanted to share with those of you who are part of an NICU team or provide services for NICU graduates an article that, while 4 years old, is still so applicable as we support change from a volume-driven to an infant-guided feeding culture in the NICU. Those of you have an interest in neuroprotection for fragile adults will also find it interesting.

Bader, L. (2014) Brain-Oriented Care in the NICU: A Case Study. Neonatal Network Sept/Oct 2014, 263-267

Brain-oriented care, or neuroprotection, is often thought of as “new” to the NICU, yet as the author states, neuroprotection encompasses all the interventions that promote development of the brain. Because our NICU infants are wiring their brains outside the womb, every experience matters. Especially when it comes to feeding. The author makes the connection to infant-guided feeding, an approach we all need to advocate minimizing the physiologic stress associated with learning to feed in the NICU, and indeed after discharge. Unfortunately, the physiologic stress that many NICU infants experience when fed using a volume-driven approach instead, can wire the brain away from feeding. The feeding outcomes of NICU infants, which are poor, make it imperative that we be a part of the change in our NICUs to listen to the infant’s communication and provide the relationship-based care, especially with feeding, that allows the preterm infant’s brain to wire in an adaptive not a maladaptive way.

I hope you find this informative.

Catherine

Schurr, P., & Findlater, C. (2012). Neonatal Mythbusters: Evaluating the Evidence For and Against Pharmacologic and Nonpharmacologic Management of Gastroesophageal Reflux. Neonatal Network, 31(4), 229-241.

Reflux is a common issue in the NICU and with many of our pediatric patients. The evidence-base for effective interventions continues to  emerge related to preterm infants in the NICU. This paper by an NICU nurse published in 2012 is a fabulous resource. It does not just provide strategies but looks at the current evidence base as of its publication and explains so well the “whys” behind the interventions. It is so easy to join a bandwagon and support the latest idea but having the rationale and the data to titrate the interventions based on the unique issues and co-morbidities of a specific population, such as the NICU, is essential. It will inform your practice!