Medical advances have improved the survival of young fragile infants and children, many of whom will present with feeding/swallowing problems. Many of these children are at risk for aspiration-induced lung disease, undernutrition or malnutrition, developmental deficits, and stressful interactions with their caregivers. Unfortunately, our understanding of the physiology/pathophysiology of swallowing and its maturation, the development of standardized and efficacious evaluation and therapy tools, and identification of functional outcomes have not kept pace with our ability to identify children who are at increased risk for dysphagia and the associated sequelae. This article focuses on updates in population demographics and advances in evaluation and treatment over the past decade and identifies future directions that may enable us to meet the needs of the children who are in our care to attain functional outcomes.
Ghalichi F1, Ghaemmaghami J2, Malek A3, Ostadrahimi A4.(2016) Effect of gluten free diet on gastrointestinal and behavioral indices for children with autism spectrum disorders: a randomized clinical trial. World J Pediatr. Nov;12(4):436-442. Epub 2016 Jun 10.
This study was undertaken to investigate the effect of gluten free diet (GFD) on gastrointestinal symptoms and behavioral indices in children with ASD. Of the 80 children, 53.9% had gastrointestinal abnormalities. In the GFD group, the prevalence of gastrointestinal symptoms decreased significantly after intake of GFD but increased insignificantly in the RD group. GFD intervention resulted in a significant decrease in behavioral disorders but an insignificant increase in the RD group. This study suggested that GFD may be effective in controlling gastrointestinal symptoms and ASD behaviors.
Merhar SL1, Pentiuk SP2, Mukkada VA2, Meinzen-Derr J3, Kaul A2, Butler DR4. (2016), A retrospective review of cyproheptadine for feeding intolerance in children less than three years of age: effects and side effects. Acta Paediatr. Aug;105(8):967-70. doi: 10.1111/apa.13477. Epub 2016 Jun 10.
Premature infants and those with brain injury often suffer from feeding intolerance and vomiting in the first several years of life. Cyproheptadine is a medication with antihistaminergic, antiserotonergic and anticholinergic effects, thought to increase gastric accommodation. In our experience, cyproheptadine appears to be safe and effective in decreasing vomiting and feeding intolerance in children less than three years of age. A trial of cyproheptadine could be considered before invasive testing in infants with feeding issues.Side effects such as sleepiness and constipation were rare. The medication had a significant positive effect, defined as resolution of vomiting, improved feeding tolerance or improved comfort with feeds, in 67% of children. An additional 28% showed possible improvement, defined as some improvement in vomiting or improvement in vomiting or feeding tolerance in conjunction with other changes in addition to cyproheptadine.
Kaya V1, Aytekin A2. (2016). Effects of pacifier use on transition to full breastfeeding and sucking skills in preterm infants: a randomised controlled trial.J Clin Nurs. Oct 18. doi: 10.1111/jocn.13617.
Pacifier use improved the sucking skills and shortened the time to transition to full breastfeeding and to discharge in preterm infants receiving complementary feeding. Seventy infants were randomised into two groups: a pacifier group and a control group. Pacifier use was applied in the preterm infants in the pacifier group, up to switching to full breastfeeding. The infants in the control group did not use pacifiers. Data were collected by a researcher using the Preterm Infant Introductory Information Form, the Preterm Infant Monitoring Form, and the LATCH Breastfeeding Assessment Tool.
Speech-language pathologists working within pediatric medical settings often identify dysphagia in patients and subsequently recommend thickened liquids to reduce aspiration risk. Caregivers frequently report difficulty attempting to prepare infant formula to the prescribed thickness. This study was designed to determine (1) the relationship between consistencies in modified barium swallow studies and thickened infant formulas and (2) the effects of time and temperature on the resulting thickness of infant formula. There were significant differences between the thickened formula and barium test consistencies. Formula thickened with rice cereal separated over time into thin liquid and solid residue. Formula thickened with a starch-based thickening agent was thicker than the desired consistency immediately after mixing, and it continued to thicken over time. The data from this project suggest that nectar-thick and honey-thick infant formulas undergo significant changes in flow rates within 30 minutes of preparation or if refrigerated and then reheated after 3 hours. Additional empirical evidence is warranted to determine the most reliable methods and safest products for thickening infant formula when necessary for effective dysphagia management.
Gasparin M1, Schweiger C2, Manica D2, Maciel AC3, Kuhl G4, Levy DS5, Marostica PJ6. (2016).Accuracy of clinical swallowing evaluation for diagnosis of dysphagia in children with laryngomalacia or glossoptosis. Pediatr Pulmonol. May 26. doi: 10.1002/ppul.23484.
To investigate the accuracy of clinical evaluation of swallowing in a sample of children with laryngomalacia or glossoptosis and describe the prevalence of dysphagia in each of these diseases, as well as characterize the swallow response to speech and language therapy interventions. Dysphagia was highly prevalent in this sample. The sensitivity of clinical evaluation to detect laryngeal penetration and tracheal aspiration was low, as the majority of aspiration events were silent. The videofluoroscopic study is important in order to determine a safest method to feed the patient.
Thottam PJ1,2,3,4, Georg M1, Chi D1, Mehta DK1,5. (2016 ). Outcomes and predictors of surgical management in type 1 laryngeal cleft swallowing dysfunction. Laryngoscope. May 12. doi: 10.1002/lary.26069.
To examine the effect of and predict the success of type 1 laryngeal cleft (LC-1) augmentation through swallowing evaluations. Sixty-eight patients with LC-1s underwent interarytenoid injection laryngoplasty (IL) and were examined. The median age at IL was 9 months. Swallowing evaluations were performed pre- and postoperatively using fiberoptic endoscopic examination of swallowing or modified barium swallow. The presence of aspiration or penetrations at various consistencies was recorded. McNemar’s tests were used to detect changes in swallowing pre- and postoperatively. Logistic regression was used to assess factors affecting the odds of postoperative success. CONCLUSION: A large proportion of patients with LC-1 and associated swallowing dysfunctions respond favorably to interarytenoid injection laryngoplasty (IL) and formal repair. Children who demonstrated penetration with thin liquids had a higher rate of swallowing dysfunction resolution post-IL; whereas patients demonstrating silent aspiration had poorer responses to IL.
Flax-Goldenberg R1, Kulkarni KS2, Carson KA3, Pinto JM4, Martin-Harris B5,6,7, Lefton-Greif MA8,9,10. (2016). Concordance Between Aspiration Detected on Upper Gastrointestinal Series and Videofluoroscopic Swallow Study in Bottle-Fed Children. Dysphagia. Aug;31(4):505-10. doi: 10.1007/s00455-016-9705-y. Epub 2016 Apr 6.
The increasing incidence of pediatric dysphagia has raised questions about how to identify children at risk for aspiration. Multiple investigative imaging modalities are considered in diagnostic algorithms, since dysphagia may involve any or all phases of swallowing. Although upper gastrointestinal (UGI) series and videofluoroscopic swallow study (VFSS) are common procedures, the utility of UGI for detection of aspiration and the impact of oropharyngeal imaging during UGI on radiation exposure have not been well described. We hypothesized that diagnosis of aspiration on UGI would be predictive of aspiration on VFSS and screening swallows during UGI would increase radiation exposure. All children with aspiration on UGI demonstrated thin liquid aspiration on VFSS; however, 53 % without aspiration on UGI aspirated on VFSS. UGI findings are specific but not sensitive markers for aspiration on VFSS. Imaging of swallowing on UGI may have an appreciable increase on radiation exposure.
Calvo I1,2, Conway A1, Henriques F1, Walshe M1. (2016). Diagnostic accuracy of the clinical feeding evaluation in detecting aspiration in children: a systematic review.Dev Med Child Neurol. 201Jun;58(6):541-53.
The aim of this systematic review is to determine the diagnostic accuracy of clinical feeding evaluation (CFE) compared to instrumental assessments in detecting oropharyngeal aspiration (OPA) in children. This is important to support clinical decision-making and to provide safe, cost-effective, higher quality care. All published and unpublished studies in all languages assessing the diagnostic accuracy of CFE compared to videofluoroscopic swallowing study (VFSS) and/or fibre-optic endoscopic examination of swallowing (FEES) in detecting OPA in paediatric populations were sought. Results suggested that CFEs trialling liquid consistencies might provide better accuracy estimates than CFEs trialling solids exclusively. This systematic review highlights the critical lack of evidence on the accuracy of CFE in detecting OPA in children. Larger well-designed primary diagnostic test accuracy studies in this area are needed to inform dysphagia assessment in paediatrics.
Goldman JA1, Descartes L2. (2016).Food depictions in picture books for preschool children: Frequency, centrality, and affect. Appetite. Jan 1;96:203-8. doi: 10.1016/j.appet.2015.09.018. Epub 2015 Sep 18.
The food content and messages depicted in popular children’s picture books were examined using a set of 100 “Favorite Books for Preschoolers.” Sixty-nine of these books depicted food and comprised the sample.
- the types and frequencies of food depicted in the text and/or illustrations of the books
- the centrality (central, background)
- the affect (positive, neutral, or negative) of those depictions.
Each food item was counted, categorized by type, and where possible, coded for centrality and affect. Fruit was the most frequently depicted food, followed by sweetened baked goods, dairy, and vegetables. However, centrality and affect differed for these foods. For example, sweet baked goods were high in both centrality and affect. In contrast vegetables were relatively high in centrality but most often neutral in affect. Ice cream, although not in many books, always was associated with positive outcomes. Results were compared to findings in the literature on food messages presented in children’s television programs. The ratio of healthy foods to nutrient-poor foods was higher in the books. However, as in television, the books emphasized the desirability of sweetened foods. The results point to the need for detailed analyses of the types of presentations associated with different foods presented in books for children, as well as for continued investigations into food messages in the growing range of media available to young children.
The aim of this study was to explore how the structure of mealtimes within the family setting is related to children’s fussy eating behaviours. Seventy-five mothers of children aged between 2 and 4 years were observed during a typical mealtime at home. Mealtime structure emerged as an important factor which significantly distinguished children with higher compared with lower levels of food fussiness. Children whose mothers ate with their child and ate the same food as their child were observed to refuse fewer foods and were easier to feed compared with children whose mothers did not. During mealtimes where no distractors were used (e.g. no TV, magazines or toys), or where children were allowed some input into food choice and portioning, children were also observed to demonstrate fewer fussy eating behaviours. Findings of this study suggest that it may be important for parents to strike a balance between structured mealtimes, where the family eats together and distractions are minimal, alongside allowing children some autonomy in terms of food choice and intake.
Peterson KM1, Piazza CC1, Volkert VM1. (2016). A comparison of a modified sequential oral sensory approach to an applied behavior-analytic approach in the treatment of food selectivity in children with autism spectrum disorder. J Appl Behav Anal. 2016 Sep;49(3):485-511. doi: 10.1002/jaba.332. Epub 2016 Jul 23.
Treatments of pediatric feeding disorders based on applied behavior analysis (ABA) have the most empirical support in the research literature (Volkert & Piazza, 2012); however, professionals often recommend, and caregivers often use, treatments that have limited empirical support. In the current investigation, we compared a modified sequential oral sensory approach (M-SOS; Benson, Parke, Gannon, & Muñoz, 2013) to an ABA approach for the treatment of the food selectivity of 6 children with autism. We randomly assigned 3 children to ABA and 3 children to M-SOS and compared the effects of treatment in a multiple baseline design across novel, healthy target foods. We used a multielement design to assess treatment generalization. Consumption of target foods increased for children who received ABA, but not for children who received M-SOS. We subsequently implemented ABA with the children for whom M-SOS was not effective and observed a potential treatment generalization effect during ABA when M-SOS preceded ABA.
The aim of this study was to report an analysis of the concept of pediatric feeding problems. Reviews of the literature on pediatric feeding problems and disorders repeatedly reference the lack of a shared conceptualization of feeding problems. It is difficult to track aetiology, prevalence and incidence of a phenomenon when available definitions and diagnoses lack practical utility. A spectrum conceptualization of feeding problems is suggested for further development, with attributes that would be critical to have a feeding problem.