On the Research Front…

Shaker CS. Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part I: Theoretical Underpinnings for Neuroprotection and Safety. Semin Speech Lang. 2017 Apr;38(2):96-105. doi: 10.1055/s-0037-1599107. Epub 2017 Mar 21.

The rapid progress in medical and technical innovations in the neonatal intensive care unit (NICU) has been accompanied by concern for outcomes of NICU graduates. Although advances in neonatal care have led to significant changes in survival rates of very small and extremely preterm neonates, early feeding difficulties with the transition from tube feeding to oral feeding are prominent and often persist beyond discharge to home. Progress in learning to feed in the NICU and continued growth in feeding skills after the NICU may be closely tied to fostering neuroprotection and safety. The experience of learning to feed in the NICU may predispose preterm neonates to feeding problems that persist. Neonatal feeding as an area of specialized clinical practice has grown considerably in the last decade. This article is the first in a two-part series devoted to neonatal feeding. Part 1 explores factors in NICU feeding experiences that may serve to constrain or promote feeding skill development, not only in the NICU but long after discharge to home. Part II describes approaches to intervention that support neuroprotection and safety.

Shaker CS. Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part II: Interventions to Promote Neuroprotection and Safety. Semin Speech Lang. 2017 Apr;38(2):106-115. Epub 2017 Mar 21.

Feeding skills of preterm neonates in a neonatal intensive care unit are in an emergent phase of development and require careful support to minimize stress. The underpinnings that influence and enhance both neuroprotection and safety were discussed in Part I. An infant-guided, co-regulated approach to feeding can protect the vulnerable neonate’s neurologic development, support the parent-infant relationship, and prevent feeding problems that may endure. Contingent interventions are used to maintain subsystem stability and enhance self-regulation, development, and coping skills. This co-regulation between caregiver and neonate forms the foundation for a positive infant-guided feeding experience. Caregivers select evidence-based interventions contingent to the newborn’s communication. When these interventions are then titrated from moment to moment, neuroprotection and safety are fostered.

Ross, ES. Flavor and Taste Development in the First Years of Life. Nestle Nutr Inst Workshop Ser. 2017;87:49-58. Epub 2017 Mar 17.

Flavor preferences affect the acceptance of novel foods. Fetuses experience flavors in the uterine environment, and some preferences appear to be innate. Sweet and salty foods tend to be accepted by most newborns, while bitter tastes are rejected. Breast fed infants appear to have an advantage over formula fed infants, as their exposure to a varying flavor profile is influenced by the mother’s diet. Infants are fairly accepting of novel foods, but rejection of new foods increases across the initial years of life. Children learn to accept novel foods through a variety of experiences, provided within social contexts. Some children are more accepting of various sensory inputs present during mealtimes. Parents report a greater challenge getting multiple taste exposures when their child exhibits less sensory adaptability. The number of foods eaten as a young child has a strong influence on the food repertoire later in childhood. Foods eaten by parents significantly predict the number and types of foods eaten by children. Strategies to help parents be more successful in achieving taste exposures in a positive social environment need to be identified.

Hsu J1, Tibbetts KM2, Wu D2, Nassar M2, Tan M2. Swallowing function in pediatric patients with bilateral vocal fold immobility. Int J Pediatr Otorhinolaryngol. 2017 Feb;93:37-41. Epub 2016 Dec 16.

Infants with bilateral vocal fold immobility (BVFI) often have poor swallow function in addition to potential airway compromise. Authors looked at 110 patients with a diagnosis of vocal fold immobility. Etiologies of vocal fold immobility include cardiac related in 13% (3/23), idiopathic in 30% (7/23) prolonged intubation in 26% (6/23) central neurologic in 22% (5/23), trauma in 4% (1/23), and infection in 4% (1/23). Average follow-up time was 44 months (range 5-94 months). Ten patients (56.5%) required a gastrostomy tube at time of diagnosis. Of this cohort who received gastrostomy tubes, three (30%) ultimately transitioned to complete oral feeds. Return of vocal fold mobility did not correlate with swallow function. In those with non-neurologic etiologies, the need for gastrostomy tube at end of follow up was unlikely. There was a statistically significant difference in the percentage of gastrostomy tube-free children at most recent follow up in patients who were normally developed (86%) versus those who were developmentally delayed (33%) (p = 0.02). Authors concluded that comorbidities are significant predictors of long term swallow function in patients with BVFI while return of vocal fold function is not.

Malhi P1, Venkatesh L2, Bharti B2, Singhi P2. Feeding Problems and Nutrient Intake in Children with and without Autism: A Comparative Study. Indian J Pediatr. 2017 Jan 12. d[Epub ahead of print]

Authors compared  parent reported feeding difficulties and nutritional adequacy of children with Autism Spectrum Disorders (ASD) to an age and socio-economically matched group of typically developing children. The majority (79%) of the parents of ASD children reported some concern regarding their feeding behavior as compared to 64% of the parents of typically developing children. As compared to controls, ASD children had significantly higher Children’s Eating Behavior Inventory (CEBI) scores and more feeding problems. Relative to controls, ASD children consumed fewer number of food items, particularly fruits, vegetables, and proteins; had significantly lower daily intake of potassium, copper, and folate. Although children with autism did not differ significantly from controls on intake of calories, height, weight, or body mass index, significantly greater proportion of ASD children failed to meet the estimated average requirement of thiamine, vitamin C , and copper. The findings underscore the need for comprehensive assessment and empirically-supported interventions for eating problems and dietary deficiencies found in ASD children.

Jadcherla SR1,2,3.  Advances with Neonatal Aerodigestive Science in the Pursuit of Safe Swallowing in Infants: Invited Review. Dysphagia. 2017 Feb;32(1):15-26. Epub 2017 Jan 2.

Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes and behaviors facilitating ingestion. Swallowing involves anterograde bolus movement during oral-, pharyngeal-, and esophageal phases of peristalsis into stomach. During these events, coordination with airway protection is vital for homeostasis in clearing any material away from airway vicinity. Neurological-airway-digestive inter-relationships are critical to the continuum of successful feeding patterns during infancy, either in health or disease. Neonatal feeding difficulties encompass a heterogeneous group of neurological, pulmonary, and aerodigestive disorders that present with multiple signs posing as clinical conundrums. Significant research breakthroughs permitted understanding of vagal neural pathways and functional aerodigestive connectivity involved in regulating swallowing and aerodigestive functions either directly or indirectly by influencing the supra-nuclear regulatory centers and peripheral effector organs. These neurosensory and neuromotor pathways are influenced by pathologies during perinatal events, prematurity, inflammatory states, and coexisting medical and surgical conditions. Approaches to clarify pathophysiologic mapping of aerodigestive interactions, as well as translating these discoveries into the development of personalized and simplified feeding strategies to advance child health are discussed in this review article.

Jadcherla SR1, Khot T2, Moore R2, Malkar M3, Gulati IK4, Slaughter JL5. Feeding Methods at Discharge Predict Long-Term Feeding and Neurodevelopmental Outcomes in Preterm Infants Referred for Gastrostomy Evaluation. J Pediatr. 2017 Feb;181:125-130.e1. Epub 2016 Dec 7.

194 neonates <37 weeks’ gestation referred for evaluation and management of feeding difficulties between July 2006 and July 2012 were studied. A total of 60% of infants were discharged on oral feedings; of these, 96% remained oral-fed at 1 year. The remaining 40% were discharged on G-tube feedings; of these, 40% remained G-tube dependent, 22% became oral-fed, and 38% were on oral and G-tube feedings at 1 year. Infants discharged on a G-tube had lower cognitive, communication, and motor composite scores. The presence of a G-tube, younger gestation, bronchopulmonary dysplasia, or intraventricular hemorrhage was associated significantly with neurodevelopmental delay. Authors concluded that for infants referred for feeding concerns, G-tube evaluations, and feeding management, the majority did not require a G-tube. Full oral feeding at first neonatal intensive care unit discharge was associated with superior feeding milestones and less long-term neurodevelopmental impairment, relative to full or partial G-tube feeding. Evaluation and feeding management before and after G-tube placement may improve long-term feeding and neurodevelopmental outcomes.

Coon ER1, Srivastava R2,3, Stoddard GJ4, Reilly S5, Maloney CG2, Bratton SL6. Infant Videofluoroscopic Swallow Study Testing, Swallowing Interventions, and Future Acute Respiratory Illness. Hosp Pediatr. 2016 Dec;6(12):707-713.  

Tube feedings are commonly prescribed to infants with swallowing abnormalities detected by videofluoroscopic swallow study (VFSS), but there are no studies demonstrating efficacy of these interventions to reduce risk of acute respiratory illness (ARI). Authors sought to measure the association between swallowing interventions and future ARI, among VFSS-tested infants. 576 infants were tested with a VFSS in their first year of life, receiving a total of 1051 VFSSs in their first 3 years of life. More than 60% of infants received a measured feeding intervention. With the exception of infants with silent OPA who received thickened feedings, neither thickening nor nasal tube feedings, compared with no intervention, were associated with a decreased risk of subsequent ARI. Swallowing interventions and repeated testing are common among VFSS-tested infants. However, the importance of diagnosing and intervening on VFSS-detected swallowing abnormalities for the majority of tested infants remains unclear.

Nicklaus S1. Complementary Feeding Strategies to Facilitate Acceptance of Fruits and Vegetables: A Narrative Review of the Literature.Int J Environ Res Public Health. 2016 Nov 19;13(11). pii: E1160.

Complementary feeding (CF), which should begin after exclusive breastfeeding for six months, according to the World Health Organization (WHO), or after four months and before six months according to the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), is a period when the infant implicitly learns what, when, how, and how much to eat. At the onset of CF, the brain and the gut are still developing and maturing, and food experiences contribute to shaping brain connections involved in food hedonics and in the control of food intake. These learning processes are likely to have a long-term impact. Children’s consumption of fruit and vegetables (FV) is below recommendations in many countries. Thus, it is crucial to establish preferences for FV early, when infants are learning to eat. The development of food preferences mainly starts when infants discover their first solid foods. This narrative review summarizes the factors that influence FV acceptance at the start of the CF period: previous milk feeding experience; timing of onset of CF; repeated exposures to the food; variety of foods offered as of the start of the CF period; quality and sensory properties of the complementary foods; quality of the meal time context; and parental responsive feeding.

Suterwala MS1, Reynolds J2, Carroll S2, Sturdivant C2, Armstrong ES3.Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit.J Perinatol. 2017 Jan 5.

FEES is safe and reliable in assessing laryngeal penetration and tracheal aspiration in NICU infants. Authors found no major complications or significant differences between FEES prefeeding and postfeeding vital signs, including respiratory rate, heart rate or oxygen saturation. FEES interrater reliability was 80% for both penetration and aspiration, compared with 87 and 90%, respectively, for VFSS.

Serel Arslan S1, Demir N1, Karaduman AA1. Both pharyngeal and esophageal phases of swallowing are associated with recurrent pneumonia in pediatric patients. Clin Respir J. 2016 Dec 7.

One of the underlying causes of recurrent pneumonia in children is swallowing dysfunction, with aspiration syndrome. Swallowing dysfunction should be considered not only a problem of the oropharyngeal phase but also a problem of the esophageal phase. A videofluroscopic swallowing study of 274 pediatric patients who had swallowing dysfunction was conducted. Information on a history of recurrent pneumonia during a 1-year period was obtained from hospital files. In the study, 83.2% of the patients had cerebral palsy, 7.7% had syndromic symptoms, 3.6% had muscular dystrophy, and 5.5% were classified as “other.” During the 1-year period, 67.9% of the participants had a history of recurrent pneumonia history. Furthermore, 66.4% had oral dysfunction, 32.5% had laryngeal penetration, 46.4% had aspiration, 45.3% had abnormal esophageal body function, and 35.8% had reflux symptoms. There was no correlation between oral dysfunction and recurrent pneumonia, but there was a positive correlation between recurrent pneumonia and laryngeal penetration, aspiration, abnormal esophageal body function, and reflux. Both pharyngeal swallowing disorders, such as penetration and aspiration, and esophageal disorders and reflux may result in recurrent pneumonia in pediatric patients. Thus, all phases of deglutition should be considered and followed up during swallowing evaluation.

Frakking T1,2, Chang A3,4,5, O’Grady K5, David M6, Weir K7. Aspirating and Nonaspirating Swallow Sounds in Children: A Pilot Study.Ann Otol Rhinol Laryngol. 2016 Dec;125(12):1001-1009. Epub 2016 Sep 28.

Cervical auscultation (CA) may be used to complement feeding/swallowing evaluations when assessing for aspiration. There are no published pediatric studies that compare the properties of sounds between aspirating and nonaspirating swallows. This pilot study has shown that certain characteristics of swallow obtained using CA may be useful in the prediction of aspiration. However, further research comparing the acoustic swallowing sound profiles of normal children to children with dysphagia (who are aspirating) on a larger scale is required.

Hersh C1, Wentland C2, Sally S3, de Stadler M4, Hardy S5, Fracchia MS6, Liu B7, Hartnick C8. Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review. Int J Pediatr Otorhinolaryngol. 2016 Oct;89:92-6. doi: 10.1016/j.ijporl.2016.07.032. Epub 2016 Jul 26.

Radiation exposure is recognized as having long term consequences, resulting in increased risks over the lifetime. Children, in particular, have a projected lifetime risk of cancer, which should be reduced if within our capacity. The objective of this study is to quantify the amount of ionizing radiation in care for children being treated for aspiration secondary to a type 1 laryngeal cleft. With this baseline data, strategies can be developed to create best practice pathways to maintain quality of care while minimizing radiation exposure.

The mean number of VFSS each child received during the total course of treatment was 3.24 studies (range 1-10). The average effective radiation dose per pediatric VFSS was 0.16 mSv (range: 0.03 mSv-0.59 mSv) per study. Clinical significance was determined by comparison to a pediatric CXR. At our facility a CXR yields an effective radiation dose of 0.017 mSv. Therefore, a patient receives an equivalent total of 30.6 CXR over the course of management. Radiation exposure has known detrimental effects particularly in pediatric patients. The total ionizing radiation from VFSS exams over the course of management of aspiration has heretofore not been reported in peer reviewed literature. With this study’s data in mind, future developments are indicated to create innovative clinical pathways and limit radiation exposure.

Fuller JC1, Sinha S2, Caruso PA3, Hersh CJ4, Butler WE5, Krishnamoorthy KS6, Hartnick CJ2. Chiari malformations: An important cause of pediatric aspiration. Int J Pediatr Otorhinolaryngol. 2016 Sep;88:124-8. Epub 2016 Jun 7.

Chronic aspiration poses a major health risk to the pediatric population. We describe four cases in which work up for chronic aspiration with a brain MRI revealed a Chiari I malformation, a poorly described etiology of pediatric aspiration. All patients had at least one non-specific neurologic symptom but had swallow studies more characteristic of an anatomic than a neurologic etiology. Patients were referred to neurosurgery and underwent posterior fossa decompression with symptom improvement. A high index of suspicion for Chiari malformation should be maintained when the standard work up for aspiration is non-diagnostic, particularly when non-specific neurologic symptoms are present.

Ferris L1, Rommel N2, Doeltgen S3, Scholten I3, Kritas S4, Abu-Assi R4, McCall L4, Seiboth G4, Lowe K4, Moore D4, Faulks J5, Omari T6.  Pressure-Flow Analysis for the Assessment of Pediatric Oropharyngeal Dysphagia. J Pediatr. 2016 Oct;177:279-285.e1. doi: 10.1016/j.jpeds.2016.06.032. Epub 2016 Aug 1.

To determine which objective pressure-impedance measures of pharyngeal swallowing function correlated with clinically assessed severity of oropharyngeal dysphagia (OPD) symptoms. Forty-five children with OPD and 34 control children without OPD were recruited and up to 5 liquid bolus swallows were recorded with a solid-state high-resolution manometry with impedance catheter. Individual measures of pharyngeal and upper esophageal sphincter (UES) function and a swallow risk index composite score were derived for each swallow, and averaged data for patients with OPD were compared with those of control children without OPD. Those objective measures that were markers of UES relaxation, UES opening, and pharyngeal flow resistance differentiated patients with and without OPD symptoms. Patients demonstrating abnormally high pharyngeal intrabolus pressures and high UES resistance, markers of outflow obstruction, were most likely to have signs and symptoms of overt Dysphagia Disorders Survey.

Pharyngeal motor patterns can be recorded in children by the use of HRIM and pharyngeal function can be defined objectively with the use of pressure-impedance measures. Objective measurements suggest that pharyngeal dysfunction is common in children with clinical signs of OPD. A key finding of this study was evidence of markers of restricted UES opening.

Minor G, Ochoa JB, Storm H, Periman S.  Formula Switch Leads to Enteral Feeding Tolerance Improvements in Children With Developmental Delays. Glob Pediatr Health. 2016 Dec 21;3:2333794X16681887. eCollection 2016 Dec 21.

Children with developmental delays are often dependent on enteral nutrition. The aim of our study was to evaluate improvement in tolerance parameters in these children who were switched from an intact protein formula to a 100% whey, peptide-based formula. Medical records of 13 children (aged 8.4 ± 4.6 years) met criteria. All children had a primary diagnosis of developmental delay, and 77% were fed via gastrostomy tube. Of the 13 children assessed, 92% experienced improved feeding tolerance, and 75% of these reported the time to improvement within 1 week after formula switch. Feeding tolerance parameters that improved were vomiting (86%), gagging and retching (75%), high residual volumes (63%), constipation (43%), diarrhea (100%), and poor weight gain (100%). Conclusion: Switching to a 100% whey, peptide-based formula improved symptoms of feeding intolerance in the majority of these developmentally delayed children.