Swallowing:
Wertz A, Ha JF, Driver LE, Zopf DA. Pediatric laryngeal cleft repair and dysphagia.Int J Pediatr Otorhinolaryngol. 2018 Jan;104:216-219. doi: 10.1016/j.ijporl.2017.11.017. Epub 2017 Nov 23. PMID: 29287871
Dysphagia improves in most patients after laryngeal cleft repair. The range in time to a normal diet was wide. This may facilitate improved preoperative counseling and preparation of families’ expectations.
Sassi FC, Bühler KCB, Juste FS, Almeida FCF, Befi-Lopes DM, de Andrade CRF. Dysphagia and associated clinical markers in neurologically intact children with respiratory disease. Pediatr Pulmonol. 2018 Feb 2. doi: 10.1002/ppul.23955. PMID: 29393599
Data analysis indicated that the clinical markers of orotracheal intubation ( OTI), duration of orotracheal intubation, and days of hospitalization were significant in children with moderate-severe dysphagia. Our data indicate that neurologically intact children with respiratory disease who were submitted to prolonged OTI (ie, over 48 h) should be prioritized for receiving a detailed swallowing assessment.
Vetter-Laracy S, Osona B, Roca A, Peña-Zarza JA, Gil JA, Figuerola J.Neonatal swallowing assessment using fiberoptic endoscopic evaluation of swallowing (FEES). Pediatr Pulmonol. 2018 Jan 22. doi: 10.1002/ppul.23946. [Epub ahead of print] PMID: 29356410
Swallowing disorders which lead to aspiration are common in premature infants born with a postmenstrual age (PMA) of >36 weeks. Aspiration is often silent and the unique symptom is desaturation during feeding. A retrospective review of 62 ex-premature babies with a median PMA of 40 weeks which underwent FEES due to persistent feeding desaturations. A total of 71% infants were diagnosed with aspiration and/or penetration. In 77.3% of the infants, use of a thickener seemed to reduce aspiration during FEES and was suggested as a treatment. 13.6% of infants received anti-reflux treatment after FEES and 9.1% required gastrostomy. Aspiration is very frequent in premature infants who present desaturations during feeding and FEES is a useful method for diagnosing and suggesting treatments.
Speyer R, Cordier R, Parsons L, Denman D, Kim JH. Psychometric Characteristics of Non-instrumental Swallowing and Feeding Assessments in Pediatrics: A Systematic Review Using COSMIN. Dysphagia. 2018 Feb;33(1):1-14. doi: 10.1007/s00455-017-9835-x. Epub 2017 Aug 17. Review. PMID: 28819914
A systematic review was performed summarizing the psychometric properties of non-instrumental assessments for swallowing and feeding difficulties in pediatrics. The COSMIN taxonomy and checklist were used to evaluate the methodological quality of 23 publications on psychometric properties. Only preliminary conclusions could be drawn; the most robust assessment based on current data is the dysphagia disorder survey (DDS). However, further research is needed to provide additional information on all psychometric properties for all assessments.
General Feeding:
Harris G, Mason S. Are There Sensitive Periods for Food Acceptance in Infancy? Curr Nutr Rep. 2017;6(2):190-196. doi: 10.1007/s13668-017-0203-0. Epub 2017 Apr 29. Review. PMID: 28596932
A sensitive period in development is one in which it is easier for learning to take place; the behaviour can however still be learned at a later stage, but with more difficulty. This is in contrast to a critical period, a time at which a behaviour must be learned, and if this window of opportunity is missed, then the behaviour can never be acquired. Both might determine food acceptance in childhood. There is evidence to support the idea of a sensitive period for the introduction of tastes, a critical period for the introduction of textures and for the development of oral motor function, and a possible critical period for the introduction of new foods but only in children where there is an innate disposition to develop early and extreme disgust responses. There are both sensitive and critical periods in the acquisition of food preferences.
Borowitz KC, Borowitz SM. Feeding Problems in Infants and Children: Assessment and Etiology. Pediatr Clin North Am. 2018 Feb;65(1):59-72. doi: 10.1016/j.pcl.2017.08.021. Review.PMID: 29173720
As many as 50% of parents report their otherwise healthy children have feeding problems and as many as 80% of children with developmental delays may have difficulties feeding. Several different ways to categorize the medical conditions that predispose infants and young children to having difficulties feeding:
- Structural abnormalities of the face, oral cavity, or aerodigestive system
- Neuromuscular dysfunction/incoordination
- Inadequate strength and/or rapid fatigue/lack of endurance
- Inability to coordinate suck/swallow/breathe normally as a result of respiratory distress
- Nausea and/or discomfort during the feeding process
Many infants suffering from the symptoms of gastroesophageal reflux have symptoms of colic and constipation, and, as such, the discomfort these infants seem to experience associated with feedings may not be the result of the reflux per se but rather are the result of a more generalized motility disorder akin to visceral hyperalgesia syndrome in older children and adults.
Oral Motor- Sensory- Behavioral:
Scarborough D, Brink KE, Bailey-Van Kuren M. Open-Cup Drinking Development: A Review of the Literature. Dysphagia. 2017 Dec 29. doi: 10.1007/s00455-017-9871-6. [Epub ahead of print] Review. PMID: 29288432
A lack of published research studies exist that analyze the factors involved with the progression of open-cup drinking in typically developing infants and toddlers. As a result, clinicians who are working with children that have delays in open-cup drinking development have a limited framework from which to base clinical decisions. The purpose of this review is to collate works from disparate and related fields to provide a brief review of the literature of pertinent sensorimotor and cognitive components necessary for successful open-cup drinking development.
da Costa SP, Remijn L, Weenen H, Vereijken C, van der Schans C. Exposure to texture of foods for 8-month-old infants: Does the size of the pieces matter? J Texture Stud. 2017 Dec;48(6):534-540. doi: 10.1111/jtxs.12271. Epub 2017 May 15. PMID: 28449229
This study examined the effect of meals varying in amount, size, and hardness of food pieces on the development of the chewing capabilities of 8-month-old infants. The study also examined changes in shivering, gagging, coughing, choking, and their ability to eat from a spoon. In an in-home setting two groups were given commercially available infant meals and fruits, purees with either less, smaller and softer or more, larger and harder pieces for 4 weeks. After the 4-week exposure period, the group that had been exposed to the foods with more, larger and harder pieces showed a significantly higher rating for chewing a piece of carrot and potato for the first time, but not for a piece of banana nor for mashed foods. Shivering, gagging, coughing, choking, and ability to eat from a spoon were not different between the two groups. The study contributes to the insight that exposure to food texture to learn how to handle texture is important for infants and showed that exposing children to a higher amount of larger pieces improves their chewing capability for a piece of carrot and potato, at least immediately after the intervention.
Simione M, Loret C, Le Révérend B, Richburg B, Del Valle M, Adler M, Moser M, Green JR. Differing structural properties of foods affect the development of mandibular control and muscle coordination in infants and young children. Physiol Behav. 2018 Mar 15;186:62-72. doi: 10.1016/j.physbeh.2018.01.009. Epub 2018 Jan 16. PMID: 29343459
The purpose of this study was to identify age-related changes in chewing motor coordination and control during chewing development at five different age groups (9-, 12-, 18-, 24-, and 36-months) and to determine the effects of differing structural properties of foods, and to explore explanatory variables, including the emergence of teeth and molars and bite force. The results of this study found that children made gains in their chewing motor control and coordination and the structural differences in foods affected chewing performance. Based on the findings, authors hypothesized that the development of chewing could be characterized into two broad phases: the premolar (9-, 12-, and 18-months) and molar (24- and 36- months) phases. Children in the premolar phase lacked molars and had the basic coordinative organization, but their jaw movements were still inefficient as compared to the children in the molar phase. The children in the later phase had begun to refine their chewing motor performance. To promote the development of chewing skills, successful feeding should be the result of the right fit between the child’s developmental skills and the food.
Coulthard H, Sealy A. Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite. 2017 Jun 1;113:84-90. doi: 10.1016/j.appet.2017.02.003. Epub 2017 Feb 12. PMID: 28202412
The objective of the current study was to ascertain whether taking part in a sensory play activity with real fruits and vegetables (FV) can encourage tasting in preschool children, compared to a non-food activity or visual exposure to the activity. Three to four year old pre-school children (N = 62) were recruited. A between participants experimental study was conducted with each class assigned to one of three conditions; sensory FV play, sensory non-food play and visual FV exposure. Parental report of several baseline variables were taken; child baseline liking of the foods used in the study, parental and child FV consumption (portions/day), child neophobia and child tactile sensitivity. Outcome measures were the number of fruits and vegetables tasted in a post experiment taste test which featured or did not feature in the task. Analyses showed that after the activity children in the sensory FV play condition tried more FV than both children in the non-food sensory play task and children in the visual FV exposure task. This was true not only for five foods used in the activity, but also three foods that were not used in the activity. Sensory play activities using fruits and vegetables may encourage FV tasting in preschool children more than non food play or visual exposure alone. Long term intervention studies need to be carried out to see if these effects can be sustained over time.
Hodges A, Davis T, Crandall M, Phipps L, Weston R. Using Shaping to Increase Foods Consumed by Children with Autism. J Autism Dev Disord. 2017 Aug;47(8):2471-2479. dos:10.1007/s10803-017-3160-y.
The current study used differential reinforcement and shaping to increase the variety of foods accepted by children with autism who demonstrated significant feeding inflexibility. Participants were introduced to four new food items via a hierarchical exposure, which involved systematically increasing the desired response with the food item. Level of food consumption was evaluated using a combined multiple baseline plus changing criterion design. Following intervention, all participants accepted all foods targeted, expanding upon the number of foods consumed.
Feeding and Medical/GI:
Hauer J. Feeding Intolerance in Children with Severe Impairment of the Central Nervous System: Strategies for Treatment and Prevention. Children (Basel). 2017 Dec 22;5(1). pii: E1. doi: 10.3390/children5010001. Review. PMID: 29271904
Children with severe impairment of the central nervous system (CNS) experience gastrointestinal (GI) symptoms at a high rate and severity, including retching, vomiting, GI tract pain, and feeding intolerance. Commonly recognized sources of symptoms include constipation and gastroesophageal reflux disease. There is growing awareness of sources due to the impaired nervous system, including visceral hyperalgesia due to sensitization of sensory neurons in the enteric nervous system and central neuropathic pain due to alterations in the thalamus. Challenging the management of these symptoms is the lack of tests to confirm alterations in the nervous system as a cause of symptom generation and it is also common to have multiple reasons for the observed symptoms. Recurrent emesis and GI tract pain can often be improved, though in some not completely eliminated. In some, this can progress to intractable feeding intolerance. This comprehensive review provides an evidence-based approach to care, a framework for recurrent symptoms, and language strategies when symptoms remain intractable to available interventions. This summary is intended to balance optimal management with a sensitive palliative care approach to persistent GI symptoms in children with severe impairment of the CNS.
Asaro J, Robinson CA, Levy PT. Visceral Hyperalgesia: When to Consider Gabapentin Use in Neonates-Case Study and Review. Child Neurol Open. 2017 Feb 10;4:2329048X17693123. doi: 10.1177/2329048X17693123. eCollection 2017 Jan-Dec. PMID: 28503628
Visceral hyperalgesia refers to increased pain sensation in response to gastrointestinal sensory stimulus. In neonates with neurological impairments, gabapentin has been successfully used as a treatment for visceral hyperalgesia in neonates. The authors describe a preterm infant with myelomeningocele and persistent neuropathic pain that manifested as irritability, hypertonicity, poor weight gain, and feeding intolerance. After exclusion of other etiologies, the diagnosis of visceral hyperalgesia was suspected and the infant was treated with gabapentin. Following appropriate titration to effect and close monitoring of side effects of gabapentin, he subsequently demonstrated improved tone, decreased irritability with feedings, and appropriate weight gain. In addition, the authors provide a review of the available literature of gabapentin use in neonates and offer suggestions on when to consider starting gabapentin in a neonate with neurological impairment and chronic unexplained gastrointestinal manifestations.
Gallagher K, Flint A, Mouzaki M, Carpenter A, Haliburton B, Bannister L, Norgrove H, Hoffman L, Mack D, Stintzi A, Marcon M. Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds Through a Gastric Tube in a Medically Complex Pediatric Population. JPEN J Parenter Enteral Nutr. 2018 Jan 16. doi: 10.1002/jpen.1049. [Epub ahead of print] PMID: 29338077
Chronically ill children often require feeding via gastrostomy tubes (G-tubes). Commercial formula is most commonly used for enteral feeding; however, caregivers have been requesting blenderized tube feeds (BTFs) as an alternative. The objective of this study was to evaluate the feasibility of using BTFs in a medically complex pediatric population and assess their impact on clinical outcomes, as well as the microbiota.Transition onto BTF was feasible in 17 participants, and 1 participant transitioned to oral feeds. Participants required 50% more calories to maintain their body mass index while on BTFs compared with commercial formula. BTF micronutrient content was superior to commercial formula. Prevalence of vomiting and use of acid-suppressive agents significantly decreased on BTFs. Stool consistency and frequency remained unchanged, while stool softener use increased. The bacterial diversity and richness in stool samples significantly increased, while the relative abundance of Proteobacteria decreased. Caregivers were more satisfied with BTFs and unanimously indicated they would recommend BTFs. Initiation and maintenance of BTFs is not only feasible in a medically complex pediatric population but can also be associated with improved clinical outcomes and increased intestinal bacterial diversity.
Sung V, D’Amico F, Cabana MD, Chau K, Koren G, Savino F, Szajewska H, Deshpande G, Dupont C, Indrio F, Mentula S, Partty A, Tancredi D. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018 Jan;141(1). pii: e20171811. doi: 10.1542/peds.2017-1811. Review. PMID: 29279326
Lactobacillus reuteri DSM17938 has shown promise in managing colic, but conflicting study results have prevented a consensus on whether it is truly effective. Four double-blind trials involving 345 infants with colic were included. The probiotic group averaged less crying and/or fussing time than the placebo group at all time points. The probiotic group was almost twice as likely as the placebo group to experience treatment success at all time points. Intervention effects were dramatic in breastfed infants but were insignificant in formula-fed infants. There were insufficient data to make conclusions for formula-fed infants with colic. L reuteri DSM17938 is effective and can be recommended for breastfed infants with colic. Its role in formula-fed infants with colic needs further research.
Pollow AS, Karls CA, Witzlib M, Noel RJ, Goday PS, Silverman AH. Safety of Appetite Manipulation in Children with Feeding Disorders Admitted to an Inpatient Feeding Program. J Pediatr Gastroenterol Nutr. 2017 Nov 28. doi: 10.1097/MPG.0000000000001849. [Epub ahead of print] PMID: 29210920
Appetite manipulation can be effective in weaning children off gastrostomy tube (G-tube) feeding dependence but can cause dehydration, hypoglycemia and ketone body production, which is anorexigenic. Since the safety of this approach has not been described, our aim was to describe adverse events observed when weaning children from G-tube dependence using our appetite manipulation protocol. This was a retrospective study of prospectively collected data of patients who completed our inpatient tube-weaning protocol. Daily safety parameters included twice-daily urine specific gravities and urine ketones and fasting capillary blood glucose. Graded clinical interventions to manage adverse events were collected. 143 children were seen in the inpatient feeding program. The children were hospitalized 10.1 ± 2.5 days with the vast majority being discharged between days 11 and 14. Overall, 78.2% of patients experienced at least one adverse event: urine specific gravity > 1.020 was seen in 60.5%, ketonuria in 48.9%, and hypoglycemia (≤60 mg/dL) in 13.4%. Only two children had blood glucose levels < 40 mg/dL and these were corrected with oral supplementation. Graded clinical interventions to manage adverse events included: oral rehydration in 89.9% of children and supplemental tube feeding in 25.2%. Adverse effects are common when appetite manipulation is used to wean children off G-tube dependence. Anticipating, monitoring, and having a clear intervention plan in a closely monitored setting are necessary to safely use this method.
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