Duncan DR, Mitchell PD, Larson K, Rosen RL. Presenting Signs and Symptoms do not Predict Aspiration Risk in Children. J Pediatr. 2018 Jun 27. pii: S0022-3476(18)30743-1. doi: 10.1016/j.jpeds.2018.05.030. [Epub ahead of print] PMID: 29960768
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). A total of 412 subjects were evaluated. No symptom, including timing relative to meals, predicted aspiration on VFSS. 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 . The CFE does not have the sensitivity to consistently diagnose aspiration so a VFSS should be performed in persistently symptomatic patients.
Tarasiuk A, Segev Y. Abnormal Growth and Feeding Behavior in Upper Airway Obstruction in Rats. Front Endocrinol (Lausanne). 2018 Jun 4;9:298. doi: 10.3389/fendo.2018.00298. eCollection 2018. Review. PMID: 29915561 Free PMC Article
Pediatric obstructive sleep apnea (OSA) is a syndrome manifesting with snoring and increased respiratory effort due to increased upper airway resistance. This syndrome has been shown to elicit either growth retardation or metabolic syndrome and obesity. Treating OSA by adenotonsillectomy is usually associated with increased risk for obesity, despite near complete restoration of breathing and sleep. However, the underlying mechanism linking upper airways obstruction (AO) to persistent change in food intake, metabolism, and growth remains unclear. Rodent models have examined the impact of intermittent hypoxia on metabolism. However, an additional defining feature of OSA that is not related to intermittent hypoxia is enhanced respiratory loading leading to increased respiratory effort and abnormal sleep. The focus of this mini review is on recent evidence indicating the persistent abnormalities in endocrine regulation of feeding and growth that are not fully restored by the chronic upper AO removal in rats. Here, we highlight important aspects related to abnormal regulation of metabolism that are not related to intermittent hypoxia per se, in an animal model that mimics many of the clinical features of pediatric OSA. Our evidence from the AO model indicates that obstruction removal may not be sufficient to prevent the post-removal tendency for abnormal growth.
Riccio MP, Franco C, Negri R, Ferrentino RI, Maresca R, D’alterio E, Greco L, Bravaccio C. Is food refusal in autistic children related to TAS2R38 genotype? Autism Res. 2018 Mar;11(3):531-538. doi: 10.1002/aur.1912. Epub 2017 Dec 28. PMID: 29282878
Several studies suggest that atypical eating behaviors, in particular food selectivity, are more frequent in children with autism spectrum disorder (ASD). A link between bitter taste perception, namely PROP/PTC sensitivity and food preferences is known in healthy children. The aim of this study is to investigate whether genetic variants of the TAS2R38 taste receptor responsible for different bitter sensitivity could affect foods preferences and consequently food refusal in ASD children. 43 children with ASD and 41 with normotypic development (TD) with or without food selectivity, aged between 2 and 11 years. A variation of the gene TAS2R38, associated with bitter taste sensitivity, can cause a different perception of some foods. In particular, some children are hypersensitive to bitterness and show a more restricted repertoire of accepted foods. We evaluate bitter sensitivity in ASD children with or without food selectivity, through a simple bitter taste test with edible strips. The results show that food refusal in ASD children can be mediated by bitter taste sensitivity thus suggesting that the bitter sensitivity test may be used as a device to orientate tailored food proposals for the practical management of food selectivity in ASD.
Cosbey J, Muldoon D. EAT-UP™ Family-Centered Feeding Intervention to Promote Food Acceptance and Decrease Challenging Behaviors: A Single-Case Experimental Design Replicated Across Three Families of Children with Autism Spectrum Disorder.J Autism Dev Disord. 2017 Mar;47(3):564-578. doi: 10.1007/s10803-016-2977-0. PMID: 27904991
This study evaluated the effectiveness of a family-centered feeding intervention, Easing Anxiety Together with Understanding and Perseverance (EAT-UP™), for promoting food acceptance of children with autism spectrum disorder at home. All children demonstrated increases in food acceptance and dietary diversity and decreased challenging behaviors. Implications for practice and research are discussed.
Sharp WG, Postorino V, McCracken CE, Berry RC, Criado KK, Burrell TL, Scahill L. Dietary Intake, Nutrient Status, and Growth Parameters in Children with Autism Spectrum Disorder and Severe Food Selectivity: An Electronic Medical Record Review. J Acad Nutr Diet. 2018 Jul 10. pii: S2212-2672(18)30679-8. doi: 10.1016/j.jand.2018.05.005. [Epub ahead of print] PMID: 30005820
This study examined the demographic characteristics, anthropometric parameters, risk of nutritional inadequacy, dietary variety, and problematic mealtime behaviors in a sample of children with ASD with severe food selectivity. Children (age 2 to 17 years) with ASD, severe food selectivity, and complete nutritional data who received a multidisciplinary evaluation at a specialty feeding clinic. Criteria for severe food selectivity used in this clinical practice required complete omission of one or more food groups (eg, fruit, vegetable, protein, grain, dairy) or consuming a narrow range of items on a weekly basis (eg, five or fewer total food items). Of the 279 patients evaluated during the 24-month period, 70 children with ASD and severe food selectivity met inclusion criteria. Caregivers reported 67% of the sample omitted vegetables and 27% omitted fruits. Seventy-eight percent consumed a diet at risk for five or more inadequacies. Risk for specific inadequacies included vitamin D (97% of the sample), fiber (91%) vitamin E (83%), and calcium (71%). Children with five or more nutritional inadequacies were more likely to make negative statements during meals. Severe food selectivity was not associated with compromised growth or obesity.
Chistol LT, Bandini LG, Must A, Phillips S, Cermak SA, Curtin C. Sensory Sensitivity and Food Selectivity in Children with Autism Spectrum Disorder.J Autism Dev Disord. 2018 Feb;48(2):583-591. doi: 10.1007/s10803-017-3340-9. PMID: 29116421
We compared oral sensory processing between children with and without ASD. We also examined the relationships between atypical oral sensory processing, food selectivity, and fruit/vegetable consumption in children with ASD. We found that more children with ASD presented with atypical sensory processing than children without ASD. Among children with ASD, those with atypical oral sensory sensitivity refused more foods and ate fewer vegetables than those with typical oral sensory sensitivity. The findings suggest that efforts to address food selectivity in children with ASD may be enhanced by including strategies that address oral sensory processing.
Levy DS, Osborn E, Hasenstab KA, Nawaz S, Jadcherla SR. The Effect of Additives for Reflux or Dysphagia Management on Osmolality in Ready-to-Feed Preterm Formula: Practice Implications.JPEN J Parenter Enteral Nutr. 2018 Jul 10. doi: 10.1002/jpen.1418. [Epub ahead of print] PMID: 29992586
A common osmolality threshold for feedings is to stay <450 mOsm/kg for normal infants. Preterm formulas are frequently modified to improve growth, modify nutrition, and manage gastroesophageal reflux (GER) or dysphagia. Relationships between osmolality and additives to ready-to-feed preterm formulas are unclear. Our aims were to evaluate and compare the effects of caloric density, thickening agent recipes, and supplements to ready-to-feed preterm formula on osmolality. A total of 470 osmolality samples were analyzed: (1) raters had high agreement; (2) for every 0.5 tsp/oz of thickener, the osmolality increases by 30 mOsm/kg; (3) osmolality was higher with the oatmeal (vs rice) thickening agent; and (4) vitamin and electrolyte supplement combinations increase osmolality. Alteration of ready-to-feed preterm formulas may significantly increase osmolality and have unintended consequences. Caution and monitoring should be exercised with modifying ready-to-feed preterm formulas for regurgitation, rumination, GER, dysphagia, feeding intolerance, or emesis. This study supports the concept of achieving volume tolerance before further manipulation of additives.
Jadcherla SR, Prabhakar V, Hasenstab KA, Nawaz S, Das J, Kern M, Balasubramanian G, Shaker R. Defining pharyngeal contractile integral during high-resolution manometry in neonates: a neuromotor marker of pharyngeal vigor.Pediatr Res. 2018 Jul 6. doi: 10.1038/s41390-018-0097-6. [Epub ahead of print] PMID: 29976974
Pharyngeal contractility is critical for safe bolus propulsion. Pharyngeal contractile vigor can be measured by Pharyngeal Contractile Integral (PhCI): product of mean pharyngeal contractile amplitude, length, and duration. We characterized PhCI in neonates and examined the hypothesis that PhCI differs with mode of stimulation. Nineteen neonates were evaluated using high-resolution manometry (HRM). PhCI was calculated using: (a) Conventional and (b) Automated Swallow Detection algorithm (ASDA) methods. PhCI of oral stimuli swallows were distinct from pharyngeal stimuli and spontaneous swallows. PhCI is a novel reliable metric capable of distinguishing (1) proximal and distal pharyngeal activity, (2) effects of oral and pharyngeal stimulation, and (3) effects of prolonged stimulation. Changes in pharyngeal contractility with maturation, disease, and therapies can be examined with PhCI.
Ferris L, King S, McCall L, Rommel N, Scholten I, Teague W, Doeltgen S, Omari T. Piecemeal Deglutition and the Implications for Pressure Impedance Dysphagia Assessment in Pediatrics. J Pediatr Gastroenterol Nutr. 2018 Jul 6. doi: 10.1097/MPG.0000000000002080. [Epub ahead of print] PMID: 29985873
High resolution impedance manometry (HRIM) enables biomechanical swallow assessment. Piecemeal deglutition (PD) defines swallowing of a single bolus in two or more portions. We investigated PD sequences on HRIM recordings to ascertain appropriate swallow selection for analysis and to determine the impact of PD on swallow function measures. Pharyngo-esophageal motility and bolus flow were assessed in 27 children with repaired esophageal atresia and trachea-esophageal fistula, but who were asymptomatic of oropharyngeal dysphagia. A consistent volume of between 2 and 5 ml saline boluses was given to each patient. Retrospectively, PD sequences were defined based on the number of swallows required to clear the bolus from the oral cavity: pattern A = 1-2 swallows; pattern B = 3 swallows; and pattern C = 4+ swallows. The largest bolus volume swallowed was noted as the dominant swallow in each pattern. Pressure Flow Analysis defined contractility, distention and flow timing metrics. Data were averaged for each PD pattern, and compared with dominant swallows from each pattern. PD pattern B (43.7%) was the most prevalent across the cohort. However, differences in UES distention and pharyngeal flow timing measures were seen in relation to both age and PD pattern, whereby a larger pharynx in older children elicited greater distention for a longer latency, and for larger volumes. PD reduces bolus volume, and biomechanical swallow measures are impacted. PD is a necessary consideration for accurate HRIM analysis of swallow function. Selection of dominant swallows from a PD sequence provides a swallow profile which best represents a child’s swallow function, and should always be reported and interpreted in context of the PD sequence observed.
Duffy KL. Dysphagia in Children. Curr Probl Pediatr Adolesc Health Care. 2018 Mar;48(3):71-73. doi: 10.1016/j.cppeds.2018.01.003. PMID: 29571543
Speech-Language Pathologists (SLP) play an integral role in evaluating and treating pediatric patients with dysphagia related to aerodigestive disorders. Non-supportive anatomy, cardio-respiratory and medical status, state control, neurologic functioning, postural stability and control, gastrointestinal functioning, hunger and satiation, developmental abilities, oral-motor skills, oral/pharyngeal reflexes, airway protection and secretion management can create barriers to successful oral feeding. Swallowing is broken down into four phases and difficulties can occur during any phase or in combination with another phase of swallowing. Dysphagia is diagnosed by both clinical and instrumental evaluation. Objective evaluations of swallowing include the Video Fluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES). A Video Fluoroscopic Swallow Study (VFSS) is a radiographic study assessing oropharyngeal swallow function. The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is conducted by passing a laryngoscope through the nose to just below the soft palate for a “bird’s eye view” of laryngeal anatomy and swallow function. Following a diagnosis of dysphagia from either a clinical or instrumental assessment, there are a variety of avenues that can be pursued including diet modifications, compensatory strategies, and use of specialized equipment to ensure a safe feeding plan and reduce the risk of aspiration. In conclusion, through numerous evaluation and intervention approaches, the contributions of SLPs helps provide input for well-rounded, multi-disciplinary plans supporting successful oral feeding.
Ferrara L, Kamity R, Islam S, Sher I, Barlev D, Wennerholm L, Redstone F, Hanna N. Short-Term Effects of Cold Liquids on the Pharyngeal Swallow in Preterm Infants with Dysphagia: A Pilot Study. Dysphagia. 2018 Feb 12. doi: 10.1007/s00455-018-9877-8. [Epub ahead of print] PMID: 29435661
Cold stimulation reduces airway compromise in adults with dysphagia. However, there is no sufficient evidence to support its use in the pediatric population. The primary goal of this pilot study is to assess the effect of cold liquid on the pharyngeal swallow mechanism in preterm infants with dysphagia. We hypothesized that thermal stimulation from cold liquid will decrease the risk of airway compromise in dysphagic preterm infants. Nine preterm infants with clinical symptoms of dysphagia were included. Video fluoroscopic swallow studies were used to assess the swallowing mechanism of each participant. The occurrence of swallow dysfunctions under room temperature liquid swallows (RTS) vs. short period cold liquid swallows (CS) was compared. The occurrence of deep penetration and aspiration decreased significantly in the CS condition compared with the RTS condition. There was a trend of less nasopharyngeal reflux with CS but did not reach statistical significance. No differences were noted for mild penetration. CS reduced airway compromise in dysphagic preterm infants compared to RTS. These data provide important information regarding the immediate effects of CS on pharyngeal swallowing in preterm infants with dysphagia. However, further investigation regarding its sustained effects is required before introducing to clinical practice.
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 Apr;53(4):517-525. doi: 10.1002/ppul.23955. Epub 2018 Feb 2. PMID: 29393599
The identification of oropharyngeal aspiration is paramount since it can have negative consequences on a compromised respiratory status. Our hypothesis was that dysphagia in neurologically intact children with respiratory disease is associated to specific clinical markers. The final study sample consisted of 102 patients (mean age of 5.88 months). For the purposes of statistical analysis, the patients were grouped according to the classification of dysphagia (ie, no dysphagia, mild dysphagia, and moderate-severe dysphagia). Data analysis indicated that the clinical markers of orotracheal intubation, 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.
Indrio F, Riezzo G, Giordano P, Ficarella M, Miolla MP, Martini S, Corvaglia L, Francavilla R. Effect of a Partially Hydrolysed Whey Infant Formula Supplemented with Starch and Lactobacillus reuteri DSM 17938 on Regurgitation and Gastric Motility. Nutrients. 2017 Oct 28;9(11). pii: E1181. doi: 10.3390/nu9111181. PMID: 29143799 Free PMC Article
Functional regurgitation (FR) is common in early infancy. This double-blind, randomized controlled trial investigated the effects of a formula containing partially hydrolysed, 100% whey protein, starch and Lactobacillus reuteri (DSM 17938) on gastric emptying rate (GErate) and regurgitation frequency in infants with FR. Ultrasound GErate assessment was performed at baseline (week 0) and at week 4; the number of regurgitations, feed volumes and potential adverse events were recorded in a daily diary. Compared to controls, the test group showed greater percentage changes in GErate. Mean daily regurgitations decreased from 7.4 (0.8) at week 0 to 2.6 (1.0) at week 4 in the test group and from 7.5 (1.0) to 5.3 (1.0) in controls. Compared to a standard formula, a starch-thickened partially hydrolysed whey protein formula supplemented with Lactobacillus reuteri is more effective in decreasing the frequency of regurgitation and improving GErate, and can be of benefit to infants with FR.
Goodell LS, Johnson SL, Antono AC, Power TG, Hughes SO. Strategies Low-Income Parents Use to Overcome Their Children’s Food Refusal.Matern Child Health J. 2017 Jan;21(1):68-76. doi: 10.1007/s10995-016-2094-x. PMID: 27443653
Parents play a key role in the development of eating habits in preschool children, as they are the food “gatekeepers.” Repeated exposure to new foods can improve child food preferences and consumption. The objective of this study was to determine parent feeding strategies used to influence child acceptance of previously rejected foods (PRF). 18 focus groups were conducted with low-income African American and Hispanic parents of preschool children (3- to 5-year-olds) in Texas, Colorado, and Washington. We found three major themes in the data: parents most often do not serve PRF; parents value their child eating over liking a food; and parents rarely use the same feeding strategy more than once for a PRF. Desiring to reduce waste and save time, parents said they most often intentionally decided not to purchase or serve PRF to their children. Because parents’ primary goal in child feeding is getting children to eat (over acceptance of a variety of foods), strategies to help parents promote consumption of less easily accepted foods could help parents with child feeding struggles and improve children’s dietary quality.
Little LM, Dean E, Tomchek S, Dunn W. Sensory Processing Patterns in Autism, Attention Deficit Hyperactivity Disorder, and Typical Development. Phys Occup Ther Pediatr. 2018 Aug;38(3):243-254. doi: 10.1080/01942638.2017.1390809. Epub 2017 Dec 14. PMID: 29240517
The purpose of this study was to examine sensory processing in children ages 3-14 years with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and typical development (TD) using the Sensory Profile 2nd Edition (Dunn, 2014). Participants included 239 children (ASD = 77; ADHD = 78; TD = 84) matched on age and gender. Analysis was used to compare the extent to which the three groups differed on sensory processing patterns (i.e., sensitivity, avoiding, registration, seeking) and sensory systems (i.e., auditory, visual, touch, movement, body position, oral, conduct, attention, social). We also examined the effect of chronological age. Children with ASD and ADHD did not differ in sensory processing patterns which were elevated as compared to a TD group. Children with ASD showed the highest rate of oral processing differences, followed by ADHD and TD. Children with ADHD had higher visual processing scores than children with ASD and TD. Older children had lower scores for seeking, auditory, visual, movement, touch, and conduct than younger children, regardless of diagnosis. Findings suggest that sensory features may be an area of overlap of behaviors in ASD and ADHD, which may have implications for intervention approaches for children with these conditions.