On the Research Front…

Pados BF. Symptoms of problematic feeding in children with CHD compared to healthy peers. Cardiol Young. 2018 Nov 20:1-10.

The purpose of this study was to describe symptoms of problematic feeding in children with CHD compared to healthy children without medical conditions,. Oral feeding was measured by the Pediatric Eating Assessment Tool. This secondary analysis used data collected from web-based surveys completed by parents of 1093 children between 6 months and 7 years of age who were eating solid foods by mouth. Covariates tested in the models included breathing tube duration, type of CHD, gastroesophageal reflux, genetic disorder, difficulty with breast- or bottle-feeding during infancy, cardiac surgery, and current child age. Children with CHD had significantly more symptoms of problematic feeding than healthy children on the Pediatric Eating Assessment Tool total score, more physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing dysfunction (p <0.001 for all), when taking into account relevant covariates. Additional research is needed in children with CHD to improve risk assessment and develop interventions to optimise feeding and growth.

Caffarelli C, Di Mauro D, Mastrorilli C, Bottau P, Cipriani F, Ricci G. Solid Food Introduction and the Development of Food Allergies. Nutrients. 2018 Nov 17;10(11). pii: E1790. Free full text

The rise of food allergy in childhood, particularly among developed countries, has a significant weight on public health and involves serious implications for patients’ quality of life. Even if the mechanisms of food tolerance and the complex interactions between the immune system and environmental factors are still mainly unknown. In the last few decades, the prevention of food allergy has tracked various strategies of complementary feeding with a modification of international guidelines from delayed introduction to early weaning. Current evidence shows that complementary foods, including allergenic ones, should be introduced into diet after four months, or even better, following World Health Organization advice, around six months irrespective of risk for allergy of the individual. The introduction of peanut is recommended before 12 months of age among infants affected by severe eczema and/or egg allergy to diminish the occurrence of peanut allergy in countries with high peanut consumption. The introduction of heated egg at 6⁻8 months of age may reduce egg allergy. Infants at high risk of allergy similarly to healthy children should introduce complementary foods taking into account family and cultural preferences.

Irace AL, Dombrowski ND, Kawai K, Dodrill P, Perez J, Hernandez K, Davidson K, Hseu A, Nuss R, Rahbar R.Aspiration in children with unilateral vocal fold paralysis. Laryngoscope. 2018 Nov 8.

To describe the prevalence of aspiration in children with unilateral vocal fold paralysis who underwent objective assessment of swallow function. Twenty-eight patients diagnosed with unilateral vocal fold paralysis underwent an MBS study at our institution in 2015. Twenty-six patients (92.9%) had dysphagia. Sixteen patients were found to aspirate on MBS study. All patients who aspirated did so without overt signs (silent aspiration). Eighteen patients had congenital heart disease (64.3%) and nine had a history of prematurity (32.1%). Eight patients (28.6%) presented with developmental delays. CONCLUSIONS: Patients who present with unilateral vocal fold paralysis and recurrent respiratory and/or feeding issues may be affected by prominent issues such as swallowing dysfunction and silent aspiration. Clinicians should be aware of this risk and evaluate patients for any signs of feeding or swallowing difficulties.

Raol N, Schrepfer T, Hartnick C. Aspiration and Dysphagia in the Neonatal Patient. Clin Perinatol. 2018 Dec;45(4):645-660.

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Serel Arslan S, Demir N, Karaduman AA, Tanyel FC, Soyer T. Chewing Function in Children with Repaired Esophageal Atresia-Tracheoesophageal Fistula. Eur J Pediatr Surg. 2018 Dec;28(6):534-538.

Feeding problems are common in children with esophageal atresia and tracheoesophageal fistula (EA-TEF). we aimed to evaluate the chewing function in children with repaired EA-TEF. Chewing disorders can be observed in children with EA-TEF, and the type of repair and the delay in oral feeding may be related to chewing disorder. Therapeutic maneuvers are needed to improve the chewing function in children with EA-TEF.

Adamiak T, Plati KF. Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis. Pediatr Rev. 2018 Aug;39(8):392-402.

Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.

Asgarshirazi M, Farokhzadeh-Soltani M, Keihanidost Z, Shariat M. Evaluation of Feeding Disorders Including Gastro-Esophageal Reflux and Oropharyngeal Dysfunction in Children With Cerebral Palsy.  J Family Reprod Health. 2017 Dec;11(4):197-201.Free PMC Article

This cross sectional study aims to survey developing feeding disorders and nutritional deficiencies disorders in children with neurodevelopmental disorders such as cerebral palsy. Prevalence of GERD was 66% and oropharyngeal dysphagia was estimated 82%. According to results of video-fluroscopy and endoscopic biopsies, 52% of patients were affected by both GERD and oropharyngeal dysfunction. The gross motor function disability was the only variable that significantly related to the prevalence of feeding disorders (p = 0.015). Despite nutritional rehabilitation only 46% of children have weight gain. Feeding disorders such as GERD and oropharyngeal dysfunction are more prevalent in children with cerebral palsy especially in children with severe gross motor disabilities. Since, clinical manifestations of these disorders can be similar accurate diagnostic methods should be selected for all children with cerebral palsy and gastrointestinal symptoms. Treatment should start early to reduce the complications and improve outcomes.

Walker RD, Messing S, Rosen-Carole C, McKenna Benoit M. Defining Tip-Frenulum Length for Ankyloglossia and Its Impact on Breastfeeding: A Prospective Cohort Study. Breastfeed Med. 2018 Apr;13(3):204-210. doi: 10.1089/bfm.2017.0116. Epub 2018 Mar 20.

The purpose of this study was to investigate the normal lingual frenulum anatomy in newborns and to evaluate tip-frenulum distance as an objective diagnostic tool for identifying newborns at risk for anterior and posterior tongue tie and breastfeeding difficulty. The distance from the tongue tip to the insertion of the lingual frenulum was measured in a group of 100 healthy newborns to establish normative data. The presence of a visible or palpable cord was noted. Mean tip-frenulum length was 9.07 mm. Intraclass correlation coefficient between observers for tip-frenulum length was 0.82. A visible cord was identified in 21 subjects (21%). A palpable cord was identified in 59 subjects (59%). Unweighted κ coefficients for inter-rater reliability of visible and palpable cords were 0.91 and 0.47, respectively. Visible cord and shorter tip-frenulum distance were independently predictive of higher maternal pain scores. A positive correlation was identified between tip-frenulum length and IBFAT scores for mothers with two or more previous breastfed children. Tongue tip-frenulum length correlated with maternal nipple pain, and was useful as an objective tool for identifying newborns at risk for ankyloglossia. Maternal breastfeeding experience appears to be an important factor in the link between tongue anatomy and breastfeeding difficulty. The presence of a palpable cord was variable across examiners, and should be interpreted with caution when evaluating newborns for posterior tongue tie.

Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional – morphological study. Orthod Craniofac Res. 2017 Nov;20(4):237-244. doi: 10.1111/ocr.12206. Epub 2017 Oct 10.

To characterize associations between restricted tongue mobility and maxillofacial development. Tongue mobility (measured with tongue range of motion ratio [TRMR] and Kotlow free tongue measurement) was correlated with measurements of the maxillofacial skeleton obtained from dental casts and cephalometric radiographs. Tongue range of motion ratio and Kotlow measures of restricted tongue mobility were associated with (i) ratio of maxillary intercanine width to canine arch length, (ii) ratio of maxillary intermolar width to canine arch length and (iii) soft palate length. Restricted tongue mobility was not associated with hyoid bone position or Angle’s skeletal classification. Restricted tongue mobility was associated with narrowing of the maxillary arch and elongation of the soft palate in this study. These findings suggest that variations in tongue mobility may affect maxillofacial development.

Cole E, Dreyzin A, Shaffer AD, Tobey ABJ, Chi DH, Tarchichi T. Outcomes and swallowing evaluations after injection laryngoplasty for type I laryngeal cleft: Does age matter? Int J Pediatr Otorhinolaryngol. 2018 Dec;115:10-18. doi: 10.1016/j.ijporl.2018.09.006. Epub 2018 Sep 13. PMID: 30368367

To improve the recognition of differences in presentation amongst patients with type 1 laryngeal clefts of various ages and better understand the age dependent outcomes of injection laryngoplasty. A second aim was to analyze the discrepancies between swallow assessment modalities in various age groups with type I laryngeal clefts undergoing injection laryngoplasty.  Formula thickening and GERD medications were used in 94/102 (92.2%) and 97/102 (95.1%) patients, respectively. Comorbid GERD, laryngomalacia, tracheomalacia, and subglottic stenosis were present in 98/102 patients. Symptoms at presentation differed between age groups with stridor and cyanosis being more common in the 0-3-month group compared to the 12-36 month group. Symptom resolution and the odds of undergoing additional surgery (second injection or suture repair) over time, however, did not differ. There was a significant reduction in aspiration with thins during FEES and aspiration with nectar during MBS post-injection. After injection, there was significant agreement in aspiration with thins between FEES and MBS. However, finding aspiration with thins was more common during MBS than during FEES. There were no differences in swallow evaluation findings between the age groups. Symptoms of type I laryngeal clefts may differ by age. However, there was no impact of age on the safety and efficacy of surgical intervention.

Goday P, Huh SY, Silverman A, Lukens CT, Dodrill P, Cohen SS, Delaney AL, Feuling MB, Noel RJ, Gisel E, Kenzer A, Kessler DB, Camargo OK, Browne J, Phalen JA. Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. J Pediatr Gastroenterol Nutr. 2018 Oct 24.

Pediatric feeding disorders lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of four closely-related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). However, previous diagnostic paradigms have typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF), a unifying diagnostic term is proposed: “Pediatric Feeding Disorder” (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.

Esteban-Figuerola P, Canals J, Fernández-Cao JC, Arija Val V. Differences in food consumption and nutritional intake between children with autism spectrum disorders and typically developing children: A meta-analysis. Autism. 2018 Oct 21:1362361318794179.

Children with autism spectrum disorders show higher food selectivity, which restricts consumption of some foods and may cause nutritional deficiencies. The aims of this meta-analysis are to determine the overall differences in nutritional intake and food consumption between children with autism spectrum disorder and control (typical development) children, as well as determine the extent to which the nutritional intake and food consumption of autistic children comply with the dietary recommendations. Children with autism spectrum disorder consume less protein, calcium, phosphorus, selenium, vitamin D, thiamine, riboflavin and vitamin B12 and more polyunsaturated fat acid and vitamin E than controls. Autistic children also consume less omega-3 and more fruit and vegetables than control children; however, these results must be considered with care due to the low number of studies included in the analysis and the high heterogeneity. The results also suggest a lower intake of calcium, vitamin D and dairy and a higher intake of fruit, vegetables, protein, phosphorus, selenium, thiamine, riboflavin and vitamin B12 than recommended.

Wallace GL, Llewellyn C, Fildes A, Ronald A. Autism spectrum disorder and food neophobia: clinical and subclinical links. Am J Clin Nutr. 2018 Oct 1;108(4):701-707.

Autism spectrum disorder (ASD) has been linked with eating- and feeding-related atypicalities, including food neophobia (FN) (refusal to try unfamiliar foods), since its earliest descriptions. Children with ASD were rated as more food neophobic than their same-age non-ASD peers, and there were subclinical associations between FN and ASD traits (social, communication, and restricted/repetitive behavior) in this community-based sample of children. Moreover, whereas FN alone predicted lower BMI, the interaction of FN and ASD traits predicted higher BMI, suggesting that elevated ASD traits in combination with FN exert opposing influences on weight compared with FN alone. These findings implicate clinical and subclinical connections between ASD traits and feeding behaviors that could affect health outcomes and therefore should be further explored in future studies of shared etiology and intervention strategy.

Chiatto F, Coletta R, Aversano A, Warburton T, Forsythe L, Morabito A. Messy Play Therapy in the Treatment of Food Aversion in a Patient With Intestinal Failure: Our Experience. JPEN J Parenter Enteral Nutr. 2018 Sep 25.

Food aversion (FA) is an eating behavior where children refuse solid or fluid intake. FA can compromise the weaning off parenteral nutrition (PN) in children with intestinal failure (IF), reducing their quality of life (QoL). Around 25% of children with IF experience FA, but few data are available on interventions to get over FA. Messy play therapy (MPT) uses sensory activities to provide another meaningful avenue for learning in children by creating a fun way to experience new textures. This study aims to assess the efficacy of MPT in FA.  MPT was started at 9 months with an enrolling time within the program of 10.11 months. MPT was ended after 19.5 months, and all patients achieved tolerance to oral diet. Significant improvement in savory, sweet, and mixed texture of food intake was reported. Better QoL and mealtimes with family were reported at median follow-up of 39 (24-56) months. MPT seems to be a positive intervention to overcome FA. In our experience, the children have gone from not tolerating any intake to tolerating an oral diet, which means enjoying their mealtimes. Further studies are needed to evaluate the effectiveness of MPT in a larger scale of patients.