Sun RW, Bonilla-Velez J, Pesek RD, Johnson AB, Cleves MA, Richter GT.
Laryngoscope. 2017 Sep 2. doi: 10.1002/lary.26838. PMID: 28865084
To delineate clinical characteristics and treatment outcomes of eosinophilic esophagitis (EoE) in the youngest of children. A 7-year retrospective chart review of children with clinicopathologic diagnosis of EoE was performed with specific analysis of patients under 5 years old. EoE was defined as the presence of symptoms of esophageal dysfunction with pathologically proven eosinophilic inflammation (≥15 eosinophils per high-power field [EOS/HPF]) unresponsive to reflux therapy. Patient parameters and clinical results were systematically reviewed.
- This subgroup presented with reflux symptoms (90.1%), vomiting (86.2%), diarrhea (55.3%), liquid dysphagia (52.0%), and constipation (50.0%), whereas food impaction (1.6%) was rare.
- Liquid dysphagia was present at all ages but significantly more common in younger children.
- The most common food and environmental allergens were egg whites, cow’s milk, peanuts, animal dander, and weed pollen. Patients were managed with antireflux medication (100%), elimination diet (83.5%), and steroid medication (68.5%).
- After treatment, 86% of parents reported symptom improvement. Mean reduction of EOS in pos-treatment biopsy was 33.5 EOS/HPF (P < .0001), and 67 patients showed histologic resolution of EoE.
- Approximately one-quarter of children with EoE present under 5 years of age with multiple esophageal symptoms, comorbidities, and allergen-sensitization profiles. These patients demonstrate substantial clinicohistologic improvement following therapy.
Svystun O, Johannsen W, Persad R, Turner JM, Majaesic C, El-Hakim H.
Int J Pediatr Otorhinolaryngol. 2017 Aug;99:54-59. doi: 10.1016/j.ijporl.2017.05.024. Epub 2017 May 30. PMID: 28688566
Whereas the literature is replete with reports on complex children with dysphagia (DP), the parameters characterizing non-neurologically impaired (NNI) children have been underreported. We set to characterize a consecutive cohort of NNI children, their management, and outcomes. Children (<18 years old) attending a tertiary multidisciplinary swallowing clinic were eligible. Primary outcomes included demographics, co-morbidities, presentations, McGill score, swallowing and airway abnormalities (and their predictors). Secondary outcomes were interventions and management response. Significant clinical presentations included recurrent pneumonias (20), cyanotic spells (14) and life-threatening events (10). Swallowing assessments revealed laryngeal penetration (67), aspiration (25). Other investigations included overnight oximetry (77), airway (70), and gastrointestinal endoscopy (24); revealing laryngomalacia (29), laryngeal mobility disorder (8), and subglottic stenosis (8). Non-surgical interventions involved oral diet modifications (85) and enteral nutrition (15). Surgical interventions included supraglottoplasties (18), endoscopic laryngeal cleft repair (14), and injection (19). 119 patients received intervention and at last follow-up 94 had improved. Of those treated 116 were on an unmodified oral diet, and 24 on a modified diet. ALTE and snoring predicted airway abnormalities, recurrent pneumonia predicted swallowing abnormalities, and age and airway lesions predicted the McGill score.
Mourão LF, Friel KM, Sheppard JJ, Kuo HC, Luchesi KF, Gordon AM, Malandraki GA. Dysphagia. 2017 Jun 8. doi: 10.1007/s00455-017-9816-0. PMID: 28597327
The purpose of this study is to determine the relationship between the structural integrity of the corpus callosum (CC) and clinical feeding/swallowing performance in children with unilateral spastic cerebral palsy (USCP). Twenty children with USCP, were assessed via the Dysphagia Disorder Survey (DDS) and diffusion tensor imaging. Children were grouped into left hemisphere lesion and right hemisphere lesion groups. DTI variables analyzed for three CC regions (anterior, middle, posterior) were: fractional anisotropy (FA), radial diffusivity (RD), mean diffusivity (MD), and fibers count. Children with RHL presented with higher clinical dysphagia severity. Six of seven children with RHL had lesions affecting periventricular/subcortical areas, and 8/13 children with LHL had lesions affecting the sensorimotor cortex. In the LHL group, as FA and fiber count of the anterior CC decreased and RD increased (all indicating reduced CC structural integrity), signs of dysphagia increased. Reduced fiber count in the middle and posterior CC was also significantly associated with increased DDS scores. For the RHL group no significant correlations were observed. We provide preliminary evidence that corpus callosum integrity correlates with feeding/swallowing performance in children with USCP, especially when cortical sensorimotor areas of the left hemisphere are impacted. In this sample, CC integrity appeared to enable interhemispheric cortical plasticity for swallowing, but was not as critical when intrahemispheric connections were disrupted, as seen in the RHL group.
Gosa MM, Carden HT, Jacks CC, Threadgill AY, Sidlovsky TC.
J Pediatr Rehabil Med. 2017 May 19;10(2):107-136. doi: 10.3233/PRM-170436. PMID: 28582883
A rise in pediatric patients with swallowing and feeding problems has resulted in increased interest in multidisciplinary treatments to address these issues. This evidence based systematic review (EBSR) examined the published evidence for the use of common strategies used by clinicians across disciplines to treat pediatric swallowing and feeding problems. A systematic search of 10 electronic databases was completed to identify relevant, peer reviewed literature published in English prior to December 2015 reporting original data that addressed at least one of the five identified clinical questions. Sixty-one studies of varying methodological quality were included. The majority of the included studies focused on the use of behavioral therapies to remediate swallowing and feeding disorders in children and reported mixed findings across all of the targeted outcomes. There is insufficient quantity of evidence to determine the effects of oral motor, sensory, and pharmaceutical therapies on functional feeding outcomes in pediatric populations. A larger body of phase 1 evidence is available that establishes the efficacy of behavioral strategies to treat some swallowing and feeding difficulties in small cohort and single subject studies. This analysis identified limited high quality (phase 4) research articles that establish the efficacy and benefit of joint nutrition and behavior intervention programs and systematic desensitization and operant conditioning behavioral therapy approaches to improve functional feeding and swallowing outcomes in children.
van den Engel-Hoek L, Harding C, van Gerven M, Cockerill H.
J Pediatr Rehabil Med. 2017 May 16;10(2):95-105. doi: 10.3233/PRM-170435. PMID: 28582882
Children with neurological disabilities frequently have problems with feeding and swallowing. Such problems have a significant impact on the health and well-being of these children and their families. The primary aims in the rehabilitation of pediatric feeding and swallowing disorders are focused on supporting growth, nutrition and hydration, the development of feeding activities, and ensuring safe swallowing with the aim of preventing choking and aspiration pneumonia. Pediatric feeding and swallowing disorders can be divided into four groups: transient, developmental, chronic or progressive.This article provides an overview of the available literature about the rehabilitation of feeding and swallowing disorders in infants and children. Principles of motor control, motor learning and neuroplasticity are discussed for the four groups of children with feeding and swallowing disorders.
Serel Arslan S, Demir N, Karaduman AA, Belafsky PC.
Disabil Rehabil. 2017 May 5:1-5. doi: 10.1080/09638288.2017.1323235. PMID: 28475381
The Pediatric Eating Assessment Tool was shown to be a valid and reliable tool to determine penetration/aspiration risk in children. Implications for rehabilitation The pediatric eating assessment tool: a new dyphagia-specific outcome survey for children. The Pediatric Version of the Eating Assessment Tool is a dysphagia specific, parent report outcome instrument to determine penetration/aspiration risk in children. The Pediatric Version of the Eating Assessment Tool has good internal consistency, test-retest reliability and criterion-based validity. The Pediatric Version of the Eating Assessment Tool may be utilized as a clinical instrument to assess the need for further instrumental evaluation of swallowing function in children.
Krummrich P, Kline B, Krival K, Rubin M.
Pediatr Pulmonol. 2017 Apr 24. doi: 10.1002/ppul.23700. PMID: 28436603
Oropharyngeal dysphagia occurs in children without known neurological disorders, increasing their risk for respiratory problems and inadequate intake. Clinicians may recommend thickening nutritive fluids; however, there is little research regarding the impact of thickening nutritive fluids on clinical outcomes in children. We used a parental reporting tool to determine whether parents identified changes in signs of dysphagia or volume of intake when thickened fluids were incorporated into an individualized feeding program for dysphagic children without known neurological problems. Fifty-five children diagnosed with dysphagia, for whom thickened fluids had been recommended per radiographic and clinical exam, qualified for the study. Compared to baseline, parents reported significant decreases in the frequency of apnea, congestion, coughing/choking with drinking, resistance to feeding, vomiting during feeding, and wheezing. For those children whose parents initially reported inadequate levels of intake, there was a significant increase in the rated adequacy of liquid intake, as well as a significant increase in the estimated volume per feeding. These results provide information for clinicians and physicians to incorporate when considering the use of thickened fluids in the dysphagia management of children without a known neurological diagnosis.
Arvedson JC, Lefton-Greif MA.
Semin Speech Lang. 2017 Apr;38(2):135-146. doi: 10.1055/s-0037-1599111. Epub 2017 Mar 21. PMID: 28324903
Speech-language pathologists (SLPs) have fulfilled primary roles in the evaluation and management of children with feeding/swallowing disorders for more than five decades. The increased incidence and prevalence of newborns, infants, and children with feeding and swallowing disorders has resulted in increased use of instrumental swallowing evaluations. The videofluoroscopic swallow study and fiberoptic endoscopic evaluation of swallowing are the two most commonly used swallowing assessments by SLPs, with ultrasound used less frequently. This article focuses on updates over the past decade in the procedures and utility of instrumental assessments of swallowing function, and identifies future directions that may enable us to meet the needs of the children who are in our care to attain functional outcomes.
Tracy LF, Gomez G, Overton LJ, McClain WG.
Int J Pediatr Otorhinolaryngol. 2017 Sep;100:223-224. doi: 10.1016/j.ijporl.2017.07.013. Epub 2017 Jul 14. PMID: 28802376
Lingual and labial frenulectomy are commonly performed as an outpatient procedure, either in an office setting or under general anesthesia. Frenulectomy is generally regarded by both otolaryngologists and dentists as a straightforward and low-risk procedure with limited evidence-based indications and similarly few contraindications. We describe two cases of hypovolemic shock occurring after outpatient frenulectomy requiring emergent interventions of cardiopulmonary resuscitation and blood transfusion. These rare, but life-threatening outcomes warrant recognition as potential complications for the presumed benign labial and lingual frenulectomy. We additionally briefly review indications for upper labial and lingual frenulectomy.
Kumar RK, Nayana Prabha PC, Kumar P, Patterson R, Nagar N.
Indian Pediatr. 2017 Feb 15;54(2):125-127. PMID: 28285282
To study the prevalence, clinical presentation and management of infants with ankyloglossia. Of the 25786 babies born during the assessment period (2007-2015), 134 (0.52%) had ankyloglossia. Sixty-four (47.7%) infants who presented with breastfeeding difficulties were diagnosed significantly earlier than the asymptomatic group (P<0.05). Of the symptomatic group, 85.9% underwent frenotomy with satisfactory results. Seventy asymptomatic infants were managed conservatively with counselling. Frenotomy seems to be a safe and effective procedure in infants with symptomatic ankyloglossia.
Shavit I, Peri-Front Y, Rosen-Walther A, Grunau RE, Neuman G, Nachmani O, Koren G, Aizenbud D.
Pain Med. 2017 Feb 1;18(2):356-362. doi: 10.1093/pm/pnw097.
To examine the comparative effectiveness of two topical anesthetics in controlling the pain associated with tongue-tie release (frenotomy) in young infants. Forty-two infants who were referred for frenotomy were randomly allocated to receive the topical anesthetic gel 2% tetracaine or 20% benzocaine applied prior to frenotomy. Frenotomies were videotaped. The primary outcome measure was the Neonatal Facial Coding System (NFCS) score. Secondary outcome measures included cry duration and a visual analog scale (VAS) assessed by the parents. These topical anesthetics seem ineffective in controlling the pain associated with frenotomy. Clinicians should continue to search for an effective treatment for this procedure.
Walsh J, Links A, Boss E, Tunkel D. Otolaryngol Head Neck Surg. 2017 Apr;156(4):735-740. doi: 10.1177/0194599817690135. Epub 2017 Feb 7. PMID: 28168891
Objectives (1) Describe trends in the diagnosis of ankyloglossia and the use of lingual frenotomy and (2) analyze patient- and hospital-level factors as compared with the total pediatric discharge population. We reviewed available data from 1997 to 2012 using the Kids’ Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. All weighted pediatric discharges with ankyloglossia, newborn feeding difficulty, or lingual frenotomy were analyzed for variables of sex, payer, zip code median income, hospital ownership, location/teaching status, bed size, region, and children’s hospital status. Diagnosis of ankyloglossia increased each year of publication (every third year)-with 3934, 5430, 7785, 11,397, 19,459, and 32,837 children, respectively, from 1997 to 2012-with the largest increase in the last 6 years. Similarly, frenotomy increased with 1279, 1633, 2538, 3988, 6900, and 12,406 procedures. Compared with the total discharge population, children with ankyloglossia or frenotomy were more often male (63.6% ankyloglossia, 65.3% frenotomy vs 51.2%), privately insured (60.1%, 62.1% vs 43.6%), from a higher median-income zip code (78.1%, 78.2% vs 68.6%), and in Midwest region (29.3%, 32.3% vs 21.7%). Conclusion These pilot data show increases in diagnoses of ankyloglossia and use of frenotomy. There is a preponderance of children who are male, privately insured, or Midwest residents being diagnosed and treated for ankyloglossia. This broad variation may reflect local practice patterns or imply cultural and socioeconomic bias.
Yoon A, Zaghi S, Weitzman R, Ha S, Law CS, Guilleminault C, Liu SY.
Sleep Breath. 2017 Jan 17. doi: 10.1007/s11325-016-1452-7. [Epub ahead of print] PMID: 28097623
Alterations of the lingual frenulum may contribute to oromyofacial dysfunction, speech and swallowing impediments, underdevelopment of the maxillofacial skeleton, and even predispose to sleep breathing disorder. This study aims to assess the utility of existing instruments for evaluation of restricted tongue mobility, describe normal and abnormal ranges of tongue mobility, and provide evidence in support of a reliable and efficient measure of tongue mobility. We propose the use of tongue range of motion ratio as an initial screening tool to assess for restrictions in tongue mobility. “Functional” ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50-80%, grade 3 < 50%, grade 4 < 25%.
Bin-Nun A, Kasirer YM, Mimouni FB. Breastfeed Med. 2017 Aug 8. doi: 10.1089/bfm.2017.0044. PMID:28787179
To study trends in yearly number of tongue tie or ankyloglossia publications.
Medline search engine was used to determine the yearly number of published consensus statements from 1949 to 2016. The total number of yearly published articles increased in a cubic fashion over time (0-7 per year from 1949 to 1989, and up to 27-44 in the last 5 years). In terms of strength of evidence hierarchy, most articles belonged to low hierarchy categories (case reports 37.9%, reviews 15.4%, and editorials/opinions 13.4%), with only 8 RCTs and 10 SRs (all of them published during the last 10 years of the study period). The yearly number of tongue tie or ankyloglossia-related articles has increased dramatically in past few years. Most articles bring little evidence, but the past few years have witnessed publication of few RCTs and SRs. If this trend continues, much more solid evidence should accumulate about diagnosis and management of tongue tie, as it relates to breastfeeding and other outcomes.
Douglas P. J Hum Lact. 2017 Aug;33(3):519-523. doi 10.1177/0890334417706694.
By performing an in-depth analysis of one high profile example, this article aims to help breastfeeding support professionals understand the methodological flaws that characterize recent studies claiming to show the efficacy of frenotomy for the diagnoses of posterior tongue-tie and upper lip-tie. The example study does not address definitional confusion or control for the effects of the passage of time. It does not consider the effects of caring attention, validation, and lactation consultant support. It also does not consider the extensive research over the past three decades that has established that reflux in the first 6 months of life is benign, even though increased reflux frequency may correlate with unsettled infant behavior. The study authors relied on the hypothesis that reflux is caused by excessive air swallowing in infants with poor latch due to posterior tongue-tie and upper lip-tie, which lacks credible physiological mechanisms or supporting evidence. The authors’ claim that conducting a randomized controlled trial to investigate the efficacy of frenotomy would be unethical contradicts the basic principles of good science. This article argues that our breastfeeding women and their babies deserve the most rigorous scientific methods available, and acknowledgment of the biases inherent in less rigorous research, if we are to make appropriate decisions concerning intervention with frenotomy and to prevent unnecessary oral surgery.
Minor G, Ochoa JB, Storm H, Periman S.
Glob Pediatr Health. 2016 Dec 21;3:2333794X16681887. doi: 10.1177/2333794X16681887. eCollection 2016. PMID: 28229094
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 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%). Switching to a 100% whey, peptide-based formula improved symptoms of feeding intolerance in the majority of these developmentally delayed children.
Harb T, Frederiksen N, Hill RJ.
Infant Behav Dev. 2017 Aug;48(Pt B):105-113. doi: 10.1016/j.infbeh.2017.05.003. Epub 2017 May 26. PMID: 28554786Abstract
To determine the association between sensory functioning, sleep, cry/fuss, and feeding behaviors of infants with colic younger than 4 months of age.
Dunn’s Infant/Toddler Sensory Profile™ and a modified Barr Baby Day Diary© were used to assess 44 breastfed infants with colic under four months of age. Colic was defined according to Wessel’s criteria. Very limited associations between infant behaviors and sensory functioning were demonstrated, suggesting that sensory functioning may not be a significant factor in the multifactorial nature of infant colic. Further well-designed studies using validated tools for infants with colic are required to determine whether associations between infant behaviors and sensory functioning exist.
Al-Talib T, Koroluk LD, Vann WF Jr, Phillips C.
J Dent Child (Chic). 2017 Jan 15;84(1):30-34. PMID: 28387187
Sleep-disordered breathing (SDB) is not uncommon in children. The purposes of this study were to investigate the relationship between non-nutritive sucking (NNS) and the risk of SDB in children as well as assess the effect of infant feeding practices on SDB. There was no statistically significant difference between low- and high-risk children for a history of NNS. A statistically significant difference was found for breastfed versus bottlefed children, with breastfeeding having a protective effect for SDB. NNS had no effect on SDB, while breastfeeding reduced the risk substantially.
Sensory profile in infants and toddlers with behavioral insomnia and/or feeding disorders.
Sleep and feeding difficulties are two common disorders in early childhood. It has been shown that feeding difficulties are more common among children with sleep disorders and vice versa. Since a child’s characteristics play a substantial role in these two conditions, we aimed to investigate the sensory profile of infants and toddlers with behavioral insomnia (BI) or feeding disorders (FDs) in comparison with healthy age-matched controls. There were considerable differences in sensory processing, as reported by parents between children with BI and those with FDs compared to healthy controls, most often in the direction of the ‘hypersensitive’ profile. These differences may underlie the development and partially explain the coexistence of the two disorders. Sensory profile may be a target of intervention as part of the management of sleep and feeding disorders in early childhood.
Curr Gastroenterol Rep. 2017 Jul;19(7):33. doi: 10.1007/s11894-017-0569-6.
Improved Outcomes with an Outpatient Multidisciplinary Intensive Feeding Therapy Program Compared with Weekly Feeding Therapy to Reduce Enteral Tube Feeding Dependence in Medically Complex Young Children.
The prevalence of feeding disorders in medically complex children is estimated to be as high as 80%. Enteral tube nutrition (ETN) is commonly used for nutritional support in children with feeding disorders. Adverse consequences of ETN include medical complications, psychosocial problems, and higher healthcare costs. We used a retrospective cohort controlled study design to compare outcomes of our outpatient multidisciplinary intensive feeding therapy (IFT) program to our traditional therapy (TT) of single-discipline, once weekly feeding therapy to reduce ETN dependence in medically complex young children. Children in the IFT cohort experienced a median reduction in ETN dependence of 49% compared with a median reduction of 0% for TT. Almost half of the IFT cohort no longer required ETN by the conclusion of the 5-week program. Medically complex young children (median age 26 months) successfully reduce or eliminate ETN in an outpatient multidisciplinary intensive feeding program.
Sharp WG, Allen AG, Stubbs KH, Criado KK, Sanders R, McCracken CE, Parsons RG, Scahill L, Gourley SL. Transl Psychiatry. 2017 Jun 20;7(6):e1157. doi: 10.1038/tp.2017.126. PMID: 28632204
Pediatric feeding disorders affect up to 5% of children, causing severe food intake problems that can result in serious medical and developmental outcomes. Behavioral intervention (BI) is effective in extinguishing feeding aversions, and also expert-dependent, time/labor-intensive and not well understood at a neurobiological level. Here we first conducted a double-blind, placebo-controlled trial comparing BI with BI plus d-cycloserine (DCS). DCS is a partial N-methyl-d-aspartate (NMDA) receptor agonist shown to augment extinction therapies in multiple anxiety disorders. We examined whether DCS enhanced extinction of feeding aversion in 15 children with avoidant/restrictive food intake disorder (ages 20-58 months). After five treatment days, BI improved feeding by 37%. By contrast, BI+DCS improved feeding by 76%. To gain insight into possible mechanisms of successful intervention, we next tested the neurobiological consequences of DCS in a murine model of feeding aversion and avoidance. In mice with conditioned food aversion, DCS enhanced avoidance extinction across a broad dose range. Confocal fluorescence microscopy and three-dimensional neuronal reconstruction indicated that DCS enlarged dendritic spine heads-the primary sites of excitatory plasticity in the brain-within the orbitofrontal prefrontal cortex, a sensory-cognition integration hub. DCS also increased phosphorylation of the plasticity-associated extracellular signal-regulated kinase 1/2. In summary, DCS successfully augments the extinction of food aversion in children and mice, an effect that may involve plasticity in the orbitofrontal cortex. These results warrant a larger-scale efficacy study of DCS for the treatment of pediatric feeding disorders and further investigations of neural mechanisms.
Morris N, Knight RM, Bruni T, Sayers L, Drayton A.
Child Adolesc Psychiatr Clin N Am. 2017 Jul;26(3):571-586. doi: 10.1016/j.chc.2017.02.011. Review. PMID: 28577610
Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders.