On the research front…

 

      Summaries of new research!

 

Simons JP, Greenberg LL, Mehta DK, Fabio A, Maguire RC1, Mandell DL. Laryngomalacia and swallowing function in children. Laryngoscope. 2016 Feb;126(2):478-84. doi: 10.1002/lary.25440. Epub 2015 Jul 7.

Swallowing dysfunction is common in children with laryngomalacia regardless of disease severity or other medical comorbidities. Swallowing function was assessed by symptoms, clinical swallowing evaluations (CSE) performed by speech pathologists, modified barium swallow (MBS) studies, and fiberoptic endoscopic evaluations of swallowing (FEES). Swallowing studies are frequently abnormal in laryngomalacia patients presenting both with and without subjective symptoms of dysphagia. Dysphagia assessment should be considered as part of the evaluation of infants with laryngomalacia. Patients with greater severity were more likely to have failure to thrive and GERD was more likely to be present in patients with moderate and severe laryngomalacia than in patients with mild disease.

 

Edwards, L., DeMeo, S., Hornik, C.D., Cotten, C.M., Smith, P.B., Pizoli, C., Hauer, J.M., and Bidegain, M. Gabapentin Use in the Neonatal Intensive Care Unit. J Pediatr. 2016 Feb;169:310-2. doi: 10.1016/j.jpeds.2015.10.013. Epub 2015 Nov 11.

The objective of this study was to present a case series of neurologically impaired term and preterm infants who were treated with gabapentin for visceral hyperalgesia, and include descriptions of clinical responses and adverse events related to this medication. Gabapentin was used for the treatment of term and preterm infants with suspected visceral hyperalgesia caused by a variety of neurologic and gastrointestinal morbidities. Improved feeding tolerance and decreased irritability were seen, as well as decreased usage of opioids and benzodiazepines. Adverse events occurred with abrupt discontinuation of this medication.

 

Arslan, S., Demir, N., Dolgun, B., Karaduman, A. Development of a new instrument for determining the level of chewing function in children. J Oral Rehabil. 2016 Apr 4. doi: 10.1111/joor.12399. [Epub ahead of print]

This study aimed to develop a chewing performance scale that classifies chewing from normal to severely impaired and to investigate its validity and reliability. The study included the developmental phase and reported the content, structural, criterion validity, interobserver and intra-observer reliability of the chewing performance scale, which was called the Karaduman Chewing Performance Scale (KCPS). The KCPS is a valid, reliable, quick and clinically easy-to-use functional instrument for determining the level of chewing function in children. The difference in the KCPS compared with all of the other methods is that it can be used to determine chewing function level. Thus, the KCPS, which classifies chewing on an ordinal scale with five levels based on the sequence of functional movements during chewing, was developed.

 

Shubert, T.R., Sitaram, S., and Jadcherla, S.R. Effects of pacifier and taste on swallowing, esophageal motility, transit, and respiratory rhythm in human neonates. Neurogastroenterol Motil. 2016 Apr;28(4):532-42. doi: 10.1111/nmo.12748. Epub 2016 Jan 4.

Pacifier use is widely prevalent globally despite hygienic concerns and uncertain mechanistic effects on swallowing or airway safety. The effects of pacifier and taste interventions on pharyngo-esophageal motility, bolus transit, and respiratory rhythms were investigated by determining the upper esophageal sphincter (UES), esophageal body, esophagogastric junction (EGJ) motor patterns and deglutition apnea, respiratory rhythm disturbances, and esophageal bolus clearance. Results indicated oral stimulus with pacifier or taste interventions decreases UES and EGJ basal pressure, but has no effects on pharyngo-esophageal motility, airway interactions, or esophageal bolus transit. A decrease in central parasympathetic-cholinergic excitatory drive is likely responsible for the basal effects.

 

Benninga,M.A., Nurko, S., Faure, C., Hyman,P.E., St. James Roberts, I., and Schechter, N.L. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016;150:1443–1455

This article provides a description, assessment, and analysis of functional gastrointestinal intestinal disorders (FGID) that affect the neonate/toddler age group (infant regurgitation, infant rumination syndrome, cyclic vomiting syndrome, infant colic, functional diarrhea, infant dyschezia, functional constipation ). Including the age of presentation, a summary of the prevalence , as well as their pathophysiology and treatment. Authors also review the developmental neurobiology of the pain response. In the past decade, new insights have been gained about the different functional gastrointestinal intestinal disorders in these age groups.

 

Madhoun, L.L, Siler-Wurst, K.K., Sitaram, S., Jadcherla, S.R.Feed-thickening practices in NICUs in the current era: Variability in prescription and implementation patterns. Journal of Neonatal Nursing (2015) 21, 255-262 .

Researchers sought to determine the prescriptions and practices currently being used for thicken feeds in the NICU. No standards currently exist regarding feed-thickening prescriptions and practices and this results in variable and potentially unsafe feeding approaches. Survey results revealed the majority of providers use thickened feeds for concerns of dysphagia or GERD with some reporting they thicken expressed breast milk. Our study findings can simply be summarized as follows: 1) there is a lack of well-defined process to achieve a given formula consistency, and 2) there is variability in the knowledge and practice attitudes of feeding providers. Due to the lack of standardization found in regards to recipes and process of formulation, short- and long-term problems may arise. Further research and standardization are required to develop thickening guidelines.

 

Reynolds, J., MS, Carroll, S., Sturdivant, C. (2016). Fiberoptic Endoscopic Evaluation of Swallowing, A Multidisciplinary Alternative for Assessment of Infants With Dysphagia in the Neonatal Intensive Care Unit. Advances in Neonatal Care • Vol. 16, No. 1 • pp. 37-43.

The standard procedure to assess an infant in the neonatal intensive care unit (NICU) who is suspected of aspirating on oral feedings is a videofluoroscopic swallowing study (VFSS). However, concerns of using the VFSS include radiation exposure, transport to radiology, usage of barium, limited positioning options, and cost. An alternative approach is fiberoptic endoscopic evaluation of swallowing (FEES), which uses a flexible endoscope passed transnasally into the pharynx to assess anatomy, movement/sensation of structures, swallow function, and response to therapeutic interventions. Fiberoptic endoscopic evaluation of swallowing has been established as a valid tool for evaluating dysphagia and utilized as an alternative or supplement to the VFSS in both adults and children. This article provides an overview of the current challenges in the NICU with assessing aspiration and introduces a multidisciplinary FEES program for bottle and breastfeeding. FEES is a safe alternative to the VFSS. It can be utilized at the infant’s bedside in a NICU for the diagnosis and treatment of swallowing disorders by allowing the clinician the ability to replicate a more accurate feeding experience, therefore, determining a safe feeding plan. Competency and training are essential to establishing a multidisciplinary FEES program in the NICU. The NICU feeding team successfully accomplished the design and implementation of a NICU FEES pro- gram for bottle-feeding and breastfeeding on the basis of 5 essential program components: equipment, education, competency, protocol, and procedure. Since program implementation, we have successively evaluated more than 50 infants utilizing FEES during bottle-feeding, with some mothers opting for evaluation during breastfeeding. The ability to evaluate feeding in the NICU environment and assess the entire feeding experience with parents as partners is a huge benefit. The use of FEES in our NICU has proven to be a safe and effective tool to evaluate swallow function and view anatomical structures in stable infants for both bottle- and breastfeeding, despite the lack of research in this area.

 

Micali, N., Rask, C.U., Olsen, E.M., Skovgaard, A.M. (2016) Early Predictors of Childhood Restrictive Eating: A Population-Based Study. J Dev Behav Pediatr. May;37(4):314-21. doi: 10.1097/DBP.0000000000000268.PMID: 26890561

Childhood eating problems, in particular restrictive eating, are common. Investigators looked at early risk factors for restrictive eating across children in a population-based sample of 1,327 Danish 5 to 7 year olds. Results indicated that feeding problems and poor growth in the first year of life show high continuity into childhood restrictive eating. Maternal psychopathology is an important risk factor. These findings confirm that early signs of poor eating and growth are persistent and might be useful in predicting eating problems in mid-childhood.

 

Adil, E., Al Shemari, H., Kacprowicz, A., Perez, J., Larson, K., Hernandez, K. Kawai, K., Cowenhoven, J., Urion, D., Rahbar, R. Evaluation and Management of Chronic Aspiration in Children With Normal Upper Airway Anatomy.JAMA Otolaryngol Head Neck Surg. 2015 Nov;141(11):1006-11. doi: 10.1001/jamaoto.2015.2266. PMID: 26501239

Chronic airway aspiration is a challenging problem for physicians and caregivers and can cause significant pulmonary morbidity in pediatric patients. In this retrospective medical record review, authors studied pediatric patients for airway disorders at a pediatric tertiary referral center who were diagnosed as having aspiration on modified barium swallow study during a 10-year period and had a direct laryngoscopy and bronchoscopy performed. Demographics, comorbidities, management, and swallowing outcomes were analyzed. Forty-six patients met the inclusion criteria. Patients were subdivided according to the consistency of the fluids that they aspirated: 25 (54%) aspirated thin liquids, 15 (33%) aspirated thickened liquids, and 6 (13%) aspirated purees. Of these patients, 21 (84%), 12 (80%), and 3 (50%) had resolution of their swallowing dysfunction with feeding and swallowing therapy, respectively. A total of 3 patients (7%) required a tracheostomy for their refractory aspiration. We recommend feeding and swallowing therapy for children with normal upper airway anatomy. Brain magnetic resonance imaging should be considered for patients with suspected brainstem or posterior fossa lesion based on neurologic examination findings. Most patients who aspirate thin and thickened liquids will have resolution of their swallowing dysfunction within 1 year of beginning therapy.

 

Barnhill, K., Tami, A., Schutte, C., Hewitson, L., and Olive, M. Targeted Nutritional and Behavioral Feeding Intervention for a Child with Autism Spectrum Disorder. Case Rep Psychiatry. 2016; 2016: 1420549.

A variety of feeding issues and concerns, including food aversion, food selectivity, and complete food refusal, are not uncommon among children with autism spectrum disorder (ASD). Other underlying issues may include food allergies, gastrointestinal issues, oral motor issues, and swallowing disorders. The refusal to consume particular foods coupled with the inability to tolerate, digest, and absorb these foods can compromise an individual’s overall nutrition status. This case report is the first to document combined medical, behavioral, and nutritional intervention for a toddler with ASD and comorbid feeding disorder. In conclusion, this study highlights the importance of a multidisciplinary approach to address pediatric feeding problems. Parents should be informed of the effectiveness of the behavioral approach and behavioral providers should be highlighted as a source of appropriate therapy for these types of concerns. Additionally, nutritional, medical, and oral motor assessments are critical components of a feeding program, and the skills and expertise of therapists should be utilized in the development and implementation of pediatric feeding programs. Finally, comprehensive multidisciplinary programs should consider the inclusion of counseling services in order to address the stressors related to intensive feeding therapy.

 

Green, RJ., Samy, G., Miqdady, MS., Salah, M., Sleiman, R., Abdelrahman, HMA, Haddad, FA., Reda, MM, Lewis, H., Ekanem, E., and Vandenplas, Y. (2015). How to Improve Eating Behavior during Early Childhood. Pediatr Gastroenterol Hepatol Nutr. 2015 Mar; 18(1): 1–9.

Eating behavior disorder during early childhood is a common pediatric problem. Due lack of standardized terminology, authors suggest “an eating behavior which has consequences for family harmony and growth”. This purpose of this review is to clarify terminology of eating behavior problems during early childhood; including benign picky eating, limited diets, sensory food aversion, selective eating, food avoidance emotional disorder, pervasive refusal syndrome, tactile defensiveness, functional dysphagia, neophobia and toddler anorexia. This tool is proposed only to ease the clinical management for child care providers. Diagnostic criteria are set and management tools are suggested. The role of dietary counseling and, where necessary, behavioral therapy is clarified.

 

Powell, F., Farrow, C., Meyer, C., and Haycraft, E. (2016) The importance of mealtime structure for reducing child food fussiness . Maternal & Child Nutrition, pg 1-7.

The aim of this study was to explore how the structure of mealtimes within the family setting is related to children’s fussy eating behaviors. Seventy-five mothers of children aged between 2 and 4 years were observed during a typical mealtime at home. These children did not have feeding difficulty. The mealtimes were coded to rate mealtime structure and environment as well as the child’s eating behaviors (food refusal, difficulty to feed, eating speed, positive and negative vocalizations). Mealtime structure emerged as an important factor which significantly distinguished children with higher compared with lower levels of food fussiness. Children whose mothers ate with their child and ate the same food as their child were observed to refuse fewer foods and were easier to feed compared with children whose mothers did not. During mealtimes where no distractors were used (e.g. no TV, magazines or toys), or where children were allowed some input into food choice and portioning, children were also observed to demonstrate fewer fussy eating behaviors. Findings of this study suggest that it may be important for parents to strike a balance between structured mealtimes, where the family eats together and distractions are minimal, alongside allowing children some autonomy in terms of food choice and intake.