Feeding and swallowing dysfunction in genetic syndromes

Factors influencing gastrostomy tube feeding duration and nutrition outcomes in pediatric patients with Down syndrome: A descriptive cohort study

BACKGROUND

Feeding difficulty is widely recognized in patients with Down syndrome, and many patients require gastrostomy tube (G-tube) placement for nutrition. No reliable factors have been identified to predict the expected duration of G-tube feeds in patients with Down syndrome. This descriptive cohort study aimed to determine the factors affecting the duration of G-tube feeds. We also investigated change in body mass index (BMI) from G-tube placement to discontinuation.

METHODS

Medical records of patients with Down syndrome seen by a pediatric gastroenterologist at a tertiary care center between September 1986 and December 2021 were reviewed. Data collection included demographics, anthropometrics, comorbidities, and feeding route. Comparison was performed between patients who discontinued G-tube feeds and those who did not.

RESULTS

Two hundred twenty patients (45% female) were included. The median age at G-tube placement was 5 months (interquartile range [IQR]: 0.2-1.3 years). There were 113 (51%) patients who discontinued G-tube feeds, after a median duration of 31.6 months (IQR: 15.6-55.7 months). Tracheostomy was the only covariant associated with a longer duration of G-tube feeds (158 months vs 53 months; P = 0.002). Neither age at G-tube placement nor any comorbidities were associated with BMI status at discontinuation of G-tube.

CONCLUSION

In our cohort of patients with Down syndrome, age at placement of G-tube did not impact the duration of G-tube feeds. Most patients who had a G-tube placed were likely to require enteral feeds for at least 1 year. Those who had a tracheostomy needed their G-tube for a longer time.

Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion

Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429-1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team's experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children's Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.

The Approach to a Child with Dysmorphic Features: What the Pediatrician Should Know

The advancement of genetic knowledge and the discovery of an increasing number of genetic disorders has made the role of the geneticist progressively more complex and fundamental. However, most genetic disorders present during childhood; thus, their early recognition is a challenge for the pediatrician, who will be also involved in the follow-up of these children, often establishing a close relationship with them and their families and becoming a referral figure. In this review, we aim to provide the pediatrician with a general knowledge of the approach to treating a child with a genetic syndrome associated with dysmorphic features. We will discuss the red flags, the most common manifestations, the analytic collection of the family and personal medical history, and the signs that should alert the pediatrician during the physical examination. We will offer an overview of the physical malformations most commonly associated with genetic defects and the way to describe dysmorphic facial features. We will provide hints about some tools that can support the pediatrician in clinical practice and that also represent a useful educational resource, either online or through apps downloaded on a smartphone. Eventually, we will offer an overview of genetic testing, the ethical considerations, the consequences of incidental findings, and the main indications and limitations of the principal technologies.

From Bedside to Bench and Back: Advancing Our Understanding of the Pathophysiology of Cleft Palate and Implications for the Future

OBJECTIVE

To provide a comprehensive understanding of the pathophysiology of cleft palate (CP) and future perspectives.

DESIGN

Literature review.

SETTING

Setting varied across studies by level of care and geographical locations.

INTERVENTIONS

No interventions were performed.

MAIN OUTCOME MEASURE(S)

Primary outcome measures were to summarize our current understanding of palatogenesis in humans and animal models, the pathophysiology of CP, and potential future treatment modalities.

RESULTS

Animal research has provided considerable insight into the pathophysiology, molecular and cellular mechanisms of CP that have allowed for the development of novel treatment strategies. However, much work has yet to be done to connect our mouse model investigations and discoveries to CP in humans. The success of innovative strategies for tissue regeneration in mice provides promise for an exciting new avenue for improved and more targeted management of cleft care with precision medicine in patients. However, significant barriers to clinical translation remain. Among the most notable challenges include the differences in some aspects of palatogenesis and tissue repair between mice and humans, suggesting that potential therapies that have worked in animal models may not provide similar benefits to humans.

CONCLUSIONS

Increased translation of pathophysiological and tissue regeneration studies to clinical trials will bridge a wide gap in knowledge between animal models and human disease. By enhancing interaction between basic scientists and clinicians, and employing our animal model findings of disease mechanisms in concert with what we glean in the clinic, we can generate a more targeted and improved treatment algorithm for patients with CP.

Validation and cross-cultural adaptation of the Italian version of the paediatric eating assessment tool (I-PEDI-EAT-10) in genetic syndromes

BACKGROUND

The Pediatric Eating Assessment Tool (PEDI-EAT-10) is a reliable and valid tool for rapid identification of dysphagia in patients aged 18 months to 18 years.

AIMS

To translate and adapt the PEDI-EAT-10 into the Italian language and evaluate its validity and reliability.

METHODS & PROCEDURES

The translation and cross-cultural adaptation of the tool consisted of five stages: initial translation, synthesis of the translations, back translation, expert committee evaluation and test of the prefinal version. The internal consistency of the translated tool was analysed in a clinical group composed of 200 patients with special healthcare needs aged between 18 months and 18 years. They were consecutively enrolled at the Rare Disease Unit, Paediatrics Department, Fondazione Policlinico Agostino Gemelli-IRCCS, Rome. For test-retest reliability, 50 caregivers filled in the PEDI-EAT-10 questionnaire for a second time after a 2-week period. Construct validity was established by comparing data obtained from patients with data from healthy participants (n = 200). The study was approved by the local ethics committee.

OUTCOMES & RESULTS

Psychometric data obtained from patients (104 M; mean age = 8.08 ± 4.85 years; median age = 7 years) showed satisfactory internal consistency (Cronbach's α = 0.89) and test-retest reliability (Pearson r = 0.99; Spearman r = 0.96). A total of 30% of children were classified as having a high risk of penetration/aspiration. The Italian PEDI-EAT-10 mean total score of the clinical group was significantly different from that resulting from healthy participants.

CONCLUSIONS & IMPLICATIONS

The PEDI-EAT-10 was successfully translated into Italian, validated and found to be a reliable one-page rapid screening tool to identify dysphagia in children and adolescents with special needs.

WHAT THIS PAPER ADDS

What is already known on the subject The PEDI-EAT-10 is a valid and reliable quick discriminative paediatric tool for identifying penetration/aspiration risks. What this paper adds to the existing knowledge In the present study we successfully translated and adapted the PEDI-EAT-10 into the Italian language. What are the potential or actual clinical implications of this work? This translation and adaptation increase access to valid feeding and swallowing assessment for children of Italian-speaking families. In addition, the I-PEDI-EAT-10 can suggest further assessment of patients' swallowing abilities.

Prevalence of swallowing disorder in different dementia subtypes among older adults: a meta-analysis

BACKGROUND

Ageing process and abnormal protein accumulation in dementia damage neural pathways affecting the swallowing process and leading to swallowing disorder.

OBJECTIVE

To estimate the prevalence of swallowing disorder among older adults with different dementia subtypes.

METHODS

We conducted a systematic search across multiple databases, including PubMed, Embase, Scopus, Web of Science and OVID Medline. The meta-analysis employed R (version 4.0.2) and utilised a generalised linear mixed model with a random-effect approach to estimate the pooled prevalence of swallowing disorder among older adults, considering various dementia subtypes. The quality of included studies was assessed using Hoy's criteria. Heterogeneity was identified through Cochrane's Q and I2 statistics. To further explore heterogeneity, moderator analysis was performed to identify the contributing variables among the included studies.

RESULTS

Eighteen studies with 12,532 older adults with different dementia subtypes were enrolled in our meta-analysis. The pooled prevalence of swallowing disorder among older adults with dementia was 58%, with 46.5% for Alzheimer's dementia, 34.9% for Parkinson's dementia, 18.8% for vascular dementia, 16.3% for mixed dementia and 12.2% for Lewy body dementia. According to assessment tools, Alzheimer's dementia had the highest prevalence, with 58% in instrumental assessments and 39% in clinical assessments. Medical history, Alzheimer's dementia, moderate-to-severe Clinical Dementia Rating, delayed oral phase, delayed pharyngeal phase and poor tongue motility contributed to the heterogeneity of the included studies.

CONCLUSIONS

More than half of older adults with dementia demonstrate to have swallowing disorder. Our findings offer valuable insights to healthcare professionals for the identification of swallowing disorder in ageing population with dementia.

Parental Stress, Infant Feeding and Well-being in Families Affected by Cleft Lip and/or Cleft Palate: The Impact of Early Follow-up

OBJECTIVE

To document the impact of early follow-up by specialized cleft nurses (SCNs) provided to families affected by cleft lip and/or palate (CL/P) and the status of parental stress, infant feeding and well-being.

DESIGN

Prospective inclusion of a control group, which only received standard care, followed by an intervention group that also received early SCN follow-up.

SETTING

The cleft lip and palate team at Oslo University Hospital, Norway.

PARTICIPANTS

Seventy families (69 mothers and 57 fathers) distributed into an intervention group (n = 32) and a control group (n = 38).

INTERVENTION

SCNs provided a consultation at the maternity ward and a follow-up conversation by phone or face-to-face at scheduled times for six months.

OUTCOME MEASURES

Parental Stress Index (PSI), Perceived Stress Scale (PSS-14), feeding questionnaire, survey of infant diets, weight percentiles.

RESULTS

The mothers reported higher stress scores than the fathers, but in the control group only in the PSI parent domain at T2 and T3 (P = .007, P = .018). Infants in the intervention group used pacifiers less frequently than in the control group (55.2% vs. 81.1%, P = .023). Otherwise, no significant differences were found between the groups. Overall, the infants received less breast milk than norms.

CONCLUSION

Contextual strategies for early follow-up of families affected by clefts need to be developed, with an emphasis on involving fathers and those parents reporting elevated stress and/or feeding difficulties. There is a need for diagnosis-specific guidelines about the use of pacifiers as well as collaboration between the health professionals involved to increase breastmilk feeding.

Attributes That Increase Vulnerabilities to Reduced Human Milk Feeding Outcomes Among Babies With Cleft Lip and Palate in the Neonatal Intensive Care Unit

OBJECTIVE

The purpose of this study was to identify infant and maternal factors associated with reduced human milk feeding among infants in a neonatal intensive care unit (NICU) with cleft lip with or without cleft palate (CL ± P).

METHOD

Data collected on mothers and infants admitted to the NICU with CL ± P from the 2018 National Vital Statistics System were used for this study. Chi-square tests of independence and independent-samples t tests were used to compare categorical variables and continuous variables, respectively, among two groups of infants admitted to the NICU with CL ± P-those who did and did not receive human milk feeding at discharge.

RESULTS

The sample included 660 infants admitted to the NICU with CL ± P, of which 353 received human milk at discharge. Significant differences were found between the two groups for marital status, mother's education, maternal smoking record, total number of prenatal visits, multiparity record, gestational age, birth weight, and use of assisted ventilation.

CONCLUSIONS

Results indicated that, as a function of human milk feeding at discharge, mothers and their infants admitted to the NICU with CL ± P exhibited differences across infant and maternal factors. These findings further our understanding of this sample of mothers and infants with CL ± P while potentially identifying determinants to human milk feeding. This study provides insight into infant and maternal characteristics that may be associated with barriers to human milk feeding.

The influence of food sensory properties on eating behaviours in children with Down syndrome

Developing new food products for children is challenging, particularly in vulnerable groups including children with Down syndrome (DS). Focusing on children with DS, the aim of this study was to study the influence of parent liking on acceptance of food products by children with DS and demonstrate the influence of food sensory properties on indicators of food acceptance, food rejection, and challenging eating behaviours. Children (ages 1158 months) with DS (n = 111) participated in a home use test evaluating snack products with varying sensory properties as profiled by a trained sensory panel. Parents recorded their children's reactions to each food product; trained coders coded videos for eating behaviours. To understand the influence of each sensory modality on eating behaviour, ordered probit regression models were run. Results found a significant correlation between the parent liking and overall child disposition to the food (p < 0.05). From the regression analysis, the inclusion of all food sensory properties, including texture, flavour, taste, product shape and size, improved the percentage of variance explained in child mealtime behaviours and overall disposition over the base model (containing no sensory modalities), with texture having the largest influence. Overstuffing the mouth, a challenging eating behaviour, was most influenced by product texture (children ≥ 30 months), and product texture and size (children < 30 months). In both age groups, coughing/choking/gagging was most influenced by food texture and was associated with a product that was grainy and angular (sharp corners). In both age groups, product acceptance was associated with a product that was dissolvable, crispy, and savoury while rejection was associated with a dense, gummy and fruity product. These results suggest that a dissolvable, crispy texture, with a cheesy or buttery flavour are the sensory properties important in a desirable flavoured commercial snack product for children with DS; however, overall disposition must be balanced against mouth overstuffing.

Comprehensive Manometric Evaluation of Dysphagia in Patients with Down Syndrome

Dysphagia is a common symptom in children with Down syndrome and is conventionally evaluated with imaging and endoscopy; high-resolution manometry is not routinely utilized. The aim of this study was to describe and correlate pharyngeal and esophageal manometry findings with contrast studies and endoscopy in patients with Down syndrome and dysphagia. Electronic medical records of patients with Down syndrome with dysphagia seen at our center between January 2008 and January 2022 were reviewed. Data collected included demographics, co-morbidities, symptoms, imaging, endoscopy, and manometry. Twenty-four patients with Down syndrome [median age of 14.9 years (IQR 7.6, 20.5), 20.8% female] met inclusion criteria. Common presenting symptoms of dysphagia included vomiting or regurgitation in 15 (62.5%) patients, and choking, gagging, or retching in 10 (41.7%) patients. Esophageal manometry was abnormal in 18/22 (81.2%) patients. The most common findings were ineffective esophageal motility in 9 (40.9%) followed by esophageal aperistalsis in 8 (36.4%) patients. Rumination pattern was noted in 5 (22.8%) patients. All 6 (25%) patients who previously had fundoplication had esophageal dysmotility. Strong agreement was noted between upper gastrointestinal studies and high-resolution esophageal manometry (p = 1.0) but no agreement was found between pharyngeal manometry and video fluoroscopic swallow studies (p = 0.041). High-resolution pharyngeal and esophageal manometry provide complementary objective data that may be critical in tailoring therapeutic strategies for managing patients with Down syndrome with dysphagia.

A Scoping Review of the Complementary Feeding Practices and Early Eating Experiences of Children With Down Syndrome

OBJECTIVE

Children with Down syndrome may experience more challenges in their early feeding and may be introduced to complementary foods comparatively later than typically developing (TD) children. This scoping review aimed to identify and synthesize the existing literature that describes feeding problems and early eating experiences relating to the period of complementary feeding for children with Down syndrome.

METHODS

Scopus, PubMed, Medline, Web of Science, and PsycInfo were searched. Journal articles published between January 1991 and June 2022 that reported on the complementary feeding period with children with Down syndrome were included.

RESULTS

Eighteen journal articles met the inclusion criteria. Children with Down syndrome were introduced to complementary foods later than TD children and progressed to more challenging food textures at a slower rate. Gross and fine motor skill delays and sensory difficulties contributed to secondary feeding problems such as difficulties chewing, biting, and reduced awareness of food on lips and tongue. Parents of children with Down syndrome reported exercising more caution and employing more controlling feeding practices compared to TD and had higher levels of concern regarding their child's weight.

CONCLUSIONS

Guidelines and early feeding support specific to children with Down syndrome should be available before the first complementary foods are introduced and throughout this period. Feeding support should aim to address parental concerns and provide assistance when feeding problems occur, to minimize delays and encourage the optimum development of eating abilities. Future research should address the development of feeding problems during this period and explore possible interventions.

Clinical Validation of Feeding Handicap Index for Children (FHI-C)

Children with developmental disabilities (DD) exhibit feeding and swallowing difficulties, which can have an impact on nutritional, developmental, and psychological aspects. The existing tools assess the nature of feeding problems and behaviors only. The present study aimed to assess the physical, functional, and emotional domains in children with DD with feeding issues using Feeding handicap index for children (FHI-C). For clinical validation, FHI-C was administered on the parents/caregivers of 60 children with cerebral palsy, 61 with autism spectrum disorder, 59 with intellectual disability and 60 typically developing children in the age range of 2 to 10 years. The results revealed that the mean scores (Total FHI-C and FHI-C domain scores) were significantly higher for all three clinical groups than for the control group, which revealed good clinical validity. Also, FHI-C was found to have significantly high test-retest reliability. The study presents a valid and reliable tool for assessing the psychosocial handicapping effects of feeding problems in children with DD. FHI-C provides a holistic picture about the psychosocial impact of feeding problems in children with DD and will assist the clinicians in prioritizing the goals for feeding therapy. The scores obtained can be used as reference for pre and post therapy comparison purposes.

From Feeding Challenges to Oral-Motor Dyspraxia: A Comprehensive Description of 10 New Cases with CTNNB1 Syndrome

CTNNB1 syndrome is an autosomal-dominant neurodevelopmental disorder featuring developmental delay; intellectual disability; behavioral disturbances; movement disorders; visual defects; and subtle facial features caused by de novo loss-of-function variants in the CTNNB1 gene. Due to paucity of data, this study intends to describe feeding issues and oral-motor dyspraxia in an unselected cohort of 10 patients with a confirmed molecular diagnosis. Pathogenic variants along with key information regarding oral-motor features were collected. Sialorrhea was quantified using the Drooling Quotient 5. Feeding abilities were screened using the Italian version of the Montreal Children's Hospital Feeding Scale (I-MCH-FS). Mild-to-severe coordination difficulties in single or in a sequence of movements involving the endo-oral and peri-oral muscles were noticed across the entire cohort. Mild-to-profuse drooling was a commonly complained-about issue by 30% of parents. The mean total I-MCH-FS t-score equivalent was 43.1 ± 7.5. These findings contribute to the understanding of the CTNNB1 syndrome highlighting the oral motor phenotype, and correlating specific gene variants with clinical characteristics.

Non-Surgical Respiratory Management in Relation to Feeding and Growth in Patients with Robin Sequence; a Prospective Longitudinal Study

OBJECTIVE

To reflect upon our non-surgical respiratory management by evaluating clinical outcomes regarding airway, feeding, and growth during the first year of life in patients with Robin Sequence.

DESIGN

Prospective study.

SETTING

Sophia Children's Hospital, Rotterdam, the Netherlands.

PATIENTS/ PARTICIPANTS

36 patients with Robin Sequence who were treated between 2011 and 2021.

INTERVENTIONS

Positional therapy and respiratory support.

MAIN OUTCOME MEASURE(S)

Data on respiratory outcomes included polysomnography characteristics and capillary blood gas values. Feeding outcomes were based on the requirement of additional tube feeding. Outcomes on growth were expressed as standard-deviation-scores (SDS) for weight-for-age (WFA) and height-for-age (HFA).

RESULTS

Twenty patients were treated with positional therapy (PT), whilst the other 16 patients required respiratory support. Twenty-two patients presented with non-isolated Robin Sequence (RS). During the first year of life, obstructive apnea hypopnea index decreased, oxygen levels enhanced, and capillary blood gas values improved. Eighty-six percent (31/36) experienced feeding difficulties, which completely resolved in 71% (22/31) during their first year of life. From start treatment, to stop treatment, to the age of 1 year, the SDS WFA worsened from -0.40 to -0.33 to -1.03, respectively.

CONCLUSIONS

Non-surgical respiratory treatment resulted in an improvement of respiratory outcomes to near normal during the first year of life in patients with RS. These patients often experience feeding difficulties and endure impaired weight gain up to 1 year of age, despite near normalization of breathing. The high prevalence of feeding difficulties and impaired weight for age indicate the urgency for early recognition and adequate treatment to support optimal growth.

The association of feeding difficulties and generic health-related quality of life among children born with esophageal atresia

BACKGROUND

Children born with esophageal atresia experience feeding difficulties. This study investigates the association of feeding difficulties and generic health-related quality of life among children aged 2-7 and 8-17 years, born with esophageal atresia.

METHODS

108 families (n = 36 aged 2-7 years; n = 72 aged 8-17) answered a survey regarding difficulties in their child's mealtimes and a validated generic health-related quality of life instrument(PedsQL 4.0). Clinical data was collected from hospital records. The association of feeding difficulties and health-related quality of life was analysed trough Mann-Whitney U-test. Linear regression determined whether the number of concurrent feeding difficulties in the child decreased the health-related quality of life scores. P < 0.05 was considered significant.

RESULTS

In children aged 2-7 and 8-17 years, to have a gastrostomy, to use a food infusion pump, need for energy-enriched food and eating small portions were respectively significantly associated with lower total health-related quality of life scores in the parent-reports (p < 0.05). Most of the feeding difficulties had a negative significant relationship with the domains of physical and social functioning. Additionally, in the older age group, long mealtimes and adult mealtime supervision were associated with lower scores in both child and parent reports. In both age groups, an increased number of feeding difficulties in the child decreased the total generic health-related quality of life scores (p < 0.01).

CONCLUSION

Specific feeding difficulties are associated with low health-related quality of life among children with esophageal atresia. An increasing number of feeding difficulties is associated to decreasing health-related quality of life-scores. Further research is needed to understand these associations.

A biophysiological framework exploring factors affecting speech and swallowing in clinical populations: focus on individuals with Down syndrome

Speech and swallowing are complex sensorimotor behaviors accomplished using shared vocal tract anatomy. Efficient swallowing and accurate speech require a coordinated interplay between multiple streams of sensory feedback and skilled motor behaviors. Due to the shared anatomy, speech and swallowing are often both impacted in individuals with various neurogenic and developmental diseases, disorders, or injuries. In this review paper, we present an integrated biophysiological framework for modeling how sensory and motor changes alter functional oropharyngeal behaviors of speech and swallowing, as well as the potential downstream effects to the related areas of language and literacy. We discuss this framework with specific reference to individuals with Down syndrome (DS). Individuals with DS experience known craniofacial anomalies that impact their oropharyngeal somatosensation and skilled motor output for functional oral-pharyngeal activities such as speech and swallowing. Given the increased risk of dysphagia and "silent" aspiration in individuals with DS, it is likely somatosensory deficits are present as well. The purpose of this paper is to review the functional impact of structural and sensory alterations on skilled orofacial behaviors in DS as well as related skills in language and literacy development. We briefly discuss how the basis of this framework can be used to direct future research studies in swallowing, speech, and language and be applied to other clinical populations.

Long-Term Outcomes After External Maxillary Distraction Surgery in Patients With Down Syndrome

BACKGROUND

Patients with Down syndrome have severe facial deformities that can precipitate functional consequences and social stigmatization. Craniofacial surgical intervention can play a role in improving these symptoms and patient quality of life. The objective of this study was to investigate the long-term outcomes of distraction osteogenesis and orthognathic surgical intervention in patients with Down syndrome.

MATERIALS AND METHODS

Charts of 3 patients with Down syndrome who were treated with external maxillary distraction osteogenesis were retrospectively reviewed. The patients' caregivers were prospectively interviewed between 10 and 15 years after surgery to determine surgical stability, long-term function, and quality of life status.

RESULTS

All patients and their caregivers reported excellent results with improvements in function and quality of life. Facial skeletal changes have been stable over time. The cephalometric analysis demonstrated significant maxillary advancement in all 3 patients and mandibular changes to correct mandibular prognathism and asymmetry in the patient who underwent finishing orthognathic surgery.

CONCLUSIONS

External maxillary distraction osteogenesis and orthognathic surgery may be considered in select patients with Down syndrome as part of their multidisciplinary health care. These interventions can result in long-term improvements in patient function and quality of life.

Predicting the clinical trajectory of feeding and swallowing abilities in CHARGE syndrome

To date, the feeding and oral-motor abilities of patients with CHARGE syndrome (CS) have not been longitudinally assessed. This study aims to investigate the level of these abilities at different ages and evaluate how they evolve during growth. We retrospectively analysed oral-motor features of 16 patients with molecularly confirmed CS (age range 4-21 years old; mean 11 years; SD 6 years; median 10 years). Nearly 100% of CS new-borns had weak sucking at birth, and half of them demonstrated poor coordination between breathing and swallowing. Over time, the percentages of children with tube feeding dependence (60% at birth) faced a slow but steady decrease (from 33% at 6 months, 25% at 12 months, to 13% at school age) in tandem with the decreasing risk of aspiration. The ability of eating foods requiring chewing was achieved at school age, after the acquisition of an adequate oral sensory processing. A mature chewing pattern with a variety of food textures was not achieved by more than half of patients, including those requiring artificial enteral nutrition. Most patients started prolonged oral-motor treatments with speech language therapists in early childhood.

CONCLUSIONS

Although feeding and swallowing disorders are constant features in CS patients, a slow and gradual development of feeding abilities occurs in most cases. Rehabilitation plays a key role in overcoming structural and functional difficulties and attaining appropriate eating skills.

WHAT IS KNOWN

• Feeding problems and swallowing dysfunction have been noted in CHARGE syndrome. • The involvement of multiple factors, including structural problems in the mouth, throat, or esophagus, and neurological impairment, make feeding a complicated task in CHARGE individuals.

WHAT IS NEW

• Dysphagia gradually improves in most CHARGE children over time, though with a wide interindividual variability. • The percentages of children with tube feeding dependence decrease over time from 60% at birth to 33% at 6 months and 13% at school age.

Gut dysmotility in children with neurological impairment: the nutritional management

Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.

Management of nutritional and gastrointestinal issues in RASopathies: A narrative review

Noonan, Costello, and cardio-facio-cutaneous syndrome are neurodevelopmental disorders belonging to the RASopathies, a group of syndromes caused by alterations in the RAS/MAPK pathway. They are characterized by similar clinical features, among which feeding difficulties, growth delay, and gastro-intestinal disorders are frequent, causing pain and discomfort in patients. Hereby, we describe the main nutritional and gastrointestinal issues reported in individuals with RASopathies, specifically in Noonan syndrome, Noonan syndrome-related disorders, Costello, and cardio-facio-cutaneous syndromes. Fifty percent of children with Noonan syndrome may experience feeding difficulties that usually have a spontaneous resolution by the second year of life, especially associated to genes different than PTPN11 and SOS1. More severe manifestations often require artificial enteral nutrition in infancy are observed in Costello syndrome, mostly associated to c.34G>A substitution in the HRAS gene. In cardio-facio-cutaneous syndrome feeding issues are usually present (90-100% of cases), especially in individuals carrying variants in BRAF, MAP2K1, and MAP2K2 genes, and artificial enteral intervention, even after scholar age, may be required. Moreover, disorders associated with gastrointestinal dysmotility as gastro-esophageal reflux and constipation are commonly reported in all the above-mentioned syndromes. Given the impact on growth and on the quality of life of these patients, early evaluation and prompt personalized management plans are fundamental.

Risk Factors for Tube Feeding at Discharge in Infants Undergoing Neonatal Surgery for Congenital Heart Disease: A Systematic Review

Approximately 30-50% of infants undergoing neonatal surgery for congenital heart disease (CHD) cannot meet oral feeding goals by discharge and require feeding tube support at home. Feeding tubes are associated with increased readmission rates and consequent hospital, payer, and family costs, and are a burden for family caregivers. Identification of modifiable risk factors for oral feeding problems could support targeted care for at-risk infants. Therefore, the aim of this systematic review is to determine risk factors for tube feeding at discharge in infants undergoing neonatal surgery for CHD. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. Studies published before 2010 were excluded. The search resulted in 607 records, of which 18 were included. Studies were primarily retrospective cohort designs and results were often inconsistent. Study quality was assessed using the Joanna Briggs Critical Appraisal Tools. As a group, the studies exhibited substantial risk for bias. Based on the findings, infants who struggle with feeding preoperatively, experience increased nil per os duration and/or low oral feeding volume postoperatively, experience increased duration of mechanical ventilation, or have vocal cord dysfunction may be at risk for tube feeding at hospital discharge. Factors warranting further examination include cardiac physiology (e.g., aortic arch obstruction) and the relationship between neurodevelopment and oral feeding. Clinicians should use caution in assuming risk for an individual and prioritize early implementation of interventions that facilitate oral feeding development.

Feeding Problems as an Indicator of Developmental Delay in Early Childhood

OBJECTIVE

To determine whether feeding problems are indicators of developmental delay.

STUDY DESIGN

In this prospective longitudinal cohort study, mothers of 3597 children (49% female, 35% multiples) reported on their children's feeding problems and developmental delays (using the Ages and Stages Questionnaire [ASQ]) when children were age 18, 24, and 30 months. Average scores of feeding problems were computed at each age, as well as a categorical score indicating a persistently high number of feeding problems ≥90th percentile across time. The Battelle Developmental Inventory, Second Edition (BDI-2) was used to assess development in 5 domains for a subset of children at 4 years.

RESULTS

In adjusted analyses, feeding problems (per point increase) were increasingly associated with 6 ASQ domains from 18 months (OR, 1.30-1.98) to 24 months (OR, 2.07-2.69) to 30 months (OR, 3.90-5.64). Compared with children who never experienced feeding problems, children who experienced a high number of feeding problems at 1 or 2 time points were more than twice as likely to have a delay on all ASQ domains (OR, 2.10-2.50), and children who experienced a high number of feeding problems at all 3 time points were ≥4-fold more likely to have a delay on all ASQ domains (OR, 3.94-5.05). Children with 1-point higher feeding problems at 30 months scored 3-4 points lower in all BDI-2 domains at 4 years.

CONCLUSIONS

Frequent feeding problems, especially those that persist into the third year, could be used to identify children at risk for developmental delay for more targeted screening.

Child feeding practices in children with Down syndrome in relationship to ethnicity and BMI

Children with Down syndrome (DS) exhibit higher overweight and obesity rates than their typically developing peers, although it is unknown whether parent feeding practices for children with DS are associated with child weight status or parental and demographic factors, especially in the Hispanic and Latino populations. A prospective study of 68 children with DS from 2 to 7 years of age, who received care at a single, large, pediatric academic hospital was conducted to evaluate parent child feeding practices. Parents completed the Child Feeding Questionnaire+ (CFQ+) assessing seven primary factors of feeding practices and comparisons to children without DS were conducted. Data for body mass index (BMI) and BMI-for-sex/age z score (BMIz scores) were collected in clinic at the time of CFQ+ completion for both parent and child. Parents of children with DS endorsed higher perceived responsibility but lower concern about child weight and restriction compared to previously reported feeding practices in typically developing children. Hispanic/Latino parents of children with DS reported higher perceived responsibility and monitoring than non-Hispanic/Latino parents of children with DS. Higher BMIz scores in children with DS correlated with greater perceived child weight (p = 0.001) and concern about child weight (p = 0.008). Differences in BMIz scores were observed when comparing sex/ethnicity groups as determined by one-way ANOVA (F(3,64) = 4.170, p = 0.009); with Hispanic/Latino boys with DS more likely to have obesity. Our results suggest a need for specific DS Guidelines to educate providers and parents of children with DS on recommended feeding practices prior to parental concern about their child's weight, especially in the Hispanic/Latino population.

Feeding Problems in Patients with Noonan Syndrome: A Narrative Review

Noonan syndrome (NS) belongs to the group of Noonan syndrome spectrum disorders (NSSD), which is a group of phenotypically related conditions. Feeding problems are often present not only in infancy but also in childhood, and even beyond that period. We describe the different aspects of feeding problems using a (theoretical) concept proposed in 2019. More than 50% of infants with NS develop feeding problems, and up to half of these infants will be tube-dependent for some time. Although, in general, there is a major improvement between the age of 1 and 2 years, with only a minority still having feeding problems after the age of 2 years, as long as the feeding problems continue, the impact on the quality of life of both NS infants and their caregivers may be significant. Feeding problems in general improve faster in children with a pathogenic PTPN11 or SOS1 variant. The mechanism of the feeding problems is complex, and may be due to medical causes (gastroesophageal reflux disease and delayed gastric emptying, cardiac disease and infections), feeding-skill dysfunction, nutritional dysfunction with increased energy demand, or primary or secondary psychosocial dysfunction. Many of the underlying mechanisms are still unknown. The treatment of the feeding problems may be a medical challenge, especially when the feeding problems are accompanied by feeding-skill dysfunction and psychosocial dysfunction. This warrants a multidisciplinary intervention including psychology, nutrition, medicine, speech language pathology and occupational therapy.

Evaluating dysphagia in infants with congenital heart disease using Fiberoptic Endoscopic Evaluation of Swallowing

OBJECTIVE

Dysphagia is common in infants with congenital heart disease (CHD). However, there is minimal published data regarding its management outside of the perioperative period. The objective of this study is to describe the role of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in the diagnosis and management of dysphagia in infants with CHD.

METHODS

Infants with CHD who underwent FEES exam for evaluation of swallowing dysfunction between February 2015 and February 2021 at a university-based, tertiary care urban pediatric hospital were studied. Demographic data, presenting symptoms, medical history, and dysphagia history were examined. The validated Dysphagia Outcome and Severity Scale (DOSS) was used to standardize and compare dysphagia severity.

RESULTS

62 FEES exams were performed on 48 patients. All 48 patients were diagnosed with dysphagia and had a mean dysphagia severity score (DOSS) of 2.68. Patients with wet laryngeal congestion on presentation had worse mean DOSS score and were more likely to demonstrate aspiration on FEES exam (p < 0.01). There was no significant difference in mean DOSS or presence of aspiration when comparing infants who had cardiothoracic surgery, vocal cord paralysis, or lower respiratory tract illness with those who had not (p > 0.05).

CONCLUSION

A FEES exam is an effective and well-tolerated procedure for evaluating swallowing dysfunction in pediatric patients with CHD and its use reduces radiation exposure for this vulnerable population. Wet laryngeal congestion was found to be predictive of more severe dysphagia and aspiration. There is no significant association between severity of dysphagia or aspiration on FEES exam and history of cardiac surgery, vocal cord paralysis, or lower respiratory tract illness.

Introduction of Complementary Foods for Children with Down Syndrome: Parent and Physician Experiences

AIMS

Children with Down syndrome are at risk for feeding difficulties due to medical comorbidities and associated developmental delays, yet there are no peer-reviewed published standards to guide families with feeding progression. This study explored family experiences introducing complementary foods (e.g., purees, table food) for children with Down syndrome. A secondary aim was to describe primary care provider (PCP) training on early progression of feeding for children with Down syndrome and investigate the recommendations they gave families.

METHODS

Semi-structured interviews with twenty-two parents and eight primary care providers (PCPs) were conducted. Descriptive statistics were used to characterize the sample and to report on findings related to feeding milestones. Qualitative interview data were considered in an iterative and cyclical fashion.

RESULTS

Parental themes included differences in feeding for children with Down syndrome, limited guidance that was not always followed, feeding difficulties and related stress, and gross motor milestone acquisition related to feeding milestones. PCP themes included limited resources/training, providing similar recommendations for children with and without Down syndrome, and desire for training/resources.

CONCLUSIONS

Published guidelines on feeding progression for children with Down syndrome are needed, including considerations for determining when skill and interest converge to signal safe introduction of complementary foods.

Pediatrics for Disability: A Comprehensive Approach to Children with Syndromic Psychomotor Delay

Intellectual disability is the impairment of cognitive, linguistic, motor and social skills that occurs in the pediatric age and is also described by the term "mental retardation". Intellectual disability occurs in 3-28 % of the general population due to a genetic cause, including chromosome aberrations. Among people with intellectual disabilities, the cause of the disability was identified as a single gene disorder in up to 12 %, multifactorial disorders in up to 4 %, and genetic disorders in up to 8.5 %. Children affected by a malformation syndrome associated with mental retardation or intellectual disability represent a care challenge for the pediatrician. A multidisciplinary team is essential to manage the patient, thereby controlling the complications of the syndrome and promoting the correct psychophysical development. This requires continuous follow-up of these children by the pediatrician, which is essential for both the clinical management of the syndrome and facilitating the social integration of these children.

Relationships between feeding problems, eating behaviours and parental feeding practices in children with Down syndrome: A cross-sectional study

BACKGROUND

Research investigating feeding problems in children with Down syndrome is scarce. This study investigated feeding problems, eating behaviours and parental feeding practices in children with Down syndrome (n = 40), and typically developing (TD) children of the same age and sex (n = 40).

METHOD

Parents of children aged 6-months to 5-years in the UK completed questionnaires assessing their child's feeding problems and eating behaviours and parental feeding practices.

RESULTS

For children with Down syndrome, feeding problems were: significantly greater than for TD children; negatively associated with breast milk duration and appetite during exclusive milk feeding; and positively associated with drinking more slowly. For both groups, feeding problems were significantly correlated with more food avoidant eating behaviours.

CONCLUSIONS

This study provides new information about the relationships between feeding problems and eating behaviours in early development. Longitudinal research is needed to further investigate these relationships, so that effective support can be developed for families.

Can I breastfeed my baby with Down syndrome? A scoping review

AIM

To summarise existing evidence about barriers and enablers to breastfeeding babies with Down syndrome (DS) in peer-reviewed literature.

METHODS

Ovid Medline, CINAHL, Scopus and Ovid Emcare were searched. Inclusion and exclusion criteria were used to screen yielded articles and those meeting the criteria were included for data extraction. Two authors extracted data including outcomes, design, definition of DS, barriers and enablers to breastfeeding babies with DS.

RESULTS

Sixteen studies met the inclusion and exclusion criteria. Barriers and enablers were categorised into maternal, child and health professional factors.

CONCLUSIONS

This review identified a significant literature gap related to breastfeeding babies with DS and more definitive research under current standards is needed. Mothers reported the need for high-quality health professional breastfeeding support and evidence-based effective breastfeeding techniques. A collaborated and concerted approach from both mothers and health professionals is important to optimise breastfeeding for babies with DS.

New Feeding Assessment Scale for individuals with genetic syndromes: Validity and reliability in the CHARGE syndrome population

AIM

To develop a feeding scale for parents/care givers of individuals of all ages with genetic syndromes experiencing extensive feeding and swallowing problems. Second, to assess its validity and reliability in CHARGE syndrome.

METHODS

The new Feeding Assessment Scale (FAS) was adapted from a scale for children who need prolonged tube feeding (Paediatric Assessment Scale for Severe Feeding Problems, PASSFP). Ten parents piloted the new scale before it was sent out with the PASSFP and feeding history questions. A subset completed the new scale again 4-8 weeks later.

RESULTS

One hundred parents of individuals with CHARGE syndrome participated from around the world. The new scale had good construct validity, with a significant effect for an increased number of feeding risk factors having higher scale scores (P < 0.001). Face validity was high, as scores significantly differed between individuals whose parents identified their feeding difficulties as very mild, mild, moderate, severe and very severe (P < 0.001). Test-retest reliability (r = 0.94, P < 0.001) and internal consistency (Cronbach's alpha 0.91) were both high. There was significant convergent validity between the new scale and the PASSFP (r = -0.79, P < 0.001).

CONCLUSIONS

This new tool is reliable and valid for parents/care givers of individuals with CHARGE syndrome. It can be used to assess the current severity of feeding difficulties and to track progress before and after treatment. It expands upon previous existing tools in that it can be used in both individuals who are not tube fed, as well as in those who are, as well as across the life-span.

Transcriptional dysregulation in developing trigeminal sensory neurons in the LgDel mouse model of DiGeorge 22q11.2 deletion syndrome

LgDel mice, which model the heterozygous deletion of genes at human chromosome 22q11.2 associated with DiGeorge/22q11.2 deletion syndrome (22q11DS), have cranial nerve and craniofacial dysfunction as well as disrupted suckling, feeding and swallowing, similar to key 22q11DS phenotypes. Divergent trigeminal nerve (CN V) differentiation and altered trigeminal ganglion (CNgV) cellular composition prefigure these disruptions in LgDel embryos. We therefore asked whether a distinct transcriptional state in a specific population of early differentiating LgDel cranial sensory neurons, those in CNgV, a major source of innervation for appropriate oropharyngeal function, underlies this departure from typical development. LgDel versus wild-type (WT) CNgV transcriptomes differ significantly at E10.5 just after the ganglion has coalesced. Some changes parallel altered proportions of cranial placode versus cranial neural crest-derived CNgV cells. Others are consistent with a shift in anterior-posterior patterning associated with divergent LgDel cranial nerve differentiation. The most robust quantitative distinction, however, is statistically verifiable increased variability of expression levels for most of the over 17 000 genes expressed in common in LgDel versus WT CNgV. Thus, quantitative expression changes of functionally relevant genes and increased stochastic variation across the entire CNgV transcriptome at the onset of CN V differentiation prefigure subsequent disruption of cranial nerve differentiation and oropharyngeal function in LgDel mice.

Identifying risk factors for enteral access procedures in neonates with congenital diaphragmatic hernia: A novel risk-assessment score

BACKGROUND/PURPOSE

The purpose of this study was to evaluate the characteristics of neonates with congenital diaphragmatic hernia (CDH) undergoing enteral access procedures (gastrostomy or jejunostomy) during their initial hospitalization, and establish a clinical scoring system based on these characteristics.

METHODS

Data were obtained from the multicenter, multinational CDH Study Group database (CDHSG Registry) between 2007 and 2019. Patients were randomly partitioned into model-derivation and validation subsets. Weighted scores were assigned to risk factors based on their calculated β-coefficients after logistic regression.

RESULTS

Of 4537 total patients, 597 (13%) underwent gastrostomy or jejunostomy tube placement. In the derivation subset, factors independently associated with an increased risk for enteral access included oxygen requirement at 30-days, chromosomal abnormalities, gastroesophageal reflux, major cardiac anomalies, ECMO requirement, liver herniation, and increased defect size. Based on the devised scoring system, patients could be stratified into very low (0-4 points; <10% risk), low (5-6 points; 10-20% risk), intermediate (7-9 points; 30-60% risk), and high risk (≥10 points; 70% risk) groups for enteral access.

CONCLUSION

This study identifies risk factors associated with enteral access procedures in neonates with congenital diaphragmatic hernia and establishes a novel scoring system that may be used to guide clinical decision making in those with poor oral feeding.

TYPE OF STUDY

Prognosis study.

Disruptions in the development of feeding for infants with congenital heart disease

Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.

Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate

OBJECTIVE

To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P).

DESIGN

This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound.

SETTING

The study population was selected from an academic, tertiary care center between 2003 and 2011.

PATIENTS/PARTICIPANTS

Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size.

RESULTS

There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all).

CONCLUSIONS

Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Assessment of clinical practice procedures among Registered Dietitian Nutritionists for identifying feeding dysfunction in the pediatric population

BACKGROUND & AIMS

Feeding dysfunction is common in children. Efficient processes to identify and treat feeding dysfunction are not commonly known or used among healthcare practitioners. The aim of this study was to develop and validate a survey tool to assess current practice procedures used by Registered Dietitian Nutritionists (RDN) in identifying, diagnosing, and treating feeding dysfunction in children 0-18 years of age.

METHODS

A survey was developed and distributed to gather information on RDN practice procedures, prevalence of pediatric feeding dysfunction, identification of pediatric feeding dysfunction, and method of treatment used to address pediatric feeding dysfunction. Emails were sent to 4449 RDNs in United States. All participants were classified by the Commission on Dietetic Registration (CDR) as clinical dietitians. Distribution and frequency of survey responses were assessed, and in the case of qualitative questions, were categorized according to themes identified.

RESULTS

Responses of RDNs from 41 states completed 341 total surveys, 179 surveys were included in data analysis. Eighty percent of participants do not use a specific screening tool to identify feeding dysfunction. Results concerning feeding therapy strategies and terms used by RDNs to describe feeding dysfunction were highly varied or lacking. Increased inclusion of RDNs on interdisciplinary teams was indicated by 80% of participants. The majority of participants indicated they refer patients with feeding dysfunction to other practitioners instead of providing feeding therapy themselves.

CONCLUSIONS

Standardized screening, diagnostic, and treatment protocols regarding feeding dysfunction are needed to provide consistent and comprehensive care for the pediatric population. Use of these protocols among RDNs would enable them to improve feeding abilities in more patients earlier in individual child development.

Neurologic complications of Down syndrome: a systematic review

Down syndrome (DS) is one of the most well-recognized genetic disorders. Persons with DS are known to have a variety of co-morbid medical problems, affecting nearly all organ systems. Improved healthcare interventions and research have allowed for increased life span of persons with DS, although disorders of the neurologic system remain underexplored. The purpose of this systematic review is to provide clinically pertinent information on the neurological phenotypes of frequently occurring or clinically relevant conditions. A retrospective review of MEDLINE, Scopus, and Pubmed were used to identify sources among seventeen, clinically relevant, search categories. MeSH terms all contained the phrase "Down Syndrome" in conjunction with the topic of interest. 'Frequently-occurring' was defined as prevalent in more than 10% of persons with DS across their lifespan, whereas 'clinically-relevant' was defined as a disease condition where early diagnosis or intervention can augment the disease course. In total, 4896 sources were identified with 159 sources meeting criteria for inclusion. Seventeen clinical conditions were grouped under the following subjects: hypotonia, intellectual and learning disability, cervical instability, autism spectrum disorder, epilepsy, cerebrovascular disease, Alzheimer's disease and neuropsychiatric disease. The results of this review provide a blueprint for the clinical neurologist taking care of persons with DS across the age spectrum and indicate that there are many underrecognized and misdiagnosed co-occurring conditions in DS, highlighting the need for further research.

Altered sucking dynamics in a breastfed infant with Down syndrome: a case report

BACKGROUND

The health and developmental advantages of human milk and breastfeeding are particularly important for infants with Down syndrome. However, they typically have shorter breastfeeding duration due to sucking issues that are not well understood. This case report describes serial measures of milk transfer volumes, sucking dynamics and tongue movement in a breastfeeding infant with Down syndrome. Management of maternal milk production enabled feeding of only breast milk until maturation of breastfeeding skills and the achievement of full breastfeeding by 6 months.

CASE PRESENTATION

The mother of a term infant with Down syndrome and no associated health complications presented with concerns regarding adequacy of milk removal at the breast and low milk supply. We monitored sucking dynamics during breastfeeding by measuring intraoral vacuum strength, nutritive and non-nutritive suck rates and burst durations, and tongue movement using submental ultrasound. Breastfeeds were monitored at 4, 10, 14, 19 and 24 weeks, and maternal 24 h milk production was measured at 4, 10 and 24 weeks postpartum. We observed a weaker suck strength and shorter nutritive suck duration, and atypical tongue movement up to 19 weeks, with low milk transfer volumes. Regular breast expression was effective in increasing maternal milk production, providing expressed milk for all complementary feeds. Full breastfeeding was achieved by 6 months when reference sucking values were observed.

CONCLUSIONS

This case report illustrates that infants with Down syndrome may have low intraoral vacuum and limited nutritive sucking that persists for several months, likely due to delayed oro-motor development. In the absence of effective sucking human milk feeding can continue when milk production is stimulated with frequent and adequate breast expression. It is possible for infants with Down syndrome and no associated health complications to eventually establish full breastfeeding. Mothers that wish to breastfeed their infant with Down syndrome require anticipatory guidance and continuing lactation and family support.

Nutrition Assessment and Intervention in a Pediatric Patient with Angelman Syndrome: A Case Presentation Highlighting Clinical Challenges and Evidence-Based Solutions

BACKGROUND

Angelman syndrome (AS) is a rare disorder of genetic imprinting which results in intellectual and developmental disability. It meets criteria of a disorder of neurologic impairment. A deletion in the long arm of chromosome 15 (del 15q11.2-q13) is responsible for about 70% of cases of AS (deletion genotype).

SUMMARY

There is a paucity of evidence to allow algorithmic nutrition assessment and intervention in pediatric patients with AS. Therefore, our objective is to use a case presentation to provide an example of nutrition assessment and intervention in a pediatric patient with the deletion genotype of AS and then highlight common challenges to providing evidenced-based nutrition care. For the highlighted challenges, we suggest evidence-based solutions to provide a resource for clinicians who may encounter similar challenges in clinical practice. Key Messages: There are genotype-phenotype correlations in AS that can help guide clinicians regarding nutritionally relevant clinical characteristics and corresponding interventions that are patient specific. The deletion genotype in AS is associated with multiple characteristics that are relevant to nutrition care and may also be different and/or more severe than characteristics seen in other AS genetic mechanisms. There is also overlap in certain nutritionally relevant clinical characteristics between AS and other conditions, including Prader-Willi syndrome, autism spectrum disorders, and disorders of neurological impairment like cerebral palsy. Clinicians can utilize nutrition resources related to these conditions to expand the scope of relevant resources available.

The Impact of Neurobehavior on Feeding Outcomes in Neonates with Congenital Heart Disease

OBJECTIVE

To evaluate the association between neonatal neurobehavioral state and oral feeding outcomes following congenital heart disease (CHD) surgery.

STUDY DESIGN

This single center retrospective cohort study described neonates undergoing cardiac surgery evaluated perioperatively with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). We compared NNNS attention scores, which evaluates neonates' ability to orient and fixate on stimuli, with the feeding outcomes percentage of feeds taken orally at discharge and time to reach full oral feeds using regression analyses. Models were constructed for both preoperative and postoperative NNNS evaluations.

RESULTS

Between August 2015 and October 2017, 124 neonates underwent 89 preoperative and 97 postoperative NNNS evaluations. In multivariable Cox regression, higher preoperative NNNS attention scores were associated with a shorter time to achieve full oral feeds (hazard ratio 1.4; 95% CI 1.0‒2.0; P = .047). This relationship was not seen for post-operative NNNS attention scores or percentage of oral feeds at discharge. Depending on the model, younger age at surgery, increased ventilator days, increased length of stay, and single or 2-ventricle anatomy with aortic arch obstruction were associated with lower percentage of oral feeds at discharge and/or delay in full oral feeds.

CONCLUSIONS

Higher neonatal attention before cardiac surgery is associated with improved feeding outcomes. Prospective assessment of neonatal neurobehavioral state may be a novel approach to predict and target interventions to improve feeding outcomes in CHD. Future studies should examine the impact of intrinsic neurodevelopmental delay vs environmental adaptation on the neurobehavioral state of neonates with CHD.

Feeding and swallowing difficulties in children with Down syndrome

BACKGROUND

The anatomical and physiological characteristics such as neuromotor coordination impairments and craniofacial and structural abnormalities frequently interfere with the acquisition of effective oral-motor skills which can in turn result in the development of potential feeding problems and swallowing dysfunction. The present study was undertaken with the aim of assessing the feeding and swallowing problems, if any, in children with Down syndrome in the age range of 2-7 years.

METHODS

A questionnaire was formulated and administered on 17 children with Down syndrome (10 females and 7 males) and 47 typically developing children (20 females and 27 males).

RESULTS

The present study revealed that feeding difficulties were predominantly present in children with Down syndrome. These difficulties were found in all the three phases of swallow and were greatest for solids followed by liquids. They also had issues with physical, functional and emotional aspects of feeding. Further, the children with Down syndrome exhibited poor orosensorimotor abilities which could have lead to the difficulties in feeding.

CONCLUSIONS

The study highlights the importance of including feeding assessment in the evaluation protocol of infants and children with Down syndrome.

Regulatory Mechanisms of Soft Palate Development and Malformations

Orofacial clefting is the most common congenital craniofacial malformation, appearing in approximately 1 in 700 live births. Orofacial clefting includes several distinct anatomic malformations affecting the upper lip and hard and soft palate. The etiology of orofacial clefting is multifactorial, including genetic or environmental factors or their combination. A large body of work has focused on the molecular etiology of cleft lip and clefts of the hard palate, but study of the underlying etiology of soft palate clefts is an emerging field. Recent advances in the understanding of soft palate development suggest that it may be regulated by distinct pathways from those implicated in hard palate development. Soft palate clefting leads to muscle misorientation and oropharyngeal deficiency and adversely affects speech, swallowing, breathing, and hearing. Hence, there is an important need to investigate the regulatory mechanisms of soft palate development. Significantly, the anatomy, function, and development of soft palatal muscles are similar in humans and mice, rendering the mouse an excellent model for investigating molecular and cellular mechanisms of soft palate clefts. Cranial neural crest-derived cells provide important regulatory cues to guide myogenic progenitors to differentiate into muscles in the soft palate. Signals from the palatal epithelium also play key roles via tissue-tissue interactions mediated by Tgf-β, Wnt, Fgf, and Hh signaling molecules. Additionally, mutations in transcription factors, such as Dlx5, Tbx1, and Tbx22, have been associated with soft palate clefting in humans and mice, suggesting that they play important regulatory roles during soft palate development. Finally, we highlight the importance of distinguishing specific types of soft palate defects in patients and developing relevant animal models for each of these types to improve our understanding of the regulatory mechanism of soft palate development. This knowledge will provide a foundation for improving treatment for patients in the future.

Gastrointestinal Conditions in Children With Severe Feeding Difficulties

Feeding aversion in children may progress to severe feeding difficulties. While oral-motor and sensory issues are usually the leading causes, organic etiologies should be considered. This study aimed to assess the prevalence of gastrointestinal conditions in children with severe feeding difficulties. We conducted a retrospective study of 93 children requiring an intensive feeding program. The medical records, radiologic and diagnostic tests, use of gastric tube feedings, preexisting medical conditions, and medications were reviewed. Fifty-two percent (52%) had esophagitis, 26.2% gastritis, and 40.7% lactase deficiency in upper endoscopy. In those who underwent an upper endoscopy, 26% of patients that were also tested for small intestinal bacterial overgrowth were found to be positive. Allergy testing was abnormal in 56.6% of those tested, while 27.5% and 75% had abnormal gastric emptying times and pH impedance results, respectively. Constipation was present in 76.3%. Thirteen of 32 were weaned off tube feedings. We conclude that gastrointestinal conditions are common in children with feeding disorders and should be investigated prior to feeding therapy.

A Pilot Study of Mothers' Breastfeeding Experiences in Infants With Cleft Lip and/or Palate

BACKGROUND

Despite the recognized importance of human milk (HM) use, breastfeeding is often discouraged for infants with cleft lip and/or palate because of their anatomical abnormalities. Poor weight gain may require formula for calorie supplementation. Stresses associated with caring for infants with cleft lip/palate may decrease rates of HM provision to these infants.

PURPOSE

This study investigates the experiences of mothers of infants with cleft lip/palate (CL/P) to determine choices and factors associated with providing HM to their infants.

METHODS

A retrospective telephone survey was administered to a cohort of mothers of infants with CL/P.

RESULTS

Fifty mothers agreed to participate in the survey. Most (78%) initiated use of HM for a median duration of 4 months, 32% provided HM for 6 months or more, and 79% exclusively expressed their HM. Poor supply was the most frequent challenge to providing HM and led to cessation in 46% of the mothers. Formula was used to supplement for poor supply or poor infant weight gain in 90% of the mothers. The best predictors of a mother's use of HM were child not in day care, genetic diagnosis, and gestational age at birth. Only 36% of mothers reported individual encouragement to provide HM, and 18% reported they were specifically discouraged from providing HM for their infants.

IMPLICATIONS FOR PRACTICE

Although initiation rates were high, there are opportunities to improve support for mothers to increase duration of HM provision in children with CL/P.

IMPLICATIONS FOR RESEARCH

This study establishes a baseline for future prospective studies looking at the impact of active encouragement and provision of lactation support within the cleft team setting.

Clinical identification of feeding and swallowing disorders in 0-6 month old infants with Down syndrome

Feeding and swallowing disorders have been described in children with a variety of neurodevelopmental disabilities, including Down syndrome (DS). Abnormal feeding and swallowing can be associated with serious sequelae such as failure to thrive and respiratory complications, including aspiration pneumonia. Incidence of dysphagia in young infants with DS has not previously been reported. To assess the identification and incidence of feeding and swallowing problems in young infants with DS, a retrospective chart review of 174 infants, ages 0-6 months was conducted at a single specialty clinic. Fifty-seven percent (100/174) of infants had clinical concerns for feeding and swallowing disorders that warranted referral for Videofluroscopic Swallow Study (VFSS); 96/174 (55%) had some degree of oral and/or pharyngeal phase dysphagia and 69/174 (39%) had dysphagia severe enough to warrant recommendation for alteration of breast milk/formula consistency or nonoral feeds. Infants with certain comorbidities had significant risk for significant dysphagia, including those with functional airway/respiratory abnormalities (OR = 7.2). Infants with desaturation with feeds were at dramatically increased risk (OR = 15.8). All young infants with DS should be screened clinically for feeding and swallowing concerns. If concerns are identified, consideration should be given to further evaluation with VFSS for identification of dysphagia and additional feeding modifications.

Aspiration and Dysphagia in the Neonatal Patient

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.

The Need of Interdisciplinary Approach for the Treatment of Children with Down Syndrome with Severe Caries Unintentionally Facilitated by Hypotonia Therapy

This manuscript describes a case of a 4-year-old child with Down syndrome involving hypotonia in which the use of sweets to induce oral muscular function contributed to the need to extract all the primary teeth due to extensive caries. The need for interdisciplinary education and practice targeted to the treatment of children with special health care needs is emphasized.

Postextubation Dysphagia in Children: The Role of Speech-Language Pathologists

OBJECTIVES

Postextubation dysphagia is common and associated with worse outcomes in the PICU. Although there has been an increased participation of speech-language pathologists in its treatment, there is limited evidence to support speech-language pathologists as core PICU team member. We aimed to assess the impact of speech-language pathologists interventions on the treatment of postextubation dysphagia.

DESIGN

A quasi-experimental prospective study. In the historical group (controls), patients received a standard care management for dysphagia whereas the intervention group was routinely treated by speech-language pathologists.

SETTING

PICU of a tertiary hospital.

PATIENTS

Children who were endotracheally intubated for a period greater than 24 hours with greater oral intake limitation as defined by a Functional Oral Intake Scale less than or equal to 3.

INTERVENTION

Routine speech-language pathologist assessment.

MEASUREMENTS AND MAIN RESULTS

A total of 74 patients were enrolled to receive intervention (January 2015 to December 2016) and 41 patients to the historical group (January 2014 to December 2014). There were no differences in the demographic and clinical characteristics. The historical group had both longer time to initiate oral intake (7 vs 4 d; p = 0.0002; hazard ratio, 2.33) and to reach full oral intake compared with intervention group (9 vs 13 d; p < 0.001; hazard ratio, 2.51). A total of 32 controls (78%) and 74 intervention patients (100%) were on total oral intake at discharge (p ≤ 0.001). Three of nine control patients were feeding tube dependent at hospital discharge. Also, controls had a longer length of hospital stay (25 vs 20 d) and a higher rate of reintubation when compared with those patients of intervention group (10% vs 2%).

CONCLUSIONS

Incorporating speech-language pathologists in the routine management of postextubation dysphagia can result in faster functional improvement and favorable patient outcomes. Yet, further and larger studies in pediatric dysphagia are required to support the related interventions and strategies to guide clinical practice.

Breastfeeding Experiences of Mothers of Children with Down Syndrome

Children with Down syndrome are less likely to be breastfed than typically developing children, and breastfeeding has a lower duration compared to recommendations of the World Health Organization. The aim of this study was to understand the breastfeeding experiences of mothers of children with Down syndrome, including their perceptions of the breastfeeding process and their specific practices. This is a qualitative study with 10 participants, mothers of children aged between 2 months and 9 years. Snowball sampling was used for participants' selection, and semi-structured interviews conducted in participants' households. Three categories emerged: "the breastfeeding experience," involving the process of breastfeeding, the breast milk, feelings, and difficulties of this practice; "experiences of health care," encompassing the support received by health professionals, dissatisfaction with health services, lack of support in breastfeeding, and discontent with health professional behavior; and "learning about Down syndrome," with search for information by parents and advice to health professionals. In this study, we found evidence that breastfeeding success relies very much on mothers' willingness and support of health professionals, namely, nurses. Findings from this study suggest that support of a multidisciplinary team is essential to the success of breastfeeding. Greater awareness is needed regarding the unique rewards and challenges of breastfeeding these infants, as well as how families cope with the ongoing challenges. Therefore, this research is relevant to understand the experiences of mothers of children with DS about breastfeeding, identifying the inhibiting factors, in order to create more appropriate strategies to intervene and implement practices that contribute to the support and promotion of breastfeeding. Results will also influence the education of health professionals, emphasizing the importance of multidisciplinary teams for a comprehensive care and contributing to increasing evidence available about this topic.

Differences in Weight Loss and Recovery After Cleft Lip and Palate Repair

OBJECTIVE

To determine the degree of weight loss, time to regain lost weight, and impact on postoperative outcomes after primary cleft lip (CL) and cleft palate (CP) repair.

DESIGN

Single institution retrospective.

PATIENTS

Two hundred seven patients who underwent primary CL and/or CP repair procedures.

RESULTS

One hundred thirty primary CL repairs (isolated CL = 59; cleft lip and palate [CLP] = 71) and 140 primary CP repairs (isolated CP = 72; CLP = 69): At the first postoperative visit, 21.54% of CL and 57.14% of CP repair patients had not returned to their immediate preoperative weights ( P < .0001). Maximum weight loss after CL repair was 0.44 kg (mean = 0.15 kg; standard deviation [SD]: 0.11) and for CP repair was 0.85 kg (mean = 0.31 kg; SD: 0.21; P = .002). Maximum percentage body weight loss was 6.11% after CL repair (mean = 2.08%; SD: 1.56) and 9.2% after CP repair (mean = 3.10%; SD: 2.13; P = .02). If not returned to preoperative weight by first postoperative visit, CP repair took significantly longer. Median time to return to preoperative weight was CL = 14.08 days (interquartile range [IQR]: 7.26) and CP = 25.37 days (IQR: 21.07; P < .0001). Patients undergoing CP repair with slowed weight recovery had a 22.5% rate of unintentional fistula/partial dehiscence compared to 10.0% of those who recovered quickly ( P = .052).

CONCLUSIONS

Primary CP repair involves significantly higher risk and degree of postoperative weight loss and slower rates of weight recovery when compared with primary CL repair. Postoperative weight loss is associated with increased risk of complications with palatal healing. Cleft palate repair patients should be monitored closely for weight recovery and considered for nutritional interventions to support improved postoperative outcomes.