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Abstract
Coronavirus (COVID-19) infection usually causes mild symptoms in children. However, serious complications may occur as a result of both acute infection or in association with the multisystem inflammatory syndrome (MIS-C). Dysphagia may develop as a sequela of COVID-19. We review the limited data on dysphagia associated with COVID-19 infection in children. Children can develop acute respiratory distress syndrome (ARDS) due to severe COVID-19 infection leading to endotracheal intubation and mechanical ventilation. These children can possibly develop post-intubation dysphagia. Screening for the presence of dysphagia, in an effort to minimize aspiration, in children with active COVID-19 infection must be done carefully to reduce the risk of transmission of the virus. Those children diagnosed with persistent dysphagia after COVID-19 infection has resolved will need further evaluation and management by pediatric subspecialists experienced in treating children with this condition. We recommend, this evaluation and treatment be done by a pediatric aerodigestive team.
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, Division of Pulmonology, Department of Pediatrics, University of Tennessee Health Science Center, LeBonheur Children's Hospital, Faculty Office Building, Room 224, 49 North Dunlap Street, Memphis, TN, 38105, USA.
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2
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, and St. Jude Children's Research Hospital, Memphis, TN
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Walker RD, Irace AL, Kenna MA, Urion DK, Rahbar R. Neurologic Evaluation in Children With Laryngeal Cleft. JAMA Otolaryngol Head Neck Surg 2017; 143:651-655. [PMID: 28384788 DOI: 10.1001/jamaoto.2016.4735] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Referral to a neurologist and imaging play important roles in the management of laryngeal cleft. Swallowing involves a complex series of neuromuscular interactions, and aspiration can result from anatomical causes (eg, laryngeal cleft), neuromuscular disorders, or some combination thereof. To date, no protocols or guidelines exist to identify which patients with laryngeal cleft should undergo neuroimaging studies and/or consultation with a neurologist. Objective To establish guidelines for neurologic evaluation and imaging techniques to identify or rule out neuromuscular dysfunction in children with laryngeal cleft. Design Retrospective review of the medical records of 242 patients who were diagnosed with laryngeal cleft at a tertiary children's hospital between March 1, 1998, and July 6, 2015. Based on this review, an algorithm to guide management of laryngeal cleft is proposed. Main Outcomes and Measures Data extracted from patient medical records included the type of laryngeal cleft, details of neurologic referral, results of neuroimaging studies, and objective swallow study outcomes. Results Of the 242 patients, 142 were male and 100 were female. Mean age at the time of data analysis was 8.7 years (range, 10 months to 25 years), and there were 164 type I clefts, 64 type II, 13 type III, and 1 type IV. In all, 86 patients (35.5%) were referred to a neurologist; among these, 33 (38.4%) had examination findings indicative of neuromuscular dysfunction or dyscoordination (eg, hypotonia, spasticity, or weakness). Abnormal findings were identified in 32 of 50 patients (64.0%) who underwent brain imaging. Neurosurgical intervention was necessary in 3 patients diagnosed with Chiari malformation and in 1 patient with an intraventricular tumor detected on neuroimaging. Conclusions and Relevance A substantial proportion of patients with laryngeal cleft have coexistent neuromuscular dysfunction as a likely contributing factor to dysphagia and aspiration. Collaboration with a neurologist and appropriate neuroimaging may provide diagnostic and prognostic information in this subset of patients. At times, imaging will identify critical congenital malformations that require surgical treatment.
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Affiliation(s)
- Ryan D Walker
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Margaret A Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - David K Urion
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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Patient-centred pharmaceutical design to improve acceptability of medicines: similarities and differences in paediatric and geriatric populations. Drugs 2015; 74:1871-1889. [PMID: 25274536 PMCID: PMC4210646 DOI: 10.1007/s40265-014-0297-2] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient acceptability of a medicinal product is a key aspect in the development and prescribing of medicines. Children and older adults differ in many aspects from the other age subsets of population and require particular considerations in medication acceptability. This review highlights the similarities and differences in these two age groups in relation to factors affecting acceptability of medicines. New and conventional formulations of medicines are considered regarding their appropriateness for use in children and older people. Aspects of a formulation that impact acceptability in these patient groups are discussed, including, for example, taste/smell/viscosity of a liquid and size/shape of a tablet. A better understanding of the acceptability of existing formulations highlights opportunities for the development of new and more acceptable medicines and facilitates safe and effective prescribing for the young and older populations.
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Reliability for Identification of a Select Set of Temporal and Physiologic Features of Infant Swallows. Dysphagia 2015; 30:365-72. [DOI: 10.1007/s00455-015-9610-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 03/19/2015] [Indexed: 10/23/2022]
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Bae SO, Lee GP, Seo HG, Oh BM, Han TR. Clinical characteristics associated with aspiration or penetration in children with swallowing problem. Ann Rehabil Med 2014; 38:734-41. [PMID: 25566471 PMCID: PMC4280368 DOI: 10.5535/arm.2014.38.6.734] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 08/01/2014] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate demographic characteristics of children with suspected dysphagia who underwent videofluoroscopic swallowing study (VFSS) and to identify factors related to penetration or aspiration. Methods Medical records of 352 children (197 boys, 155 girls) with suspected dysphagia who were referred for VFSS were reviewed retrospectively. Clinical characteristics and VFSS findings were analyzed using univariate and multivariate analyses. Results Almost half of the subjects (n=175, 49%) were under 24 months of age with 62 subjects (18%) born prematurely. The most common condition associated with suspected dysphagia was central nervous system (CNS) disease. Seizure was the most common CNS disorder in children of 6 months old or younger. Brain tumor was the most important one for school-age children. Aspiration symptoms or signs were the major cause of referral for VFSS in children except for infants of 6 months old or where half of the subjects showed poor oral intake. Penetration or aspiration was observed in 206 of 352 children (59%). Subjects under two years of age who were born prematurely at less than 34 weeks of gestation were significantly (p=0.026) more likely to show penetration or aspiration. Subjects with congenital disorder with swallow-related anatomical abnormalities had a higher percentage of penetration or aspiration with marginal statistical significance (p=0.074). Multivariate logistic regression analysis revealed that age under 24 months and an unclear etiology for dysphagia were factors associated with penetration or aspiration. Conclusion Subjects with dysphagia in age group under 24 months with preterm history and unclear etiology for dysphagia may require VFSS. The most common condition associated with dysphagia in children was CNS disease.
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Affiliation(s)
- Soon Ook Bae
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Gang Pyo Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Tai Ryoon Han
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Singendonk MMJ, Rommel N, Omari TI, Benninga MA, van Wijk MP. Upper gastrointestinal motility: prenatal development and problems in infancy. Nat Rev Gastroenterol Hepatol 2014; 11:545-55. [PMID: 24890279 DOI: 10.1038/nrgastro.2014.75] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Deglutition, or swallowing, refers to the process of propulsion of a food bolus from the mouth into the stomach and involves the highly coordinated interplay of swallowing and breathing. At 34 weeks gestational age most neonates are capable of successful oral feeding if born at this time; however, the maturation of respiration is still in progress at this stage. Infants can experience congenital and developmental pharyngeal and/or gastrointestinal motility disorders, which might manifest clinically as gastro-oesophageal reflux (GER) symptoms, feeding difficulties and/or refusal, choking episodes and airway changes secondary to micro or overt aspiration. These problems might lead to impaired nutritional intake and failure to thrive. These gastrointestinal motility disorders are mostly classified according to the phase of swallowing in which they occur, that is, the oral preparatory, oral, pharyngeal and oesophageal phases. GER is a common phenomenon in infancy and is referred to as GERD when it causes troublesome complications. GER is predominantly caused by transient relaxation of the lower oesophageal sphincter. In oesophageal atresia, oesophageal motility disorders develop in almost all patients after surgery; however, a congenital origin of disordered motility has also been proposed. This Review highlights the prenatal development of upper gastrointestinal motility and describes the most common motility disorders that occur in early infancy.
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Affiliation(s)
- Maartje M J Singendonk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Nathalie Rommel
- Department of Neurosciences, ExpORL, KU Leuven, O&N II Herenstraat 49, Box 721, 3000 Leuven, Belgium
| | - Taher I Omari
- Gastroenterology Unit, Women's and Children's Health Network, 72 King William Street, 5006 SA, Australia
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Michiel P van Wijk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol 2012; 47:321-37. [PMID: 22009835 DOI: 10.1002/ppul.21576] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/11/2011] [Indexed: 11/08/2022]
Abstract
Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children's Hospital, St. Jude Children's Research Hospital, Memphis, Tennessee 38103, USA.
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Williams S, Witherspoon K, Kavsak P, Patterson C, McBlain J. Pediatric Feeding and Swallowing Problems: An Interdisciplinary Team Approach. CAN J DIET PRACT RES 2006; 67:185-90. [PMID: 17150140 DOI: 10.3148/67.4.2006.185] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 1995, Oshawa General Hospital (now Lakeridge Health Corporation, Oshawa site) developed an interdisciplinary feeding and swallowing clinic to serve children with feeding problems. After four years, a retrospective chart review of 104 subjects was completed to assess the performance of the clinic, which consists of a pediatrician, a speech-language pathologist (S-LP), an occupational therapist (OT), and a registered dietitian (RD). Goals were set at the initial and follow-up visits. These goals were individualized according to client needs and were related to improvements in growth and/or feeding abilities. During this period, 176 of 232, or 75.9% (70-81, 95% confidence interval), of the initial goals were attained by the first follow-up visit. Progress in the clinic, as measured by the number of goals achieved by the first follow-up visit, was further analyzed according to the patient age group/category (i.e., infant, toddler, and child) and by the health care professional (i.e., S-LP, OT, and RD) to ascertain and compare success rates in these groups and professionals. The overall success rates in the patient age groups (p=0.07) and among the different professionals (p=0.92) were not significantly different. In short, the interdisciplinary team approach proved successful in treating feeding problems in patients referred to the clinic.
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Hormann M, Pokieser P, Scharitzer M, Pumberger W, Memarsadeghi M, Partik B, Ekberg O. Videofluoroscopy of deglutition in children after repair of esophageal atresia. Acta Radiol 2002. [DOI: 10.1034/j.1600-0455.2002.430511.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lifschitz CH. Feeding Problems in Infants and Children. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:451-457. [PMID: 11560792 DOI: 10.1007/s11938-001-0010-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article focuses on factors related to decreased food intake of infants and children, but does not address anorexia or bulimia nervosa. The nature of feeding problems may be behavioral, organic, or a mixture of both. Behavioral problems that affect intake have their roots in 1) parental or cultural expectations for food intake and body habit, 2) parental anxiety about weight gain in a vulnerable child or insecurity about parental skills, 3) power struggles between parent and child that manifest in eating habits, 4) conditions that may have enhanced the gag reflex, such as prolonged orotracheal intubation or a nasogastric tube, 5) failure to establish links between hunger, food intake, and satiety in infants who had not been fed orally for a relatively prolonged period of time at a critical age, and 6) anxiety or depression. Organic causes that lead to decreased food intake include swallowing problems (neurologic or conditioned hypersensitive gag, structural anomalies of the oropharynx, dyscoordinated swallow, painful swallow, and obstructed swallow ), respiratory distress, excessive fatigability (heart failure, respiratory failure), and lack of appetite (many chronic systemic illnesses). At particular risk for feeding problems are infants of premature birth, children with craniofacial anomalies, those with certain genetic syndromes, and those with neurologic involvement. An evaluation by specialists is recommended for children with obvious behavioral problems but for whom the usual recommendations have failed and for those in whom symptoms cannot be explained solely by behavioral issues or in whom organic causes are suspected. The evaluation preferably should be performed by a team specialized in pediatric feeding disorders or otherwise by an occupational therapist or speech pathologist with expertise in the area of feeding.
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Affiliation(s)
- Carlos H. Lifschitz
- United States Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates, Houston, TX 77030, USA.
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Abstract
OBJECTIVE To investigate the diagnostic and rehabilitative usefulness of routine fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric population. STUDY DESIGN Prospective, consecutive, blinded. PATIENTS AND METHODS Thirty pediatric inpatients from a large, urban, tertiary care teaching hospital participated. Their ages ranged from 11 days to 20 years (mean, 10 years and 4 months). In a random fashion, seven subjects were assessed with both videofluoroscopic evaluation of swallowing (VFES) and FEES and 23 subjects were assessed solely with FEES. Diagnosis of dysphagia was determined by spillage, residue, laryngeal penetration, and aspiration. Rehabilitative strategies, e.g., positioning and modification of bolus consistencies, were based on diagnostic findings. RESULTS There was 100% agreement between the blinded diagnostic results and implementation of rehabilitative strategies for subjects randomly assigned to receive both VFES and FEES and for subjects who received solely FEES. Of the 23 subjects assessed solely with FEES, 13 of 23 (57%) exhibited normal swallowing and 10 of 23 (43%) exhibited dysphagia. The feeding recommendation for 4 of 10 subjects with dysphagia (40%) was for a non-oral diet because of aspiration. FEES allowed for specific feeding recommendations (i.e., bolus consistency modifications, positioning, and feeding strategies) to reduce aspiration risk in 6 of 10 subjects with dysphagia (60%). CONCLUSION FEES can be used routinely to diagnose and treat pediatric dysphagia in the acute care setting.
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Affiliation(s)
- S B Leder
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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Abstract
OBJECTIVES/HYPOTHESIS To determine the utility of preoperative feeding assessments in children undergoing airway reconstruction, identifying parameters that correlate with functional deficits in swallowing and postoperative feeding difficulties. STUDY DESIGN Prospective, sequential enrollment. METHODS Two hundred fifty-five patients with structural abnormalities of the upper aerodigestive tract underwent endoscopic swallow studies. Classification of preoperative feeding abilities, specific feeding disorders, and abnormal endoscopic feeding parameters were used to predict the postoperative course of patients undergoing airway reconstruction. The relationships between diagnoses and functional feeding categories and postoperative outcomes and functional feeding categories were appraised by chi2 analysis. RESULTS The median age of the study population was 2.5 years. Fifty-three percent of the patients were tracheotomy dependent. Only 13% of the patients had diagnoses limited to the airway, with 45% of patients having three or more diagnoses. Worse preoperative feeding abilities were associated with the presence of a tracheotomy, age 2 years or less, and multiple underlying diagnoses. Neurological diagnoses were associated with worse feeding abilities. Preoperative feeding assessments directly altered the course of management of 15% of operative patients, by recommending a delay in the surgical correction, the placement of a gastrostomy tube preoperatively, or a modification in the surgical reconstruction planned for the patient. Postoperative airway protection predictions were 80% accurate. Twelve percent of the predictions involved patients who developed unforeseen complications that required additional treatments or prolonged the hospital stay secondary to difficulties with airway protection. There was no correlation between the preoperative feeding abilities of the patients and their postoperative course after airway reconstruction. CONCLUSION Transient dysphagia is common after laryngotracheal reconstruction. Preoperative feeding abilities do not correlate with the postoperative airway protection abilities of a patient. Feeding assessments before pediatric airway reconstruction provide a means of identifying patients with poor airway protection mechanisms that may compromise the patient after reconstruction. Findings on swallowing evaluations that predict poor airway protective mechanisms are 1) pooling of secretions in the hypopharynx, 2) poor oral motor skills, allowing premature spillage of material into the hypopharynx where it penetrates the larynx, and 3) residue that persists in the hypopharynx after multiple swallows. The integration of information generated from the preoperative swallowing assessment promotes the selection of operative procedures that are optimal for that patient and highlights specific therapy issues that may need to be addressed in the postoperative management of the patient that may not have been obvious without the study.
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Affiliation(s)
- J P Willging
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA
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Senez C, Guys JM, Mancini J, Paz Paredes A, Lena G, Choux M. Weaning children from tube to oral feeding. Childs Nerv Syst 1996; 12:590-4. [PMID: 8934018 DOI: 10.1007/bf00261653] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Most of the children seen by specialists in neonatalogy, neuropaediatrics or neurosurgery do not have any problems in starting with oral feeding after a period of tube feeding lasting between 15 and 20 days. Children who have been tube fed for a longer period, however, can find it very difficult or even impossible to re-establish oral feeding when they have sufficiently recovered from their underlying problem. To cope with this situation we propose a procedure based on the afferentation or re-afferentation of the oropharyngeal cavity by sensory stimulations and by re-establishment of the biological clock (circadian rhythm) by applying these stimulations during tube feeding at regular hours. In 19 children who showed difficulties oral feeding became possible a short time after such a procedure had been applied. If the principles of swallowing neurophysiology and the biological rhythm are respected, this procedure, which also involves a contribution from the family, leads to quicker oral feeding and shorter stay in hospital.
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Affiliation(s)
- C Senez
- Department of Pediatric Neurosurgery, Hôpital des Enfants, La Timone, Marseille, France
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Abstract
In contrast to adult humans, the epiglottis of other mammals and infant humans is situated close to the soft palate. It has been argued that this posture is maintained during swallowing, with food passing laterally around an intact airway. To test this supposition, the movement of the epiglottis in two contrasting mammalian species, pigs and ferrets, was studied by placing radiopaque markers on the epiglottis and soft palate. Swallowing was observed with videofluoroscopy while the animals were feeding on hard and soft foods, liquids, and food mixed with barium sulfate. Analysis of the images showed that bolus formation and downward movement of the epiglottis away from the soft palate were unvarying phenomena in both animals for all tested foods. The duration of the epiglottic movement was approximately 0.3 S for liquids and slightly longer for solids. Because swallowing never occurred past an upright epiglottis, the results of this study do not support the hypothesis that adult animals maintain a patent airway during swallowing. Instead, the epiglottis in nonhuman mammals downfolds similarly to that of adult humans during swallowing.
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Affiliation(s)
- J E Larson
- Department of Orthodontics, University of Washington, Seattle, Washington 98195, USA
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