Preterm infant swallowing of thin and nectar-thick liquids: changes in lingual-palatal coordination and relation to bolus transit

Assessment and management of feeding difficulties for infants with complex CHD

Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.

Non-Pharmacological and Non-Surgical Feeding Interventions for Hospitalized Infants with Pediatric Feeding Disorder: A Scoping Review

Infants born prematurely or with complex medical conditions often require treatment to facilitate safe and efficient feeding. Practice is based on evidence, so frontline clinicians look to the literature to make informed clinical decisions. The aim of this scoping review was to map and describe the literature base for infant feeding and swallowing interventions and to identify areas for further research. Four electronic databases were searched from the sources' inceptions through April 2020 using a search strategy designed by a health sciences research librarian. Thirteen grey literature sources were searched and forward and backward citation chasing was performed. Inclusion criteria were English-language studies reporting non-pharmacological and non-surgical interventions for hospitalized infants. Exclusion criteria included interventions exclusively for infants with cleft lip or palate or for infants being fed exclusively though enteral feeding. Data were extracted using a form created a priori and data were reported descriptively. We reviewed 6654 abstracts: 725 were chosen for full-text review and 136 met inclusion. Most studies explored interventions for infants born prematurely (n = 128). Studies were stratified by intervention domain: bridging (n = 91) and feeding/swallowing (n = 45); intervention approach: direct (n = 72), indirect (n = 31), or combination (n = 33); and outcome: feeding performance (n = 125), physiologic stability (n = 40), and swallowing physiology (n = 12). The body of research in infant feeding has grown; however, a need remains for research focused on populations of infants with various medical complexities and for frequently used interventions that lack supporting evidence.

Instrumental texture assessment of IDDSI texture levels for dysphagia management. Part 1: Thickened fluids

Thickened fluids are commonly used in the medical management of individuals who suffer from swallowing difficulty (known as dysphagia). International Dysphagia Diet Standardization Initiative (IDDSI) developed a standardized terminology and description for texture-modified foods and thickened fluids to allow dysphagia patients to receive the correct consistency of food/drink. Syringe flow test and fork drip test are suggested by IDDSI to identify the drink category (IDDSI Levels 1-4). These practical methods are widely welcomed by carers and patients because of their simplicity. However, these methods are not most feasible for industrial applications, where objective measurements are required for industry for the purpose of quality control of such products. Therefore, our aim in this work was to develop quantitative and objective measurements that best describe IDDSI level category for use as an objective framework. Two measuring techniques, syringe flow test and fork drip test, recommended by IDDSI were evaluated in two different sets of experiment. Participants were recruited to categorize fluid samples of known texture parameters using syringe flow test and fork drip test techniques. The apparent stress measured from Ball-Back Extrusion (BBE) technique for each of the fluid category (IDDSI Levels 1-4) was calculated. Bands of apparent stress for each of the fluid category were developed from two measuring techniques, syringe flow test and fork drip test. An inconsistency was observed between these two measuring techniques for IDDSI Level 3 fluid due to different dominating factors in the two tests. However, we proposed to combine the results from the two experiments to develop a quantitative range for each IDDSI Level as objective complements to the IDDSI Framework. Thickened fluid manufacturers are encouraged to follow the proposed guidelines presented once they are clinically validated and use them fine-tune their products, thus enhancing the safety of individuals with dysphagia.

Instrumental texture assessment of IDDSI texture levels for dysphagia management. Part 2: Texture modified foods

Texture-modified foods and thickened fluids play a major role in clinical treatment for individuals who suffer from swallowing difficulties (known as dysphagia). International Dysphagia Diet Standardization Initiative (IDDSI) developed a standardized terminology and description for texture-modified foods and thickened fluids to allow dysphagia patients to receive the correct consistency of food/drink. While the IDDSI framework provides a consistent texture description (Levels 0-7) and is widely accepted as an international standard, testing and assessment of IDDSI texture level are qualitative in nature and subjective in manner. These methods were proposed primarily for use by frontline carers, but are not most ideal for industrial purposes of quality control of such products. Therefore, the main aim of this work was to develop a quantitative instrumental method that best describes IDDSI levels as an objective framework. A set of test samples, including commercially available instant mashed potato, baby rice cereal, and cooked potato cubes of varying texture, were prepared. Two IDDSI measuring techniques, fork pressure test and spoon tilt test, were used to evaluate texture grades of these samples. Puncture and compression tests based on texture analyzer were used to assess cohesiveness, adhesiveness, firmness, and hardness for each food category (Levels 4-7). Thresholds of cohesiveness and adhesiveness, as well as bands of acceptable firmness and hardness for each food category were clearly identified and are proposed as objective complements to the IDDSI framework.

Developing a Protocol for Quantitative Analysis of Liquid Swallowing in Children

PURPOSE

Objective measures in videofluoroscopic swallow studies (VFSSs) can quantify swallow biomechanics. There are a wide array of validated measures studied in infants, children, and adults. There is a need for a pediatric VFSS protocol that consists of a small number of vital, time efficient, and clinically relevant measures. In this study, we aimed to establish a standard protocol for quantitative VFSS analysis in children.

METHOD

Protocol development began with a systematic literature review, which identified 22 quantitative and eight descriptive measures available in the literature. A pediatric VFSS database of 553 children was collected using a standardized VFSS protocol. Studies were evaluated using the 30 previously reported measures covering displacement and timing parameters as well as penetration-aspiration and residue. Measures were tested for rater reliability and internal consistency. Measures meeting acceptable values for protocol inclusion were included in the final protocol (Cronbach's alpha > .53).

RESULTS

Interrater and intrarater reliability of 17 measures met acceptable reliability levels. During internal consistency testing, we removed six further measures based on Cronbach's alpha levels indicating that two or more measures were equivalent in measuring the same aspect of swallow biomechanics in children. A VFSS protocol of reliable, valid, and obtainable objective quantitative (n = 6) and descriptive measures (n = 3) with separate protocols for young infants (≤ 9 months) and older children was established.

CONCLUSIONS

A standardized quantitative VFSS protocol for children has been developed to suit two age groups (≤ 9 and > 9 months old). Consistent VFSS administration and reporting support assessment over time and across disease groups. Future research should focus on how this information can be used by clinicians to produce individualized treatment plans for children with swallowing impairment.

Thickened liquids: do they still have a place in the paediatric dysphagia toolkit?

PURPOSE OF REVIEW

Use of thickened fluids has long been a cornerstone of dysphagia management. However, clinicians and researchers are increasingly questioning their effectiveness and highlighting potential harms. This review aims to present the current state of the evidence for use of thickened fluids in children.

RECENT FINDINGS

The relationship between aspiration and respiratory infection is complex. The role of thickened fluids in improving respiratory health is limited and contradictory. A high level of variability exists in all aspects of thickened fluid use. Little is known about patient and family perspectives on meaningful endpoints for intervention.

SUMMARY

Clinicians should be open and transparent in their decision making with patients and families, acknowledging the limited evidence and the need for individualised care. Further research is needed to establish the efficacy of thickened fluid use in children with regard to improvements in respiratory health, fluid intake and child and family wellbeing.

Texture and texture assessment of thickened fluids and texture-modified food for dysphagia management

Thickened fluids and texture-modified foods are commonly used in the medical management of individuals who suffer from swallowing difficulty (known as dysphagia). However, how to reliably assess texture properties of such food systems is still a big challenge both to industry and to academic researchers. This article aims to identify key physical parameters that are important for objective assessment of such properties by reviewing the significance of rheological or textural properties of thickened fluids and texture-modified foods for swallowing. Literature reviews have identified that dominating textural properties in relation to swallowing could be very different for thickened fluids and for texture-modified foods. Important parameters of thickened fluids are generally related with the flow of the bolus in the pharyngeal stage, while important parameters of texture-modified foods are generally related with the bolus preparation in the oral stage as well as the bolus flow in the pharyngeal stage. This review helps to identify key textural parameters of thickened fluids and texture-modified foods in relation to eating and swallowing and to develop objective measuring techniques for quality control of thickened fluids and texture-modified foods for dysphagia management.

Quantitative video-fluoroscopic analysis of swallowing in infants

OBJECTIVES

To utilize objective, quantitative videofluoroscopic swallow measures to profile swallowing in infants and to determine the likelihood of objective swallow measures to predict risk of swallow impairments such as airway violation, reflux and post swallow residue.

STUDY DESIGN

Our single center retrospective observational study used a cohort of 146 bottle-fed infants (0-9 months) referred for VFSS with any kind of feeding related concern. Frame-by-frame analysis of 20-s video loops of mid-feed sucking was completed to obtain quantitative timing, displacement and coordination measures as well as presence of other findings including aspiration, residue and naso-pharyngeal reflux (NPR) and esophago-pharyngeal reflux (EPR). Spearman correlation, Mann-Whitney U test and binomial logistic regression were conducted to determine statistical associations between swallow measures and binary reporting of swallow impairments.

RESULTS

Videofluoroscopic data of 146 infants were reviewed and analyzed. 49% of infants demonstrated at least one penetration or aspiration event. Total pharyngeal transit time (TPT) and suck-swallow ratio were associated with aspiration (p < .05). Infants with >3 sucks per swallow had significantly longer TPT and their risk of aspiration was greater than those with <3 sucks per swallow (RR 1.23, 95% CI 0.43-8.507, p = .03). Pharyngeal constriction ratio (PCR) and bolus clearance ratio (BCR) were associated with residue, NPR and EPR (p < .05).

CONCLUSION

Objective measures provide clinicians with reliable timing and displacement data even in the very young. These measures correlate with swallowing safety and may help to identify enhanced risk in some infants, which may influence management recommendations.

Twenty years of quantitative instrumental measures of swallowing in children: a systematic review

Early identification and intervention has shown better health outcomes for children with dysphagia. Instrumental swallowing assessments are vital and have been a focus of dysphagia research in the last two decades. This systematic review explores published quantitative instrumental measures of swallowing in children. Five subject-related databases were searched to identify original scientific articles published in English, using instrumental quantitative measures of swallowing to study swallowing/feeding mechanism in children since 1998. Two thousand two hundred and two articles were found from the initial database search and 36 were included in the final qualitative synthesis following PRISMA guidelines. Selected studies showed great diversity in target population, phase/s of swallowing studied, instrumentation used (n = 10) and quantitative measures reported (n = 144). Videofluoroscopy and manometry have been studied most repeatedly. With less frequency, a variety of other instruments has been used to describe suck-swallow patterns and swallowing-related respiration. High-resolution manometry shows the greatest increase in publications with validated, reliable quantitative measures of pharyngeal and oesophageal pressures and timing. More recently, quantification of videofluoroscopy analysis has been a focus.Conclusion: A diverse range of quantitative measures of swallowing is available for children in the literature. However, further reliability and validity testing is needed. Opportunities for clinical application of these quantitative manometric and videofluoroscopic measures are restricted by limited normative comparisons and vast variability in published measures.What is known?• Instrumental swallowing assessments are reliable and accurate in diagnosing swallowing difficulties in children.• However, subjective interpretation of observational findings often questions the optimal use of instrumentation.What is new?• High-resolution manometry has shown promising progress with the development of quantitative objective swallow measures for children. While attempts to quantify video-fluoroscopic measures have been increased in the recent past.• A vast variety of instruments has been used to obtain quantitative and/or objective swallow measures of children, yet clinical application is still in progress.

Reduced Coordination of Hyolaryngeal Elevation and Bolus Movement in a Pig Model of Preterm Infant Swallowing

Preterm infants often have dysphagia. Because reducing lifetime cumulative exposure to radiation in the context of diagnosis and treatment is a continuing goal of all medical fields which use X-ray imaging, efforts exist to reduce reliance on the gold standard diagnostic tool for dysphagia, VFSS. Alternatives, such as video of external hyolaryngeal movement using video recordings of the anterior surface of the neck, must be evaluated and validated against videofluoroscopy, a task for which non-human animal models are appropriate. In this study, we tested the hypotheses that (1) swallows could be identified equally well from video of external hyolaryngeal movement and bolus movement in videofluoroscopy, and that (2) the two measures would be tightly temporally linked in both term and preterm infant pigs. We recorded 222 swallows in simultaneous and precisely synchronized high-speed videofluoroscopy and high-speed camera films of 4 preterm and 3 term infant pigs drinking milk from a bottle. In term pigs, the two measures consistently identified the same swallows in each image stream. However, in preterm pigs there was a high rate of false positives (~ 10% per feeding sequence) and false negatives (~ 27% per feeding sequence). The timing of hyolaryngeal elevation (external video) and bolus movement (videofluoroscopy) was correlated and consistent in terms pigs, but not in preterm pigs. Magnitude of hyolaryngeal elevation was less in preterm pig swallows than term pig swallows. Absence of epiglottal inversion in preterm pigs was not linked to variation in the timing of the two swallow events. Video of external hyolaryngeal movement, though a reliable swallow indicator in term infant pigs, was unreliable in preterm infant pigs. The coordination of swallowing events differs in preterm and term infant pigs. More research is needed into the distinctive biomechanics of preterm infant pigs.

Swallowing Analyses of Neonates and Infants in Breastfeeding and Bottle-feeding: Impact on Videofluoroscopy Swallow Studies

Introduction  Dysphagia, when left untreated, can result in an increase in morbidity and mortality rates, especially among infants with history of life-threatening neonatal diseases. The videofluoroscopy swallowing study (VFSS) is considered the gold standard for the diagnosis of dysphagia. There are few imaging studies of infant swallowing based on videofluoroscopy, none of which were performed during breast-feeding. Objective  To analyze the similarities and differences in infant swallowing function -regarding the feeding method - breast or bottle - and the impact on videofluoroscopy findings. Methods  A retrospective study of 25 VFSSs of breastfeeding and bottle-feeding infants was performed. The studied variables were: oral capture and control; tongue versus mandible movement coordination; sucking pattern; mandible excursion; liquid flow; bolus retention; laryngeal penetration; tracheal aspiration; clearing of material collected in the pharynx; and gastroesophageal reflux (GER). Results  The study showed a statistically significant association between nipple/areole capture; oral control; sucking pattern; mandibular excursion; liquid flow and feeding method. The velar sealing deficit, the place that trigger the pharyngeal swallow, food retention in the pharyngeal recesses, laryngeal penetration and GER were also factors associated with the feeding method. Conclusion  The analysis of the swallowing characteristics of both feeding methods revealed significant differences between them, with an impact on the diagnosis in the VFSSs, especially regarding velar function.

Clinical Aspects of Thickeners for Pediatric Gastroesophageal Reflux and Oropharyngeal Dysphagia

PURPOSE OF REVIEW

The purpose of this review is to discuss current knowledge and recent findings regarding clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. We review evidence for thickener efficacy, discuss types of thickeners, practical considerations when using various thickeners, and risks and benefits of thickener use in pediatrics.

RECENT FINDINGS

Thickeners are effective in decreasing regurgitation and improving swallowing mechanics and can often be used empirically for the treatment of infants and young children. Adverse effects have been reported, but with careful consideration of appropriate thickener types, desired thickening consistency, and follow-up in collaboration with feeding specialists, most patients have symptomatic improvements. Thickeners are typically well tolerated and with few side effects, but close follow-up is needed to make sure patients tolerate thickeners and have adequate symptom improvement.

Aspiration in the otherwise healthy Infant-Is there a natural course for improvement?

OBJECTIVES/HYPOTHESIS

Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration.

STUDY DESIGN

Retrospective case series at a tertiary children's hospital.

METHODS

Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan-Meier survival analysis was performed.

RESULTS

Forty patients (25 patients [50%] by 6 months, 10 [20%] by 1 year, three [6%] by 2 years, and two [4%] at the end of the follow-up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow-up interval. Median time to resolution was 202 ± 7 days (range, 19-842 days), probability 48% (95% confidence interval [CI]: 0.34-0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4-0.68), at 1 year was 64% (95% CI: 0.51-0.77), at 2 years was 76% (95% CI: 0.64-0.88), and at the end of the follow-up interval 81.3% (95% CI: 0.7-0.92).

CONCLUSIONS

The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:514-520, 2020.

The Effect of Additives for Reflux or Dysphagia Management on Osmolality in Ready-to-Feed Preterm Formula: Practice Implications

BACKGROUND

A common osmolality threshold for feedings is to stay <450 mOsm/kg for normal infants. Preterm formulas are frequently modified to improve growth, modify nutrition, and manage gastroesophageal reflux (GER) or dysphagia. Relationships between osmolality and additives to ready-to-feed preterm formulas are unclear. Our aims were to evaluate and compare the effects of caloric density, thickening agent recipes, and supplements to ready-to-feed preterm formula on osmolality.

METHODS

A freezing point osmometer was used to measure the osmolality of 47 preterm infant formula combinations with varying caloric densities (ready-to-feed 22 and 30 cal/oz), thickening agents (rice vs oatmeal cereal), thickener amounts (0.0, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 tsp/oz), and combinations of supplements (saline, iron, vitamin D, or multivitamin). Ten samples per combination were tested using a 10-μL pipette. Comparisons were made using analysis of variance and t-tests for group and pair-wise comparisons, respectively.

RESULTS

A total of 470 osmolality samples were analyzed: (1) raters had high agreement (r = 0.98; P < .001); (2) for every 0.5 tsp/oz of thickener, the osmolality increases by 30 mOsm/kg (P < .001); (3) osmolality was higher with the oatmeal (vs rice) thickening agent (P < .001); and (4) vitamin and electrolyte supplement combinations increase osmolality.

CONCLUSIONS

Alteration of ready-to-feed preterm formulas may significantly increase osmolality and have unintended consequences. Caution and monitoring should be exercised with modifying ready-to-feed preterm formulas for regurgitation, rumination, GER, dysphagia, feeding intolerance, or emesis. This study supports the concept of achieving volume tolerance before further manipulation of additives.

Neonatal swallowing assessment using fiberoptic endoscopic evaluation of swallowing (FEES)

OBJECTIVES

Swallowing disorders which lead to aspiration are common in premature infants with a postmenstrual age (PMA) of >36 weeks. Aspiration is often silent and the unique symptom is desaturation during feeding. The aim of this study was 1) to determine the number of prematures with desaturations during feeding due to aspiration, using Fiberoptic Endoscopic Evaluation of Swallowing (FEES); 2) to relate clinical factors and FEES findings to aspiration; and 3) to describe type and efficacy of suggested treatments.

METHODS

A retrospective review of 62 ex-premature babies with a median PMA of 40 weeks which underwent FEES due to persistent feeding desaturations. Aspiration was related to other FEES findings and to clinical and demographic data. The efficacy of the treatment was evaluated during the FEES and by comparing recorded desaturations during feeding 7 days before and after FEES.

RESULTS

A total of 44 (71%) infants were diagnosed with aspiration and/or penetration. No relation was found to demographic or clinical data. The accumulation of saliva and residues post-swallowing were related to aspiration (P < 0.01). In 77.3% of the infants, use of a thickener seemed to reduce aspiration during FEES and was suggested as a treatment. 13.6% of infants received anti-reflux treatment after FEES and 9.1% required gastrostomy.

CONCLUSIONS

Aspiration is very frequent in premature infants who present desaturations during feeding and FEES is a useful method for diagnosing and suggesting treatments.

A review of diet standardization and bolus rheology in the management of dysphagia

PURPOSE OF REVIEW

Texture modification is a widespread practice as a strategy for the management of dysphagia and can be very effective in individual cases. However, it is often performed in a qualitative, subjective manner and practices vary internationally according to multiple sets of national guidelines. This article aims to identify best practice by reviewing the theory and practice of texture modification, focussing on recent advances.

RECENT FINDINGS

Instrumental assessment of texture modification in vivo is challenging, and studies including rheology and perception have indicated that fluid viscosity is only one of many factors affecting texture modification in practice. Systematic reviews have identified a historical lack of high-quality clinical evidence, but recent controlled studies are beginning to identify positive and negative aspects of thickened fluids. Research and practice to date have been limited by the lack of control and standardization of foods and drinks. However in 2015 a not-for-profit organization, the International Dysphagia Diet Standardisation Initiative, has published a framework for texture modification from thin liquids to solid foods based on all the existing documentation and guidance, and the - limited - available clinical evidence.

SUMMARY

Rheology exists in the lab; however, normal practice is often subjective or lacking control and standardization. In the near future, cohesion of practice and the availability of practical standardization tools may increase awareness and use of rheology.

Effect of Single-Use, Laser-Cut, Slow-Flow Nipples on Respiration and Milk Ingestion in Preterm Infants

PURPOSE

Single-use, laser-cut, slow-flow nipples were evaluated for their effect on respiration and milk ingestion in 13 healthy preterm infants (32.7-37.1 weeks postmenstrual age) under nonlaboratory, clinical conditions.

METHOD

The primary outcomes of minute ventilation and overall milk transfer were measured by using integrated nasal airflow and volume-calibrated bottles during suck bursts and suck burst breaks during slow-flow and standard-flow nipple bottle feedings. Wilcoxon signed-ranks tests were used to test the effect of nipple type on both outcomes.

RESULTS

Prefeeding minute ventilation decreased significantly during suck bursts and returned to baseline values during suck burst breaks across both slow-flow and standard-flow nipples. No differences were found in minute ventilation (p > .40) or overall milk transfer (p = .58) between slow-flow and standard-flow nipples.

CONCLUSIONS

The lack of difference in primary outcomes between the single-use slow-flow and standard-flow nipples may reflect variability in nipple properties among nipples produced by the same manufacturer. Future investigations examining the effect of both single-use and reusable nipple products are warranted to better guide nipple selection during clinical care.

Effects of milk flow on the physiological and behavioural responses to feeding in an infant with hypoplastic left heart syndrome

Infants with hypoplastic left heart syndrome often experience difficulty with oral feeding, which contributes to growth failure, morbidity, and mortality. In response to feeding difficulty, clinicians often change the bottle nipple, and thus milk flow rate. Slow-flow nipples have been found to reduce the stress of feeding in other fragile infants, but no research has evaluated the responses of infants with hypoplastic left heart syndrome to alterations in milk flow. The purpose of this study was to evaluate the physiological and behavioural responses of an infant with hypoplastic left heart syndrome to bottle feeding with either a slow-flow (Dr. Brown's Preemie) or a standard-flow (Dr. Brown's Level 2) nipple. A single infant was studied for three feedings: two slow-flow and one standard-flow. Oral feeding, whether with a slow-flow or a standard-flow nipple, was distressing for this infant. During slow-flow feeding, she experienced more coughing events, whereas during standard-flow she experienced more gagging. Disengagement and compelling disorganisation were most common during feeding 3, that is slow-flow, which occurred 2 days after surgical placement of a gastrostomy tube. Clinically significant changes in heart rate, oxygen saturation, and respiratory rate were seen during all feedings. Heart rate was higher during standard-flow and respiratory rate was higher during slow-flow. Further research is needed to examine the responses of infants with hypoplastic left heart syndrome to oral feeding and to identify strategies that will support these fragile infants as they learn to feed. Future research should evaluate an even slower-flow nipple along with additional supportive feeding strategies.

Feed-Thickening Practices in NICUs in the Current Era: Variability in Prescription and Implementation Patterns

BACKGROUND

Feed-thickening for infants in the Neonatal Intensive Care Unit (NICU) is performed due to concerns of dysphagia and gastroesophageal reflux disease (GERD). No standards currently exist regarding feed-thickening prescriptions and practices and this results in variable and potentially unsafe feeding approaches.

METHODS

Electronic surveys were sent to neonatal feeding therapists and providers in order to determine the prescriptions and practices currently being used for feed-thickening in the NICU.

RESULTS

A total of 313 responses were collected. Results revealed the majority of providers use thickened feeds for concerns of dysphagia or GERD with some reporting they thicken expressed breast milk. Variability of thickening prescriptions was noted regarding consistencies, thickening agents, and recipes used. Reported approaches for measuring, mixing, and warming thickened feeds varied.

CONCLUSION

Variability was noted in the feed-thickening prescriptions and practices performed in the NICU. Further research and standardization are required to develop thickening guidelines.

The influence of food texture and liquid consistency modification on swallowing physiology and function: a systematic review

Texture modification has become one of the most common forms of intervention for dysphagia, and is widely considered important for promoting safe and efficient swallowing. However, to date, there is no single convention with respect to the terminology used to describe levels of liquid thickening or food texture modification for clinical use. As a first step toward building a common taxonomy, a systematic review was undertaken to identify empirical evidence describing the impact of liquid consistency and food texture on swallowing behavior. A multi-engine search yielded 10,147 non-duplicate articles, which were screened for relevance. A team of ten international researchers collaborated to conduct full-text reviews for 488 of these articles, which met the study inclusion criteria. Of these, 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. Qualitative synthesis revealed two key trends with respect to the impact of thickening liquids on swallowing: thicker liquids reduce the risk of penetration-aspiration, but also increase the risk of post-swallow residue in the pharynx. The literature was insufficient to support the delineation of specific viscosity boundaries or other quantifiable material properties related to these clinical outcomes. With respect to food texture, the literature pointed to properties of hardness, cohesiveness, and slipperiness as being relevant both for physiological behaviors and bolus flow patterns. The literature suggests a need to classify food and fluid behavior in the context of the physiological processes involved in oral transport and flow initiation.