Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit

Fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics: A systematic review

OBJECTIVES

The systematic review aimed to provide an overview of the state-of-art regarding the use of fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics, specifically investigating FEES feasibility, safety, diagnostic accuracy, and protocols.

METHODS

Four electronic databases were searched for original studies on the pediatric population that instrumentally assessed swallowing function using FEES. A hand-search of the references of included studies was performed. Data on the population, feasibility of endoscope insertion and bolus trials, adverse events, sensitivity and specificity, and FEES equipment and protocol were extracted. The quality of the studies was assessed using the checklists of the Johanna Briggs Institute. Selection of the studies, data extraction, and quality appraisal were conducted by two independent researchers.

RESULTS

Eighty-two reports from 81 studies were included. The mean overall quality of the studies was 80 % (17-100 %). The feasibility of endoscope insertion was high (89%-100 %), while the feasibility of bolus trials varied from 40 % to 100 %. Adverse events were excessive crying (8 studies), irritability or agitation (4 studies), transitory oxygen desaturations (3 studies, 1.2-6.7 % of the patients), epistaxis (3 studies, 0.8-3.3 % of the patients), increased heart rate (1 study, 1 patient), vomiting (1 study, 1 patient), hypertonia (1 study), and hypersalivation (1 study). No major complications were reported. Using VFSS as the reference standard, FEES was generally found to be less sensitive (25-94 %) but more specific (75-100 %) for aspiration, whereas the reverse was true for penetration (sensitivity 76-100 %, specificity 44-83 %). FEES protocols were highly heterogeneous with poor reporting.

CONCLUSION

FEES is a safe, accurate, and generally feasible examination in the pediatric population with suspected dysphagia. However, a consensus on the best FEES protocol for clinical practice and research is currently lacking.

Risk of Aspiration Increased by Post-swallow Residue in Infant Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

OBJECTIVE

To assess the risk of aspiration associated with post-swallow residue subsites in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in bottle-fed infants <1 year of age.

METHODS

This is a retrospective matched-pairs cohort study at an academic tertiary children's hospital. FEES and Videofluoroscopic Swallowing Study (VFSS) trials performed within the same infant <5 days apart were paired by matching bolus consistency and bottle flow rate. Positive aspiration was defined by the "or rule" in which aspiration is positive when either FEES or VFSS within a matched pair is positive.

RESULTS

Eighty-seven FEES-VFSS matched pairs from 29 patients (16 males; mean [SD] age, 2.9 [2.8] months) were included. The rate of positive aspiration, as defined by the "or rule", was 59% (51/87). In FEES, post-swallow pyriform sinus residue was present in 16% (14/87) and anterior commissure residue 27% (31/87). Risk of positive aspiration was increased by pyriform sinus residue (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.9-19.3, p < 0.01) and anterior commissure residue in FEES (OR 2.5, 95% CI 1.1-6.1, p = 0.03). In the neonate subgroup, <1 month of age, multivariate-adjusted analysis showed that anterior commissure residue had better diagnostic accuracy for aspiration than in older infants (overall 70% vs. 42%, p < 0.01; sensitivity 60% vs. 10%, p < 0.01), whereas pyriform sinus residue had worse accuracy (overall 41% vs. 70%, p = 0.02; sensitivity 13% vs. 43%, p = 0.02).

CONCLUSION

This study demonstrates that pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively.

LEVEL OF EVIDENCE: 3

Using a retrospective matched-pairs cohort, this study assesses the diagnostic accuracy of post-swallow residue in FEES for predicting aspiration. Laryngoscope, 134:1431-1436, 2024.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.

The Influence of Side-Lying Position on Oropharyngeal Swallow Function in At-Risk Infants: An Exploratory Study

This investigation assessed the effect of side-lying position on infant oropharyngeal swallow physiology. Infant modified barium swallow studies (MBS) recordings were retrospectively examined in matched-pairs comparing at-risk infants swallowing in both an upright/cradled position and a side-lying position. Swallow parameters were measured independently and through a consensus coding approach. Infants fed in side-lying position showed a decrease in airway invasion severity as compared with when those same infants were fed in an upright/cradled position (P = .009). Bolus location at the time of swallow initiation was higher when infants were fed in side-lying position as compared with cradle position (P = .024), representing decreased risk of airway invasion. Infants fed in side-lying position demonstrated fewer swallows per breaths (P = .032). This pilot study validates the need for additional research to further define the mechanisms related to this improvement, and to determine how diagnosis and medical stability moderate these findings.

Utility of Fiberoptic Endoscopic Evaluation of Swallowing After Left Ventricular Assist Device Implantation

Objective Dysphagia following cardiac surgery is common and associated with adverse outcomes. Among patients receiving left ventricular assist devices (LVAD), we evaluated the impact of fiberoptic endoscopic evaluation of swallowing (FEES) on outcomes. Methods A single-center pilot study was conducted in adults (≥18 years of age) undergoing durable LVAD (February 2019 - January 2020). Six patients were prospectively enrolled, evaluated, and underwent FEES within 72 hours of extubation-they were compared to 12 control patients. Demographic, surgical, and postoperative outcomes were collected. Unpaired two-sided t-tests and Fisher's exact tests were performed. Results Baseline characteristics were similar between groups. Intraoperative criteria including duration of transesophageal echo (314 ± 86 min) and surgery (301 ± 74 min) did not differ. The mean time of intubation was comparable (57.3 vs. 68.7 hours, p=0.77). In the entire cohort, 30-day, one-year, two-year, and three-year mortality were 0%, 5.6%, 5.6%, and 16.7%, respectively. Sixty-seven percent of the patients that underwent FEES had inefficient swallowing function. The FEES group trended to a shorter hospital length of stay (LOS) (29.1 vs. 46.6 days, p=0.098), post-implantation LOS (25.3 vs 30.7 days, p=0.46), and lower incidence of postoperative pneumonia (16.7% vs. 50%, p=0.32) and sepsis (0% vs. 33.3%, p=0.25). Conclusion FEES did not impact 30-day, one-year, two-year, or three-year mortality. Though not statistically significant, patients who underwent FEES trended toward shorter LOS and lower postoperative pneumonia and sepsis rates. Additionally, we report a higher incidence of dysphagia among patients undergoing FEES despite comparable baseline risk factors with controls.

Position Statement of the Union of European Phoniatricians (UEP): Fees and Phoniatricians' Role in Multidisciplinary and Multiprofessional Dysphagia Management Team

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.

Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure With Pediatric Populations: Part 2

PURPOSE

This is Part 2 of a two-part tutorial series establishing clinical guidelines pertaining to the administration of fiberoptic endoscopic evaluation of swallowing (FEES) developed by representatives of the American Board of Swallowing and Swallowing Disorders, all of whom are members of Special Interest Group 13. Whereas Part 1 focused on use of FEES with adults and included general information common to using FEES in any population, the purpose of this tutorial is to provide clinicians with updated best practice clinical guidelines for performing, interpreting, and documenting outcomes when using FEES with the pediatric population. This document has two main sections. The first section discusses the history of pediatric FEES, needed knowledge and skill pertaining to all elements of performing and interpreting the examination including detailed information related to indications and contraindications, developmental anatomical and physiological changes across childhood, preparing for and conducting the examination, medical collaboration, and patient safety. The second section provides detailed guidelines for clinicians who require training for use of FEES with the pediatric population.

CONCLUSIONS

This first of its kind tutorial offers guidelines for clinicians who perform, interpret, and/or want to train to perform FEES in the pediatric population. Important clinical distinctions exist when using FEES with the pediatric population versus with the adult population. Developmental changes, pediatric medical frailty, provider-parent/caregiver interaction, collaboration with physician colleagues, and patient safety are representative of key areas highlighted in this document.

Implementation of Pediatric Flexible-Endoscopic Evaluation of Swallowing: A Systematic Review and Recommendations for Future Research

BACKGROUND

Although pediatric flexible-endoscopic evaluation of swallowing (FEES) has developed into a standard in dysphagia diagnostics, there are no valid protocols and procedures for children available to date.

OBJECTIVE

This systematic PROSPERO-registered review aimed to identify implementation protocols for pediatric FEES described in research studies, and to analyze them in detail concerning procedural steps, equipment, and reported outcome.

METHODS

Included were all studies reporting a pediatric FEES protocol for children aged 0-18 years, if they described at least two criteria defined in advance. The databases MEDLINE and CINHAL were searched systematically from January 2000 to February 2021. Risk of bias for included studies was assessed using the National Institutes of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies. A narrative synthesis of the FEES protocols was conducted and the results compared in tabular form.

RESULTS

In total 22 studies were included, reporting on FEES in 1547 infants, children, and adolescents with a wide range of diagnoses. It was possible to identify protocols related to all age groups in general as well as to particular groups such as breastfed or bottle-fed infants. None of the included studies demonstrated a good methodological quality; all studies had missing data. Uniform implementation for sub-groups could not be determined. The reported outcome of FEES examinations could not be compared.

DISCUSSION

None of the included studies showed good methodological quality and a significant amount of data were missing; the review still offers a systematic basis for future research to close the serious gap in the area of pediatric FEES. A proposal is made for a minimum requirement for pediatric FEES protocols in scientific studies.

Validation and Cultural Adaptation of an Arabic Version of Pediatric Eating Assessment Tool (Pedi-EAT-10Arabic)

Pediatric eating assessment tool (Pedi-EAT-10_Arabic) is a validated and reliable caregiver administered outcome instrument designed for detection of children at high risk of penetration/aspiration. The objective of this study is to translate and validate the Arabic version of Pedi-EAT-10 and to correlate its results with pharyngeal residue and aspiration on fiber optic endoscopic examination of swallowing (FEES). A cross-sectional study including 202 children selected randomly from those attending the swallowing clinic in phoniatrics unit, Otorhinolaryngology department (ORL) at main university hospital between February 2019 and October 2020 complaining of dysphagia. For test-retest reliability, one hundred caregivers refilled the Pedi-EAT-10_Arabic after a 2-week period following their first visit. Validity was established by comparing the scores of dysphagia patients to healthy controls. Internal consistency of Pedi-EAT-10_Arabic was high (Cronbach's alpha 0.986). Intra class correlation showed excellent test-retest reliability (r = 0.968). The median Pedi-EAT 10_Arabic score was significantly higher in dysphagia group compared to healthy controls. (Median 27 IQR 21-34 for cases compared to median zero IQR 0-2 points for healthy controls, P less than 0.001). A strong correlation was found between Pedi-EAT 10_Arabic scores and PAS scores with Spearman's correlation coefficient r = 0.803 and P < 0.001. The ROC for evaluating the discriminatory capacity of Pedi-EAT 10 for aspiration showed an AUC of 0.92 (95% CI of 0.89 to 0.96)_. Conclusion: Pedi-EAT 10_Arabic was found to be a valid and reliable screening tool for further instrumental assessment of risk of dysphagia in pediatric population.

Feeding Problems and Long-Term Outcomes in Preterm Infants—A Systematic Approach to Evaluation and Management

Preterm infants are known to have long-term healthcare needs. With advances in neonatal medical care, younger and more preterm infants are surviving, placing a subset of the general population at risk of long-term healthcare needs. Oral feeding problems in this population often play a substantial yet under-appreciated role. Oral feeding competency in preterm infants is deemed an essential requirement for hospital discharge. Despite achieving discharge readiness, feeding problems persist into childhood and can have a residual impact into adulthood. The early diagnosis and management of feeding problems are essential requisites to mitigate any potential long-term challenges in preterm-born adults. This review provides an overview of the physiology of swallowing and oral feeding skills, disruptions to oral feeding in preterm infants, the outcomes of preterm infants with feeding problems, and an algorithmic approach to the evaluation and management of neonatal feeding problems.

Videoendoscopic evaluation of swallowing using normal saline in NICU infants

BACKGROUND

Videoendoscopic evaluation (VE) of swallowing involves inserting a small flexible endoscope transnasally to allow direct observation of pharyngeal and laryngeal structures and swallowing functions. In our neonatal intensive care unit (NICU) VE is performed in infants suspected of severe swallowing dysfunction, using normal saline (NS) with the aim of minimizing the detrimental effect of aspiration on respiration caused by VE. This retrospective study was conducted to evaluate the usefulness of VE using NS in NICU infants.

METHODS

We enrolled 28 infants who demonstrated clinical signs of swallowing dysfunction or who were ready to start oral feeding. Swallowing evaluations were completed using flexible fiberoptic laryngobronchoscopy (FLB). While observing the pharyngeal and laryngeal cavity with FLB, NS was gradually increased by 1 mL and injected up to a maximum of 3 mL, and the swallowing reflex, tracheal aspiration, and pharyngeal residue were observed.

RESULTS

Median gestational age was 37 weeks 6 days, median birthweight 2,539 g, and median age at first examination was 107.5 days. Abnormalities in VE were observed in 20 cases, most of which were upper airway lesions. Most of these upper airway abnormalities were pharyngeal lesions. In two pharyngeal lesion cases, swallowing function improved using positive airway pressure.

CONCLUSIONS

Infants with pharyngeal lesions demonstrated abnormal VE findings. Furthermore, positive airway pressure improved swallowing in some cases, suggesting that narrowing of the pharyngeal cavity may affect swallowing function. In addition, results suggest that VE using NS is a safe and useful method for evaluating swallowing function and determining countermeasures in NICU infants.

Instrumental Swallowing Assessments in the Neonatal and Pediatric Populations: A Systematic Review

The scientific scope of swallowing disorders in the neonatal and pediatric populations is growing exponentially; however, the preponderance of evidence for evaluation protocols has been concentrated in non-instrumental evaluations creating a lack of research about protocols for instrumental swallowing assessment. Thus, the purpose of this study was to systematically review the literature to identify and to report protocols used in instrumental assessments through videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) in the neonatal and pediatric populations to support clinical decision making. The search strategy was applied in five online databases, no filters were applied to restrict languages or publication dates and the gray literature was reviewed. PRISMA statement was used to guide the construction of this review. The studies included validated and unvalidated protocols, the validated protocols had their risk of bias estimated using the QUADAS-2. In total, 13 studies were included in the final review, of these eleven assessed through QUADAS-2, and two classified with low risk of bias. One study is in the process of standardization and validation of an instrumental assessment protocol for swallowing in bottle-fed infants through VFSS. Information about validity and reliability of published protocols for instrumental evaluation in the neonatal and pediatric populations is limited. Therefore, further research is needs to development studies aiming to standardize and validate protocols for instrumental assessments in these populations.

Diagnosis and management of aspiration using fiberoptic endoscopic evaluation of swallowing in a Pediatric Pulmonology Unit

BACKGROUND AND OBJECTIVES

Swallowing disorders lead to chronic lung aspiration. Early detection and treatment of aspiration in children with dysphagia are important to prevent lung damage. Diagnosis of aspiration, which may be silent, requires an instrumental study such as fiberoptic endoscopic evaluation of swallowing (FEES). Despite its usefulness, it is rarely practiced by pediatric pulmonologists. This study aimed to evaluate the feasibility and utility of FEES performed in the pediatric respiratory unit of a tertiary hospital, analyze the clinical characteristics, endoscopic findings and proposed treatments, and identify the factors associated with penetration or aspiration.

METHODS

Medical records of 373 children with suspected aspiration who were referred to the pediatric respiratory unit for FEES were reviewed retrospectively. Clinical characteristics, FEES findings, and the proposed treatments were analyzed.

RESULTS

Laryngeal penetration/aspiration was seen in 47.9% of the patients. The most common associated conditions were neurological disease and prematurity. The most frequently observed endoscopic finding was altered laryngeal sensitivity (36.5%). Intervention was recommended in 54.2% of the patients. Complications were not seen during any of the procedures. The multivariate logistic regression model revealed an independent association between aspiration and alterations in laryngeal sensitivity (odds ratio [OR], 5.68), pharyngeal pooling (OR, 11.47), and post-swallowing food residues (OR, 8.08).

CONCLUSIONS

The FEES procedure performed by pediatric pulmonologists is a reliable method for diagnosing aspiration in children. It can be safely executed by trained pulmonologists, and significant endoscopic signs other than aspiration can guide in the diagnosis and management recommendations.

Pediatric Flexible Endoscopic Evaluation of Swallowing: Critical Analysis of Implementation and Future Perspectives

This study aimed to critically review pediatric swallowing assessment data to determine the future need for standardized procedures. A retrospective analysis of 152 swallowing examinations in 128 children aged 21 days to 18 years was performed. The children were presented at a university dysphagia center between January 2015 and June 2020 for flexible-endoscopic evaluation of swallowing (FEES). Descriptive analysis was conducted for the sample, swallowing pathologies, diagnosis, and missing values. Using binary logistic regression, the relationship between dysphagia and underlying diseases was investigated. The largest group with a common diagnosis in the cohort were children with genetic syndromes (n = 43). Sixty-nine children were diagnosed with dysphagia and 59 without dysphagia. The non-dysphagic group included 15 patients with a behavioral feeding disorder. The presence of an underlying disease significantly increased the chance of a swallowing problem (OR 13.08, 95% CI 3.66 to 46.65, p = .00). In particular, the categories genetic syndrome (OR 2.60, 95% CI 1.15 to 5.88) and neurologic disorder (OR 4.23, 95% CI 1.31 to 13.69) were associated with higher odds for dysphagia. All pediatric FEES were performed without complications, with a completion rate of 96.7%, and with a broad variability of implementation. Several charts lacked information concerning swallowing pathologies, though. Generally, a more standardized protocol and documentation for pediatric FEES is needed to enable better comparability of studies on epidemiology, assessment, and treatment outcomes in future.

Implementing point of care ultrasound in the neonatal intensive care unit: a safety study

OBJECTIVE

Point of care ultrasound (POCUS) use is increasing in pediatrics and has been demonstrated to be superior in identifying central catheter tip location in neonatal intensive care units. However, limited data exist regarding cardiorespiratory changes secondary to POCUS in neonates.

STUDY DESIGN

A prospective observational equivalence study was performed on 50 POCUS assessments of central catheter tip location in 46 patients ≥23 weeks gestation. Heart rate (HR), respiratory rate (RR), and percent oxygen saturation (SpO2) levels were collected before and after POCUS. Limits of equivalence were set in advance.

RESULT

Equivalence was demonstrated in HR, RR, and SpO2 before and after POCUS. HR decreased by 3.24 beats per minute (90% CI: -5.36, -1.14). RR increased by 0.71 breath/min (90% CI: -1.84, +3.27). SpO2 increased by 0.54 percentage points (90% CI: -0.23, +1.31).

CONCLUSION

Identifying central catheter tip location using POCUS in neonates appears safe without affecting cardiorespiratory stability.

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.

Fiberoptic Endoscopic Evaluation of Swallowing Across the Age Spectrum

Purpose Fiberoptic endoscopic evaluation of swallowing (FEES) is a widely used instrumental procedure used to assess swallowing function in persons of all ages, from infants to older adults. In this article, the history of FEES in adults, the protocol, the scoring system, and the interpretation of abnormal findings are summarized. The use of FEES to guide treatment in adults is also covered briefly. Following this review in adults, the use of FEES in infants and children is presented, including the anatomical-physiological assessment and the assessment of swallowing of food and liquid. Interpretation of findings and therapeutic applications are discussed. Conclusion FEES is a valuable part of the clinical protocol for evaluation and management of dysphagia across the life span. It provides a mechanism for in-depth analysis of swallowing structures and function during intake of liquid and food boluses. Future developments include standardized training content to ensure clinical competency and the development of standardized examination and interpretation protocols.

Assessment Across the Life Span: The Clinical Swallow Evaluation

Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.

Assessing Swallowing of the Breastfeeding NICU Infant Using Fiberoptic Endoscopic Evaluation of Swallowing: A Feasibility Study

BACKGROUND

Premature infants may demonstrate feeding difficulties requiring an instrumental swallowing assessment. Fiberoptic endoscopic evaluation of swallowing (FEES) is one assessment that can evaluate bottle feeding and breastfeeding.

PURPOSE

This pilot study investigated the safety and feasibility of FEES for neonatal intensive care unit (NICU) infants during breastfeeding.

METHODS

The setting for this prospective, descriptive study was an urban level III NICU that provided care for premature and critically ill infants. Participants were 5 infants recruited from a convenience sample who were at least 37 weeks postmenstrual age, demonstrated feeding difficulties during a bedside feeding and swallowing examination, and were breastfeeding. Each participant received a FEES assessment while breastfeeding (FEES-B). Adverse events and vital signs including prefeeding and postfeeding respiratory rate, heart rate, and oxygen saturation level were recorded to assess safety. Visualization of milk, laryngeal penetration, and tracheal aspiration assessed feasibility.

RESULTS

Participants had a mean postmenstrual age of 39.8 weeks. No adverse events, including epistaxis or laryngospasm, were reported; there were no instances of autonomic instability; and there were no statistically significant differences between prefeeding and postfeeding respiratory rate, heart rate, or oxygen saturation level. Two infants successfully breastfed during FEES-B. Human milk was observable, and laryngeal penetration was noted with 1 infant.

IMPLICATION FOR PRACTICE

FEES-B was found to be safe, with limited data supporting feasibility. Infants demonstrated no physiologic instability during FEES-B, and milk was visualized in the pharynx during breastfeeding with 2 infants.

IMPLICATION FOR RESEARCH

Further studies are warranted to assess effectiveness of FEES-B in infants.

Simultaneous Videofluoroscopy and Endoscopy for Dysphagia Evaluation in Preterm Infants-A Pilot Study

Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.

Comparing videofluoroscopy and endoscopy to assess swallowing in bottle-fed young infants in the neonatal intensive care unit

OBJECTIVE

To determine the diagnostic accuracy of videofluoroscopy (VFSS) and endoscopy (FEES) in detecting laryngeal penetration and tracheal aspiration in bottle-fed young infants in the NICU.

STUDY DESIGN

VFSS and FEES findings of 22 infants were compared to each other and to a composite reference standard in this prospective study. Sensitivity, specificity, positive and negative predictive values were calculated for each assessment.

RESULT

Agreement between VFSS and FEES was high (92%) for aspiration and moderate (56%) for penetration, with FEES detecting more instances of penetration. Compared to the composite reference standard, FEES had greater sensitivity and a higher negative predictive value for penetration than VFSS. Because of the low prevalence of aspiration, diagnostic accuracy could not be determined for aspiration for either assessment.

CONCLUSION

FEES appears to be more accurate in detecting penetration in this population, and both assessments are valuable tools in a comprehensive feeding and swallowing evaluation.

Assessing the Breastfeeding Dyad: A Guide for Speech-Language Pathologists

Purpose

More than 80% of U.S. mothers initiate breastfeeding; for many of them, direct breastfeeding is an important goal. Speech-language pathologists (SLPs) who assess infants with feeding concerns, however, are generally much more familiar with assessing bottle-feeding. The purpose of this tutorial is to assist SLPs in building on their existing assessment skills in order to provide effective, evidence-based options for mothers who wish to breastfeed their infants.

Conclusion

SLPs can assist families in meeting their breastfeeding goals through effective assessment of breastfeeding dyads.

Feeding Interventions Are Associated With Improved Outcomes in Children With Laryngeal Penetration

OBJECTIVES

To determine if children with laryngeal penetration on videofluoroscopic swallow study (VFSS) who received feeding interventions (thickened liquids, change in liquid flow rate, and/or method of liquid delivery) had improved symptoms and decreased hospitalizations compared with those without intervention.

METHODS

We performed a retrospective cohort study of children under 2 years with laryngeal penetration on VFSS at our institution in 2015 to determine initial and follow-up VFSS findings, symptom improvement at follow-up, and hospitalization risk before and after VFSS. Proportions were compared with Fisher exact test and hospitalizations with paired t tests.

RESULTS

We evaluated 137 subjects with age 8.93 ± 0.59 months who had laryngeal penetration without aspiration on VFSS. Fifty-five percent had change in management, with 40% receiving thickening and 15% a change in flow rate. There was significant improvement in symptoms for children that had feeding intervention and this improvement was the greatest with thickening (OR 41.8, 95% CI 12.34-141.69, P < 0.001). On repeat VFSS, 26% had evidence of aspiration that was not captured on initial VFSS. Subjects had decreased total and pulmonary hospitalizations with feeding intervention and decreased pulmonary nights with thickening (P < 0.05).

CONCLUSIONS

Laryngeal penetration appears to be clinically significant in children with oropharyngeal dysphagia and interventions to decrease its occurrence are associated with improved outcomes including decreased symptoms of concern and hospitalization nights. Thickening or other feeding intervention should be considered for all symptomatic children with laryngeal penetration on swallow study.

Outcomes and swallowing evaluations after injection laryngoplasty for type I laryngeal cleft: Does age matter?

OBJECTIVES

To improve the recognition of differences in presentation amongst patients with type 1 laryngeal clefts of various ages and better understand the age dependent outcomes of injection laryngoplasty. A second aim was to analyze the discrepancies between swallow assessment modalities in various age groups with type I laryngeal clefts undergoing injection laryngoplasty.

METHODS

A retrospective review of electronic medical records of patients who underwent injection laryngoplasty from 2009 through 2015 at a tertiary care children's hospital. Data extracted included: Demographics, histories and physical exam findings, diagnostic studies, and medical and surgical treatments.

RESULTS

Most (72/102, 70.6%) patients were male with a median gestational age at birth of 37 weeks (range 24-41 weeks). Formula thickening and GERD medications were used in 94/102 (92.2%) and 97/102 (95.1%) patients, respectively. Comorbid GERD, laryngomalacia, tracheomalacia, and subglottic stenosis were present in 98/102 (96.1%), 40/102 (39.2%), 9/102 (8.8%), and 14/102 (13.7%) patients, respectively. There was no significant difference in demographics, comorbidities or medical therapy between age groups. Symptoms at presentation differed between age groups with stridor (χ²(1) = 11.6, p = 0.002) and cyanosis (χ²(1) = 8.13, p = 0.012) being more common in the 0-3-month group compared to the 12-36 month group. Symptom resolution and the odds of undergoing additional surgery (second injection or suture repair) over time, however, did not differ. There was a significant reduction in aspiration with thins during FEES (McNemar χ²(1) = 10.7, p = 0.002) and aspiration with nectar during MBS (McNemar χ²(1) = 5.26, p = 0.035) post-injection. After injection, there was significant agreement in aspiration with thins between FEES and MBS (kappa = 0.308 ± SE 0.170, p = 0.035). However, finding aspiration with thins was more common during MBS than during FEES (McNemar χ²(1) = 7.00, p = 0.016). There were no differences in swallow evaluation findings between the age groups.

CONCLUSIONS

Symptoms of type I laryngeal clefts may differ by age. However, there was no impact of age on the safety and efficacy of surgical intervention.

Feeding Problems in Infants and Children: Assessment and Etiology

Feeding problems in infants and young children are common. In healthy children who are developing and growing normally, feeding problems are usually not serious and can be managed conservatively by reassuring the family and providing them with anticipatory guidance and follow-up. A majority of serious childhood feeding problems occur in children who have other medical, developmental, or behavioral problems. These are best evaluated and treated by an interprofessional team who can identify and address issues in the medical and/or developmental history, problems with oral motor control and function, problems with swallowing, and behavioral and/or sensory issues that may interfere with normal feeding.