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

Breastfeeding in infants who aspirate may increase risk of pulmonary inflammation

OBJECTIVE

To evaluate management strategies and pulmonary outcomes for breastfed infants with oropharyngeal dysphagia.

STUDY DESIGN

We performed a retrospective cohort study of breastfed infants diagnosed with oropharyngeal dysphagia with documented aspiration or laryngeal penetration on videofluoroscopic swallow study (VFSS). Medical records were reviewed for VFSS results and speech-language pathologist recommendations following VFSS, results of chest x-ray, results of bronchoalveolar lavage (BAL) within 1 year of VFSS, and aspiration-related hospitalizations occurring before or within 1 year of VFSS. Subjects were categorized as cleared or not cleared to breastfeed based on the VFSS. Proportions were compared with Chi-square and Fisher's exact tests and means with Student's t-tests.

RESULTS

Seventy-six infants (4.7 ± 0.4 months old) were included; 50% (38) had aspiration and 50% (38) had laryngeal penetration. After VFSS, 70% (53) were cleared to breastfeed while 30% (23) were not cleared to breastfeed. Patients with aspiration were less likely to be cleared to breastfeed (p = .006); however, 55% (21/38) of those with aspiration were still cleared to breastfeed. Infants cleared to breastfeed had significantly more pulmonary hospitalizations (p = .04) and were also at increased risk of elevated neutrophil count (p = .02) and culture growth on BAL (p = .01). Significantly increased abnormal neutrophil count was also found in those cleared to breastfeed with laryngeal penetration (p = .01).

CONCLUSIONS

Infants with oropharyngeal dysphagia counseled to continue breastfeeding had increased risk of BAL inflammation and more pulmonary hospitalizations compared to those that were told to stop breastfeeding.

[Latest Findings on the Suck-Swallow-Breathe Mechanism of Direct Breastfeeding From the Breast to an Infant]

A mother's breast milk is the best nourishing food for infants. No only does it provide sufficient nutrition, but it is also well suited to infants' immature digestive function, thus promoting their growth and organ maturation. A 6-month period of breastfeeding can provide infants with the necessary nutrients, energy, and fluids. The best feeding method is direct breastfeeding from the breast to an infant, yet the difficulties involved in breastfeeding should not be overlooked. Approximately 1/3 the mothers who are performing direct breastfeeding from the breast to an infant experience moderate or higher levels of feeding difficulties. Difficulties in direct breastfeeding from the breast to an infant can lead to decreased feeding efficiency, hamper the growth and development of infants, and affect the emotional communication between mothers and infants. At present, many relevant studies have focused on topics such as the mothers' psychology, family and social support, and the immature development of infants. However, little research has been done to investigate suck-swallow-breathe, a physiological mechanism that infants undertake during the process of direct breastfeeding from the breast to an infant. In this paper, we summarized published literature, research parameters, measurement instruments, and physical intervention methods of the suck-swallow-breathe mechanism in infants, aiming to facilitate the early identification of breastfeeding difficulties and the subsequently provision of early intervention measures and to promote the early identification of neurodevelopmental abnormalities and other developmental abnormalities in infants.

Lactation physiokinetics-using advances in technology for a fresh perspective on human milk transfer

Introduction

Though the nature of breastfeeding is critical, scant information is available on how the action of the milk transfer from mother to infant is regulated in humans, where the points of dysfunction are, and what can be done to optimize breastfeeding outcomes. While better therapeutic strategies are needed, before they can be devised, a basic scientific understanding of the biomechanical mechanisms that regulate human milk transfer from breast to stomach must first be identified, defined, and understood.

Methods

Combining systems biology and systems medicine into a conceptual framework, using engineering design principles, this work investigates the use of biosensors to characterize human milk flow from the breast to the infant's stomach to identify points of regulation. This exploratory study used this framework to characterize Maternal/Infant Lactation physioKinetics (MILK) utilizing a Biosensor ARray (BAR) as a data collection method.

Results

Participants tolerated the MILKBAR well during data collection. Changes in breast turgor and temperature were significant and related to the volume of milk transferred from the breast. The total milk volume transferred was evaluated in relation to contact force, oral pressure, and jaw movement. Contact force was correlated with milk flow. Oral pressure appears to be a redundant measure and reflective of jaw movements.

Discussion

Nipple and breast turgor, jaw movement, and swallowing were associated with the mass of milk transferred to the infant's stomach. More investigation is needed to better quantify the mass of milk transferred in relation to each variable and understand how each variable regulates milk transfer.

Fiberoptic Endoscopic Evaluation of Swallowing in the Breastfeeding Infant

OBJECTIVE

To demonstrate the importance of utilizing fiberoptic endoscopic evaluation of swallowing (FEES) when evaluating breastfeeding infants with suspected dysphagia. Failure to recognize and account for the fundamentally different physiology of the primarily breastfed infant can lead to false assumptions about the safety of breastfeeding in this understudied patient population.

METHODS

Case-series. The medical records of patients referred to an urban, university-based, pediatric hospital for FEES from February 2017 to October 2020 were reviewed. Their presenting symptoms, dysphagia severity, comorbidity, dysphagia workup, and management were analyzed. The standardized Dysphagia Outcome and Severity Scale was used to appraise dysphagia severity.

RESULTS

204 FEES exams were reviewed. 35 were conducted on breastfed infants. 34 of the 35 infants calmed for the FEES exam while breastfeeding. Cohorts were defined by a particular presenting sign (cough, laryngeal congestion, choking, and respiratory illness) and anatomical characteristic (laryngomalacia, vocal cord paralysis, aspiration, penetration, etc.) and then compared to all other exams. The average dysphagia score for all the exams was 2.37. Patients presenting with laryngeal congestion had an average dysphagia score of 2.81. There was no difference in dysphagia score based on comorbidities or anatomy.

CONCLUSIONS

FEES is the instrumental exam of choice when evaluating a primarily breastfed infant who has suspected dysphagia. The exam is well tolerated and provides accurate, objective information while accounting for this population's unique swallowing physiology. Primarily breastfed infants presenting with laryngeal congestion are more likely to have clinically worse dysphagia than those presenting with other clinical symptoms.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2803-2807, 2023.

Aspiration in the First Year of Life and Later Tube Feeding: A Retrospective Cohort from a Low-Income Country

The objective of this study is to investigate in infants submitted to videofluoroscopic swallowing study (VFSS) during the first year of life, the association between aspiration and later tube feeding, and to identify potential risk factors related to feeding route outcome. Retrospective cohort study with data from electronic health records was performed. Data were collected from infants < 12 months of age who underwent VFSS during inpatient hospital stay in the period between 2013 and 2018. Patient charts after 24 months of age were reviewed to ascertain the outcome and study factors, including VFSS findings, neonatal data, clinical comorbidities, nutritional status, ICU admissions, and hospital readmissions. Relative risk (RR) for tube feeding was calculated, and a Poisson regression with robust variance was used to identify potential risk factors. VFSS data from 164 patients < 1 year old were retrieved, of whom 112 (68%) contributed with data about feeding route after 2 years of age. Most infants were preterm < 37 weeks (66%), with a median age of 9.28 weeks at the time of the exam. Aspiration occurred in 33% of the patients, with no statistically significant difference between full-term or premature infants (p = 0.173). The relative risk of tube feeding after the age of 2 among infants who aspirated in VFSS was 0.74 (CI 0.25-2.16, p = 0.573). Poisson regression analysis showed that number of hospital readmissions (RR 1.04, 95%CI 1.01-1.07, p = 0.005) and gestational age < 34 weeks (RR 0.26, 95%CI 0.07-0.089, p = 0.032) were associated with later tube feeding. Early VFSS findings have low predictive value regarding later feeding route. Aspiration events should be considered as complementary information for clinical decision.

Aspiration does not mean the end of a breast-feeding relationship

OBJECTIVE

Breastfeeding is widely recommended as optimal nutrition for infants. However, there are no known publications on the impact of prandial aspiration of breast milk fed infants with dysphagia. The goal of this study was to assess pulmonary outcomes in infants with dysphagia who were given medical clearance for intake of breast milk.

METHODS

This retrospective cohort study included review of 80 infants examined between August 2016 to March 2021. Patients were evaluated by an interdisciplinary team of providers in a tertiary pediatric aerodigestive center. Patient inclusion criteria included a VFSS with documented aspiration or penetration with thin liquids. Participants met inclusion criteria if given medical clearance for intake of breast milk despite aspiration risk. Pulmonary health was monitored for three months following medical clearance for the consumption of breast milk. Pulmonary illness was defined as development of bronchiolitis, wheezing, unexplained stridor during feeding, croup, pneumonia, or persistent bacterial bronchitis requiring medical intervention.

RESULTS

Forty-three males (54%) and 37 females (46%) enrolled in the study with an age range of 1 month-6 months corrected age. Mean age at initial VFSS was 3.6 months. Twenty-six out of 80 (32.5%) had a report of a mild cough but did not require intervention. Eight out of 80 (10%) received a diagnosis of a pulmonary illness. Seventy-two out of 80 (90%) did not report pulmonary illness.

CONCLUSION

This pilot study reveals that the majority (90%) of this single institution, small sample size cohort of breast milk fed infants with documented oropharyngeal dysphagia remained healthy despite continued intake of breast milk. Prospective investigation is warranted to follow pulmonary health outcomes longitudinally and a head to head comparative study would be helpful to identify whether there were indeed significant changes to pulmonary health according to differential feeding regimens offered and followed.

Australian foster carers' views of supporting maternal breastfeeding and attachment in out-of-home care

BACKGROUND

Breastfeeding supports infant health, growth and development, and promotes maternal attachment and sensitive caregiving. Maternal separation due to child protection concerns can result in termination of breastfeeding with associated adverse outcomes. How to preserve breastfeeding when infants are placed in out-of-home care is an issue of concern.

OBJECTIVE

To consider the views of foster carers towards provision of breastmilk and breastfeeding for infants in their care.

PARTICIPANTS AND SETTING

Foster carers (including kinship carers), in Australia, who had cared for at least one infant in the years 2013-2018 completed an online survey.

METHODS

Foster carer's views were collected via an online survey and subjected to content analysis.

RESULTS

Respondents (n = 184) expressed mixed views about; mothers breastfeeding during contact visits, increased frequency of contact visits for breastfeeding; and the provision of expressed breastmilk to infants in their care. Concerns were raised about the safety of breastmilk from mothers abusing substances and the value of breastfeeding if reunification was not possible. Because of these concerns, some carers discarded expressed breastmilk and resisted frequent contact. Conversely, breastfeeding was also viewed positively as a way for mothers to maintain attachment with their infants, where reunification of the mother-infant dyad was the goal.

CONCLUSIONS

This study highlights foster carers' view of breastfeeding as a facilitator of attachment between mothers and their infants. While fosters carers were largely supportive of breastfeeding as a way to improve infant health and facilitate mother-infant attachment, they held concerns regarding the safety of breastmilk supplied to them.

Enhanced rapid review of the applicability of ultrasound in the assessment of sucking, swallowing and laryngeal function in the paediatric population

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has renewed interest in the use of ultrasound (US) amongst dysphagia-trained clinicians working with infants and children. US is a portable, minimally intrusive tool which carries reduced risk of aerosol-generation provoked by other instrumental swallowing assessment tools such as fibreoptic endoscopic evaluation of swallowing (FEES). For this reason, US could be a valuable addition to the dysphagia assessment toolkit. A recently published rapid review of US evidence for the assessment of swallowing and laryngeal function in the adult population provided a framework for this neonatal and paediatric review.

AIMS

This enhanced rapid review aimed to establish the applicability of US as an instrumental assessment tool for sucking, swallowing and laryngeal function in the neonatal and paediatric populations.

METHODS & PROCEDURES

A rapid review of six electronic databases was conducted to identify articles using US to assess sucking, swallowing or laryngeal function in the selected populations, compared with varied reference tests. Abstract screening was completed according to pre-defined inclusion/exclusion criteria with 10% of articles assessed by a second screener. Data was extracted from the included studies using a pre-developed form. A modified QUADAS-2 tool was used to assess study quality. Results from the included studies were summarised and grouped into sucking, swallowing and laryngeal function data.

OUTCOMES & RESULTS

Twelve studies using US in the assessment of swallowing and/or laryngeal function met inclusion criteria. No studies using US for assessment of sucking met the inclusion criteria. All were peer-reviewed, primary studies across a range of clinical populations and with a wide geographical spread. Five studies had an overall low risk of bias. Seven studies had at least one domain where risk of bias was judged as high. All studies had high applicability. The two studies assessing swallowing differed in terms of aims and use of US. The studies assessing laryngeal function predominately investigated vocal fold movement and laryngeal pathology. Sensitivity and specificity data were provided or calculated from raw data for nine of the laryngeal function studies (respective ranges of 75%-100% and 80%-100%).

CONCLUSIONS & IMPLICATIONS

Emerging evidence exists to support the use of US as adjunct to clinical assessment of swallowing and laryngeal function in the neonatal and paediatric population. A paucity of evidence to support use of US in the assessment of sucking exists. Further research is needed to establish evidence-based assessment and analysis protocols as well as development of paediatric data.

Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns

Tongue motility is an essential physiological component of human feeding from infancy through adulthood. At present, it is a challenge to distinguish among the many pathologies of swallowing due to the absence of quantitative tools. We objectively quantified tongue kinematics from ultrasound imaging during infant and adult feeding. The functional advantage of this method is presented in several subjects with swallowing difficulties. We demonstrated for the first time the differences in tongue kinematics during breast- and bottle-feeding, showing the arrhythmic sucking pattern during bottle-feeding as compared with breastfeeding in the same infant with torticollis. The method clearly displayed the improvement of tongue motility after frenotomy in infants with either tongue-tie or restrictive labial frenulum. The analysis also revealed the absence of posterior tongue peristalsis required for safe swallowing in an infant with dysphagia. We also analyzed for the first time the tongue kinematics in an adult during water bolus swallowing demonstrating tongue peristaltic-like movements in both anterior and posterior segments. First, the anterior segment undulates to close off the oral cavity and the posterior segment held the bolus, and then, the posterior tongue propelled the bolus to the pharynx. The present methodology of quantitative imaging revealed highly conserved patterns of tongue kinematics that can differentiate between swallowing pathologies and evaluate treatment interventions. The method is novel and objective and has the potential to advance knowledge about the normal swallowing and management of feeding disorders.

Flexible Endoscopic Evaluation of Swallowing in Breastfeeding Infants With Laryngomalacia: Observed Clinical and Endoscopic Changes With Alteration of Infant Positioning at the Breast

OBJECTIVES

This retrospective cohort study uses endoscopic assessment of the pharyngeal phase of swallowing in infants with laryngomalacia, to ascertain the impact of infant positioning on airway compromise and fluid dynamics during breastfeeding. The study aims to identify whether modification of infant positioning at the breast may improve the possibility of safe, successful breastfeeding in infants with laryngomalacia and concurrent breastfeeding difficulty.

METHODS

Twenty-three infants referred for noisy breathing and difficulty feeding were assessed with flexible endoscopic evaluation of swallowing (FEES) during breastfeeding. All had endoscopically confirmed laryngomalacia. During FEES, observations were made of clinical signs of airway compromise as well as endoscopically observable anatomical features and swallowing dynamics during breastfeeding, including tongue base position, view of laryngeal inlet and vocal folds, dynamic supraglottic soft tissue collapse, timing of milk flow into pyriform fossae/hypopharynx relative to sucking, and presence of penetration and/or aspiration. If airway and/or swallowing compromise was present, the infant's initial position at the breast was altered from supine or semi lateral decubitus position to semi-prone, with a description of the clinical and endoscopically observable changes that subsequently occurred.

RESULTS

Signs of dynamic airway obstruction and/or compromised airway protection with swallowing were present in 20 of the 23 infants (87%) in their initial supine or semi lateral decubitus position. These 20 infants were repositioned to semi-prone, with improvement and/or resolution of stridor and an improved ability to maintain latch in all infants. Continued endoscopic evaluation following positional change was possible in 16 infants, identifying anterior positioning of the tongue base, reduced dynamic supraglottic tissue collapse, reduced volume of milk flow into pyriform fossae during pauses in sucking and resolution of penetration and aspiration.

CONCLUSION

This study has shown how alteration of breastfeeding position to semi-prone may improve dynamic airway obstruction and reduce aspiration risk in infants with laryngomalacia.

Analysis of Clinical Efficacy of Traditional Chinese Medicine in Recovery Stage of Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

We provide an updated meta-analysis with detailed information on a combination of TCM and routine treatment.

METHODS

Retrieve appropriate articles with no language restrictions on keywords until 8 July 2019 in an electronic database. All trajectories are screened according to certain criteria. The quality of certified research was also evaluated. We made a detailed record of the results of the measurement. Meta-analysis was carried out by using the Revman 5.3 software.

RESULTS

Sixty-seven RCTs were included, and 6594 subjects were analyzed. Compared with routine treatment, the total effective rate (TER) of TCM combined with routine treatment was improved, and the recovery of stroke was also significantly accelerated. Regulation of blood lipids by notably shrinking the contents of TC, TG, and LDL and enhancing the levels of HDL. The levels of serum hs-CRP, WHV, and WLV decreased significantly, indicating that the expression of thrombomodulin was decreased after the comprehensive treatment of traditional Chinese medicines (TCMs). The combination of TCM treatment could enhance the protection of neural function by decreasing the NIHSS scoring while increasing the BI scoring. Paeoniae Radix Rubra, Angeticae Sinensis Radix, etc., can effectively improve the clinical symptoms of stroke convalescent patients and promote the recovery of neurological function. ACU of Baihui, Renzhong, etc., can improve the clinical rehabilitation effect of patients. However, our findings must be handled with care because of the small sample size and low quality of clinic trials cited. Other rigorous and large-scale RCTs are in need to confirm these results.

CONCLUSION

A combination of TCM and routine treatment in the treatment of stroke could improve TER, and it is beneficial to the rehabilitation of patients in the recovery period of apoplexy. These effects can be mediated by a combination of several mechanisms. Nevertheless, due to the limitations of this study, these results should be handled with caution.

Imaging the breastfeeding swallow: Pilot study utilizing real-time MRI

OBJECTIVE

Knowledge of the breastfeeding swallow is limited by practical challenges. Radiation exposure to both mother and infant and the radiolucent properties of breastmilk make videofluoroscopy an unsuitable imaging modality. Furthermore, ultrasound is not ideal for capturing the complex 3-dimensional functional anatomy of swallowing. In this study we explore the feasibility of using real-time MRI to capture the breastfeeding swallow.

METHODS

Prospective observational study: Review of imaging from 12 normal infants (<5 months of age) and their mothers while breastfeeding using real-time MRI.

RESULTS

Static images were successfully captured in 11 infants and dynamic images in nine infants. This imaging modality confirms the dorsal surface of the infant's tongue elevates the maternal nipple to the hard palate, closing the space around the nipple with no air visible in the oral cavity during sucking and swallowing. We obtained dynamic imaging of mandibular movement with sucking, palatal elevation and pharyngeal constriction with swallowing, diaphragm movement with breathing and milk entering the stomach. Breastmilk was easily visualized, being high intensity on T2 sequences. Technical challenges were encountered secondary to infant movement and difficulties acquiring and maintaining midsagittal orientation. The similarity in tissue densities of the lips, tongue, nipple and hard palate limited definition between these structures.

CONCLUSION

Real-time MRI imaging was successful in capturing dynamic images of the breastfeeding swallow. However, technical and practical challenges make real-time MRI unlikely at present to be suitable for swallow assessment in clinical practice. Advances in technology and expertise in dynamic image capture may improve the feasibility of using MRI to understand and assess the breastfeeding swallow in the near future.

LEVEL OF EVIDENCE

4.