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Njeh M, Sultana Z, Plumb T, Alshaikh E, Jadcherla SR. Comparison of direct effects of rice-thickened formula vs routine feeds on symptoms and gastroesophageal reflux indices: A crossover cohort study. JPEN J Parenter Enteral Nutr 2024; 48:64-73. [PMID: 37850573 DOI: 10.1002/jpen.2566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND We compared the direct effects of routine vs rice-thickened formula on 24-h pH-impedance and symptom characteristics and then examined if dietary effects were modified by acid reflux index severity in infants. METHODS Forty infants under consideration for gastroesophageal reflux disease and therapies were evaluated at 43 ± 1 weeks postmenstrual age. Each infant was equally fed routine diet and thickened formula during evaluations. Postprandial sessions were analyzed for acid reflux index, reflux events, clearance times, distal baseline impedance, and symptoms. RESULTS Thickened formula has no effect (P ≥ 0.05) on acid reflux events' characteristics or overall symptom frequency. However, refluxate height and frequency of weakly acidic events and cough were decreased (P < 0.05). Prolonged bolus clearance and a decrease in distal baseline impedance were noted with thickened feeds (vs routine feeds) when acid reflux index was >7 (P < 0.05). CONCLUSION Our pH-impedance testing protocol identifies direct effects of potential therapies at the point of care. Acutely, thickened formula does not impact acid-specific reflux indices but decreases full-column reflux and cough reflexes. In those with an acid reflux index of >7, thickened formula prolongs the distal esophageal bolus clearance (the mechanisms of which are uncertain). Clinical trials are needed to clarify objective indications and therapeutic use of thickened formulas for infants with gastroesophageal reflux disease, along with short- and long-term side effects.
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Affiliation(s)
- Minna Njeh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Zakia Sultana
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Toni Plumb
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Enas Alshaikh
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sudarshan R Jadcherla
- Innovative Feeding Disorders Research Program, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology and Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio, USA
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Hasenstab KA, Prabhakar V, Helmick R, Yildiz V, Jadcherla SR. Pharyngeal biorhythms during oral milk challenge in high-risk infants: Do they predict chronic tube feeding? Neurogastroenterol Motil 2023; 35:e14492. [PMID: 36371708 PMCID: PMC10078406 DOI: 10.1111/nmo.14492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Eating difficulties are common in high-risk neonatal intensive care unit (NICU) infants; mechanisms remain unclear. Crib-side pharyngo-esophageal motility testing is utilized to assess contiguous swallowing physiology, and cross-system interplay with cardio-respiratory rhythms. Aims were to: (1) identify whether distinct pharyngeal rhythms exist during oral milk challenge (OMC), and (2) develop a chronic tube feeding risk prediction model in high-risk infants. METHODS Symptomatic NICU infants (N = 56, 29.7 ± 3.7 weeks birth gestation) underwent pharyngo-esophageal manometry with OMC at 40.9 ± 2.5 weeks postmenstrual age (PMA). Exploratory cluster data analysis (partitioning around k-medoids) was performed to identify patient groups using pharyngeal contractile rhythm data (solitary swallows and swallows within bursts). Subsequently, (a) pharyngeal-esophageal, cardio-respiratory, and eating method characteristics were compared among patient groups using linear mixed models, and (b) chronic tube feeding prediction model was created using linear regression. RESULTS Three distinct patient groups were identified with validity score of 0.6, and termed sparse (high frequency of solitary swallows), intermediate, or robust (high swallow rate within bursts). Robust group infants had: lesser pharyngeal and esophageal variability, greater deglutition apnea, pharyngeal activity, and esophageal activity (all p < 0.05), but less frequent heart rate decreases (p < 0.05) with improved clinical outcomes (milk transfer rate, p < 0.001, and independent oral feeding at discharge, p < 0.03). Chronic tube feeding risk = -11.37 + (0.22 × PMA) + (-0.73 × bronchopulmonary dysplasia) + (1.46 × intermediate group) + (2.57 × sparse group). CONCLUSIONS Robust pharyngeal rhythm may be an ideal neurosensorimotor biomarker of independent oral feeding. Differential maturation of cranial nerve-mediated excitatory and inhibitory components involving foregut, airway, and cardiac rhythms distinguishes the physiologic and pathophysiologic basis of swallowing and cardio-respiratory adaptation.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Varsha Prabhakar
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Roseanna Helmick
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Vedat Yildiz
- Biostatistics Resource at Nationwide Children's Hospital (BRANCH), Columbus, Ohio, USA.,Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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3
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Sultana Z, Hasenstab KA, Moore RK, Osborn EK, Yildiz VO, Wei L, Slaughter JL, Jadcherla SR. Symptom Scores and pH-Impedance: Secondary Analysis of a Randomized Controlled Trial in Infants Treated for Gastroesophageal Reflux. GASTRO HEP ADVANCES 2022; 1:869-881. [PMID: 36310566 PMCID: PMC9615096 DOI: 10.1016/j.gastha.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND AIMS To evaluate and compare gastro-esophageal reflux (GER) symptom scores with pH-impedance and test the effects of acid-suppressive medications with or without feeding modifications on pH-impedance in high-risk infants. METHODS Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and 24-hour pH-impedance data were analyzed from 94 infants evaluated in a tertiary care setting for GER disease. Longitudinal data from 40 infants that received randomized GER therapy (proton pump inhibitor [PPI] with or without feeding modifications) for 4 weeks followed by 1-week washout were analyzed. Relationships between I-GERQ-R and pH-impedance metrics (acid reflux index, acid and bolus GER events, distal baseline impedance, and symptoms) were examined and effects of treatments compared. RESULTS (A) Correlations between I-GERQ-R and pH-impedance metrics were weak. (B) I-GERQ-R sensitivity, specificity, and positive predictive values were suboptimal when correlated with pH-impedance metrics. I-GERQ-R negative predictive value (NPV) was high for acid symptom-association probability (NPV = 84%) and distal baseline impedence (NPV = 86%) thresholds. (C) PPI with feeding modifications (vs PPI alone) did not alter pH-impedance metrics or symptom scores (P > .05); however, bolus clearance metrics worsened for both treatment groups (P < .05). CONCLUSIONS In high-risk infants (1) I-GERQ-R may be a helpful clinical screening tool to exclude acid-GER disease diagnosis and minimize unnecessary acid-suppressive treatment, but further testing is needed for diagnosis. (2) Acid-suppressive therapy with feeding modifications has no effect on symptom scores or pH-impedance metrics. Clearance of refluxate worsened despite PPI therapy, which may signal development of pharyngoesophageal dysmotility and persistence of symptoms. (3) Placebo-controlled trials are needed in high-risk infants with objective pH-impedance criteria to determine efficacy, safety, and underlying mechanisms. Clinicaltrials.gov ID: NCT02486263.
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Affiliation(s)
- Zakia Sultana
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Rebecca K. Moore
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Erika K. Osborn
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Vedat O. Yildiz
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lai Wei
- Biostatistics Resource at Nationwide Children’s Hospital, (BRANCH), Columbus, Ohio
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan L. Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Neonatology, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, The Ohio State University College of Medicine, Columbus, Ohio
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Hasenstab KA, Jadcherla SR. Evidence-Based Approaches to Successful Oral Feeding in Infants with Feeding Difficulties. Clin Perinatol 2022; 49:503-520. [PMID: 35659100 DOI: 10.1016/j.clp.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infants in the neonatal intensive care unit (NICU) frequently have feeding difficulties with the root cause remaining elusive to identify. Evaluation of the provider/parent/infant feeding process may provide objective clues to sources of feeding difficulty. Specialized testing may be necessary to determine if the infant's swallowing skills are dysfunctional, immature, or maldeveloped, and to determine the risk of feeding failure or chronic tube feeding. Current evidence-based diagnostic and management approaches resulting in successful oral feeding in the NICU infant are discussed.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroads, Columbus, OH 43215, USA; Division of Neonatology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Division Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, USA.
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5
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Heo JS, Kim EK, Kim SY, Song IG, Yoon YM, Cho H, Lee ES, Shin SH, Oh BM, Shin HI, Kim HS. Direct swallowing training and oral sensorimotor stimulation in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2022; 107:166-173. [PMID: 34281934 DOI: 10.1136/archdischild-2021-321945] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the effects of direct swallowing training (DST) alone and combined with oral sensorimotor stimulation (OSMS) on oral feeding ability in very preterm infants. DESIGN Blinded, parallel group, randomised controlled trial (1:1:1). SETTING Neonatal intensive care unit of a South Korean tertiary hospital. PARTICIPANTS Preterm infants born at <32 weeks of gestation who achieved full tube feeding. INTERVENTIONS Two sessions per day were provided according to the randomly assigned groups (control: two times per day sham intervention; DST: DST and sham interventions, each once a day; DST+OSMS: DST and OSMS interventions, each once a day). PRIMARY OUTCOME Time from start to independent oral feeding (IOF). RESULTS Analyses were conducted in 186 participants based on modified intention-to-treat (63 control; 63 DST; 60 DST+OSMS). The mean time from start to IOF differed significantly between the control, DST and DST+OSMS groups (21.1, 17.2 and 14.8 days, respectively, p=0.02). Compared with non-intervention, DST+OSMS significantly shortened the time from start to IOF (effect size: -0.49; 95% CI: -0.86 to -0.14; p=0.02), whereas DST did not. The proportion of feeding volume taken during the initial 5 min, an index of infants' actual feeding ability when fatigue is minimal, increased earlier in the DST+OSMS than in the DST. CONCLUSIONS In very preterm infants, DST+OSMS led to the accelerated attainment of IOF compared with non-intervention, whereas DST alone did not. The effect of DST+OSMS on oral feeding ability appeared earlier than that of DST alone. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02508571).
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Affiliation(s)
- Ju Sun Heo
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Ee-Kyung Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Sae Yun Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Catholic University of Korea Yeouido Saint Mary's Hospital, Seoul, Korea (the Republic of)
| | - In Gyu Song
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Korea University Guro Hospital, Seoul, Korea (the Republic of)
| | - Young Mi Yoon
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Jeju National University Hospital, Jeju, Korea (the Republic of)
| | - Hannah Cho
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Eun Sun Lee
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Paediatrics, Chung-Ang University Hospital, Seoul, Korea (the Republic of)
| | - Seung Han Shin
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea (the Republic of).,Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea (the Republic of).,Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea (the Republic of)
| | - Han-Suk Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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Jadcherla SR, Hasenstab KA, Osborn EK, Levy DS, Ipek H, Helmick R, Sultana Z, Logue N, Yildiz VO, Blosser H, Shah SH, Wei L. Mechanisms and management considerations of parent-chosen feeding approaches to infants with swallowing difficulties: an observational study. Sci Rep 2021; 11:19934. [PMID: 34620898 PMCID: PMC8497609 DOI: 10.1038/s41598-021-99070-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/20/2021] [Indexed: 02/08/2023] Open
Abstract
Videofluoroscopy swallow studies (VFSS) and high-resolution manometry (HRM) methods complement to ascertain mechanisms of infant feeding difficulties. We hypothesized that: (a) an integrated approach (study: parent-preferred feeding therapy based on VFSS and HRM) is superior to the standard-of-care (control: provider-prescribed feeding therapy based on VFSS), and (b) motility characteristics are distinct in infants with penetration or aspiration defined as penetration-aspiration scale (PAS) score ≥ 2. Feeding therapies were nipple flow, fluid thickness, or no modification. Clinical outcomes were oral-feeding success (primary), length of hospital stay and growth velocity. Basal and adaptive HRM motility characteristics were analyzed for study infants. Oral feeding success was 85% [76-94%] in study (N = 60) vs. 63% [50-77%] in control (N = 49), p = 0.008. Hospital-stay and growth velocity did not differ between approaches or PAS ≥ 2 (all P > 0.05). In study infants with PAS ≥ 2, motility metrics differed for increased deglutition apnea during interphase (p = 0.02), symptoms with pharyngeal stimulation (p = 0.02) and decreased distal esophageal contractility (p = 0.004) with barium. In conclusion, an integrated approach with parent-preferred therapy based on mechanistic understanding of VFSS and HRM metrics improves oral feeding outcomes despite the evidence of penetration or aspiration. Implementation of new knowledge of physiology of swallowing and airway protection may be contributory to our findings.
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Affiliation(s)
- Sudarshan R. Jadcherla
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA ,grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, 575 Children’s Crossroads, Columbus, OH 43215 USA ,grid.412332.50000 0001 1545 0811Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Kathryn A. Hasenstab
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Erika K. Osborn
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA ,grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, 575 Children’s Crossroads, Columbus, OH 43215 USA
| | - Deborah S. Levy
- grid.8532.c0000 0001 2200 7498Department of Speech and Language Pathology, Hospital de Clínicas de Porto Alegre, Department of Health and Communication, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Haluk Ipek
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Roseanna Helmick
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Zakia Sultana
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Nicole Logue
- grid.240344.50000 0004 0392 3476The Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH USA ,grid.240344.50000 0004 0392 3476Division of Neonatology, Nationwide Children’s Hospital, 575 Children’s Crossroads, Columbus, OH 43215 USA
| | - Vedat O. Yildiz
- grid.240344.50000 0004 0392 3476Biostatistics Resource at Nationwide Children’s Hospital (BRANCH), Nationwide Children’s Hospital, Columbus, OH USA ,grid.261331.40000 0001 2285 7943Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH USA
| | - Hailey Blosser
- grid.240344.50000 0004 0392 3476Division of Clinical Therapies, Nationwide Children’s Hospital, Columbus, OH USA
| | - Summit H. Shah
- grid.240344.50000 0004 0392 3476Department of Radiology, Nationwide Children’s Hospital, Columbus, OH USA
| | - Lai Wei
- grid.261331.40000 0001 2285 7943Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH USA
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Sultana Z, Hasenstab KA, Jadcherla SR. Pharyngoesophageal motility reflex mechanisms in the human neonate: importance of integrative cross-systems physiology. Am J Physiol Gastrointest Liver Physiol 2021; 321:G139-G148. [PMID: 34105355 PMCID: PMC8410102 DOI: 10.1152/ajpgi.00480.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Swallowing is a critical function for survival and development in human neonates and requires cross-system coordination between neurological, airway, and digestive motility systems. Development of pharyngoesophageal motility is influenced by intra- and extrauterine development, pregnancy complications, and neonatal comorbidities. The primary role of these motility reflex mechanisms is to maintain aerodigestive homeostasis under basal and adaptive biological conditions including oral feeding, gastroesophageal reflux, and sleep. Failure may result in feeding difficulties, airway compromise, dysphagia, aspiration syndromes, and chronic eating difficulties requiring prolonged tube feeding. We review the integration of cross-systems physiology to describe the basis for physiological and pathophysiological neonatal aerodigestive functions.
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Affiliation(s)
- Zakia Sultana
- 1Innovative Infant Feeding Disorders Research Program, Center for
Perinatal Research, Nationwide Children’s Hospital Research Institute, Columbus, Ohio
| | - Kathryn A. Hasenstab
- 1Innovative Infant Feeding Disorders Research Program, Center for
Perinatal Research, Nationwide Children’s Hospital Research Institute, Columbus, Ohio
| | - Sudarshan R. Jadcherla
- 1Innovative Infant Feeding Disorders Research Program, Center for
Perinatal Research, Nationwide Children’s Hospital Research Institute, Columbus, Ohio,2Divisions of Neonatology, Pediatric Gastroenterology, and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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8
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Characterization of Esophageal and Sphincter Reflexes across Maturation in Dysphagic Infants with Oral Feeding Success vs Infants requiring Gastrostomy. Dysphagia 2021; 37:148-157. [PMID: 33576892 DOI: 10.1007/s00455-021-10258-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
To test the hypothesis that esophageal and sphincteric sensory-motor reflexes are distinct across maturation in infants with dysphagia receiving gastrostomy-tube (G-tube). This is a retrospective review of 29 dysphagic infants (N = 15 study requiring gastrostomy, N = 14 age matched control achieving oral feeds) that underwent longitudinal pharyngeal-esophageal manometry at 42.3 (37-50.2) weeks postmenstrual age (PMA) and 48.9 (43.3-57.9) weeks PMA. Graded stimuli (0.1-5 mL) of varying media (air, water, and apple juice) tested esophageal peristaltic reflex, upper esophageal sphincter contractile reflex (UESCR), and lower esophageal sphincter relaxation reflex (LESRR). Comparisons were performed between study and controls and across maturation (time-1 vs time-2). Data represented as mean ± SE or OR (95% CI). Across maturation (time-1 vs time-2): Study infants did not exhibit significant differences across in peristaltic, UES, or LES reflexes (all p > 0.05). In contrast, controls exhibited increased UES resting pressure (13 ± 3 vs 17 ± 3 mmHg, p = 0.001), LES resting pressure (22 ± 3 vs 25 ± 3 mmHg, p < 0.009), LES nadir pressure (0.5 ± 1 vs 4.3 ± 1 mmHg, p = 0.001), and esophago-deglutition responses [2.5 (1.23-4.88), p = 0.04], and decreased secondary peristalsis [0.44 (0.31-0.61), p = 0.001], UESCR [0.4 (0.25-0.65), p = 0.001], LESRR [0.4 (0.24-0.75), p = 0.01], and symptoms [0.6 (0.45-0.83), p = 0.005]. Among infants with dysphagia, esophageal provocation induced peristaltic reflex, UESCR, and LESRR advance with longitudinal maturation when infants are oral-fed successfully, but not in those who received gastrostomy. Underlying mechanisms may be related to esophageal sensitivity, afferent or efferent transmission, and coordination of upstream excitation and downstream inhibition, which can be potential therapeutic targets for improving feeding capabilities after gastrostomy placement in infants with dysphagia.
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9
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Differentiating esophageal sensitivity phenotypes using pH-impedance in intensive care unit infants referred for gastroesophageal reflux symptoms. Pediatr Res 2021; 89:636-644. [PMID: 32375162 PMCID: PMC7644596 DOI: 10.1038/s41390-020-0930-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/24/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND To identify esophageal sensitivity phenotypes relative to acid (SAcid), bolus (SBolus), acid and bolus (SAcid+Bolus), and none (SNone) exposures in infants suspected with gastroesophageal reflux disease (GERD). METHODS Symptomatic infants (N = 279) were evaluated for GERD at 42 (40-45) weeks postmenstrual age using 24-h pH-impedance. Symptom-associated probability (SAP) for acid and bolus components defined esophageal sensitivity: (1) SAcid as SAP ≥ 95% for acid (pH < 4), (2) SBolus as SAP ≥ 95% for bolus, (3) SAcid+Bolus as SAP ≥ 95% for acid and bolus, or (4) SNone as SAP < 95% for acid and bolus. RESULTS Esophageal sensitivity prevalence (SAcid, SBolus, SAcid+Bolus, SNone) was 28 (10%), 94 (34%), 65 (23%), and 92 (33%), respectively. Emesis occurred more in SBolus and SAcid+Bolus vs SNone (p < 0.05). Magnitude (#/day) of cough and emesis events increased with SBolus and SAcid+Bolus vs SNone (p < 0.05). SAcid+Bolus had increased acid exposure vs SNone (p < 0.05). Distributions of feeding and breathing methods were distinct in infants with SBolus vs SNone (both, p < 0.05). Multivariate analysis revealed that arching and irritability events/day were lesser at higher PMAs (p < 0.001) and greater for infants on NCPAP (p < 0.01) with SBolus and SAcid+Bolus (p < 0.05). Coughs/day was greater at higher PMAs (p < 0.001) for infants with gavage and transitional feeding methods (p < 0.02) with SBolus and SAcid+Bolus (p < 0.05) but lesser with Trach (p < 0.001). Number of emesis events/day were greater with SBolus and SAcid+Bolus (p < 0.001). Sneezes/day decreased for infants on Trach (p = 0.02). CONCLUSIONS Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. We differentiated esophageal sensitivity phenotypes in NICU infants referred for GERD symptoms using pH-impedance. Acid sensitivity alone was rare, which may explain poor response to acid suppressives; aerodigestive symptoms were predominantly linked with bolus spread. Magnitude of esophageal acid exposure and esophageal sensitivity to bolus spread may explain the pathophysiological basis for symptoms. IMPACT Objective GERD diagnosis and reasons for symptoms in NICU infants remains unclear. Differentiation of esophageal sensitivities by acid and bolus components of GER reveal distinct symptom profiles, specifically the bolus component of GER significantly contributes to symptom occurrence. Acid only sensitivity to GER is rare, and acid-suppressive therapy alone may not improve symptoms in a majority of NICU infants. Magnitude of esophageal acid exposure and esophageal sensitivity to any bolus spread may explain the pathophysiological basis for symptoms. Feeding and breathing methods can influence the frequency and type of aerodigestive symptoms. GERD treatments should be individualized to the patient's GERD phenotype and likely also target the bolus component of GER.
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Jadcherla SR, Hasenstab KA, Gulati IK, Helmick R, Ipek H, Yildiz V, Wei L. Impact of Feeding Strategies With Acid Suppression on Esophageal Reflexes in Human Neonates With Gastroesophageal Reflux Disease: A Single-Blinded Randomized Clinical Trial. Clin Transl Gastroenterol 2020; 11:e00249. [PMID: 33259163 PMCID: PMC7643906 DOI: 10.14309/ctg.0000000000000249] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Aims were to test hypothesis that esophageal provocation-induced reflexes are superior with acid suppression plus feeding modifications vs acid suppression alone among infants treated for gastroesophageal reflux disease (GERD). METHODS Infants (N = 49, 41.3 ± 2.6 of postmenstrual age) with acid reflux index >3% underwent longitudinal motility testing (weeks 0 and 5) with graded midesophageal provocation to test randomly allocated therapies (4 weeks' proton pump inhibitor [PPI] ± feeding modifications) on sensory-motor aerodigestive reflexes. Feeding modification included restricted fluid volume <140 mL/kg per day, fed over 30 minutes in right lateral position and supine postprandial position. Primary motility outcome was frequency-occurrence of peristaltic reflex. Secondary outcomes included upper esophageal sphincter contractile reflex, lower esophageal sphincter (LES) relaxation reflex, respiratory change, and symptom characteristics. RESULTS Treatment groups did not differ for primary outcome (odds ratio = 0.8, 95% confidence interval 0.4-1.6, P = 0.99) or secondary outcomes (all P > 0.05). For both treatment groups at follow-up, distal esophageal contraction and LES tone decreased, and LES relaxation reflex occurrence is less frequent (all P < 0.05). In a subgroup analysis, comparing infants with PPI washout (N = 40) vs with continued (N = 9) PPI therapy, no differences were noted for aerodigestive reflex response frequency-occurrence (all P > 0.05). DISCUSSION In infants with GERD, feeding modification with acid suppression is not superior to acid suppression alone in modifying aerodigestive reflexes (frequency, sensation, or magnitude). Contiguous areas targeted by GER, i.e., LES and distal esophageal functions, worsened at follow-up for both groups despite PPI therapy. Maturation is likely the key factor for GERD resolution in infants, justifying the use of placebo in clinical trials for objectively determined GERD.
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Affiliation(s)
- Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital Columbus, Ohio, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ish K. Gulati
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital Columbus, Ohio, USA
| | - Roseanna Helmick
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Haluk Ipek
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Vedat Yildiz
- Biostatistics Resource at Nationwide Children's Hospital (BRANCH), Columbus, Ohio, USA
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Hasenstab KA, Jadcherla SR. Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Neonate: Controversies, Current Understanding, and Future Directions. Clin Perinatol 2020; 47:243-263. [PMID: 32439110 DOI: 10.1016/j.clp.2020.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Gastroesophageal reflux (GER) is considered physiologic and is a normal process; whereas, when aerodigestive consequences are associated, it is often interpreted as GER disease (GERD). However, the distinction between them remains a challenge in infants in the NICU. Reflux-type of symptoms are heterogeneous, and often managed with changes in diet, feeding methods, and acid-suppressive therapy; all these empiric therapies lack objectivity; hence, practice variation is universal. We clarify the current controversies, explain the potential role of GERD in causing symptoms and complications, and highlight current advances. The evidence basis for the diagnostic strategies is discussed.
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Affiliation(s)
- Kathryn A Hasenstab
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute, 575 Children's Crossroads, Columbus, OH 43215, USA
| | - Sudarshan R Jadcherla
- Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute, 575 Children's Crossroads, Columbus, OH 43215, USA; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA; Division Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, College of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
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12
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Gulati IK, Jadcherla SR. Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Infant: Who Needs to Be Treated and What Approach Is Beneficial? Pediatr Clin North Am 2019; 66:461-473. [PMID: 30819348 PMCID: PMC6400306 DOI: 10.1016/j.pcl.2018.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastroesophageal reflux (GER) and GER disease (GERD) pertaining to infants in the neonatal intensive care unit (NICU) are reviewed, based on research in this specific population. The developmental biology of the gastroesophageal junction, physiology of GER, and pathophysiology of GERD in this setting are summarized, and risk factors for GER and GERD identified. The epidemiology, economic burden, and controversies surrounding GERD in NICU infants are addressed, and an approach to GER and GERD in these patients formulated. Recent advancements in individual assessment of GER and GERD in the NICU infant are examined, and evidence-based guidelines for their adoption provided.
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Affiliation(s)
- Ish K Gulati
- Innovative Research Program in Neonatal Feeding Disorders; The Neonatal and Infant Feeding Disorders Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sudarshan R Jadcherla
- Innovative Research Program in Neonatal Feeding Disorders; The Neonatal and Infant Feeding Disorders Program, Nationwide Children's Hospital, Columbus, OH, USA; Division of Neonatology, Department of Pediatrics, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 575 Children's Cross Roads, Columbus, OH 43215, USA; Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 575 Children's Cross Roads, Columbus, OH 43215, USA.
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13
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Jetté ME, Clary MS, Prager JD, Finger TE. Chemical receptors of the arytenoid: A comparison of human and mouse. Laryngoscope 2019; 130:423-430. [PMID: 30908677 DOI: 10.1002/lary.27931] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/25/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS The larynx is a highly responsive organ exposed to mechanical, thermal, and chemical stimuli. Chemicals elicit responses both in intraepithelial nerve fibers and in specialized chemosensory cells, including scattered solitary cells as well as taste cells organized into taste buds. Activation of both chemosensory cells and taste buds in the larynx elicit cough, swallow, or apnea with exposure to sour or bitter substances, and even by water or sweet-tasting chemicals. In an effort to begin understanding their function, we sought to compare the distribution, density, and types of chemosensory cells and chemoresponsive nerve fibers in laryngeal epithelium of humans and mice. STUDY DESIGN Animal and human laboratory analysis. METHODS Using immunohistochemistry, we identified taste cells and polymodal nociceptive nerve fibers in the arytenoid area of the laryngeal epithelium of the following: 1) infants undergoing supraglottoplasty for laryngomalacia, and 2) a cadaveric specimen procured from a 34-year-old donor. We then compared these findings to both preweanling and mature mouse tissue. RESULTS Arytenoid tissue from both human and mouse contained many taste buds containing type II taste cells-bitter, sweet, or umami sensing-which were innervated by nerve fibers expressing P2X3 type adenosine triphosphate receptors. Type III cells (acid responsive) were also present, but they were fewer in human tissue than in equivalent tissue from mice. In both species, the epithelium was densely innervated by free nerve endings. CONCLUSIONS Our findings suggest that from a standpoint of chemosensation, human and mouse larynges are biologically similar. This suggests that a murine model can be used effectively in laryngeal chemosensory research. LEVEL OF EVIDENCE NA Laryngoscope, 130:423-430, 2020.
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Affiliation(s)
- Marie E Jetté
- Department of Otolaryngology, in the School of Medicine at the University of Colorado, Aurora, Colorado, U.S.A.,Rocky Mountain Taste and Smell Center, Aurora, Colorado, U.S.A
| | - Matthew S Clary
- Department of Otolaryngology, in the School of Medicine at the University of Colorado, Aurora, Colorado, U.S.A
| | - Jeremy D Prager
- Department of Otolaryngology, in the School of Medicine at the University of Colorado, Aurora, Colorado, U.S.A.,Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Thomas E Finger
- Department of Cell and Developmental Biology, Aurora, Colorado, U.S.A.,Rocky Mountain Taste and Smell Center, Aurora, Colorado, U.S.A
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Esophageal Impedance-pH Monitoring and Pharyngeal pH Monitoring in the Diagnosis of Extraesophageal Reflux in Children. Gastroenterol Res Pract 2019; 2019:6271910. [PMID: 30944563 PMCID: PMC6421743 DOI: 10.1155/2019/6271910] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/21/2018] [Indexed: 12/14/2022] Open
Abstract
Various clinical symptoms are attributed to extraesophageal reflux disease (EERD). Multichannel intraluminal impedance-pH monitoring (MII-pH) is considered to correlate symptoms with acid and nonacid gastroesophageal reflux (GER) events. Pharyngeal pH monitoring (Dx-pH) is considered to correlate the decrease in the pH level in the oropharynx with reported symptoms and to diagnose supraesophageal reflux. We aimed to assess the correlation between acid reflux episodes recorded by Dx-pH and GER detected via MII-pH in children with suspected EERD. The study enrolled 23 consecutive children (15 boys and 8 girls; median age 8.25 [range 3-16.5] years) with suspected EERD. MII-pH and Dx-pH were conducted concurrently in all patients. A total of 1228 reflux episodes were recorded by MII-pH. With the antimonic sensor placed inside the impedance probe, 1272 pH-only reflux episodes were recorded. Of these, 977 (76.81%) were associated with a retrograde bolus transit. Regarding GER, 630 full-column episodes extended to the most proximal pair of impedance sensors; 500 (83.33%) demonstrated an acidic character. The following acid reflux numbers were determined by the Dx-pH system: for pH < 4, n = 126; pH < 4.5, n = 136; pH < 5, n = 167; and pH < 5.5, n = 304, and for a decrease in pH > 10% relative to the baseline, n = 324. There was no significant correlation between the number of pharyngeal reflux episodes detected by Dx-pH and that of GERs identified by MII-pH. The proportion of oropharyngeal pH events that were temporally related to a GER episode increased with the extended pH criteria. The highest proportion was observed for a pH decrease of ≥10% from the baseline and did not exceed 5.2%. The application of the extended pH criteria in the Dx-pH system resulted in an increase in the number of diagnosed laryngopharyngeal refluxes; most were not temporally associated with GER episodes confirmed by MII-pH. Thus, the efficacy of the exclusive application of Dx-pH for supraesophageal gastric reflux diagnosis is uncertain.
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Collins CR, Hasenstab KA, Nawaz S, Jadcherla SR. Mechanisms of Aerodigestive Symptoms in Infants with Varying Acid Reflux Index Determined by Esophageal Manometry. J Pediatr 2019; 206:240-247. [PMID: 30466790 PMCID: PMC6389384 DOI: 10.1016/j.jpeds.2018.10.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To test whether symptom generation in infants is related to the severity of gastroesophageal reflux disease (GERD) symptoms as determined by the Acid Reflux Index (ARI), stimulus media, and stimulus volume during provocative esophageal manometry. STUDY DESIGN Symptomatic neonates (n = 74) born at a median of 28.9 weeks gestation (range, 23.4-39.4 weeks) were studied at a median of 41.0 weeks (range, 34.6-48.0 weeks) postmenstrual age using 24-hour pH-impedance methods to determine ARI severity, followed by provocative esophageal manometry with graded mid-esophageal infusions (0.1-5.0 mL) of air, water, and apple juice. Peristaltic reflexes and symptom characteristics were compared among ARI severity categories using linear mixed models and generalized estimating equations. RESULTS The effects of 2635 separate esophageal stimuli on reflexes and symptoms were analyzed. Peristaltic reflexes occurred in 1880 infusions (71%), and physical, cardiorespiratory, sensory symptoms were seen in 439 infusions (17%). Symptom prevalence did not differ across the ARI severity categories (ARI <3, 18%; ARI 3-7, 17%; ARI >7, 16%; P = 1.0). Symptom and peristaltic responses increased with incremental stimulus volumes (all media, P < .001). CONCLUSIONS Symptoms and peristaltic reflexes are manifestations of the recruitment of several neurosensory and neuromotor pathways evoked by mid-esophageal infusions. ARI severity grade plays no role in symptom generation, indicating that GERD should not be diagnosed and severity should not be assigned based on symptoms alone. An increase in symptom occurrence was noted with increasing stimulus volumes, which provided increased activation of receptors, afferents, and efferents in evoking peristaltic clearance reflexes.
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Affiliation(s)
- Carissa R. Collins
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Saira Nawaz
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Center for Perinatal Research, Division of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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16
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Hasenstab KA, Nawaz S, Lang IM, Shaker R, Jadcherla SR. Pharyngoesophageal and cardiorespiratory interactions: potential implications for premature infants at risk of clinically significant cardiorespiratory events. Am J Physiol Gastrointest Liver Physiol 2019; 316:G304-G312. [PMID: 30543445 PMCID: PMC6397335 DOI: 10.1152/ajpgi.00303.2018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aims of this study were to 1) examine pharyngoesophageal and cardiorespiratory responses to provoking pharyngeal stimuli, and 2) to determine potential contributory factors impacting heart rate (HR) changes to provide insight into cardiorespiratory events occurring in preterm infants. Forty-eight neonates (19 females and 29 males, born at 27.7 ± 0.5 wk; mean ± SE) pending discharge on full oral feeds were studied at 38.7 ± 0.2 wk postmenstrual age using concurrent pharyngoesophageal manometry, electrocardiography, respiratory inductance plethysmography, and nasal airflow thermistor. Pharyngoesophageal and cardiorespiratory responses (prevalence, latency, and duration) were quantified upon abrupt pharyngeal water stimuli (0.1, 0.3, and 0.5 ml in triplicate). Mixed linear models and generalized estimating equations were used for comparisons between HR changes. Contributory factors included stimulus characteristics and subject characteristics. Of 338 pharyngeal stimuli administered, HR increased in 23 (7%), decreased in 108 (32%), and remained stable in 207 (61%) neonates. HR decrease resulted in repetitive swallowing, increased respiratory-rhythm disturbance, and decreased esophageal propagation rates (all, P < 0.05). HR responses were related to stimulus volume, stimulus flow rate, and extreme prematurity (all, P < 0.05). In preterm infants, HR remains stable in a majority of pharyngeal provocations. HR decrease, due to pharyngeal stimulation, is related to aberrant pharyngoesophageal motility and respiratory dysregulation and is magnified by prematurity. We infer that the observed aberrant responses across digestive, respiratory, and cardiovascular systems are related to maladaptive maturation of the parasympathetic nervous system. These aberrant responses may provide diagnostic clues for risk stratification of infants with troublesome cardiorespiratory events and swallowing difficulty. NEW & NOTEWORTHY Cardiorespiratory rhythms concurrent with pharyngeal, upper esophageal sphincter, and esophageal body responses were examined upon pharyngeal provocation in preterm-born infants who were studied at full-term maturation. Decreased heart rate (HR) was associated with extreme preterm birth and stimulus flow/volume. With HR decrease responses, aerodigestive reflex abnormalities were present, characterized by prolonged respiratory rhythm disturbance, repetitive multiple swallowing, and poor esophageal propagation. Promoting esophageal peristalsis may be a potential therapeutic target.
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Affiliation(s)
- Kathryn A. Hasenstab
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Saira Nawaz
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Ivan M. Lang
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Reza Shaker
- 2Medical College of Wisconsin Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sudarshan R. Jadcherla
- 1Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,4Division of Neonatology, Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
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Calkovska A, Mokra D, Calkovsky V, Matasova K, Zibolen M. Clinical considerations when treating neonatal aspiration syndromes. Expert Rev Respir Med 2019; 13:193-203. [DOI: 10.1080/17476348.2019.1562340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Andrea Calkovska
- Department of Physiology and Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Daniela Mokra
- Department of Physiology and Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Vladimir Calkovsky
- Clinic of Otorhinolaryngology and Head and Neck Surgery, Jessenius Faculty of Medicine, Comenius University and University Hospital Martin, Martin, Slovakia
| | - Katarina Matasova
- Clinic of Neonatology, Jessenius Faculty of Medicine, Comenius University and University Hospital Martin, Martin, Slovakia
| | - Mirko Zibolen
- Clinic of Neonatology, Jessenius Faculty of Medicine, Comenius University and University Hospital Martin, Martin, Slovakia
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Hart BJ, Viswanathan S, Jadcherla SR. Persistent feeding difficulties among infants with fetal opioid exposure: mechanisms and clinical reasoning. J Matern Fetal Neonatal Med 2018; 32:3633-3639. [PMID: 30198364 DOI: 10.1080/14767058.2018.1469614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Aims: Infants with fetal exposure to opioids have varying pattern of feeding difficulties mainly manifesting as difficulties with aerodigestive adaptation and disruptive feeding behavior. The reasons are unclear; in a pilot study, we determined basal and adaptive pharyngo-esophageal motility in a group of infants with fetal exposure to opioids and persistent feeding difficulties impeding their discharge. Methods: Six infants with fetal opioid exposure compared to 12 controls who underwent basal and adaptive pharyngo-esophageal manometry to characterize the basis for their symptoms. Spontaneous swallows (N = 180) and pharyngeal stimuli (N = 113)-induced swallowing responses were analyzed. Results: Resting upper esophageal sphincter (UES) pressure was similar in both the groups, but resting lower esophageal sphincter (LES) pressure was significantly high and it relaxed slowly and inadequately in opioid-exposed infants (p < .05). Upon pharyngeal provocation, opioid-exposed infants had higher LES nadir pressure, increased duration of esophageal body contraction at proximal-, mid-, and distal-esophagus, as well as greater area under the curve with distal esophageal waveforms, compared to controls (all p < .05). Conclusions: These pilot observations are suggestive of up-regulation of central vagal effects with heightened cholinergic excitatory responses and inadequate relaxation responses at the foregut, and may form the basis for persistent feeding difficulties in opioid-exposed infants. Abnormality with both sensory and motor aspects of vagal reflexes may be contributory.
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Affiliation(s)
- Brandon J Hart
- a Department of Pediatrics , McKay-Dee Hospital, Intermountain Health Care , Ogden , UT , USA
| | - Sreekanth Viswanathan
- b Division of Neonatology, Department of Pediatrics , Nationwide Children's Hospital, Ohio State University College of Medicine , Columbus , OH , USA.,c Innovative Feeding Disorders Research Program , Center for Perinatal Research, The Research, Institute at Nationwide Children's Hospital , Columbus , OH , USA
| | - Sudarshan R Jadcherla
- b Division of Neonatology, Department of Pediatrics , Nationwide Children's Hospital, Ohio State University College of Medicine , Columbus , OH , USA.,c Innovative Feeding Disorders Research Program , Center for Perinatal Research, The Research, Institute at Nationwide Children's Hospital , Columbus , OH , USA
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Jadcherla SR, Prabhakar V, Hasenstab KA, Nawaz S, Das J, Kern M, Balasubramanian G, Shaker R. Defining pharyngeal contractile integral during high-resolution manometry in neonates: a neuromotor marker of pharyngeal vigor. Pediatr Res 2018; 84:341-347. [PMID: 29976974 PMCID: PMC6258262 DOI: 10.1038/s41390-018-0097-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/17/2018] [Accepted: 06/16/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pharyngeal contractility is critical for safe bolus propulsion. Pharyngeal contractile vigor can be measured by Pharyngeal Contractile Integral (PhCI): product of mean pharyngeal contractile amplitude, length, and duration. We characterized PhCI in neonates and examined the hypothesis that PhCI differs with mode of stimulation. METHODS Nineteen neonates born at 38.6 (34-41) weeks gestation were evaluated at 42.9 (40.4-44.0) weeks postmenstrual age using high-resolution manometry (HRM). PhCI was calculated using: (a) Conventional and (b) Automated Swallow Detection algorithm (ASDA) methods. Contractility metrics of all pharyngeal regions were examined using mixed statistical models during spontaneous and adaptive state (pharyngeal and oral stimulus) swallowing. RESULTS PhCI of oral stimuli swallows were distinct from pharyngeal stimuli and spontaneous swallows (P < 0.05). Correlation between conventional and ASDA methods was high (P < 0.001). PhCI increased with swallows for pharyngeal stimulation (P < 0.05) but remained stable for swallows with oral stimulation. PhCI differed between proximal and distal pharynx (P < 0.001). CONCLUSIONS PhCI is a novel reliable metric capable of distinguishing (1) proximal and distal pharyngeal activity, (2) effects of oral and pharyngeal stimulation, and (3) effects of prolonged stimulation. Changes in pharyngeal contractility with maturation, disease, and therapies can be examined with PhCI.
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Affiliation(s)
- Sudarshan R. Jadcherla
- Innovative Infant Feeding Disorders Research Program; The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Division of Neonatology, Pediatric Gastroenterology and Nutrition; Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH
| | - Varsha Prabhakar
- Innovative Infant Feeding Disorders Research Program; The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Kathryn A. Hasenstab
- Innovative Infant Feeding Disorders Research Program; The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Saira Nawaz
- Innovative Infant Feeding Disorders Research Program; The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Jayajit Das
- Center for Mathematical Medicine, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Mark Kern
- Division of Gastroenterology and Hepatology and Internal Medicine; Medical College of Wisconsin, Milwaukee, WI
| | | | - Reza Shaker
- Division of Gastroenterology and Hepatology and Internal Medicine; Medical College of Wisconsin, Milwaukee, WI
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20
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Ballester A, Gould F, Bond L, Stricklen B, Ohlemacher J, Gross A, DeLozier K, Buddington R, Buddington K, Danos N, German R. Maturation of the Coordination Between Respiration and Deglutition with and Without Recurrent Laryngeal Nerve Lesion in an Animal Model. Dysphagia 2018; 33:627-635. [PMID: 29476275 DOI: 10.1007/s00455-018-9881-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/15/2018] [Indexed: 01/02/2023]
Abstract
The timing of the occurrence of a swallow in a respiratory cycle is critical for safe swallowing, and changes with infant development. Infants with damage to the recurrent laryngeal nerve, which receives sensory information from the larynx and supplies the intrinsic muscles of the larynx, experience a significant incidence of dysphagia. Using our validated infant pig model, we determined the interaction between this nerve damage and the coordination between respiration and swallowing during postnatal development. We recorded 23 infant pigs at two ages (neonatal and older, pre-weaning) feeding on milk with barium using simultaneous high-speed videofluoroscopy and measurements of thoracic movement. With a complete linear model, we tested for changes with maturation, and whether these changes are the same in control and lesioned individuals. We found (1) the timing of swallowing and respiration coordination changes with maturation; (2) no overall effect of RLN lesion on the timing of coordination, but (3) a greater magnitude of maturational change occurs with RLN injury. We also determined that animals with no surgical intervention did not differ from animals that had surgery for marker placement and a sham procedure for nerve lesion. The coordination between respiration and swallowing changes in normal, intact individuals to provide increased airway protection prior to weaning. Further, in animals with an RLN lesion, the maturation process has a larger effect. Finally, these results suggest a high level of brainstem sensorimotor interactions with respect to these two functions.
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Affiliation(s)
- Ashley Ballester
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA.,Division of Obstetrics and Gynecology, Akron General Hospital, Akron, OH, USA
| | - François Gould
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Laura Bond
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Bethany Stricklen
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Andrew Gross
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Katherine DeLozier
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA
| | - Randall Buddington
- School of Health Studies, University of Memphis, Memphis, TN, 38152, USA
| | - Karyl Buddington
- Department of Biological Sciences, University of Memphis, Memphis, TN, 38152, USA
| | | | - Rebecca German
- Department of Anatomy and Neurobiology, NEOMED, Rootstown, OH, 44272, USA.
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21
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Broers C, Tack J, Pauwels A. Review article: gastro-oesophageal reflux disease in asthma and chronic obstructive pulmonary disease. Aliment Pharmacol Ther 2018; 47:176-191. [PMID: 29193245 DOI: 10.1111/apt.14416] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/29/2017] [Accepted: 10/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND When gastro-oesophageal reflux is causing symptoms or lesions in the oesophagus, this is referred to as gastro-oesophageal reflux disease (GERD). GERD can manifest itself through typical symptoms (heartburn, regurgitation) or may lead to extra-oesophageal symptoms. Extra-oesophageal manifestations of GERD gained increasing attention over the last decade, especially respiratory disorders, because of the prevalent co-occurrence with GERD. The role of GERD in the pathogenesis of respiratory disorders has become a topic of intense discussion. AIM To provide an overview of the current knowledge on the role of GERD in asthma and chronic obstructive pulmonary disease (COPD). METHODS PubMed was searched for relevant articles using the keywords: GERD, asthma, COPD, prevalence, treatment. Case reports were excluded, only English language articles were considered. RESULTS Estimates for the prevalence of GERD in asthma range from 30% to 90%, compared to an average of 24% in controls. In COPD patients, the prevalence of GERD ranges from 19% to 78% compared to an average of 18% in controls. These data indicate an increased prevalence of GERD in patients with asthma and COPD, although causality is not established and GERD treatment yielded inconsistent effects. Literature supports GERD as a risk factor for COPD-exacerbations and a predictor of the 'frequent-exacerbator'-phenotype. CONCLUSIONS Despite the high prevalence of GERD in asthma and COPD, a causal link is lacking. The results of anti-reflux therapy on pulmonary outcome are inconsistent and contradictory. Future studies will need to identify subgroups of asthmatics and COPD patients that may benefit from anti-reflux therapy (nocturnal or silent reflux).
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Affiliation(s)
- C Broers
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - J Tack
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium.,Department of Gastroenterology, Leuven University Hospitals, Leuven, Belgium
| | - A Pauwels
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
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22
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Maturation Modulates Pharyngeal-Stimulus Provoked Pharyngeal and Respiratory Rhythms in Human Infants. Dysphagia 2017; 33:63-75. [PMID: 28828751 DOI: 10.1007/s00455-017-9833-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
Pharyngeal-provocation induced aerodigestive symptoms in infants remain an enigma. Sources of pharyngeal provocation can be anterograde as with feeding, and retrograde as in gastroesophageal reflux. We determined maturational and dose-response effects of targeted pharyngeal-stimulus on frequency, stability, and magnitude of pharyngeal and respiratory waveforms during multiple pharyngeal swallowing responses in preterm-born infants when they were of full-term postmenstrual age (PMA). Eighteen infants (11 male) were studied longitudinally at 39.8 ± 4.8 weeks PMA (time-1) and 44.1 ± 5.8 weeks PMA (time-2). Infants underwent concurrent pharyngo-esophageal manometry, respiratory inductance plethysmography, and nasal airflow thermistor methods to test sensory-motor interactions between the pharynx, esophagus, and airway. Linear mixed models were used and data presented as mean ± SEM or %. Overall, responses to 250 stimuli were analyzed. Of the multiple pharyngeal swallowing responses (n = 160), with maturation (a) deglutition apnea duration decreases (p < 0.01), (b) number of pharyngeal waveform peaks and duration decreases for initial responses (p < 0.01), and subsequent responses have lesser variation and greater stability (p < 0.01). With increment in stimulus volumes we noted (a) increased prevalence (%) of pharyngeal responses (p < 0.05), (b) increased number of pharyngeal peaks (p < 0.05), yet pharyngeal frequency (Hz), variability, and stability remain unaffected (p > 0.05), and (c) respiratory changes were unaffected (p > 0.05). Initial and subsequent pharyngeal responses and respiratory rhythm interactions become more distinct with maturation. Interval oromotor experiences and volume-dependent increase in adaptive responses may be contributory. These mechanisms may be important in modulating and restoring respiratory rhythm normalcy.
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23
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Nault S, Samson N, Nadeau C, Djeddi D, Praud JP. Reflex cardiorespiratory events from esophageal origin are heightened by preterm birth. J Appl Physiol (1985) 2017; 123:489-497. [PMID: 28572501 DOI: 10.1152/japplphysiol.00915.2016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 05/08/2017] [Accepted: 05/24/2017] [Indexed: 12/19/2022] Open
Abstract
The involvement of gastroesophageal refluxes in cardiorespiratory events of preterm infants remains controversial. While a few studies in full-term newborn animals have shown that stimulation of esophageal receptors leads to cardiorespiratory reflexes, the latter remain largely unknown, especially after premature birth. The present study aimed to 1) characterize the cardiorespiratory reflexes originating from esophageal receptors in newborn lambs and 2) test the hypotheses that preterm birth enhances reflex cardiorespiratory inhibition and that C-fibers are involved in these reflexes. Eight full-term lambs and 10 lambs born 14 days prematurely were studied. Following surgical instrumentation, a 6-h polysomnography was performed without sedation to record electrocardiogram, respiratory movements, arterial pressure, laryngeal constrictor muscle activity, state of alertness, and hemoglobin oxygen saturation. Five esophageal stimulations of the upper and/or lower esophagus, including rapid balloon inflation and/or HCl injection, were performed in random order. A second recording was performed in full-term lambs 24 h later, after C-fiber blockade by capsaicin. Results confirmed that esophageal stimulations induced inhibitory cardiorespiratory reflexes combined with protective mechanisms, including laryngeal closure, swallowing, coughing, increased arterial pressure, and arousal. Preterm birth heightened cardiorespiratory inhibition. The strongest cardiorespiratory inhibition was observed following simultaneous stimulation of the lower and upper esophagus. Finally, cardiorespiratory inhibition was decreased after C-fiber blockade. In conclusion, esophageal stimulation induces inhibitory cardiorespiratory reflexes, which are partly mediated by C-fibers and more pronounced in preterm lambs. Clinical relevance of these findings requires further studies, especially in conditions associated with increased cardiorespiratory events, e.g., neonatal infection.NEW & NOTEWORTHY Preterm birth heightens the cardiorespiratory events triggered by esophageal stimulation. The most extensive cardiorespiratory events are induced by simultaneous stimulation of the proximal and distal esophagus.
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Affiliation(s)
- Stéphanie Nault
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Quebec, Canada; and
| | - Nathalie Samson
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Quebec, Canada; and
| | - Charlène Nadeau
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Quebec, Canada; and
| | - Djamal Djeddi
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Quebec, Canada; and.,Department of Pediatrics, Université de Picardie Jules Verne, Amiens, France
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, Quebec, Canada; and
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24
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Effects of Esophageal Acidification on Troublesome Symptoms: An Approach to Characterize True Acid GERD in Dysphagic Neonates. Dysphagia 2017; 32:509-519. [PMID: 28365873 DOI: 10.1007/s00455-017-9792-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
To quantify and compare maximal extent (height) of acid reflux events (AREs) on symptom generation in dysphagic neonates. Dysphagic neonates (N = 53), born at 30 ± 5.3 weeks gestation, underwent 24-hour pH-impedance study for the evaluation of troublesome symptoms purported to be due to gastroesophageal reflux disease (GERD). AREs (pH < 4 for >4 s) detected by impedance (Z) were categorized by maximal extent as refluxate reaching distal (Z6, Z5), middle (Z4, Z3), or proximal (Z2, Z1) impedance channels. AREs reaching the pH sensor only were categorized as distal. Symptom correlation (%, symptom index, symptom sensitivity index, and symptom associated probability) and temporal characteristics (clearance times) of AREs were analyzed using linear mixed and GEE models comparing height categories presented as mean ± SEM, median (IQR), and OR (95% CI). Of the 2003 AREs, 1) distal extent AREs (n = 1642) had increased frequency (p < 0.05), decreased ACT (p < 0.05), and decreased acidity (p < 0.05); 2) in middle and proximal AREs, acid clearance was longer than bolus clearance, (p < 0.01); and 3) the odds of having cardiorespiratory (cough or sneeze) symptoms are increased with proximal and middle AREs (p < 0.05). Most proximal ascent of AREs into middle or proximal esophagus likely activates protective aerodigestive reflexes (peristalsis) or vigilant states to facilitate bolus and chemical clearance. Heightened esophageal sensitivity, acid neutralization delays, or clearance mechanism delays may accentuate multi-systemic troublesome symptoms.
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25
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Coutier-Marie L, Ioan I, Bonabel C, Demoulin B, Leblanc AL, Debitu L, Schweitzer C, Marchal F, Demoulin-Alexikova S. Maturation of Airway Defensive Reflexes Is Related to Development of Feeding Behavior during Growth in Rabbits. Front Physiol 2017; 8:64. [PMID: 28228733 PMCID: PMC5296324 DOI: 10.3389/fphys.2017.00064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Cough and expiration reflex are major lower airway defense mechanisms that have not been studied throughout development in relation with the feeding behavior. Aim: To describe airway defense reflexes evoked by mechanical stimulation of the trachea in developing rabbit pups. Material and Methods: Sixty one pups were allocated to 3 groups according to their feeding behavior: suckling (n = 22), weanling (n = 21) and weaning (n = 18) group. The incidence and sensitivity of defense reflexes triggered by mechanical tracheal stimulation were studied in anesthetized and tracheotomized animals. Data are expressed as median (25th to 75th percentile). Results: The overall incidence of defensive responses (cough and/or expiration reflex) was found to be significantly higher in suckling [100% (50–100%); p = 0.01] and weanling [75% (40–100%); p = 0.05] animals when compared to weaning ones [37.5% (0–75%)]. However, cough motor pattern accounted for only 29% (0–62%) of all defensive responses in suckling rabbits and its frequency was significantly lower in this group when compared with weanling [100%(50–100%); p = 0.006] or weaning group [62%(50–100%), p = 0.05]. In other word the expiration reflex was the dominant response in suckling animals. Conclusion: Incidence and motor pattern of defensive responses were found to be linked to the pup feeding behavior and the expiration reflex was the major response triggered in suckling pups. The results suggest that this reflex is especially fitted to occur during the coordinated swallowing - breathing fast activities of sucking.
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Affiliation(s)
- Laurianne Coutier-Marie
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de LorraineVandœuvre-lès-Nancy, France; Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'EnfantsVandœuvre-lès-Nancy, France; Service de Pneumologie, Hôpital Femme-Mère-Enfant, Hospices Civils de LyonLyon, France
| | - Iulia Ioan
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de LorraineVandœuvre-lès-Nancy, France; Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'EnfantsVandœuvre-lès-Nancy, France
| | - Claude Bonabel
- Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'Enfants Vandœuvre-lès-Nancy, France
| | - Bruno Demoulin
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de Lorraine Vandœuvre-lès-Nancy, France
| | - Anne-Laure Leblanc
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de Lorraine Vandœuvre-lès-Nancy, France
| | - Ludivine Debitu
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de Lorraine Vandœuvre-lès-Nancy, France
| | - Cyril Schweitzer
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de LorraineVandœuvre-lès-Nancy, France; Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'EnfantsVandœuvre-lès-Nancy, France
| | - François Marchal
- Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'Enfants Vandœuvre-lès-Nancy, France
| | - Silvia Demoulin-Alexikova
- EA 3450DevAH - Laboratoire de Physiologie, Faculté de Médicine, Université de LorraineVandœuvre-lès-Nancy, France; Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'EnfantsVandœuvre-lès-Nancy, France
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26
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Jadcherla SR. Advances with Neonatal Aerodigestive Science in the Pursuit of Safe Swallowing in Infants: Invited Review. Dysphagia 2017; 32:15-26. [PMID: 28044203 PMCID: PMC5303645 DOI: 10.1007/s00455-016-9773-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/21/2016] [Indexed: 11/26/2022]
Abstract
Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes and behaviors facilitating ingestion. Swallowing involves anterograde bolus movement during oral-, pharyngeal-, and esophageal phases of peristalsis into stomach. During these events, coordination with airway protection is vital for homeostasis in clearing any material away from airway vicinity. Neurological-airway-digestive inter-relationships are critical to the continuum of successful feeding patterns during infancy, either in health or disease. Neonatal feeding difficulties encompass a heterogeneous group of neurological, pulmonary, and aerodigestive disorders that present with multiple signs posing as clinical conundrums. Significant research breakthroughs permitted understanding of vagal neural pathways and functional aerodigestive connectivity involved in regulating swallowing and aerodigestive functions either directly or indirectly by influencing the supra-nuclear regulatory centers and peripheral effector organs. These neurosensory and neuromotor pathways are influenced by pathologies during perinatal events, prematurity, inflammatory states, and coexisting medical and surgical conditions. Approaches to clarify pathophysiologic mapping of aerodigestive interactions, as well as translating these discoveries into the development of personalized and simplified feeding strategies to advance child health are discussed in this review article.
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Affiliation(s)
- Sudarshan R Jadcherla
- The Neonatal and Infant Feeding Disorders Program, Department of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA.
- Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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27
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Sankaran J, Qureshi AH, Woodley F, Splaingard M, Jadcherla SR. Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events. J Pediatr 2016; 179:42-48.e1. [PMID: 27692861 PMCID: PMC5206757 DOI: 10.1016/j.jpeds.2016.08.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/01/2016] [Accepted: 08/19/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state. STUDY DESIGN Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state. RESULTS Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups. CONCLUSIONS Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.
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Affiliation(s)
- Janani Sankaran
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide sChildren’s Hospital, Columbus, Ohio
| | - Aslam H. Qureshi
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide sChildren’s Hospital, Columbus, Ohio
| | - Frederick Woodley
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
| | - Mark Splaingard
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio,Division of Pulmonary Medicine, Sleep Laboratory, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sudarshan R Jadcherla
- Innovative Neonatal and Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Division of Pediatric Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.
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28
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Lang IM, Medda BK, Jadcherla SR, Shaker R. Characterization and mechanisms of the pharyngeal swallow activated by stimulation of the esophagus. Am J Physiol Gastrointest Liver Physiol 2016; 311:G827-G837. [PMID: 27634013 PMCID: PMC5130554 DOI: 10.1152/ajpgi.00291.2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/07/2016] [Indexed: 01/31/2023]
Abstract
Stimulation of the esophagus activates the pharyngeal swallow response (EPSR) in human infants and animals. The aims of this study were to characterize the stimulus and response of the EPSR and to determine the function and mechanisms generating the EPSR. Studies were conducted in 46 decerebrate cats in which pharyngeal, laryngeal, and esophageal motility was monitored using EMG, strain gauges, or manometry. The esophagus was stimulated by balloon distension or luminal fluid infusion. We found that esophageal distension increased the chance of occurrence of the EPSR, but the delay was variable. The chance of occurrence of the EPSR was related to the position, magnitude, and length of the stimulus in the esophagus. The most effective stimulus was long, strong, and situated in the cervical esophagus. Acidification of the esophagus activated pharyngeal swallows and sensitized the receptors that activate the EPSR. The EPSR was blocked by local anesthesia applied to the esophageal lumen, and electrical stimulation of the recurrent laryngeal nerve caudal to the cricoid cartilage (RLNc) activated the pharyngeal swallow response. We conclude that the EPSR is activated in a probabilistic manner. The receptors mediating the EPSR are probably mucosal slowly adapting tension receptors. The sensory neural pathway includes the RLNc and superior laryngeal nerve. We hypothesize that, because the EPSR is observed in human infants and animals, but not human adults, activation of EPSR is related to the elevated position of the larynx. In this situation, the EPSR occurs rather than secondary peristalsis to prevent supraesophageal reflux when the esophageal bolus is in the proximal esophagus.
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Affiliation(s)
- Ivan M. Lang
- 1MCW Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Bidyut K. Medda
- 1MCW Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
| | - Sudarshan R. Jadcherla
- 2Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital & The Ohio State University College of Medicine, Columbus, Ohio
| | - Reza Shaker
- 1MCW Dysphagia Institute, Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; and
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29
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Hegyi Szynkiewicz S, Mulheren RW, Palmore KW, O'Donoghue CR, Ludlow CL. Using devices to upregulate nonnutritive swallowing in typically developing infants. J Appl Physiol (1985) 2016; 121:831-837. [PMID: 27471240 DOI: 10.1152/japplphysiol.00797.2015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 07/26/2016] [Indexed: 11/22/2022] Open
Abstract
The role of various sensory stimuli for stimulating swallowing in infants may be of importance for assisting infants to develop oral feeding. We evaluated the swallowing mechanism response to two devices for increasing the rate of nonnutritive swallowing in two typically developing infant age groups, ages 2-4 mo and 7-9 mo. One device was a pacifier familiar to the infant; the other was a small vibrator placed on the skin overlying the thyroid cartilage. The rate of nonnutritive swallowing while infants were awake was compared in three 10-min conditions: at rest without stimulation (spontaneous); during nonnutritive sucking with a pacifier; and over 10 min containing 18 epochs of vibratory stimulation for 10 s each. To assess whether vibration on the throat over the laryngeal area altered respiration, the mean cycle length was compared between 10-min intervals either containing vibratory stimulation or without stimulation at rest. Both the pacifier and laryngeal vibration stimulation doubled the rate of swallowing in the infants with a mean age of 3 mo 16 days and infants with a mean age of 8 mo 8 days. No differences occurred in the mean respiratory cycle length between intervals with and without vibration in either age group. Results suggest that nonnutritive sucking, vibration, or both might be beneficial in enhancing swallowing in young infants. Because vibration on the neck would not interfere with oral transfer of liquid, it might provide additional stimulation for swallowing during oral feeding. Both stimulation types should be evaluated for enhancing swallowing in infants with immature swallowing skills.
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Affiliation(s)
- Sarah Hegyi Szynkiewicz
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virginia
| | - Rachel W Mulheren
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virginia
| | - Kathryn W Palmore
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virginia
| | - Cynthia R O'Donoghue
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virginia
| | - Christy L Ludlow
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, Virginia
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30
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Jadcherla SR, Hasenstab KA, Sitaram S, Clouse BJ, Slaughter JL, Shaker R. Effect of nasal noninvasive respiratory support methods on pharyngeal provocation-induced aerodigestive reflexes in infants. Am J Physiol Gastrointest Liver Physiol 2016; 310:G1006-14. [PMID: 27012774 PMCID: PMC4935482 DOI: 10.1152/ajpgi.00307.2015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 03/22/2016] [Indexed: 01/31/2023]
Abstract
The pharynx is a locus of provocation among infants with aerodigestive morbidities manifesting as dysphagia, life-threatening events, aspiration-pneumonia, atelectasis, and reflux, and such infants often receive nasal respiratory support. We determined the impact of different oxygen delivery methods on pharyngeal stimulation-induced aerodigestive reflexes [room air (RA), nasal cannula (NC), and nasal continuous positive airway pressure (nCPAP)] while hypothesizing that the sensory motor characteristics of putative reflexes are distinct. Thirty eight infants (28.0 ± 0.7 wk gestation) underwent pharyngoesophageal manometry and respiratory inductance plethysmography to determine the effects of graded pharyngeal stimuli (n = 271) on upper and lower esophageal sphincters (UES, LES), swallowing, and deglutition-apnea. Comparisons were made between NC (n = 19), nCPAP (n = 9), and RA (n = 10) groups. Importantly, NC or nCPAP (vs. RA) had: 1) delayed feeding milestones (P < 0.05), 2) increased pharyngeal waveform recruitment and duration, greater UES nadir pressure, decreased esophageal contraction duration, decreased distal esophageal contraction amplitude, and decreased completely propagated esophageal peristalsis (all P < 0.05), and 3) similarly developed UES contractile and LES relaxation reflexes (P > 0.05). We conclude that aerodigestive reflexes were similarly developed in infants using noninvasive respiratory support with adequate upper and lower aerodigestive protection. Increased concern for GERD is unfounded in this population. These infants may benefit from targeted oromotor feeding therapies and safe pharyngeal bolus transit to accelerate feeding milestones.
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Affiliation(s)
- Sudarshan R. Jadcherla
- 1The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus Ohio; ,2The Neonatal Aerodigestive Pulmonary Program, Nationwide Children's Hospital, Columbus, Ohio; ,3Divisions of Neonatology, Department of Pediatrics; The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Kathryn A. Hasenstab
- 1The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus Ohio; ,2The Neonatal Aerodigestive Pulmonary Program, Nationwide Children's Hospital, Columbus, Ohio;
| | - Swetha Sitaram
- 1The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus Ohio;
| | - Brian J. Clouse
- 2The Neonatal Aerodigestive Pulmonary Program, Nationwide Children's Hospital, Columbus, Ohio;
| | - Jonathan L. Slaughter
- 3Divisions of Neonatology, Department of Pediatrics; The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Reza Shaker
- 4Gastroenterology and Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Ptok M, Kühn D, Miller S, Jungheim M, Schroeter S. [Laryngeal and larynx-associated reflexes]. HNO 2016; 64:435-44. [PMID: 27240793 DOI: 10.1007/s00106-016-0169-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The laryngeal adductor reflex and the pharyngoglottal closure reflex protect the trachea and lower respiratory tract against the entrance of foreign material. The laryngeal expiration reflex and the cough reflex serve to propel foreign material, which has penetrated in the cranial direction. The inspiration reflex, the sniff reflex, and the swallowing reflex are further larynx-associated reflexes. In patients with dysphagia the laryngeal adductor reflex can be clinically tested with air pulses. The water swallow test serves to show the integrity of the cough reflex. The sniff reflex is useful to test the abduction function of the vocal folds. Future studies should address laryngeal reflexes more specifically, both for a better understanding of these life-supporting mechanisms and to improve diagnostic procedures in patients with impaired laryngeal function.
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Affiliation(s)
- M Ptok
- Klinik für Phoniatrie und Pädaudiologie, MHH OE 6510, 30623, Hannover, Deutschland.
| | - D Kühn
- Klinik für Phoniatrie und Pädaudiologie, MHH OE 6510, 30623, Hannover, Deutschland
| | - S Miller
- Klinik für Phoniatrie und Pädaudiologie, MHH OE 6510, 30623, Hannover, Deutschland
| | - M Jungheim
- Klinik für Phoniatrie und Pädaudiologie, MHH OE 6510, 30623, Hannover, Deutschland
| | - S Schroeter
- Klinik für Phoniatrie und Pädaudiologie, MHH OE 6510, 30623, Hannover, Deutschland
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Pavić I, Čepin-Bogović J, Hojsak I. The Relationship Between Gastroesophageal Reflux and Chronic Unexplained Cough in Children. Clin Pediatr (Phila) 2016; 55:639-44. [PMID: 26324664 DOI: 10.1177/0009922815603675] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The aim of this study was to assess the association between chronic cough and acid or weakly acid gastroesophageal reflux (GER) determined by 24-hour multichannel intraluminal impedance-pH monitoring and to assess whether the association is age dependent. Overall 150 children (mean age 7.5 years; range 0.3-18.0 years; male/female 90/60) were enrolled. Median of 87.5% (0% to 100%) of all cough episodes were associated with reflux; 9% (0% to 100%) with acidic and 60% (0% to 100%) with weakly acidic episodes. In 52 children (34.7%), all cough episodes were associated with GER (100% association). Children younger than 2 years had significantly higher number of cough episodes associated with total (P = .03) and weakly acidic GER (P = .01). Binary logistic regression confirmed that only increase in age decreases the risk for complete (100%) association between cough episode and GER. Cough is significantly associated with weakly acidic GER and children of younger age are at higher risk.
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Affiliation(s)
- Ivan Pavić
- Children's Hospital Zagreb, Zagreb, Croatia
| | | | - Iva Hojsak
- Children's Hospital Zagreb, Zagreb, Croatia
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Shubert TR, Sitaram S, Jadcherla SR. Effects of pacifier and taste on swallowing, esophageal motility, transit, and respiratory rhythm in human neonates. Neurogastroenterol Motil 2016; 28:532-42. [PMID: 26727930 PMCID: PMC4808369 DOI: 10.1111/nmo.12748] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/12/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pacifier use is widely prevalent globally despite hygienic concerns and uncertain mechanistic effects on swallowing or airway safety. AIMS The effects of pacifier and taste interventions on pharyngo-esophageal motility, bolus transit, and respiratory rhythms were investigated by determining the upper esophageal sphincter (UES), esophageal body, esophagogastric junction (EGJ) motor patterns and deglutition apnea, respiratory rhythm disturbances, and esophageal bolus clearance. METHODS Fifteen infants (six males; median gestation 31 weeks and birth weight 1.4 kg) underwent high-resolution impedance manometry at 43 (41-44) weeks postmenstrual age. Manometric, respiratory, and impedance characteristics of spontaneous swallows, pacifier-associated dry swallowing and taste (pacifier dipped in 3% sucrose)-associated swallowing were analyzed. Linear mixed and generalized estimating equation models were used. Data are presented as mean ± SEM, %, or median (IQR). KEY RESULTS Pharyngo-esophageal motility, respiratory, and impedance characteristics of 209 swallows were analyzed (85 spontaneous swallows, 63 pacifier- swallows, 61 taste- swallows). Basal UES and EGJ pressures decreased upon pacifier (p < 0.05) and taste interventions (p < 0.05); however, esophageal motility, respiratory rhythm, and impedance transit characteristics were similar with both interventions. CONCLUSIONS & INFERENCES Oral stimulus with pacifier or taste interventions decreases UES and EGJ basal pressure, but has no effects on pharyngo-esophageal motility, airway interactions, or esophageal bolus transit. A decrease in central parasympathetic-cholinergic excitatory drive is likely responsible for the basal effects.
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Abstract
Neonatal dysphagia, or abnormalities of swallowing, represent a major global problem, and consequences of dysfunctional feeding patterns carry over into infancy and toddler age groups. Growth, development, and independent feeding skills are all delayed among high-risk infants. Such a group comprises premature birth, low-birth-weight, congenital anomalies, perinatal asphyxia, postsurgical, and sepsis categories. The conflict between pathophysiologic and pragmatic feeding strategies remains a major conundrum and is largely due to a lack of validated diagnostic approaches amid heterogeneity of the patient phenotype. Thus, well-tested feeding management strategies that can be generalizable are lacking. Furthermore, the aerodigestive symptoms and signs, potential risk factors, and contributory etiologies remain nonspecific. This article presents mechanistic evidence related to the pathophysiologic basis of neonatal dysphagia as well as potential opportunities to improve feeding abilities and long-term development.
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Affiliation(s)
- Sudarshan Jadcherla
- Nationwide Children's Hospital Research Institute and The Ohio State University College of Medicine, Columbus, OH
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Jadcherla SR, Shubert TR, Malkar MB, Sitaram S, Moore RK, Wei L, Fernandez S, Castile RG. Gestational and postnatal modulation of esophageal sphincter reflexes in human premature neonates. Pediatr Res 2015; 78:540-6. [PMID: 26270576 PMCID: PMC4628557 DOI: 10.1038/pr.2015.149] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/14/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Effects of gestational age (GA) and postnatal maturation on upper and lower esophageal sphincter (UES and LES) reflex development remain unclear. We hypothesized very-preterm (VPT) born neonates (< 32 wk GA) have delayed maturation of UES contractile reflex (UESCR) and LES relaxation reflex (LESRR) vs. preterm (PT) born (32-37 wk GA) neonates. METHODS Using provocative manometry, effects of 1,263 graded mid-esophageal stimuli (air, liquid) on sensory-motor characteristics of UESCR and LESRR were investigated in 24 VPT-born and 12 PT-born neonates (37.8 ± 0.6 vs. 38.9 ± 0.4 wk postmenstrual age respectively, P = 0.14). RESULTS In response to liquid stimuli (vs. air), VPT-born neonates displayed prolonged UESCR and LESRR response latencies (P < 0.001) and prolonged UESCR and LESRR durations (P < 0.01); unlike PT-born neonates, who exhibit prolonged LESRR response latency (P < 0.01), but similar UESCR and LESRR durations (P = 0.2). Differences were noted in LESRR duration in VPT vs. PT neonates for air stimuli (P = 0.04). With liquid stimuli, increasing GA was associated with decreasing response onset latencies to UESCR and LESRR (P < 0.05), and increasing LESRR duration (P = 0.02). CONCLUSION Using GA as categorical or continuous variable, vagus-mediated mechano-sensitive and liquid-sensitive reflex characteristics of UESCR and LESRR are distinct; LESRR differs with varying intrauterine maturation suggesting inhibitory modulation progresses with advancing maturation.
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Affiliation(s)
- Sudarshan R. Jadcherla
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Divisions of Neonatology, Pediatric Gastroenterology and Nutrition; Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH, USA,ADDRESS FOR CORRESPONDENCE: Sudarshan R. Jadcherla, MD, Professor of Pediatrics & Associate Division Chief, Academics, Division of Neonatology, Director, The Neonatal and Infant Feeding Disorders Program, Director, Neonatal Aerodigestive Pulmonary Program, Principal Investigator, Innovative Feeding Disorders Research Program, Center for Perinatal Research, WB 5211, The Research Institute at Nationwide Children’s Hospital, Nationwide Children’s Hospital, 575 Children’s Crossroads, Columbus, Ohio 43215, Phone: 614- 355-6643, Facsimile: 614-355-5899,
| | - Theresa R. Shubert
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Manish B. Malkar
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Divisions of Neonatology, Pediatric Gastroenterology and Nutrition; Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Swetha Sitaram
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Rebecca K. Moore
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Lai Wei
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Soledad Fernandez
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Robert G. Castile
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Neonatal Aerodigestive & Pulmonary Program, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Division of Respiratory Medicine, Department of Pediatrics; The Ohio State University College of Medicine, Columbus, OH, USA
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Mechanisms of cough provocation and cough resolution in neonates with bronchopulmonary dysplasia. Pediatr Res 2015; 78:462-9. [PMID: 26151491 PMCID: PMC4800483 DOI: 10.1038/pr.2015.131] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/17/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cough and deglutition are protective mechanisms that defend against aspiration. We identified mechanisms associated with cough provocation as well as those associated with cough resolution in infants with bronchopulmonary dysplasia (BPD). METHODS Manometry signatures of cough were recognized in 16 premature infants with BPD undergoing concurrent esophageal manometry, respiratory inductance plethysmography, and nasal air flow measurements. Pretussive and post-tussive pharyngo-esophageal motility changes were analyzed. Mechanisms associated with cough and mechanisms that restored respiratory and esophageal normalcy were analyzed. RESULTS We analyzed 312 cough events during 88 cough clusters; 97% were associated with recognizable manometric patterns. Initial mechanisms related with coughing included nonpropagating swallow (59%), upper esophageal sphincter (UES) reflex contraction (18%), and lower esophageal sphincter (LES) relaxation (14%). UES and LES dysfunction was present in 69% of nonpropagating swallow-associated cough clusters. Mechanisms restoring post-tussive normalcy included primary peristalsis (84%), secondary peristalsis (8%), and none recognized (8%). UES contraction reflex was associated with cough clusters more frequently in infants on nasal continuous positive airway pressure (NCPAP) (OR = 9.13, 95% CI = 1.88-44.24). CONCLUSION Cough clusters in infants with BPD had identifiable etiologies associated with esophageal events; common initial mechanisms were of upper aerodigestive origin, while common clearing mechanisms were peristaltic reflexes.
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Prakash M, Johnny JC. Whats special in a child's larynx? J Pharm Bioallied Sci 2015; 7:S55-8. [PMID: 26015749 PMCID: PMC4439709 DOI: 10.4103/0975-7406.155797] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 10/31/2014] [Accepted: 11/09/2014] [Indexed: 11/10/2022] Open
Abstract
What's special in a child's larynx? Many of us know only a few specialties of the pediatric larynx, but there are much more features, which are unique and often not highlighted. To understand the pediatric larynx, we have reviewed the development, the functions in-utero and new born period and peculiarities.
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Affiliation(s)
- Manoharan Prakash
- Department of ENT, Sree Balaji Medical College and Hospital, Bharath University, Chromepet, Chennai, Tamil Nadu, India
| | - J Carlton Johnny
- Department of ENT, Sree Balaji Medical College and Hospital, Bharath University, Chromepet, Chennai, Tamil Nadu, India
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Jadcherla SR, Dail J, Malkar MB, McClead R, Kelleher K, Nelin L. Impact of Process Optimization and Quality Improvement Measures on Neonatal Feeding Outcomes at an All-Referral Neonatal Intensive Care Unit. JPEN J Parenter Enteral Nutr 2015; 40:646-55. [DOI: 10.1177/0148607115571667] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/18/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Sudarshan R. Jadcherla
- The Neonatal and Infant Feeding Disorders Program
- Center for Perinatal Research
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - James Dail
- Neonatal Quality Improvement Service, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Manish B. Malkar
- The Neonatal and Infant Feeding Disorders Program
- Center for Perinatal Research
- Innovative Infant Feeding Disorders Research Program, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Richard McClead
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Neonatal Quality Improvement Service, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Kelly Kelleher
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Innovative Pediatric Health, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Leif Nelin
- Center for Perinatal Research
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Jadcherla SR, Shubert TR, Gulati IK, Jensen PS, Wei L, Shaker R. Upper and lower esophageal sphincter kinetics are modified during maturation: effect of pharyngeal stimulus in premature infants. Pediatr Res 2015; 77:99-106. [PMID: 25279989 PMCID: PMC4268006 DOI: 10.1038/pr.2014.147] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 08/06/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND We hypothesized that changes in proximal and distal esophageal sphincter kinetics evoked upon pharyngeal provocation undergo longitudinal maturation. METHODS Pharyngeal stimulation-induced reflexes were characterized using novel pharyngo-esophageal motility methods in 19 healthy premature neonates, studied at 34.7 ± 0.8 wk (time-1) and 39.3 ± 1.1 wk postmenstrual age (time-2). Graded volumes of air (290 infusions) and sterile water (172 infusions) were infused to define sensory-motor characteristics of upstream (pharyngeal reflexive swallow, PRS) and downstream (pharyngo-lower esophageal sphincter relaxation reflex, PLESRR) esophageal reflexes. Data displayed as mean ± SE. RESULTS Threshold volumes were similar with air and water for PRS and PLESRR at time-1 and time-2. Multiple PRS responses were noted with water stimulus and were different between the media (time-1 vs. air, P < 0.0001; time-2 vs. air, P = 0.0003). Dose-response relationships for water were significant (P < 0.01 for PRS and PLESRR time-1 and time-2), but not with air. CONCLUSION Significantly, the recruitment frequency of PRS and PLESRR increases with maturation, liquid is a superior medium for evoking such swallowing reflexes, and stimulus-response relationships for these reflexes are evident. These changes in aerodigestive protective reflexive activity may indicate differences in modulation of excitatory and inhibitory pathways during longitudinal postnatal maturation.
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Affiliation(s)
- Sudarshan R. Jadcherla
- Sections of Neonatology, Pediatric Gastroenterology and Nutrition, The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Department of Pediatrics, The Ohio State University College of Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
- The Neonatal and Infant Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Theresa R. Shubert
- The Neonatal and Infant Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Ish K. Gulati
- Sections of Neonatology, Pediatric Gastroenterology and Nutrition, The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Department of Pediatrics, The Ohio State University College of Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
- The Neonatal and Infant Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Preceousa S. Jensen
- Sections of Neonatology, Pediatric Gastroenterology and Nutrition, The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Department of Pediatrics, The Ohio State University College of Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
- The Neonatal and Infant Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Lai Wei
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH
| | - Reza Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Asaoka D, Nagahara A, Matsumoto K, Hojo M, Watanabe S. Current perspectives on reflux laryngitis. Clin J Gastroenterol 2014; 7:471-5. [PMID: 25491904 DOI: 10.1007/s12328-014-0535-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/17/2014] [Indexed: 12/12/2022]
Abstract
Laryngopharyngeal reflux (LPR) is an extraesophageal manifestation of gastroesophageal reflux disease (GERD). With the increase of GERD patients, the importance of LPR is acknowledged widely. However, the pathophysiology of LPR is not understood completely and the diagnostic criteria for LPR remain controversial. Unfortunately, a gold standard diagnostic test for reflux laryngitis is not available. Recently, an experimental animal model for reflux laryngitis was developed to investigate the pathophysiology of reflux laryngitis. An empirical trial of lifestyle modification and proton pump inhibitor therapy is a reasonable approach for LPR symptoms. Alternatives after failure with aggressive medical treatment are limited and multichannel intraluminal impedance and pH monitoring is currently the best alternative to detect nonacid reflux. Additional prospective and evidence-based research is anticipated.
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Affiliation(s)
- Daisuke Asaoka
- Department of Gastroenterology, Juntendo University, School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan,
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Hasenstab KA, Jadcherla SR. Respiratory events in infants presenting with apparent life threatening events: is there an explanation from esophageal motility? J Pediatr 2014; 165:250-255.e1. [PMID: 24681180 PMCID: PMC4112005 DOI: 10.1016/j.jpeds.2014.02.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/10/2014] [Accepted: 02/03/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To test the hypothesis that proximal aerodigestive clearance mechanisms mediated by pharyngoesophageal motility during spontaneous respiratory events (SREs) are distinct in infants with apparent life threatening events (ALTEs). STUDY DESIGN Twenty infants (10 with proven ALTE, 10 healthy controls) had pharyngoesophageal manometry to investigate motility changes concurrent with respiratory events detected by respiratory inductance plethysmography and nasal thermistor methods. We measured changes in resting upper esophageal and lower esophageal sphincter pressures, esophageal peristalsis characteristics, and gastroesophageal reflux. Statistical analysis included mixed models; data presented as mean±SD, median (range), or percentage. RESULTS Infants with ALTE (vs controls) had: (1) delays in restoring aerodigestive normalcy as indicated by more frequent (P=.03) and prolonged SREs (P<.01); (2) a lower magnitude of protective upper esophageal sphincter contractile reflexes (P=.01); (3) swallowing as the most frequent esophageal event associated with SREs (84%), with primary peristalsis as the most prominent aerodigestive clearance mechanism (64% vs 38%, P<.01); (4) a higher proportion of failed esophageal propagation (10% vs 0%, P=.02); and (5) more frequent mixed apneic mechanisms (P<.01) and more gasping breaths (P=.04). CONCLUSIONS In infants with ALTE, prolonged SREs are associated with ineffective esophageal motility characterized by frequent primary peristalsis and significant propagation failure, thus suggestive of dysfunctional regulation of swallow-respiratory junction interactions. Hence, treatment should not target gastroesophageal reflux, but rather the proximal aerodigestive tract.
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Affiliation(s)
- Kathryn A Hasenstab
- Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus, OH
| | - Sudarshan R Jadcherla
- Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, Nationwide Children's Hospital Research Institute, Columbus, OH; Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.
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Jadcherla SR, Pakiraih JF, Hasenstab KA, Dar I, Gao X, Bates DG, Kashou NH. Esophageal reflexes modulate frontoparietal response in neonates: Novel application of concurrent NIRS and provocative esophageal manometry. Am J Physiol Gastrointest Liver Physiol 2014; 307:G41-9. [PMID: 24789204 PMCID: PMC4080167 DOI: 10.1152/ajpgi.00350.2013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Central and peripheral neural regulation of swallowing and aerodigestive reflexes is unclear in human neonates. Functional near infrared spectroscopy (NIRS) is a noninvasive method to measure changes in oxyhemoglobin (HbO) and deoxyhemoglobin (HbD). Pharyngoesophageal manometry permits evaluation of aerodigestive reflexes. Modalities were combined to investigate feasibility and to test neonatal frontoparietal cortical changes during pharyngoesophageal (visceral) stimulation and/or swallowing. Ten neonates (45.6 ± 3.0 wk postmenstrual age, 4.1 ± 0.5 kg) underwent novel pharyngoesophageal manometry concurrent with NIRS. To examine esophagus-brain interactions, we analyzed cortical hemodynamic response (HDR) latency and durations during aerodigestive provocation and esophageal reflexes. Data are presented as means ± SE or percent. HDR rates were 8.84 times more likely with basal spontaneous deglutition compared with sham stimuli (P = 0.004). Of 182 visceral stimuli, 95% were analyzable for esophageal responses, 38% for HDR, and 36% for both. Of analyzable HDR (n = 70): 1) HbO concentration (μmol/l) baseline 1.5 ± 0.7 vs. 3.7 ± 0.7 poststimulus was significant (P = 0.02), 2) HbD concentration (μmol/l) between baseline 0.1 ± 0.4 vs. poststimulus -0.5 ± 0.4 was not significant (P = 0.73), and 3) hemispheric lateralization was 21% left only, 29% right only, and 50% bilateral. During concurrent esophageal and NIRS responses (n = 66): 1) peristaltic reflexes were present in 74% and HDR in 61% and 2) HDR was 4.75 times more likely with deglutition reflex vs. secondary peristaltic reflex (P = 0.016). Concurrent NIRS with visceral stimulation is feasible in neonates, and frontoparietal cortical activation is recognized. Deglutition contrasting with secondary peristalsis is related to cortical activation, thus implicating higher hierarchical aerodigestive protective functional neural networks.
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Affiliation(s)
- Sudarshan R. Jadcherla
- 1Divisions of Neonatology and Pediatric Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio; ,2Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; ,3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio;
| | - Joanna F. Pakiraih
- 2Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; ,5Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Kathryn A. Hasenstab
- 2Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio;
| | - Irfaan Dar
- 2Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; ,4Biomedical, Industrial & Human Factors Engineering, Wright State University, Ohio; and
| | - Xiaoyu Gao
- 2Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio;
| | - D. Gregory Bates
- 3Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; ,5Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Nasser H. Kashou
- 4Biomedical, Industrial & Human Factors Engineering, Wright State University, Ohio; and
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Jadcherla SR, Chan CY, Fernandez S, Splaingard M. Maturation of upstream and downstream esophageal reflexes in human premature neonates: the role of sleep and awake states. Am J Physiol Gastrointest Liver Physiol 2013; 305:G649-58. [PMID: 24008357 PMCID: PMC3840236 DOI: 10.1152/ajpgi.00002.2013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We tested the hypothesis that the sensory-motor characteristics of aerodigestive reflexes are dependent on stimulus type and volumes, sleep or awake states, and maturation. Thirteen neonates were studied at 33.6 ± 0.5 wk (time 1) and 37.3 ± 0.5 wk (time 2) postmenstrual age using multimodal provocative esophageal manometry concurrent with video polysomnography. Effects of graded volumes (399 infusions at time 1, 430 infusions at time 2) of midesophageal stimulation with air, water, and apple juice on the sensory thresholds and recruitment frequency of upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) reflexes were investigated during sleep and awake states. Sensory thresholds for aerodigestive reflexes between maturational stages were similar. Increased frequency recruitment of UES contractile reflex, LES relaxation reflex, and peristaltic reflexes were noted at time 2 (all, P < 0.05). Graded stimulus-response relationships were evident at time 1 and time 2 during awake and sleep states (P < 0.05). Secondary peristalsis vs. esophago-deglutition response proportions during sleep at time 1 vs. time 2 (P = 0.001) and awake vs. sleep at time 2 (P = 0.02) were distinct. We concluded that sensory-motor effects of esophageal mechanosensitivity, osmosensitivity, and chemosensitivity are advanced in sleep with maturation. Sleep further modulates the frequency recruitment and the type of aerodigestive reflexes.
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Affiliation(s)
- Sudarshan R. Jadcherla
- 1Sections of Neonatology, Pediatric Gastroenterology and Nutrition, ,2The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research,
| | - Chin Yee Chan
- 2The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research,
| | | | - Mark Splaingard
- 4Pediatric Sleep Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Extra-Esophageal Manifestations of Gastroesophageal Reflux Disease: Diagnosis and Treatment. Drugs 2013; 73:1281-95. [DOI: 10.1007/s40265-013-0101-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ates F, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Pract Res Clin Gastroenterol 2013; 27:415-31. [PMID: 23998979 DOI: 10.1016/j.bpg.2013.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
Abstract
Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.
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Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN Nashville, TN, USA
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Esophageal mechanosensitive mechanisms are impaired in neonates with hypoxic-ischemic encephalopathy. J Pediatr 2013; 162:976-82. [PMID: 23260103 PMCID: PMC5051571 DOI: 10.1016/j.jpeds.2012.11.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 10/03/2012] [Accepted: 11/01/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To test the hypothesis that esophageal mechanodistention in infants with hypoxic-ischemic encephalopathy (HIE) results in altered upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) responses, compared with controls. As a secondary aim, we tested the hypothesis that infants with HIE receiving therapeutic hypothermia had different aerodigestive reflex characteristics than infants with HIE who received traditional neonatal care. STUDY DESIGN Provocative esophageal manometry was performed in 34 neonates (27 with HIE and 7 controls). Mechanodistention was performed using graded volumes of air. Peristaltic reflexes, UES contractile reflexes, and LES relaxation reflexes were analyzed for frequency, magnitude, and aberrancies. RESULTS Infants with HIE demonstrated more rapid recruitment of responses and greater UES magnitude (P < .05). They had more frequent secondary peristalsis and lower LES nadir pressures with prolonged LES nadir durations (P < .05). Most notable were the prolonged peristaltic response durations and increases in the number of polymorphic waveforms (P < .05). Compared with infants with HIE receiving traditional care, infants with HIE treated with hypothermia had higher UES pressures and shorter peristaltic response duration (P < .05). CONCLUSIONS Mechanodistention in infants with HIE results in upregulation of central vagal effects (ie, heightened cholinergic excitatory responses as demonstrated by exaggerated UES contractile reflex activity and heightened inhibitory responses evident by exaggerated LES relaxation reflex activity). Prolonged and poorly coordinated peristaltic responses may underlie dysfunction of aerodigestive regulation. Modulation of sensorimotor aspects of aerodigestive reflexes is altered in infants with HIE, and hypothermia may further modify such effects.
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Abstract
This article discusses the current state of knowledge regarding the relationship between gastroesophageal reflux disease (GERD) and pulmonary and ear/nose/throat manifestations of reflux and outlines the recent developments in the diagnostic and treatment strategies for this difficult group of patients. Upper gastrointestinal endoscopy and pH monitoring are poorly sensitive for diagnosing reflux in this group of patients. Instead it is recommended that in those without warning symptoms, an empiric trial of proton-pump inhibitors be the initial approach to diagnosing and treating the potential underlying cause of these extraesophageal symptoms.
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Chan CY, Jadcherla SR. Clinical Perspectives on Esophageal Disorders in Infants. ASHA LEADER 2012; 21:10.1044/sasd21.2.52. [PMID: 24244099 PMCID: PMC3828998 DOI: 10.1044/sasd21.2.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Esophageal pathologies are complex and lend themselves to multivariable analysis before a definitive diagnosis can be considered. It is imperative that the clinician establish a methodology for selecting the appropriate technological assessment within scientific testing parameters to establish optimal clinicopathological presentation and determine best practice for patient care.
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Affiliation(s)
- Chin Yee Chan
- The Neonatal and Infant Feeding Disorders Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital Columbus, OH
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Babaei A, Dua K, Naini SR, Lee J, Katib O, Yan K, Hoffmann R, Shaker R. Response of the upper esophageal sphincter to esophageal distension is affected by posture, velocity, volume, and composition of the infusate. Gastroenterology 2012; 142:734-743.e7. [PMID: 22248662 PMCID: PMC3327135 DOI: 10.1053/j.gastro.2012.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 12/21/2011] [Accepted: 01/03/2012] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Studies of the pressure response of the upper esophageal sphincter (UES) to simulated or spontaneous gastroesophageal reflux have shown conflicting results. These discrepancies could result from uncontrolled influence of variables such as posture, volume, and velocity of distension. We characterized in humans the effects of these variables on UES pressure response to esophageal distension. METHODS We studied 12 healthy volunteers (average, 27 ± 5 years old; 6 male) using concurrent esophageal infusion and high-resolution manometry to determine UES, lower esophageal sphincter, and intraesophageal pressure values. Reflux events were simulated by distal esophageal injections of room temperature air and water (5, 10, 20, and 50 mL) in individuals in 3 positions (upright, supine, and semisupine). Frequencies of various UES responses were compared using χ(2) analysis. Multinomial logistical regression analysis was used to identify factors that determine the UES response. RESULTS UES contraction and relaxation were the overriding responses to esophageal water and air distension, respectively, in a volume-dependent fashion (P < .001). Water-induced UES contraction and air-induced UES relaxation were the predominant responses among individuals in supine and upright positions, respectively (P < .001). The prevalence of their respective predominant response significantly decreased in the opposite position. Proximal esophageal dp/dt significantly and independently differentiated the UES response to infusion with water or air. CONCLUSIONS The UES response to esophageal distension is affected by combined effects of posture (spatial orientation of the esophagus), physical properties, and volume of refluxate, as well as the magnitude and rate of increase in intraesophageal pressure. The UES response to esophageal distension can be predicted using a model that incorporates these factors.
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Affiliation(s)
- Arash Babaei
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Sohrab Rahimi Naini
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Justin Lee
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Omar Katib
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ke Yan
- Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raymond Hoffmann
- Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Reza Shaker
- Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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