Initial treatment and early weight gain of children with Robin Sequence in Germany: a prospective epidemiological study

Airway management in infants with Robin sequence in the United Kingdom and Ireland: A prospective population-based study

OBJECTIVE

There is currently no consensus about managing upper airway obstruction (UAO) in infants with Robin sequence (RS), in terms of treatment efficacy or clinical outcomes. This study describes UAO management in UK/Ireland, and explores relationships between patient characteristics, UAO management, and clinical outcomes in the first 2 years of life.

METHODS

Active surveillance of RS throughout UK/Ireland via the British Paediatric Surveillance Unit and nationally commissioned cleft services. Clinical data were collected at initial notification and 12-month follow-up.

RESULTS

173 infants with RS were identified, of which 47% had additional congenital anomalies or an underlying syndrome (non-isolated RS). Two-thirds (n = 119) required an airway intervention other than prone positioning: non-surgical in 84% and surgical (tracheostomy) in 16%. Nasopharyngeal airway (NPA) was the most common intervention, used in 83% (n = 99) for median 90 days (IQR 136). Surgical UAO management was associated with prolonged hospital admission, higher prevalence of neurodevelopmental delay (NDD), lower weight-for-age z-scores, and delayed oral feeding. These findings were not attributable to a higher prevalence of non-isolated RS in this group. Although more commonly associated with non-isolated RS, growth faltering was also identified in 48%, and NDD in 18%, of cases of isolated RS.

CONCLUSIONS

In UK/Ireland, most infants with RS are managed with NPA, and tracheostomy is reserved for refractory severe UAO. Clinical outcomes and duration of use indicate that NPA is a safe and feasible first-line approach to UAO. Longitudinal assessment of neurodevelopment and growth is imperative, including in children with isolated RS. Current variations in practice reinforce the need for evidence-based treatment guidelines.

Diagnosis and Early Management of Robin Sequence

The results of a survey of twenty-four neonatal units in the United Kingdom and Ireland are presented. A structured ten-item questionnaire was used, and demonstrated the variation in how infants with RS are diagnosed and managed. Notably, the survey revealed that a minority of infants were diagnosed antenatally. There were significant discrepancies in diagnostic criteria used and 79% of the units referred the patients to tertiary services. A preference for minimally invasive approaches to managing upper airway obstruction, such as a trial of prone positioning before progressing to a nasopharyngeal airway, was reported by 96% of the centers. A narrative review was undertaken which discusses the current practices for diagnosis and early management of Robin sequence (RS). The challenges of antenatal diagnosis, strategies to enhance outcomes through early detection and controversies surrounding the management of neonatal upper airway obstruction associated with RS are included. The results of the survey and our comprehensive review of the literature emphasize that there remains uncertainty regarding the best approach to treating Robin sequence.

Non-operative interventions for Pierre-Robin sequence: A systematic review and meta-analysis

Pierre-Robin Sequence (PRS) is a sequence of micrognathia, glossoptosis, and airway obstruction. There is no standardized consensus on the management of respiratory distress for patients with PRS, and operative interventions have associated complications. The purpose of this study is to identify all modalities of non-operative airway intervention for PRS infants. Following PRISMA 2020 guidelines, Embase, Medline, Cochrane, EMCARE, and Web of Science electronic databases were searched from 1992 to 2022 reporting on PRS infants under one year of age who were managed non-operatively. Publications with non-original research designs, an exclusive focus on surgical interventions, case reports, and non-English language articles were excluded. Analysis was performed using non-pooled and pooled proportions (PP). 3280 abstracts were screened, and 88 articles included. Retrospective methodologies were most common. Of the 60 studies where both operative and non-operative interventions were included, 2924 of 4708 PRS infants were administered a non-operative intervention (PP 65.8 % [95%CI 58.5, 72.7]). Reported definitive non-operative interventions, either alone or in combination with another non-operative intervention, included infant positioning (n = 1664), orthodontic appliances (n = 1299), nasopharyngeal tube insertion (n = 983), supplemental oxygen (n = 306), non-invasive ventilation (n = 290), oral airway (n = 46), endotracheal intubation (n = 36), and other (n = 40). The mean MINORS risk of bias score was 6.3 (range 1-12), indicating that the present review was limited by moderate methodological quality for included studies. This is the largest systematic review of non-operative interventions for PRS infants thus far. Most infants are managed non-operatively, with positioning, orthodontic appliances, and nasopharyngeal tubes being the most commonly reported modalities.

Long-term mandibular growth in patients with airway obstruction treated with mandibular distraction

Congenital craniofacial malformations play an important role in upper airway obstruction. One of the main causes is mandibular hypoplasia which is present in the pierre robin sequence. Mandibular distraction osteogenesis (MDO) is one of the most commonly used treatments for the resolution of upper airway obstruction in patients that do not respond to a conservative treatment. We performed a long term follow up of syndromic and non-syndromic patients with pierre robin sequence where the lateral xrays were studied before surgery (T1), after MDO (T2) and long-term follow-up (T3, at least 5 years). Possible complications of the surgery were also studied through panoramic x-rays and clinical controls. The results evidenced an increase of mandibular length comparing T1-T2 and a good stability during the long-term follow-up. The Sd patients presented smaller mandible dimensions. We had not found any complications during the follow-up. The scars outcomes are modest, but none of the patients requested a surgical correction. Mandibular distraction osteogenesis is a treatment to be considered in patients with upper airway obstruction that do not respond to conservative treatments. The results of the surgery are stable and the complications in experienced hands are low.

Evaluation of hard palate and cleft morphology in neonates with Pierre Robin Sequence and Cleft Palate Only

OBJECTIVES

This study aimed to establish a fully digital measurement protocol for standardizing the description of hard palate and cleft morphology in neonates with an isolated cleft palate (CPO) and Pierre Robin sequence (PRS).

MATERIALS AND METHODS

A total of 20 digitized plaster models of neonates with CPO and 20 digitized plaster models of neonates with PRS were retrospectively investigated. For the control group, the hard palate was segmented from 21 pre-existing 1.5 T MRI datasets of neonates and exported as an STL file. The digital models were marked with predefined reference points by three raters. Distance, angular, and area measurements were performed using Blender and MeshLab.

RESULTS

Neonates with CPO (20.20 ± 2.33 mm) and PRS (21.41 ± 1.81 mm) had a significantly shorter hard palate than the control group (23.44 ± 2.24 mm) (CPO vs. control: P < .001; PRS vs. control: P = .014). Notably, neonates with PRS (33.05 ± 1.95 mm) demonstrated a significantly wider intertuberosity distance than those with CPO (30.52 ± 2.28 mm) (P = .012). Furthermore, there were also significant differences measured between the cleft and control groups (25.22 ± 2.50 mm) (P < .001).

CONCLUSIONS

The data from this study demonstrate the feasibility of using MRI datasets to generate digital models of the hard palate. The presence of a cleft palate leads to pronounced adaptations of the total palatal surface area, dorsal width, and length of the hard palate. Mandibular retrognathia and altered tongue position in PRS, as opposed to CPO, might further impact palatal morphology and intertuberosity distance.

Oral health-related quality of life in patients with cleft lip and/or palate or Robin sequence

PURPOSE

To compare the oral health-related quality of life (OHRQoL) in patients with cleft lip and/or palate or Robin sequence versus a healthy control group using the Child Oral Health Impact Profile (COHIP-G19). Factors such as age, gender, and cleft type were considered.

METHODS

Over an 8-month period, the OHRQoL was surveyed by using the COHIP-G19 questionnaire. Included were patients with a craniofacial disorder (n = 61; average age 11.24 years) and a healthy control group (n = 70, average age 12.63 years) for a total of 131 patients (average age 11.99 years) from the Department of Orthodontics University Hospital Tübingen, Germany. These were divided into two age groups (6-11 years; 12-18 years).

RESULTS

Statistically, patients with a craniofacial disorder presented a significantly lower OHRQoL than the control group (p = 0.0055). In the craniofacial disorder group, older patients revealed a significantly (p = 0.005) lower OHRQoL than the younger patients. Female patients showed in nearly all groups a better OHRQoL than male patients, but this difference was not statistically significant (p > 0.05). Males with a craniofacial disorder scored significantly lower than males without (p = 0.016); females showed no differences between the groups. Visibility, location, and severity of the craniofacial malformation did not have a significant influence on the OHRQoL.

CONCLUSION

The occurrence of a craniofacial malformation impacted the OHRQoL especially in older and male affected patients, unrelated to the expression level or localization. An early instruction about oral health, rehabilitation and functional training should be considered in therapy.

Weight Gain of Infants with Robin Sequence Treated Nonsurgically Using the Stanford Orthodontic Airway Plate (SOAP): 1-Year Follow-Up

OBJECTIVE

To identify weight gain trends of infants with Robin sequence (RS) treated by the Stanford Orthodontic Airway Plate treatment (SOAP).

DESIGN

Retrospective longitudinal cohort study.

SETTING

Single tertiary referral hospital.

PATIENTS

Eleven infants with RS treated with SOAP.

INTERVENTIONS

Nonsurgical SOAP.

MAIN OUTCOME MEASURES

Body weight, Weight-for-age (WFA) Z-scores, and WFA percentiles at birth (T0), SOAP delivery (T1), SOAP graduation (T2), and 12-months old (T3).

RESULTS

Between T0 and T1, the weight increased but the WFA percentile decreased from 36.5% to 15.1%, and the Z-score worsened from -0.43 to -1.44. From T1 to T2, the percentile improved to 22.55% and the Z-score to -0.94. From T2 to T3, the percentile and the Z-scores further improved to 36.59% and -0.48, respectively.

CONCLUSIONS

SOAP provided infants experiencing severe respiratory distress and oral feeding difficulty with an opportunity to gain weight commensurate with the WHO healthy norms without surgical intervention.

Tracheal intubation in patients with Pierre Robin sequence: development, application, and clinical value based on a 3-dimensional printed simulator

Background: The main clinical manifestations of patients with Pierre Robin sequence (PRS) include micrognathia, the glossoptosis and dyspnoea. The difficulty of tracheal intubation (TI) in such patients is increased. Objective: The purpose of the study was to evaluate the reliability and efficacy of the PRS simulator. Methods: A PRS simulator was developed by using 3-dimensional (3D) printing technology under computer-aided design. A total of 12 anaesthesiologists each trained 5 times for TI on the PRS Training Simulator-1 and recorded the simulation time. After the training, they were randomly divided into three groups with a total of 12 nontrained anaesthesiologists, and the simulation was completed on PRS Simulator-2, 3 and 4. The simulation time was recorded, and the performance was evaluated by three chief anaesthesiologists. Then, all 24 anaesthesiologists completed the questionnaire. Results: A PRS simulator developed by 3D printing was used to simulate the important aspects of TI. The average number of years worked was 6.3 ± 3.1 years, and 66.7% were female. The time for the 12 anaesthesiologists to complete the training gradually decreased (p < 0.01). Compared with the trained anaesthesiologists, the simulation time of TI in the nontrained anaesthesiologists was much longer (all p < 0.01). In addition, the simulation performance of the trained anaesthesiologists was relatively better (all p < 0.01). Conclusion: The reliability and efficacy of the PRS simulator is herein preliminarily validated, and it has potential to become a teaching and training tool for anaesthesiologists.

Global birth prevalence of Robin sequence in live-born infants: a systematic review and meta-analysis

Robin sequence (RS), a congenital disorder of jaw maldevelopment and glossoptosis, poses a substantial healthcare burden and has long-term health implications if airway obstruction is suboptimally treated. This study describes the global birth prevalence of RS and investigates whether prevalence estimates differ by geographical location, ethnicity or study data source (registry versus non-registry data). The protocol was prospectively registered with PROSPERO.Databases were searched using keywords and subject terms for "Robin sequence", "epidemiology", "incidence" and "birth prevalence". Meta-analysis was performed fitting random effects models with arcsine transformation.From 34 eligible studies (n=2722 RS cases), pooled birth prevalence was 9.5 per 100 000 live births (95% CI 7.1-12.1) with statistical heterogeneity. One third of studies provided a case definition for RS and numerous definitions were used. A total of 22 countries were represented, predominantly from European populations (53% of studies). There was a trend towards higher birth prevalence in European populations and lower prevalence from registry-based studies. Only two studies reported ethnicity.This study indicates that RS occurs globally. To investigate geographical differences in prevalence, additional studies from non-European populations and reporting of ethnicity are needed. Heterogeneity of estimates may be due to variable diagnostic criteria and ascertainment methods. Recently published consensus diagnostic criteria may reduce heterogeneity among future studies.

The Evolution of Robin Sequence Treatment Based on the Biomimetic Interdisciplinary Approach: A Historical Review

The Robin sequence is a congenital anomaly characterized by a triad of features: micrognathia, glossoptosis, and airway obstruction. This comprehensive historical review maps the evolution of approaches and appliances for its treatment from the past to the current modern possibilities of an interdisciplinary combination of modern engineering, medicine, materials, and computer science combined approach with emphasis on designing appliances inspired by nature and individual human anatomy. Current biomimetic designs are clinically applied, resulting in appliances that are more efficient, comfortable, sustainable, and safer than legacy traditional designs. This review maps the treatment modalities that have been used for patients with a Robin sequence over the years. Early management of the Robin sequence focused primarily on airway maintenance and feeding support, while current management strategies involve both nonsurgical and surgical interventions and biomimetic biocompatible personalized appliances. The goal of this paper was to provide a review of the evolution of management strategies for patients with the Robin sequence that led to the current interdisciplinary biomimetic approaches impacting the future of Robin Sequence treatment with biomimetics at the forefront.

Maxillary canine position of patients with non-syndromic craniofacial disorder: a retrospective evaluation of panoramic radiographs

BACKGROUND

The study evaluates the position and displacement tendency of unerupted maxillary canines in orthodontic patients with non-syndromic craniofacial disorders (CD) compared to a control (C) group.

METHODS

Canine position and displacement tendency were evaluated using panoramic radiographs (PAN) examined with parameters such as sector classification (sectors 1-5) and inclination angles (α and β). The displacement tendency was defined as the positioning of the tip in sectors 1 or 2, as well as its combination with increased angles (α > 30° and β > 39°). In addition, the correlation of the tooth position and agenesis, cleft side, and sex was assessed.

RESULTS

A total of 116 pre-treatment PAN, divided into the CD group (n = 50; mean age 8.32 ± 2.27 years) and the C group (n = 66; mean age 10.80 ± 2.82 years), were evaluated in this study. The sector classification showed no displacement tendency in both groups. Inclination angles α/β showed a statistically significant higher displacement tendency (p = 0.01) of the CD group (n = 5) on the right side, compared to healthy subjects (n = 1). Male CD patients had a statistically significant higher displacement tendency on the right side (p = 0.03). A statistically significant correlation between cleft and non-cleft-side (p = 0.03) was found.

CONCLUSION

Patients with CD showed a statistically significant higher displacement tendency of the maxillary canine affected by the cleft side. The inclination angle was found to be the better predictor compared to the sector classification which should be considered in the orthodontic treatment planning.

Non-Surgical Respiratory Management in Relation to Feeding and Growth in Patients with Robin Sequence; a Prospective Longitudinal Study

OBJECTIVE

To reflect upon our non-surgical respiratory management by evaluating clinical outcomes regarding airway, feeding, and growth during the first year of life in patients with Robin Sequence.

DESIGN

Prospective study.

SETTING

Sophia Children's Hospital, Rotterdam, the Netherlands.

PATIENTS/ PARTICIPANTS

36 patients with Robin Sequence who were treated between 2011 and 2021.

INTERVENTIONS

Positional therapy and respiratory support.

MAIN OUTCOME MEASURE(S)

Data on respiratory outcomes included polysomnography characteristics and capillary blood gas values. Feeding outcomes were based on the requirement of additional tube feeding. Outcomes on growth were expressed as standard-deviation-scores (SDS) for weight-for-age (WFA) and height-for-age (HFA).

RESULTS

Twenty patients were treated with positional therapy (PT), whilst the other 16 patients required respiratory support. Twenty-two patients presented with non-isolated Robin Sequence (RS). During the first year of life, obstructive apnea hypopnea index decreased, oxygen levels enhanced, and capillary blood gas values improved. Eighty-six percent (31/36) experienced feeding difficulties, which completely resolved in 71% (22/31) during their first year of life. From start treatment, to stop treatment, to the age of 1 year, the SDS WFA worsened from -0.40 to -0.33 to -1.03, respectively.

CONCLUSIONS

Non-surgical respiratory treatment resulted in an improvement of respiratory outcomes to near normal during the first year of life in patients with RS. These patients often experience feeding difficulties and endure impaired weight gain up to 1 year of age, despite near normalization of breathing. The high prevalence of feeding difficulties and impaired weight for age indicate the urgency for early recognition and adequate treatment to support optimal growth.

Epidemiology of Robin sequence in the UK and Ireland: an active surveillance study

BACKGROUND

Birth prevalence of Robin sequence (RS) is commonly reported as 1 case per 8000-14 000 live births. These estimates are based on single-source case ascertainment and may miss infants who did not require hospital admission or those without overt upper airway obstruction at birth.

OBJECTIVES

To identify the true birth prevalence of RS with cleft palate in the UK and Ireland from a population-based birth cohort with high case ascertainment.

METHODS

Active surveillance of RS with cleft palate was carried out in the UK/Ireland using dual sources of case ascertainment: British Paediatric Surveillance Unit (BPSU) reporting card and nationally commissioned cleft services. Clinical data were collected from notifying clinicians at two time points.

RESULTS

173 live-born infants met the surveillance case definition, giving a birth prevalence of 1 case per 5250 live births (19.1 per 100 000 (95% CI 16.2 to 21.9)), and 1:2690 in Scotland. 47% had non-isolated RS, with Stickler syndrome the most common genetic diagnosis (12% RS cases). Birth prevalence derived from the combined data sources was significantly higher than from BPSU surveillance alone.

CONCLUSIONS

Birth prevalence of RS in the UK/Ireland derived from active surveillance is higher than reported by epidemiological studies from several other countries, and from UK-based anomaly registries, but consistent with published retrospective data from Scotland. Dual case ascertainment sources enabled identification of cases with mild or late-onset airway obstruction that were managed without hospital admission. Studies of aetiology and equivalent well-designed epidemiological studies from other populations are needed to investigate the identified geographical variability in birth prevalence.

Masticatory Efficiency in Orthodontic Patients with Craniofacial Disorder

This study evaluates the masticatory efficiency in patients with craniofacial disorders (CD) compared to controls (C). A total of 119 participants (7-21 years), divided into CD group (n = 42, mean age 13.45 ± 5.2 years) and C group (n = 77, mean age 14.3 ± 3.27 years) under an orthodontic treatment were included. Masticatory efficiency was assessed using a standard food model test. The masticated food was examined according to its number of particles (n) and area (mm²), wherein a higher number of particles alongside a smaller area was an indication of better masticatory efficiency. Additionally, the influence of cleft formation, chewing side, dentition stage, age and sex were evaluated. Patients with CD chewed the standardized food in fewer particles (n_CD = 61.76 vs. n_C = 84.58), with a significantly higher amount of area than the controls (A_CD = 192.91 mm² vs. A_C = 146.84 mm²; p = 0.04). In conclusion, patients with CD showed a significantly decreased mastication efficiency compared to healthy patients. Factors such as stage of cleft formation, chewing side, dentition stage and age showed an influence on masticatory efficiency, whereas no gender effect on the masticatory efficiency of CD patients was found.

Pierre Robin and breathing: What to do and when?

Robin sequence is characterized by mandibular retrognathia, airway obstruction, and glossoptosis; 80%-90% also have a cleft palate. Various treatment approaches exist, and although controlled studies are rare, objective assessment of treatment outcomes that address the leading clinical issues, namely obstructive sleep apnea and failure to thrive, are essential. Sleep-disordered breathing may be detected using cardiorespiratory polygraphy or polysomnography. Pulse oximetry alone may miss infants with frequent obstructive apneas, yet no intermittent hypoxia. Among conservative treatment options, the Tubingen Palatal Plate with a velar extension shifting the tongue base forward is the only approach that corrects the underlying anatomy and that has undergone appropriate evaluation. Of the surgical treatment options, which are not necessarily the first line of therapy, mandibular distraction osteogenesis (MDO) is effective and has been most extensively adopted. Notwithstanding, it is puzzling that MDO is frequently used in some countries, yet hardly ever in others, despite similar tracheostomy rates. Thus, prospective multicenter studies with side-by-side comparisons aimed at identifying an optimal treatment paradigm for this potentially life-threatening condition are urgently needed.

Tooth agenesis in German orthodontic patients with non-syndromic craniofacial disorder: a retrospective evaluation of panoramic radiographs

Objectives

The study objective was to evaluate the tooth agenesis in German orthodontic patients with non-syndromic cleft lip and/or palate and Robin sequence compared to a control group without craniofacial disorder.

Materials/methods

A total of 108 panoramic radiographs were examined using the binary system of Tooth Agenesis Code (TAC) (excluding the third molar). Patients were divided into the craniofacial disorder group 1 (n = 43) and the healthy control group 2 (n = 65). Parameters such as skeletal class malformation, sex, localization of the cleft, craniofacial disorder, and interobserver reliability were assessed.

Results

Permanent tooth agenesis was observed in 44% of group 1 and 14% in group 2 with a statistically significant higher prevalence (p = 0.00162 (χ²)). Fourteen different TAC patterns were observed in group 1, ten of these occurring only once in separate patients. The distribution of the TAC codes in group 2 showed nine different possibilities of TAC code patterns; seven TACs were unique. In group 1, the most frequently absent teeth were the maxillary lateral incisor of the left side (30%); in group 2, the second premolar of the lower jaw on the right side (9%). Male patients with craniofacial disorder showed a higher percentage of tooth agenesis than female.

Conclusion

The data presented here shows a statistically significant higher prevalence of tooth agenesis in German patients with non-syndromic craniofacial disorder.

Clinical relevance

Radiographic evaluation enables the diagnosis of tooth agenesis. Recognizing early on the higher prevalence of tooth agenesis in patients exhibiting a craniofacial disorder is an important issue when developing long-term and comprehensive interdisciplinary treatment.

Split orthodontic airway plate: An innovation to the utilization method of conventional orthodontic airway plate for neonates with Robin sequence

Since the emergence of neonatal infant orthodontics for treatments of cleft lip and palate with or without Robin sequence (RS) in Europe in the 1950s, advancements in design and scope of its application have been remarkable. As the first institution to adopt orthodontic airway plate (OAP) treatment in the United States in 2019, we saw a need for innovation of the original design to streamline the most labor-intensive and time-consuming aspects of OAP utilization. A solution is introduced using a systematic split expansion mechanism to re-size the OAP periodically to accommodate the neonate’s maxillary growth. To date, seven RS patients have received this modified treatment protocol at our institution. Each patient completed full treatment using only one OAP. This innovative utilization method is aptly named the split orthodontic airway plate (S-OAP). Details of the S-OAP and its modifications from conventional OAP are reported.

Disruptive Therapy Using a Nonsurgical Orthodontic Airway Plate for the Management of Neonatal Robin Sequence: 1-Year Follow-up

We recently published the 3-month follow-up of 2 neonates with Robin sequence whose mandibular hypoplasia and restricted airway were successfully treated with an orthodontic airway plate (OAP) without surgical intervention. Both infants were successfully weaned off the OAP after several months of continuous use. We present the course of OAP treatment in these patients with a focus on breathing, feeding, and facial growth during their first year of life. Both infants demonstrated stable mandibular projection, resolution of obstructive sleep apnea, and normal development.

A parent's view on the care of their baby with Robin sequence

A Robin sequence parent presents the view that Robin sequence healthcare providers are engaging in practices which may be outdated, excessively invasive, and unnecessarily detrimental to quality of life, and proposes possible areas of research to improve patient outcomes.

Managing infants with craniofacial malformations - Where to go next?

Treatment of infants with craniofacial malformations, e.g. Robin sequence, is characterized by considerable heterogeneity and a lack of randomized trials to identify an optimal approach. We propose to establish an international register using a common minimal dataset that will better allow for a comparison between key determinants and outcomes in these patients. In infants, this should include an assessment of mandibular micrognathia, glossoptosis, upper airway obstruction, weight gain and mode of feeding. Later on, neurocognition, speech development, hearing and quality of life should also be included. Together, these data will help better to advice parents on which treatment to choose for their baby with a craniofacial malformation.

Feeding considerations for infants with craniofacial malformations

Approximately 5% of children experience difficulty with the complex coordination of sucking, swallowing and breathing required for feeding. Infants with craniofacial malformations may have anatomic and neurologic contributions to feeding problems. Examples include cleft lip and/or palate, micrognathia, maxillary hypoplasia, and pharyngeal dysfunction. Interventions may facilitate weight gain and avoid failure-to-thrive in these infants. An interdisciplinary approach to address feeding challenges in children with craniofacial differences is necessary. Positional changes, latching maneuvers, specialized feeder nipples, squeezable bottles, and cup feeding can be implemented early. Surgical intervention, including gastrostomy tube placement, tongue lip adhesion, mandibular distraction osteogenesis and tracheostomy, may be required in more severe cases.

Pierre Robin sequence causes position-dependent obstructive sleep apnoea in infants

INTRODUCTION

Obstructive sleep apnoea (OSA) and feeding difficulties are key problems for Pierre Robin sequence (PRS) infants. OSA management varies between treatment centres. Sleep positioning represents the traditional OSA treatment, although its effectiveness remains insufficiently evaluated.

DESIGN

To complete a polysomnographic (PSG) evaluation of effect of sleep position on OSA in PRS infants less than 3 months of age. We analysed a 10-year national reference centre dataset of 76 PRS infants. PSG was performed as daytime recordings for 67 in the supine, side and prone sleeping position when possible. In most cases, recording included one cycle of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep in each position.

RESULTS

One-third of infants (9/76, 12%) had severe OSA needing treatment intervention prior to PSG. During PSG, OSA with an obstructive apnoea and hypopnoea index (OAHI) >5 per hour was noted in 82% (55/67) of infants. OSA was most severe in the supine and mildest in the side or in the prone positions. The median OAHI in the supine, side and prone positions were 31, 16 and 19 per hour of sleep (p=0.003). For 68% (52/67) of the infants, either no treatment or positional treatment alone was considered sufficient.

CONCLUSIONS

The incidence of OSA was 84% (64/76) including the nine infants with severe OSA diagnosed prior to PSG. For the most infants, the OSA was sleep position dependent. Our study results support the use of PSG in the evaluation of OSA and the use of sleep positioning as a part of OSA treatment.

Retrospective study on growth in infants with isolated Robin sequence treated with the Tuebingen Palate Plate

BACKGROUND

Children with Robin sequence (RS) are at risk of growth failure, mainly due to their increased work of breathing and feeding difficulties. Various conservative and surgical treatment approaches exist, but their impact on weight gain has not yet been adequately addressed. A functional treatment concept, used in our center for > 20 years, includes a pre-epiglottic baton plate (Tuebingen palatal plate) and intensive feeding training.

OBJECTIVE

To investigate the effect of the Tuebingen treatment protocol on growth and weight trajectories during infancy.

METHODS

This retrospective study analyzed longitudinal data from infants with isolated RS admitted to Tuebingen University Children's Hospital, Germany between 1998 and 2019. Through our electronic patient database, we evaluated anthropometric parameters until reaching 1-year follow-up. Results are shown as median (IQR).

RESULTS

In 307 infants analyzed, median Z-score for weight decreased from - 0.28 at birth to - 1.12 upon admission to our center at a median age of 22 days. Z-score then remained largely unchanged until discharge (Z-score difference, - 0.08), while the proportion of infants receiving tube feedings decreased from 55.1 to 13.7%. Z-score subsequently increased from - 1.17 at discharge to - 0.44 at the 1-year follow-up (p < 0.001).

CONCLUSION

Based on a comparatively large cohort, this functional treatment was associated with better weight gain and improved feeding. As RS infants often show postnatal growth failure, weight monitoring may be a valuable parameter for monitoring treatment effectiveness. Clinical Trial Registration Not necessary due to the retrospective design.

Nasopharyngeal Tube and Functional Treatment in Pierre Robin Sequence: A Tertiary Clinical Experience From 150 Cases

OBJECTIVES

To describe the initial care practices for children with Pierre Robin sequence (PRS) and analyze the factors predicting the severity of the obstruction breathing disorders.

DESIGN

A retrospective single-center study of 150 children with PRS.

SETTING

Single tertiary care center, Regional Competence Center for the diagnosis and treatment of PRS.

PATIENTS

A total of 150 children with PRS consecutively followed between 1986 and 2017. Group 1 comprises children without specific respiratory management; group 2, children requiring prone positioning to alleviate their respiratory distress symptoms; and group 3, children requiring nasopharyngeal airway tube (NT) or nonconservative surgical treatment.

MAIN OUTCOME MEASURES

Evolution and results of the initial treatment of PRS.

RESULTS

Forty-two percent (n = 63) were attributed to group 1, 39% (n = 50) to group 2, and 19% (n = 29) to group 3. Preterm birth, birth weight, or associated congenital malformations were not significantly different between the groups. However, the age of exclusive oral feeding was significantly different: 1 day (quartiles: 0-3) for group 1; 11 days (quartiles: 1-28) for group 2; 39 days (quartiles: 19-111) for group 3 (P < .0001). Considering the NT, its use relieves the upper airway obstruction, assessed by a respiratory polygraphy, in 14 children.

CONCLUSIONS

Nasopharyngeal airway tube has become our major first-line treatment, avoiding more complex procedures in most of the cases. The achievement of exclusive oral feeding seems to be a good predictor of the severity of respiratory symptoms in PRS.

Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database

OBJECTIVES

This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO).

DESIGN

Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012.

SETTING

Inpatient database from the United States.

PARTICIPANTS

Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic.

INTERVENTIONS

Mandibular distraction osteogenesis.

MAIN OUTCOME MEASURES

Length of hospital stay, adjunct airway and nutritional interventions and disposition.

RESULTS

The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32).

CONCLUSIONS

Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.

Nonsurgical Orthodontic Airway Plate Treatment for Newborns With Robin Sequence

Despite promising outcomes for >50 years, nonsurgical orthodontic airway plates (OAP) are only infrequently offered for babies with Robin sequence in a few parts of the world. This article demonstrates possibility of providing functional improvement using an OAP to help these babies overcome their functional and structural difficulties on their own. Two consecutively treated cases are presented exemplifying that OAP treatment that had originated from Europe is reproducible and effective in an institution in the United States.

Study on the Effect of Bilateral Mandible Distraction Osteogenesis About the Nutrition Status of Infants With Pierre-Robin Sequence

Objective: By comparing and studying the changes of food intake, weight, body length, BMI, blood albumin level and other indicators of infants with Pierre-Robin Sequence (PRS) before and after Bilateral Mandible Distraction Osteogenesis operation, to explore the effect of distraction osteogenesis on PRS patients about the improvement of nutrition status. Methods: The children with PRS who admitted to the Oral and Maxillofacial Surgery Department of Guangzhou Women and Children's Medical Center from July 2015 to December 2020 were selected. All patients accepted bilateral mandible distraction osteogenesis surgery, and the pre- and post-operative indicators were recorded, such as food intake, weight, length, blood albumin level and others. BMI was calculated based on the indicators mentioned above, and comparative statistical analysis was performed. Results: 1. All patients were fed with whole milk before the first surgery, and the average calorie per kg was 91.8 kcal/kg, significantly lower than the standard (100-150 kcal/kg), suggesting the overall nutritional intake of PRS patients is low; 2. t tests for independent samples were used to analyze the pre-operative and post-operative indicators. The WFA percentile increased from 14.16 ± 2.17 to 15.01 ± 1.85% (P = 0.0048), WFA z score increased from -2.40 ± 0.18 to -1.90 ± 0.14 after the surgery (P = 0.0010), LFA percentile increased from 20.04 ± 3.48 to 33.67 ± 4.29% (P = 0.0098), LFA z score increased from -2.09 ± 0.19 to -1.42 ± 0.23 (P = 0.0009), BMI z score increased from -1.95 ± 0.22 to -1.39 ± 0.16 (P = 0.0408), ALB raised from 37.06 ± 0.51 to 42.85 ± 0.30 g/L (P < 0.001), which indicating that the physique of patients improved after the distraction osteogenesis surgery, mainly was reflected by the lifting of weight and length growth curves; the body shape also improved, indicating that the patients' nutrition status after the surgery is also improved. Conclusion: Bilateral mandible distraction osteogenesis surgery has a positive effect on the nutrition status of children with PRS. This effect is mainly reflected by the improvements of the body physical indicators after surgery.

Treatment of infants with craniofacial malformations

Infants with craniofacial malformations (CFMs) are at increased risk of various clinical problems, including respiratory and feeding disorders, the result of which may be long-lasting. An improvement in clinical care can be achieved by prenatal diagnosis and interdisciplinary birth preparation. Feeding problems may particularly be stressful for the family and require a team approach involving nursing staff, speech therapists and nutritional specialists to anticipate, avoid and treat sequelae such as failure to thrive or recurrent aspirations. Special techniques (eg, optimisation of breast feeding, alternative feeding methods or manual orofacial therapy) may be used individually to improve feeding competence; supplemental nutrition via a nasogastric or gastrostomy tube may be temporarily necessary to ensure adequate weight gain. The high prevalence of respiratory disorders in infants with craniofacial abnormalities requires anticipation and screening to prevent growth failure and neurological deficits. Treatment of upper airway obstruction varies widely, strategies can be divided into non-surgical and surgical, and in those aimed at widening the pharyngeal space (eg, prone position, palatal plates, craniofacial surgery) and those bridging the narrow upper airway (eg, nasopharyngeal airway, modified palatal plate, pneumatic airway stenting, tracheostomy). The complex management of an infant with CFM should be performed by a multidisciplinary team to offer specialised support and care for affected families.

Neonatal Aerodigestive Disorders: Epidemiology and Economic Burden

Aerodigestive disorders, those affecting the upper and lower airway or upper gastrointestinal tract, are interrelated anatomically during fetal development and functionally after birth. Successful respiration and feeding requires careful coordination to promote effective swallowing and prevent aspiration. I describe the epidemiology, including the prevalence of the most common aerodigestive disorders. The ability of an infant to feed by mouth at discharge, without a surgically placed feeding tube, is an important neurodevelopmental marker. Therefore, aerodigestive disorders have a high potential for lifelong morbidities and health care expenditures. When available, published research on related medical costs for these disorders is provided.

Weight Gain in Infants With Pierre Robin Sequence in the First Year of Life

OBJECTIVE

To compare growth trends among infants with Pierre Robin sequence (PRS) to normal World Health Organization (WHO) growth standards.

STUDY DESIGN

Case series with chart review.

SUBJECTS AND METHODS

Twenty-four infants with syndromic and nonsyndromic PRS (54% male) treated at an urban academic medical center between 2009 and 2017 were included. Infants with symptomatic hypoventilation underwent mandibular distraction osteogenesis (71%). Weights were recorded at roughly 1- to 3-month intervals from birth to 12 months, with ages adjusted for prematurity. The 50th percentile (P50) for this cohort was calculated and compared to WHO standards.

RESULTS

In total, 135 weight entries for 24 subjects were included. The birth weight P50 was similar to the WHO standard (females: 0.09 kg above WHO [95% CI, -0.25 to +0.43; z score = 0.19]; males: 0.38 kg below WHO [95% CI, -0.77 to 0.00; z score = -0.79]). A slower growth rate was noted among female and male infants with PRS: in month 5, the PRS P50 among females was 1.42 kg below the WHO standard (95% CI, -1.77 to -1.07; z score = -1.64). Among males in month 3, the PRS P50 was 1.68 kg below the WHO standard (95% CI, -2.12 to -1.24; z score = -2.19). By month 12, weight deficiencies had resolved in both groups.

CONCLUSION

Newborns with and without PRS may have similar birth weights, but the growth rate among male and female infants with PRS may lag behind that of unaffected infants, even when upper airway obstruction has been addressed in early infancy.

The Tübingen palatal plate approach to Robin sequence: Summary of current evidence

Various treatments, many of them considerably invasive, are currently applied to infants with Robin sequence (RS) and accompanying upper airway obstruction (UAO). We present a narrative review of our data on the Tübingen palatal plate (TPP) which show the following: a) in a randomized trial, the TPP was superior to a sham procedure in alleviating UAO; b) children treated with the TPP in infancy showed an intellectual development within the reference range; c) prone positioning is no alternative, as it is ineffective and associated with an increased risk of sudden death; d) the TPP reduces the mixed-obstructive apnea index to near-normal values, both in isolated and most (83%) syndromic RS, e) of 443 infants (129 syndromic) treated with the TPP in our center, 23 (5%) ultimately received a tracheostomy (all with syndromic RS), f) recent data suggest that the TPP may induce mandibular catch-up growth, g) the TPP may also help to reduce respiratory complications following cleft closure in RS, and h) TPP treatment is applied by various centers around the world, although it is unclear if its effectiveness is invariably controlled by endoscopy and sleep studies, although both are necessary. Given these data from peer-reviewed studies, it may be questioned whether the "First do no harm" principle is always adhered to when subjecting RS infants to more invasive procedures such as mandibular distraction osteogenesis or tongue-lip adhesion.

Mandibular growth in infants with Robin sequence treated with the Tübingen palatal plate

Background

Robin sequence (RS) is characterized by mandibular retrognathia, glossoptosis and upper airway obstruction. Whether mandibular catch-up growth may occur in RS is yet controversial. Our functional and less invasive treatment including the Tübingen Palatal Plate (TPP), early oral feeding and orofacial stimulation may promote mandibular catch-up growth. We evaluated the effect of the Tübingen Palatal Plate on mandibular growth, expressed by the Jaw index, sleep study results and weight gain in infants admitted with isolated and syndromic RS, born at or referred to our center between 6/2015 and 5/2018.

Methods

Retrospective analysis of our electronic patient database that included data on jaw index measurements, sleep study results and standard deviation (Z-)scores for weight.

Results

Of 31 patients referred for RS treatment (22 isolated, 9 syndromic), we had data on the above parameters, determined at admission, discharge and 3 months after discharge, in 20. Jaw index at admission and 3-month follow-up was 8.8 (6.3–11.3) and 2.1 (2.0–4.0), respectively (median (IQR); p < 0.0001). Mixed-obstructive apnea index (MOAI) decreased from 9.7 (4.8–24.2) to 0.0 (0–1.3; p < 0.002). No significant correlation was observed between MOAI and Jaw Index, but MOAI correlated with the Maxillary/Mandibular arch ratio (r = 0.58; p < 0.001).

Z-scores for weight were similar at both time points at − 1.34 (− 1.76 – − 0.57) and − 1.50 (− 1.89 – − 0.54), while the proportion of infants requiring nasogastric tube feeding decreased from 84 to 8%. No infant had craniofacial surgery; one with syndromic RS required tracheostomy.

Conclusion

These longitudinal cohort data suggest that the Tübingen Palatal Plate as used here may alleviate upper airway obstruction by promoting mandibular growth.

Trial registration

N.A.

Epidemiology of Robin sequence with cleft palate in the East of Scotland between 2004 and 2013

BACKGROUND

Robin sequence (RS) is a congenital disorder characterized by cleft palate, micrognathia, and glossoptosis which can result in clinically significant upper airway obstruction (UAO). Historically, incidence of RS in the UK has been estimated as 1 in 8500 live births. Our study describes birth prevalence, clinical characteristics, and management of RS in the East of Scotland (EoS) region.

METHODS

Retrospective case note review of infants born in EoS from 2004 to 2013 with a clinical diagnosis of RS. Cases were identified by searching the regional cleft service patient database and review of Hospital Activity Statistics data. Regional live birth rate provided the denominator for incidence calculations.

RESULTS

A total of 105 cases of RS were identified, giving a birth prevalence of 1:2685 live births. No trends in annual incidence were observed over the 10-year period. Intrauterine exposure to potentially teratogenic agents was identified in 17% cases, including Methadone in 8% cases. Signs of UAO were present in 93% of infants, 63% of whom required active airway management. Nasopharyngeal airway (NPA) was the most commonly used intervention (53% cases), whilst only 7% required surgical management. Infants with an underlying syndrome or additional anomalies (RS+) were significantly more likely to be admitted to a tertiary center and require surgical airway or feeding support compared to those with isolated RS.

CONCLUSIONS

RS incidence in EoS is substantially higher than that reported within other populations, and than previously reported in the UK. A possible association with intrauterine Methadone exposure warrants further investigation.

Mandibular Catch-Up Growth in Pierre Robin Sequence: A Systematic Review

Objective:

The concept of mandibular catch-up growth is often quoted in the literature regarding Pierre Robin sequence (PRS). We endeavored to perform a systematic review of whether the literature supports this concept.

Design:

Systematic review.

Interventions:

A PubMed-based systematic review of the English literature was performed of articles objectively measuring mandibular growth or position after nonoperative management of PRS.

Main Outcome Measures:

Rate and end point of mandibular length, ramus length, gonial angle, and maxillomandibular discrepancy.

Results:

The initial search delivered 607 English-language abstracts. Of these, 16 met inclusion criteria. Eight articles evaluating 143 patients followed longitudinal patient data and therefore allowed comparison of growth rates to controls. Ten articles evaluating 228 patients presented cross-sectional data and therefore could only evaluate a single time point. Two of the 8 longitudinal studies reported faster than normal growth of mandibular length in a significant portion of their cohort. Five of 8 reported equal growth rates. One of 16 studies reported that mandibular length of patients with PRS normalized compared to controls. Two of 16 studies reported no difference in maxillomandibular discrepancy between PRS and controls, whereas 10 reported a posteriorly displaced mandible relative to the maxilla in PRS. Significant differences in control groups, patients, and age existed between studies.

Conclusions:

While the concept of catch-up growth in PRS is often quoted, a minority of objective studies suggest increased mandibular growth rates in isolated PRS. Even fewer studies suggest that the maxillomandibular discrepancy in PRS completely resolves.

Severity of Retrognathia and Glossoptosis Does Not Predict Respiratory and Feeding Disorders in Pierre Robin Sequence

Pierre Robin sequence (PRS) may lead to life-threatening respiratory and feeding disorders. With the aim to analyse the association of the severities of retrognathia and glossoptosis with those of respiratory and feeding disorders, we retrospectively studied a series of 50 infants with retrognathia, glossoptosis, cleft palate, and airway obstruction. The patients were managed from birth to at least 6 years of age by a single pediatric team at the Armand Trousseau Hospital in Paris within a 12 years period (2000-2012). Retrognathia and glossoptosis were graded in the neonatal period according to a specific clinical examination. Ventilation assistance was required for 32/50 (64%) patients, and enteral feeding for 41/50 (82%). The grades of retrognathia and glossoptosis and the severity of respiratory disorders did not differ between patients with isolated PRS and syndromic PRS. Severe respiratory disorders were more common and long-lasting feeding (>12 months) was more frequently required in patients with syndromic PRS compared with isolated PRS (42 vs. 13%, p = 0.04 and 42 vs. 4%, p < 0.01 respectively). Using univariate analysis, neurological impairments and laryngomalacia were associated with severe respiratory disorders [Odds ratio (OR) 5.0, 95% CI 1.3-19.6; and OR 14.6, 95% CI 1.3-161.4; p < 0.05] as well as with long-lasting feeding (>12 months) disorders (OR 18.6, 95% CI 3.9-89.2 and OR 20.4, 95% CI 3,4-122.8; p < 10^-2). Syndromic SPR status was also associated with severe respiratory disorders (OR 4.9, 95% CI 1-32.5; p < 0.05). Using multivariate analysis, only syndromic PRS status was predictive for severe respiratory disorders (adjusted OR 8, 95% CI 1.47-44.57; p < 0.05); and only neurological impairments remained a significant risk for long lasting feeding disorders (>12 months) (adjusted OR 21.72, 95% CI 3.4-138.63; p < 10^-2). The grades of retrognathia and glossoptosis were not predictive factors for the severity of respiratory and feeding disorders. Conclusion: In children with PRS, the severity of clinical conditions may not correlate with anatomic variables but rather with laryngeal abnormalities, neurological impairement and syndromic PRS status.

Multicenter study on the effectiveness of the pre-epiglottic baton plate for airway obstruction and feeding problems in Robin sequence

Background

Treatment of Robin sequence is often either invasive or of unproven effectiveness. The pre-epiglottic baton plate (PEBP) is a well-studied alternative, yet is not widely applied internationally. We report on a prospective 3-center cohort study investigating this treatment. Based on an agreed protocol, parents of infants with Robin sequence referred to participating centers were offered enrollment, which involved taking a maxillary cast followed by endoscopy to fit the plate and sleep studies to monitor its effectiveness. Recordings were centrally analyzed by sleep specialists blinded to timing and center. Primary outcome was the mixed-obstructive apnea index, defined as the number of such apneas/h of sleep; secondary outcomes included the desaturation index to <80% pulse oximeter saturation and weight gain.

Results

Of 75 infants referred, 49 could be included; 1 center failed to perform appropriate sleep studies. Within a mean hospitalization of 3 weeks, the mixed-obstructive apnea index decreased (median; interquartile range) from 15.9 (6.3–31.5) to 2.3 (1.2–5.4); it decreased further to 0.7 (0.1–2.4) in the 32 infants who had a successful 3-month follow-up sleep study performed. The desaturation index normalized (from 0.38 (0–2.7) to 0.0 (0–0.1)). Mean standard deviation score for weight remained unchanged between admission and follow-up, while the proportion of tube-fed infants decreased from 74 to 14%.

Conclusions

This prospective multi-center cohort study confirms retrospective audits on the effectiveness of PEBP treatment in improving upper airway obstruction and feeding problems, the main clinical problems of infants with Robin sequence. International collaboration is required to compare this with other treatment approaches.

Trial registration

Number NCT02266043, Registered 30/09/2014; registered partially retrospectively.

Functional treatment of airway obstruction and feeding problems in infants with Robin sequence

BACKGROUND

Robin sequence (RS), characterised by micrognathia/retrognathia and glossoptosis with or without cleft palate, presents with intermittent upper airway obstruction and feeding difficulties. Active intervention is required to reduce the risk of brain damage or sudden death. Most treatment options are poorly studied and/or invasive. Our group developed a functional approach including early feeding training and the pre-epiglottic baton plate (PEBP), an orthodontic appliance with a velar extension shifting the base of the tongue forward.

PATIENTS AND METHODS

We evaluated the effect of this approach on sleep study results and early weight gain by searching our electronic patient database for infants with isolated RS, born at or referred to our department between 1 January 2003 and 31 December 2012 and treated with the PEBP.

RESULTS

Of 122 patients identified, 360 overnight sleep study results, obtained at admission, prior to hospital discharge and 3 months postdischarge, were available (117 infants had complete data). These showed a decrease in the mixed-obstructive apnoea index from (median; IQR) 8.8 (2.1-19.7) to 1.8 (0.6-5.4); p<0.001 and 0.2 (0-1.3); p<0.001, respectively. Z-scores for weight improved from -0.7 (-1.39 to -0.24) upon admission to -0.5 (-0.90 to +0.02) at follow-up (p=0.02), accompanied by a decrease in the proportion of infants requiring nasogastric tube feeding from 66% to 8%. No infant required craniofacial surgery or tracheostomy.

CONCLUSIONS

These longitudinal cohort data suggest that this functional approach may be an option to treat both, upper airway obstruction and feeding problems, in infants with isolated RS.

Growth and prevalence of feeding difficulties in children with Robin sequence: a retrospective cohort study

OBJECTIVES

In addition to breathing problems, patients with Robin sequence (RS) often encounter feeding difficulties (FD). Data regarding the occurrence of FD and possible influencing factors are scarce. The study aim was to elucidate these factors to improve treatment strategies.

MATERIAL AND METHODS

A retrospective comparative cohort study was conducted, consisting of 69 infants diagnosed with both RS and a cleft palate and 64 isolated cleft palate only (iCPO) infants. Data regarding FD, growth, and airway intervention were collected during the first 2 years of life. A systematic review of the literature was conducted to identify reported FD in RS patients.

RESULTS

RS patients had more FD (91 %) than iCPO patients (72 %; p = 0.004). Also, nasogastric (NG)-tube feeding was necessary more frequently and for a longer period (both p < 0.001). Growth was lower in RS than iCPO infants (p = 0.008) and was not affected by the kind of airway management (conservative/surgical; p = 0.178), cleft palate grade (p = 0.308), or associated disorders (p = 0.785). By contrast, surgical intervention subtype did significantly affect growth. Mean reported FD for RS in the literature is 80 % (range = 47-100 %), and 55 % (range = 11-100 %) of infants need NG-tube feeding.

CONCLUSIONS

FD is present in a large proportion of infants with RS, which indicates the need for early recognition and proper treatment to ensure optimal growth. Growth during the first 2 years of life is significantly lower in RS patients than iCPO patients, which indicates the need for careful attention and long-term follow-up.

CLINICAL RELEVANCE

This study indicates the need for early recognition and proper treatment of FD in RS to ensure optimal growth. In addition, growth needs careful attention and long-term follow-up.

Feeding and reflux in children after mandibular distraction osteogenesis for micrognathia: A systematic review

Mandibular distraction osteogenesis (MDO) is becoming increasingly more commonly used as in neonates and infants with upper airway obstruction secondary to micrognathia. A significant number of these children are dependent on nasoenteric feeding or gastrostomies after birth for adequate nutrition and often suffer from gastro-esophageal reflux (GERD).

OBJECTIVE

This analysis is a subset of a larger systematic review. The objective of this study is to determine the effects of MDO on feeding and GERD.

DATA SOURCES

The databases searched included PubMed, Embase, Scopus, Web of Knowledge and grey literature sources.

STUDY SELECTION

The inclusion criterion included studies in children with clinical evidence of micrognathia/Pierre Robin Sequence (PRS) who have failed conservative treatments, including both syndromic (sMicro) and non-syndromic (iPRS) patients. 21 studies relevant to feeding and 4 studies relevant to GERD outcomes were included. All studies included were case series and case reports.

RESULTS

MDO leads to a significant improvement in feeding, with 82% of children feeding exclusively orally after surgery. The overall percentage of children with iPRS who were feeding orally was 93.7% compared with only 72.9% in the sMicro group (p<0.004). A growth decline within the first six weeks after surgery was observed in multiple studies. Overall, out of 70 patients with pre-operative GERD, only four had evidence of GERD after surgery.

CONCLUSIONS

Considering the limitations of this systematic review, this study found that successful relief of airway obstruction by MDO leads to improvement of feeding and improvement in symptoms of GERD in children with upper airway obstruction secondary to micrognathia. Clinicians need to be aware of the risk of growth decline in the initial post-operative period.

Pierre Robin sequence: review of diagnostic and treatment challenges

Pierre Robin sequence is not a rare condition and paediatric specialists caring for respiratory related issues are likely to encounter cases in their practice. There have been a few recent reviews on the topic, mostly focusing on the surgical interventions performed for cases with severe airway obstruction. In the present review, we will highlight the different challenges that remain today in the global evaluation of infants afflicted with this condition through a thorough review of the medical literature, giving the clinician a full scope of the disease and of the various management options. The need for an improved objective evaluation of airway obstruction and for a better classification will be emphasized. We are therefore proposing a novel classification scheme that will better account for respiratory and feeding difficulties in these infants. Finally, many knowledge gaps persist regarding this condition, underlining the necessity for further research both in the genetic field and regarding the outcome of therapy.

A pragmatic approach to infants with Robin sequence: a retrospective cohort study and presence of a treatment algorithm

Objectives

Initial approaches to and treatments of infants with Robin sequence (RS) is diverse and inconsistent. The care of these sometimes critically ill infants involves many different medical specialties, which can make the decision process complex and difficult. To optimize the care of infants with RS, we present our institution’s approach and a review of the current literature.

Material and methods

A retrospective cohort study was conducted among 75 infants diagnosed with RS and managed at our institution in the 1996–2012 period. Additionally, the conducted treatment regimen in this paper was discussed with recent literature describing the approach of infants with RS.

Results

Forty-four infants (59 %) were found to have been treated conservatively. A significant larger proportion of nonisolated RS infants than isolated RS infants needed surgical intervention (53 vs. 25 %, p = .014). A mandibular distraction was conducted in 24 % (n = 18) of cases, a tracheotomy in 9 % (n = 7), and a tongue–lip adhesion in 8 % (n = 6). Seventy-seven percent of all infants had received temporary nasogastric tube feeding. The literature review of 31 studies showed that initial examinations and the indications to perform a surgical intervention varied and were often not clearly described.

Conclusions

RS is a heterogenic group with a wide spectrum of associated anomalies. As a result, the decisional process is challenging, and a multidisciplinary approach to treatment is desirable. Current treatment options in literature vary, and a more uniform approach is recommended.

Clinical Relevance

We provide a comprehensive and pragmatic approach to the analysis and treatment of infants with RS, which could serve as useful guidance in other clinics.