Development of Swallowing Function in Infants with Oral Feeding Difficulties

Global State of the Art and Science of Childhood Dysphagia: Similarities and Disparities in Burden

Feeding/swallowing and airway protection are complex functions, essential for survival, and continue to evolve throughout the lifetime. Medical and surgical advances across the globe have improved the long-term survival of medically complex children at the cost of increasing comorbidities, including dysfunctional swallowing (dysphagia). Dysphagia is prominent in children with histories of preterm birth, neurologic and neuromuscular diagnoses, developmental delays, and aerodigestive disorders; and is associated with medical, health, and neurodevelopmental problems; and long-term socioeconomic, caregiver, health system, and social burdens. Despite these survival and population trends, data on global prevalence of childhood dysphagia and associated burdens are limited, and practice variations are common. This article reviews current global population and resource-dependent influences on current trends for children with dysphagia, disparities in the availability and access to specialized multidisciplinary care, and potential impacts on burdens. A patient example will illustrate some questions to be considered and decision-making options in relation to age and development, availability and accessibility to resources, as well as diverse cultures and family values. Precise recognition of feeding/swallowing disorders and follow-up intervention are enhanced by awareness and knowledge of global disparities in resources. Initiatives are needed, which address geographic and economic barriers to providing optimal care to children with dysphagia.

Differences in the swallowing process of newborns and healthy preterm infants: first results with a non-invasive bioimpedance and electromyography measurement system

PURPOSE

Preterm infants (PI) have difficulty coordinating sucking, swallowing and breathing, and there is a risk of aspiration. The causes of this are not yet sufficiently understood. The aim of this study was to test a novel measurement device to measure breathing and pharyngeal processes involved in swallowing externally in everyday life to identify possible differences in neonates (NB) and PI.

METHODS

Forty healthy NB were studied at 4-8 weeks of age (mean: 6.7 weeks) and 20 healthy PI (mean gestational age 30.5 weeks) at postmenstrual age (PMA) 34/35 weeks (mean PMA 35.1 weeks) during a single feeding. Surface electrodes were used to measure bioimpedance and electromyography reflecting swallow-related changes in the pharynx and muscle activation of the tongue and submental muscles. A respiratory belt was combined with recording of the depth of chest movements and the occurrence of pauses in breathing.

RESULTS

Velocity and extent of pharyngeal closure did not differ significantly across the feeding period (velocity: p=0.09, closure: p=0.17), but during the first two suck-swallow bursts PI had greater velocity (p<0.001*) and extent of pharyngeal closure (p=0.004*) than NB. The duration of swallowing phases was significantly longer in PIs (p<0.001*), their muscle activation decreased faster (p<0.001*), and they had more pauses in breathing than NBs.

CONCLUSIONS

The novel measurement device allowed, for the first time in everyday life, the measurement of factors influencing swallowing and breath-swallow coordination in NBs and PIs. PIs showed differences from NBs most likely due to differences in muscle strength and condition.

Evaluation of the Effect of Oral Motor Stimulation Exercises on Feeding Skills in Premature Infants

Objectives

Oral feeding in preterm infants is a complex and dynamic process involving oral motor development and interaction between the neurological, cardiorespiratory, and gastrointestinal systems. Oral motor stimulation (OMS) is defined as stimulating the oropharyngeal components such as the lips, jaw, tongue, and soft palate with fingers in preterm infants to increase their feeding skills. In this study, we aimed to evaluate the effect of OMS exercises on the sucking and swallowing skills of preterm infants and demonstrate the utility of objective scales to evaluate infants' readiness for oral feeding.

Methods

This single-center, prospective cohort study was conducted between June 1st and December 31st, 2020, which included preterm infants born at ≤34 weeks of gestation and admitted to the neonatal intensive care unit of our hospital. All procedures of the OMS program were performed once a day, 5 times a week by a language and speech therapist who is an expert in oral feeding skills (OFS) staging and non-nutritive sucking (NNS) scoring. All infants were followed up until discharge with a weekly evaluation of OFS staging and NNS scoring.

Results

A total of 50 infants were included in this prospective cohort study. The mean birth weight was 1376.9±372 g, and the median gestational age was 30 weeks (interquartile range: 25-34). The comparison of OFS stages on day 5 and day 10 of OMS revealed a significant increase (p<0.001). Similarly, there was a significant improvement in the NNS scores on days 5 and 10 compared to the baseline.

Conclusion

In preterm infants, OMS during the transition from gavage feeding to oral feeding improves feeding skills.

A thickened formula reduces feeding-associated oxygen desaturation and bradycardia in preterm infants

BACKGROUND

Although preterm infants often experience desaturation or bradycardia during oral feeding, specific guidelines for its management are lacking.

PURPOSE

This study aimed to investigate the effects of a commercial thickened formula (TF) on oxygen saturation and heart rate stabilization during oral feeding in preterm infants.

METHODS

This retrospective study included 122 infants born at a median (interquartile range [IQR]) 31+6 weeks (29+4 -34+6 weeks) of gestation weighing 1,725 g (1,353-2,620 g) and fed commercial cornstarch-containing TF due to feeding-associated desaturation or bradycardia. We excluded infants fed TF to treat symptomatic regurgitation. Desaturation and bradycardia events were compared between 3 days prior to the change and 3 days after the change to TF. Desaturation and bradycardia were defined as SpO2 <85% and heart rate <100 beats/min during or immediately after oral bottle feeding, respectively.

RESULTS

The median (IQR) postmenstrual age and weight were 36+1 weeks (34+6-38+0 weeks) and 2,395 g (2,160-2,780 g), respectively, at the time of change to TF. The frequency of desaturation significantly decreased after TF feeding (median [IQR]: 2.3 [1.3-3.3] events/day vs. 0.3 [0-1.7] events/day, P< 0.001). Bradycardia also decreased after TF feeding (0.3 [0-1] events/day vs. 0 [0-0.7] events/day, P=0.006). There were no cases of diarrhea or electrolyte abnormalities after TF feeding. Defecation frequency decreased (P=0.037), and polyethylene glycol was prescribed to 27% of the TF-fed infants. In a subgroup analysis of 16 infants with bronchopulmonary dysplasia, the frequency of desaturation was reduced (2.3 [1.8-3.8] events/day vs. 0.5 [0-1.5] events/day, P=0.042), and weight gain improved (22.5 [3.1-36.3] g/day vs. 41.3 [28.1-55.1] g/day, P=0.019), after TF feeding.

CONCLUSION

TF feeding significantly reduces oral feeding-associated oxygen desaturation and bradycardia in preterm infants. TF may be useful for stabilizing oxygen saturation and heart rate among preterm infants with difficulties in oral feeding.

Partial Enteral Discharge Programs for High-risk Infants

Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.

To Individualize the Management Care of High-Risk Infants With Oral Feeding Challenges: What Do We Know? What Can We Do?

The increase in preterm infants' survival over the last 30 years has shed light over their inability to feed by mouth safely and efficiently. With adverse events such as increased risks for oxygen desaturation, bradycardia, penetration/aspiration, infants' hospitalization in neonatal intensive care units (NICUs) are understandably prolonged. Unfortunately, this leads to delayed mother-infant reunion, maternal stress, breastfeeding obstacles, and increased medical costs. Such impediments have stimulated clinicians and researchers to better understand the underlying causes and develop evidence-based solutions to assist these infants. However, it is notable that the research-to-practice translation of this knowledge has been limited as there are still no validated guidelines or protocols as how to best diagnose and care for these infants. This report revisits the immature physiologic functions at the root of these infants' oral feeding difficulties, the current practices, and the recent availability of evidence-based efficacious tools and interventions. Taking advantage of the latter, it presents a renewed perspective of how management strategies can be tailored to the specific needs of individual patients.