Swallowing dysfunction and aspiration in neonates and infants

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

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Symptomatic vocal cord paresis/paralysis in infants operated on for esophageal atresia and/or tracheo-esophageal fistula

OBJECTIVES

To describe the prevalence and pathogenesis of symptomatic vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA), tracheo-esophageal fistula (TEF) or both.

STUDY DESIGN

Retrospective study of all patients treated for EA/TEF in our center (1995 to 2009). Patients with and without symptomatic VCP were compared for gestational age, birth weight, associated anomalies, referrals, long-gap EA (> 3 cm or 3 vertebral bodies), cervical esophagostomy, anastomotic leakage, length of ventilation, and major cardiac surgery. Prevalence or median (IQR) is reported.

RESULTS

Of 174 patients, 7 (4%) had symptomatic VCP. Prevalence of referrals (5/7 versus 21/167; P = .0009), long gap (5/7 versus 41/167; P = .0146), previous cervical esophagostomy (5/7 versus 7/167; P < .0001), and anastomotic leakage (3/7 versus 10/167; P = .0097) was higher, and ventilation longer (8.5 days [7.0 to 15.5] versus 6.0 days (5.0 to 7.0); P = .0072) in patients with VCP.

CONCLUSIONS

In infants treated for EA/TEF, VCP should be ruled out in case of persistent respiratory morbidity or, when present, cautiously monitored. Surgical risk factors should be actively controlled. Further studies are needed to define the prevalence of acquired and congenital VCP in patients with EA/TEF.

Vocal cord dysfunction and feeding difficulties after pediatric cardiovascular surgery

OBJECTIVE

To evaluate the impact of vocal cord dysfunction on feeding in children after cardiovascular surgery.

STUDY DESIGN

Of the 2255 children who had cardiovascular surgery between January 2000 to January 2006, 38 (1.7%) had postoperative vocal cord dysfunction confirmed at laryngoscopy. The following data were obtained retrospectively: type of surgery, laryngoscopic examination results, swallowing studies, upper gastrointestinal (UGI) studies, and feeding route: oral, nasogastric tube (NG), and gastrostomy.

RESULTS

Surgeries included aortic arch reconstruction (n = 20), patent ductus arteriosus ligation (n = 8), arterial switch (n = 3), cervical cannulation for extracorporeal membrane oxygenation (n = 2), and others (n = 5). A swallowing study confirmed dysfunction in 27 of 29 patients. Gastrostomy was placed in 18/38 patients. At discharge, 18 patients were fed by gastrostomy, 13 orally, 3 by NG, and 4 by combination oral/NG. At a median follow-up of 12 months, 20 were fed orally, 1 by NG, 7 by gastrostomy, 7 by combination gastrostomy/orally, 1 was lost to follow-up, 2 died.

CONCLUSION

Vocal cord dysfunction after pediatric cardiovascular surgery is associated with significant feeding problems and may require prolonged gastrostomy feeding. These findings support aggressive surveillance for vocal cord dysfunction, especially in patients undergoing aortic arch surgery.

Selective medicated (normal saline and exogenous surfactant) bronchoalveolar lavage in severe aspiration syndrome in children

OBJECTIVE

To study the ability of volume-controlled ventilation and medicated (normal saline plus surfactant) bronchoalveolar lavage in aspiration to reduce the duration of intubation and improve gas exchange.

DESIGN

: Randomized controlled clinical trial.

SETTING

Pediatric intensive care unit.

PATIENTS

Twenty children, 1 month to 16 yrs old, who were intubated and mechanically ventilated, were randomized within 6 hrs of aspiration to receive volume-controlled ventilation plus medicated bronchoalveolar lavage (treatment group) or the same ventilation and bronchosuction (control group).

INTERVENTIONS

Volume-controlled ventilation and positive end-expiratory pressure (10-12 cm H2O) were applied. Medicated bronchoalveolar lavage was performed using five aliquots of 5 mL of saline plus 10 mg/mL Curosurf (porcine surfactant, Chiesi Pharmaceutical SpA, Parma, Italy) in infants, five boluses of 10 mL of saline plus 5 mg/mL Curosurf in children, and four boluses of 25 mL of saline with 2.4 mg/mL Curosurf in adolescents for each affected lobe. One hour after bronchoalveolar lavage, 240 mg of Curosurf was administered locally.

MEASUREMENTS AND MAIN RESULTS

All patients survived. In the treatment group, days of intubation were 4.6 (+/-1.07), oxygenation index and Pao2/Fio2 improved significantly at 24 hrs, and statistical reduction in tidal volume mL/kg was observed from 36 hrs. In the control group, days of intubation were 11.8 (+/-3.22) (p < .0001), no improvement in oxygenation was noted, and pneumonia was observed in seven children (70%).

CONCLUSIONS

Even though this was an unblinded small clinical trial and low tidal volume strategy was not employed at an early stage after lung injury, there is some evidence that bronchoalveolar lavage with normal saline and surfactant may have clinical value in treating severe aspiration syndrome in children. More clinical studies are warranted to overcome study limitations and potential bias.

Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors

BACKGROUND

The presence of swallowing dysfunction in children without obvious risk factors remains under appreciated. Early identification and prompt initiation of appropriate treatments are critical for reduction of morbidities associated with dysphagia.

OBJECTIVE

: To describe the clinical presentations, radiologic characteristics, and long-term outcomes in children with oropharyngeal dysphagia presenting as unexplained respiratory problems. We completed a retrospective chart review of all children without known dysphagic risk factors upon presentation to Speech-Language Pathology (December 1991-April 1995) for feeding/swallowing evaluations because of refractory respiratory problems and dysphagic concerns, and who subsequently were diagnosed with dysphagia on Videofluoroscopic Swallow Study (VFSS). In August 2002, follow-up telephone interviews were conducted with caregivers of 14 children.

RESULTS

: We identified 19 children (mean age 1.14 years; range 0.9-5.75) with dysphagia presenting as unexplained respiratory problems. On VFSS, delayed pharyngeal swallow onset was the most common abnormal radiologic finding and always preceded penetration or tracheal aspiration. Eleven (57.9%) children aspirated. Aspiration occurred only with liquids and 100% of aspiration events were silent (i.e., no cough). Dysphagia was not a concern in 11 children at a mean age 3.2 years (range 0.7-10) and persisted in three children who were 9 years or older.

CONCLUSIONS

: Oropharyngeal dysphagia should be considered in the differential diagnosis of young children without known risk factors associated with swallowing dysfunction when they present with unexplained respiratory problems. Although the prognosis for resolution of dysphagic concerns is very good, it may take several years.

Laryngopharyngeal dysfunction after the Norwood procedure

OBJECTIVE

We sought to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction after a Norwood procedure compared with that after biventricular aortic arch reconstruction.

METHODS

From April 2003 through December 2004, 36 neonates underwent a Norwood procedure; 33 of 36 had postoperative fiberoptic laryngoscopy and modified barium swallow. Study results were used to guide the transition from nasogastric tube to oral feeding and placement of gastrostomy tubes. During the same time period, 18 neonates underwent aortic arch reconstruction as part of a biventricular repair.

RESULTS

After a Norwood procedure, laryngoscopy showed left true vocal fold (cord) paralysis in 3 (9%) of 33 patients. The results of a modified barium swallow were abnormal in 16 (48%) of 33 patients, with aspiration in 8 (24%) of 33 patients. Of the 3 patients with vocal fold paralysis, 2 had a normal modified barium swallow result, and 1 had aspiration. Gastrostomy tubes were placed in 6 (18%) of 33 patients, all with an abnormal modified barium swallow result. Hospital stay was longer in patients with an abnormal modified barium swallow result: 34 +/- 13 versus 22 +/- 7 days (P < .01). After biventricular repair with aortic arch reconstruction, left true vocal fold paralysis occurred in 4 (25%) of 16 patients; results of a modified barium swallow were abnormal in 10 (59%) of 17 patients, with aspiration in 6 (35%) of 17 patients (all nonsignificant vs patients undergoing the Norwood procedure). Follow-up laryngoscopy in 4 patients with vocal fold paralysis showed no change in 3 of 4 patients and improvement in 1 patient. Follow-up modified barium swallow showed resolution of aspiration in 11 (85%) of 13 patients. Hospital survival was 32 (89%) of 36 patients for the Norwood procedure and 18 (100%) of 18 patients for biventricular repair. There has been 1 sudden death before second-stage palliation.

CONCLUSIONS

After a Norwood procedure, swallowing dysfunction occurs in 48% of patients, with aspiration in 24%, and results in increased length of hospital stay. Left recurrent laryngeal nerve injury, seen in 9% of patients, is an uncommon cause of swallowing dysfunction. Postoperative aspiration generally resolves over time, whereas vocal fold paralysis does not. Systematic evaluation of swallowing function allows appropriate tailoring of feeding regimens and might contribute to decreased hospital and interstage mortality.

Life expectancy of children in vegetative and minimally conscious states

We determined estimates of survival in children, 3-15 years of age, in the vegetative state (VS) (n = 564), immobile minimally conscious state (MCS) (n = 705), and mobile MCS (n = 3,806). Data were extracted from the annual Client Development Evaluation Reports of the California Department of Developmental Services between 1988 and 1997 using the operational definitions for these three states on the basis of 15 descriptive behavioral categories. Patients were also categorized according to the following four etiologies: acquired (traumatic and nontraumatic) brain injury; perinatal/genetic; degenerative; and unknown/undetermined. The percentage of patients surviving 8 years was 63%, 65%, and 81%, for the VS, immobile MCS, and mobile MCS, respectively. Children in the VS and MCSs with acquired brain injury had lower mortality rates and those with degenerative diseases the highest mortality rates. We observed little difference in survival between patients in the VS and immobile MCS, suggesting that the presence of consciousness is not a critical variable in determining life expectancy. Furthermore, survival was much greater for patients in the mobile MCS than for those in the immobile MCS, suggesting that mobility is more important in predicting survival than the level of consciousness.