Effects of Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Sucking, Swallowing, and Breathing during Bottle-Feeding in Lambs

Historical Perspectives and Clinical Updates on Preterm Bottle Feeding With Noninvasive Ventilation

The controversial topic of oral feeding while on noninvasive ventilation remains at the forefront of preterm intensive care management. The intersection of pulmonary, neurologic, and gastrointestinal maturation coalesces at a postmenstrual age that requires changes in practices compared with those used in older infants. Various animal models in the past decades aimed to gain physiological knowledge of noninvasive ventilation effects on the suck-swallow-breathe coordination sequence. However, the preterm infant poses nuanced anatomic challenges. Although concerns for oral feeding while on noninvasive ventilation include aspiration risks and potential inpatient obstacles, there is evidence to support the feasibility, initiation, and progression of oral feedings while an infant is supported on high-flow nasal cannula and continuous positive airway pressure. There is evidence to support that this may accelerate attainment of oral feeding milestones and, thus, eventual hospital discharge. More recent multidisciplinary institutional protocols may provide cautious guidance on evaluation and algorithms to assess infants who may benefit from initiation and advancement of oral feeding versus awaiting further maturation.

Pediatric Aerodigestive Medicine: Advancing Collaborative Care for Children With Oropharyngeal Dysphagia

OBJECTIVES

Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full-day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients.

METHODS

The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model.

CONCLUSIONS

The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high-quality, and evidence-based care for patients, including those with OPD.

Safety of Bottle-Feeding Under Nasal Respiratory Support in Preterm Lambs With and Without Tachypnoea

Aim: Convalescing preterm infants often require non-invasive respiratory support, such as nasal continuous positive airway pressure or high-flow nasal cannulas. One challenging milestone for preterm infants is achieving full oral feeding. Some teams fear nasal respiratory support might disrupt sucking–swallowing–breathing coordination and induce severe cardiorespiratory events. The main objective of this study was to assess the safety of oral feeding of preterm lambs on nasal respiratory support, with or without tachypnoea.

Methods: Sucking, swallowing and breathing functions, as well as electrocardiogram, oxygen haemoglobin saturation, arterial blood gases and videofluoroscopic swallowing study were recorded in 15 preterm lambs during bottle-feeding. Four randomly ordered conditions were studied: control, nasal continuous positive airway pressure (6 cmH₂O), high-flow nasal cannulas (7 L•min^–1), and high-flow nasal cannulas at 7 L•min^–1 at a tracheal pressure of 6 cmH₂O. The recordings were repeated on days 7–8 and 13–14 to assess the effect of maturation.

Results: None of the respiratory support impaired the safety or efficiency of oral feeding, even with tachypnoea. No respiratory support systematically impacted sucking–swallowing–breathing coordination, with or without tachypnoea. No effect of maturation was found.

Conclusion: This translational physiology study, uniquely conducted in a relevant animal model of preterm infant with respiratory impairment, shows that nasal respiratory support does not impact the safety or efficiency of bottle-feeding or sucking–swallowing–breathing coordination. These results suggest that clinical studies on bottle-feeding in preterm infants under nasal continuous positive airway pressure and/or high-flow nasal cannulas can be safely undertaken.

Nasal respiratory support and tachypnea and oral feeding in full-term newborn lambs

Newborn infants with respiratory difficulties frequently require nasal respiratory support such as nasal continuous positive airway pressure (nCPAP) or high-flow nasal cannulae (HFNC). Oral feeding of these infants under nasal respiratory support remains controversial out of fear of aspiration and cardiorespiratory events. The main objective of this study was to evaluate the safety of oral feeding under different types of nasal respiratory support in newborn lambs without or with tachypnea. Eight lambs aged 4-5 days were instrumented to record sucking, swallowing, respiration, ECG, oxygen saturation, and arterial blood gases. Each lamb was given two bottles of 30 mL of milk with a pause of 30 s under videofluoroscopy in four conditions [no respiratory support, nCPAP 6 cmH₂O, HFNC 7 L/min, HFNC_CPAP (= HFNC 7 L/min + CPAP 6 cmH₂O)] administered in random order. The study was conducted in random order over 2 days, with or without standardized tachypnea induced by thoracic compression with a blood pressure cuff. Generalized linear mixed models were used to compare the four nasal respiratory supports in terms of safety (cardiorespiratory events and aspiration), sucking-swallowing-breathing coordination, and efficacy of oral feeding. Results reveal that no nasal respiratory support impaired the safety of oral feeding. Most of the few laryngeal penetrations we observed occurred with HFNC_CPAP. Nasal CPAP modified sucking-swallowing-breathing coordination, whereas the efficiency of oral feeding decreased under HFNC_CPAP. Results were similar with or without tachypnea. In conclusion, oral feeding under nasal respiratory support is generally safe in a term lamb, even with tachypnea.NEW & NOTEWORTHY The practice of orally feeding newborns suffering from respiratory problems while on nCPAP or HFNC remains controversial for fear of triggering cardiorespiratory events or aspiration pneumonia, or aggravating chronic lung disease. The present results show that bottle-feeding is generally safe in full-term lambs under nasal respiratory support, both without and with tachypnea.

Oral-feeding guidelines for preterm neonates in the NICU: a scoping review

OBJECTIVE

This scoping review describes the nature and evidence base of internationally available guidelines for the introduction of oral feeding for preterm infants in neonatal units.

STUDY DESIGN

Thirty-nine current infant oral feeding introduction guidelines were obtained, and their recommendations contrasted with available scientific literature.

RESULT

Documents were primarily from the USA, UK, Canada, and Australia, from hospitals, regional health authorities, and journal articles. Specifics of nonnutritive sucking, gestational age at first feed, exclusions to oral feeding, suggested interventions, and the definition of full oral feeding varied between documents. There was variable use of scientific evidence to back up recommendations.

CONCLUSION

Guidelines for oral feeding, whether written by clinicians or researchers, vary greatly in their recommendations and details of interventions. Areas more widely researched were more commonly discussed. Recommendations varied more when evidence was not available or weak. Guideline developers need to synthesize evidence and local variability to create appropriate guidelines.

Efficacy of nasal high flow therapy on the coordination between breathing and swallowing of saliva during daytime nap in chronic obstructive pulmonary disease patients: A single center, randomized crossover controlled study

BACKGROUND

There are some clinical reports on dysphagia in patients with chronic obstructive pulmonary disease (COPD); however, its pathophysiology remains largely unknown.Changes in respiratory function occur in patients with COPD causing a decrease in tidal volume and an increase in respiratory rate (tachypnea). In addition, it leads to lack of coordination between respiration and swallowing.A new treatment called nasal high flow (NHF) has been introduced for patients with COPD, replacing the traditional non-invasive ventilation (NIV) procedure. The NHF therapy involves inhalation of high flow of humidified air, which reduces respiratory effort in patients with COPD. Furthermore, NHF therapy facilitates swallowing of saliva even during respiratory management. A recent clinical study reported that high-flow nasal cannula oxygen therapy for 6 weeks improved the health-related quality of life and reduced hypercapnia in patients with stable COPD. Taken together, NHF therapy is gaining attention in the clinical management of patients with COPD.Therefore, in this study, we aim to examine the efficacy of NHF therapy on the coordination between breathing and swallowing of saliva during daytime nap in patients with COPD.

METHODS/DESIGN

This open-label, investigator-initiated, single center study will evaluate the efficacy of NHF therapy on the coordination between breathing and swallowing of saliva during the daytime nap in COPD patients with forced expiratory volume in 1 second (FEV1%) of <70% during treatment at the Nagasaki University Hospital Respiratory Rehabilitation Center. Evaluations will be performed during the 90 to 180 minute "daytime nap" in the measurement room of the hospital. The primary endpoint will be the rate of appearance of the expiratory phase after swallowing of saliva and the frequency of swallowing during the measurement period.

DISCUSSION

The purpose of this study is to obtain evidence regarding the utility of NHF as a potential therapeutic device for COPD patients to prevent aspiration of saliva during the sleep stage of daytime nap. The utility will be assessed by comparing the decrease in incidence rates of the expiratory phase after swallowing of saliva in the NHF device group and the control group, wherein this device was not used.

Characterization of esophageal motility and esophagogastric junction in preterm infants with bronchopulmonary dysplasia

BACKGROUND

To characterize esophageal motility and function of the esophagogastric junction (EGJ) in preterm infants with bronchopulmonary dysplasia (BPD).

METHODS

High-resolution manometry with impedance was used to investigate esophageal motility and EGJ function in 28 tube-fed preterm infants with BPD. Patients with BPD were studied at term age during oral feeding. Thirteen healthy term-aged infants were included as controls. Esophageal analysis derived objective measures to evaluate esophageal contractile vigor, bolus distension pressure, EGJ relaxation, and EGJ barrier function (in rest and during respiration). In addition, we investigated the effect of BPD severity on these measures.

KEY RESULTS

A total of 140 nutritive swallows were analyzed (BPD, n = 92; controls, n = 48). Normal esophageal peristaltic wave patterns were observed in all infants. BPD patients had higher distal contractile esophageal strength compared with controls (Kruskal-Wallis (KW) P = .048), and their deglutitive EGJ relaxation was comparable to controls. Severe BPD patients showed higher bolus distension pressures, higher EGJ resting pressures, and increased EGJ contractile integrals compared with mild BPD patients (Mann-Whitney U P = .009, KW P = .012 and KW P = .028, respectively).

CONCLUSIONS AND INFERENCES

Preterm infants with BPD consistently present with normal peristaltic esophageal patterns following nutritive liquid swallows. The EGJ barrier tone and relaxation pressure appeared normal. In general, infants with BPD do not have altered esophageal motor function. There is however evidence for increased flow resistance at the EGJ in severe BPD patients possibly related to an increased contractility of the diaphragm.

Physiological Basis of Neonatal Aerodigestive Difficulties in Chronic Lung Disease

In the United States, preterm birth rates have steadily increased since 2014. Despite the recent advances in neonatal-perinatal care, more than 40% of very low-birth-weight infants develop chronic lung disease (CLD) and almost 25% have feeding difficulties resulting in delayed achievement of full oral feeds and longer hospital stay. Establishment of full oral feeds, a major challenge for preterm infants, becomes magnified among those on respiratory support and/or with CLD. The strategies to minimize aerodigestive disorders include supporting nonnutritive sucking, developing infant-directed feeding protocols, sensory oromotor stimulation, and early introduction of oral feeds.

Oral feeding practices and discharge timing for moderately preterm infants

BACKGROUND

Oral feeding skills of moderately preterm infants are not mature at birth.

AIMS

To establish the relationship between postmenstrual age at introduction of first oral feeding and attainment of full oral feeding and hospital discharge for moderately preterm infants.

STUDY DESIGN

Multicenter retrospective analysis of a prospective cohort of moderately preterm infants admitted to a Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network hospital.

SUBJECTS

6146 infants born at 29-33 weeks' gestation from January 2012 to November 2013.

OUTCOME MEASURES

Postmenstrual age at full oral feeding and at hospital discharge.

RESULTS

The median postmenstrual age at first oral feeding was 33.9 weeks (interquartile range 33.1-34.3). For each week earlier at first oral feeding, full oral feeding occurred 4.5 days earlier (p < 0.0001) and hospital stay was shortened by 3.4 days (p < 0.0001). Higher birth weight (p < 0.0001) and black maternal race (p = 0.0001) were associated with younger postmenstrual age at full oral feeding and at discharge.

CONCLUSION

Moderately preterm infants with earlier introduction of oral feeding achieved earlier full oral feeding and hospital discharge.