Enhanced rapid review of the applicability of ultrasound in the assessment of sucking, swallowing and laryngeal function in the paediatric population

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has renewed interest in the use of ultrasound (US) amongst dysphagia-trained clinicians working with infants and children. US is a portable, minimally intrusive tool which carries reduced risk of aerosol-generation provoked by other instrumental swallowing assessment tools such as fibreoptic endoscopic evaluation of swallowing (FEES). For this reason, US could be a valuable addition to the dysphagia assessment toolkit. A recently published rapid review of US evidence for the assessment of swallowing and laryngeal function in the adult population provided a framework for this neonatal and paediatric review.

AIMS

This enhanced rapid review aimed to establish the applicability of US as an instrumental assessment tool for sucking, swallowing and laryngeal function in the neonatal and paediatric populations.

METHODS & PROCEDURES

A rapid review of six electronic databases was conducted to identify articles using US to assess sucking, swallowing or laryngeal function in the selected populations, compared with varied reference tests. Abstract screening was completed according to pre-defined inclusion/exclusion criteria with 10% of articles assessed by a second screener. Data was extracted from the included studies using a pre-developed form. A modified QUADAS-2 tool was used to assess study quality. Results from the included studies were summarised and grouped into sucking, swallowing and laryngeal function data.

OUTCOMES & RESULTS

Twelve studies using US in the assessment of swallowing and/or laryngeal function met inclusion criteria. No studies using US for assessment of sucking met the inclusion criteria. All were peer-reviewed, primary studies across a range of clinical populations and with a wide geographical spread. Five studies had an overall low risk of bias. Seven studies had at least one domain where risk of bias was judged as high. All studies had high applicability. The two studies assessing swallowing differed in terms of aims and use of US. The studies assessing laryngeal function predominately investigated vocal fold movement and laryngeal pathology. Sensitivity and specificity data were provided or calculated from raw data for nine of the laryngeal function studies (respective ranges of 75%-100% and 80%-100%).

CONCLUSIONS & IMPLICATIONS

Emerging evidence exists to support the use of US as adjunct to clinical assessment of swallowing and laryngeal function in the neonatal and paediatric population. A paucity of evidence to support use of US in the assessment of sucking exists. Further research is needed to establish evidence-based assessment and analysis protocols as well as development of paediatric data.

Abnormal Nutritive Sucking as an Indicator of Neonatal Brain Injury

A term neonate is born with the ability to suck; this neuronal network is already formed and functional by 28 weeks gestational age and continues to evolve into adulthood. Because of the necessity of acquiring nutrition, the complexity of the neuronal network needed to suck, and neuroplasticity in infancy, the skill of sucking has the unique ability to give insight into areas of the brain that may be damaged either during or before birth. Interpretation of the behaviors during sucking shows promise in guiding therapies and how to potentially repair the damage early in life, when neuroplasticity is high. Sucking requires coordinated suck-swallow-breathe actions and is classified into two basic types, nutritive and non-nutritive. Each type of suck has particular characteristics that can be measured and used to learn about the infant's neuronal circuitry. Basic sucking and swallowing are present in embryos and further develop to incorporate breathing ex utero. Due to the rhythmic nature of the suck-swallow-breathe process, these motor functions are controlled by central pattern generators. The coordination of swallowing, breathing, and sucking is an enormously complex sensorimotor process. Because of this complexity, brain injury before birth can have an effect on these sucking patterns. Clinical assessments allow evaluators to score the oral-motor pattern, however, they remain ultimately subjective. Thus, clinicians are in need of objective measures to identify the specific area of deficit in the sucking pattern of each infant to tailor therapies to their specific needs. Therapeutic approaches involve pacifiers, cheek/chin support, tactile, oral kinesthetic, auditory, vestibular, and/or visual sensorimotor inputs. These therapies are performed to train the infant to suck appropriately using these subjective assessments along with the experience of the therapist (usually a speech therapist), but newer, more objective measures are coming along. Recent studies have correlated pathological sucking patterns with neuroimaging data to get a map of the affected brain regions to better inform therapies. The purpose of this review is to provide a broad scope synopsis of the research field of infant nutritive and non-nutritive feeding, their underlying neurophysiology, and relationship of abnormal activity with brain injury in preterm and term infants.

Comparison of the Finger Feeding Method Versus Syringe Feeding Method in Supporting Sucking Skills of Preterm Babies

Aim: The aim of this study is to compare the efficiency of a new method called "finger feeding" with a well-known technique called syringe feeding for improving sucking skills and accelerating transition to breastfeeding in preterm infants. Materials and Methods: Totally 70 babies were included in this prospective randomized controlled study. Finger feeding method was applied in Group 1 (n = 35) and syringe feeding method was applied in Group 2 (n = 35). The COMFORTneo scale (CnS), oxygen saturation, pulse, respiratory rate, body temperature, amount of breast milk taken, and vomiting data were recorded before and after both applications. Hospitalization period and time elapsed for complete transition from both methods to breastfeeding were also recorded. Results: There was no statistical difference for birth weights, mean gestational age, and vital signs recorded before and after feeding between two groups. Predicted comfort and distress scores of Group 1 determined by the CnS were significantly lower than those of Group 2. This means that babies in the finger feeding group had better comfort than the those in Group 2 (p = 0.000). Time passed for transition to breastfeeding was significantly shorter than that in Group 2 (19.4 ± 15.0 days versus 29.7 ± 10.2 days, p = 0.000). Group 1 had lower amount of food leakage while feeding and their average weight gain at the end of 10th day was significantly higher (322.1 ± 82.3 g versus 252 ± 108.4 g, p = 0.004). They also were discharged earlier than Group 2 (25.8 ± 17.4 days versus 35.9 ± 13.0 days, p = 0.001). Conclusion: Finger feeding method is an effective way for increasing sucking abilities, accelerating transition to breastfeeding, and shortens duration of hospitalization in preterm infants.

Oral Sensorimotor Intervention Enhances Breastfeeding Establishment in Preterm Infants

OBJECTIVE

To assess the efficacy of an oral sensorimotor intervention on breastfeeding establishment and maintenance in preterm infants.

STUDY DESIGN

Thirty-one preterm infants born ≤34 weeks gestation were randomized into an experimental or control group. The experimental group received a 15-minute program consisting of stroking the peri-oral structures for the first 5 minutes, tongue exercises for the next 5 minutes, followed by non-nutritive sucking for the final 5 minutes. The control group received a sham intervention for the same duration. The interventions were administered once daily for 10 days. The outcomes included: time to attainment of full oral feeding, breastfeeding acquisition (i.e., ≥50% of direct breastfeeding at hospital discharge), breastfeeding skill assessment using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), length of hospitalization, and breastfeeding maintenance at 3 and 6 months posthospitalization.

RESULTS

Full oral feeding was attained earlier in the experimental group compared with the control (10.7 ± 2.1 vs. 19.3 ± 3.6 days, p < 0.01). This was associated with a greater number of infants in the intervention group acquiring breastfeeding at hospital discharge compared with the controls (n = 11 vs. 5, p = 0.049). There was no statistical difference in PIBBS score, length of hospitalization, and breastfeeding rates at 3 and 6 months posthospitalization between the two groups (all tests, p > 0.32).

CONCLUSIONS

An oral sensorimotor intervention accelerated the achievement of full oral feeding and enhanced direct breastfeeding rates at hospital discharge only. Provision of an oral sensorimotor intervention is a safe and low-cost intervention that may increase breastfeeding rates in a highly vulnerable population.

Therapeutic effect of a cleft lip teat on infants with respiratory and feeding disorders: Two case reports

RATIONALE

Existing research into the effects of teat application has mainly focused on its negative and positive influence on the development of the oral cavity. Our work demonstrates that apart from changing the setting of the articulatory organs, the teat can also affect the quality of breathing, eating and sleeping.

PATIENTS CONCERNS

We described the cases of 2 children: a 19-month-old girl and a 2.5-month-old boy, who had breathing disorders due to withdrawal of the tongue and impaired food intake.

INTERVENTION

The babies were bottled fed with a special teat for cleft lip patients to observe the influence of the teat on the setting of the articulatory organs and breathing.

DIAGNOSIS

We suspected that the specific construction of the teat-the wide outer part and the short internal part-would affect children's reflexes and articulatory organs so as to force the frontal position of the tongue, which was meant to facilitate breathing and eating.

OUTCOMES

It was found that feeding with the cleft lip teat stimulates the gyro-linguistic muscle, which results in the proper position of the tongue and consequently better breathing and improved quality of sleep.

LESSONS

A specialist bottle teat designed for babies with cleft lips can constitute an effective tool in the therapy of nonspecific respiratory disorders resulting from improper position of the tongue and other articulatory organs.

Rehabilitation of Infant Oral Feeding Difficulties: A Survey of Occupational Therapists Practice Approaches

This study identifies the scope of occupational therapy practice for the rehabilitation of oral feeding difficulties in infants who are in the neonatal intensive care unit (NICU). A written survey was administered to 127 occupational therapists who work with infants in the NICU. All 68 (54%) respondents used a client-centered approach, taking into consideration the infant (intrinsic), caregiver, and environmental (extrinsic) factors. Family and health team education was the most commonly provided service with the majority of occupational therapists providing services only until feeding problems were resolved. Continuing education (n = 20, 30%) and own clinical experience (n = 22, 33%) were the two most common justifications to support their choice of practice. These results suggest a client-centered approach in the rehabilitation of oral feeding difficulties is commonly used, but services are not extended beyond hospitalization. Few occupational therapists used peer-reviewed journals as sources of evidence for their practice strategies.

OC24 - An algorithm proposal to oral feeding in premature infants

Theme: Transition of care.

INTRODUCTION

Oral feeding is one of the hardest steps for premature infants after respiratory independence and is a challenge for nurses in neonatology.

OBJECTIVES

To know the characteristics of preterm infants, essential for oral feeding; to know the nurses' opinion on nursing interventions, that promote the transition of gavage feeding for oral feeding in preterm infants.

METHODS

An exploratory, descriptive study with a qualitative approach was used. Semi-structured interviews with neonatal nurses were conducted and data was submitted to content analysis.

RESULTS

Weight, gestational age, physiological stability, sucking coordination, swallowing and breathing, and the overall look and feeding involvement are fundamental parameters to begin oral feeding. Positioning the baby, reflexes stimulation, control stress levels, monitoring the temperature and the milk flow are nursing interventions that promote the development of feeding skills.

CONCLUSION

An algorithm for the oral feeding of preterm infants was developed grounded in the opinions of nurses.

Suck-Swallow-Breathe Dynamics in Breastfed Infants

Despite the importance of the suck-swallow-breathe reflex during breastfeeding, a large proportion of our understanding is derived from bottle-feeding studies. Given the differences in the delivery of milk during breast and bottle feeding, it is imperative that a more general view of the suck-swallow-breathe and milk removal process during breastfeeding is available. This systematic review aimed to assess the evidence for the mechanism of milk removal during breastfeeding; evaluate how the term infant coordinates sucking, swallowing, breathing (SSwB) and cardiorespiratory patterns; and how these patterns change with maturation during breastfeeding. A literature search of PubMed and MEDLINE was performed to assess the mechanism of milk removal and patterns of sucking, swallowing, breathing, and cardiorespiratory control during breastfeeding in healthy term infants. Seventeen studies were selected and a narrative synthesis was performed. Nine studies assessing the infant sucking mechanism consistently provided evidence that vacuum is essential to milk removal from the breast. The limited data on swallowing and breathing and cardiorespiratory control showed mixed results. Overall, results highlighted the high variability in breastfeeding studies and suggested that swallowing, breathing, and cardiorespiratory patterns change with maturation, and within a breastfeed. These findings show potential for devising breastfeeding interventions for populations at risk of SSwB problems. However, consistent methods and definitions of breastfeeding parameters are required before interventions can be adequately developed and tested.

Ultrasound Imaging of Breastfeeding--A Window to the Inside: Methodology, Normal Appearances, and Application

Ultrasound imaging has been employed as a noninvasive technique to explore the sucking dynamics of the breastfeeding infant over the past 40 years. Recent improvements in the resolution of ultrasound images have allowed a more detailed description of the tongue movements during sucking, identification of oral structures, and measurements of nipple position and tongue motion. Several different scanning planes can be used and each show sucking from a different perspective. Ultrasound techniques and image anatomy are described in detail in this review and provide the basis for implementation in the objective assessment of breastfeeding.

Minimizing cows' stress when calves were early weaned using the two-step method with nose flaps

Early weaning may be used in beef cattle production to improve reproduction rates in range conditions. However, weaning causes a stress response in cows, which may be especially strong in early weaning management, as the bond between the cow and the calf is still strong. We hypothesized that weaning calves in two steps, with the aid of anti-sucking devices (nose flaps) would reduce the behavioural stress response in the cows separated from their calves 2 months after parturition. We compared the behaviour frequency and weight change in cows that were weaned abruptly, by separation of the calf on day 0 of the study, or in two steps, consisting of the use of anti-sucking nose flaps for 5 days before permanent separation; a third group was not weaned to serve as control. Thirty-six crossbred multiparous Aberdeen Angus×Hereford cows and their calves (n=12/treatment) were managed in three paddocks with similar pasture availability, with four dyads from each treatment per paddock. Cows' behaviour was observed by direct visual instantaneous sampling, at 10 min intervals from days -3 to 11. Weaning the calves in two steps clearly attenuated the behavioural stress response observed in abruptly weaned cows, which included reductions in grazing and lying, and increases in pacing, walking and vocalizing. Our results corroborate those previously shown for cows nursing older calves, and indicate that step weaning can reduce the behavioural stress response of cows at weaning, even when the calf is weaned shortly after birth, when the bond between the cow and calf is still very strong.

The response of newly born mice to odors of murine colostrum and milk: unconditionally attractive, conditionally discriminated

It is a general rule that milk conveys chemosensory cues that are attractive to mammalian neonates. This study investigated whether compositional fluctuations in milk along lactation induce variations in newborn mouse pups' (Mus musculus, strain BALB/c) attraction to milk odor. Pups differing in suckling experience were exposed to the odor of milk sampled from females varying in lactational stage. Immediately after birth, suckling-inexperienced (P0) and suckling-experienced (P0suck ) pups were assayed in a series of paired-choice tests contrasting murine milk [of lactation days 0, 3, 15 (abridged L0, L3, L15, respectively)] and a blank (water) to evaluate olfactory detection and attraction of milk odor. Preference tests further paired these milk two-by-two to assess their relative attraction. Results showed first that P0 and P0suck pups detect and positively orient to any milk odor. When L0 is presented against L15 milk, P0 pups orient for a similar duration towards these odor stimuli, whereas P0suck pups spend more time toward the odor of L0 than of L15 milk. Finally, P0suck pups orient similarly to odors of L0 milk collected before/after the first suckling episode (L0 and L0suck , respectively), but the odor of L0 milk was more attractive than that of L3 milk. Thus, mouse pups' positive orientation toward the odors of murine colostrum (assumed to correspond to L0/L0suck milk) and later-lactation milk appears unconditional of previous suckling experience, whereas their ability to discriminate or display preference between milk differing in lactation stage appears conditional on postnatal exposure effects.

Sucking and swallowing rates after palatal anesthesia: an electromyographic study in infant pigs

Infant mammalian feeding consists of rhythmic suck cycles and reflexive pharyngeal swallows. Although we know how oropharyngeal sensation influences the initiation and frequency of suck and swallow cycles, the role of palatal sensation is unknown. We implanted EMG electrodes into the mylohyoid muscle, a muscle active during suckling, and the thyrohyoid muscle, a muscle active during swallowing, in eight infant pigs. Pigs were then bottle-fed while lateral videofluoroscopy was simultaneously recorded from the electrodes. Two treatments were administered prior to feeding and compared with control feedings: 1) palatal anesthesia (0.5% bupivacaine hydrochloride), and 2) palatal saline. Using the timing of mylohyoid muscle and thyrohyoid muscle activity, we tested for differences between treatment and control feedings for swallowing frequency and suck cycle duration. Following palatal anesthesia, four pigs could not suck and exhibited excessive jaw movement. We categorized the four pigs that could suck after palatal anesthesia as group A, and those who could not as group B. Group A had no significant change in suck cycle duration and a higher swallowing frequency after palatal saline (P = 0.021). Group B had significantly longer suck cycles after palatal anesthesia (P < 0.001) and a slower swallowing frequency (P < 0.001). Swallowing frequency may be a way to predict group membership, since it was different in control feedings between groups (P < 0.001). The qualitative and bimodal group response to palatal anesthesia may reflect a developmental difference. This study demonstrates that palatal sensation is involved in the initiation and frequency of suck and swallow cycles in infant feeding.

Analgesic effect of 30% glucose, milk and non-nutritive sucking in neonates

Background

The aim of this study was to evaluate nondrug management practices concerning pain induced by blood sampling in newborns in a Moroccan neonatal unit and to determine whether the results reported from a randomized clinical study of nondrug analgesia could be reproduced in a routine care setting.

Methods

Standardized prospective observation of analgesic practices used during blood sampling was performed. Pain was assessed using the Douleur Aiguë Nouveau-né (DAN, [Newborn Acute Pain]) scale that incorporates facial expression, vocal expression, and limb movements of the newborn during realization of a painful procedure. Five different nondrug analgesic practices were investigated in 125 infants.

Results

Median DAN scores for the five methods were 6 (1–10) for venous sampling with oral administration of 30% glucose, 5 (1–10) for venous sampling with sucking, 3 (0–6) for venous sampling with oral administration of 30% glucose combined with sucking, 4 (0–10) for venous sampling with oral administration of 30% glucose combined with sucking and administration of 2 mL of adapted infant formula, and 6 (3–8) for venous sampling with administration of 2 mL of adapted infant formula.

Conclusion

Oral administration of 30% glucose combined with sucking provided better control of pain induced by blood sampling in newborns at our neonatal unit.

An unusual sucking habit in a child

Presence of oral habit in 3-6 year old children is an important finding in the clinical examination. An oral habit is no longer considered as normal for children near the end of this age group. In pre-school children, digit and dummy sucking is a predominant habit, and girls are found to have a higher level of sucking habit then boys do. Here is a case report of a unique sucking habit, which if not stopped, will lead to dental problem in the child.

Preterm infants' behavioural indicators of oxygen decline during bottle feeding

BACKGROUND

During the time when preterm infants' oral feeding skills are developing they often experience physiological instability and need assistance from caregivers to maintain adequate oxygenation. Assisting infants to maintain optimal oxygenation during oral feeding requires an understanding of how they express and aim to self-regulate their oxygen status.

AIM

The purpose of this study was to identify potential behavioural indicators of declining oxygenation during preterm infant early bottle-feeding.

METHOD

The design was explorative. Data were collected from a secondary analysis of 20 videotapes of preterm infant bottle feedings which included concurrent oxygen saturation data. In this analysis infant behaviours and quality of breathing were coded and compared across three periods: high oxygen saturation, immediately preceding an oxygen desaturation event, and during an oxygen desaturation event.

FINDINGS

Infants gave limited behavioural indicators of declining oxygenation. Immediately prior to a desaturation event, they had an increase in eye flutter and were typically sucking and apnoeic. During a desaturation event, they typically relaxed their arms/hands and stopped sucking.

CONCLUSIONS

Reliance on preterm infant behavioural cues will be insufficient for detection of oxygen desaturation during oral feeding. Attention to changes in breath sounds and to the pattern of sucking are potentially important intervention strategies for the prevention of and appropriate response to oxygen decline during feeding. Sucking pauses may be a time when preterm infants aim to regulate their breathing pattern and thereby increase oxygenation. Interventions that focus on detection and minimization of apnoea during feeding, and which aim to protect infant sucking pauses, may reduce the number and severity of desaturation events preterm infants experience during bottle feeding.