Swallowing In Infants Research Articles

The Impact of Videofluoroscopic Pulse Rate on Duration and Kinematic Measures in Infants and Adults with Feeding and Swallowing Disorders.

This investigation assessed the impact of temporal resolution during a videofluoroscopic evaluation of swallowing (VFSS) on measures of duration and kinematics. Thirty adult and ten infant swallow studies, all acquired at 30 frames and 30 pulses per second, were obtained from a New Mexico hospital. All swallow studies were altered to simulate 15 and 5 pulses per second. Duration measures included pharyngeal response time, duration of upper esophageal sphincter (UES) opening, velopharyngeal closure duration and total swallow duration. Kinematic measures were assessed in adults only and included peak hyoid position and extent of UES opening during the swallow. Analysis of outcome measures was performed and compared across the three temporal resolutions (30, 15, and 5 pulses per second). For data points where normative values are available, we evaluated the impact of temporal resolution on clinical determination (i.e., did a change in pulse rate alter the clinical classification). Kinematic and duration measures were altered with changes in pulse rate and these changes increased as temporal resolution decreased. For outcome measures where normative values are available, accuracy of clinical determination decreased with decreased pulse rate. Temporal resolution impacts duration and kinematic measures. However, the direction of these changes is unpredictable, indicating sensitivity and specificity are both affected. Without a predictable impact, the use of lower pulse rates may alter clinical impressions and treatment recommendations yielding inappropriate treatment goals and treatment duration.

Impact of volume and rate of milk delivery on coordination of respiration and swallowing in infant pigs.

The coordination of respiration and swallowing is a life-critical function in infants. Varying volume and rate of milk delivery changes swallowing frequency and bolus volume but any impact on swallow-respiration coordination is unknown. Five infant pigs were filmed with simultaneous high speed videofluoroscopy and plethysmography while feeding from an automatic system delivering milk across a range of volumes and frequencies. Swallow inspiration delay, respiratory cycle duration, and distribution of inspiratory and expiratory swallows were calculated. At constant volume, there were more inspiratory phase swallows when frequency increased. At high constant frequency, increasing volume changed swallow-respiration coordination patterns, with increased occurrence of inspiratory phase swallows. Respiratory cycle duration did not change in response to changes in oral milk delivery. These results suggest that the observed pattern of expiratory swallowing in infants is achieved primarily by regulation of milk intake, not modulation of respiratory patterns by oral sensation.

Risk of Aspiration Increased by Post-swallow Residue in Infant Fiberoptic Endoscopic Evaluation of Swallowing (FEES).

To assess the risk of aspiration associated with post-swallow residue subsites in Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in bottle-fed infants <1 year of age. This is a retrospective matched-pairs cohort study at an academic tertiary children's hospital. FEES and Videofluoroscopic Swallowing Study (VFSS) trials performed within the same infant <5 days apart were paired by matching bolus consistency and bottle flow rate. Positive aspiration was defined by the "or rule" in which aspiration is positive when either FEES or VFSS within a matched pair is positive. Eighty-seven FEES-VFSS matched pairs from 29 patients (16 males; mean [SD] age, 2.9 [2.8] months) were included. The rate of positive aspiration, as defined by the "or rule", was 59% (51/87). In FEES, post-swallow pyriform sinus residue was present in 16% (14/87) and anterior commissure residue 27% (31/87). Risk of positive aspiration was increased by pyriform sinus residue (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.9-19.3, p < 0.01) and anterior commissure residue in FEES (OR 2.5, 95% CI 1.1-6.1, p = 0.03). In the neonate subgroup, <1 month of age, multivariate-adjusted analysis showed that anterior commissure residue had better diagnostic accuracy for aspiration than in older infants (overall 70% vs. 42%, p < 0.01; sensitivity 60% vs. 10%, p < 0.01), whereas pyriform sinus residue had worse accuracy (overall 41% vs. 70%, p = 0.02; sensitivity 13% vs. 43%, p = 0.02). This study demonstrates that pyriform sinus and anterior commissure residue during infant FEES were associated with fivefold and twofold increased risk of aspiration, respectively. Using a retrospective matched-pairs cohort, this study assesses the diagnostic accuracy of post-swallow residue in FEES for predicting aspiration. Laryngoscope, 134:1431-1436, 2024.

Early indices of safety related to the effects of transcutaneous auricular vagus nerve stimulation on oropharyngeal swallowing in infants

Early indices of safety related to the effects of transcutaneous auricular vagus nerve stimulation on oropharyngeal swallowing in infants

Flexible endoscopic evaluation of swallowing in children with type 1 spinal muscular atrophy

PurposeThis study aimed to report on implementing flexible endoscopic evaluation of swallowing (FEES) in infants and toddlers with type 1 spinal muscular atrophy (SMA). In addition, a comparison of FEES results and clinical scores was carried out.MethodsA prospective pilot study was conducted including ten symptomatic children with SMA type 1 (two SMN2 copies). They started treatment with one of the three currently approved therapies for SMA at a median age of 3.8 months (range 0.7–8.9). FEES was performed according to a standard protocol using Penetration–Aspiration Scale (PAS) and Murray Secretion Scale as a primary outcome. The Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) for motor function, Neuromuscular Disease Swallowing Status Scale (NdSSS), Oral and Swallowing Abilities Tool (OrSAT), and single clinical swallowing-related parameters were also assessed.ResultsDistinct swallowing disorders were already evident in eight children at inclusion. The most common findings from FEES were pharyngeal secretion pooling, penetration, and aspiration of saliva and food as well as delayed initiation of swallowing. Despite an average increase in motor function, no comparable improvement was found in swallowing function. None of the surveyed clinical scores showed a significant dependence on PAS in a mixed linear model.ConclusionsValuable information regarding the status of dysphagia can be gathered endoscopically, particularly concerning secretion management and when oral intake is limited. Currently available clinical tools for children with type 1 may represent a change in nutritional status but are not yet mature enough to conclude swallowing ability. Further development is still required.

Surgically Acquired Vocal Cord Palsy in Infants and Children with Congenital Heart Disease (CHD): Description of Feeding Outcomes.

Impaired swallowing in infants can impact upon the ability to feed orally, often resulting in dependency on supplementary feeding. Such difficulties can lead to an increased burden of care and associated costs. The primary aim of this study was to investigate the impact of vocal cord palsy (VCP), acquired intraoperatively during cardiac surgery, on the feeding outcomes of infants at a tertiary metropolitan children's hospital. An additional aim was to obtain preliminary information on the impact of feeding difficulties in this group on the quality of life of parents and families. A review of 48 patients who had been referred to the speech pathology service was undertaken. Participants presented with heterogeneous cardiac diagnoses, and had an initial Videofluoroscopic Swallow Study (VFSS) at a median corrected age of 3.6weeks. Sixty percent of participants presented with silent aspiration on VFSS. Thirty percent of participants required supplementary tube feeding more than 6months post-surgery. Six percent of participants with poor feeding progress and persistent aspiration required further surgical intervention to support nutrition. Findings revealed no significant relationship between participant factors and the presence of feeding difficulties, however, infants with concomitant genetic and syndromic conditions were found to be most at-risk for long-term feeding difficulties. Analysis of informal parent questionnaire responses indicated parents experienced stress and anxiety after their child's discharge. This was noted in regard to their child's feeding, which impacts quality of life across a number of domains. Findings of this study highlight the importance of communicating the potential feeding difficulties to parents of at-risk infants prior to cardiac surgery. This study further highlighted the importance of routine post-operative otorhinolaryngology examinations following high-risk surgeries, as well as speech pathology management for all infants and children identified with VCP. Post-operative input from appropriately trained Speech Pathologists is vital in assisting parents to support and mitigate their child's difficulties through the provision of early intervention for feeding difficulties.

Advances in Swallowing Neurophysiology across Pediatric Development: Current Evidence and Insights.

This review article analyzes current evidence on the neurophysiology of swallowing during development and offers expert opinion on clinical implications and future research directions. In the past five years, basic and clinical research has offered advances in our understanding of pediatric swallowing neurophysiology. Animal models have elucidated the role of brainstem circuits and the peripheral and central nervous system in neonatal swallowing. Recent human studies have further showcased that fetal and infant swallowing require cerebral inputs in order to develop functionally. Finally, neurophysiological and neuroimaging studies are starting to better define these cerebral inputs, as well as neuroplastic adaptations that may be needed for optimal feeding development. The neural development of swallowing is a complex and dynamic process. Continued research is needed to better understand influences on swallowing neural development, which can be essential for improving prevention, diagnosis, and interventions for pediatric dysphagia.

P0283 / #969: RHEOLOGICAL ANALYSIS OF LIQUIDS OFFERED IN VIDEOFLUOROSCOPY EXAM TO NEONATES AND INFANTS: A PRELIMINARY STUDY

Aims & Objectives: Objective The propose of this exploratory study was to know the behavior and macroscopic properties of untreated breast milk and infant formula, isolatedly and with barium sulfate added, providing information that can help speech-therapists and radiologists during the videofluoroscopy swallowing studies (VFSS). Methods: Method Rheological measurements were taken in an R/S+ Rheometer SST, SN 7023123, with a sample of regular infant formula; a sample of untreated breast milk; both isolated and with barium sulfate added, in the proportion of 2:1, respectively. Results: Results The breast milk and the infant formula have presented the adjusted viscosity similar between them, considered as thin liquid, according to the National Dysphagia Diet (NDD) classification (1.73 ± 0.12 cP and 1.53 ± 0.06 cP, respectively). The addition of barium in the proportions used in this study increased the viscosities of untreated breast milk 18 times, from 1.73 ± 0.12 cP to 31.30 ± 0.32 cP, and of the formula 25 times, from 1.53 ± 0.06 to 38.31 ± 2.19 cP, reaching thresholds close to that of nectar. Conclusions: Conclusion The results indicated confirm the need of knowledge and care in preparing liquids to be offered in pediatric VFSS, especially with neonates and infants. The use of liquids in consistency and viscosity as close as possible to what will be proposed in the indication of the patient’s diet is fundamental for their safety, thus contributing for clinical decision-making and speech-language practice. This will guarantee more confidence that VFSS represents the infant swallow function, minimizing risks on their treatment.

Does birth weight affect neonatal body weight, growth, and physiology in an animal model?

Infant birth weight affects neuromotor and biomechanical swallowing performance in infant pig models. Preterm infants are generally born low birth weight and suffer from delayed development and neuromotor deficits. These deficits include critical life skills such as swallowing and breathing. It is unclear whether these neuromotor and biomechanical deficits are a result of low birth weight or preterm birth. In this study we ask: are preterm infants simply low birth weight infants or do preterm infants differ from term infants in weight gain and swallowing behaviors independent of birth weight? We use a validated infant pig model to show that preterm and term infants gain weight differently and that birth weight is not a strong predictor of functional deficits in preterm infant swallowing. We found that preterm infants gained weight at a faster rate than term infants and with nearly three times the variation. Additionally, we found that the number of sucks per swallow, swallow duration, and the delay of the swallows relative to the suck cycles were not impacted by birth weight. These results suggest that any correlation of developmental or swallowing deficits with reduced birth weight are likely linked to underlying physiological immaturity of the preterm infant.

Evaluation of Swallowing in Infants with Congenital Heart diseases

Background: Infants with congenital anomalies are at increased risk of developing oropharyngeal dysphagia. The life expectancy of pediatric patients with congenital heart disease has increased, and some studies reported the prevalence of dysphagia in this population. Objective: This pilot study aimed to describe the swallowing abnormalities found in infants with congenital heart diseases using clinical feeding evaluation (CFE) and videofluoroscopic swallowing study (VFSS). Methods: This study was conducted on 20 infants with congenital heart diseases in the age range 2-19 months (median seven months) with suspected aspiration and/or feeding problems. All cases were subjected to both clinical and videofluoroscopic evaluation of swallowing. Results and conclusion: The most commonly observed clinical finding was gagging during feeding in 85%, cough during feeding in 65%, and gurgly voice in 50% of infants. The majority of the studied infants (75%) showed laryngotracheal aspiration caused by suck-swallow-breathing incoordination. Early diagnosis and management of dysphagia in this population are mandatory to prevent serious complications.

Quantitative video-fluoroscopic analysis of swallowing in infants

ObjectivesTo utilize objective, quantitative videofluoroscopic swallow measures to profile swallowing in infants and to determine the likelihood of objective swallow measures to predict risk of swallow impairments such as airway violation, reflux and post swallow residue. Study designOur single center retrospective observational study used a cohort of 146 bottle-fed infants (0–9 months) referred for VFSS with any kind of feeding related concern. Frame-by-frame analysis of 20-s video loops of mid-feed sucking was completed to obtain quantitative timing, displacement and coordination measures as well as presence of other findings including aspiration, residue and naso-pharyngeal reflux (NPR) and esophago-pharyngeal reflux (EPR). Spearman correlation, Mann-Whitney U test and binomial logistic regression were conducted to determine statistical associations between swallow measures and binary reporting of swallow impairments. ResultsVideofluoroscopic data of 146 infants were reviewed and analyzed. 49% of infants demonstrated at least one penetration or aspiration event. Total pharyngeal transit time (TPT) and suck-swallow ratio were associated with aspiration (p < .05). Infants with >3 sucks per swallow had significantly longer TPT and their risk of aspiration was greater than those with <3 sucks per swallow (RR 1.23, 95% CI 0.43–8.507, p = .03). Pharyngeal constriction ratio (PCR) and bolus clearance ratio (BCR) were associated with residue, NPR and EPR (p < .05). ConclusionObjective measures provide clinicians with reliable timing and displacement data even in the very young. These measures correlate with swallowing safety and may help to identify enhanced risk in some infants, which may influence management recommendations.

Swallow Safety is Determined by Bolus Volume During Infant Feeding in an Animal Model.

Feeding difficulties are especially prevalent in preterm infants, although the mechanisms driving these difficulties are poorly understood due to a lack of data on healthy infants. One potential mechanism of dysphagia in adults is correlated with bolus volume. Yet, whether and how bolus volume impacts swallow safety in infant feeding is unknown. A further complication for safe infant swallowing is recurrent laryngeal nerve (RLN) injury due to patent ductus arteriosus surgery, which exacerbates the issues that preterm infants face and can increase the risk of dysphagia. Here, we used a validated animal model feeding freely to test the effect of preterm birth, postnatal maturation and RLN lesion and their interactions on swallow safety. We also tested whether bolus size differed with lesion or birth status, and the relationship between bolus size and swallow safety. We found very little effect of lesion on swallow safety, and preterm infants did not experience more penetration or aspiration than term infants. However, term infants swallowed larger boluses than preterm infants, even after correcting for body size. Bolus size was the primary predictor of penetration or aspiration, with larger boluses being more likely to result in greater degrees of dysphagia irrespective of age or lesion status. These results highlight that penetration and aspiration are likely normal occurrences in infant feeding. Further, when comorbidities, such as RLN lesion or preterm birth are present, limiting bolus size may be an effective means to reduce incidences of penetration and aspiration.

Current Resources for Evidence-Based Practice, January/February 2020.

Current Resources for Evidence-Based Practice, January/February 2020.

Fiberoptic Endoscopic Evaluation of Swallowing in Infants and Children: Protocol, Safety, and Clinical Efficacy: 25 Years of Experience.

The application of fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric dysphagia protocol requires specialized knowledge of pediatric conditions that result in dysphagia, recognition of normal and abnormal laryngopharyngeal anatomy and function across ages, and the ability to identify maturational changes in anatomy and function of the aerodigestive tract that pertain to airway protection and swallowing function. Over the past 25 years, we have performed over 7,000 collaborative Otolaryngology and Speech-Language Pathology FEES examinations in patients ranging from 2 days of age to young adults. During this time period, we have monitored the safety of the procedure, explored the feasibility and utility of FEES across conditions, compared and contrasted FEES to the videofluoroscopic evaluation of swallowing (VFSS), and developed specific pediatric FEES protocols with operational definitions for identification and interpretation of swallowing parameters. FEES has proved to be a safe procedure in patients across ages. There have been no significant adverse events. FEES is comparable to the VFSS in the assessment of events before and after the swallow. It provides unique information regarding laryngopharyngeal anatomy and function, airway protection integrity, sensory threshold, and secretion management ability, as well as pharyngeal swallowing dynamics and the efficacy of compensatory swallowing strategies. There are specific indications and contraindications for pediatric FEES, and unique components that characterize the pediatric FEES protocols across ages and conditions. FEES procedures performed jointly by an Otolaryngologist and Speech-Language pathologist offer a team approach to interpretation and management recommendations.

Capturing infant swallow impairment on videofluoroscopy: timing matters.

Infant videofluoroscopic swallow studies (VFSSs) require clinicians to make determinations about swallowing deficits based on a limited number of fluoroscopically observed swallows. Although airway protection is known to decline throughout a bottle-feed, the paucity of data regarding the timing of this degradation has limited the development of procedural protocols that maximize diagnostic validity. We tested the stability of key components of swallow physiology and airway protection at four standardized timepoints throughout the VFSS. Thirty bottle-fed infants with clinical signs of swallow dysfunction underwent VFSS. Fluoroscopy was turned on to allow visualization of five swallows at 0:00, 0:30, 1:30 and 2:30 (minutes:seconds [min:s]). We evaluated swallows for components of swallow physiology (oral bolus hold, initiation of pharyngeal swallow, timing of swallow initiation) and airway protection (penetration, aspiration). We used model-based linear contrasts to test differences in the percentage of swallows with low function component attributes. All components of swallow physiology exhibited a change throughout the VFSS (P≤0.0005). Changes were characterized by an increase in the number of sucks per swallow (P<0.0001), percentage of swallows with incomplete bolus hold (P=0.0005), delayed initiation of pharyngeal swallow (P<0.0001), delayed timing of swallow initiation (P=0.0004) and bolus airway entry (P<0.0001). These findings demonstrate that infants with dysphagia exhibit a change in swallow physiology throughout the videofluoroscopic swallow exam. Fluoroscopic visualization that is confined to the initial swallows of the bottle feed limit the exam's diagnostic validity. Developing evidence-based procedural guidelines for infant VFSS execution is crucial for maximizing the exam's diagnostic and treatment yield.

Reduced Coordination of Hyolaryngeal Elevation and Bolus Movement in a Pig Model of Preterm Infant Swallowing.

Preterm infants often have dysphagia. Because reducing lifetime cumulative exposure to radiation in the context of diagnosis and treatment is a continuing goal of all medical fields which use X-ray imaging, efforts exist to reduce reliance on the gold standard diagnostic tool for dysphagia, VFSS. Alternatives, such as video of external hyolaryngeal movement using video recordings of the anterior surface of the neck, must be evaluated and validated against videofluoroscopy, a task for which non-human animal models are appropriate. In this study, we tested the hypotheses that (1) swallows could be identified equally well from video of external hyolaryngeal movement and bolus movement in videofluoroscopy, and that (2) the two measures would be tightly temporally linked in both term and preterm infant pigs. We recorded 222 swallows in simultaneous and precisely synchronized high-speed videofluoroscopy and high-speed camera films of 4 preterm and 3 term infant pigs drinking milk from a bottle. In term pigs, the two measures consistently identified the same swallows in each image stream. However, in preterm pigs there was a high rate of false positives (~ 10% per feeding sequence) and false negatives (~ 27% per feeding sequence). The timing of hyolaryngeal elevation (external video) and bolus movement (videofluoroscopy) was correlated and consistent in terms pigs, but not in preterm pigs. Magnitude of hyolaryngeal elevation was less in preterm pig swallows than term pig swallows. Absence of epiglottal inversion in preterm pigs was not linked to variation in the timing of the two swallow events. Video of external hyolaryngeal movement, though a reliable swallow indicator in term infant pigs, was unreliable in preterm infant pigs. The coordination of swallowing events differs in preterm and term infant pigs. More research is needed into the distinctive biomechanics of preterm infant pigs.

Thickener Is Not the Answer in the NICU

Thickener Is Not the Answer in the NICU

Aspiration in the otherwise healthy Infant-Is there a natural course for improvement?

Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration. Retrospective case series at a tertiary children's hospital. Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan-Meier survival analysis was performed. Forty patients (25 patients [50%] by 6 months, 10 [20%] by 1 year, three [6%] by 2 years, and two [4%] at the end of the follow-up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow-up interval. Median time to resolution was 202 ± 7 days (range, 19-842 days), probability 48% (95% confidence interval [CI]: 0.34-0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4-0.68), at 1 year was 64% (95% CI: 0.51-0.77), at 2 years was 76% (95% CI: 0.64-0.88), and at the end of the follow-up interval 81.3% (95% CI: 0.7-0.92). The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants. 4 Laryngoscope, 130:514-520, 2020.

Sensory analysis of 20% solids fortified blended porridge

Purpose Evaluations of food aid products such as corn soy blend (CSB) suggest that higher nutrient-dense weaning foods are needed. CSB at 20 per cent solids was suggested, but it is too thick for weaning use. The purpose of this paper is to examine if high or low pressure extrusion or a change from corn to sorghum could reduce viscosity without major sensory changes compared to CSB, a widely used fortified blended food (FBF). Design/methodology/approach A 2×2 factorial design of grain (corn or sorghum) and extrusion pressure (low or high) was used to produce fortified extruded CSB and sorghum soy blend (SSB) that match new nutritional recommendations at 20 per cent solids. A control CSB sample was also produced. Porridge was made and a descriptive panel measured sensory properties and a Bostwick Consistometer determined viscosity. Findings Control CSB was thicker, lumpier, and stickier than the extruded samples. Sorghum samples had more sorghum flavour and corn samples had more corn flavour, but generally other flavour characteristics differed only slightly from the control product. None of the samples were as thin as recommended for infant swallowing, but the extruded sorghum samples were less viscous than other samples. Originality/value Nutrient-dense FBFs at high solids content have been recommended but not yet well tested. This paper provides a sensory examination of high solids FBFs with the potential for use as supplementary foods for infants and children.

삼킴장애를 가진 유아 및 아동의 삼킴 시간 측정 : 비디오조영검사 예비연구

목적: 유아 및 아동기의 삼킴장애는 다양한 의학적 합병증을 야기할 수 있다. 유아 및 아동의 삼킴기능에 대한 이해는 적절한 삼킴평가와 효과적인 삼킴치료를 실행할 수 있게 하며 유아와 아동의 성장에 위험한 합병증을 줄일 수 있을 것이다. 방법 : 비디오투시조영검사 중 침습이나 흡인을 보인 10명의 유아 및 아동의 삼킴을 분석하였다. 구강채움시간, 구강통과시간, 인두삼킴 지연시간, 음식덩이 출현부터 후두폐쇄까지 걸리는 시간, 인두통과시간을 측정하였다. 침습이나 흡인을 보인 유아 및 아동의 시간 측정 결과를 삼킴장애가 없는 정상유아 및 아동의 시간 측정 결과 (Weckmueller et al., 2011)와 비교하였다. 두 집단의 시간 측정 결과를 비교하기 위해서 기술적 분석을 실시하였다. 결과: 침습이나 흡인을 보인 유아 및 아동의 구강채움시간, 인두삼킴 지연시간, 음식덩이 출현부터 후두폐쇄까지 걸리는 시간, 인두통과 시간이 정상 대조군의 시간 측정값보다 길었다. 결론: 본 연구에서 구강과 인두에서 특정한 삼킴 병리적 현상을 보이는 유아 및 아동이 침습이나 흡인을 보일 위험성이 높은 것으로 나타났다.