Pediatric Dysphagia: Evidence into Practice 4 Mayfield ICCD 2017 Laryngeal Cleft: Symptoms •Possible overt symptoms •Stridor •Hoarse cry •Coughing/choking with feedings •Cyanosis

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    Pediatric Dysphagia:Evidence into Practice

    Emily Mayfield, MA, CCC-SLP, BCS-S, IBCLC

    Mayfield ICCD 2017

    Disclosures

    Financial: Mercy Medical Center (employment)

    Non-financial: No relevant disclosures

    Content: Pictures and videos of breastfeeding to follow!

    Mayfield ICCD 2017

    No photos or videos please!

    Outline for Today

    Evidence Based Practice

    Anatomy & physiology

    Breastfeeding Basics

    Assessment principles

    Aspiration: current information & theories

    Intervention principles

    Time for questions

    Mayfield ISHA 2015

    Evidence Based Practice: what is it?

    Goal= integrate these three factors to deliver high-quality service

    Dynamic process

    Allows for individualized care

    Mayfield, ISHA 2014

    Evidence Based Practice: why do we need it?

    Crucial for the sustainability of our profession

    ASHA Code of Ethics

    Andits the best thing for our patients and families!

    Mayfield, ISHA 2014

    Evidence Based Practice: What are the (perceived) barriers? Time

    Access

    Research reading skills ASHA tutorials

    Check out dysphagiagrandrounds.com!

    Resistance to practice changes

    Available research to read

    Mayfield, ISHA 2014

    http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=rKQPCrVZ1S3C2M&tbnid=u3s1sUWawwUJVM:&ved=0CAUQjRw&url=http://www.pallimed.org/2010_11_01_archive.html&ei=tC0KVPDsLI20yATN6IDYCg&bvm=bv.74649129,d.aWw&psig=AFQjCNGSa9Rk29lMkAiq4_jxx9cSsfQqvA&ust=1410039502873634

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    Evidence Based Practice: How do we get there? External scientific evidence

    Where to find Free/open access

    www.doaj.org Possible library access Great analysis of topics via ASHA SIG 13 Perspectives

    How to evaluate ASHA website

    EBP Tutorials Evidence maps

    http://www.cebm.net/critical-appraisal/ Databases such as PEDro

    Share the load Form journal groups

    Mayfield, ISHA 2014

    ASHA Practice Portal

    Mayfield, ISHA 2014

    www.new-vis.com

    Anatomy

    Mayfield ICCD 2017

    Anatomy

    Mayfield ICCD 2017

    Anatomy

    Vocal fold composition Arytenoid length

    Mayfield ICCD 2017

    Monnier, P., Bernath, M. A., Chollet-Rivier, M., Cotting, J., George, M., & Perez, M. H. (2011). Pediatric

    airway surgery: Management of laryngotracheal stenosis in infants and children. Pediatric Airway

    Surgery: Management of Laryngotracheal Stenosis in Infants and Children.

    http://doi.org/10.1007/978-3-642-13535-4

    Anatomy

    Mayfield ICCD 2017

    http://www.cebm.net/critical-appraisal/

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    Newborn & Adult Larynx

    Mayfield ICCD 2017

    http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?29/15/29939

    http://www.entusa.com/larynx_photo.htm

    Anatomical Deviations of the Larynx: Laryngomalacia

    Laryngomalacia Softening of laryngeal tissue

    Typically symptoms present at birth or within first month Inspiratory stridor

    Difficulty feeding

    Apnea/cyanosis

    Etiology Anatomic?

    Inflammatory?

    Neurologic?

    Mayfield ICCD 2017

    Laryngomalacia

    Management Depends on severity

    Manage the associated dysphagia Typically resolves without

    intervention before 2 years of age

    Reflux management

    May require surgical intervention if severely impacting breathing/feeding

    Mayfield ICCD 2017

    Laryngomalacia

    Mayfield ICCD 2017

    Simons, J. P., Greenberg, L. L., Mehta, D. K., Fabio, A., Maguire, R. C., & Mandell, D. L. (2016).

    Laryngomalacia and swallowing function in children. The Laryngoscope, 126(2), 478484.

    http://doi.org/10.1002/lary.25440

    Laryngomalacia

    Laryngomalacia endoscopic view

    Mayfield ICCD 2017

    Anatomical Deviations of the Larynx: Laryngeal Cleft Congenital malformation

    Abnormal communication between the posterior larynx/trachea and the esophagus

    Benjamin, B., & Inglis, A. (1989). Minor congenital laryngeal clefts: Diagnosis and classification. Annals of Otology, Rhinology and Laryngology, 98(6), 417-420.

    Mayfield ICCD 2017

    Benjamin, B., & Inglis, A. (1989). Minor congenital laryngeal clefts: Diagnosis and classification. Annals of Otology, Rhinology and Laryngology, 98(6), 417-420.

    Picture: GI Motility online

    http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwijs4qG7MfSAhUL4oMKHZrzB0oQjRwIBw&url=http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?29/15/29939&psig=AFQjCNFpt6MU9rPumBXKCJV2KURdlHyMjA&ust=1489094655432995

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    Mayfield ICCD 2017

    Laryngeal Cleft: Symptoms

    Possible overt symptoms Stridor

    Hoarse cry Coughing/choking with feedings

    Cyanosis

    Can be associated with other congenital anomalies or occur in isolation

    Mayfield ICCD 2017

    Chien, W., Ashland, J., Haver, K., Hardy, S. C., Curren, P., & Hartnick, C. J. (2006). Type 1 laryngeal cleft: Establishing a functional diagnostic and management algorithm. International Journal of Pediatric Otorhinolaryngology, 70(12), 20732079.

    Laryngeal Cleft: Symptoms

    Clinical presentation suspicious for cleft Penetration/aspiration despite intact timing and lack of other

    oropharyngeal pathophysiology But may also be co-occurring with other issues

    Penetration/aspiration despite typical neurodevelopment

    Persistent, unexplained pulmonary issues Penetration/aspiration typically appears to occur between the

    arytenoids

    Penetration/aspiration that is persistent despite interventions

    Mayfield ICCD 2017

    Laryngeal Cleft: Diagnosis

    Multi-disciplinary Collaboration amongst multiple professionals

    May include chest CT, broncho-alveolar lavage

    Referral to ENT Flexible laryngoscopy Direct/rigid scope in OR with palpation of inter-arytenoid space

    Mayfield ICCD 2017

    Chien et al., 2006; Rahbar et al., 2006; Williams et al., 2011; Neubauer, Rosenthal, Wooten III, Zdanski, & Drake, 2013.

    Laryngeal Cleft: Management

    Conservative Diet modification/swallow maneuvers based on swallow study

    On-going assessment to try to wean

    Reflux management Wait and see

    Surgical Open or endoscopic

    Gel injection or suture repair

    Mayfield ICCD 2017Chien et al 2006, Ojha et al 2014

    Laryngeal Cleft: Surgical Management

    Injection laryngoplasty Suture repair

    Mayfield ICCD 2017

    WARNING: Intra-operative video, theres blood!

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    Post-operative Dysphagia Management

    Typically wait at least 6-8 weeks post repair for repeat swallow study Some advocate for clinical weaning/monitoring with repeat VFSS only as

    necessary if pt had no co-morbidities and symptomatic aspiration

    (Wentland et al., 2016)(Hersh et al., 2016)

    Dysphagia may persist post-operatively Neurodevelopmental compromise strongest predictor of continued need for

    thickened liquids or NPO (Osborn et al., 2014)

    Mayfield ICCD 2017

    Swallow physiology

    Pediatrics: Phase model Anticipatory Phase

    Oral Preparatory Phase Oral Transit Phase

    Pharyngeal Phase

    Esophageal Phase* Leopold & Kagel, 1997; Logemann 1998

    Useful for organizing thoughts & guiding differential diagnosis Infants: Add layer of suck/swallow/breathe

    Mayfield ICCD 2017

    Suck/Swallow/Breathe Physiology: Sucking

    Efficient sucking is comprised of both suction & expression (compression) (Lau & Kusnierczyk 2001; Cannon

    et al 2016, Elad et al 2014; Geddes, Chadwick, Kent, Garbin, & Hartmann, 2010)

    Mayfield ICCD 2017

    Suck/Swallow/Breathe Physiology: Sucking

    Mayfield ICCD 2017

    Elad, D., Kozlovsky, P., Blum, O., Laine, A. F., Po, M. J., Botzer, E., Ben Sira, L. (2014). Biomechanics of milk extraction during breast-feeding. Proceedings of the National Academy of Sciences of the United States of America, 111(14), 52305.

    Suck/Swallow/Breathe Physiology: Sucking

    Mayfield ICCD 2017

    Suck/Swallow/Breathe Physiology: Sucking

    Breastfeeding vs bottle feeding Muscle activation

    Bottle feeding: buccinators & orbicularis oris

    Breastfeeding: Mentalis, masseter, temporalis, M Pterygoid

    Mayfield ICCD 2017

    Ardran, Kemo, & Lind, 1958; Sakalidis et al., 2012; Geddes et al, 2008; Gomes 1996; Inoue, 1995; Sakashita 1996; Nyvquist2001

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    Suck/Swallow/Breathe Physiology: Sucking

    Sucking Expression develops before

    consistent use of suction (Lau et al, 2000)

    Mayfield ICCD 2017

    Suck/Swallow/Breathe Physiology: Swallowing

    Swallowing Tongue base pressure (Rommel 2006)

    Pharyngeal clearance

    Shortening & contraction present (Rommel 2006, 2011)

    Adequate valving needed

    Reduced pharyngeal peak pressure above the UES which disappears with increasing age (Rommel 2011)

    Airway protection**

    Pharyngo-esophageal sphincter opening

    UES relaxation found to be less complete at time of maximum proximal pharyngeal contraction, improved with age (Rommel 2011)

    UES resting tone increases with age (Jadcherla 2005)

    Mayfield ICCD 2017

    Suck/Swallow/Breathe Physiology: Swallowing

    Esophageal motility Esophageal function: Peristalsis & aerodigestive protection

    Amplitude of esophageal peristalsis increases with maturation (Gupta 2009)

    Airway Protection