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Pediatric Dysphagia:Evidence into Practice

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

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Disclosures

• Financial: Mercy Medical Center (employment)

• Non-financial: No relevant disclosures

• Content: Pictures and videos of breastfeeding to follow!

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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

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Evidence Based Practice: what is it?

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

• Dynamic process

• Allows for individualized care

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Evidence Based Practice: why do we need it?

• Crucial for the sustainability of our profession

• ASHA Code of Ethics

• And…it’s the best thing for our patients and families!

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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

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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

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ASHA Practice Portal

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www.new-vis.com

Anatomy

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Anatomy

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Anatomy

• Vocal fold composition • Arytenoid length

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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

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Newborn & Adult Larynx

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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?

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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

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Laryngomalacia

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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), 478–484.

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

Laryngomalacia

• Laryngomalacia endoscopic view

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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.

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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

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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

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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), 2073–2079.

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

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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

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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

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WARNING: Intra-operative video, there’s 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)

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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

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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)

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Suck/Swallow/Breathe Physiology: Sucking

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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), 5230–5.

Suck/Swallow/Breathe Physiology: Sucking

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Suck/Swallow/Breathe Physiology: Sucking

• Breastfeeding vs bottle feeding• Muscle activation

• Bottle feeding: ↑ buccinators & orbicularis oris

• Breastfeeding: ↑ Mentalis, masseter, temporalis, M Pterygoid

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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)

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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)

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Suck/Swallow/Breathe Physiology: Swallowing

• Esophageal motility• Esophageal function: Peristalsis & aerodigestive protection

• Amplitude of esophageal peristalsis increases with maturation (Gupta 2009)

Airway Protection

• Hyolaryngeal positioning

• Vestibule closure

• Epiglottic inversion?

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Epiglottic Inversion

• Rommel 2002, Rommel 2006• No consistent epiglottic tilting until after 5 years of age

• Epiglottis moved an average 34°, range of 9°-49°

• Mean age of participants was 18 months, range 2-30 months

• Gosa 2012 & Gosa, Suiter, & Kahane 2014 • Absence of full epiglottic tilting during swallows of infants (age range 1 week-3 months)

• Anterior movement of arytenoids was sufficient for laryngeal closure

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Videoswallow: Epiglottic Inversion?

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Suck/Swallow/Breathe Physiology: Breathing

• Swallow Apnea• Nasal airflow maintained during

sucking, swallow apnea required during swallow

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Suck/Swallow/Breathe Coordination

• S/S/B coordination requires complex neural control

• Respiratory phase coordination of swallow apnea• I-I, I-E, E-E, E-I, P (Martin et al, 1994)

• Term infants: E-E then I-E most dominant (Kelly et al, 2007)

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Mizuno, K., & Ueda, A. (2003). The maturation and coordination of sucking, swallowing, and respiration in preterm infants. Journal of

Pediatrics, 142(1), 36–40.

Suck/Swallow/Breathe Physiology: Breathing

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Kelly, B. N., Huckabee, M., Jones, R. D., & Frampton, C. M. A. (2007). The First Year of Human Life : Coordinating Respiration and Nutritive

Swallowing. Dysphagia, 22, 37–43.

Suck/Swallow/Breathe Physiology: Breathing

• Healthy preterm infants:

• I-I and P most dominant (Lau et al, 2003), difference not significant when taking 6-8 oral feedings

• Pattern matures to I-E dominant by 35 weeks in healthy preterms (Mizuno & Ueda, 2003)

• Preterm infants with lung disease:

• Worsened with time, 32.8% E-I (Gewolb & Vice, 2006)

• Highly disorganized (Mizuno et al, 2007)

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BreastfeedingCredit on slides in this section shared with:

Colleen Gould, MS, CCC-CLP, IBCLC

Jenny Walters, MPH, IBCLC, LLLL

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Breastfeeding: Anatomy

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Left: Ameda.comRight: Kopans DB. Breast Imaging. Philadelphia, PA: Lippincott; 1989:20.

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Breastfeeding: Flow rate

• Flow rate: baby driven vs passive flow• Bottle feeding

• Respond to more of a passive flow

• Same relative flow rate throughout a feeding (minus gravity)

• Breastfeeding• Milk ejection reflex

• Milk flow rate likely to vary by time of day

• Milk composition may vary

• Dependent upon supply and inherent flow characteristics

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Photo source: KellyMom.com

Meier 1996, 1988, Goldfield 2006, Mathew 1989

The Basics: Positioning

• Basic principles of positioning for preterm infants• Baby facing directly at the breast, close to mother’s abdomen

• Provide breast support and wedging• Keep chin off chest

• Provide stability/bracing to feet

http://www.nursingnurture.com/breastfeeding-positions/

The Basics: PositioningPosition Pros Cons

Cradle • “Natural” position that mothers recognize

• Side-lying

• Less head/neck controlDifficult to maintain positioning

Cross Cradle • Easy to simulate with bottles

• Side-lying• Head/neck alignment• Easy to maintain

position

• May not feel “natural”• Takes

learning/maneuvering

Football • Ease of self-positioning for mothers

• Baby gets close touch

• Places baby more supine• Need to avoid heavy

breast across chest

“Laid-back”/prone • Flow rate management• Reflexive positioning

• Can be difficult to manage in NICU

Slide credit shared with: Colleen Gould, MS, CCC-SLP. Jenny Walters, MPH, IBCLC, LLLL, ASHA 2012

The Basics: Positioning

Cradle hold Cross cradle hold

Mayfield ICCD 2017http://www.pnmag.com/h-s/breastfeeding-positions/

The Basics: PositioningPosition Pros Cons

Cradle • “Natural” position that mothers recognize

• Side-lying

• Less head/neck controlDifficult to maintain positioning

Cross Cradle • Easy to simulate with bottles

• Side-lying• Head/neck alignment• Easy to maintain

position

• May not feel “natural”• Takes

learning/maneuvering

Football • Ease of self-positioning for mothers

• Baby gets close touch

• Places baby more supine• Need to avoid heavy

breast across chest

“Laid-back”/prone • Flow rate management• Reflexive positioning

• Can be difficult to manage in NICU

Slide credit shared with: Colleen Gould, MS, CCC-SLP. Jenny Walters, MPH, IBCLC, LLLL, ASHA 2012

The Basics: Positioning

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Football hold

https://www.babble.com/baby/best-breastfeeding-positions/

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The Basics: Positioning

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Article of interest: Colson, S. D., Meek, J. H., & Hawdon, J. M. (2008). Optimal positions for the release of primitive neonatal

reflexes stimulating breastfeeding. Early Human Development, 84(7), 441–449.

The Basics: Latch

• Latch • Characteristics

• Deep positioning• Comfort for mother

• Strategies• Breast wedging• Asymmetric latch

• Nipple shield

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The Basics: Latch

• Breast wedging to facilitate a deeper latch

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The Basics: Latch

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Asymmetric Latch

Photo credit: La Leche League

The Basics: Latch

• Silicone nipple shield• Ultrathin

• Come in a variety of brands, shapes, sizes• Can help sustain latch and facilitate milk transfer

• Preterm population: Meier et al 2000

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Questions?

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Assessment

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Clinical Swallow Evaluation

• Evolving utility with adult populations• Judging HLE from our fingers

• No empirical evidence we can do this reliably

• Interpreting presence/absence of “wet” vocal quality• Less than 50% reliable in identifying aspirators on VFSS based on wet vocal quality

(Groves -Wright et al., 2010).

• Cough after swallow• Smith-Hammond et al 2009: clinical signs <60% sensitivity for aspiration

• Daniels 1998: silent aspiration in 2/3 stroke patients

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Clinical Swallow Evaluation• Symptom correlation with pediatrics?

• DeMatteo, et al, 2005

• Prospective, 75 children

• Mean age= 2 years, 62% were < 1 year

• Cough was most significant predictor of fluid aspiration

• Cough+ gag + reflux had a significant relative risk for fluid penetration

• Weir, et al, 2009

• Retrospective, 150 children

• Mean age= 37 months, 35% were ≤ 1 year

• Wet voice had highest likelihood ratio for aspiration

• No clinical markers were associated with penetration

• Uhm, et al 2013

• Retrospective, 107 children

• Mean age=4.5 months +/- 5.3

• Cough was only clinical predictor of aspiration

• 81% (34/42) of aspiration was silentMayfield ISHA 2015

Silent aspiration in pediatrics: what do we know?• Children with neurologic impairment predisposed to silent aspiration

• Arvedson et al 1994, Morton et al 1993, Rogers et al 1994

• Silent aspiration described in both neurologic & non-neurologic populations• Weir et al, 2011: 81% silent, Newman at al: 89% silent, Uhm et al, 2013: 81%

silent

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Goals of Assessment

• Overall goals: minimize risk, maximize health, support development, support family goals

• Key= Differential Diagnosis• Key factor in pediatric evaluation

• What are contributing factors?

• What more information do you need? (i.e., referrals)

• Immature vs. abnormal patterns?

• Sensory vs. Motor?

• Sensory issue vs. behavior?

• Motor weakness vs incoordination vs abnormal tone?

• Structural vs neurologic?

Shaker/Gager 2005

Pediatric Clinical Swallow Evaluations

• Likely components• Detailed history (feeding, medical, developmental)

• Cranial nerve exam/oral assessment

• Reflex exam (as appropriate)

• Assessment of positioning/postural stability

• Sensory responses

• Behaviors/state control

• Feeding/swallowing assessment (as appropriate)

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Additional Factors to Consider

• Age/developmental stage

• Experience

• Diagnosis

• Status of dysphagia: acute or chronic?

• Setting

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Delaney, A. L. (2015). Special Considerations for the Pediatric Population Relating to a Swallow Screen Versus Clinical Swallow or Instrumental Evaluation. SIG 13: Perspectives on Swallowing & Swallowing Disorders, 24(February), 26–33.

Clinical Swallow Examination: Special Considerations for Pediatrics

• Developing system• 0-3 year age range is highly heterogeneous (Delaney & Rudolph

2012)

• Interpreting signs/symptoms in the context of disrupted development

• Developing lungs

• Nutrition is paramount

• Lifetime potential of radiation exposure

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Clinical Swallow Evaluation: Summary of Utility

• Acknowledge limitations but also benefits

• Key component: dysphagia assessment involves more than just aspiration risk

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Formal Assessment Tools

• Pados, B. F., Park, J., Estrem, H., & Awotwi, A. (2016). Assessment Tools for Evaluation of Oral Feeding in Infants Younger Than 6 Months. Advances in Neonatal Care, 16(2), 143–150.

• Benfer, K. A., Weir, K. A., & Boyd, R. N. (2012). Clinimetrics of measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities: A systematic review. Developmental Medicine and Child Neurology, 54(9), 784–795.

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Pados, B. F., Park, J., Estrem, H., & Awotwi, A. (2016). Assessment Tools for Evaluation of Oral Feeding in Infants Younger Than 6 Months. Advances in Neonatal Care, 16(2), 143–150.

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Benfer, K. A., Weir, K. A., & Boyd, R. N. (2012). Clinimetrics of measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities: A systematic review. Developmental Medicine and Child Neurology, 54(9), 784–795.

• Brief Assessment of Motor Function-Oral Motor Deglutition Scale (BAMF-OMD)

• Behavioral Assessment Scale of Oral Functions in Feeding (BASOFF)• Dysphagia Disorders Survey** (DDS)• Feeding Behaviour Scale (FBS)• Functional Feeding Assessment, modified (FFA-m)• Gisel Video Assessment (GVS)• Oral Motor Assessment Scale (OMAS)• Pre-Speech Assessment Scale (PSAS)• Schedule for Oral Motor Assessment (SOMA)**

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Videofluoroscopic Swallow Studies(VFSS)

• General procedure

• Goals of the exam• Clinical question

• Dysphagia ≠ aspiration

• Pathophysiology detailed

• Compensatory strategies/utensils tested

• Part of the overall picture, but is not the whole answer

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Videofluoroscopic Swallow Studies

• Key points to consider (Arvedson & Lefton-Greif, 2017)• Increased concern of radiation exposure with infants/children

• Justification• Adequate knowledge to know risks vs benefits

• (Huda, 2009)

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Videofluoroscopic Swallow Studies

• Optimization • ALARA (As Low As Reasonably Achievable)

• Plan exam to limit fluoro time needed to answer questions

• Number of swallows needed? Plan for fatigue?

• Pulse rate : 30 fps (Bonilha et al., 2013)

Videoswallow studies: Standardization?

Gosa, M. M., Suiter, D. M., & Kahane, J. C. (2015). Reliability for Identification of a Select Set of Temporal and Physiologic Features of Infant Swallows. Dysphagia, 365–372.

Videofluoroscopic Swallow Studies (VFSS)

• Selected references• Information about normal function

• Weckmueller, Easterling, & Arvedson, 2011

• Significance of penetration• Friedman & Frazier, 2000

• Barium use • Cichero, Nicholson, & Dodrill, 2011

• Stuart & Motz, 2009

• Steele, Molfenter, Péladeau-Pigeon, & Stokely, 2013

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Temporal Measures: Normal

• Preliminary Temporal Measurement Analysis of Normal Oropharyngeal Swallowing in Infants and Young ChildrenWeckmueller, Julia, Easterling, Caryn, Arvedson, JoanDysphagia (2011) 26:135–143

• Retrospective review of 15 normal swallow studies

• Separated into 3 age categories

• Important findings re: initial look at “normal”

• Most clinically applicable findings:• Bolus at or fully contained in the valleculae at the onset of laryngeal closure

• For all 15 subjects, laryngeal closure occurred after the head of the bolus passed the tongue base

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Penetration • Retrospective review of videoswallow studies

• N=125, aged 7 days to 19 years

• Significant increase in incidence of aspiration in children w/deep penetration (85%)

Deep Laryngeal Penetration as a Predictor of Aspiration. Friedman, B., & Frazier, J. B. (2000). Dysphagia, 158, 153–158.

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Deep Laryngeal Penetration as a Predictor of Aspiration. Friedman, B., & Frazier, J. B. (2000). Dysphagia, 158, 153–158.

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Barium Use in Pediatric Studies

• Cichero, J., Nicholson, T., & Dodrill, P. (2011).• Barium liquids were more viscous, more dense, & had higher yield

stress than mealtime liquids

• Stuart, S., & Motz, J. M. (2009). • No comparability between barium and formula mixtures

• Gosa & Dodrill (2016)

• Frazier et al. (2016)• Several infant formulas stayed within NDD thin range with 20% w/v E-Z

Paque barium added• Specialty formulas acted differently: Enfamil AR 20 cal got thinner with

addition of barium, the 24 cal Enfamil AR got thicker

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FEES: Fiberoptic Endoscopic Evaluation of Swallowing

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FEES: Fiberoptic Endoscopic Evaluation of Swallowing

Indications

• Question aspiration of secretions

• Patients who are NPO or minimal PO intake

• Question airway protection specifically

• Need more information after a videoswallow

• Unable to adequately simulate feeding position with fluoroscopy

In the Literature

• Description of procedure with pediatric patients: Willging 1995

• Clinical utility: Hartnick et al 2000

• Good correlation with VFSS: Madden et al 2000, Leder & Karas2000

• Sensory thresholds correlated positively with pooled secretions, penetration, & aspiration: Link et al 2000

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Adapted from Miller, CK 2013

FEES: Fiberoptic Endoscopic Evaluation of Swallowing

Pros

• Better simulates feeding environment & experience

• Clear view of structures • No barium or radiation • Assess caregiver interventions • Assess during breastfeeding • No set time constraints • Promote family involvement

Cons

• Possible discomfort to patient

• Specialized training required

• No view of esophageal phase

• Chain swallows in infants can be difficult to interpret

• White out during the swallow

• Equipment cost

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FEES in the NICU

• Safety/tolerance• No major complications occurred when used in NICU infants under the age of

3 months; stable physiologic parameters (Willette et al, 2016) (Suterwala et al, 2017)

• Breastfeeding assessment (Willette et al, 2016)• Used safely and effectively during breastfeeding assessments

• Not able to establish reliability due to lack of other instrumental option

• Reliability (Suterwala et al, 2017)• Good inter-rater agreement for penetration with VFSS (87%) and FEES (80%)• Good inter-rater agreement for aspiration with VFSS (90%) and FEES (80%)

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Decision Making: Aspiration

• Response to aspiration • Protection: mechano & chemo receptors on surface of pharynx, epiglottis,

arytenoid cartilages, vocal folds (Tutor & Gosa, 2012)

• Protective response varies by age• Preterm infants: apnea (prolonged), bradycardia, and reduced respiratory

efforts (Thach 2001, Miller 1952)

• Term infants: brief cessation in respiration and initiated 1-2 swallows (Thach, 2001)

• Adults: Cough, swallow (Thach, 2007)

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Health Impact of Aspiration

• Short term• Apnea/bradycardia/desats?

• Could these lead to longer term growth issues? • (Wang, 2010)

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Health Impact of Aspiration

• Long term• Evidence of pulmonary symptoms & CXR finding?

• Mercado-Deane et al, 2001

• Odds ratio of PNA• Taniguchi & Moyer, 1994

• Lung damage via high resolution chest CT• Piccione et al 2012***, Boesch et al 2006***

• High prevalence of bronchiectasis in children with chronic pulmonary aspiration, seen as early as 8 months

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Recommendations: Factors to Consider

• Developing system/loss of milestones• Principles of motor learning/neuroplasticity (Robbins et al 2008)

• Developing systems may be more vulnerable to sensory deprivation (Johnston 2009)

• Brain changes can be more pronounced during periods of development (Martin, 2009)

• Deprivation of oral feeding opportunities may lead to a delay in acquisition of skills in healthy preterm infants (Bingham 2009)

• Possible sensitive or critical period for swallow-respiratory coordination from 2 weeks-2 months in term infants (Kelly et al, 2007)

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Recommendations: Factors to Consider

• Patient characteristics• Age

• Environment• Overall health status

• Co-morbidities, ability to fight infection

• Capability of following through with plan• Need for adequate nutrition

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(Tutor & Gosa, 2012)(Wallis & Ryan, 2012)(Cass, Wallis, Ryan, Reilly, & McHugh, 2005)(Lefton-Greif & McGrath, 2003)

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Recommendations: Factors to Consider

• Dysphagia Characteristics• Frequency and amount of aspiration

• Chronicity of the problem• What is aspirated

• Liquids only? Solids?

• Source of aspiration• Likely to improve with time? Structural?

• Support for pt/family goals in the context of the disease trajectory (Pollens 2004)

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Recommendations?

Field, M. J., & Behrman, R. E. (2003). When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families (p. 712). Washington DC: National Academies Press.

Recommendations?

• What to do?• Individualized, team-based approach, based on each patient’s medical history, presentation,

& goals of care

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Intervention

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Flow Rate: Bottle Feeding

• Rationale:• Faster milk flow contributes to decreased ventilation, decreased sucking

amplitude (Mathew 1991, Mizuno 2007, Gewolb 2001, 2003, 2006)• Preterm infants more efficient with more controlled flow rate (Chang 2007,

Lau et al 1997, Lau & Schanler 2000)

• Bottle characteristics (Ross & Furham, 2015)• Hole size (Jackman, 2013; Pados, Park, Thoyre, Estrem, & Nix, 2015), • Pliability (Zimmerman & Barlow, 2008)• Shape and size (Eishima, 1991; Segami 2013)• Air exchange (Lau 2015)• Hydrostatic pressure (Lau & Schanler, 2000)

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Milk Flow Rates From Bottle Nipples Used for Feeding Infants Who Are Hospitalized. Pados, B. F., Park, J., Thoyre, S. M., Estrem, H., & Nix, W. B. (2015). American Journal of Speech-Language Pathology, July, 1–9.

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Milk Flow Rates From Bottle Nipples Used for Feeding Infants Who Are Hospitalized. Pados, B. F., Park, J., Thoyre, S. M., Estrem, H., & Nix, W. B. (2015). American Journal of Speech-Language Pathology, July, 1–9.

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Flow Rate: Bottle Feeding

• Rationale:• Faster milk flow contributes to decreased ventilation, decreased sucking

amplitude (Mathew 1991, Mizuno 2007, Gewolb 2001, 2003, 2006)• Preterm infants more efficient with more controlled flow rate (Chang 2007,

Lau et al 1997, Lau & Schanler 2000)

• Bottle characteristics (Ross & Furham, 2015)• Hole size (Jackman, 2013; Pados, Park, Thoyre, Estrem, & Nix, 2015), • Pliability (Zimmerman & Barlow, 2008)• Shape and size (Eishima, 1991; Segami 2013)• Air exchange (Lau 2015)• Hydrostatic pressure (Lau & Schanler, 2000)

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Suck/Swallow/Breathe Coordination

• External pacing/co-regulated feeding• Rationale: responding to cues from the infant that intervention/increased

support is needed to maintain coordinated breathing/swallowing, postural stability, & state regulation (Shaker, 2013)

• Articles of interest: (Shaker, 2017) x2• Thoyre 2012

• Co-regulated feeding resulted in: less oxygen variability, decline, and time spent in desatstate; less heart rate variation & decline; less behavioral dysregulation, better fluid management, decreased work of breathing

• Law-Morstatt et al, 2003• Pacing resulted in: statistically significant decrease in bradycardia, more efficient sucking

pattern

Mayfield ICCD 2017

Flow Rate: Breastfeeding

• Prone positioning

• Pump before feeding

• Nipple shield

• Scissor hold

• Flat hand/heel pressure (DrCarol Chamblin)

Mayfield ICCD 2017

Positioning

Elevated side-lying (ESL) Why would this work?• Possible decreased work of

breathing due to less anti-gravity movement required (Vanderghem, Beardsmore, & Silverman, 1983)

• Can help to decrease gravity effect on bolus (toward pharynx)

• Simulates cross-cradle breastfeeding position

• Clinical expertise: does this work? My experience is yes.

• Any cons?

Mayfield ICCD 2017

(Shaker4swallowingandfeeding.com)

Positioning

• Side-lying position• Clark et al 2007

• Trend toward greater physiologic stability in ESL position (increased sp02, more stable heart rate)

• Dawson et al, 2013• Little difference found in infants’ physiologic stability between the

two feeding positions

• Trend toward infants consuming a smaller proportion of their feed in cradle hold

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Positioning

• Lau, 2013• No difference in time to attain full oral feeding between cradle, side-lying, and upright

positions

• Park, Thoyre, Knafl, Hodges, & Nix, 2014• Elevated side-lying: Significantly less variation in HR, less severe & fewer decreases in HR,

RR closer to pre-feeding state, shorter & more regular intervals b/t breaths, briefer feeding-related apneic events

Mayfield ICCD 2017

Intervention: Thickening

• Gosa, Schooling, Coleman 2011• Evidence Based Systematic Review

• Currently we have an insufficient evidence base for the use of this intervention

• (Madhoun, Siler-Wurst, Sitaram, & Jadcherla, 2015)• Survey• Variability of thickening prescriptions, thickening agents, recipes

Mayfield ICCD 2017

Intervention: Thickening

• Possible benefits of thickened liquids• Slower moving liquids may give increased sensory information and allow for

greater oral motor control (Goldfield, Smith, Buonomo, Perez, & Larson, 2013)

• Slower flowing to improve timing of airway protection (Rempel & Moussavi2005)

• Possibly decrease/eliminate aspiration (Mercado-Deane et al 2001; Gosa, Suiter, Kahane, 2011).

• Alter temporal measures (Gosa, Suiter, Kahane, 2011)• Clinical experience?

Mayfield ICCD 2017

Intervention: Thickening• Possible downsides/risks

• Malnutrition/dehydration?• Evidence exists that thickening does not affect bioavailability of water in healthy controls (Hill

et al 2010, Sharpe et al 2007)• May impact efficiency, and therefore intake/weight gain

• Gut health?• Woods 2012 detailed development of necrotizing enterocolitis in premature infants using

Simply Thick®• Nutrient density: McCallum 2011• Constipation

• Inconsistency of viscosity/recipes• Viscosities vary by time, temperature, etc (Garcia et al 2005, 2008) (Gosa & Dodrill, 2016)• Even experienced SLPs not able to reproduce consistent nectar or honey (Glassburn & Dean

1998)

• Possible cessation of breastmilk

Mayfield ICCD 2017

Thickening: Factors to Consider

• What type of thickener to use• Rice/oatmeal, starch, gum, Gelmix, fortified specialty formula**

• Weaning from thickened liquids• Based on individual swallow physiology

• May repeat instrumental exam or wean clinically and closely monitor• Progressive weaning of thickening

Mayfield ICCD 2017

Thickening: Fortified Formula

• Rationale: • Many preterm infants need higher caloric density and added

calcium/phosphorus

• Clinicians have long noted the perception of increased thickness of anti-reflux formula (Enfamil AR), approximating half strength nectar

• Anecdotally, NICU clinicians report that frequently half strength nectar is sufficient for swallowing safety with use of slow flow nipples (Dr Brown’s P and Ultra P)

• Possible option:• Enfamil AR fortified to 24 cal

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Viscosity Measurements of Fortified Infant FormulasMayfield, Woods, Gould, Walters, Bullock2014 ASHA Convention

Mayfield ICCD 2017

Frazier, J., Chestnut, A. H., Jackson, A., Barbon, C. E. A., Steele, C. M., & Pickler, L. (2016). Understanding the Viscosity of Liquids used in Infant Dysphagia Management. Dysphagia, 31(5), 672–679.

Mayfield ICCD 2017

Direct Muscle Intervention

• Motor training principles• Robbins et al, 2008 principles of

neuroplasticity• Use it or lose it• Use it and improve it• Plasticity is experience specific**• Repetition matters• Intensity matters• Age matters• Time matters• Salience matters***• Transference• Interference

Mayfield ICCD 2017

Direct Muscle Intervention

• Oral phase interventions for preterm infants• 3 systematic reviews

• (Arvedson, Clark, Lazarus, Schooling, & Frymark, 2010)

• (Lima, Côrtes, Bouzada, & Friche, 2015)

• (Tian et al., 2015)

• Conclusion from 2015 studies: oral phase interventions may shorten the transition time to full oral feeding

• Oral phase interventions for older infants/children• One systematic review

• (Arvedson, Clark, Lazarus, Schooling, & Frymark, 2010)

• Conclusion: insufficient evidence for OR against

Mayfield ICCD 2017

(Gosa & Dodrill, 2017)

Direct Muscle Intervention

• Pharyngeal phase intervention• Neuro Muscular Electrical Stimulation: (Christiaanse et al., 2011)

• Conclusion: NMES did not improve swallow function

• Two systematic reviews• (Morgan, Dodrill, & Ward, 2012)

• Insufficient evidence to support or refute

• (Harding & Cockerill, 2015)

• Lack of evidence to support of refute

Mayfield ICCD 2017(Gosa & Dodrill, 2017)

Questions?

Mayfield ICCD 2017