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 3.6 weeks. Sixty percent of participants presented with silent aspiration on VFSS. Thirty percent of participants required supplementary tube feeding more than 6 months 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.

The Evolution of an Interdisciplinary Developmental Round in a Surgical Neonatal Intensive Care Unit.

BACKGROUND: Developmentally supportive environments are known to improve medical outcomes for hospitalized neonates and are considered the overarching philosophy for practice in the neonatal setting. Developmental rounds are a strategy incorporated by multidisciplinary teams to support development within and beyond the neonatal unit. Typically, they consist of bedside consultations and individualized developmentally supportive recommendations for families and clinicians. Globally, the use of developmental rounds has been described since the early 1990s. They are viewed as a measure to counter some of the barriers to developmental care implementation while buffering against the effect of an intensive care admission. To date, their use in the surgical neonatal intensive care unit (sNICU) has been minimally reported in literature. PURPOSE: This article describes the focus and work of a developmental round team and strategy in the sNICU. METHOD: A retrospective audit of developmental round key performance criteria undertaken over a 4-year period (2015-2018). FINDINGS/RESULTS: More than 300 developmental consults and 2000 individualized developmental recommendations occurred annually. Parental presence during the developmental round increased by 10%, from 48% to 58%, during the audit period. IMPLICATIONS FOR PRACTICE/IMPLICATIONS FOR RESEARCH: Literature has supported the use of developmental round interventions; however, minimal data have been reported to date. This article provides retrospective audit data of a developmental round intervention in the sNICU with a focus on data over 4 years to highlight key areas, including the structure and process, recommended educational standards for team members, and parental engagement, as key markers for developmental round efficacy. Future research should focus on the link between the developmental round intervention and long-term neonatal outcomes.

Motor Learning Feeding Interventions for Infants at Risk of Cerebral Palsy: A Systematic Review.

Feeding difficulties and dysphagia are common in cerebral palsy (CP) and can lead to deficiencies of development and aspiration pneumonia; a leading cause of death in CP. Motor learning interventions have shown positive results in other clinical areas and may be beneficial for this population. This systematic review appraises research that addresses the question: are motor learning-based interventions more effective than compensatory strategies alone in treating dysphagia in infants with, or at risk of, CP?. Systematic searches were conducted in nine electronic databases. All levels of evidence, with at least one infant between 37 weeks post-menstrual age and 12 months corrected age who were at risk of, or diagnosed with CP, implemented interventions which aimed to improve oropharyngeal function for feeding, and aligned with at least two motor learning principles, were included. Studies were appraised by two independent reviewers using the Cho & Bero Instrument and GRADE. One historical case-control study and four case series met inclusion criteria. All involved a combination of motor learning interventions and compensatory strategies, which do not traditionally align with motor learning principles. All studies reported improvements in oral feeding outcomes, however, only three reported statistical analysis. The best available evidence collectively demonstrated a very weak positive effect for motor learning-based interventions for feeding difficulties in infants with, or at risk of, CP.

Routine vocal cord mobility assessment post cardiac surgery via median sternotomy approach.

OBJECTIVES: Surgery of the aortic arch carries a risk of injury to the vagus and recurrent laryngeal nerves, particularly in a young child, as these structures lie in close proximity to aortic arch. This study aimed to determine the incidence, symptomatology and natural history of vocal cord dysfunction (VCD) following aortic arch reconstructive surgery through a median sternotomy approach. METHODS AND MATERIALS: Prospective assessment was performed of all consecutive newborns who underwent cardiac surgery for aortic arch surgery via median sternotomy between January 2016 and May 2017 at a tertiary paediatric hospital. All patients underwent post-operative flexible fibreoptic nasolaryngoscopy (FNL) after extubation to assess for the presence of vocal cord dysfunction (VCD). Those with VCD were re-examined at followup. A feeding assessment performed by speech pathologists (SPs) and a video fluoroscopic swallow study (VFSS) were also performed in those with VCD or feeding difficulties. RESULTS: A total of 35 newborns were included in the study. At initial review, left sided VCD was demonstrated in 65.7% of patients (n=23). Significant associations with VCD were younger age (3.0 versus 6.5 days, p=0.041) and a weak or absent cry (Relative Risk=16.4, 95%CI 3.8-47.8, p<0.001). 52.5% (n=11) of patients with VCD had evidence of aspiration on VFSS. There was no significant difference in intensive care unit stay or overall hospital stay between patients with VCD compared to those without (33.0 days vs 28.8 days, p=0.73; 52.5 vs 45.9, p=0.72.) Infants with either proven VCD or a weak cry were more likely to be discharged home with a nasogastric (NG) tube (RR=4.67, p= 0.048; RR=7.00 p=0.022 respectively). At followup after 106 days, complete resolution was seen in 100% patients with partial VCD and 61.5% with complete VCD. CONCLUSIONS: VCD is a common complication following neonatal aortic arch surgery, although most experience resolution of symptoms over time. The authors recommend post-operative laryngoscopy in all patients should be routine, and particularly those with a weak cry.