Neuromuscular electrical stimulation improves feeding and aspiration status in medically complex children undergoing feeding therapy.

OBJECTIVES: Neuromuscular electrical stimulation (NMES) therapy in the head and neck has been effectively used to rehabilitate swallowing in adult patients with acquired dysphagia. Limited data is available for the effectiveness of NMES in medically complex children with dysphagia and aspiration. This study intends to determine the efficacy of NMES as a therapeutic adjunct to improve aspiration and feeding status in medically complex children with severe dysphagia undergoing comprehensive speech and swallow therapy. STUDY DESIGN: Case series. SETTING: Tertiary children's hospital. SUBJECTS: and Methods: Medically complex children undergoing treatment for dysphagia using NMES during a three year period were included. Duration of treatment routinely ranged from 20 to 26 weeks. Demographic information, pre and post-NMES treatment aspiration status via modified barium swallow (MBS), and pre and post-NMES treatment feeding status were examined. RESULTS: 15 medically complex children underwent NMES as a component of their feeding therapy. The mean age was 2.51 ±â€¯3.20 years. Mean pre-treatment Functional Oral Intake Scale(FOIS) was 3.07 ±â€¯1.94. Following NMES, FOIS improved to 4.47 ±â€¯2.26 (p < 0.0001). Fourteen patients were evaluated with MBS prior to NMES. Pre-treatment aspiration and penetration were noted in 10 and 2 patients respectively. Two patients did not aspirate on pre-treatment MBS. Improvement was noted in 9 of 11 children with post-treatment MBS. CONCLUSION: NMES was safely completed in all children without complication. Improvement in aspiration status was seen in 83.3% of patients with pre- and post-treatment MBS. Feeding status as measured by textures was advanced in all patients with a significant improvement in FOIS. Future prospective studies are required to investigate the specific role in children with acquired and congenital dysphagia.

Infant Videofluoroscopic Swallow Study Testing, Swallowing Interventions, and Future Acute Respiratory Illness.

OBJECTIVES: Tube feedings are commonly prescribed to infants with swallowing abnormalities detected by videofluoroscopic swallow study (VFSS), but there are no studies demonstrating efficacy of these interventions to reduce risk of acute respiratory illness (ARI). We sought to measure the association between swallowing interventions and future ARI, among VFSS-tested infants. METHODS: Retrospective cohort of all infants (<12 months) tested with VFSS at a children's hospital between January 1, 2010, and January 1, 2012. Hospital ARI encounters (emergency, observation, or inpatient status) in a 22-hospital integrated health care delivery system, between the first VFSS and age 3 years, were measured. VFSS results were grouped by normal, intermediate, and oropharyngeal aspiration (OPA), with OPA further subdivided by silent versus cough and thin versus thick liquid OPA. Cox regression modeled the association between swallowing interventions (thickened or nasal tube feedings) and ARI, accounting for changes in swallowing and interventions over time. RESULTS: 576 infants were tested with a VFSS in their first year of life, receiving a total of 1051 VFSSs in their first 3 years of life. More than 60% of infants received a measured feeding intervention. With the exception of infants with silent OPA who received thickened feedings, neither thickening nor nasal tube feedings, compared with no intervention, were associated with a decreased risk of subsequent ARI. CONCLUSIONS: Swallowing interventions and repeated testing are common among VFSS-tested infants. However, the importance of diagnosing and intervening on VFSS-detected swallowing abnormalities for the majority of tested infants remains unclear.

Characterizing risk factors for pediatric lamp oil product exposures.

UNLABELLED: Poisonings from lamp oil ingestion continue to occur worldwide among the pediatric population despite preventive measures such as restricted sale of colored and scented lamp oils. This suggests that optimal prevention practices for unintentional pediatric exposures to lamp oil have yet to be identified and/or properly implemented. OBJECTIVE: To characterize demographic, health data, and potential risk factors associated with reported exposures to lamp oil by callers to poison centers (PCs) in the US and discuss their public health implications. STUDY DESIGN: This was a two part study in which the first part included characterizing all exposures to a lamp oil product reported to the National Poison Data System (NPDS) with regard to demographics, exposure, health, and outcome data from 1/1/2000 to 12/31/2010. Regional penetrance was calculated using NPDS data by grouping states into four regions and dividing the number of exposure calls by pediatric population per region (from the 2000 US census). Temporal analyses were performed on NPDS data by comparing number of exposures by season and around the July 4th holiday. Poisson regression was used to model the count of exposures for these analyses. In the second part of this project, in order to identify risk factors we conducted a telephone-based survey to the parents of children from five PCs in five different states. The 10 most recent lamp oil product exposure calls for each poison center were systematically selected for inclusion. Calls in which a parent or guardian witnessed a pediatric lamp oil product ingestion were eligible for inclusion. Data on demographics, exposure information, behavioral traits, and health were collected. A descriptive analysis was performed and Fisher's exact test was used to evaluate associations between variables. All analyses were conducted using SAS v9.3. RESULTS: Among NPDS data, 2 years was the most common patient age reported and states in the Midwestern region had the highest numbers of exposure calls compared to other regions. Exposure calls differed by season (p < 0.0001) and were higher around the July 4th holiday compared to the rest of the days in July (2.09 vs. 1.89 calls/day, p < 0.002). Most exposures occurred inside a house, were managed on-site and also had a "no effect" medical outcome. Of the 50 PC-administered surveys to parents or guardians, 39 (78%) met inclusion criteria for analysis. The majority of ingestions occurred in children that were 2 years of age, that were not alone, involved tiki torch fuel products located on a table or shelf, and occurred inside the home. The amount of lamp oil ingested did not appear to be associated with either the smell (p = 0.19) or the color of the oil (p = 1.00) in this small sample. Approximately half were asymptomatic (n = 18; 46%), and of those that reported symptoms, cough was the most common (n = 20, 95%) complaint. CONCLUSIONS: Lamp oil product exposures are most common among young children (around 2 years of age) while at home, not alone and likely as a result of the product being in a child-accessible location. Increasing parental awareness about potential health risks to children from these products and teaching safe storage and handling practices may help prevent both exposures and associated illness. These activities may be of greater benefit in Midwestern states and during summer months (including the period around the July 4th holiday).

An alternative method of management of pediatric airway foreign bodies in the absence of rigid bronchoscopy.

OBJECTIVE: Pediatric airway foreign body aspiration is a life-threatening clinical entity. The standard of care for managing this situation is endoscopic retrieval using rigid bronchoscopy. However in resource-limited settings rigid bronchoscopy may not be available. This retrospective case series describes the successful application of one treatment modality for pediatric airway foreign body. METHODS: A retrospective review was performed for seven pediatric patients who were treated at Soddo Christian Hospital with a diagnosis of airway foreign body aspiration. All patients were treated in the operating room using general anesthesia, a combination of inhaled halothane and intravenous ketamine. Paralytics were not used in any patient and spontaneous breathing was maintained. Flexible fiberoptic bronchoscopy was initially performed on each patient to confirm the presence of a foreign body and identify the anatomic position with the airway. Using a standard technique, a tracheotomy was performed. If the foreign body was still noted to be distal to the tracheotomy, postural percussion was performed to dislodge the foreign body into the trachea. Once the foreign body was identified at the tracheotomy, it was removed. RESULTS: All seven patients presented in respiratory distress and were emergently managed in the operating room. The average age was 2.8 years (6 months-8 years of age). The foreign bodies were successfully removed in all patients. There were no mortalities and all patients were successfully discharged from the hospital. CONCLUSIONS: Pediatric airway foreign body aspiration is a life-threatening clinical entity in any setting, but it presents unique challenges in resource-limited settings where rigid bronchoscopy is not available. This report presents one such treatment modality and utilizes a combination of flexible fiberoptic bronchoscopy and tracheotomy to treat such patients.

Extraction of tracheobronchial foreign bodies in children and adults with rigid and flexible bronchoscopy.

BACKGROUND: Tracheobronchial foreign bodies (TBFBs) due to accidental aspiration are seen in both children and adults and are usually extracted by flexible bronchoscopy (FB) or rigid bronchoscopy (RB). The experience over a decade of treating 214 patients with TBFBs has been analyzed retrospectively. METHODS: The records of all patients who presented with possible TBFB aspiration since 2001 were analyzed. A clinical profile of these patients was compiled. The method of extraction and its success was noted. Asphyxiating TBFBs were extracted straight away by RB, whereas for nonasphyxiating TBFBs, extraction was first attempted with FB and RB used only if the former failed. The success of the 2 procedures was compared. RESULTS: : Of a total of 266 patients in whom TBFBs were suspected, the diagnosis was confirmed by bronchoscopy in 214. TBFBs were more common in males, and in the age group between 1 and 2 years. Successful extraction could be achieved in 40% of the patients with FB and in 95% with RB where it was required. CONCLUSIONS: From our experience of extraction of TBFBs over more than a decade, we have drawn the following conclusions: (1) TBFBs present most frequently in the age group of 1 to 2 years, with cough and/or breathlessness commonly following a choking episode; (2) a high index of suspicion is essential and diagnostic FB should be performed in all such cases even though the chest radiograph is normal; (3) TBFBs can be life threatening and may require to be treated as an emergency; (4) FB may be used first for diagnosis and extraction under conscious sedation for nonasphyxiating TBFBs. It is usually more successful in adults and less so in children; (5) in these patients, if FB is unsuccessful, then RB may be used to extract the TBFB; (6) for asphyxiating TBFBs, RB is the procedure of choice; (7) pulmonologists who wish to practice extraction of TBFBs ought to be trained in both FB and RB and must possess adequate equipment and a skilled team to assist them.

Recurrent stridor in a 9-year-old child after a choking and aspiration event.

This is a case report of a 9-year-old boy with new onset stridor 5 days after a choking event. Symptoms would last 5-45 minutes. His stridor was unresponsive to nebulized epinephrine but improved when he relaxed. Otlaryngology examination noted laryngeal irritation that was suggestive of gastroesophageal reflux (GER). Episodic stridor continued, despite treatment for GER, prompting hospitalization. On admission, barium swallow indicated hyperinflation of the left lung and bronchoscopy confirmed the aspiration of food. Within 12 hours of bronchoscopy, his stridor recurred. The recurrence of stridor after bronchoscopy resulted in further evaluation of his upper airway disorder. The true diagnosis was revealed during methacholine challenge. This case illustrates a unique presentation of a common upper respiratory disorder, the need for a high index of suspicion to make the diagnosis, and the importance of the multispecialty approach needed to treat patients with this disorder.

Aspiration of an impacted lower third molar during its surgical removal under local anaesthesia.

In this case of an aspirated impacted lower third molar during its removal under local anaesthesia, the problem was recognized immediately during the surgical procedure. The patient, a 23-year-old male, was subjected to urgent radiological examination. The aspirated tooth was detected in the right bronchus and eventually removed by rigid bronchoscopy. Oral surgeons should suspect any tooth that has been avulsed or extracted and not found as having been aspirated. Early diagnosis and management of such incidents is essential.