The follow up of complex infants in an aerodigestive clinic.

The current available literature evaluating pediatric multidisciplinary aerodigestive programs for the management of aerodigestive disorders in infants was reviewed. Multidisciplinary aerodigestive programs have emerged to provide coordinated and comprehensive care for the growing population of children with aerodigestive conditions, including complex airway, pulmonary, gastrointestinal, and feeding disorders, which are prevalent among infants discharged from the neonatal intensive care unit (NICU). The team approach central to aerodigestive clinics offers a comprehensive diagnostic workup and unified management plan through consolidated interdisciplinary clinics, combined endoscopic procedures, and regular team discussions, leading to improved resource utilization and health care outcomes. We review common conditions presenting in the NICU that benefit from the aerodigestive model of care, including esophageal atresia, prematurity, bronchopulmonary dysplasia with or without tracheostomy or ventilator dependence, and dysphagia.

Airway and Swallowing Outcomes Following Laryngotracheoplasty With Posterior Grafting in Children.

OBJECTIVES/HYPOTHESIS: Evaluate swallowing and airway outcomes following laryngotracheoplasty with posterior grafting (LTP PCCG). METHODS: Retrospective review of pediatric patients undergoing LTP PCCG from 2016 to 2019 at a tertiary care pediatric hospital. We included demographics, indications, approach, and revision status. We evaluated preoperative and postoperative instrumental and functional swallow evaluations, and we also gathered information on airway outcomes. RESULTS: Thirty-one patients were included in the study. Median (interquartile range [IQR]) age was 4.0 (2.0, 7.0) years old. Primary indication for surgery was bilateral vocal cord immobility (BVCI) in 11 (35.5%) and posterior glottic stenosis (PGS) in 20 (64.5%). Mean (standard deviation) length of follow-up was 11.0 (8.3) months. Twelve patients had gastrostomy tubes (GT) before surgery, and no patients required placement of GT after surgery. Of the remaining 19 patients, 6 required nasogastric feeding for >4 weeks (average length 1.8 months, longest 3.5 months). At last follow-up, 25 (80.6%) patients were primarily orally fed. Eighteen patients had tracheotomies prior to surgery. No patients without a tracheostomy required placement of tracheostomy before or after surgery and only 1 patient had a tracheostomy at last follow-up. Average time to decannulation was 3.7 months, with surgery-specific success of 87.1% and overall success of 96.8%. Four (12.9%) patients required a major intervention to achieve decannulation. CONCLUSION: LTP PCCG is an effective surgical technique to address PGS and BVCI with high decannulation rates. It may cause temporary swallowing dysfunction, but in this series a majority of children were orally fed at last follow-up. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2798-2804, 2021.

Swallowing function after laryngeal cleft repair: more than just fixing the cleft.

OBJECTIVES/HYPOTHESIS: To evaluate and describe the swallowing function in children after laryngeal cleft repair. STUDY DESIGN: Ten-year (2002-2012) retrospective chart review. SETTING: Academic tertiary care pediatric otolaryngology practice. METHODS: Records of 60 children who had surgical repair of laryngeal cleft (ages 2 weeks-14 years) and postoperative functional endoscopic evaluation of swallowing or videofluoroscopic swallow studies were examined retrospectively. RESULTS: Twenty-nine children had one postoperative swallow evaluation, 19 children had two, 4 children had three, 5 children had four, and 3 children had five. Median time to the first evaluation was 10.8 weeks (interquartile range [IQR]: 36.5, 231). On the final swallow evaluation, 34 (57%) children demonstrated normal swallowing parameters, 12 (20%) children showed penetration, and 14 (23%) children showed aspiration. Forty-three (72%) children were able to take everything by mouth normally or with minor behavioral modifications, 11 (18%) children required thickened fluids, and six (10%) children were kept nil per os (NPO). Mean improvement on the penetration-aspiration (pen-asp) scale was 2.13. On multivariable analysis, neurodevelopmental issues and gastronomy tube use were associated with the need for NPO status. CONCLUSION: Despite a high rate of surgical success, a substantial minority of children have persistent swallowing dysfunction after laryngeal cleft repair. Swallowing dysfunction after repair is multifactorial and arises from concomitant neurologic, anatomic, or other comorbidities that contribute to oropharyngeal and pharyngeal dysphagia. Based on our results, we recommend a testing schedule for postoperative swallowing evaluations after cleft repair.

Feeding issues and interventions in infants and children with clefts and craniofacial syndromes.

Problems with oral feeding occur in varying degrees in infants born with cleft lip/palate and/or craniofacial syndromes. The extent of clefting is associated with the severity of feeding problems, and if cleft lip/palate occurs in conjunction with a craniofacial syndrome, additional structural, airway, and neuromotor issues may be present. The infant's feeding and swallowing skills may be significantly impaired, characterized by inefficient oral feeding skills coupled with poor airway protection ability during swallowing. Inadequate airway protection during swallowing has serious implications for the infant's respiratory health as sequelae of chronic aspiration during feeding may include recurrent respiratory illness, pneumonia, and lung damage. Feeding difficulty in nonsyndromic and syndromic cleft lip/palate infants has been documented as source of considerable stress for parents and can have a potential negative effect on the parent-infant bonding process. Therefore, timely identification of feeding problems by the speech pathologist with subsequent intervention and modification in the feeding method is essential, along with provision of early feeding instruction to families. The objective of this article is to review expert opinion and available evidence regarding factors that influence feeding success and efficiency in infants with nonsyndromic and syndromic cleft lip/palate. The types of compensatory strategies or interventions that are effective in alleviation of feeding and swallowing difficulties will be described. Descriptive reports, expert opinion, and available evidence from clinical trials to support the use of feeding interventions in treatment are reviewed.