A Literature Review of Feeding Disorders in Children with Tracheostomies and Ventilators.

Feeding disorders and gastrostomy use are highly prevalent in children with invasive mechanical ventilation (IMV) due to both common risk factors (eg, prematurity, neurological disorders) and resultant experiential deprivation (eg, long hospitalizations, delayed feeding experiences). Feeding in children with IMV is complicated by the presence of a tracheostomy, lung vulnerability, and medical complexity. The potential comorbidity of swallowing difficulties (dysphagia) and atypical early feeding experiences can result in complex feeding disorders. In this review of pediatric feeding disorders in children with invasive mechanical ventilation (IMV), we identify gaps in clinical translational research for this patient population and opportunities for improving evidence-based management. To improve long-term feeding outcomes and maximize oral feeding in this vulnerable population, children would benefit from earlier feeding opportunities during critical developmental windows, standardized protocols for advancing oral feeding, and involvement of intensive, comprehensive therapies throughout hospitalizations and early childhood. [Pediatr Ann. 2022;51(7):e291-e296.].

Airway obstruction and inflammation on combined bronchoscopy in children with Down syndrome.

OBJECTIVE: To characterize the upper and lower airway findings in children with Down syndrome and chronic respiratory symptoms, based on evaluation by flexible bronchoscopy (FB) with bronchoalveolar lavage and microlaryngoscopy with bronchoscopy (MLB). STUDY DESIGN: A retrospective review was conducted of children with Down syndrome aged 1 month to 17 years, who underwent both FB and MLB within a 1-year timeframe between 2010 and 2019 at Children's Hospital Colorado. Anatomic airway findings are reported as frequencies within the cohort. Bronchoalveolar lavage fluid (BALF) culture results, cell differential, and cytopathology are reported as frequencies or mean ± standard deviation. BALF results were compared between children with and without dysphagia documented on a recent swallow evaluation. RESULTS: Overall, 168 children with Down syndrome were included, with median age of 2.1 years (interquartile range: 0.9-5.1 years). At least one abnormal airway finding was recorded in 96% of patients and 46% had at least three abnormal findings. The most common findings included tracheomalacia (39% FB; 37% MLB), subglottic stenosis (35% MLB), pharyngomalacia (32% FB), and laryngomalacia (16% FB; 30% MLB). Comparison of BALF based on dysphagia status showed that children with dysphagia had more frequent cultures positive for mixed upper respiratory flora (76% vs. 47%, p = 0.004) and a higher percentage of neutrophils (20% vs. 7%, p = 0.006). CONCLUSION: Abnormal findings for FB and MLB are common in children with Down syndrome and chronic respiratory symptoms, and performing the procedures together may increase the diagnostic yield.

Validation of the Childhood Dysphagia Management Scale (CDMS): An Impact Scale for determining medical home for dysphagia.

BACKGROUND: The results and recommendations from instrumental assessments of swallowing do not, by themselves, provide guidance regarding the type of medical management that might be needed for the pediatric patient with dysphagia. The aim of this study is to evaluate the reliability and validity of the Childhood Dysphagia Management Scale (CDMS), a clinical scale developed to estimate the impact of dysphagia and determine the need for a multidisciplinary medical home to manage dysphagia. METHODS: This was a prospective observational study implemented in three phases to evaluate validity and reliability of the CDMS. Analyses for internal consistency, inter-rater and intra-rater reliability, repeated measure, content, structural, criterion and external validity and hypothesis testing were conducted. RESULTS: This study established content, structural, internal, external, and criterion validity of the CDMS. The CDMS was found to have robust inter-rater (κ = 0.776) and intra-rater reliability (κ = 0.853), and consistency across repeated measures (κ = 0.853). Providers who used the CDMS had a high level of agreement with the recommended medical management plan. CDMS scores correlated (F(5,118) = 22.105, p < 0.001) with Functional Oral Intake Scale (FOIS) scores confirming that patients with significant diet restrictions were more likely to be referred for multidisciplinary care. To establish external validity, the CDMS was administered to a higher risk group, patients with Down syndrome, who were more likely to be referred for multidisciplinary care based on CDMS results versus the general swallowing disorders clinic population (F(1,281) = 24.357, p < 0.001). CONCLUSION: The CDMS is a reliable and valid scale for guiding decision-making regarding the medical home for pediatric dysphagia management.

Associations between age, respiratory comorbidities, and dysphagia in infants with down syndrome.

OBJECTIVES: Children with Down syndrome (DS) have a high risk of dysphagia and the pediatric pulmonologist may be involved in diagnosis and management. The objective of this study is to evaluate the associations between age, dysphagia, and medical comorbidities in young children with DS. We hypothesized that swallow study findings are more likely to change in younger infants and that medical comorbidities may be associated with dysphagia. STUDY DESIGN: Results of videofluoroscopic swallow studies (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) from 2010 to 2016 were collected retrospectively in children with DS with initial swallow study at less than 12 months of age. Results were analyzed for findings and change based on age at initial study, reason for referral, and medical comorbidities. RESULTS: One hundred eleven infants with 247 VFSS and 14 FEES were included. Deep laryngeal penetration and/or aspiration were found in 31.9% of infants less than 6 months and 51.3% of infants 6 to 12 months. Children with initial swallow study performed at greater than or equal to 6 months of age were more likely (80.0%) to have unchanged findings on follow-up study compared to children imaged at less than 6 months (35.3%). Laryngomalacia, pulmonary hypertension, pneumonia, and congenital cardiac disease were associated with dysphagia. CONCLUSION: We confirmed that dysphagia is common in infants with DS and comorbidities and provided preliminary evidence that swallow study findings may be more likely to change in children tested under 6 months of age. Providers should consider that results for instrumental swallow studies may change, particularly if the test was completed on a young infant.

Understanding the Viscosity of Liquids used in Infant Dysphagia Management.

When assessing swallowing in infants, it is critical to have confidence that the liquids presented during the swallow study closely replicate the viscosity of liquids in the infant's typical diet. However, we lack research on rheological properties of frequently used infant formulas or breastmilk, and various forms of barium contrast media used in swallow studies. The aim of the current study was to provide objective viscosity measurements for typical infant liquid diet options and barium contrast media. A TA-Instruments AR2000 Advanced Rheometer was used to measure the viscosity of five standard infant formulas, three barium products, and two breastmilk samples. Additionally, this study measured the viscosity of infant formulas and breastmilk when mixed with powdered barium contrast in a 20 % weight-to-volume (w/v) concentration. The study findings determined that standard infant formulas and the two breastmilk samples had low viscosities, at the lower end of the National Dysphagia Diet (NDD) thin liquid range. Two specialty formulas tested had much thicker viscosities, close to the lower boundary of the NDD nectar-thick liquid range. The study showed differences in viscosity between 60 % w/v barium products (Liquid E-Z-Paque(®) and E-Z-Paque(®) powder); the powdered product had a much lower viscosity, despite identical barium concentration. When E-Z-Paque(®) powdered barium was mixed in a 20 % w/v concentration using water, standard infant formulas, or breastmilk, the resulting viscosities were at the lower end of the NDD thin range and only slightly thicker than the non-barium comparator liquids. When E-Z-Paque(®) powdered barium was mixed in a 20 % w/v concentration with the two thicker specialty formulas (Enfamil AR 20 and 24 kcal), unexpected alterations in their original viscosity occurred. These findings highlight the clinical importance of objective measures of viscosity as well as objective data on how infant formulas or breastmilk may change in consistency when mixed with barium.

Clinical Characteristics of Dysphagia in Children with Down Syndrome.

Aspiration is an often unrecognized comorbidity in children with Down syndrome with serious medical consequences. This retrospective chart review of swallow study reports characterizes oral and pharyngeal phase dysphagia and diet modifications on videofluoroscopic swallow studies (VFSS) in a large cohort of children with Down syndrome. A total of 158 pediatric patients (male = 95; female = 63; mean age 2.10 years, SD 3.17 years) received an initial VFSS at a pediatric teaching hospital as part of their medical care. A total of 56.3 % (n = 89) children had pharyngeal phase dysphagia with aspiration and deep laryngeal penetration occurring most frequently. Of the 61 patients who aspirated, 90.2 % (n = 55) did so silently with no cough or overt clinical symptoms. In 76.7 % of cases of pharyngeal phase dysphagia, a functional feeding plan, with use of thickened liquids or change in feeding system to control flow rate and/or bolus size, was able to be established, which allowed children to continue eating by mouth. Thickened liquids (76.7 %, n = 46) were the most effective adaptation, with change in feeding system alone effective in only 8.3 % (n = 5) cases. Oral phase dysphagia was reported in the majority of patients (63.8 %, n = 88/138); however, this was not predictive of pharyngeal phase dysphagia. Age, sex, and reason for referral, including prior clinical symptoms, did not have a statistically significant impact on the presence of dysphagia. This comprehensive review has application to clinical understanding and management of dysphagia in children with Down syndrome.