Growth and Duration of Inflammation Determine Short- and Long-Term Outcome in Very-Low-Birth-Weight Infants Requiring Abdominal Surgery.

Necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP) and meconium-related ileus (MI) requiring surgical intervention are associated with a high risk of severe short- and long-term complications in very-low-birth-weight (VLBW) infants including poor growth, cholestasis and neurodevelopmental impairment. This retrospective study aimed to identify risk factors for such complications in a cohort of 55 VLBW preterm infants requiring surgery with enterostomy creation due to NEC, SIP or MI. Long-term follow-up was available for 43 (78%) infants. Multiple regression analyses revealed that the duration of inflammation and longitudinal growth determined the risk of cholestasis and neurodevelopmental outcome at 2 years corrected age independent of the aetiology of the intestinal complication. Direct bilirubin increased by 4.9 µmol/L (95%CI 0.26-9.5), 1.4 µmol/L (95%CI 0.6-2.2) and 0.8 µmol/L (95%CI 0.22-1.13) with every day of elevated (Interleukin-6) IL-6, (C-reactive protein) CrP and parenteral nutrition. The mental development index at 2 years corrected age decreased by 3.8 (95%CI -7.3--0.36), 0.4 (95%CI 0.07-0.80) and 0.3 (95%CI 0.08-0.57) with every day of elevated IL-6 and every 1 point decrease in weight percentile at discharge and 2 years. These data stress the importance of optimal timing for the initial surgery in order to prevent prolonged inflammation and an early reversal of the enterostomy in case of poor growth or insufficient enteral nutrition.

MUC-FIRE: Study protocol for a randomized multicenter open-label controlled trial to show that MUCous FIstula REfeeding reduces the time from enterostomy closure to full enteral feeds.

Background: After enterostomy creation, the distal bowel to the ostomy is excluded from the physiologic passage of stool, nutrient uptake, and growth of this intestinal section. Those infants frequently require long-term parenteral nutrition, continued after enterostomy reversal due to the notable diameter discrepancy of the proximal and distal bowel. Previous studies have shown that mucous fistula refeeding (MFR) results in faster weight gain in infants. The aim of the randomized multicenter open-label controlled MUCous FIstula REfeeding ("MUC-FIRE") trial is to demonstrate that MFR between enterostomy creation and reversal reduces the time to full enteral feeds after enterostomy closure compared to controls, resulting in shorter hospital stay and less adverse effects of parenteral nutrition. Methods/Design: A total of 120 infants will be included in the MUC-FIRE trial. Following enterostomy creation, infants will be randomized to either an intervention or a non-intervention group.In the intervention group, perioperative MFR between enterostomy creation and reversal will be performed. The control group receives standard care without MFR.The primary efficacy endpoint of the study is the time to full enteral feeds. Secondary endpoints include first postoperative bowel movement after stoma reversal, postoperative weight gain, and days of postoperative parenteral nutrition. In addition adverse events will be analyzed. Discussion: The MUC-FIRE trial will be the first prospective randomized trial to investigate the benefits and disadvantages of MFR in infants. The results of the trial are expected to provide an evidence-based foundation for guidelines in pediatric surgical centers worldwide. Trial registration: The trial has been registered at clinicaltrials.gov (number: NCT03469609, date of registration: March 19, 2018; last update: January 20, 2023, https://clinicaltrials.gov/ct2/show/NCT03469609?term=NCT03469609&draw=2&rank=1).

Epidemiology and infection control of Methicillin-resistant Staphylococcus aureus in a German tertiary neonatal intensive and intermediate care unit: A retrospective study (2013-2020).

In preterm and term infants who require intermediate or intensive care Methicillin-resistant Staphylococcus aureus (MRSA) infection can lead to significant morbidity. In this study MRSA colonization and infection were assessed in a mixed tertiary neonatal intensive and intermediate care unit in Germany over an 8-year period (2013-2020). We investigated patient-related factors, associated with nosocomial MRSA acquisition, and we discuss our infection control concept for MRSA. Of 3488 patients treated during the study period, 24 were MRSA positive patients, corresponding to 26 patient hospital stays. The incidence was 0.7 MRSA patients per 100 patients. The incidence density was 0.4 MRSA patient hospital stays per 1000 patient days. Twelve patients (50%) acquired MRSA in the hospital. One patient developed a hospital acquired MRSA bloodstream infection 9 days after birth (i.e., 0.03% of all patients on the ward during the study period). A total of 122 patients had to be screened to detect one MRSA positive patient. In a logistic regression model, the use of 3rd generation intravenous cephalosporin (cefotaxim) was associated with nosocomial MRSA acquisition compared with matched control patients who did not acquire MRSA. In sum, the burden of MRSA colonization and infection in the ward was low during the study period. A comprehensive infection control concept that included microbiologic colonization screening, prospective infection surveillance together with isolation and emphasis on basic hygiene measures is essential to handle MRSA in this specialized setting.

Possible role of SIRT1 and SIRT3 in post-translational modifications in human breast milk during the neonatal period.

We measured free and proteinic concentrations of native and modified amino acids from post-translational modifications (PTMs) and correlated them with the activity of SIRT1 and SIRT3 in the pellet and aqueous phases of human breast milk samples of ten lactating women during the neonatal period. SIRT1 and SIRT3 correlated directly with citrullination, asymmetric dimethylation and glycation of L-arginine, hydroxylation and glycation of L-lysine. SIRT1 and SIRT3 correlated inversely with the hydroxylation of L-proline. SIRT1 and SITR3 tended to correlate inversely with oxidative stress measured as malondialdehyde. Our study suggests that SIRT1 and SIRT3 may modulate PTMs in human breast milk cells.

Cardiorespiratory Events Following the Second Routine Immunization in Preterm Infants: Risk Assessment and Monitoring Recommendations.

Due to frequent cardiorespiratory events (CREs) in response to the first routine immunization (rIM), current guidelines recommend readmitting and monitoring extremely preterm infants after the second rIM, though evidence on CREs in response to the second rIM is weak. In a prospective observational study, preterm infants with an increase in CREs after the first rIM were monitored for CREs before and after the second rIM. Seventy-one infants with a median gestational age of 26.4 weeks and a median weight of 820 g at birth were investigated at a median postnatal age of 94 days. All but seven infants showed an increase in CREs after the second rIM. The frequency of hypoxemias (p < 0.0001), apneas (p = 0.0003) and cardiorespiratory events requiring tactile stimulation (CRE-ts) (p = 0.0034) increased significantly. The 25 infants (35%) presenting with CRE-ts were significantly more likely to have been continuously hospitalized since birth (p = 0.001) and to receive analeptic therapy at the first rIM (p = 0.002) or some kind of respiratory support at the first (p = 0.005) and second rIM (p < 0.0001). At a postmenstruational age of 43.5 weeks, CRE-ts ceased. Our data support the recommendation to monitor infants who fulfil the above-mentioned criteria during the second rIM up to a postmenstruational age of 44 weeks.

Analysis of Sirtuin 1 and Sirtuin 3 at Enzyme and Protein Levels in Human Breast Milk during the Neonatal Period.

Breast feeding is regarded as the preferred nutrition modality for children during the first few months of life. It not only furthers growth and development but also is supposed to impact later life. The first 1000 days are regarded as a critical window for development, even beyond infancy. The physiological basis underlying this beneficial effect is not clear. Sirtuins are important regulatory proteins of metabolism and are supposed to play a critical role in ageing and longevity as well as in diseases. In the present study, we developed novel methods to assay sirtuin 1 and sirtuin 3 at enzyme activity (via fluorometry) and protein levels (by Western blot) in the aqueous phase and in the cell pellet of human breast milk and assessed the impact of ongoing lactation during the neonatal period. Sirtuin activities in the aqueous phase were negatively correlated with the duration of lactation in the neonatal period. There was no correlation of sirtuin activities in the cell pellet with the duration of lactation. The amounts of sirtuin 1 and sirtuin 3 measured by Western blot were negatively correlated with the lactation period.

Detection of Serratia marcescens in neonatal intensive care units requires a rapid and comprehensive infection control response starting with the very first case.

Background: Serratia marcescens is a well-known and challenging pathogen in neonatal intensive care units. It is responsible for severe infections and can cause nosocomial outbreaks. Methods: We present the infection control response to a Serratia marcescens cluster which occurred in a tertiary neonatal intensive care unit. Results and conclusions: The presented comprehensive and decisive hygiene management response starting with the very first case aims especially at early detection and immediate interruption of nosocomial transmission. Frequent and sensitive microbiological screening, rigorous spatial isolation of colonized infants, and reinforcing adherence to hand hygiene are essential in this response, which comprises eight measures. It prevented a full-blown outbreak.

Application of two different nasal CPAP levels for the treatment of respiratory distress syndrome in preterm infants-"The OPTTIMMAL-Trial"-Optimizing PEEP To The IMMAture Lungs: study protocol of a randomized controlled trial.

BACKGROUND: Nasal continuous positive airway pressure (CPAP) applies positive end-expiratory pressure (PEEP) and has been shown to reduce the need for intubation and invasive mechanical ventilation in very low birth weight infants with respiratory distress syndrome. However, CPAP failure rates of 50% are reported in large randomized controlled trials. A possible explanation for these failure rates is the application of insufficient low levels of PEEP during nasal CPAP treatment to maintain adequate functional residual capacity shortly after birth. The optimum PEEP level to treat symptoms of respiratory distress in very low birth weight infants has not been assessed in clinical studies. The aim of the study is to compare two different PEEP levels during nasal CPAP treatment in preterm infants. METHODS: In this randomized multicenter trial, 216 preterm infants born at 26 + 0-29 + 6 gestational weeks will be allocated to receive a higher (6-8 cmH2O) or a lower (3-5 cmH2O) PEEP during neonatal resuscitation and the first 120 h of life. The PEEP level within each group will be titrated throughout the intervention based on the FiO2 (fraction of inspired oxygen concentration) requirements to keep oxygenation within the target range. The primary outcome is defined as the need for intubation and mechanical ventilation for > 1 h or being not ventilated but reaching one of the two pre-defined CPAP failure criteria (FiO2 > 0.5 for > 1 h or pCO2 ≥ 70 mmHg in two consecutive blood gas analyses at least 2 h apart). DISCUSSION: Based on available data from the literature, the optimum level of PEEP that most effectively treats respiratory distress syndrome in preterm infants is unknown, since the majority of large clinical trials applied a wide range of PEEP levels (4-8 cmH2O). The rationale for our study hypothesis is that the early application of a higher PEEP level will more effectively counteract the collapsing properties of the immature and surfactant-deficient lungs and that the level of inspired oxygen may serve as a surrogate marker to guide PEEP titration. Finding the optimum noninvasive continuous distending pressure during early nasal CPAP is required to improve CPAP efficacy and as a consequence to reduce the exposure to ventilator-induced lung injury and the incidence of chronic lung disease in this vulnerable population of very preterm infants. TRIAL REGISTRATION: drks.de DRKS00019940 . Registered on March 13, 2020.

Home oxygen therapy after hospital discharge.

Home oxygen therapy is increasingly prescribed for various conditions in the neonatal period, particularly for infants with bronchopulmonary dysplasia. Due to limited evidence on indication, minimal target oxygen saturation, monitoring, application and discontinuation of home oxygen therapy clinical practice varies widely throughout the world. International guidelines provide recommendations mostly on the basis of nonsystematic clinical observations. Most relevant points for the clinical management of home oxygen therapy include a minimal target oxygen saturation of equal to or greater than 93%, the provision of a home monitoring of oxygen saturation ideally with a memory function, and the conduct of continuous overnight oximetry or polysomnography during weaning from supplemental oxygen. This review summarizes relevant literature as well as existing guidelines and recommendations on home oxygen therapy to aid clinicians in the management of these patients and identifies areas for future research.

Parents' Prenatal, Onward, and Postdischarge Experiences in Case of Extreme Prematurity: When to Set the Course for a Trusting Relationship between Parents and Medical Staff.

OBJECTIVES: This article aims to investigate the impact of prenatal counseling on subsequent parents' experiences during in-patient care of their infant(s) and whether feelings of parents with deceased infants are different in principle. STUDY DESIGN: A questionnaire was sent to 99 families with a child born less than 26 weeks' gestational age at Medical School Hanover 2000-2008. Statistical analysis was performed using Fisher exact t test and chi-square tests in IBM SPSS Statistics for Windows, Version 20.0. RESULTS: Response rate was 73%. Parents with solely surviving children significantly more often answered the questionnaire (p < 0.001). Regardless of the infants' outcome, parents who felt well involved in prenatal decision making significantly more often also felt adequately involved in postnatal treatment of their child (p = 0.006) and would again decide on life-sustaining treatment of an extremely premature infant (p = 0.007). Furthermore, they were significantly less dubious about the treatment of their baby (p = 0.013) than parents not feeling sufficiently involved. Significantly fewer parents with only surviving child(ren) decided to have another baby later than parents with at least one deceased child (p = 0.004). CONCLUSION: This study stresses the impact of prenatal counseling and shows that, regardless of outcome, the course of a trusting relationship between parents and health care team is already set before birth.

Prescription of home oxygen therapy to very low birth weight infants in Germany: a nationwide survey.

OBJECTIVE: There is no consensus on prescription of home oxygen therapy to infants in Germany. We hypothesized that this causes considerable variability in prescribing home oxygen to infants. STUDY DESIGN: A structured questionnaire involving management of home oxygen therapy was sent to all German pediatric departments (n = 293). RESULTS: Response rate was 84% (247/293). SpO2 cutoff values below which oxygen therapy was considered indicated showed a wide range (80% to 94%, mean 90%). Respondents admitting >50 very low birth weight infants annually significantly more frequently prescribed home oxygen (P < .001) and aimed for SpO2 levels closer to the physiological range than those admitting less very low birth weight infants (P = .046). CONCLUSION: Management of pediatric home oxygen therapy is diverse in Germany. Optimal SpO2 targets have to be further investigated by controlled studies and German guidelines should be established. Until then practice should abide by existing foreign guidelines.

Closed versus open endotracheal suctioning in extremely low-birth-weight neonates: a randomized, crossover trial.

BACKGROUND: Endotracheal suctioning, which is frequently necessary in mechanically ventilated patients, might cause complications, especially in patients with compromised lung function such as extremely low-birth-weight (ELBW) neonates. OBJECTIVES: To investigate whether closed endotracheal suctioning (CS) reduces the frequency of hypoxemia and bradycardia in ELBW neonates compared to open suctioning (OS). METHODS: In a randomized, crossover trial, 15 ventilated ELBW neonates (mean birth weight 655 g) underwent suctioning with both techniques. Data on oxygen saturation (SpO2), heart rate (HR), arterial blood pressure, arterial blood gases, duration of the suctioning procedure and recovery time were collected. Statistical analysis was done using the SPSS t test for paired samples. RESULTS: The mean frequency of hypoxemia <85% was significantly decreased (p = 0.012) during CS (0.5) versus OS (1.1). The mean minimum SpO2 was significantly higher (p = 0.012) during CS (87%) compared to OS (84%), and a significantly less steep drop in mean SpO2 (p = 0.007) (CS: -5%, OS: -8%) was found. Mean arterial PO2 (p = 0.035; CS: 59 mm Hg, OS: 53 mm Hg) and mean oxygenation ratio (p = 0.016; CS: 197, OS: 171) were significantly higher after CS. No significant differences were found in HR, incidence or duration of bradycardia, recovery time, arterial blood pressure, duration of suctioning, number of complications, or duration of hypoxemia. CONCLUSION: CS was superior to OS on oxygenation values. To prove its overall superiority, further research is required. So, in this group of patients, CS should currently be administered on an individual basis.

Procalcitonin and valuable clinical symptoms in the early detection of neonatal late-onset bacterial infection.

AIM: To evaluate which clinical symptoms indicate proven neonatal bacterial infection (NBI) and whether measuring procalcitonin aside from C-reactive protein and interleukin 6 improves sensitivity and specificity in diagnosis. METHODS: In a prospective observational study, clinical symptoms and procalcitonin, C-reactive protein and interleukin 6 were simultaneously determined from the 4th day of life in 170 preterm and term neonates at the first time of suspicion of NBI. Proven NBI was defined as a positive culture of otherwise sterile body fluids or radiologically verified pneumonia in combination with elevated inflammatory markers. RESULTS: Fifty-eight (34%) patients were diagnosed with proven late-onset NBI. In case of proven NBI, odds ratio and 95% confidence intervals were 2.64 (1.06-6.54) for arterial hypotension, 5.16 (2.55-10.43) for feeding intolerance and 9.18 (4.10-20.59) for prolonged capillary refill. Sensitivity of combined determination of C-reactive protein (>10 mg/L) and interleukin 6 (>100 pg/mL) was 91.4%, specificity 80.4%, positive predictive value 70.7% and negative predictive value 94.7%. The additional determination of procalcitonin (>0.7 ng/mL) resulted in 98.3%, 65.2%, 58.8% and 98.6%, respectively. CONCLUSION: Arterial hypotension, feeding intolerance and especially prolonged capillary refill indicate proven neonatal late-onset bacterial infection, even at the time of first suspicion. Additional measurement of procalcitonin does indeed improve sensitivity to nearly 100%, but is linked to a decline in specificity. Nevertheless, in the high-risk neonatal population, additional procalcitonin measurement can be recommended because all infants with NBI have to be identified.

Successful treatment of vancomycin-resistant Enterococcus faecium ventriculitis with combined intravenous and intraventricular chloramphenicol in a newborn.

Vancomycin-resistant Enterococcus faecium (VRE) infection is a rare event in paediatric patients and often occurs under immunosuppression or after surgical intervention. We report what we believe to be the first paediatric case of ventriculitis due to VRE (in a 2-month-old infant) to be successfully treated with combined intravenous (i.v.) and intraventricular chloramphenicol after failure of i.v. linezolid and intraventricular gentamicin.

Oral versus nasal route for placing feeding tubes: no effect on hypoxemia and bradycardia in infants with apnea of prematurity.

BACKGROUND: Raised upper airway resistance may be involved in apnea of prematurity (AOP). OBJECTIVES: To determine the effects of an oral versus a nasal gastric tube on episodes of hypoxemia and bradycardia in infants with AOP. METHODS: In a randomized controlled cross-over trial, 32 infants (median gestational age 29 (range 24-31) weeks, postmenstrual age at study 32 (range 30-35) weeks) with the need for tube feeding and symptoms of AOP underwent a 24-hour recording of breathing movements, nasal airflow, heart rate, pulse oximeter saturation and pulse waveforms. A 5-Fr feeding tube was placed orally or nasally for 12 h each, the position selected first was randomly assigned. When the feeding tube was placed nasally, always the smaller nostril was selected. Each infant acted as his/her own control. Recordings were analyzed for the summed rate of bradycardia and desaturation (heart rate <2/3 of baseline, saturation

Bradycardia and desaturation during skin-to-skin care: no relationship to hyperthermia.

OBJECTIVE: We recently found increased temperature and increased bradycardia and desaturation during skin-to-skin care (SSC). We wanted to determine if these effects were related. STUDY DESIGN: Twenty-two infants (median gestational age at birth 28.5 weeks [range 24-31], median age at study 25.5 days [range 10-60 days], median birth weight 1025 g [range 550-1525 g], median weight at study 1320 g [range 900-2460 g]) underwent three 2-hour recordings of breathing movements, nasal airflow, heart rate, and pulse oximeter saturation (SpO 2 ): at thermoneutrality (TN) during incubator care, at TN during SSC, and at elevated temperature (ET) during incubator care. Core temperature was measured via a rectal probe. Recordings were analyzed for the summed rate of bradycardia and desaturation (heart rate <2/3 of baseline; SpO 2

Randomized, controlled trial of oral creatine supplementation (not effective) for apnea of prematurity.

BACKGROUND: Hypoxic ventilatory depression in mice and muscle fatigue in adult humans are improved by creatine supplementation (CS). Because these issues may be operative in apnea of prematurity (AOP), we hypothesized that CS reduces episodes of hypoxemia and bradycardia in infants with AOP. METHODS: Infants were eligible for this double-blind, controlled trial if gestational age was <32 weeks and AOP was severe enough to require treatment with caffeine. If they had > or = 1 desaturation (pulse oximeter saturation [SpO2] < or = 80%) or bradycardia (heart rate < or = two thirds of baseline) per hour in an initial 6-hour recording, they were randomized to a 2-week course of oral CS (200 mg/kg per day) or placebo (P). Infants then underwent 2 additional 6-hour recordings of breathing movements, nasal airflow, heart rate, pulse oximeter saturation (SpO2) and pulse waveforms after 7 and 14 days of treatment. Urinary creatine excretion was measured also. Recordings were analyzed for the frequency of bradycardia and desaturation, the primary outcome parameter, as well as for apnea (> or =10 seconds), baseline heart and respiratory rate, and SpO2. RESULTS: Of 38 infants enrolled, 34 completed the study (17 in each group). Median (range) gestational age at birth was 27 (25-30) vs 27 (25-30) weeks, and at study 29 (26-36) vs 29 (27-33) weeks. Oral CS was well tolerated; no side effects were noted. Urinary creatine excretion was low in the P group (median: 27 mmol/mol of creatinine; range: 18-102) and increased in the CS group (6949 mmol/mol of creatinine; range: 1427-11807). CS, however, had no effect on the combined rate of bradycardia and desaturation (P: 2.7 per hour [range: 0.2-10.3]; CS: 4.1 per hour [range: 0.6-12.1]), nor was there any decrease in apnea rate (P: 1.7 per hour [range: 0-4.5]; CS: 2.2 per hour [range: 0.2-5.1]). CONCLUSION: Despite a significant increase in creatine excretion, suggesting good enteral absorption, CS did not, in the dose and for the duration given in this study, improve symptoms of AOP in these infants.

Inter- and intraobserver agreement for gastroesophageal reflux detection in infants using multiple intraluminal impedance.

The multiple intraluminal impedance (MII) technique is a new method that allows pH-independent gastroesophageal reflux detection via changes in impedance caused by a liquid bolus inside the esophagus. We wanted to know whether this technique yields objective and reproducible results. Twenty 3- to 6-hour recordings of MII from 19 preterm infants (median gestational age at birth 30 weeks, range 24-34 weeks; age at study 26 days, range 13-93 days) were divided into 23-second segments and analyzed for reflux episodes by three investigators; one investigator analyzed the data set twice. Observer agreement was assessed using kappa statistics. Each investigator analyzed 16,627 23-second segments, with a median of 854 (range 486-979) segments per recording. Median kappa values for the 20 recordings were 0.79, 0.83, and 0.83 for the three pairs of investigators and 0.84 for the repeated scoring procedure. MII recordings could be analyzed with a high level of inter- and intraobserver agreement.

Early feeding after necrotizing enterocolitis in preterm infants.

OBJECTIVE: To report our experience with an early initiation of enteral feedings after necrotizing enterocolitis (NEC). STUDY DESIGN: Over a 4-year period, all inborn infants with NEC Bell stage II or greater received enteral feedings, increased by 20 mL/kg/d, once no portal vein gas had been detected on ultrasound for 3 consecutive days (group 1). Infants were compared with a historic comparison group (group 2). RESULTS: Necrotizing enterocolitis rates were 5% (26/523) in the early feeding group and 4% (18/436) in the comparison group. One early feeding infant and two comparison group infants died of NEC, whereas two and one, respectively, had recurrent NEC. Enteral feedings were restarted at a median of 4 days (range, 3-14) versus 10 days (range, 8-22) after onset of NEC. Early feeding was associated with shorter time to reach full enteral feedings (10 days [range, 7-31] vs 19 days [range, 9-76], P<.001), a reduced duration of central venous access (13.5 days [range, 8-24] vs 26.0 days [range, 8-39], P<.01), less catheter-related septicemia (18% vs 29%, P<.01), and a shorter duration of hospital stay (63 days [range, 28-133] vs 69 days [range, 36-150], P<.05). CONCLUSION: Early enteral feeding after NEC was associated with significant benefits and no apparent adverse effects. This study was underpowered, however, to exclude a higher NEC recurrence risk potentially associated with this change in practice.

Detection of small bolus volumes using multiple intraluminal impedance in preterm infants.

BACKGROUND: Multiple intraluminal impedance (MII) is a new technique that allows detection of reflux and swallows via changes in impedance caused by a liquid bolus inside the esophagus. The method is independent of pH. The authors studied the ability of this technique to detect the small bolus volumes potentially occurring in young infants. METHODS: Ten preterm infants (median gestational age at birth, 33 weeks; range, 25-36 weeks; age at study, 9 days; range, 2-39 days) underwent 10 instillations each of 0.1 mL to 0.5 mL saline while MII was recorded via a 2.4-mm nasogastric catheter. MII signals were analyzed for swallows, defined as a decrease in impedance starting within 1 minute. From the liquid instillation in the most proximal channel and extending downward, impedance changes during these induced swallows were compared with those occurring during spontaneous swallows. RESULTS: All 100 liquid instillations resulted in a typical impedance pattern, occurring after a median interval of 4.4 seconds (range, 1.8-8.9 seconds). The decrease in impedance was more pronounced than after spontaneous swallows (30% vs. 24%, P < 0.03) and extended downward more rapidly (12.3 cm/s vs. 5.8 cm/s, P < 0.01). CONCLUSION: Bolus transport of small liquid volumes can be detected via MII.