Factors associated with frenotomy after a multidisciplinary assessment of infants with breastfeeding difficulties.

OBJECTIVE: Frenotomy for ankyloglossia has increased nearly 10-fold over the past few decades despite insufficient evidence that the procedure improves breastfeeding outcomes. There is no universally accepted method for identifying patients who may benefit from the procedure. The objective of this study is to determine if comprehensive feeding evaluations and targeted interventions can identify children who should undergo procedures, and to identify factors associated with lip or tongue frenotomy to treat breastfeeding difficulties. METHODS: This observational quality improvement study followed infant-mother dyads between March 2018 and December 2019 referred to our tertiary care center for breastfeeding difficulties. Speech and language pathologists performed comprehensive feeding evaluations on infants prior to surgical consultation for frenotomy. Infants' oral anatomy and function and their ability to breast and bottle feed were assessed, and techniques for mothers to address feeding difficulties without a procedure were offered prior to surgical consultation. Infants either found success over a short observation period or underwent procedures (lip and/or tongue frenotomy). RESULTS: 153 patients (mean age 47.0 days (stdev 39.0 days, 56.2% male) were referred for surgical division of the lingual frenulum. Following development of a program utilizing pediatric speech language pathologists to perform feeding evaluations prior to surgical consultation, 69.9% of patients subsequently did not undergo surgical procedures. 11 (23.9%) underwent labial frenotomy alone and 30 (65.2%) underwent both labial and lingual frenotomies. Frenotomy was associated with significantly increased worry subscale of the Feeding Swallow Impact Survey (FSIS) and decreased mean Breastfeeding Self Efficacy Scale score (p = 0.0001, p = 0.006, respectively). Tongue appearance was significantly associated with having a procedure, while lip appearance was not. The Bristol Breastfeeding Assessment Tool (BBAT) was lower in children undergoing tongue and/or lip frenotomy (p = 0.0006), while the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) appearance and function scores were lower in children undergoing lingual frenotomy with or without lip frenotomy (p = 0.0008, p = 0.0009, respectively). CONCLUSIONS: The majority of patients referred for ankyloglossia may benefit from nonsurgical intervention strategies based on findings from comprehensive feeding evaluation. Frenotomy is associated with higher maternal feeding-related worry and reduced breastfeeding self-efficacy scores. While tongue appearance is associated with frenotomy, functional assessment is critical for identifying patients who may also benefit from lip frenotomy.

Association of Feeding Evaluation With Frenotomy Rates in Infants With Breastfeeding Difficulties.

IMPORTANCE: Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding. Clear indications for surgical release remain murky, and best practice guidelines have yet to be developed. OBJECTIVE: To determine whether infants referred for frenotomy to treat breastfeeding difficulties should undergo procedures after comprehensive feeding examination, during which the primary cause of feeding issues was identified, and targeted intervention was provided. DESIGN, SETTING, AND PARTICIPANTS: This observational quality improvement study followed mother-infant dyads between March and December of 2018 who were referred to our tertiary care center for difficulty with breastfeeding. All infants underwent a comprehensive feeding evaluation by speech and language pathologists who examined the infants' ability to breastfeed prior to a surgical consultation for initial frenotomy. Data analysis was performed between January 2019 and May 2019. INTERVENTIONS: A multidisciplinary feeding evaluation that examined infants' oral structure and function and their ability to breastfeed and that offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of frenotomy procedures following implementation of a multidisciplinary feeding team evaluation. The secondary outcome was the percentage of infants referred for lingual frenotomy who later had either combined lingual and labial frenotomy or labial frenotomy alone. RESULTS: Included in the study were 115 patients (median age, 34 days [interquartile range, 19-56 days], 68 (59%) were male) referred for surgical division of the lingual frenum. Following the development of a program with feeding examination with a pediatric speech and language pathologist, 72 (62.6%) patients subsequently did not undergo surgical procedures. Although all of the referrals were for lingual frenotomy, 10 (8.7%) underwent labial frenotomy alone and 32 (27.8%) underwent both labial and lingual frenotomy. CONCLUSIONS AND RELEVANCE: The majority of patients referred for ankyloglossia may benefit from alternative intervention strategies following comprehensive feeding evaluation. Close collaboration and formation of multidisciplinary teams are imperative for treating these children.

Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field.

OBJECTIVE: Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined. METHOD: In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder. RESULTS: By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment. CONCLUSIONS: This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review.

INTRODUCTION: Radiation exposure is recognized as having long term consequences, resulting in increased risks over the lifetime. Children, in particular, have a projected lifetime risk of cancer, which should be reduced if within our capacity. The objective of this study is to quantify the amount of ionizing radiation in care for children being treated for aspiration secondary to a type 1 laryngeal cleft. With this baseline data, strategies can be developed to create best practice pathways to maintain quality of care while minimizing radiation exposure. METHODS: Retrospective review of 78 children seen in a tertiary pediatric aerodigestive center over a 5 year period from 2008 to 2013 for management of a type 1 laryngeal cleft. The number of videofluoroscopic swallow studies (VFSS) per child was quantified, as was the mean effective dose of radiation exposure. The 78 children reviewed were of mean age 19.9 mo (range 4 mo-12 years). All children were evaluated at the aerodigestive center with clinical symptomatology and subsequent diagnosis of a type 1 laryngeal cleft. Aspiration was assessed via VFSS and exposure data collected. Imaging exams where dose parameters were not available were excluded. RESULTS: The mean number of VFSS each child received during the total course of treatment was 3.24 studies (range 1-10). The average effective radiation dose per pediatric VFSS was 0.16 mSv (range: 0.03 mSv-0.59 mSv) per study. Clinical significance was determined by comparison to a pediatric CXR. At our facility a CXR yields an effective radiation dose of 0.017 mSv. Therefore, a patient receives an equivalent total of 30.6 CXR over the course of management. CONCLUSIONS: Radiation exposure has known detrimental effects particularly in pediatric patients. The total ionizing radiation from VFSS exams over the course of management of aspiration has heretofore not been reported in peer reviewed literature. With this study's data in mind, future developments are indicated to create innovative clinical pathways and limit radiation exposure.

Modified Best-Practice Algorithm to Reduce the Number of Postoperative Videofluoroscopic Swallow Studies in Patients With Type 1 Laryngeal Cleft Repair.

IMPORTANCE: There is no consensus as to the timing of videofluoroscopic swallow studies (VFSSs) in determining resolving aspiration after laryngeal cleft repair. There is a growing literature on the effect of radiation exposure in children. OBJECTIVE: To modify a previously published best-practice algorithm based on a literature review and our clinical experience to maintain the quality of care provided after successful type 1 laryngeal cleft repair, while reducing the total number of postoperative VFSSs by 10% or greater. DESIGN, SETTING, AND PARTICIPANTS: The previously published algorithm was modified by a multidisciplinary group at a tertiary care academic medical center (Massachusetts Eye and Ear) and was prospectively applied to 31 children who underwent type 1 laryngeal cleft repair from January 1, 2013, to February 28, 2015. MAIN OUTCOMES AND MEASURES: The number of VFSSs obtained in the first 7 months after surgery was compared with the peer-reviewed literature and with a retrospective cohort of 27 patients who underwent type 1 laryngeal cleft repair from January 1, 2008, to December 31, 2012. RESULTS: The study cohort comprised 31 patients. Their ages ranged from 10 to 48 months, with a mean (SD) age of 23.94 (9.93) months, and 19% (6 of 31) were female. The mean (SD) number of postoperative VFSSs per patient before and after implementation of the algorithm was 1.22 (0.42) and 1.03 (0.55), respectively. The use of the algorithm reduced the number of VFSSs by 0.19 (95% CI, -0.07 to 0.45). This reduction in radiation exposure is equivalent to 1.47 chest radiographs per child per course of care. Surgical success was 87% (27 of 31) compared with our group's previously published success rate of 78% (21 of 27) (absolute difference, 0.09; 95% CI, -0.17 to 0.34). CONCLUSIONS AND RELEVANCE: This modified algorithm to help guide decisions on when and how often to obtain VFSSs after type 1 laryngeal cleft repair can limit patients' radiation exposure, while maintaining high surgical success rates.