Growth trajectories and need for oral feeding support among infants with neonatal encephalopathy treated with therapeutic hypothermia.

OBJECTIVE: Identify feeding supports required among infants with neonatal encephalopathy and determine growth trajectories to 3 years. STUDY DESIGN: Single-center retrospective cohort study of 120 infants undergoing therapeutic hypothermia. Logistic regression and stratified analyses identified whether clinical factors, EEG-determined encephalopathy severity, and MRI-based brain injury predict feeding supports (nasogastric tube, oral feeding compensations) and growth. RESULTS: 50.8% of infants required feeding supports in the hospital, decreasing to 14% at discharge. Moderate-to-severe encephalopathy and basal ganglia injury predicted feeding support needs. Yet, 35% of mildly encephalopathic infants required gavage tubes. Growth trajectories approximated expected growth of healthy infants. CONCLUSION: Infants with neonatal encephalopathy-even if mild-frequently experience feeding difficulties during initial hospitalization. With support, most achieve full oral feeds by discharge and adequate early childhood growth. Clinical factors may help identify infants requiring feeding support, but do not detect all at-risk infants, supporting routine screening of this high-risk population.

Patient-Reported Outcome Measures That Describe the Feeding Skills Domain for Pediatric Feeding Disorder: A Clinimetric Review.

OBJECTIVES: Pediatric feeding disorder (PFD) is defined as "impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction." Patient-reported outcome measures (PROMs) are tools that complement clinical assessment, but many have limited clinimetric data. This review aimed to assess PROMs that reported on the feeding skills domain for PFD in children. METHODS: A search strategy across 4 databases was conducted (July 2022). PROMs were included in the review if they described elements of the feeding skills domain of PFD, had criterion/norm-referenced data and/or a standardized assessment procedure, description, or scoring system available, and were applicable to children ≥6 months. PROMs were mapped to the PFD diagnostic domains and aspects of the International Classification of Function (ICF) model. Quality assessment was completed using the COnsensus-based Standards to the selection of health Measurement Instruments methodology. RESULTS: Overall, 14 PROMs across 22 papers met inclusion criteria. There was variable methodological quality across the tools, with those more recently developed often receiving better scores, particularly where a more rigorous process for tool development and content validity was reported. Most tools captured ICF aspects of impairment (n = 11, eg, biting/chewing) or activity (n = 13, eg, eating a meal), rather than social participation (n = 3, eg, going to a restaurant). CONCLUSIONS: Using PROMs with strong content validity, and including some measure of social participation, is recommended as part of an assessment battery for PFD. Consideration of the caregiver/child perspective is an essential component of family-centered care.

A Multidisciplinary Approach to Pediatric Feeding Disorders: Roles of the Speech-Language Pathologist and Behavioral Psychologist.

Purpose Pediatric feeding disorders (PFDs) present as a complex clinical challenge because of the heterogeneous underlying etiologies and their impact on health, safety, growth, and psychosocial development. A multidisciplinary team approach is essential for accurate diagnosis and prompt interventions to lessen the burdens associated with PFDs. The role of the speech-language pathologist (SLP) as a member of the multidisciplinary team will be highlighted. Method This clinical focus article reviews the definition of PFDs and pertinent literature on factors that contribute to the development of PFDs, the accurate diagnosis, and current interventions for infants and children. As part of the multidisciplinary team, the SLP has an integral role in determining whether a child cannot or will not eat and working with the team to identify and carryout appropriate interventions. Collaboration between SLPs and psychologists/behavioral specialists in conjunction with the parents/caregivers as part of the multidisciplinary team is essential to the advancement of therapeutic goals. Conclusions Due to their complex nature, the successful management of PFDs is only possible with the care and expertise of a multidisciplinary team, which includes parents/caregivers. SLPs are important members of these multidisciplinary teams and provide valuable input for the accurate identification and effective remediation of PFDs.

Assessment Across the Life Span: The Clinical Swallow Evaluation.

Purpose This clinical focus article considers the roles of the clinical swallow examination (CSE) as a clinically meaningful assessment method used in both adult and pediatric populations. Method This clinical focus article explores the utility of the CSE across the life span. Specifically, components, reliability, standardized assessments, and limitations of the CSE within the adult and pediatric populations are highlighted. Conclusions The CSE remains a crucial assessment tool for the speech-language pathologist. The experienced clinician can make important judgments regarding patient safety and function. If the CSE is conducted mindfully and methodically, findings can help chart the course of care for individuals needing additional assessment and possibly intervention.

Frontline Interventions: Considerations for Modifying Fluids and Foods for Management of Feeding and Swallowing Disorders Across the Life Span.

Purpose Individuals with dysphagia across the age continuum may require dietary modifications of fluids and foods for safe and adequate oral intake. Considerations of this frontline intervention are presented in this clinical forum dedicated to the discussion of dysphagia. Method This clinical focus article reviews the technical challenges of providing modified fluids and foods across the life span as well as the literature specific to its origins, efficacy, challenges and solutions to standardization, and the methods for ensuring quality service delivery. Conclusion Dietary modification is an often-used method of dysphagia management that presents unique challenges to the clinician for successful application. Speech-language pathologists in clinical practice across all settings must remain dedicated to evidence-based practice as they navigate service delivery of this strategy to individuals with dysphagia across the life span.

The Growth and Development Unit. A proposed approach for enhancing infant neurodevelopment and family-centered care in the Neonatal Intensive Care Unit.

There is growing evidence that the neurosensory and social environment of the Neonatal Intensive Care Unit (NICU) has lasting effects on the neurodevelopment of the high-risk hospitalized infant. Thus, many NICUs are transitioning from traditional, medical healing approaches to enhanced family-centered developmental care approaches with the aim of improving infant outcomes and parental mental health. This commentary describes a transdisciplinary neurodevelopmental program based on key principles and recommendations from current and evolving evidence-based care practice guidelines. This clinical initiative, known as the Growth and Development Unit (GDU), was developed within the context of a 66-bed level III NICU. The process of program inception, key elements of program development, as well as program strengths and challenges are discussed.

Know the Flow: Milk Flow Rates From Bottle Nipples Used in the Hospital and After Discharge.

BACKGROUND: Milk flow rate may play an important role in an infant's ability to safely and efficiently coordinate sucking, swallowing, and breathing during feeding. PURPOSE: To test milk flow rates from bottle nipples used in the hospital and after discharge. METHODS: Bottle nipples used in hospitals (10 unique types) and available nationwide at major retailers (15 unique types) were identified. For each of the 25 nipple types, 15 nipples of that type were tested by measuring the amount of infant formula extracted in 1 minute by a breast pump. Mean milk flow rate (mL/min) and coefficient of variation (CV) were calculated for each nipple type. Comparisons between nipple types were made within brand and within category (eg, Slow, Standard). A cluster analysis was conducted to identify nipples of comparable flow. RESULTS: A total of 375 individual nipples were tested. Milk flow rates varied widely, from 0.86 to 37.61 mL/min. There was also a wide range of CVs, from 0.03 to 0.35. Packing information did not accurately reflect the flow rates of bottle nipples. The cluster analysis revealed 5 clusters of nipples, with flow rates from Extra Slow to Very Fast. IMPLICATIONS FOR PRACTICE: These data can be used to guide decisions regarding nipples to use for feeding infants with medical complexity in the hospital and after discharge. IMPLICATIONS FOR RESEARCH: Research on infant feeding should consider the flow rate and variability of nipples used, as these factors may impact findings.

Aspiration in children with unilateral vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: To describe the prevalence of aspiration in children with unilateral vocal fold paralysis who underwent objective assessment of swallow function. STUDY DESIGN: Retrospective chart review. METHODS: A study of patients presenting to our institution with unilateral vocal fold paralysis in 2015 was conducted. All patients were diagnosed using flexible laryngoscopy. Patients were included if they underwent at least one modified barium swallow (MBS) study for evaluation of their swallowing function due to recurrent respiratory issues and/or feeding difficulty. RESULTS: Twenty-eight patients diagnosed with unilateral vocal fold paralysis underwent an MBS study at our institution in 2015. Median age at the time of MBS study was 1.7 years (interquartile range: 0.4-4.3). Twenty-six patients (92.9%) had dysphagia. Sixteen patients were found to aspirate on MBS study. All patients who aspirated did so without overt signs (silent aspiration). Eighteen patients had congenital heart disease (64.3%) and nine had a history of prematurity (32.1%). Eight patients (28.6%) presented with developmental delays. CONCLUSIONS: Patients who present with unilateral vocal fold paralysis and recurrent respiratory and/or feeding issues may be affected by prominent issues such as swallowing dysfunction and silent aspiration. Clinicians should be aware of this risk and evaluate patients for any signs of feeding or swallowing difficulties. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:569-573, 2019.

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework.

Pediatric feeding disorders (PFDs) lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization International Classification of Functioning, Disability, and Health, a unifying diagnostic term is proposed: "Pediatric Feeding Disorder" (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Evaluation of Aspiration in Infants With Laryngomalacia and Recurrent Respiratory and Feeding Difficulties.

Importance: Laryngomalacia is the most common laryngeal anomaly and is commonly associated with stridor in children, but the recurrent respiratory and/or feeding difficulties associated with this condition may pose a threat to the well-being of the affected child. Objective: To describe the prevalence of aspiration in pediatric patients with laryngomalacia who present with recurrent respiratory issues and/or feeding difficulty. Design, Setting, and Participants: This retrospective review of medical records involved 142 pediatric patients. These patients received a laryngomalacia diagnosis, presented with recurrent respiratory and/or feeding difficulties, and underwent a modified barium swallow (MBS) study at a tertiary referral children's hospital from January 1, 2015, to December 31, 2015. Each patient was assessed for aspiration and swallowing discoordination. Data collection and analysis were performed from December 1, 2016, to September 30, 2017. Main Outcomes and Measures: Demographic data, presenting symptoms, medical comorbidities, and feeding and dysphagia details were collected and analyzed. Speech-language pathologists reviewed all MBS reports to identify the presence and type of aspiration (ie, silent vs nonsilent) with different textures and consistencies of food and liquid. Results: A total of 395 patients were diagnosed with laryngomalacia in 2015. One hundred forty-two of these patients (35.9%) presented with recurrent respiratory issues and/or feeding difficulties and were referred for MBS study for further evaluation. Ninety-two (64.8%) were male, with a median (interquartile range) age at the time of MBS study of 7.9 (3.2-20.5) months. Among these patients, 128 (90.1%) had swallowing dysfunction documented during the MBS study. Aspiration was identified in 60 patients (42.3%), and silent aspiration was documented in 59 (98.3%) of these 60 patients. Epilepsy or seizures (risk difference [RD], 11%; 95% CI, 5%-17%), laryngeal cleft (RD, 8%; 95% CI, 3%-13%), and premature birth (RD, 15%; 95% CI, 5%-25%) were statistically significantly associated with abnormal MBS findings. Conclusions and Relevance: Swallowing dysfunction and aspiration were commonly found in pediatric patients with laryngomalacia and recurrent feeding and/or respiratory issues; these children should undergo an MBS study for dysphagia and silent aspiration.

Intervention for Feeding Difficulties in Children With a Complex Medical History: A Randomized Clinical Trial.

OBJECTIVE: This study aimed to compare outcomes of different multidisciplinary feeding therapy approaches in children with feeding difficulties. METHODS: Children aged 2 to 6 years with feeding difficulties and a medically complex history (MC) were recruited. Children with feeding difficulties and a nonmedically complex history (NMC) were included as a comparison group. Participants attended a clinical assessment, and eligible participants were randomized to receive targeted feeding intervention incorporating either operant conditioning or systematic desensitization. Parents could elect to receive intervention in an intensive (10 sessions in a week) or weekly (10 sessions during 10 weeks) format. Both groups received immersive parent training. A review was completed 3 months post-intervention. RESULTS: In total, 98 participants were eligible to participate (MC, n = 43; NMC, n = 55). Data from 20 children from the MC group (47%) and 41 children from the NMC group (75%) were included in the final analysis. Clinically significant improvements were observed following both arms of therapy, consistent with previous research. Parents of children in the MC arm were significantly more likely to elect for intensive intervention than weekly (MC = 12/20, 60%; 12/41, 29%; P = 0.02). CONCLUSIONS: Both therapy protocols were considered clinically effective. The difference in attrition rates between the etiological groups suggests primary differences in how service delivery should be managed. Progress for the medically complex child may be slower while medical issues are stabilized, or while the focus for parents shifts to other developmental areas. In planning services for a medically complex group, therefore, it is essential that consideration be given to medical and family needs.

Silent aspiration: Who is at risk?

OBJECTIVE: To determine the prevalence of silent aspiration in pediatric patients and identify which diagnoses may be associated with this finding. METHODS: An institutional review board-approved retrospective review was conducted for all patients under the age of 18 who underwent modified barium swallow (MBS) studies at a tertiary children's hospital in 2015. Speech-language pathologists reviewed MBS studies to identify aspiration/silent aspiration on each fluid consistency tested. Charts were reviewed to collect demographic information and the otolaryngologic, neurologic, genetic, and syndromic diagnoses of each patient. RESULTS: Among 1,286 patients who underwent MBS, 440 (34%) demonstrated aspiration. Within the aspiration group, 393 (89%) specifically demonstrated silent aspiration. Thin fluids were silently aspirated in 81% of these patients. Of children aged <6 months, 41% were found to aspirate and, of those, 95% silently aspirated. Median age at which patients demonstrated silent aspiration was 1.1 years. Silent aspiration was documented in 41% of patients with laryngeal cleft, 41% of patients with laryngomalacia, and 54% of patients with unilateral vocal fold paralysis. Laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis, developmental delay, epilepsy/seizures, syndrome, and congenital heart disease were all associated with silent aspiration. CONCLUSION: Silent aspiration may be associated with a number of underlying conditions and is more common than previously described. Caregivers and clinicians should be aware that the absence of cough does not eliminate the possibility of aspiration. Modified barium swallow studies can reveal silent aspiration, which is difficult to detect on clinical feeding evaluation. Modified barium swallow findings can guide feeding therapy and the overall management of aspiration. LEVEL OF EVIDENCE: 4. Laryngoscope, 1952-1957, 2018.

Dysphagia and feeding difficulties post-pediatric ingestion injury: Perspectives of the primary caregiver.

PURPOSE: To explore the experiences of children with dysphagia and/or feeding difficulties post-chemical or button battery ingestion injury from the perspective of the primary caregiver. METHOD: Five primary caregivers of children with a history of dysphagia and/or feeding difficulties post-ingestion injury (4 chemical, 1 button battery) completed the Children's Picky Eating Questionnaire (CPEQ), and participated in a semi-structured interview. Interviews explored experiences of caring for a child with dysphagia and/or feeding difficulties, impressions of services and supports, and additional impacts to the child and family. Content analysis was used to identify key themes. RESULT: Primary caregiver report and CPEQ results confirmed all children had some degree of persisting dysphagia and/or feeding difficulties at time of interview (mean 4.13 years' post-injury). Interviews identified five key themes: 1) The initial trauma of the injury, 2) The experience of associated and ongoing medical issues, 3) Managing altered oral intake, 4) Experiences of services and support, and 5) Impacts on the child, primary caregiver, and wider family unit. All caregivers reported significant challenges and concerns, and potential areas of service improvement were highlighted. CONCLUSION: The current data highlights specific issues experienced by primary caregivers, and poses areas for improving primary caregiver and family supports. Family-centered models of care are needed to support the whole family unit in caring for a child with dysphagia and/or feeding difficulties post-ingestion injury.

Speech-language Pathology in Acute Pediatric Chemical or Button Battery Ingestion Injury.

OBJECTIVES: Dysphagia is a common consequence of pediatric ingestion injury, yet there is a lack of data relating to recommencement of oral (per os; PO) intake or use of feeding therapy. We describe patterns of early PO intake, and referral to speech-language pathology (SLP) for feeding therapy, during the acute admission of a pediatric cohort postchemical or button battery ingestion injury. METHODS: Retrospective chart review of pediatric ingestion injuries admitted to a quaternary hospital from 2008 to 2013. Clinical parameters, PO intake progression, and nature of referrals for feeding therapy during the acute admission were examined. RESULTS: Fifty-one children (26 boys; mean age: 31.5, range 4-170 months) were identified (75% with grade II or III mucosal injuries), of whom 31 (60%) had impaired PO intake. Of these, 5 recommenced premorbid PO intake during admission. At discharge, 16 remained on modified PO intake, and 10 remained nil PO. Eight (26%) were referred to SLP for feeding therapy during acute admission, or within 4 months of discharge. Feeding therapy-referred children were more likely to have pediatric intensive care admission (PICU) (100% vs 26%), and longer hospital admission (36.1 vs 9.3 days for those not referred). CONCLUSIONS: More than half of the cohort had impaired PO intake, and one-third were nil PO at time of discharge. Referrals for feeding therapy were limited. Our findings may provide some guidance for clinicians, patients, and their families regarding possible PO intake recovery patterns, as well as provide background for evaluating the potential for feeding therapy and SLP involvement within this population.

Dysphagia progression and feeding skills following pediatric alkali ingestion injury: two case reports.

PURPOSE: There is limited information regarding the nature of dysphagia and feeding difficulties following alkali ingestion injury to inform multidisciplinary intervention. The aim was to describe the history and nature of chronic dysphagia and feeding difficulties in two children following severe alkali ingestion injury. METHODS: Medical records, primary caregiver report, and clinical assessment were used to compile detailed case histories and assess current dysphagia and feeding skills. RESULTS: Both cases demonstrated heterogeneous oral motor and feeding outcomes, including delayed oral motor skills, restricted dietary variety, and difficult mealtime behaviors that contributed to protracted recovery of age-appropriate PO intake. Both children required ongoing diet and/or fluid modification and supplemental non-PO feeding via gastrostomy at the time of review, that is, 2-year post-injury. CONCLUSIONS: Recovery from dysphagia post-alkali ingestion is protracted and complex. Dysphagia, delayed oral motor skills, and difficult mealtime behaviors may persist secondary to ingestion injury and its associated complications. These cases highlight the importance of considering early referral for feeding assessment and intervention to assist children and families with recovery. Progression through safe and effective oral (per os, PO) intake is needed, as well as provision of support for primary caregivers. Implications for Rehabilitation Pediatric chemical ingestion injury can cause long-term dysphagia and long-term feeding difficulties Initial injury severity does not reliably correlate with eventuating level of aerodigestive impairment. Clinical and instrumental assessment is required to monitor swallow function to enable commencement of targeted rehabilitation when appropriate. Early involvement of a feeding therapist is recommended to minimize the long-term effects on oral motor skill development, progression to age-appropriate diet, and provision of family-centered care.

Effect of Time and Temperature on Thickened Infant Formula.

BACKGROUND: Unlike adult populations, who primarily depend on liquids for hydration alone, infants rely on liquids to provide them with hydration and nutrition. Speech-language pathologists working within pediatric medical settings often identify dysphagia in patients and subsequently recommend thickened liquids to reduce aspiration risk. Caregivers frequently report difficulty attempting to prepare infant formula to the prescribed thickness. MATERIALS AND METHODS: This study was designed to determine (1) the relationship between consistencies in modified barium swallow studies and thickened infant formulas and (2) the effects of time and temperature on the resulting thickness of infant formula. Prepackaged barium consistencies and 1 standard infant formula that was thickened with rice cereal and with 2 commercially available thickening agents were studied. Thickness was determined via a line spread test after various time and temperature conditions were met. RESULTS: There were significant differences between the thickened formula and barium test consistencies. Formula thickened with rice cereal separated over time into thin liquid and solid residue. Formula thickened with a starch-based thickening agent was thicker than the desired consistency immediately after mixing, and it continued to thicken over time. The data from this project suggest that nectar-thick and honey-thick infant formulas undergo significant changes in flow rates within 30 minutes of preparation or if refrigerated and then reheated after 3 hours. CONCLUSIONS: Additional empirical evidence is warranted to determine the most reliable methods and safest products for thickening infant formula when necessary for effective dysphagia management.

Swallowing dysfunction among patients with laryngeal cleft: More than just aspiration?

BACKGROUND: The Modified Barium Swallow (MBS) is the most widely utilized instrumental assessment of swallowing disorders in children; however, the exact role in the evaluation of laryngeal clefts remains controversial. METHODS: This study was an IRB-approved retrospective review on patients diagnosed with laryngeal cleft from 2002 to 2014. The objective was to describe the range of swallowing dysfunction that may be present in patients with laryngeal clefts both pre- and post-intervention (conservative management versus surgery). A speech-language pathologist reviewed MBS studies and medical records to determine Penetration-Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS) scores. RESULTS: One hundred seventy-five patients who underwent laryngeal cleft repair during the study period (type 1, n=111; type 2, n=54; type 3, n=9; type 4, n=1) were included. Fifty patients who were managed conservatively (type 1) were also included. Swallowing impairment was demonstrated in all phases of swallowing for all cleft types. Oral phase impairment ranged from 27-67% pre-intervention to 19-75% post-intervention, triggering impairment from 24-42% pre-intervention to 24-75% post-intervention, and pharyngeal phase impairment (laryngeal penetration and aspiration) from 57-100% pre-intervention to 40-100% post-intervention. Laryngeal penetration and aspiration on thin and thick liquids, silent aspiration, PAS, and FOIS scores are reported. Significant improvements in swallowing function (p<0.05) were documented in all of the conservatively and surgically managed sub-groups. CONCLUSIONS: The MBS study is a useful tool for evaluating swallowing function in patients with laryngeal cleft and provides information beyond the lack or presence of aspiration. Understanding impairments in all phases of swallowing may be beneficial for perioperative management.

Clinical Characteristics of 2 Groups of Children With Feeding Difficulties.

OBJECTIVES: The primary aim of this study was to describe and compare the clinical characteristics of 2 groups of children presenting to a feeding clinic: children with autism spectrum disorder (ASD) and children with a nonmedically complex history (NMC). A secondary aim was to compare participants according to the degree of oral motor impairment, presence of oral hypersensitivity, and clinically significant parent stress. METHODS: Children with feeding difficulties ages between 2 and 6 years were recruited. Prospective data were collected on dietary intake, general development, mealtime behaviors, oral motor skills, oral sensory processing, and parental stress via parent questionnaire and clinical assessment. RESULTS: In total, 68 children (ASD = 33 and NMC  = 35) participated in the study. Both groups presented with a large number of difficult mealtime behaviors. Although stress was elevated in both groups, parents of children in the ASD group reported significantly higher stress levels than those with children in the NMC group (mean difference 27.3 on a percentile scale, 95% confidence interval [CI] 15.5-39.2, P < 0.01). Across both groups, the majority of children presented with mild-to-moderate oral motor impairments (ASD = 28, 85%; NMC = 28, 80%). Children with heightened oral sensory sensitivity consumed significantly fewer unprocessed fruits and vegetables (mean difference 3.3 foods, 95% CI 1.3-5.3, P < 0.01), and their parents reported a significantly greater frequency of difficult mealtime behaviors (mean difference 5.8 behaviors, 95% CI 3.4-8.1, P < 0.01). CONCLUSIONS: Features of feeding difficulty presented similarly across the ASD and NMC groups in this study. Oral motor impairment, oral sensory sensitivity, and parental stress should not be overlooked in the management of children with feeding difficulties, regardless of etiology.