Intensive Multidisciplinary Feeding Day Programs in the United States: A Report Regarding the Treatment Landscape.

Intensive multidisciplinary intervention is increasingly recognized as the standard of care for children with complex feeding problems. Much, however, remains unknown about this treatment model. This current qualitative, prospective study sought to identify intensive multidisciplinary day hospital programs operating in the US, describe the treatment approach, and summarize current capacity.

Quantitative impact of frenotomy on breastfeeding: a systematic review and meta-analysis.

BACKGROUND: Symptoms related to infant ankyloglossia/tongue-tie may deter mothers from breastfeeding, yet frenotomy is controversial. METHODS: Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar from 1961-2023. Controlled trials and cohort studies with validated measures of surgical efficacy for breastfeeding outcomes were eligible. Meta-analyses synthesized data with inverse-variance weighting to determine standardized mean differences (SMD) between pre-/postoperative scores. RESULTS: Twenty-one of 1568 screened studies were included. Breastfeeding self-efficacy improved significantly post-frenotomy: medium effect after 5-10 days (SMD 0.60 [95% CI: 0.48, 0.71; P < 0.001]), large effect after 1 month (SMD 0.91 [CI: 0.79, 1.04; P < 0.001]). Nipple pain decreased significantly post-frenotomy: large effect after 5-15 days (SMD -1.10 [CI: -1.49, -0.70; P < 0.001]) and 1 month (SMD -1.23 [CI: -1.79, -0.67; P = 0.002]). Frenotomy had a medium effect on infant gastroesophageal reflux severity at 1-week follow-up (SMD -0.63 [CI: -0.95, -0.31; P = 0.008]), with continued improvement at 1 month (SMD -0.41 [CI: -0.78, -0.05; P = 0.04]). From LATCH scores, breastfeeding quality improved after 5-7 days by a large SMD of 1.28 (CI: 0.56, 2.00; P = 0.01). CONCLUSIONS: Providers should offer frenotomy to improve outcomes in dyads with ankyloglossia-associated breastfeeding difficulties. PROTOCOL REGISTRATION: PROSPERO identifier CRD42022303838 . IMPACT: This systematic review and meta-analysis showed that breastfeeding self-efficacy, maternal pain, infant latch, and infant gastroesophageal reflux significantly improve after frenotomy in mother-infant dyads with breastfeeding difficulties and ankyloglossia. Providers should offer frenotomy to improve breastfeeding outcomes in symptomatic mother-infant dyads who face challenges associated with ankyloglossia.

Feeding after congenital heart surgery: a mixed-methods study of the caregiver experience.

OBJECTIVES: Feeding difficulties after congenital heart surgery are a common concern for caregivers of children with CHD. Insight into the intricacies of their experience is lacking. With a better understanding, healthcare providers can continue to optimize the approach and support mechanisms for these families. This study will explore the psychosocial impacts on caregivers, define barriers to care, and identify areas to improve their care. STUDY DESIGN: This mixed-methods study combined semi-structured interviews with surveys. Purposive sampling targeted caregivers of a child who underwent heart surgery and was discharged with alternative enteral feeding access. A hybrid inductive-deductive methodology was used to analyse interview transcripts. Survey scores were compared to interview content for concordance. RESULTS: Fifteen interviews were conducted with socio-demographically diverse caregivers. Feeding difficulties were often identified as their greatest challenge, with the laborious feeding schedule, sleep deprivation, and tube management being common contributors. Most caregivers described feeling overwhelmed and worried. Time-intensive feeding schedules and lack of appropriate childcare options precluded caregivers' ability to work. Barriers to care included imperfect feeding education, proximity of specialist clinics, and issues with medical supply companies. Caregiver proposals for improved care addressed easing the transition home, improving emotional support mechanisms, and intensifying feeding therapy for expedited tube removal. CONCLUSION: This study describes the psychosocial toll on the caregiver, typical barriers to care, and ideas for improved provision of care. These themes and ideas can be used to advance the family-centered approach to feeding difficulties after heart surgery.

Assessing the US treatment landscape for paediatric feeding disorder: A survey of multidisciplinary providers.

BACKGROUND: Paediatric feeding disorder (PFD) is a common childhood condition, estimated to impact one in 37 American children under the age of five. Such high prevalence occurs against a backdrop of limited understanding of the community treatment landscape in the United States. METHOD: To better understand the community treatment landscape for PFD in the United States and identify provider and treatment delivery characteristics, we collected primary data through a web-based survey targeting providers from all four PFD domains (i.e., medical, nutritional, feeding skill, and/or psychosocial) between January 2022 and March 2022. The 71-item cross sectional survey focussed on patient, provider and treatment characteristics. We distributed the survey using an electronic survey tool through Feeding Matters listserv followed by solicitation to discipline specific listservs and professional networks. The analytic approach involved descriptive statistics compared across settings and provider types, focussing on respondents within the United States. RESULTS: Eighty-three percent of respondents reported practicing in the United States. Most of the US sample (74.3%) involved providers from the feeding skill domain (speech-language pathologist - SLP, occupational therapist - OT) who reported delivering care through early intervention or outpatient settings using responsive and sensory based approaches. These approaches lack rigorous empirical evaluation. CONCLUSIONS: Survey results suggest a need to support community providers in engagement with research activity to promote a better understanding of treatment approaches and outcomes associated with a large cohort of providers delivering care (i.e. SLPs, OTs) to patients with PFD.

Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery.

OBJECTIVE: To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery. STUDY DESIGN: A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery. RESULTS: A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without. CONCLUSIONS: Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.

Severity and prevalence of ankyloglossia-associated breastfeeding symptoms: A systematic review and meta-analysis.

AIM: To evaluate breastfeeding symptoms associated with ankyloglossia/tongue-tie. METHODS: Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar. Eligible studies reported baseline breastfeeding symptoms/severity from tongue-tied infants. Two reviewers independently screened studies, extracted data, and assessed quality. Low-quality studies were excluded. Main outcomes were weighted mean severity scores for dyads with ankyloglossia relative to reference values for successful breastfeeding. Meta-analyses used inverse-variance-weighted random-effects models. RESULTS: Of 1328 screened studies, 39 were included (5730 infants with ankyloglossia). The mean LATCH score for patients with untreated ankyloglossia, 7.1 (95% CI: 6.7-7.4), was significantly below the good-breastfeeding threshold. The mean Infant Breastfeeding Assessment Tool score, 10.0 (8.2-11.7), was not significantly below the good-breastfeeding threshold. The mean Infant-Gastroesophageal Reflux Questionnaire-Revised score, 18.2 (10.5-26.0), was consistent with gastroesophageal reflux disease. The mean Breastfeeding Self-Efficacy Scale-Short Form score, 43.7 (39.3-48.1), indicated significant risk of cessation of exclusive breastfeeding within 1-3 months. Mean nipple pain was 4.9 (4.1-5.7) on a 0-10 scale, greater than typical scores for breastfeeding mothers without nipple damage. Total prevalence of breastfeeding difficulties was 49.3% (95% CI: 47.3-51.4%). Early, undesired weaning occurred in 20.3% (18.5-22.2%) of cases before intervention. CONCLUSION: Ankyloglossia is adversely associated with breastfeeding success and maternal well-being.

The prevalence of Chiari malformation among children with persistent dysphagia.

BACKGROUND: Brain imaging has been utilized as a diagnostic tool in the workup of persistent pediatric dysphagia, yet the indications for imaging and the prevalence of Chiari malformation (CM) have not been established. OBJECTIVE: to evaluate the prevalence of CM anomalies in children who underwent brain magnetic resonance imaging (MRI) for pharyngeal dysphagia and to review the clinical findings in the CM group compared to the non-CM group. METHODS: A retrospective cohort study of children who underwent MRI as part of the workup for the diagnosis of dysphagia in a tertiary care children's hospital between 2010 and 2021. RESULTS: 150 patients were included. The mean age at diagnosis of dysphagia was 1 ± 3.4 years, and the mean age at MRI was 3.5 ± 4.2 years. Common comorbidities in our cohort included prematurity (n = 70, 46.7 %), gastroesophageal reflux (n = 65, 43.3 %), neuromuscular/seizure disorder (n = 53,35.3 %), and underlying syndrome (n = 16, 10.7 %). Abnormal brain findings were seen in 32 (21.3 %) patients, of whom 5 (3.3 %) were diagnosed with CM-I and 4 (2.7 %) patients with tonsillar ectopia. Clinical characteristics and dysphagia severity were similar between patients with CM-I/tonsillar ectopia and patients without tonsillar herniation. CONCLUSIONS: Brain MRI should be pursued as part of the work-up for persistent dysphagia in pediatric patients given the relatively higher prevalence of CM-I. Multi-institutional studies are required to establish the criteria and timing of brain imaging in patients with dysphagia.

Pediatric Medullary Stroke, Severe Dysphagia, and Multimodal Intervention.

Lateral medullary syndrome/Wallenberg syndrome is a stroke in the lateral medulla with symptoms often including dysphagia and dysphonia. In adults, this stroke is the most common brainstem stroke, but it is rare in the pediatric population. Insults to the medulla can involve the "swallowing centers," the nucleus ambiguus and nucleus tractus solitarius, and the cranial nerves involved in swallowing, namely IX (glossopharyngeal) and X (vagus). These individuals can develop severe dysphagia with an inability to trigger a swallow due to pharyngeal weakness and impaired mechanical opening of the upper esophageal sphincter (UES) which can result in aspiration. We present a 7-year-old male with 22q11.2 deletion syndrome (velocardiofacial syndrome) and velopharyngeal insufficiency who underwent pharyngeal flap surgery at an outside hospital whose post-operative course was complicated by adenovirus, viral myocarditis, and dorsal medullary stroke. He required a tracheostomy and gastrostomy tube. He was discharged from that hospital and readmitted to our hospital 4 months later for increased oxygen requirement, requiring a 5 month admission in the intensive care units. His initial VFSS revealed absent UES opening with the entire bolus remaining in the pyriform sinuses resulting in aspiration. His workup over the course of his admission included multiple videofluoroscopic swallow studies (VFSS), flexible endoscopic evaluation of swallowing (FEES), and pharyngeal and esophageal manometry. Intervention included intensive speech therapy, cricopharyngeal Botox® injection, and cricopharyngeal myotomy. Nineteen months after his stroke, he transitioned to oral intake of solids and liquids with adequate movement of the bolus through the pharynx and UES and no aspiration on his VFSS.

The utility of preoperative echocardiography in pediatric obstructive sleep apnea.

PURPOSE: The purpose of this study was to determine the associations between cardiac function and postoperative adverse events in pediatric patients with obstructive sleep apnea (OSA). METHODS: Patients between birth and 18 years of age diagnosed with OSA between January 1, 2015, and December 31, 2018, who underwent echocardiographic evaluation within 6 months of surgery at a tertiary care children's hospital were evaluated. Exclusion criteria included history of neuromuscular disorders, tracheostomy placement, or a predominance of central apneic events recorded during polysomnography (PSG). Patients were grouped by OSA severity. Chi-squared analysis and logistic regression were utilized to determine associations between demographic characteristics, OSA severity, preoperative echocardiographic abnormalities, and postoperative adverse events. RESULTS: One hundred ten children met inclusion criteria for the study, including 22 with mild OSA, 22 with moderate OSA, and 66 with severe OSA. Race and the presence of congenital heart disease (CHD) were significantly associated with differences in OSA severity. Echocardiographic abnormalities were found in 45 patients, but exclusion of patients with CHD revealed no significant associations with differences in OSA severity. Postoperative adverse events were identified in 18 (16%) patients, and only O2 saturation nadir was found to be a significant predictor of these complications. CONCLUSION: Preoperative echocardiogram abnormalities are not commonly found in children with OSA and presence of abnormalities does not predict postoperative adverse events. O2 saturation nadir measured on preoperative PSG is a significant predictor of postoperative adverse events and should be examined as a clinical indicator of OSA severity.

Evaluating parental genetic knowledge of hearing loss with and without pre-test genetic counseling in a pediatric otolaryngology clinic.

This study evaluated parental knowledge of genetics of sensorineural hearing loss (SNHL) and satisfaction following pre-test consult with and without genetic counseling (GC). A survey evaluating parents' knowledge of genetics for SNHL with and without GC was administered to parents of children with SNHL who were offered genetic testing. The survey also inquired about satisfaction, and decision to pursue genetic testing. Statistical tests included Fisher-Freeman-Halton test and Mann-Whitney test. Forty-nine participants completed the survey and were seen by both otolaryngology and GC intern (ENT + GC) (n = 24) or by otolaryngology (ENT) only (n = 25). Participation groups were not randomized. There were no significant differences in demographics between groups. Participants in the ENT + GC group had higher average genetics knowledge score of 72% correct (range 22%-100%), compared to the ENT only group with 44% (range 22%-78%) (p < .001). Participants in the ENT + GC group were more likely to know the different test result possibilities (p = .002), the most common form and pathogenic variant associated with SNHL (p < .001), that only a subset of genes are evaluated (p = .004), and that genetic testing may not explain SNHL etiology (p = .013), in comparison with the ENT only group. There was no significant difference in parental satisfaction or ultimate decision to undergo testing between groups. Obtaining genetic testing plays an integral role in the diagnosis and management of SNHL in the pediatric population. Our results suggest that the addition of GC increases parent knowledge of genetics and SNHL. This knowledge allows the family to make a more informed decision as to whether or not to pursue genetic testing.

Feeding outcomes after paediatric cardiothoracic surgery: a retrospective review.

BACKGROUND: Feeding difficulty is a known complication of congenital heart surgery. Despite this, there is a relative sparsity in the available data regarding risk factors, incidence, associated symptoms, and outcomes. METHODS: In this retrospective chart review, patients aged 0-18 years who underwent congenital heart surgery at a single institution between January and December, 2017 were reviewed. Patients with feeding difficulties before surgery, multiple surgeries, and potentially abnormal recurrent laryngeal nerve anatomy were excluded. Data collected included patient demographics, feeding outcomes, post-operative symptoms, flexible nasolaryngoscopy findings, and rates of readmission within a 1-year follow-up period. Multivariable regression analyses were performed to evaluate the risk of an alternative feeding plan at discharge and length of stay. RESULTS: Three-hundred and twenty-six patients met the inclusion criteria for this study. Seventy-two (22.09%) were discharged with a feeding tube and 70 (97.22%) of this subgroup were younger than 12 months at the time of surgery. Variables that increased the risk of being discharged with a feeding tube included patient age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, procedure group, aspiration, and reflux. Speech-language pathology was the most frequently utilised consulting service for patients discharged with feeding tubes (90.28%) while other services were not frequently consulted. The median length of stay was increased from 4 to 10 days for patients who required an enteral feeding tube at discharge. DISCUSSION: Multidisciplinary management protocol and interventions should be developed and standardised to improve feeding outcomes following congenital heart surgery.

Posterior Tongue Tie, Base of Tongue Movement, and Pharyngeal Dysphagia: What is the Connection?

Ankyloglossia, or tongue tie, and its impact on the oral phase of feeding has been studied and debated for decades. However, the impact of posterior tongue ties on the pharyngeal phase of swallowing is not well documented in the literature. A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the swallow. When decreased base of tongue movement, impaired pharyngeal pressure generation, and presence of pharyngeal residue are noted during a VFSS, a neurologic etiology can be suspected. However, in the setting of a normal MRI with normal motor development, other etiologies need to be explored. If it is not neurologic, could it be anatomic? We present a 21-month-old patient with significant pharyngeal phase dysphagia which was most saliently characterized by impaired base of tongue movement, poor pressure generation, and diffuse residue resulting in aspiration. He was eventually diagnosed with a posterior tongue tie and underwent a frenulectomy. Results via subsequent VFSS revealed significant improvement in base of tongue movement, pharyngeal pressure generation, and pharyngeal constriction, resulting in efficient movement of the bolus through the pharynx into the esophagus, no nasopharyngeal regurgitation, no aspiration, and near resolution of his pharyngeal dysphagia. Patients with impaired base of tongue movement and impaired pressure generation resulting in pharyngeal residue in the setting of a normal neurologic workup could possibly present with a posterior tongue tie which should be examined and included in the differential diagnosis.

Pediatric Surgical Risk Assessment Tools: A Systematic Review.

BACKGROUND: Pediatric surgical risk assessment tools use patient- and procedure-specific variables to predict postoperative complications. These tools assist clinicians in preoperative counseling and surgical decision-making. The objective of this systematic literature review was to compile and compare existing pediatric surgical risk tools that are broadly applicable across pediatric surgical specialties. METHODS: A systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Relevant publications were identified and screened based on predefined eligibility criteria: (1) a preoperative risk assessment tool predicting postoperative complications or mortality, (2) applicable across various surgical specialties, and (3) pertinent to the pediatric population. Studies with specialty- or procedure-specific risk scores and validation studies were excluded. Included articles were assessed for quality and risk of bias by using the Newcastle-Ottawa Scale. RESULTS: Four studies met inclusion criteria. Risk factors were evaluated across the models as proxies for operative suitability of patients before surgery. Risk factors common to all studies were the presence of cardiovascular or neurological diseases and history of prematurity. Three of the four included studies defined most risk factors in binary terms, whereas one study used a scale of severity of organ system disease when defining preoperative risk. Generated risk score models provided good to strong concordance with inpatient mortality or postoperative complications, with c-statistic values ranging from 0.77 to 0.98. CONCLUSIONS: Each study reported an assessment of a novel, generally applicable pediatric surgical risk assessment tool for risk-stratifying children preoperatively for complications that rise after surgery. More studies are needed to assess generalizability in all populations and procedures.

Sex Differences in Faculty Rank Among Academic Surgeons in the United States in 2014.

OBJECTIVE: The aim of this study was to evaluate sex differences in full professorship among a comprehensive, contemporary cohort of US academic surgeons. SUMMARY OF BACKGROUND DATA: Previous work demonstrates that women are less likely than men to be full professors in academic medicine, and in certain surgical subspecialties. Whether sex differences in academic rank exist across all surgical fields, and after adjustment for confounders, is not known. METHODS: A comprehensive list of surgeons with faculty appointments at US medical schools in 2014 was obtained from Association of American Medical Colleges (AAMC) faculty roster and linked to a comprehensive physician database from Doximity, an online physician networking website, which contained the following data for all physicians: sex, age, years since residency, publication number (total and first/last author), clinical trials participation, National Institutes of Health grants, and surgical subspecialty. A 20% sample of 2013 Medicare payments for care was added to this dataset. Multivariable regression models were used to estimate sex differences in full professorship, adjusting for these variables and medical school-specific fixed effects. RESULTS: Among 11,549 surgeon faculty at US medical schools in 2014, 1692 (14.7%) were women. Women comprised 19.4% of assistant professors (1072/5538), 13.8% of associate professors (404/2931), and 7.0% of full professors (216/3080). After multivariable analysis, women were less likely to be full professors than men (adjusted odds ratio: 0.76, 95% confidence interval: 0.6-0.9). CONCLUSION: Among surgical faculty at US medical schools in 2014, women were less likely than men to be full professors after adjustment for multiple factors known to impact faculty rank.

Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency.

OBJECTIVE: This study aimed to describe syndromes where preoperative imaging may be essential in determining the course of the carotid arteries before velopharyngeal insufficiency (VPI) surgery and therefore affect surgical planning. METHODS: Records of children who underwent surgery for VPI between May 1, 2012, and October 30, 2013, at a tertiary care pediatric otolaryngology center were reviewed. Data collected included age at operation, preoperative and postoperative nasometry values, presence of underlying genetic disorders, and imaging findings. RESULTS: Twenty-five patients underwent 33 surgeries for VPI, with 1 posterior pharyngeal wall augmentation, 6 Furlow palatoplasties, 11 sphincter pharyngoplasties, and 15 pharyngeal flaps. Medialized carotid vasculature was identified in 5 of 25 patients (20%). Seven syndromic patients were identified, with 3 patients having 22q11.2 deletion syndrome. All patients (100%) with 22q11.2 deletion syndrome had medialized carotid arteries. Of the 4 additional syndromic children, 2 (50%) had medial internal carotid arteries, with 1 patient diagnosed with neurofibromatosis 1 and another with Prader-Willi syndrome. Both patients underwent Furlow palatoplasty. CONCLUSION: Whereas 22q11.2 deletion syndrome is recognized as an entity where a medial carotid is often present, other syndromic children may also demonstrate vascular variability. Although a larger study is needed to confirm an increased prevalence in these patients, clinicians may need a higher degree of suspicion while performing the physical examination. If examination findings are suggestive or the disease process may lend itself to this abnormality, vascular imaging can be considered as part of presurgical planning to help guide surgical technique and prevent complications.

Operation airway: the first sustainable, multidisciplinary, pediatric airway surgical mission.

OBJECTIVE: This study aimed to describe the development and implementation of the first sustainable, multidisciplinary, pediatric airway surgical mission in an underserved country. METHODS: This prospective, qualitative study was conducted for the first 4 Operation Airway missions in Quito, Ecuador. The major goals of the missions were to assist children with aerodigestive abnormalities, create a sustainable program where the local team could independently provide for their own patient population, develop an educational curriculum and training program for the local team, and cultivate a collaborative approach to provide successful multidisciplinary care. RESULTS: Twenty patients ages 4 months to 21 years were included. Twenty-three bronchoscopies, 5 salivary procedures, 2 tracheostomies, 1 T-tube placement, 1 tracheocutaneous fistula closure, 2 open granuloma excisions, and 6 laryngotracheal reconstructions (LTRs) were performed. All LTR patients were decannulated. A new type of LTR (1.5 stage) was developed to meet special mission circumstances. Two videofluoroscopic swallow studies and 40 bedside swallow evaluations were performed. One local pediatric otolaryngologist, 1 pediatric surgeon, 3 anesthesiologists, 7 intensivists, 16 nurses, and 2 speech-language pathologists have received training. More than 25 hours of lectures were given, and a website was created collaboratively for educational and informational dissemination (http://www.masseyeandear.org/specialties/pediatrics/pediatric-ent/airway/OperationAirway/). CONCLUSION: We demonstrated the successful creation of the first mission stemming from a teaching institution with the goal of developing a sustainable, autonomous surgical airway program.

Multisystem approach for management of OSA in Down syndrome: a case report.

Obstructive sleep apnea (OSA) is common in children with Down syndrome, with reported prevalence rates as high as 69-76%. Multiple factors predispose children with Down syndrome for OSA, including craniofacial hypoplasia (maxillary and mandibular), airway abnormalities, macroglossia, generalized hypotonia, airway hypotonia, adenotonsillar hypertrophy, and obesity. Despite the fact that the pathophysiology for OSA in children with Down syndrome is multifactorial in nature, treatment methods have focused on soft tissue in the upper airway using adenotonsillectomy and/or continuous positive airway pressure therapy. Here we present a case of a patient with Down syndrome whose severe OSA was approached in a multisystem manner, including upper airway soft tissue, orthognathic, maxillofacial, and bariatric surgery, resulting in resolution of the OSA without reliance on a continuous positive airway pressure device. CITATION: Finch CE, Raol N, Roser SM, Leu RM. Multisystem approach for management of OSA in Down syndrome: a case report. J Clin Sleep Med. 2024;20(3):471-473.

A Mobile Application for Child-Focused Tonsillectomy Education: Development and User-Testing.

OBJECTIVE: Patient education is central to Enhanced Recovery After Surgery protocols, but child-focused materials are lacking. We developed and piloted a mobile application to support accessible, interactive patient and caregiver education about pediatric tonsillectomy. METHODS: Thirty children ages 5-12 who were preparing for tonsillectomy, their caregivers, and six attending otolaryngologists participated in a user-testing trial of a web-based prototype. The trial measured feasibility, fidelity, and patient-centered outcomes. Patients and caregivers rated usability/likeability on the mHealth App Usability Questionnaire. Otolaryngologists rated quality on the Mobile App Rating Scale. The full mobile application, "Ready for Tonsillectomy," was then developed for iOS and Android. RESULTS: Enrollment was 88.2%, retention was 90.0%, and use was 96.3%. Mean (SD) patient ratings for usability/likeability were 6.3 (1.1) out of 7; caregiver ratings were 6.5 (1.1). In common themes from open-ended feedback, patients described the application as helpful and appealing, and caregivers described it as informative, easy to understand, calming, and easy to use. Among caregivers who used the application during recovery, 92.3% reported that it helped them manage their child's pain. Providers would recommend the application to many or all of their patients (mean [SD]: 4.7 [0.5] out of 5). Mean provider ratings for domains of engagement, functionality, aesthetics, information quality, subjective quality, and app-specific value ranged from 4.1 to 4.8 out of 5. CONCLUSION: Feasibility and fidelity were high. Families and otolaryngologists endorsed the resource as an engaging, informative tool that supports positive coping. Our mobile application offers a patient-centered solution readily scalable to other surgeries. LEVEL OF EVIDENCE: NA Laryngoscope, 134:2455-2463, 2024.

Intensive Outpatient Programs for Pediatric Feeding Disorder: A Qualitative Study of Current Challenges and Future Directions.

BACKGROUND: Although intensive multidisciplinary interventions (IMIs) provide benefits for patients with pediatric feeding disorders (PFD), access to these programs is limited and challenges faced by the programs remain unclear. OBJECTIVE: To better understand the barriers faced by existing day programs that provide IMI, disparities in patient care, and areas for improvement to better inform policy and improve access to treatment for PFD. METHODS: Semi-structured interviews were conducted with a leader of outpatient programs providing IMI in the United States. Data regarding leader's perspectives on disparities in patient care, barriers faced by the intensive multidisciplinary feeding day programs, and future goals and directions for their programming were collected. Afterward, a qualitative content analysis was conducted to consolidate and categorize information related to patient care, access, and barriers faced by day programs and patients with PFD. RESULTS: Barriers and challenges were identified at the patient, program, and systems levels. Patient-level barriers included familial resources or socioeconomic status, geographic distance from the program site, and difficulty with the time commitment, whereas program-level barriers included limited site personnel and capacity and long wait times. System-level barriers primarily center on insurance, with inconsistent coverage of services and limited payer knowledge about PFD and IMI. CONCLUSION: IMIs are effective in managing PFD; however, a variety of patient-level, program-level, and systems-level factors serve as barriers for patient access to care and program success. Further research, improved reimbursement, and consensus statements on effective treatments can help improve access to and coverage for care, allowing for the development and sustainability of more programs.

Healthcare Spending and Systemic Bevacizumab for Recurrent Respiratory Papillomatosis.

OBJECTIVES: Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is a rare, costly condition linked to human papillomavirus. Standard of care is serial surgical debridement. Many adjunctive therapies have been trialed, with recent success with systemic bevacizumab. This paper examines healthcare spending associated with systemic bevacizumab use for JoRRP and compares it to healthcare spending for surgical care alone to determine whether bevacizumab has a financial benefit. METHODS: Five patients treated with systemic bevacizumab for JoRRP were identified at a single institution. Spending data was derived from the electronic medical record. Sensitivity analysis was performed using variation in spending and frequency of treatments. RESULTS: Patients had an average of 4.2 treatments per year prior to bevacizumab (95% confidence interval [CI] 1.4-7.0) and 1.1 after (0.2-2.0). Patients underwent an average of 9.2 bevacizumab treatments in their first year after initiation, 4.0 in the second, and 4.5 in their third. Mean payment per debridement was $3198 ($2856-3539), with mean total surgical payment per year of $17,966 ($11,673-24,259) prior to initiating bevacizumab. Mean payment on a single bevacizumab infusion visit was $6508 ($6063-6952). Mean total surgical and bevacizumab spending per year after bevacizumab initiation were $83,951 ($12,938-154,964). CONCLUSIONS: Accounting for variations in the number of treatments per year with bevacizumab after initiation, healthcare spending after bevacizumab initiation is similar to spending on surgery alone for JoRRP in patients with severe disease.