Upper GI examinations in older premature infants with persistent apnea: correlation with simultaneous cardiorespiratory monitoring

Swallowing dysfunction in very low birth weight infants with oral feeding desaturation

BACKGROUND

We detected swallowing dysfunction by the modified barium swallow (MBS) test and determined risk factors for swallowing dysfunction in very low birth weight (VLBW) infants with oral feeding desaturation near discharge.

METHODS

We retrospectively reviewed 41 VLBW infants referred for MBS test because of significant oral feeding desaturation at ≥ 35 weeks of postmenstrual age. Infants who showed impaired airway protection, including inadequate epiglottic closure, laryngeal penetration and/or tracheal aspiration by MBS test, were compared to those without impaired airway protection.

RESULTS

Eleven infants (26.8%) showed impaired airway protection by MBS test. They had a significantly lower gestational age at birth but a similar postmenstrual age compared to those without impaired airway protection. All infants with impaired airway protection were born at ≤ 28 weeks of gestation.

CONCLUSIONS

Swallowing dysfunction resulting in aspiration should be considered as a cause of significant oral feeding desaturation in infants born at ≤ 28 weeks of gestation regardless of postmenstrual age.

The early impact of feeding on infant breathing-swallowing coordination

This longitudinal study assessed the coordination of nutritive and non-nutritive swallowing with breathing in 10 healthy term infants from birth to 1 year of age. Swallows were classified into five respiratory-phase categories: mid-inspiration (II), mid-expiration (EE), inspiratory-expiratory cusp (IE), expiratory-inspiratory cusp (EI), and mid-pause (P). Breathing-swallowing coordination differed markedly between the two swallowing conditions, especially between 2 weeks and 2 months. Significant condition effects were found in up to four respiratory-phase categories (II, IE, EI, and P). The condition effect was minimal from 9 months with only IE swallow proportions differing between conditions. These data suggest a 'critical period' in infantile neural response to oropharyngeal stimulation during feeding and that the impact of this on infants with neurological and/or respiratory disorders should be further investigated.

Swallowing function and medical diagnoses in infants suspected of Dysphagia

OBJECTIVE

There has been an increase in infant swallowing disorders as a result of improved survival for infants born prematurely or with life-threatening medical disorders. These infants often have multiple health issues and an increased risk of respiratory complications. However, there is little understanding of the biomechanics of infant swallowing disorders. Therefore, the objectives of this study were to determine 1) the percentage of dysphagic infants who experience laryngeal penetration, aspiration, or nasopharyngeal backflow; 2) reasons for laryngeal penetration/aspiration; 3) whether infants with laryngeal penetration/aspiration clear their airway; and 4) the relationship between swallowing disorders and medical diagnoses.

METHODS

Patients included 43 infants who were referred for videofluoroscopic swallowing studies in a university-affiliated pediatric medical center. Medical charts were reviewed. The videofluoroscopic swallowing studies were recorded on videotape, and each swallow was analyzed for laryngeal penetration, aspiration, nasopharyngeal backflow, cough, airway clearance, and reason for penetration/aspiration. Statistics included chi2 for nonparametric data and measures of central tendency for numeric/timing data.

RESULTS

More than half of the infants experienced laryngeal penetration, aspiration, or nasopharyngeal backflow; however, the first occurrence of these events was after multiple swallows. Only 3 infants experienced laryngeal penetration and aspiration on the first swallow and all 3 had an absent pharyngeal response. Premature infants experienced significantly more nasopharyngeal backflow. Material in the pyriform sinuses before pharyngeal swallowing was associated with penetration/aspiration. In episodes of laryngeal penetration, all patients were able to clear their airway during the swallow without a cough. Almost all infants (8 of 9) who aspirated did not cough or clear their airway.

CONCLUSIONS

This study demonstrated that most infants suspected of dysphagia showed overt abnormalities: laryngeal penetration, aspiration, and/or nasopharyngeal backflow on the videofluoroscopic swallowing study. Most of these infants did not demonstrate abnormalities in the first few swallows but displayed deterioration in swallowing function as they continued to feed. Thus, radiographic assessments in infants must examine multiple swallows. The high incidence of silent aspiration demonstrates the necessity of a videofluoroscopic assessment to evaluate swallowing function in these infants.

The evaluation of pediatric feeding abnormalities

An appreciation of normal age-related feeding behavior is a prerequisite for the study of pediatric feeding disorders. When faced with a child with dysphagia, the diagnostic evaluation including history, physical and developmental exam, and feeding observation, followed by appropriate diagnostic tests forms the basis for understanding the underlying pathophysiology and the anticipated developmental progression. It makes possible the formulation and implementation of an optimal treatment strategy, which can be monitored for results and modified when needed. Four case examples are provided.

Infant apnea and gastroesophageal reflux

The value of a combination of ultrasound studies and barium swallow examination in the analysis of temporal relationships between apnea and reflux is demonstrated. The two techniques allow acute apneic spells induced by gastroesophageal reflux to be documented and underlying specific digestive tract disorders demonstrated. The high incidence of digestive tract disorders in this area has been identified.