Instrumental Swallowing Assessments in the Neonatal and Pediatric Populations: A Systematic Review

Evaluation of Swallowing Dysfunction With Flexible Endoscopic Evaluation of Swallowing in the Neonatal Unit

BACKGROUND

Preterm and low-birth-weight infants often experience discoordination of the suck-swallow-breathe pattern, leading to dysrhythmic feeding, inefficient feeding skills, and swallowing dysfunction, increasing the risk of aspiration and respiratory morbidity. While videofluoroscopic swallowing study is commonly utilized to assess swallow function in neonates, flexible endoscopic evaluation of swallowing (FEES) has been an emerging modality and has been utilized routinely at our institution since 2018.

METHOD

A single-center, retrospective study including 90 infants admitted to the neonatal unit between 2018-2023 who underwent FEES procedure. Our objective was to evaluate the utility of FEES for evaluating functional and anatomical abnormalities, secretions, penetration/aspiration, and residue in infants in the Neonatal Intensive Care Unit. Our secondary objective was to observe whether clinical feeding decisions were changed based on FEES and describe progress in oral feeding.

RESULTS

A majority of infants (85.5%) were reported to have abnormal FEES findings, with aspiration below the vocal cords noted in 37.7% and laryngeal penetration reported in 34.5% of the infants. Anatomical abnormalities were reported in 39% of infants including predominantly laryngomalacia (27.7%). Ten infants were noted to have unanticipated anatomical abnormalities, of which four went on to require surgical interventions. Changes in nipple or bottle were the most frequent recommendations (68.8%) with thickening of feeds recommended in 35% of infants. The percentage of oral feedings increased from median of 45% to 75% with a decrease in infants with apneic, bradycardic, and desaturation events in the 7 days after FEES guided interventions were introduced.

CONCLUSIONS

Majority of the infants with clinical concerns of swallow dysfunction were noted to have abnormalities on FEES, with one third of infants reported to have aspiration and anatomical abnormalities. Changes in feeding practices were recommended to majority of the infants based on FEES evaluation. Four of the five infants with anatomical abnormalities referred urgently for specialist evaluation required interventions.

Fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics: A systematic review

OBJECTIVES

The systematic review aimed to provide an overview of the state-of-art regarding the use of fiberoptic endoscopic evaluation of swallowing (FEES) in pediatrics, specifically investigating FEES feasibility, safety, diagnostic accuracy, and protocols.

METHODS

Four electronic databases were searched for original studies on the pediatric population that instrumentally assessed swallowing function using FEES. A hand-search of the references of included studies was performed. Data on the population, feasibility of endoscope insertion and bolus trials, adverse events, sensitivity and specificity, and FEES equipment and protocol were extracted. The quality of the studies was assessed using the checklists of the Johanna Briggs Institute. Selection of the studies, data extraction, and quality appraisal were conducted by two independent researchers.

RESULTS

Eighty-two reports from 81 studies were included. The mean overall quality of the studies was 80 % (17-100 %). The feasibility of endoscope insertion was high (89%-100 %), while the feasibility of bolus trials varied from 40 % to 100 %. Adverse events were excessive crying (8 studies), irritability or agitation (4 studies), transitory oxygen desaturations (3 studies, 1.2-6.7 % of the patients), epistaxis (3 studies, 0.8-3.3 % of the patients), increased heart rate (1 study, 1 patient), vomiting (1 study, 1 patient), hypertonia (1 study), and hypersalivation (1 study). No major complications were reported. Using VFSS as the reference standard, FEES was generally found to be less sensitive (25-94 %) but more specific (75-100 %) for aspiration, whereas the reverse was true for penetration (sensitivity 76-100 %, specificity 44-83 %). FEES protocols were highly heterogeneous with poor reporting.

CONCLUSION

FEES is a safe, accurate, and generally feasible examination in the pediatric population with suspected dysphagia. However, a consensus on the best FEES protocol for clinical practice and research is currently lacking.

Evaluation of feeding difficulties using videofluoroscopic swallow study and swallowing therapy in infants and children

BACKGROUND

Infants and children with feeding difficulties have swallowing dysfunction and high risk of aspiration, which could be silent without choking, resulting in recurrent pneumonia and long-term respiratory morbidity. Videofluoroscopic swallow study (VFSS) is a useful tool for real-time visualization of the swallowing process and airway aspiration. This study reported a single-institutional 10-year experience of VFSS in pediatric patients with feeding difficulties and the efficacy of swallowing therapy.

METHODS

From 2011 to 2020, 30 infants and children with feeding difficulties received VFSS examinations in a medical center at a median age of 19 months (range 7 days-8 years). The images of the swallowing process (oral phase, triggering of pharyngeal swallowing, and pharyngeal phase) under videofluoroscopy were analyzed by a radiologist and a speech-language pathologist. Aspiration severity was assessed from VFSS observations and rated by an eight-point Penetration-Aspiration-Scale (PAS), with higher scores indicating increased severity. Swallowing therapy was performed by experienced speech-language therapists, and follow-up of oral feeding tolerance and risk of aspiration pneumonia was done.

RESULTS

Of the 30 patients, 24 (80%) had neurological deficits. High PAS scores (6-8) were observed in 25 (83.4%) patients, and 22 had a PAS score of 8, indicating silent aspiration. Of the 25 patients with high PAS scores, 19 (76%) had neurological deficits, and 18 (72%) depended on tube feeding at a median age of 20 months. Swallowing problems occurred most frequently during the pharyngeal phase in the patients with high PAS scores. VFSS-based swallowing therapy improved oral feeding ability and reduced aspiration episodes.

CONCLUSION

Infants and children with swallowing dysfunction and neurological deficits had high risk of severe aspiration. Swallowing problems in the pharyngeal phase were the most common VFSS findings in patients with severe aspiration. VFSS may help guide problem-oriented swallowing therapy to reduce the risk of recurrent aspiration.