Updates on pediatric feeding and swallowing problems

Risk Factors for Feeding and Swallowing Disorders in Very Low Birth Weight Infants in Their Second Year of Life

Background and Objectives: This study aimed to identify the prevalence of feeding and swallowing disorders (FSD) in very low birth weight (VLBW, 1500 g or less) infants in the first two years after discharge from the maternity hospital, their possible risk factors, and the consequences of them. Materials and Methods: A total of 117 preterm children with VLBW born between 2013 and 2015 were included. The data concerning possible FSD after discharge from the hospital were obtained through accessible medical documentation for the child and a short parental questionnaire. Results: FSD was reported in 32 (27.4%) infants following discharge from the hospital but in only five children (4.3%) at a mean age of four years. Four variables (birth gestational age less than 28 weeks, birth weight equal to or less than 1000 g, birth length below 33 cm, and start of oral feeding after the 34th gestational week) were identified as risk factors for FSD after discharge. However, only birth length remained a significant predictor after being included in a binary logistic regression model (p = 0.000). Abnormal oral sensitivity and a decrease in weight to under the 10th percentile were significantly more common in the FSD group at follow-up visits at the age of about 2 years. Conclusions: FSD was still present in more than one-quarter of VLBW infants after discharge from the maternity hospital but mostly disappeared within four years. A birth gestational age under 28 weeks, weight up to 1000 g, the late beginning of per oral feeding, and a birth length below 33 cm were determined to be significant predictive factors for FSD. Having a birth length below 33 cm was associated with an almost 6.5-fold increase in the odds of having persistent FSD after discharge from the hospital. FSD in the first years of life may have an impact on the child's further growth and development.

The Quality, Reliability, and Accuracy of Videos Regarding Exercises and Management for Dysphagia in Pediatric Populations Uploaded on YouTube

Objectives: YouTube is well known for providing easy access to various kinds of video content. In this study, we investigated the quality and reliability of videos on YouTube addressing exercise or dysphagia management in the pediatric population. Methods: Video quality and reliability were assessed by using the Global Quality Scale (GQS) and a modified DISCERN tool, respectively. The accuracy of the information in each video was also evaluated. Other information, including the video source, length, date of upload, as well as the number of views, likes, dislikes, and comments were investigated, and statistical significance was determined. Results: In total, 22 videos on exercises and dysphagia management in pediatric populations were evaluated; 36.4% and 72.7% of these videos did not have high quality or reliability, respectively. Moreover, half of the videos did not contain accurate information. Even when videos were created by medical specialists, many of these YouTube videos were of low quality, reliability, and accuracy. Conclusions: The reliability, quality, and accuracy of many videos on exercise or dysphagia management in the pediatric population were low. Video creators, especially medical specialists, should strive to create videos with high quality, reliability, and accuracy.

Family-centered Outcomes that Matter Most to Parents: A Pediatric Feeding Disorders Qualitative Study

OBJECTIVE

The purpose of this study was to examine the perspectives of caregivers of children with feeding disorders. We sought to understand their child's feeding impairment through the lens of caregivers, including the impact impairments had on daily life and social participation, what outcomes matter most to caregivers, contextual determinants that affect achieving desired outcomes, and how treatment approaches can optimally support families.

METHODS

We interviewed caregivers of children, ages 2 to 5 years, who received care at the Center for Feeding and Nutrition at MassGeneral Hospital for Children in Boston, MA. All children had a feeding disorder diagnosis, defined as an impairment in oral intake. We analyzed interview transcripts using principles of immersion-crystallization.

RESULTS

We reached thematic saturation after interviewing 30 caregivers (25 female). 66.7% of the children were white, 13.3% Asian, 10.0% black, and 10.0% were more than 1 race. Thirty percent were Hispanic. We identified four themes: feeding impairments impact the daily life and social participation of children; improving their child's health and quality of life is most important to caregivers; child, caregiver, and community factors are facilitators of achieving desired outcomes; whereas time, financial, access, and knowledge factors are barriers; and caregivers prefer treatment approaches that incorporate principles of family-centered care.

CONCLUSIONS

Given the daily life and social participation impacts of pediatric feeding disorders, treatment approaches should be family-centered, focus on functional and meaningful outcomes to improve the health and quality of life of children and their families, and address modifiable sociocontextual determinants.

Reliability and validity of the neonatal feeding assessment scale (NFAS) for the early identification of dysphagia in moderate to late preterm neonates

Background

A clinical feeding assessment instrument to assist with early identification of oropharyngeal dysphagia (OPD) in neonates was developed.

Objective

To investigate the validity and reliability of the Neonatal Feeding Assessment Scale (NFAS) in comparison to the modified barium swallow study (MBSS) as gold standard.

Method

A within-subject design was implemented. A group of 48 late premature neonates (mean gestational age 35.5 weeks) were sampled in the neonatal intensive care unit.

Results

The NFAS consists of six subsections, including physiological stability, infant state, stress cues, screening of muscle tone and control, oral peripheral examination and feeding/swallowing assessment. 93% of participants (14/15) received confirmatory diagnosis of OPD on MBSS. The NFAS presented with high sensitivity (78.6%) and specificity (88.2%) scores. The positive predictive value was 78.6%. Subsequently the accuracy of the NFAS to identify the presence of OPD accurately was 85.4% when compared to MBSS. Inter-rater reliability was determined on 35% of the sample. The inter-rater agreement on overall instrument outcome was substantial beyond chance.

Conclusion

The NFAS may be of use to clinicians to support the early identification of OPD in this population, especially in resource constrained settings working without access to MBSS and to reach under served neonates.

RDH10 function is necessary for spontaneous fetal mouth movement that facilitates palate shelf elevation

Cleft palate is a common birth defect, occurring in approximately 1 in 1000 live births worldwide. Known etiological mechanisms of cleft palate include defects within developing palate shelf tissues, defects in mandibular growth and defects in spontaneous fetal mouth movement. Until now, experimental studies directly documenting fetal mouth immobility as an underlying cause of cleft palate have been limited to models lacking neurotransmission. This study extends the range of anomalies directly demonstrated to have fetal mouth movement defects correlated with cleft palate. Here, we show that mouse embryos deficient in retinoic acid (RA) have mispatterned pharyngeal nerves and skeletal elements that block spontaneous fetal mouth movement in utero. Using X-ray microtomography, in utero ultrasound video, ex vivo culture and tissue staining, we demonstrate that proper retinoid signaling and pharyngeal patterning are crucial for the fetal mouth movement needed for palate formation. Embryos with deficient retinoid signaling were generated by stage-specific inactivation of retinol dehydrogenase 10 (Rdh10), a gene crucial for the production of RA during embryogenesis. The finding that cleft palate in retinoid deficiency results from a lack of fetal mouth movement might help elucidate cleft palate etiology and improve early diagnosis in human disorders involving defects of pharyngeal development.

Summary: Fetal mouth immobility and defects in pharyngeal patterning underlie cleft palate in retinoid-deficient Rdh10 mutant mouse embryos.

Predictors and outcomes of the Neonatal Oral Motor Assessment Scale (NOMAS) performance: a systematic review

The NOMAS is by far the most used tool to screen early oral-motor skills in newborns. Here we provide an updated review of scientific literature on the use of the Neonatal Oral Motor Assessment Scale (NOMAS) to screen early oral-motor skills in newborns. An integrative review has been carried out consistent with PRISMA guidelines and standardized qualitative appraisal. Data abstracting and synthesis were executed by two independent co-authors who solved disagreement in conference. Twenty records have been included and reviewed. The efficacy of the NOMAS in screening and identifying precocious oral-motor skills received inconsistent support. Moderate validity and low reliability emerged. Moreover, despite the NOMAS' adequately screen efficient and inefficient feeders, limited evidence emerged for predictive value of NOMAS score on feeding and psychomotor developmental trajectories during the first 2 years of age.

CONCLUSION

The present review highlights benefits and limitations of the NOMAS. Future research is needed to develop observational and clinically-relevant tools to better identify newborns which are at lower- and higher-risk of developing less-than-optimal feeding behaviors and to guide with greater precision the diagnostic and therapeutic journey of these newborns. What is Known: • The assessment of oral-motor skills in newborns and infants is critical for early intervention • The NOMAS is the most adopted tool to assess oral-motor skills in newborns and infants What is New: • The ability of the NOMAS to target newborn at risk for feeding disorders is confirmed • Nonetheless, the capacity to predict long-term developmental outcomes is limited.

Preliminary psychometric performance of the Neonatal Feeding Assessment Scale

Objective

The objective was to determine the preliminary psychometric performance of a new clinical feeding scale to diagnose oropharyngeal dysphagia (OPD) in neonates.

Methods

Twenty neonates with a median gestational age of 35 weeks were evaluated using the Neonatal Feeding Assessment Scale (NFAS) and modified barium swallow studies (MBSS). The results were compared.

Results

Nine of the 20 participants presented with OPD on the NFAS. Comparison of the scale’s results with instrumental MBSS indicated that all participants without OPD were correctly excluded (100% sensitivity). The specificity was 78.6%, indicating that three participants were falsely identified with OPD on the scale. Inter-rater reliability was determined on 50% (n = 10) of the sample. Substantial agreement (80%) was obtained between two raters in five of the six sections of the scale and on the diagnostic outcome.

Conclusion

The preliminary performance of the scale appears to be promising. A further validation study will take place.

Hard to swallow: Developmental biological insights into pediatric dysphagia

Pediatric dysphagia-feeding and swallowing difficulties that begin at birth, last throughout childhood, and continue into maturity--is one of the most common, least understood complications in children with developmental disorders. We argue that a major cause of pediatric dysphagia is altered hindbrain patterning during pre-natal development. Such changes can compromise craniofacial structures including oropharyngeal muscles and skeletal elements as well as motor and sensory circuits necessary for normal feeding and swallowing. Animal models of developmental disorders that include pediatric dysphagia in their phenotypic spectrum can provide mechanistic insight into pathogenesis of feeding and swallowing difficulties. A fairly common human genetic developmental disorder, DiGeorge/22q11.2 Deletion Syndrome (22q11DS) includes a substantial incidence of pediatric dysphagia in its phenotypic spectrum. Infant mice carrying a parallel deletion to 22q11DS patients have feeding and swallowing difficulties that approximate those seen in pediatric dysphagia. Altered hindbrain patterning, craniofacial malformations, and changes in cranial nerve growth prefigure these difficulties. Thus, in addition to craniofacial and pharyngeal anomalies that arise independently of altered neural development, pediatric dysphagia may result from disrupted hindbrain patterning and its impact on peripheral and central neural circuit development critical for feeding and swallowing. The mechanisms that disrupt hindbrain patterning and circuitry may provide a foundation to develop novel therapeutic approaches for improved clinical management of pediatric dysphagia.

Empirically supported treatments for feeding difficulties in young children

Pediatric feeding problems are common among children and present severe issues for families. Unfortunately, treatment outcome studies with this population are sparse. The current study reviews the literature regarding treatment studies of children with severe feeding issues, provides an overview of empirically supported treatments for children who do eat orally, and finally summarizes interventions that attempt to reintroduce oral feeding to children who have been fed by gastrostomy tube or other non-oral feeding route.