Global State of the Art and Science of Childhood Dysphagia: Similarities and Disparities in Burden

Feeding/swallowing and airway protection are complex functions, essential for survival, and continue to evolve throughout the lifetime. Medical and surgical advances across the globe have improved the long-term survival of medically complex children at the cost of increasing comorbidities, including dysfunctional swallowing (dysphagia). Dysphagia is prominent in children with histories of preterm birth, neurologic and neuromuscular diagnoses, developmental delays, and aerodigestive disorders; and is associated with medical, health, and neurodevelopmental problems; and long-term socioeconomic, caregiver, health system, and social burdens. Despite these survival and population trends, data on global prevalence of childhood dysphagia and associated burdens are limited, and practice variations are common. This article reviews current global population and resource-dependent influences on current trends for children with dysphagia, disparities in the availability and access to specialized multidisciplinary care, and potential impacts on burdens. A patient example will illustrate some questions to be considered and decision-making options in relation to age and development, availability and accessibility to resources, as well as diverse cultures and family values. Precise recognition of feeding/swallowing disorders and follow-up intervention are enhanced by awareness and knowledge of global disparities in resources. Initiatives are needed, which address geographic and economic barriers to providing optimal care to children with dysphagia.

Treatment of Pediatric Patients With High-Flow Nasal Cannula and Considerations for Oral Feeding: A Review of the Literature

PURPOSE

High-Flow Nasal Cannula (HFNC) has become an increasingly common means of noninvasive respiratory support in pediatrics and is being used in infants and children with respiratory distress both inside and outside of the intensive care units. Despite the widespread use of HFNC, there remains a paucity of data on optimal flow rates and its impact on morbidity, mortality, and desired outcomes. Given the scarcity of information in these critical areas, it is not surprising that guidelines for initiation of oral feeding do not exist. This review article will review HFNC mechanisms of action, its use in specific populations and settings, and finally what is known about initiation of feeding during this therapy.

CONCLUSIONS

The practice of withholding oral feeding solely, because of HFNC, is not supported in the literature at the time of this writing, but in the absence of safety data from clinical trials, clinicians should proceed with caution and consider patient-specific factors while making decisions about oral feeding. Well-controlled prospective clinical trials are needed for development of best practice clinical guidelines and attainment of optimal outcomes.

Multidisciplinary Management of Ataxia Telangiectasia: Current Perspectives

Ataxia telangiectasia (A-T) is a rare autosomal recessive disease caused by mutations in the ataxia telangiectasia mutated (ATM) gene. In the absence of a family history, the diagnosis of A-T is usually not made until the child is older and symptomatic. Classic A-T is characterized by a constellation of clinical symptoms including progressive ataxia, oculocutaneous telangiectasias and sinopulmonary disease and is usually associated with absence of ATM protein. Other laboratory features associated with A-T include elevated serum levels of alpha-fetoprotein (AFP) and increased chromosomal breakage with in vitro exposure to ionizing radiation. Sinopulmonary symptoms can occur to varying degrees across the lifespan. Some children will also have hypogammaglobulinemia and impaired antibody responses requiring supplemental gamma globulin. People with hypomorphic ATM mutations are often considered to have mild A-T with onset of ataxia and neurological progression occurring later in life with less impairment of the immune system. The risk of malignancy, however, is significantly increased in people with either classic or mild A-T. While hematological malignancies are most common in the first two decades of life, solid organ malignancies become increasingly common during young adulthood. Deterioration of neurologic function with age is associated with dysphagia with aspiration, growth faltering, loss of ambulation and decline in pulmonary function, morbidities that contribute to shortened life expectancy and decreased quality of life. Premature death is often due to malignancies or chronic respiratory insufficiency. A-T is currently managed with supportive care and symptomatic treatment. Current clinical trials, however, represent progress and hope towards disease-modifying therapies for A-T.

Correction to: Growth in ataxia telangiectasia

An amendment to this paper has been published and can be accessed via the original article.

Factors That Impact the Timing and Removal of Gastrostomy Placement/Nissen Fundoplication in Children with Bronchopulmonary Dysplasia

OBJECTIVE

 The study aimed to identify factors that impact timing of gastrostomy placement/removal and Nissen fundoplication (NF) in infants with bronchopulmonary dysplasia (BPD).

STUDY DESIGN

 Clinical data were reviewed retrospectively from patients recruited from the Johns Hopkins Bronchopulmonary Dysplasia Clinic (January 1, 2014-December 31, 2018).

RESULTS

 Patients with gastrostomy tubes (GTs) placed in the neonatal intensive care unit (NICU) were older at discharge (p < 0.001) and less likely to have abnormal upper gastrointestinal series findings (p = 0.005) than those with GTs placed after NICU discharge. Patients with NF had lower mean gestational ages (p = 0.011), longer NICU stays (p = 0.019), more frequent home ventilation requirements (p = 0.005), and greater likelihood of pulmonary hypertension (p = 0.032) compared with those without. Median age of GT removal was 61.6 months. Patients with GTs were weaned from supplemental oxygen and/or home ventilation before GT removal (p < 0.001).

CONCLUSION

 Patients with GT/NF were more medically complex than those with GT alone. Patients were more likely to be weaned from home respiratory support before GT removal.

KEY POINTS

· Patients with GT/NF were more medically complex than those with GT alone.. · Patients were more likely to be weaned from home respiratory support before GT removal.. · Patients with GTs placed in NICU were older at discharge and less likely to have abnormal upper gastrointestinal series result..

Growth in ataxia telangiectasia

BACKGROUND

Ataxia telangiectasia (A-T) is a DNA repair disorder that affects multiple body systems. Neurological problems and immunodeficiency are two important features of this disease. At this time, two main severity groups are defined in A-T: classic (the more severe form) and mild. Poor growth is a common problem in classic A-T. An objective of this study was to develop growth references for classic A-T. Another objective was to compare growth patterns in classic A-T and mild A-T with each other and with the general population, using the CDC growth references. A final objective was to examine the effects of chronic infection on height.

RESULTS

We found that classic A-T patients were smaller overall, and suffered from height and weight faltering that continued throughout childhood and adolescence. When compared to the CDC growth references, the median heights and weights for both male and female patients eventually fell to or below the 3rd centile on the CDC charts. Height faltering was more pronounced in females. Birthweight was lower in the classic A-T group compared to mild A-T and the general population, whereas birth length was not. Finally, we investigated height and BMI faltering in relation to number of infections and found no association.

CONCLUSIONS

Classic A-T appears to affect growth in utero. Although children appear to grow well in very early life, faltering begins early, and is unrelenting.

Inflammatory Effects of Thickened Water on the Lungs in a Murine Model of Recurrent Aspiration

OBJECTIVE

Liquid thickeners are commonly recommended in individuals with dysphagia and recurrent aspiration as a strategy for pneumonia prevention. The goal of this study was to examine the effects of small amounts of aspirated liquid thickener on the lungs.

STUDY DESIGN

Animal model. Prospective small animal clinical trial.

METHODS

Adult Sprague Dawley rats (n = 19) were divided into two groups and underwent three intratracheal instillations of either xanthan gum-based nectar-thick water (0.1-0.25 mL/kg) or water-only control over the course of 8 days. Blood was collected from a peripheral vein on days 1 and 8 and submitted for complete blood count (CBC) analysis. Rats were euthanized 10 days after the last instillation, and the lungs were harvested. Histopathology was conducted on lung specimens by a blinded licensed veterinary pathologist and scored for evidence of lung injury and pneumonia.

RESULTS

Fifteen animals (8 nectar-thickener group, 7 control group) survived until the endpoint of the study (day 18). Serum CBC did not show abnormalities at any timepoint in either group. Histological evidence of lung inflammation and edema were significantly greater in the nectar-thick group compared to controls (P < .05). Signs of inflammation included aggregates of foamy macrophages, expansion of bronchiolar lymphoid tissue, and large numbers of eosinophilic intraalveolar crystals. Histiocytic and neutrophilic pneumonia was noted in one animal that received thickened liquids.

CONCLUSION

Recurrent aspiration of small amounts of thickened water resulted in significant pulmonary inflammation in a murine model of aspiration. Results of this study support the need for further investigation of liquid thickener safety and its efficacy in reducing the pulmonary complications of swallowing disorders.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:1223-1228, 2021.

Best Practices in Modified Barium Swallow Studies

Purpose The modified barium swallow study (MBSS) is a widely used videofluoroscopic evaluation of the functional anatomy and physiology of swallowing that permits visualization of bolus flow throughout the upper aerodigestive tract in real time. The information gained from the examination is critical for identifying and distinguishing the type and severity of swallowing impairment, determining the safety of oral intake, testing the effect of evidence-based frontline interventions, and formulating oral intake recommendations and treatment planning. The goal of this review article is to provide the state of the science and best practices related to MBSS. Method State of the science and best practices for MBSS are reviewed from the perspectives of speech-language pathologists (SLPs) and radiologists who clinically practice and conduct research in this area. Current quandaries and emerging clinical and research trends are also considered. Results This document provides an overview of the MBSS and standards for conducting, interpreting, and reporting the exam; the SLPs' and radiologist's perspectives on standardization of the exam; radiation exposure; technical parameters for recording and reviewing the exam; the importance of an interdisciplinary approach with engaged radiologists and SLPs; and special considerations for examinations in children. Conclusions The MBSS is the primary swallowing examination that permits visualization of bolus flow and swallowing movement throughout the upper aerodigestive tract in real time. The clinical validity of the study has been established when conducted using reproducible and validated protocols and metrics applied according to best practices to provide accurate and reliable information necessary to direct treatment planning and limit radiation exposure. Standards and quandaries discussed in this review article, as well as references, provide a basis for understanding the current best practices for MBSS.

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.

BaByVFSSImP© A Novel Measurement Tool for Videofluoroscopic Assessment of Swallowing Impairment in Bottle-Fed Babies: Establishing a Standard

AIM

This investigation tested the construct validity of the first standardized assessment tool, the BaByVFSS Impairment Profile, (BaByVFSSImP©), developed for the quantification of swallowing observations made from videofluoroscopic swallow studies (VFSS) in bottle-fed babies.

METHOD

Construct validity of the measures was tested using descriptive methods and confirmatory factor analysis (CFA) of swallowing scores obtained from a cohort of bottle-fed babies (median age 3 months 1 day, interquartile range 1 month 4 days-7 months 4 days) sequentially referred for VFSS based on clinical signs, symptoms, or risk factors associated with dysphagia and/or aspiration. Main outcome measures were emergence of functional domains derived from swallowing component impairment scores.

RESULTS

Confirmatory factor analysis resulted in 21 significant components (factor loadings ≥ 0.5) grouping into five functional domains labeled for common contribution to overall swallowing function. The tool was organized into the BaByVFSSImP. Clinical relevance was explored using correlational analyses between domain scores, maximum penetration/aspiration scores, feeding status, and caregiver burden.

INTERPRETATION

Quantification of physiologic swallowing impairment captured by BaByVFSSImP holds promise for identification of physiologically based targets for intervention, clinical decisions regarding enteral feeding, and tracking the trajectory of swallowing impairment throughout development in young children.

Quantification of the source, amount and duration of aspiration in the lungs of infants using gamma scintigraphy

BACKGROUND

Aspiration can cause acute symptoms and chronic lung disease in the developing lung. However, the source of aspiration in infants is often unclear, making the choice of intervention difficult.

OBJECTIVE

To quantify the source, amount and duration of lung aspiration in infants using gamma scintigraphy.

METHODS

Two infants with clinical evidence of gastroesophageal reflux and oropharyngeal dysphagia swallowed formula radiolabeled with ^99mtechnetium on Visit 1. Radiolabeled-formula was instilled by nasogastric tube on Visit 2. Lung aspiration was quantified over four hours and expressed as percent of total radioactivity administered.

RESULTS

Aspiration was greatest with swallowing, compared to instillation, peaking between 2.0% and 2.4% within 30 min and between 0.40% and 0.65% within 20 min, respectively. Radioactivity remained above zero four hours after either administration.

CONCLUSIONS

Quantification of the source, amount and duration of lung aspiration in infants is feasible using gamma scintigraphy. The impact of aspiration accrual on clinical care deserves further investigation.

Feeding methods for infants with single ventricle physiology are associated with length of stay during stage 2 surgery hospitalization

BACKGROUND

Tube feedings are often needed to achieve the growth and nutrition goals associated with decreased morbidity and mortality in patients with single ventricle anatomy. Variability in feeding method through the interstage period has been previously described, however, comparable information following stage 2 palliation is lacking.

OBJECTIVES

To identify types of feeding methods following stage 2 palliation and their influence on length of stay.

DESIGN

Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative registry was performed on 932 patients. Demographic data, medical characteristics, postoperative complications, type of feeding method, and length of stay for stage 2 palliation were analyzed.

RESULTS

Type of feeding method remained relatively unchanged during hospitalization for stage 2 palliation. Gastrostomy tube fed only patients were the oldest at time of surgery (182.7 ± 57.7 days, P < .001) and had the lowest weight-for-age z scores at admission (-1.6 ± 1.4, P < .001). Oral + gastrostomy tube groups had the longest median bypass times (172.5 minutes, P = .001) and longest length of stay (median 12 days, P < .001). Multivariable modeling revealed that feeding by tube only (P < .001), oral + tube feeding (P ≤ .001), reintubation (P < .001), and prolonged intubation (P < .001) were associated with increased length of stay. Neither age (P = .156) nor weight-for-age z score at admission (P = .066) was predictive of length of stay.

CONCLUSIONS

Feeding methods established at admission for stage 2 palliation are not likely to change by discharge. Length of stay is more likely to be impacted by tube feeding and intubation history than age or weight-for-age z score at admission. Better understanding for selection of feeding methods and their impact on patient outcomes is needed to develop evidence-based guidelines to decrease variability in clinical practice patterns and provide appropriate counseling to caregivers.

Structure and Functions of Pediatric Aerodigestive Programs: A Consensus Statement

Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

Ataxia telangiectasia: a review

Definition of the disease

Ataxia telangiectasia (A-T) is an autosomal recessive disorder primarily characterized by cerebellar degeneration, telangiectasia, immunodeficiency, cancer susceptibility and radiation sensitivity. A-T is often referred to as a genome instability or DNA damage response syndrome.

Epidemiology

The world-wide prevalence of A-T is estimated to be between 1 in 40,000 and 1 in 100,000 live births.

Clinical description

A-T is a complex disorder with substantial variability in the severity of features between affected individuals, and at different ages. Neurological symptoms most often first appear in early childhood when children begin to sit or walk. They have immunological abnormalities including immunoglobulin and antibody deficiencies and lymphopenia. People with A-T have an increased predisposition for cancers, particularly of lymphoid origin. Pulmonary disease and problems with feeding, swallowing and nutrition are common, and there also may be dermatological and endocrine manifestations.

Etiology

A-T is caused by mutations in the ATM (Ataxia Telangiectasia, Mutated) gene which encodes a protein of the same name. The primary role of the ATM protein is coordination of cellular signaling pathways in response to DNA double strand breaks, oxidative stress and other genotoxic stress.

Diagnosis

The diagnosis of A-T is usually suspected by the combination of neurologic clinical features (ataxia, abnormal control of eye movement, and postural instability) with one or more of the following which may vary in their appearance: telangiectasia, frequent sinopulmonary infections and specific laboratory abnormalities (e.g. IgA deficiency, lymphopenia especially affecting T lymphocytes and increased alpha-fetoprotein levels). Because certain neurological features may arise later, a diagnosis of A-T should be carefully considered for any ataxic child with an otherwise elusive diagnosis. A diagnosis of A-T can be confirmed by the finding of an absence or deficiency of the ATM protein or its kinase activity in cultured cell lines, and/or identification of the pathological mutations in the ATM gene.

Differential diagnosis

There are several other neurologic and rare disorders that physicians must consider when diagnosing A-T and that can be confused with A-T. Differentiation of these various disorders is often possible with clinical features and selected laboratory tests, including gene sequencing.

Antenatal diagnosis

Antenatal diagnosis can be performed if the pathological ATM mutations in that family have been identified in an affected child. In the absence of identifying mutations, antenatal diagnosis can be made by haplotype analysis if an unambiguous diagnosis of the affected child has been made through clinical and laboratory findings and/or ATM protein analysis.

Genetic counseling

Genetic counseling can help family members of a patient with A-T understand when genetic testing for A-T is feasible, and how the test results should be interpreted.

Management and prognosis

Treatment of the neurologic problems associated with A-T is symptomatic and supportive, as there are no treatments known to slow or stop the neurodegeneration. However, other manifestations of A-T, e.g. immunodeficiency, pulmonary disease, failure to thrive and diabetes can be treated effectively.

Assessment of impaired coordination between respiration and deglutition in children and young adults with ataxia telangiectasia

AIM

This cross-sectional investigation aimed to assess the value of non-invasive measures of temporal respiratory-swallow coupling in individuals with ataxic swallowing.

METHOD

Twenty participants (11 males, 9 females; range 9-21y) with ataxia telangiectasia were presented with water and pudding boluses. Their 193 swallows were compared with 2200 swallows from 82 age-matched healthy controls. The two components of airway protection during swallowing that were analyzed were: direction of peri-deglutitive airflow and duration of deglutitive inhibition of respiratory airflow (DIORA).

RESULTS

Safe expiratory patterns of peri-deglutitive airflow occurred significantly less often in participants with ataxia telangiectasia than in age-matched control participants (younger p<0.015 and older p<0.001). The frequency of an expiratory pattern of peri-deglutitive airflow increased with age in participants in the comparison group (p=0.006), but not in those with ataxia telangiectasia (p=0.234). With age, mean duration of DIORA decreased in controls (p<0.001) but was unchanged in participants with ataxia telangiectasia (p=0.164).

INTERPRETATION

Non-invasive quantitative measures of respiratory-swallow coupling capture temporal relationships that plausibly contribute to airway compromise from dysphagia. Changes in respiratory-swallow coupling observed with advancing age in control participants were not seen in participants with ataxia telangiectasia. Measures of perturbations may herald swallowing problems prior to development of pulmonary and nutritional sequelae.

Financial and Health Impacts of Multidisciplinary Aerodigestive Care

OBJECTIVES

(1) Analyze upstream and downstream activity before and after enrollment with the Multidisciplinary Pediatric Aerodigestive Care Team (MPACT). (2) Identify potential demand for MPACT services with ICD-9 data.

STUDY DESIGN

Retrospective review of financial claims data.

SETTING

Tertiary care children's center.

SUBJECTS

Pediatric patients (0-18 years old) enrolled with MPACT (pediatric otolaryngology, gastroenterology, pulmonary, speech-language pathology).

METHODS

Case mix data from fiscal years (FYs) 2010-2013 were analyzed for primary, secondary, and tertiary ICD-9 codes in 4 aerodigestive diagnostic categories (ADCs): dysphagia, chronic cough, gastroesophageal disease, and chronic pulmonary disease/asthma. Inclusion criteria included patients <18 years old, seen by MPACT, with FY2010-FY2013 case mix data and ≥2 ADCs. Unique outpatient and inpatient encounters and associated charges were evaluated to determine upstream and downstream activity trends.

RESULTS

Of the 126 patients meeting inclusion criteria, 55 (44%) had ≥3 ADCs, and 11 (9%) had 4. These 126 patients received outpatient care during 3068 unique encounters. Outpatient total charges were $282,102 before and $744,542 after MPACT intervention. Eighty-six (68%) patients received inpatient care during 423 unique encounters. Inpatient charges were $4,257,137 before and $2,872,849 after MPACT enrollment. Overall, a net reduction of $921,848 in total charges, $7316 per MPACT patient, was noted. FY2010-FY2014 data identified an additional 1728 pediatric patients with ≥2 ADCs not enrolled in MPACT.

CONCLUSION

A cohort of children with aerodigestive disease experienced a shift from inpatient to outpatient care with an overall 20% reduction in patient charges when the years before and after MPACT enrollment were compared. Available ICD-9 data suggest potential demand for MPACT services.

Impact of children's feeding/swallowing problems: validation of a new caregiver instrument

The impact of caring for children with deglutition disorders is poorly understood and tools to measure the unique concerns of these caregivers are lacking. The aims of this investigation were to develop and validate The Feeding/Swallowing Impact Survey (FS-IS) as an instrument designed to measure and improve understanding of caregiver issues. Demographic, economic, and dysphagic data were provided by the primary caregivers of 164 children (median age: 14 months, male: 78, female: 86) presenting for initial outpatient feeding/swallowing evaluations. Caregivers completed the PEDS-QL™ Family Impact Module (PEDS-QL™ FIM) and the FS-IS. A principal component analysis was conducted on the FS-IS to identify appropriate subscales. Concurrent validity was assessed by examining correlations between the FS-IS and PEDS-QL™ FIM. Caring for children with feeding/swallowing problems adversely impacted the Health-Related Quality of Life (HRQoL) of their caregivers. The FS-IS had a strong 3-factor solution to indicate 3 subscales: Daily Activities, Worry, and Feeding Difficulties. All three subscales and total score of the FS-IS correlated with PEDS-QL™ FIM. The FS-IS was validated as an instrument that may help clinicians detect specific factors that influence caregiver HRQoL, identify caregivers who might benefit from additional support, and ultimately improve the care of their children with feeding/swallowing disorders.

Pulmonary function in children and young adults with ataxia telangiectasia

BACKGROUND

Pulmonary disease contributes to significant morbidity and mortality in people with ataxia telangiectasia (A-T). To determine the association between age and lung function in children and young adults with A-T and to identify factors associated with decreased lung function, pulmonary function tests were performed in 100 consecutive people with A-T.

METHODS

Children and adults ranging from 6 to 29 years of age and with the diagnosis of A-T were recruited, and underwent pulmonary function tests.

RESULTS

The mean forced vital capacity % predicted (FVC %) in the population was 56.6 ± 20.0. Males and females between 6 and 10 years of age had similar pulmonary function. Older females were found to have significantly lower FVCs % than both older males (P < 0.02) and younger females (P < 0.001). The use of supplemental gamma globulin was associated with significantly lower FVC %. A modest correlation was found between higher radiation-induced chromosomal breakage and lower FVC % in males. No significant change in FVC % was found in a subset of subjects (n = 25) who underwent pulmonary function testing on two or more occasions over an average of 2 years.

CONCLUSION

In children and young adults with A-T, older females and people who required supplemental gamma globulin had significantly lower lung function by cross-sectional analysis. Stable lung function is possible over a 2-year period. Recognition of groups who are at higher risk for lower pulmonary function may help direct care and improve clinical outcomes in people with A-T.

The impact of bronchopulmonary dysplasia on caregiver health related quality of life during the first 2 years of life

OBJECTIVES

Preterm children with bronchopulmonary dysplasia (BPD) frequently require complex home medical regimens and re-hospitalization during the first 2 years of life. The burden of caring for these medically complex children may negatively affect caregiver health related quality of life (HRQoL). The objectives of this study were to measure caregiver HRQoL of children with BPD and to identify factors that impact caregiver HRQoL during the first 2 years of life.

METHODS

Children (n = 186) were recruited from the Johns Hopkins BPD Outpatient Clinic between January 2008 and July 2011. Caregiver HRQoL was measured using The PedsQL(TM) Family Impact Module. Respiratory symptoms and morbidities were assessed using questionnaires.

RESULTS

Among caregivers of BPD children, significant improvement in physical, worry, and daily domains improved longitudinally as children aged. An association was found between lower total HRQoL scores and caregivers of BPD children who reported more respiratory symptoms and acute care usage. No difference in total HRQoL scores was found between caregivers of BPD children requiring respiratory/enteral support and caregivers of children who did not. Caregiver income and educational level did not predict total HRQoL score, but Non-White race and public insurance was associated with a higher total HRQoL score at the first outpatient visit.

CONCLUSION

An association was found between lower HRQoL scores and caregivers of BPD children with frequent respiratory symptoms and acute care usage. Screening for low HRQoL in caregivers of BPD children with frequent respiratory illnesses should be considered to identify those who may benefit from additional support and intervention.

Safety and caregiver satisfaction with gastrostomy in patients with Ataxia Telangiectasia

Background

Ataxia Telangiectasia (A-T) is a rare monogenetic neurodegenerative disease with pulmonary, nutritional, and dysphagic complications. Gastrostomy tube (GT) feedings are commonly recommended to manage these co-morbidities. In general, outcomes of GT placement in patients with progressive diseases that develop during childhood are not well characterized. The primary purposes of this study were to determine whether GT placement in patients with A-T would be tolerated and associated with caregiver satisfaction.

Methods

We completed a retrospective review of 175 patients who visited the A-T Children's Center at Johns Hopkins Hospital from 2001 through 2008, and identified 28 patients with A-T (19 males, 9 females) who underwent GT placement for non-palliative reasons. Information was obtained from medical records, interviews with primary health care providers, and 24 (83%) caregivers of patients with GT's who responded to survey requests.

Results

Twenty-five (89%) patients tolerated GT placement and were a median of 5.0 (0.4-12.6) years post GT placement at the time of this investigation. Three (11%) patients died within one month of GT placement. In comparison to patients who tolerated GT placement, patients with early mortality were older when GT's were placed (median 24.9 vs. 12.3 years, p = 0.006) and had developed a combination of dysphagia, nutritional, and respiratory problems. Caregivers of patients tolerating GT placement reported significant improvements in mealtime satisfaction and participation in daily activities.

Conclusions

GT placement can be well tolerated and associated with easier mealtimes in patients with A-T when feeding tubes are placed at young ages. Patients with childhood onset of disorders with predictable progression of the disease process and impaired swallowing may benefit from early versus late placement of feeding tubes.

Day care increases the risk of respiratory morbidity in chronic lung disease of prematurity

OBJECTIVES

Infants and children with chronic lung disease of prematurity (CLDP) are at increased risk for morbidity and mortality from respiratory viral infections. Exposure to respiratory viruses may be increased in the day care environment. The risk of respiratory morbidity from day care attendance in the CLDP population is unknown. We therefore sought to determine if day care attendance is a significant risk factor for increased respiratory morbidity and symptoms in infants and children with CLDP.

METHODS

Between January 2008 and October 2009, parents of infants and children with CLDP were surveyed. Information on perinatal history, sociodemographic information, day care attendance, and indicators of respiratory morbidity, including emergency department (ED) visits, hospitalizations, systemic corticosteroid use, antibiotic use, and respiratory symptoms, was collected on children<3 years of age. Logistic regression models were constructed to examine associations between exposure to day care and respiratory morbidities.

RESULTS

Data were collected from 111 patients with CLDP. The average gestational age was 26.2±2.0 weeks. Day care attendance was associated with significantly higher adjusted odds for ED visits (odds ratio [OR]: 3.74 [95% confidence interval (CI): 1.41-9.91]; P<.008), systemic corticosteroid use (OR: 2.22 [CI: 1.10-4.49]; P<.026), antibiotic use (OR: 2.40 [CI: 1.08-5.30]; P<.031), and days with trouble breathing (OR: 2.72 [CI: 1.30-5.69]; P<.008). Although there was an increased OR for hospitalization (OR: 3.22 [CI: 0.97-10.72]; P<.057), this did not reach statistical significance.

CONCLUSIONS

We found that day care attendance is associated with increased respiratory morbidities in young children with CLDP. Physicians should consider screening for and educating caregivers about the risks of day care attendance by young children with CLDP.

Evaluation and management of pulmonary disease in ataxia-telangiectasia

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disorder caused by mutations in the ATM gene, resulting in faulty repair of breakages in double-stranded DNA. The clinical phenotype is complex and is characterized by neurologic abnormalities, immunodeficiencies, susceptibility to malignancies, recurrent sinopulmonary infections, and cutaneous abnormalities. Lung disease is common in patients with A-T and often progresses with age and neurological decline. Diseases of the respiratory system cause significant morbidity and are a frequent cause of death in the A-T population. Lung disease in this population is thought to exhibit features of one or more of the following phenotypes: recurrent sinopulmonary infections with bronchiectasis, interstitial lung disease, and lung disease associated with neurological abnormalities. Here, we review available evidence and present expert opinion on the diagnosis, evaluation, and management of lung disease in A-T, as discussed in a recent multidisciplinary workshop. Although more data are emerging on this unique population, many recommendations are made based on similarities to other more well-studied diseases. Gaps in current knowledge and areas for future research in the field of pulmonary disease in A-T are also outlined.

Elevated serum IL-8 levels in ataxia telangiectasia

Serum interleukin (IL)-8 levels were measured in 50 patients with ataxia telangiectasia (A-T) and 22 without A-T. In a cross-sectional study, the geometric mean of IL-8 level was significantly higher in the patients with A-T (P <.0001). Elevated serum IL-8 levels in patients with A-T suggest that systemic inflammation may contribute to the disease phenotype.

Congenital nasal pyriform aperture stenosis: feeding evaluation and management

PURPOSE

We identified four patients with congenital nasal pyriform aperture stenosis (CNPAS) with feeding and respiratory difficulties. While feeding difficulties have been described in infants with other causes of nasal obstruction (e.g., choanal atresia), little attention has been focused on feeding in infants with CNPAS.

FINDINGS

All four patients were treated with nasal steroids and nasal saline and two underwent surgical repair of the CNPAS at 2 months of age. Except for gastroesophageal reflux in one patient, upper gastrointestinal tract (UGI) contrast studies were normal in all patients. Three patients underwent bedside swallow evaluations, two of whom participated in videoflouroscopic swallow studies (VFSS) because of limited oral intake or respiratory problems during feeding. These three patients presented with intact oral-motor coordination at rest and during non-nutritive sucking, and nasal whistling, nasal congestion, or breathing difficulties/desaturations with oral feeding. On VFSS, one infant had trace aspiration with thin and thick liquids. Three patients required supplemental feeding during the first year of life. All three patients with normal brain MRIs were successful oral feeders by 16 months of age, the fourth is undergoing feeding therapy at 24 months of age.

SUMMARY

Feeding problems are common in infants with CNPAS and supplemental feedings may be needed even after management of airway difficulties. Infants with CNPAS should undergo comprehensive feeding/swallowing evaluations which may include bedside swallow evaluations and VFSSs. The prognosis for transitioning to total oral feedings is good and related to the extent of the airway obstruction and presence of other comorbidities.

Polysomnographic values in adolescents with ataxia telangiectasia

Most adolescents with ataxia telangiectasia (A-T) develop progressive bulbar muscle weakness and decreased pulmonary reserve. The purpose of this study was to define the patterns of sleep and respiration during sleep, and to identify sleep-related breathing problems in subjects with A-T. To address these issues, overnight polysomnography was performed on 12 adolescents with A-T. Eleven of the 12 subjects completed overnight polysomnography. The median age was 16 years (range, 13-20 years). All subjects in the study were wheelchair-bound and the median forced vital capacity (% predicted of normal) was 44% (range, 16-82%). The mean sleep efficiency was 72.6% with a mean apnea hypopnea index (AHI) of 0.7 events/hr (range, 0-2.2). The majority of apnea/hypopneas were REM related. The mean central apnea index was 0.1 events/hr (range, 0-0.2). The mean oxygen saturation nadir was 92.7% (range, 87-96) and the mean peak end-tidal carbon dioxide ET(CO(2) ) value was 53.8 mm Hg (range, 49-60). Two of 11 subjects had ET(CO(2) ) values >or=50 mm Hg for more than 50% of total sleep time. In this study, the majority of A-T adolescents had infrequent partial or complete upper airway obstructions during sleep and minimal nighttime hypoxemia. They did, however, have decreased sleep efficiency most likely, due in part, to their underlying neurological condition. This decrease in total sleep time may underestimate hypoventilation. Based on these findings, overnight polysomnography should be considered in adolescents with A-T, particularly in those in which there is a clinical suspicion of sleep related breathing abnormalities.

Schoolchildren With Dysphagia Associated With Medically Complex Conditions

Purpose

This article reviews population trends and general characteristics of children with dysphagia in schools, provides an overview of dysphagia teams and the roles of the speech-language pathologist (SLP) in school and hospital settings, and describes assessment and treatment of swallowing and feeding problems in children with complex medical histories.

Method

A review of the literature of swallowing and feeding problems in young children and population trends for children who are at risk for dysphagia was completed. Two case studies are presented to illustrate the complexities that are common to this population and to provide practical information to maximize the health and education outcomes of children with dysphagia.

Results

SLPs in schools are increasingly evaluating and treating children with dysphagia associated with medically complex conditions. There is a rising incidence in preterm births and the survival of medically fragile children, suggesting that a greater number of children will be at risk for dysphagia in the future. Limited evidence is available to support most therapeutic interventions.

Conclusion

School-based SLPs are uniquely positioned to identify swallowing and feeding problems, evaluate and treat children with dysphagia, participate on dysphagia teams in the school setting, and interact with the medical team.

Deglutition and respiration: development, coordination, and practical implications

Temporal coordination of deglutition and respiration is essential for survival because both functions share the pharynx as a common pathway. Disruptions in this interface in young infants may result in dysphagia that may lead to aspiration and injury to the developing lung. Likewise, respiratory problems may contribute to the development of swallowing problems. This article focuses on the coordination between swallowing and breathing in infants and children, aspiration during periods of postnatal lung development and airway protective mechanisms. Identification of infants and children at increased risk for oropharyngeal dysphagia and respiratory disease is critical for optimal intervention. Assessment and management considerations are described.

Ethical and legal challenges in feeding and swallowing intervention for infants and children

Over the past decade, speech-language pathologists (SLPs) have increased their involvement in the assessment and management of infants and children with complex feeding and swallowing problems. Given the complex problems demonstrated by these infants and children that vary across a range of conditions and degrees of severity, SLPs need to increase their knowledge in all the topics covered in this issue. This article will discuss the current state of evidence-based decision making, levels of evidence for studies of treatment efficacy, ethical principles in evidence-based decision making, and ethical decision-making considerations with feeding and swallowing issues using examples of three types of populations of infants and children with complex feeding and swallowing problems.

Pediatric Feeding and Swallowing Disorders: State of Health, Population Trends, and Application of the International Classification of Functioning, Disability, and Health

Over the past two decades, the definition of the STATE OF HEALTH has been expanded from a disease-based condition to one that includes the impact of the disease on an individual's ability to function. The World Health Organization identified the International Classification of Functioning, Disability, and Health (ICF) as a potential framework for coding functional status and establishing a common, standardized language to describe and study health and health-related domains. The ICF could have significant benefits for speech-language pathologists working with children with feeding and swallowing problems. In this article, the authors describe the changes in the definition of health and justification for the ICF, review population trends relevant to pediatric feeding and swallowing disorders, and summarize potential applications of the ICF.

Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors

BACKGROUND

The presence of swallowing dysfunction in children without obvious risk factors remains under appreciated. Early identification and prompt initiation of appropriate treatments are critical for reduction of morbidities associated with dysphagia.

OBJECTIVE

: To describe the clinical presentations, radiologic characteristics, and long-term outcomes in children with oropharyngeal dysphagia presenting as unexplained respiratory problems. We completed a retrospective chart review of all children without known dysphagic risk factors upon presentation to Speech-Language Pathology (December 1991-April 1995) for feeding/swallowing evaluations because of refractory respiratory problems and dysphagic concerns, and who subsequently were diagnosed with dysphagia on Videofluoroscopic Swallow Study (VFSS). In August 2002, follow-up telephone interviews were conducted with caregivers of 14 children.

RESULTS

: We identified 19 children (mean age 1.14 years; range 0.9-5.75) with dysphagia presenting as unexplained respiratory problems. On VFSS, delayed pharyngeal swallow onset was the most common abnormal radiologic finding and always preceded penetration or tracheal aspiration. Eleven (57.9%) children aspirated. Aspiration occurred only with liquids and 100% of aspiration events were silent (i.e., no cough). Dysphagia was not a concern in 11 children at a mean age 3.2 years (range 0.7-10) and persisted in three children who were 9 years or older.

CONCLUSIONS

: Oropharyngeal dysphagia should be considered in the differential diagnosis of young children without known risk factors associated with swallowing dysfunction when they present with unexplained respiratory problems. Although the prognosis for resolution of dysphagic concerns is very good, it may take several years.

Respiratory flutter syndrome: an underrecognized cause of respiratory failure in neonates

We report the clinical and respiratory data of three neonates with flutter of the diaphragm and intercostal muscles, presenting soon after birth with respiratory failure. The breathing pattern was dirhythmic with superimposed frequencies, one regular and slow (60/min) representing the underlying respiratory rate, the other fast (> 300/min) and limited to inspiration. Nasal continuous positive airway pressure immediately normalized the breathing pattern in one infant, and improved ventilation in the two others. Pharmacologic therapy with chlorpromazine terminated the respiratory flutter and permitted weaning of ventilatory support within a few hours. Coexistent dysphagia suggested a disorder of brainstem function, although the children were otherwise developmentally normal at 8, 10, and 26 mo old. Laryngomalacia and gastroesophageal reflux were also present. We propose that the occurrence of respiratory flutter, dysphagia, laryngomalacia, and gastroesophageal reflux in a neonate constitutes a distinct clinical entity, termed the "respiratory flutter syndrome." The diagnosis of three infants with this presentation during an 18-mo period suggests that this may be a more frequent cause of respiratory failure in newborns than previously recognized.

Quantitative neurologic assessment of ataxia-telangiectasia

BACKGROUND

Ataxia telangiectasia (A-T) is a rare disorder with many distinctive neurologic features. Although there is substantial individual variation in the rate of progression of these features, their relationship to one another or to age has not been characterized.

METHODS

We formulated and tested multiple elements that assess different neurologic functions known to be affected by A-T. The overall index was applied to 52 patients with A-T, 2 to 29 years of age.

RESULTS

Seven elements items proved to be informative, and three elements were added based on face validity. In a linear regression model of individuals under 19 years of age, controlled for correlation within sibships, age accounted for 87% of the variation in the A-T Index.

CONCLUSION

Despite substantial individual variability of the phenotypic elements of A-T, scores on this multidimensional index have a very high correlation with age, indicating that there is a characteristic rate of progression of the disease, although functional domains in the brain are differentially affected. The pattern of scores suggests that a severe and a mild form of A-T may be distinguished by this quantitative measure. With further development this index may become useful as an outcome measure for treatment studies and prognosis.

Oropharyngeal dysphagia and aspiration in patients with ataxia-telangiectasia

OBJECTIVES

To determine whether patients with ataxia-telangiectasia exhibit oropharyngeal dysphagia with concomitant aspiration and to examine the relationships among swallowing function, age, and nutritional status.

STUDY DESIGN

Seventy patients (mean age, 10.7 years; range, 1.8 to 30 years) had feeding/swallowing and nutritional evaluations. Fifty-one patients, in whom there were concerns about swallowing safety, were examined with a standardized videofluoroscopic swallow study.

RESULTS

Fourteen of the 51 patients (27%) with histories suggestive of dysphagia demonstrated aspiration. Of these, silent aspiration (aspiration without a cough) occurred in 10 (71%) patients. Aspirators were significantly older than non-aspirators (mean age, 16.9 vs 10.8 years; P =.002). Advancing age was the strongest factor associated with aspiration during continuous drinking (P =.01). In patients with ataxia-telangiectasia, weight and weight/height were abnormally low at all ages and most compromised in older patients. Patients who aspirated had significantly lower mean weight (P <.002) and weight/height z scores (P <.001) than did patients who did not aspirate.

CONCLUSIONS

Oropharyngeal dysphagia is common and appears to be progressive in patients with ataxia-telangiectasia. Older patients also have a higher incidence of poorer nutritional status. The relationship between dysphagia and nutritional status deserves further investigation.

Pediatric feeding/swallowing teams

A team approach is advocated for the evaluation and management of children with impairments in deglutition. The complexity of their needs requires the coordination of evaluation and management efforts so that the impact of a child's feeding/swallowing impairment on general health, development, and overall well-being may be addressed. This article reviews the rationale supporting the use of a team approach, the organizational structures of teams, and the challenges of using a team model of service delivery to meet the needs of this population.

Ethical considerations in pediatric dysphagia

Speech-language pathologists (SLPs) are bound by ethical codes that reflect professional and institutional commitments. When professional activities involve working with children with dysphagia and other complex medical issues, SLPs frequently must make judgments that have bioethical implications. This article reviews general ethical theories and principles, examines SLPs' ethical commitments, and presents an approach for ethical decision making and reasoning. Case studies of children with dysphagia are presented to illustrate ethical dilemmas.

Anatomy, physiology, and development of feeding

Dysphagia in infants and children is usually only one part of a broad spectrum of complex medical, health, and developmental problems. As etiologies vary, so do prognoses. Increased survival rates of infants in recent years have been accompanied by an increased prevalence of neurologic, cardiorespiratory, and structural impairments that can affect nutritional status and feeding function. Knowledge of anatomy, physiology, and normal development of feeding skills is basic to the assessment and management of pediatric dysphagia.

Specialized studies in pediatric dysphagia

The evaluation and management of the pediatric patient with a feeding and swallowing disorder may require the use of specialized studies to evaluate specific aspects of swallowing function; to judge the consequences of the swallowing dysfunction; and to assess factors that may be contributing to swallowing dysfunction. Instrumental assessment of swallowing function may include upper gastrointestinal studies, videofluoroscopy or videofluoroscopic swallow studies, ultrasonography, radionuclide imaging, fiberoptic endoscopy of swallowing, and cervical auscultation. Procedures that assess the consequences and/or identify factors contributing to swallowing dysfunction may include pulse oximetry, chest x-rays, laryngoscopy and/or bronchoscopy, and pulmonary function tests. The use of such specialized procedures to evaluate children with dysphagia is the focus of this article.