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Pediatric Dysphagia: Myths vs Evidence
Emily Mayfield, MA, CCC-SLP, BCS-S, IBCLC
Julianna Hoffman Kuklin, MA, CCC-SLP
ISHA Convention 2019
Disclosures
• Emily Mayfield• Financial
• Salary from MercyOne Des Moines/CommonSpirit Health
• Non-financial• Executive Committee/Board Member of the American Board of Swallowing & Swallowing
Disorders
• Editorial Board member: ASHA Perspectives of SIG 13: Swallowing & Swallowing Disorders
• Julianna Hoffman Kuklin• Financial
• Salary from MercyOne Des Moines/CommonSpirit Health
Mayfield/Kuklin ISHA 2019
Outline
• Why do clinical myths persist?
• Myths:• Feeding on high flow oxygen/CPAP is safe
• Thicker is always better…but there are no safe ways to thicken liquids for infants
• Instrumental exams are pass/fail
• Slow flow nipples make infants work harder to feed
• Epiglottic inversion is key to infant swallowing safety
• Questions/discussion
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Why do clinical myths persist?
• Slow adoption of research into clinical practice
• What are we reading?• And ARE we reading?
• Different perspectives and experiences
• Variable practice patterns
• Resistance to change
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Balas & Boren, 2000; Morris, Wooding, & Grant, 2011; Reynolds, 2016; Madhoun, Siler-Wurst, Sitaram, & Jadcherla, 2015
Myth #1: Feeding on HFNC/CPAP is perfectly safe!
Mayfield/Kuklin ISHA 2019
Portions of slides in this section were developed collaboratively and credit shared with: Dr. Jim Coyle, Dr. Martin Brodsky, and Dana Novotny, RRT
Pediatrics: Nasal Continuous Positive Airway Pressure & High Flow Nasal Cannula
Nasal CPAP HFNC
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Adults: High-Flow Nasal Cannula
F&P Optiflow VapoTherm Precision Flow
When is non-invasive support used?
• Pediatrics• Primary after birth vs post-extubation support• Any illness with reduced functional residual capacity (FRC)
•Adults• Post-operative pulmonary insufficiency • Respiratory failure (broad diagnostic diversity)• Avoid intubation• Post-extubation support
How it works: HFNC
• Flow• Nasopharyngeal “dead space”
wash out
• Gas conditioning• Heated & humidified=
decreased metabolic workload
• Pressure?
How it works: CPAP
•Goal: Distending pressure• Recruits lung volume• Increases the Functional
Reserve Capacity• Splint upper airways• Also: gas conditioning
Mayfield/Kuklin ISHA 2019https://youtu.be/iuUSDR4ocCY
What’s the big deal?
• Pharyngeal pressure/pressure on the bolus?
• Impact on laryngeal sensation/closure?
• Impact on breathing/swallowing coordination?
• Is it evidence of an unstable acute illness/risk of decompensation?
Guidance from the literature
• Pharyngeal pressure • Pediatrics
• CPAP: Pressure ordered might not be the pressure delivered, but it is not typically higher than ordered (De Paoli, Lau, Davis, & Morley, 2005)
• HFNC
• MULTIPLE studies available, difficult to compare findings
• Factors that influence pressure: patient weight, nare: prong ratio, location of prongs, mouth open/closed
• Variable correlation of pressure with flow…roughly 1:1 relationship except at <3 L/m
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(Collins, Holberton, & König, 2013; De Paoli et al., 2005; De Paoli, Morley, & Davis, 2002; Iyer & Chatburn, 2015; Lampland, Plumm, Meyers, Worwa, & Mammel, 2009; Sivieri, Gerdes, & Abbasi, 2013; Spence, Murphy, Kilian, McGonigle, & Kilani, 2007; Sreenan et al., 2001; Wilkinson, Andersen, Smith, & Holberton, 2008)
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Guidance from the literature
• Pharyngeal pressure• Adults
• Few studies available
• Average pressures recorded were lower, but peaks existed to 6 cm H2O and higher
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(Groves & Tobin, 2007; Okuda et al., 2017; Parke, Eccleston, & McGuinness, 2011; Parke & McGuinness, 2013; Parke, McGuinness, & Eccleston, 2009; Ritchie, Williams, Gerard, & Hockey, 2011; Ward, 2013)
Guidance from the literature
• Pharyngeal/laryngeal sensation & closure• Pharyngeal distension on CPAP: Sinha
et al, 2015; Walor et al 2005
• Laryngeal distension on CPAP: Gaenet al 1999
• Mixed results on swallow timing: Sanuki et al., 2017 (HFNC); Jadcherlaet al., 2016; Nishino et al, 1989 (NCPAP)
• Short term outcomes• Hanin et al., 2015; Leder et al 2016;
Shetty et al., 2016; Slain et al., 2017; Glackin et al., 2017; Sochet et al., 2017; Dalgleish et al., 2016
• Breathing/swallowing coordination• Sanuki et al 2017 (HFNC); Jadcherla et
al., 2016; Bernier et al., 2013*; Samson et al., 2017*; Samson et al., 2018*
Mayfield/Kuklin ISHA 2019
* Completed with lambs
Guidance from the literature
• Objective swallowing information
• Ferrara et al., 2017
Guidance from the literature
• Additional factors to consider for pediatrics• Heightened risk for (silent) aspiration
• Mizuno et al 2007, Gewolb et al 2003, Gewolb & Vice 2006, Arvedson et al 1994, Velayutham et al., 2018; Weir et al 2011
• Risk for negative pulmonary sequelae • Piccione et al 2012, Radford et al 1995
• Developmental vulnerability • Browne & Ross, 2011; Cong et al.,
2017; Hawden et al 2000, Smith et al 2011, Thoyre 2007
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Does it have to be an “always” or “never”?
Mayfield/Kuklin ISHA 2019
VS.
RESIST THE URGE TO PLANT YOUR FEET IN ONE CAMP!!
CLINICAL Decision Making
• Illness trajectory• Can the patient tolerate an
instrumental assessment?
• Patient/family goals
• What are the goals of the medical team? • Short term
• Long term
• How are we going to measure if we are meeting our goals?
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Myth #2: Thicker is Always Better, and There Are No Safe Options for Thickening In Infants• Gosa, Schooling, Coleman 2011
• Evidence Based Systematic Review
• Currently insufficient evidence base for the use of this intervention as a treatment for dysphagia
• Establishment of safe/effective feeding and swallowing skills that is least disruptive to the developmental progress of feeding acquisition
• Madhoun, Siler-Wurst, Sitaram, & Jadcherla 2015• Survey of NICU professionals across US
• High variability of thickening practices
To thicken…
• Possible Benefits• Slower moving liquids may given increased sensory information and allow for
greater motor control (Goldfield, Smith, Buonomo, Perez, & Larson, 2013)
• Improvement in swallow/breath coordination, airway protection
(Rempel & Moussavi 2005)
• Possible decrease/elimination of aspiration and penetration
(Mercado-Deane et al 2001; Gosa, Suiter, Kahane, 2011).
• Temporal Measures – duration of UES opening
(Gosa, Suiter, Kahane, 2011)
…Or Not To Thicken
• Possible Risks• Malnutrition/Dehydration
• Evidence that thickening does NOT effect bioavailability of water in healthy controls
• Impact on efficiency, and in turn reduced intake with negative impact on weight gain
• Gut Health• Woods 2012: development of necrotizing enterocolitis in premature infants using Simply
Thick®
• Nutrient density (McCallum 2011)
• Constipation/diarrhea/malabsorption
• Impact on breastmilk intake
• Inconsistency of viscosity/recipes• Viscosity varies by time, temperature, etc (Gosa and Dodrill 2016)
Thickening Options
• What type of thickener?• Infant rice cereal/oatmeal, starch, gum, Gelmix®, fortified specialty formula
• Thickening breastmilk (Martins and Krebs 2009, Almeida et al 2017)
Fortified Formula
• Rationale• Caloric density,
calcium/phosphorous
• Increased swallow safety with slow flow nipples (Dr Brown Preemie and Ultra Preemie)
• Supported with classifications of IDDSI Slightly Thick viscosities (Steele et al 2014)
• Enfamil AR 24 cal formula
Frazier, J., Chestnut, A. H., Jackson, A., Barbon, C. E. A., Steele, C. M., & Pickler, L. (2016). Understanding the Viscosity of Liquids used in Infant Dysphagia Management.Dysphagia, 31(5), 672–679.
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https://iddsi.org
Additional Considerations
• Comparable to VFSS barium viscosities• Thickening agents may result in formulas that are
thinner or thicker than test consistencies• Too thin, may not to prevent aspiration = risk of poor
pulmonary outcomes• Too thick, excessive effort expenditure = risk of fatigue
and reduction in total volume of intake, resulting in malnutrition and dehydration
• Home bottle/nipple systems must be examined in VFSS
• Consistency in preparation• Complexity of successfully carrying out thickening
liquids for infants with dysphagia• Standard instrunctions on thickeners without
consideration of makeup of specialty types of fluids (formula)
• Parent Training and compliance
(Gosa and Dodrill 2016)
Enfamil AR 24 kCal Syringe Test
Enfamil AR 24 kcal 2:1 Nectar:Thin Barium
Myth: Instrumental Exams are Pass/Fail
• ASHA Practice Portal • Visualize structures
• Assess physiology
• Presence/cause/severity of dysphagia by visualizing bolus
• Responsivity to bolus misdirection and residue
• Presence/location/amount of secretions
• Sensitivity to secretions, attempts to clear
• Determine cause of penetration/aspiration
• Effects/safety of varying bolus consistencies and strategies
https://www.asha.org/practice-portal/
Videofluoroscopic Swallow Studies
• Adults• Standardized protocols to interpret and
communicate swallowing impairments (Ex: MBSImp, ASPEKT) (Martin-Harris et al 2008, Steele et al., 2019)
• MBSImp• Standardized online training and reliability
testing• Assessment of 17 components in adults• Scoring metric• Reporting results
• Pediatrics• Standardization in the works! (Lefton-Grief
et al., 2017)• Lack of normative data, but must complete
descriptive analysis and use available norms (Weckmeuller et al., 2011; Gosa et al., 2015; Arvedson & Lefton-Grief, 2017)
Credit: MBSImp (mbsimp.com, Northern Speech Services)
No aspiration, no risk?
• What you don’t see might still hurt you…
• Factors that might increase/decrease actual aspiration risk• Impairments in timing and/or
coordination?• Normative data: Weckmeuller et al., 2011
• Frequent/deep laryngeal penetration• (Friedman & Frazier, 2000)
• Airway protection?• Residue ?• Fatigue?
• Results must be validated by clinical observation
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Video Swallow Studies Video Swallow Studies
FEES
• 3 distinct and necessary parts to FEES• Part 1
• Anatomy observation• Secretions rated• Movement of structures in view• Assessment of sensation
• Part 2• Direct evaluation of swallowing of various bolus consistencies
• Part 3• Postural, dietary, behavioral changes trialed as indicated
(Langmore, 2017)
Part 1• Anatomy
• Symmetry of structures
• Integrity/condition of structures and mucosa
• Lesions/abnormalities observed
• Secretions• Presence and severity of secretions prior to
bolus administration
• Murray Secretion Scale 1996
• Pluschinski et al 2016
• Kuo et al 2017
(Langmore, 2017)(Murray et al, Dysphagia. 1996;11:99-103.)
Part 1 - Pediatrics
• Anatomy• Appearance, movement and
function of the nasopharynx, pharynx/larynx
• Secretions• No standardized scales
• Descriptive in nature
Part 1 (Langmore, 2017)
• Movement• Vocal fold mobility
• Base of tongue retraction
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Part 1 - Pediatrics
• Movement• Vocal Fold Mobility
• Swallow Frequency
http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?29/15/29939
Part 1 (Langmore, 2017)
• Movement• Pharyngeal constriction
• Fuller 2009: Pharyngeal Squeeze Maneuver vs Pharyngeal Constriction Ratio (in fluro)
Part 1 (Langmore, 2017)
• Pharyngeal elevation• Miloro et al 2014 : effortful pitch glide imitates kinematics of swallow
Part 1 (Langmore, 2017)
• Sensation• FEEST = air pulses delivered to mucosa at juncture of arytenoids and AE folds
• “Touch Method” = light touch to arytenoids to assess for laryngeal adductor reflex
• Kaneoka 2014: touch method was significantly associated with abnormal PAS scores
• Part 2• Intake of various consistencies
• Part 3• Compensatory strategies as
indicated
(Langmore, 2017)
Part 2 – Pediatrics Part 3 – Pediatrics
• Bottle/Breast feeding trials • Response to Compensatory Strategies
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FEES – Normal Adult FEES - Infant
Pediatric FEES
• Safety/tolerance• No major complications occurred when used in NICU infants under the age of 3 months;
stable physiologic parameters (Willette et al, 2016) (Suterwala et al, 2017)
• Breastfeeding assessment (Willette et al, 2016)• Used safely and effectively during breastfeeding assessments• Not able to establish reliability due to lack of other instrumental option
• Reliability (Suterwala et al, 2017)• Good inter-rater agreement for penetration with VFSS (87%) and FEES (80%)• Good inter-rater agreement for aspiration with VFSS (90%) and FEES (80%)
• Accuracy (Armstrong et al, 2019)• Agreement between VFSS and FEES – 92% for aspiration, 56% for penetration• FEES detected more instances of penetration than VFSS (greater sensitivity to penetration
than VFSS)
Myth #4: Infants work harder to feed with a slow flowing bottle nipple
Mayfield/Kuklin ISHA 2019
Slowing the flow
• Rationale based on knowledge of typical development
• What can disrupt this typical patterning?
• What happens when flow rate exceeds ability?
• What happens when flow rate matches ability?
• How do we “know the flow”?
Mayfield/Kuklin ISHA 2019
Rationale for slowing the flow
• Organized suck/swallow/breathe patterning• Brief apnea during swallowing when vocal
folds close (Barlow, 2009; Hanlon et al., 1997; Hiss et al 2003)
• Larger the bolus, longer the apneic period?? (Shibata et al., 2017)
• More frequent swallows= decreased minute ventilation (Koenig 1990)
• Term infants are good at modulating this process (al-Sayed et al., 1994, Bamford et al., 1992)
• Maturation effect on improving coordination and phase timing (Kelly, 2007)
Wolf & Glass (1992)
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Rationale for slowing the flow
• What can alert this rhythmic patterning?• Immaturity
• Central pattern generators and cross-system interaction (Amaizu, et al., 2008; Barlow, 2009, 2010; Barlow & Estep, 2006)
• Illness• Decreased cardio-pulmonary reserve
• Decreased ability to make modifications to pattern
• Decreased endurance
Mayfield/Kuklin ISHA 2019 Wolf & Glass (1992)
(Gewolb et al., 2001; Gewolb et al., 2003; Gewolb & Vice, 2006; Indramohan et al., 2017; Jadcherla et al., 2010; McGrattan et al., 2017; Park et al., 2016; Yi et al., 2013)
Rationale for slowing the flow
• Patterning can be HIGHLY variable• Smaller bolus=less disruption
Mayfield/Kuklin ISHA 2019 (Mizuno et al., 2007)
What happens when the flow is too fast?
Infant attempts to make modifications
• Alter sucking pattern to decrease flow• Decrease suck amplitude
• Short sucking bursts
• Long pauses between bursts
• Oral loss
Infant not able to make modifications
• Airway compromise• Physiologic instability
• Aspiration
Al-Sayed et al., 1994; Capilouto & Cunningham, 2016; Craig, et al., 1999; Craig et al., 1999, Davis et al., 2013; Dodrill & Gosa, 2018; Gewolb et al., 2003; Goldfield et al., 2006; Eishima, 1991; Lee et al., 2011; Mathew, 1991; Mizuno et al., 2007
Mayfield/Kuklin ISHA 2019
https://www.nfant.com/
Video: fast flow feeding
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Stressful experiences
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What happens when the flow rate is manageable?• Anecdotal/theoretical
• Key part of infant-guided feeding
• Improved behavioral tolerance
• Optimizes stability and safety
• Supports overall positive experience
• Direct evidence• Increased intake/efficiency
• Increased physiologic stability
Mayfield/Kuklin ISHA 2019
(Chang, Lin, Lin, & Lin, 2007; Lau & Schanler, 2000; Lau, Sheena, Shulman, & Schanler, 1997; Pados et al., 2017)
Video: slow flow feeding
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Brain-oriented care
• Impact of stress on infant
• Impact of stress on parents
• Motor learning and adaptation
• Impact of feeding skill on future development
Mayfield/Kuklin ISHA 2019
Altimier & Phillips, 2013; Bader, 2014; Coughlin et al., 2009; Browne & Ross, 2011; Cong et al., 2017; Estrem et al., 2016; Hawdon et al., 2000; Mathisen et al., 2000; McDonald et al., 2013; Medoff-Cooper et al., 2009; Milette et al., 2019; Sanders & Hall, 2018; Smith et al., 2011; Spittle & Treyvaud, 2016; Tully et al., 2017; Van Den Engel-Hoek et al., 2017
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Know the Flow!
Mayfield/Kuklin ISHA 2019
(Pados, Park, & Dodrill, 2019)
Mayfield/Kuklin ISHA 2019
(Pados, Park, & Dodrill, 2019)
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Flow Rate: Bottle Feeding
•Bottle characteristics (Ross & Furham, 2015)• Hole size (Jackman, 2013; Pados, Park, Thoyre, Estrem, & Nix,
2015; Pados, Park, & Dodrill, 2019), • Pliability (Zimmerman & Barlow, 2008)
• Shape and size (Eishima, 1991; Segami 2013)• Air exchange (Lau 2015)
• Hydrostatic pressure (Lau & Schanler, 2000)
Mayfield ICCD 2017
Myth: Epiglottic Inversion Is Key To Infant Swallowing Safety• Rommel 2006
• No consistent epiglottic tilting until after age 5 years of age
• Epiglottic movement ranged average 34°, range of 9°-49°
• Gosa 2012 and Gosa, Suiter, & Kahane 2014• Absence of full epiglottic tilting
during swallows of infants
• Anterior movement of arytenoids was sufficient for laryngeal closure
Epiglottic Inversion Physiology
• Adult Movement: 2 components• Thyrohyoid approximation =
horizontal movement
• Traction of the hyoepiglotticligament = retroflexion
(Van Daele, Perlman, Cassell 1995)
• Is this even physiologically possible for infants/young children?
www.new-vis.com
Video Swallow: Epiglottic Inversion? Thank you!
It is not enough to do your best; you must know what to do, and then do your best.—Attributed to W.E. Deming
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