Differences in the swallowing process of newborns and healthy preterm infants: first results with a non-invasive bioimpedance and electromyography measurement system.

PURPOSE: Preterm infants (PI) have difficulty coordinating sucking, swallowing and breathing, and there is a risk of aspiration. The causes of this are not yet sufficiently understood. The aim of this study was to test a novel measurement device to measure breathing and pharyngeal processes involved in swallowing externally in everyday life to identify possible differences in neonates (NB) and PI. METHODS: Forty healthy NB were studied at 4-8 weeks of age (mean: 6.7 weeks) and 20 healthy PI (mean gestational age 30.5 weeks) at postmenstrual age (PMA) 34/35 weeks (mean PMA 35.1 weeks) during a single feeding. Surface electrodes were used to measure bioimpedance and electromyography reflecting swallow-related changes in the pharynx and muscle activation of the tongue and submental muscles. A respiratory belt was combined with recording of the depth of chest movements and the occurrence of pauses in breathing. RESULTS: Velocity and extent of pharyngeal closure did not differ significantly across the feeding period (velocity: p=0.09, closure: p=0.17), but during the first two suck-swallow bursts PI had greater velocity (p<0.001*) and extent of pharyngeal closure (p=0.004*) than NB. The duration of swallowing phases was significantly longer in PIs (p<0.001*), their muscle activation decreased faster (p<0.001*), and they had more pauses in breathing than NBs. CONCLUSIONS: The novel measurement device allowed, for the first time in everyday life, the measurement of factors influencing swallowing and breath-swallow coordination in NBs and PIs. PIs showed differences from NBs most likely due to differences in muscle strength and condition.

Safety, feasibility and diagnostic value of Clinical Swallow Examination and FEES in children between 0 and 24 months.

BACKGROUND: Clinical Swallowing Examination (CSE) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) are relevant diagnostic methods in pediatric dysphagia. Satisfactory and comprehensive healthcare is still not part of the standard diagnostic process. AIMS: The purpose of this article is to evaluate the safety, feasibility, and diagnostic value of CSE and FEES in children 0-24 months of age. STUDY DESIGN: A retrospective cross-sectional study which was conducted at the pediatric clinic of the University Hospital Düsseldorf, Germany, between 2013 and 2021. SUBJECTS: A total of 79 infants and toddlers with suspected dysphagia were included. OUTCOME MEASURES: Analyses of the cohort and FEES pathologies were performed. Dropout criterion, complications and change of diet were recorded. Chi-square identified associations between clinical symptoms and FEES results. RESULTS: All FEES examinations were performed without complications and with a completion rate of 93.7 %. Anatomical abnormalities in the laryngeal region were diagnosed in 33 children. Wet voice was significantly associated with premature spillage (p = .028). CONCLUSIONS: CSE and FEES are important and uncomplicated examinations for children with suspected dysphagia between 0 and 24 months. They are equally helpful for differential diagnosis of feeding disorders and anatomical abnormalities. The results underline the added value of combining both examinations and their importance for individual nutritional management. History taking and CSE are mandatory as they reflect the everyday eating situation. This study adds essential knowledge to the diagnostic work-up of dysphagic infants and toddlers. Standardizing the examinations and validating dysphagia scales are future tasks.

Laryngeal sensation and its association with aspiration and cough in children with neurological impairment.

BACKGROUND: Aspirations are frequent in children with neurological impairment. They significantly increase the risk for acute and chronic respiratory insufficiencies leading to high morbidity and mortality. Laryngeal sensation deficits have been linked to aspirations in adults and are a suspected cause for dysphagia in children. In a similar neurological circuit as swallowing, laryngeal receptors trigger coughing as a protective airway reflex. The aim of this study was to examine the association between impaired laryngeal sensation (ILS), aspiration, and coughing in neurologically impaired children. DESIGN AND METHODS: In a retrospective study, 110 children with suspected dysphagia underwent a clinical evaluation of swallowing and a flexible endoscopic evaluation of swallowing (FEES) between 2013 and 2019 in the children's university clinic Düsseldorf were analyzed. Laryngeal sensation was tested by the endoscopic touch method. Associations were computed using χ2 -test. RESULTS: Fifty-four patients (49.1%) had a neurological impairment, 56 patients (50.9%) had no or other comorbidities and served as a control cohort. Children with neurological impairment suffered from ILS significantly more often than children with no or other comorbidities (χ²(1) = 4.63, p = .031). ILS was associated with all other FEES variables but did not correlate with coughing. The symptom coughing correlated with aspiration in the group of neurologically impaired children and in children ILS. CONCLUSION: ILS is a potential cause of aspirations in children with neurological impairment. Physicians need to pay special attention to the occurrence of coughing in children with neurological impairment and/or ILS since it signals aspirations that took place.

Sucking patterns are not predictive of further feeding development in healthy preterm infants.

Preterm infants are at risk of experiencing difficulties in their feeding development. For a possible early identification of these, we examined the association between sucking patterns, assisted spoon feeding, and chewing skills in 40 healthy preterm infants, and the role of experience in the acquisition of these skills in a prospective longitudinal study. Sucking patterns were evaluated at 34, 37, and 44 weeks postmenstrual age (PMA), assisted spoon feeding was evaluated at 6, 9, and 12 months PMA, and chewing was evaluated at 9, 12, and 24 months PMA. Sucking patterns were rated using the Neonatal Oral Motor Assessment Scale, assisted spoon feeding was rated using the Observation List Spoon Feeding, and chewing was evaluated using the Mastication Observation and Evaluation Instrument. All infants showed progression in their oral motor skills during the study period, but not all demonstrated a stable progression of skills. Quality of sucking patterns was not associated with skill level achievement of assisted spoon feeding or with chewing. Length of experience in sucking was significantly associated with duration of supplemental tube feeding but not with the quality of the sucking pattern. Length of chewing experience was significantly associated with chewing abilities at 9 and 12 months PMA. No clinical characteristics were sufficiently predictive of oral motor skill development. Results show that sucking patterns are not predictive of subsequent feeding development in healthy preterm infants. The food consistency offered and the length of feeding experience influenced the acquisition and quality of oral motor skills differently.

New scoring system improves inter-rater reliability of the Neonatal Oral-Motor Assessment Scale.

AIM: The Neonatal Oral-Motor Assessment Scale (NOMAS) is a standardised tool to assess sucking patterns in infants to 48 weeks of postmenstrual age (PMA). In the Netherlands, the interpretation of specific NOMAS items has evolved, leading to a new scoring system. Recent research using the NOMAS describes a way of clustering the most frequent items, and the aim of this study was to determine whether those changes improved the inter-rater reliability. METHODS: The inter-rater reliability was tested by two NOMAS-certified therapists who scored 120 video recordings of 40 preterm infants, admitted to the University Hospital of Düsseldorf, Germany, at 34, 37 and 44 weeks PMA, for normal, disorganised and dysfunctional diagnosis. The NOMAS comprised 28 items and five clusters of items. RESULTS: The therapists agreed on the level of diagnoses for 116 of 120 recordings (Cohen's Κ 0.90), on an item level for 107 of 120 recordings (Cohen's Κ 0.78) and on a cluster level for 108 of 120 recordings (Cohen's K 0.90). CONCLUSION: The new scoring system improved the inter-rater reliability of the NOMAS on all levels, highlighting the importance of NOMAS user having a clear understanding on how to interpret and score each item.