Brief Resolved Unexplained Events Symptoms Frequently Result in Inappropriate Gastrointestinal Diagnoses and Treatment.

OBJECTIVE: To determine associations between presenting symptoms and oropharyngeal dysphagia diagnoses, gastroesophageal reflux disease (GERD) diagnoses, and treatment with acid suppression medication in infants with brief resolved unexplained event (BRUE). STUDY DESIGN: We performed a prospective cohort study of infants with BRUE to review presenting symptoms and their potential impact on testing and treatment. Videofluoroscopic swallow study (VFSS) results and explanatory diagnoses were obtained from medical record review; acid suppression use was determined by parental survey. Binary and multivariable logistic regression models were used to evaluate associations between presenting symptoms and obtaining VFSS, VFSS results, GERD diagnoses, and acid suppression medication. RESULTS: Presenting symptoms were varied in 157 subjects enrolled at 51.0 ± 5.3 days of age, with many symptoms that may be related to GERD or dysphagia. Of these, 28% underwent VFSS with 71% abnormal. Overall, 42% had their BRUE attributed to GERD, and 33% were treated with acid suppression during follow-up. Presenting symptoms were significantly associated with the decision to obtain VFSS but not with abnormal VFSS results. Presenting symptoms were also associated with provision of GERD explanatory diagnoses. Both presenting symptoms and GERD explanatory diagnoses were associated with acid suppression use (aOR 2.3, 95% CI 1.03-5.3, P = .04). CONCLUSIONS: Presenting symptoms may play a role in clinicians' decisions on which BRUE patients undergo VFSS but are unreliable to make a diagnosis of oropharyngeal dysphagia. Presenting symptoms may also influence assignment of GERD explanatory diagnoses that is associated with increased acid suppression medication use.

Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients.

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

Breastfeeding in infants who aspirate may increase risk of pulmonary inflammation.

OBJECTIVE: To evaluate management strategies and pulmonary outcomes for breastfed infants with oropharyngeal dysphagia. STUDY DESIGN: We performed a retrospective cohort study of breastfed infants diagnosed with oropharyngeal dysphagia with documented aspiration or laryngeal penetration on videofluoroscopic swallow study (VFSS). Medical records were reviewed for VFSS results and speech-language pathologist recommendations following VFSS, results of chest x-ray, results of bronchoalveolar lavage (BAL) within 1 year of VFSS, and aspiration-related hospitalizations occurring before or within 1 year of VFSS. Subjects were categorized as cleared or not cleared to breastfeed based on the VFSS. Proportions were compared with Chi-square and Fisher's exact tests and means with Student's t-tests. RESULTS: Seventy-six infants (4.7 ± 0.4 months old) were included; 50% (38) had aspiration and 50% (38) had laryngeal penetration. After VFSS, 70% (53) were cleared to breastfeed while 30% (23) were not cleared to breastfeed. Patients with aspiration were less likely to be cleared to breastfeed (p = .006); however, 55% (21/38) of those with aspiration were still cleared to breastfeed. Infants cleared to breastfeed had significantly more pulmonary hospitalizations (p = .04) and were also at increased risk of elevated neutrophil count (p = .02) and culture growth on BAL (p = .01). Significantly increased abnormal neutrophil count was also found in those cleared to breastfeed with laryngeal penetration (p = .01). CONCLUSIONS: Infants with oropharyngeal dysphagia counseled to continue breastfeeding had increased risk of BAL inflammation and more pulmonary hospitalizations compared to those that were told to stop breastfeeding.

Laryngeal Penetration and Risk of Aspiration Pneumonia in Children with Dysphagia-A Systematic Review.

This study was a systematic review and meta-analysis that assessed the risk of aspiration pneumonia in children with laryngeal penetration or tracheal aspiration via a video-fluoroscopic study (VFSS) and compared the results to those for children with neither condition. Systematic searches were conducted using databases, including PubMed, Cochrane Library, and Web of Science. Meta-analysis was used to obtain summary odds ratios (OR) and 95% confidence intervals (CI). The overall quality of evidence was assessed using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. In total, 13 studies were conducted with 3159 participants. Combined results from six studies showed that laryngeal penetration on VFSS may be associated with aspiration pneumonia compared to no laryngeal penetration; however, the summary estimate was imprecise and included the possibility of no association (OR 1.44, 95% CI 0.94, 2.19, evidence certainty: low). Data from seven studies showed that tracheal aspiration might be associated with aspiration pneumonia compared to no tracheal aspiration (OR 2.72, 95% CI 1.86, 3.98, evidence certainty: moderate). The association between aspiration pneumonia and laryngeal penetration through VFSS seems to be weaker than that for tracheal aspiration. Prospective cohort studies with clear definitions of laryngeal penetration and that measure clinical and patient reported outcomes are needed to further define the association between laryngeal penetration and aspiration pneumonia.

Oral Feeding in Infants After Congenital Diaphragmatic Hernia Repair While on Non-invasive Positive Pressure Ventilation: The Impact of a Dysphagia Provider-Led Protocol.

Infants with congenital diaphragmatic hernia (CDH) who require non-invasive positive pressure ventilation or high flow nasal cannula are at risk for aspiration and delayed initiation of oral feeding. We developed a dysphagia provider-led protocol that involved early consultation with an occupational therapist or speech/language pathologist and modified barium swallow study (MBSS) to assess for readiness for oral feeding initiation/advancement on non-invasive positive pressure ventilation. The objective of this study was to retrospectively compare this intervention cohort to a historical control cohort to evaluate the protocol's impact on the time to initiate oral feeding. We describe the development and implementation of the protocol, the MBSS findings of the intervention cohort, and compared the control (n = 64) and intervention (n = 37) cohorts using Fischer's exact test and Mann-Whitney test. We found that both cohorts had similar prenatal and neonatal characteristics including age at extubation. Significantly more infants in the intervention cohort were on non-invasive positive pressure ventilation or high flow nasal cannula at the time of oral feeding initiation (84% vs. 28%, p < 0.0001). None of the control cohort infants underwent MBSS while on respiratory support. Of the intervention cohort, 15 infants underwent a MBSS while on non-invasive positive pressure ventilation; 6 had no evidence of laryngeal penetration and/or aspiration during swallowing. Infants in the control cohort initiated oral feeds significantly sooner after extubation (6 versus 11 days, p = 0.001) and attained full oral feeds earlier (20 days versus 28 days, p = 0.02) than the intervention group. There was no difference in the rate of gastrostomy tube placement (38%). Appropriate monitoring by a dysphagia provider and evaluation with clinical and radiological means are crucial to determine the safety of initiating oral feeding in term infants with CDH. Continued surveillance is needed to determine the long-term impact on oral feeding progression in this population.

Videofluoroscopic Swallow Studies and Diagnostic Outcomes in Otherwise Healthy Infants With Dysphagia.

OBJECTIVES: To evaluate videofluoroscopic swallow study (VFSS) findings in infants with dysphagia and without prior diagnoses, and to characterize the outcomes and any diagnoses that follow. METHODS: A chart review of all pediatric patients who received a VFSS at a tertiary children's hospital from November 2008 to March 2017 was performed. RESULTS: There were 106 infants (57 males and 49 females) with 108 VFSS. VFSS was normal in 18 (16.98%) infants. Regarding airway protection, 50 (47.17%) infants had laryngeal penetration, and 8 (7.55%) had tracheal aspiration; 3 (2.83%, 37.5% of all aspirators) exhibited silent aspiration. Of the 75 infants with minimum 2-year follow-up, 35 (46.67%) had no sequelae of disease and received no diagnoses. The most common diagnoses and pathologic sequelae were gastroesophageal reflux (n = 18, 24.00%), asthma (n = 8, 10.67%), laryngomalacia (n = 6, 8.00%), and tracheomalacia (n = 4, 5.33%), all consistent with United States pediatric data on prevalence. All infants (n = 51) with follow-up for dysphagia had resolution of symptoms within 9 months from VFSS order date. CONCLUSIONS: Otherwise healthy infants may show signs of dysphagia and not develop later illness. Parents can thus be counseled on the implications of dysphagia in a previously healthy infant. Our findings provide comparative statistics for future research in pediatric dysphagia.

Reliability of Machine and Human Examiners for Detection of Laryngeal Penetration or Aspiration in Videofluoroscopic Swallowing Studies.

Computer-assisted analysis is expected to improve the reliability of videofluoroscopic swallowing studies (VFSSs), but its usefulness is limited. Previously, we proposed a deep learning model that can detect laryngeal penetration or aspiration fully automatically in VFSS video images, but the evidence for its reliability was insufficient. This study aims to compare the intra- and inter-rater reliability of the computer model and human raters. The test dataset consisted of 173 video files from which the existence of laryngeal penetration or aspiration was judged by the computer and three physicians in two sessions separated by a one-month interval. Intra- and inter-rater reliability were calculated using Cohen's kappa coefficient, the positive reliability ratio (PRR) and the negative reliability ratio (NRR). Intrarater reliability was almost perfect for the computer and two experienced physicians. Interrater reliability was moderate to substantial between the model and each human rater and between the human raters. The average PRR and NRR between the model and the human raters were similar to those between the human raters. The results demonstrate that the deep learning model can detect laryngeal penetration or aspiration from VFSS video as reliably as human examiners.

Simultaneous Videofluoroscopy and Endoscopy for Dysphagia Evaluation in Preterm Infants-A Pilot Study.

Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.

Narrow Band Imaging Enhances the Detection Rate of Penetration and Aspiration in FEES.

Narrow band imaging (NBI) is widely used in gastrointestinal, laryngeal, and urological endoscopy. Its original purpose was to visualize vessels and epithelial irregularities. Based on our observation that adding NBI to common white light (WL) improves the contrast of the test bolus in fiberoptic endoscopic evaluation of swallowing (FEES), we now investigated the potential value of NBI in swallowing disorders. 148 FEES images were analyzed from 74 consecutive patients with swallowing disorders, including 74 with and 74 without NBI. All images were evaluated by four dysphagia specialists. Findings were classified according to Rosenbek's penetration-aspiration scale modified for evaluating these FEES images. Intra- and inter-rater reliability was determined as well as observer confidence. A better visualization of the bolus is the main advantage of NBI in FEES. This generally leads to sharper optical contrasts and better detection of small bolus quantities. Accordingly, NBI enhances the detection rate of penetration and aspiration. On average, identification of laryngeal penetration increased from 40 to 73% and of aspiration from 13 to 24% (each p < 0.01) of patients. In contrast to WL alone, the use of NBI also markedly increased the inter- and intra-rater reliability (p < 0.01) and the rating confidence of all experts (p < 0.05). NBI is an easy and cost-effective tool simplifying dysphagia evaluation and shortening FEES evaluation time. It leads to a markedly higher detection rate of pathological findings. The significantly better intra- and inter-rater reliability argues further for a better overall reproducibly of FEES interpretation.

Laryngeal penetration on videofluoroscopic swallowing study is associated with increased pneumonia in children.

OBJECTIVES: To determine whether children with laryngeal penetration on videofluoroscopic swallowing study are at higher risk for pneumonia than those with normal findings. METHODS: We reviewed the charts of 235 pediatric patients presenting to our Swallowing and Dysphagia clinic for videofluoroscopic swallowing study over a 3-year period. Patients with unsuccessful swallowing studies, incomplete charts, extra-laryngeal etiologies for recurrent pneumonia, or who were lost to follow up were excluded. Out of the 165 patients remaining, 58 had normal findings, 59 had laryngeal penetration, and 48 had tracheobronchial aspiration. The number of cases of pneumonia, aspiration events, and demographic data were recorded for all patients. RESULTS: Children with laryngeal penetration on videofluoroscopic swallowing study had significantly (P=0.032) more pneumonia than patients with neither penetration nor aspiration (median 2 vs. 0; mean 2.22 vs. 1.60). Furthermore, analysis revealed that glottic abnormalities (e.g. laryngeal cleft) represented a significant independent risk factor (P=0.004) for pneumonia and aspiration, while being diagnosed with a syndrome did not (P=0.343). CONCLUSION: To our knowledge, this is the first study to demonstrate that laryngeal penetration on videofluoroscopic swallowing study is associated with significantly more cases of pneumonia in children. While this remains a retrospective study demonstrating a weak association, the results suggest a need for future prospective studies to evaluate this important clinical question in children.

Assessment of laryngopharyngeal sensation in children with dysphagia.

OBJECTIVES/HYPOTHESIS: To assess laryngopharyngeal sensation, prevalence of laryngopharyngeal sensory deficit and abnormal swallowing function parameters in children with dysphagia. STUDY DESIGN: Retrospective chart review. METHODS: The medical records of children who underwent flexible endoscopic evaluation of swallowing with sensory testing (FEESST) were reviewed. Laryngopharyngeal sensory threshold (LPST) was assessed based on the threshold intensity of air pulse stimulation eliciting laryngeal adductor reflex. Swallowing function parameters including pharyngeal residue, hypopharyngeal pooling of secretions, premature spillage, laryngeal penetration, and aspiration were evaluated. Prevalence of abnormal swallowing function parameters in children with normal and impaired LPST was compared. RESULTS: Forty children with dysphagia (28 male, 12 female; age range, 3 months to 17 years) underwent FEESST. LPST was normal in six patients, moderately impaired in 20 patients, and severely impaired in 10 patients. LPST could not be measured in four patients. Children showed one or more abnormal swallowing function parameters. The prevalence of abnormal swallowing parameters in patients with normal LPST was lower than that of patients with moderately or severely impaired LPST (P < .05). The prevalence of pharyngeal residue, hypopharyngeal pooling of secretions, and spillage in patients with severely impaired LPST was higher than that of patients with moderately impaired LPST (P < .05). CONCLUSIONS: The majority of children with dysphagia have impaired LPST. The prevalence of abnormal swallowing function parameters in children with normal LPST is lower than that in children with moderately or severely impaired LPST. Prevalence of aspiration tends to increase when the abnormal swallowing function parameters are associated with severely impaired LPST.

Relationship between the Type of Laryngeal Penetration and Severity of Tracheal Aspiration in the Brain Injured

OBJECTIVE: To assess the incidence of tracheal aspiration in the brain injury patients with laryngeal penetration, and to investigate the relationship between the type of laryngeal penetration and the severity of tracheal aspiration. METHOD: One hundred videofluoroscopic swallowing tests in brain injury patients who showed laryngeal penetration were analyzed retrospectively. Laryngeal penetrations were classified into three groups: anterior, posterior and both. The incidence of the tracheal aspiration among the laryngeal penetration was evaluated. The severity of the tracheal aspiration was analyzed into the three groups: mild, moderate and severe. Each type of the laryngeal penetration were compared with the severity of the tracheal aspiration. RESULTS: Seventy-one patients showed the tracheal aspiration among the 100 patients with laryngeal penetration. The incidence of tracheal aspiration according to the type of the laryngeal penetration was 100% in both, 86.8% in posterior, and 50.9% in anterior type. The more severe tracheal aspiration was associated with the higher proportion of the posterior and both types. CONCLUSION: The incidence of tracheal aspiration in laryngeal penetration was 71%. More severe tracheal aspiration occurred with both & posterior laryngeal penetration than anterior type.