Pediatric Dysphagia: Myths vs Evidence · 2019-10-18 · Pediatric Dysphagia: Myths vs Evidence Emily Mayfield, MA, CCC-SLP, BCS-S, IBCLC Julianna Hoffman Kuklin, MA, CCC-SLP ISHA

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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


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


Balas & Boren, 2000; Morris, Wooding, & Grant, 2011; Reynolds, 2016; Madhoun, Siler-Wurst, Sitaram, & Jadcherla, 2015

Myth #1: Feeding on HFNC/CPAP is perfectly safe!


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


(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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• Pharyngeal pressure• Adults

• Few studies available

• Average pressures recorded were lower, but peaks existed to 6 cm H2O and higher


(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)


• 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*


* Completed with lambs


• Objective swallowing information

• Ferrara et al., 2017


• 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


Does it have to be an “always” or “never”?


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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https://www.asha.org/practice-portal/

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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


• Movement• Pharyngeal constriction

• Fuller 2009: Pharyngeal Squeeze Maneuver vs Pharyngeal Constriction Ratio (in fluro)


• Pharyngeal elevation• Miloro et al 2014 : effortful pitch glide imitates kinematics of swallow


• 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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http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwijs4qG7MfSAhUL4oMKHZrzB0oQjRwIBw&url=http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?29/15/29939&psig=AFQjCNFpt6MU9rPumBXKCJV2KURdlHyMjA&ust=1489094655432995

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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


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”?


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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• 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)


• 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


https://www.nfant.com/

Video: fast flow feeding


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


(Chang, Lin, Lin, & Lin, 2007; Lau & Schanler, 2000; Lau, Sheena, Shulman, & Schanler, 1997; Pados et al., 2017)

Video: slow flow feeding


Brain-oriented care

• Impact of stress on infant

• Impact of stress on parents

• Motor learning and adaptation

• Impact of feeding skill on future development


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


Know the Flow!


(Pados, Park, & Dodrill, 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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Pediatric Dysphagia: Myths vs Evidence · 2019-10-18 · Pediatric Dysphagia: Myths vs Evidence Emily Mayfield, MA, CCC-SLP, BCS-S, IBCLC Julianna Hoffman Kuklin, MA, CCC-SLP ISHA