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Neonatal Instrumental Swallowing Assessment

Scientific Principles to Maximize Diagnostic & Therapeutic Yield

Objectives

Describe normal oropharyngeal sucking and swallowing physiology.

Identify one way that variability in fluoroscopic execution may negatively impact diagnostic results.

Describe two indications for performing an infant FEES exam.

Agenda

I. Oropharyngeal Feeding PhysiologyII. Indications for Instrumental AssessmentIII. State of the Science in Videofluoroscopic Swallow Study ExecutionIV. Extrapolating Fluoroscopic Findings to Determine Clinical TreatmentsV. FEES Expansion to New Populations: What’s in the EvidenceVI. Clinical Considerations of FEES with Bottle Feeding & Breast Feeding

Infants

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Oropharyngeal Feeding Physiology

Supports & DisclosuresSalary Support University of Minnesota Masonic Children’s Hospital

Grants and Research Support NSF, IIP, 1735858, Non-Invasive Neonatal Feeding Assessment Device (I-Corps STEM

Team, PI: McGrattan) University of Chicago New Venture Challenge, Non-Invasive Neonatal Feeding

Assessment Device (PI: McGrattan) University of Chicago Innovation Fund, Non-Invasive Neonatal Feeding Assessment

Device (PI: McGrattan) NIH, NIDCD, 1R01HD096881-01A1, The Effect of Sensory Interventions on Swallowing

and Respiration Through Neurological Maturation in Preterm Infants (PI: German) Biogen, Phenotypes of Swallowing Physiology & Function Among Patients with Spinal

Muscular Atrophy Type 1 (PI: McGrattan)

Disclosures nuBorn Medical, VP of Research Biogen, Consultant

Basic Physiology of Bottle Feeding

Sucking Swallow Respiration

Coordination

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Sucking Physiology

Compression

Positive pressure generated within the nipple as the lingual surface rises in an anterior-posterior wave of contraction.

Intraoral Suction

Negative pressure generated in the oral cavity as the lingual-mandibular complex moves in an inferior-anterior trajectory in preparation for the next sucking cycle.

Sameroff, 1968Bosma, 1990

Sucking Physiology

Compression

Positive pressure generated within the nipple as the lingual surface rises in an anterior-posterior wave of contraction.

Intraoral Suction

Negative pressure generated in the oral cavity as the lingual-mandibular complex moves in an inferior-anterior trajectory in preparation for the next sucking cycle.

Sameroff, 1968Selley, 1990

+

0.0

-160.0

mm

Hg

0.0

2.0

mm

Hg

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Normal ValuesHealthy Term Infant at Birth

Suck/Burst 10.27Suck Burst Break Duration 13.44 secondsSucking Rate 1.14 sucks/ secondAmplitude -107.81 mmHg*Values from infants assessed within 10 hours of birth

Suck Burst Suck Burst Break

Selley, 1990Lang, 2010

Medoff Cooper, 2010

Sucking Physiology: Clinical Significance

Time Since Start of Oral Intake

Suction

Compression

0.0

mm

Hg

1.5

0.0

mm

Hg

180

Lau,2000Initiation Full Oral


Suction

Compression

0.0

mm

Hg

1.5

0.0

mm

Hg

180

(Lau,2000)Time Since Start of Oral IntakeInitiation Full Oral

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Postmenstrual Age

Suction

Compression

0.0

mm

Hg

1.5

0.0

mm

Hg

180

Lau,2000


Overall Transfer (%)

Suction

Compression

0.0

mm

Hg

1.5

0.0

mm

Hg

180

Lau,2000


Rate of Transfer (mL/min)

Suction

Compression

0.0

mm

Hg

1.5

0.0

mm

Hg

180

Lau,2000

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Number of Oral Feeds per Day

Suction

Compression

0.0

mm

Hg

1.5

0.0

mm

Hg

180

Lau,2000

Sucking Adaptations for Swallowing Abilities

Suction DurationSuction Amplitude

LowFlow

HighFlow

-50

0

0.5

0.0

mm

Hg

seco

nds

LowFlow

HighFlow

Mathew, 1991Scheel, 2005

Oropharyngeal Sensory-Motor Cascade

VVIIIXXXII

Afferent

VVIIIXXXII

Efferent

DSGVSG

Laryngeal Elevation

Laryngeal Excursion

Soft Palate Elevation

Tongue Base Retraction

Pharyngeal Contraction

PES Opening

Esophageal Clearance

Cranial Nerves

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Pharyngeal Swallow Functions

19

Airway Closure

Bolus Clearance

Laryngeal Elevation

Laryngeal Excursion




PES Opening



20

Airway Closure

Bolus Clearance

Laryngeal Elevation

Laryngeal Excursion




PES Opening


Airway ClosureLaryngeal Elevation

Anterior Laryngeal Excursion

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Airway Closure

Bolus Clearance

Laryngeal Elevation

Laryngeal Excursion




PES Opening


Pharyngeal Clearance

23

Biogen-04163


Pharyngeal Stripping Wave

Personal communication: Dr Katlyn McGrattan

Deglutition Inducted Respiratory Cessation

0.67 Seconds

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Indications & Selection of Instrumental Assessment

High Incidence of Silent Aspiration

Author Year Population Age Sample Size Incidence of Silent Aspiration

Arvedson 1994 Heterogenous 5.8 ± 5.9 yrs 186 94%

Lundine 2018 Cardiac, Single Ventricle

50 NA 93%

Ferrera 2017 Preterm, CPAP 37 wks 7 100%

Jackson 2016 Down Syndrome NA 61 90%

Irace 2019 Laryngomalacia 7.9 mths 50 98%

Weir 2011 Heterogenous 1.4 yrs 300 77%

*Does not speak to other more subtle signs of impairment or coughs later in feed

Almost all infants who aspirate on videofluoroscopy do so without an overt cough response:

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Clinical Swallowing Assessment Algorithm

Clinical Swallow

Assessment

PositiveAirway Invasion

NegativeNo Airway Invasion

VFSS

- Discharge- Behavioral Treatment- Gastroenterology Workup



- Nipple Modification- Thickening- Alternative Nutrition

Questionable Accuracy of the Clinical Evaluation

Clinical Swallow

Assessment



VFSS





Arvedson, 1994Gasparin, 2017Lundine, 2018Weir, 2009,Weir, 2011

How confident should I be in forgoing a VFSS when I do not see clinical signs of aspiration?

Clinical Swallow

Assessment



VFSS





79%Range (42%-88%)

Probability You are Correct

21%Probability You are Wrong

Gasparin, 2017Lundine, 2018Weir, 2009,Weir, 2011

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How confident should I be that the patient is aspirating when I do see clinical signs of aspiration?

Clinical Swallow

Assessment



VFSS





54%Range (19%-80%)

Probability You are Correct

46%Probability You are Wrong

Gasparin, 2017Lundine, 2018Weir, 2009,Weir, 2011

When to complete instrumental assessment

When knowledge gained has the potential to change the patient’s treatment

State of the Science in Videofluoroscopic Swallow Study Assessment

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Standard Practice Parameters

‘Ultimate judgement regarding the propriety of any specific procedure or course of action must be made by the practitioner in light of the circumstances presented.’

American College of Radiology

Evidence-based guidelines developed to assist practitioners in

providing best patient care. Clinician Competencies Procedure Indications Procedure Execution Exam Interpretation

Standard Practice Parameters

‘Ultimate judgement regarding the propriety of any specific procedure or course of action must be made by the practitioner in light of the circumstances presented.’

American College of Radiology

Evidence-based guidelines developed to assist practitioners in

providing best patient care. Clinician Competencies Procedure Indications Procedure Execution Exam Interpretation

Videofluoroscopic Swallow Study ParametersAmerican College of Radiology

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Urgent Need for Guiding Parameters

Diagnostic Validity

Diagnostic Reliability

Clinical Translation

Radiation Exposure

Fragmented Care

Goals of the Videofluoroscopic Swallow Study

Identify DeficitsPhysiologyBolus Flow

Test Treatment Classes

ExtrapolationDiscrepancies Between Testing and Clinical Environments Requires

Extrapolation To Typical Feeding Contexts

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Pulse Rate

Radiation Dose and Carcinogenic Risk

Bonilha, 2018Bonilha, 2019

Interventional Radiology: 200 Gy-Cm2

Videofluoroscopic Swallow: 1.0 Gy-Cm2

Chest X-Ray: 0.1 Gy-Cm2

Radiation Dose Across Fluoroscopic Exams

Significance of Dose is Dependent on the Patient

Age, Sex and Organ Exposed

Patient & Clinician Shielding: Radiation Exposure

ALARAPrincipal guiding the fluoroscopic procedure execution in a way that keeps radiation exposure as low as

reasonably achievable.

Collimation

Magnification

Pulse Rate

Duration

Reducing these so much that you do not achieve valid results is not reasonable.

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Fluoroscopic Settings: Pulse Rate

10 0.5Seconds

Actual Physiology

‘Continuous’ Fluoroscopy30 pps

Fluoroscopy15 pps

Fluoroscopy7 pps

AirwayEntry

Swallow

30 pulses per second


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7 pulses per second

Reduced Diagnostic Yield at 15 pps

Bonilha, 2013

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Non-Linear Relationship Between Pulse Settings and Dose

Need to Increase

milliamperage

Protocol use did not increase radiation exposure

Timing of Visualization

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Clinical Changes in Sucking and Swallowing

Clinical evidence suggests feeding performance changes throughout the course of a bottle-feed:

Time into Feed

Suck

ing

Rate

Swal

low

ing

Rate

Suck

s Pe

r Sw

allo

w

Suck

ing

Ampl

itude

Koenig, 1990Lang, 2011Pollitt, 1980

Fluoroscopy Limits Duration of Visualization

Bolus Size…………………………………….0.2mLVolume Consumed per Feed………120mL (4oz)Swallowing Rate………………………..1.2/secSwallows per Feed………………………600 Swallows

Typical Feed Swallow Study Sample

20 Swallows…..…3% of Feed..........24 sec fluoro50 Swallows……..8% of Feed…………1 min fluoro75 Swallows………13% Feed.........1.5 min fluoro

Best Case ScenarioExtrapolating for 87% of

Swallows

Specific Aim

Identify the stability of oropharyngeal swallow physiology and airway protection throughout the VFSS exam.

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∗

∗

∗

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Analysis

VFSS scored frame-by-frame by two SLP’s with ≥80% reliability in scoring characteristics of oropharyngeal swallow physiology and bolus flow:

Number of Sucks per Swallow Oral Bolus Containment Prior to Swallow Bolus Location at Initiation of Swallow Timing of Initiation of Pharyngeal Swallow Bolus Airway Entry

Differences in swallow attributes between time points were tested using student t-test and Rao-Scott Chi-Square test with clustering to account for multiple data points within subjects.

McGrattan, 2019

McGrattan, 2019

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Number of Sucks per Swallow

p= 0.004

Mea

n N

umbe

r of

Suc

ksP

er S

wal

low

Time (min:sec)

0

0.5

1

1.5

2

2.5

3

0:00 0:30 1:30 2:30

p= 0.004

McGrattan, 2019

Oral Bolus Hold

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0:00 0:30 1:30 2:30

p= 0.003p= 0.001

Per

cent

of S

wal

low

s w

ith

bolu

s es

cape

to

the

phar

ynx

Time (min:sec)McGrattan, 2019

Initiation of Pharyngeal Swallowp< 0.001

Per

cent

of S

wal

low

s In

itiat

ing

Bel

ow t

he V

alle

cula

e

Time (min:sec)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0:00 0:30 1:30 2:30

p= 0.024

McGrattan, 2019

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Timing of Initiation of Pharyngeal Swallow

Mea

n Ti

min

g of

Ini

tiatio

n of

P

hary

ngea

l Sw

allo

w (

ms)

Time (min:sec)

0

50

100

150

200

250

300

0:00 0:30 1:30 2:30

p= 0.003 p= 0.032

McGrattan, 2019

Bolus Airway Entry

Per

cent

of S

wal

low

s w

ith

pene

trat

ion

or a

spir

atio

n

Time (min:sec)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0:00 0:30 1:30 2:30

p< 0.001

McGrattan, 2019

Infants with Penetration Missed

43% (13)

00:00 00:30 01:30

0% (0)7% (2)

Penetration Detected Penetration Missed McGrattan, 2019

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Infants with Aspiration Missed

67% (10)

00:00 00:30 01:30

0% (0)53% (8)

Aspiration Detected Aspiration Missed

02:30

13% (2)

McGrattan, 2019

Conclusions and Future Directions

Protocol Needed for Validity

Percentage of Low Function Attributes Potentially of Greater Significance

Further Protocol Refinement• Stability 01:30 to 02:30• Missed Events Beyond 02:30

Mechanisms Responsible for the Change

Treatment Presentations

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Fluoroscopic Interventions

ViscosityReduce Flow Rate

Nectar BariumSmaller Orifice Size

Dr. Brown’s Level 1

Dr. Brown’s Preemie




Dr. Brown’s Level 1

Dr. Brown’s Preemie




Clinician Attributes Safety to Nectar Liquid

Can’t Express Bedside so Increase Flow

Aspiration When Nectar Provided at Typical Flow

Reduced Flow + Viscosity

Nectar Barium without Nipple Change

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Verify Thin Liquid Nipple Testing Validity

Dr. Brown’s Preemie Dr. Brown’s® Level 1 Dr. Brown’s® Level 2 Dr. Brown’s® Level 3 Dr. Brown’s® Level 4

Ameda Pulsated Pressure Pump

McGrattan 2019

Verify Nipple for Nectar Barium Expression

Dr. Brown’s Preemie Dr. Brown’s® Level 1 Dr. Brown’s® Level 2 Dr. Brown’s® Level 3 Dr. Brown’s® Level 4

Ameda Pulsated Pressure Pump

McGrattan 2019

Dr. Brown’s Level 1 Nipple

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Formula Barium McGrattan 2019

Dr. Brown’s Preemie Nipple

0 10 20 30 40 50 600 10 20 30 40 50 60

Formula Barium McGrattan 2019

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Term 12 wksTypical: Thin via Level 1

Viscosity: Nectar Barium via Dr. Brown’s Level 3

Baseline: Thin Barium via Dr. Brown’s Level 1

Flow Rate: Thin Barium via Dr. Brown’s Preemie

Preterm 37 wksTypical: Thin via Preemie

Baseline: Thin Barium via Dr. Brown’s Preemie

Flow Rate: Thin Barium via Dr. Brown’s Ultra Preemie

Viscosity: Nectar Barium via Dr. Brown’s Level 2 (slow)OR

Nectar Barium via Dr. Brown’s Level 3 (fast)

Study Analysis

Lefton-Greif, 2017Martin-Harris, 2019

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Extrapolating Fluoroscopic Findings to Determine Clinical Treatments

0%10%20%30%40%50%60%70%80%90%

1 2 3 4

Percentage of Feeds with a Cough Among Healthy Non-Dysphagic Infants

Subject 1 Subject 2 Subject 3 Subject 4 Subject 5

Feed

s w

ith C

ough

Weeks Old

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Thickened Liquids: Reduce Penetration & Aspiration

Studies examining the effect of thickened liquids show an overwhelming beneficial treatment effect on reducing bolus airway entry and feeding symptoms across populations:

Cardiac(Single Ventricle

Post Stage 1 Palliation)

McGrattan, 2016

45% Aspiration ReductionNectar vs. Thin

(p=0.006)

Down Syndrome

Jackson, 2016


Laryngomalacia &Glossoptosis

Gasparin, 2017


(p=0.015)

31% Penetration ReductionNectar vs. Thin

(p=0.001)

Thickened Liquids: Improve Symptoms

Krummrich, 2016

0 10 20 30 40 50 60 70 80

ApneaBlue/DuskyCongestion

CoughResists Feeding

Respiratory IllnessVomiting

Wheezing

Effect of Thickened Liquids on Infant Symptoms

Post-Treatment Pre-Treatment

**

**

*

*

N=44

Simply Thick (41%)Thick N Easy (59%)

Thickened Liquids: Improve Symptoms

Krummrich, 2016

0 10 20 30 40 50 60 70 80

ApneaBlue/DuskyCongestion

CoughResists Feeding

Respiratory IllnessVomiting

Wheezing

Effect of Thickened Liquids on Infant Symptoms

Post-Treatment Pre-Treatment

**

**

*

*

N=44

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Significance of Laryngeal Penetration

Evaluation of outcomes among 137 infants <2 years old who exhibited isolated laryngeal penetration (no aspiration) on their first videofluoroscopy revealed:

Duncan, 2019Krummrich, 2017

26% Exhibited Aspiration on

a Follow-Up Exam

Symptoms (P<0.001)Total Hospital Admissions (P=0.035)

Pulmonary Hospital Admissions (P=0.032)

Significance of Laryngeal PenetrationEvaluation of outcomes among 137 infants <2 years old who exhibited isolated laryngeal penetration (no aspiration) on their first videofluoroscopy revealed:

Duncan, 2019Krummrich, 2017

26% Exhibited Aspiration on

a Follow-Up Exam

Symptoms (P<0.001)

Thickener Can Use on Breastmilk

Maintain Thickness Over Feed

Cohesiveness Population Requirements

Rice Cereal No No Reduces Thickness

Separates

Oatmeal No NoReduces Thickness

Separates

Xanthan Gum-Simply Thick

Yes Yes Smooth Full Term > 12 mths oldContraindicated for preterm or children <12 years if history of NEC

Carob Bean Gum- Gelmix

Yes Yes Smooth Slightly-Mildly Thick >42 wks PMAModerate-Extremely ThickMust be greater than 1 yr PMA

Modified Corn Starch- Thick & Easy- Thicken Up- Thick-It

No NoIncreases Thickness

Smooth Thick & Easy: 3+ yrs

Thicken Up: 3+ yrs

Not indicated for preterm

Foods Yes Yes Separates

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ArsenicMetalloid element commonly found as a compound in water and food as a result of contamination.

• Natural deposits• Mining• Manufacturing Processes• Metal SmeltingNaujokas, 2013

Highest Health Hazard

Agency for Toxic Substances and Disease Registry Rankings (ATSDR)

Ranks chemicals based on numerous factors that generate a composite score for their overall public health risk:• Frequency of occurrence• Toxicity• Potential for human exposure

Naujokas, 2013

Group 1 Carcinogen

Cardiovascular• Carotid Atherosclerosis• Ischemic Heart Disease

High Arsenic Exposure Effects

Cancer• Lung• Bladder• Kidney

4x Mortality

>850µg/L

>100µg/L

Demonstrated Association Threshold

Typical Latency

20-30 Years

Neurologic• Neuropathy• IQ• Communication

Respiratory• Bronchiectasis Mortality• Lung Volumes & Capacities• Congestion• Cough• Lower Respiratory Infection

Immune• Infant Mortality

from Infectious Disease

• Inflammation

Naujokas, 2013

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Food & Water Contamination

Drinking WaterWells

10µg/L

U.S. Environmental Protection Agency

Threshold Regulated in government managed water lines to be

within threshold bounds but not in wells.

Duncan, 2019Carignan, 2015

Food ExposureRice

Limited known on low level

exposure effects

Present in low volumes in rice products , grains, and

infant formula.¾ Cup Rice per Day

36 tsp

American Academy of Pediatrics

Higher Infant Susceptibility

Children of All Ages

https://www.consumerreports.org/cro/magazine/2012/11/arsenic-in-your-food/index.htm


Arsenic Exposure: Thin Liquids

New Hampshire Birth Cohort Study• 10% families had water exceeding 10µg/L• Maximum 189 µg/L

7.5x

For every 1oz in formula intake2.6% in arsenic level

Arsenic in formula fed than breast fed

infants

Carignan, 2015

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Sources of Infant Arsenic Exposure

Rice Cereal54%

Other Solids19%

Water18%

Formula9%

AssumptionsWater: 0-10 µg/LCereal: .0007 µg/L6 tsp Daily Rice Cereal (4mth)

Average Daily Dose of Arsenic

Shibata, 2016

Lifetime Cancer Risk: Arsenic in Infancy

World HealthAcceptable Cancer

Risk from Water

10-5

Total Infant Intake Risk

10-5

Much more research needed in acceptable low

levels

Minimal Risk

Higher rice intake paces infants at more than minimal risk (10-6)

for carcinogenic effects:

Formula…………….….4 oz/120mLFeeds…………………….6/dayMildly Thick……….…1 tsp/20mLTotal Intake…………..36 tsp/day

Shibata, 2016

6 tsp/day 4 mths

Increasing viscosity or fluid intake will place above APA

36 tsp


Duncan, 2019

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International Thickening Standardization: IDDSI

THIN½ NECTAR

NECTAR

HONEY

HONEY +

THIN (0-1mL)

SLIGHTLY THICK (1-4ml)

MILDLY THICK (4-8mL)

MODERATELY THICK (8-<10mL)

EXTREMELY THICK

Old New

Cichero, 2017

IDDSI Flow Testing: Liquid Testing

Caution:

Syringe type influences results. Be sure to use a syringe with 10mL scale measuring 61.5mm and a luer tip.

Extremely thick liquids should be measured with the fork test

www.iddsi.org THIN (0-1mL)

SLIGHTLY THICK (1-4ml)

MILDLY THICK (4-8mL)

MODERATELY THICK (8-<10mL)

EXTREMELY THICK (Fork)

Anna Maunu Abbey Sterkowitz Abbey Spoden

Effect of Common Formula Variables on Thickness

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Non AR Formulas

0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

Non AR Ready to Feed Formula Thickness20 kcal/oz

Enfamil Infant Similac Advance

Thin

Slightly Thick

Mildly Thick

Moderately Thick

*Lines offset to show dimension only both were 0

0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

Effect of Non AR Ready to Feed vs Powder Formula on Thickness20 kcal/oz

Enfamil Infant RTF Enfamil Infant P Similac Advance RTF Similac Advance P

Thin

Slightly Thick

Mildly Thick

Moderately Thick

*Lines offset to show dimension only all were 0

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0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

Effect of Caloric Density on Non AR Enfamil Infant Powder Formula Thickness

Enfamil Infant 20 Enfamil Infant 22 Enfamil Infant 24

Enfamil Infant 26 Enfamil Infant 28 Enfamil Infant 30

Thin

Slightly Thick

Mildly Thick

Moderately Thick


0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

Effect of Caloric Density on Non AR Similac Infant Powder Formula Thickness

Similac Advance 20 Similac Advance 22 Similac Advance 24

Similac Advance 26 Similac Advance 28 Similac Advance 30

Thin

Slightly Thick

Mildly Thick

Moderately Thick


Mildly Thick4-8 ml

Slightly Thick1-4 ml

8

4

1

020 24 26 30

Thin0 ml

Similac AdvanceCaloric Densities (kcal/oz)

Effect of Refrigeration and Warming on Thickness of Non AR Formulas

Residual Volume (m

l)

Moderately Thick

8-10 ml

10

20 22 22 24 24 26 26 28 28 30 30 20 20 22 22 24 24 26 26 28 28 30 30Enfamil Infant

Caloric Densities (kcal/oz)

Warmed to room temperature

After 3 hr. refrigeration

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AR Formulas

0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

AR Ready to Feed Formula Thickness20 kcal/oz

Enfamil AR Similac Spit Up

Thin

Slightly Thick

Mildly Thick

Moderately Thick

Thin

Slightly Thick

Mildly Thick

Moderately Thick

0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

AR Ready to Feed vs Powder Formula Thickness20 kcal/oz

Enfamil AR RTF Enfamil AR P Similac Spit Up RTF Similac Spit Up P

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Thin

Slightly Thick

Mildly Thick

Moderately Thick

*Manufacturer does not recommend higher than 25 kcal/ox

0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

Effect of Caloric Density on AR Enfamil Infant Powder Formula Thickness

Enfamil AR 20 Enfamil AR 22 Enfamil AR 24

Enfamil AR 26 Enfamil AR 28 Enfamil AR 30

20

22

24

26

28

30

0

1

2

3

4

5

6

7

8

9

10

0 5 10 15 20 25 30

Effect of Caloric Density on AR Similac Spit-Up Powder Formula Thickness

Similac Spit-Up 20 Similac Spit-Up 22 Similac Spit-Up 24

Similac Spit-Up 26 Similac Spit-Up 28 Similac Spit-Up 30

Thin

Slightly Thick

Mildly Thick

Moderately Thick

*Manufacturer does not recommend higher than 25 kcal/ox

Thin

Slightly Thick

Mildly Thick

Moderately Thick

0

1

2

3

4

5

6

7

8

9

10

20 22 24 26 28 30

Effect of Refrigeration and Warming on Enfamil AR Thickness

Baseline Refriderator Warm

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Thin

Slightly Thick

Mildly Thick

Moderately Thick

0

1

2

3

4

5

6

7

8

9

10

20 22 24 26 28 30

Effect of Refrigeration and Warming on Similac Spit Up Thickness

Baseline Refriderator Warm

Effect of Anti-Reflux Formula on Thickness

Thin0

1

Slightly Thick

(1/2 Nectar)

4

Enfamil InfantSimilac Advance

AR Formula20 kcal Powder

Regular Formula20 kcal Powder

Enfamil ARSimilac Spit-Up

McGrattan, 2020

Mildly Thick

(Nectar)

8

Effect of Ready to Feed Formula on Thickness

Ready to Feed Formula20 kcal

Powder Formula20 kcal

Enfamil InfantEnfamil ARSimilac AdvanceSimilac Spit-Up

McGrattan, 2020

Enfamil InfantSimilac Advance

Similac Spit-UpThin0

1

Slightly Thick

(1/2 Nectar)

4

Mildly Thick

(Nectar)

8

Enfamil AR

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Effect of Caloric Density on Thickness

McGrattan, 2020

Thin0

1

Slightly Thick

(1/2 Nectar)

4

Mildly Thick

(Nectar)

8

20 22 24 26 30Similac Advance

20 22 24 27 30

Enfamil Infant22 24

Similac Spit-Up20 22

Enfamil AR20 24

Powder FormulaAfter Mixing

26 28 30

Measurements made after manufacturer wait times

Enfamil AR Formula Powder Thickness

Thin

SlightlyThick

Mildly Thick

20kcal

22kcal

24kcal

mL

Rem

aini

ng in

Syr

inge

Time

Moderately Thick

28kcal

30kcal

0

1

2

3

4

5

6

7

8

9

10

0 10 20 30 40 50 60

Manufacturer does not recommend > 24 kcal

Enfamil AR Formula Powder Thickness Refrigeration

Thin0

1

Slightly Thick

(1/2 Nectar)

4

Mildly Thick

(Nectar)

8

Moderately Thick

(Honey)

10

Immediately20

3 Hrs Cold20

3 Hrs Warmed20

Refrigeration

30 30 30

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Projected Time to Aspiration Resolution: Healthy Infants

In a sample of 50 otherwise healthy infants (<12 mths) without significant comorbidities or laryngeal anomalies identified on laryngeal endoscopy:

6.7 Months (IQR: 1-28)

Average Time to Resolution

Casazza, 2019

46% Probability of Resolution6 mths after detection





Casazza, 2019

64% Probability of Resolution1 yr after detection





Casazza, 2019

76% Probability of Resolution2 yrs after detection

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Average Time to Resolution6.7 Months (IQR: 1-28)

Casazza, 2019

81% Probability of Resolution4 yrs after detection

Projected Time to Recovery: Pediatric Co-Morbidities

In a sample of 46 pediatric patients (1.57 yrs, range 6wks-9yrs) without a laryngeal cleft as identified on direct laryngeal endoscopy/bronchoscopy:

Thin Liquid Aspiration(N=21)

87% Exhibited Full Resolution

8 mthsTime to Full Recovery

Thickened Liquid Aspiration(N=15)

80% Exhibited Full Resolution

10 mthsTime to Full Recovery

Science Standwww.ScienceStand.org

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[email protected] CPAA_UMNScience Stand

www.ScienceStand.org

Alexander, N. S. L., J.Z.; Bhushan, B.; Holinger, L.D.; Schroder, J.W. (2015). Postoperative observation of children after endoscopic type 1 posterior laryngeal cleft repair. Otolaryngol Head Neck Surg, 152(1), 153-158.

Bonilha HS, Wilmskoetter J, Tipnis SV, Martin-Harris B, Huda W. Estimating thyroid doses from modified barium swallow studies. Health Phys. 2018;115(3):360-68.

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Bonilha HS, Blair J, Carnes B, Huda W, Humphries K, McGrattan K, et al. Preliminary investigation of the effect of pulse rate on judgments of swallowing impairment and treatment recommendations. Dysphagia. 2013;28(4):528-38.

Casazza, G. C. G., M.E.; Asfour, F.; O'Gorman, M.; Skirko, J.; Meier, J.D. (2019). Aspiration in the otherwise healthy infant- is there a natural course for recovery. Laryngoscope. doi:10.1002/lary.27888

Cichero, J. A. L., P.; Steele, C.M.; Hanson, B.; Chen, J.; Dantas, R.O.; Duivestein, J.; Kayashita, J.; Lecko, C.; Murray, J.; Pillay, M.; Riquelme, L.; Stanschus, S. (2017). Development of international terminology and definitation for texture-modified foods and thickened fluids used in dysphagia management: the IDDSI framework. Dysphagia, 32(2), 293-314.

Cohen, M. S. Z., L.; Simons, J.P.; Chi, D.H.; Maguire, R.C.; Mehta, D.K. (2011). Injection laryngoplasty for type 1 laryngeal cleft in children. Otolaryngol Head Neck Surg, 144(5), 789-793.

Coppess, S. P., R.; Horn, D.; Parikh, S.R.; Inglis, A.; Bly, R.; Dahl, J.; Dudley, D.; Johnson, K. (2019). Standardizing laryngeal cleft evaluations: relaibility of the interarytenoid assessment. Otolaryngol Head Neck Surg, 160(3), 533-539.

Duncan, R. L., K.; Davidson, K.; May, K.; Rahbar, R.; Rosen, R.L. (2019). Feeding interventions are associated with improved outcomes in children with laryngeal penetration. J Pediatr Gastroenterol Nutr, 68(2), 218-224.

Gasparin, M. S., C.; Manica, D.; Maciel, A.C.; Kuhl, G.; Levy, D.S.; Marostica, P.J. (2017). Accuracy of clinical swallowing evaluation for diagnosis of dysphagia in children with laryngomalacia or glossoptosis. Pediatr Pulmonol, 52(1), 41-47.

Pollitt E, Consolazio B, Goodkin F. Changes in nutritive sucking during a feed in two-day-and thirty-day-old infants. Early human development. 1981;5(2):201-10.

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Isaac, A. E.-H., H. (2019). Type 1 laryngeal cleft and feeding and swallowing difficulties in infants and toddlers: a review. Clin Otolaryngol, 44(2), 107-113.

Jackson, A. M., J.; Moran, M.K.; Wolter-Warmerdam, K.; Hickey, F. (2016). Clinical characteristics of dysphagia in children with down syndrome. Dysphagia, 31(5), 663-671.

Krummrich, P. K., B.; Krival, K.; Rubin, M. (2017). Parent perception of the impact of using thickened fluids in children with dysphagia. Pediatr Pulmonol, 51(11), 1486-1494.

Lefton-Greif MA, McGrattan, K.E., Carson, K.A., Pinto, J.M., Wright, J.M., Martin-Harris, B. First steps towards development of an instrument for the reproducible quantification of oropharyngeal swallow physiology in bottle-fed children. Dysphagia. 2017;33(1):76-82.

Martin-Harris BC, K.A.; Pinto, J.; McGrattan, K.; Lefton-Greif, M.A., editor VFSS Measurment Tool for Swallowing Impairment in Bottle-Fed Babies: Establishing a Standard. Dysphagia Research Society; 2018; Baltimore, MD.

Mathew, O. (1991). Breathing patterns of preterm infants during bottle feeding: role of milk flow. J Pediatr, 119(6), 960-965.

McGrattan KE, McGhee H, DeToma A, Hill EG, Zyblewski SC, Lefton-Greif M, et al. Dysphagia in infants with single ventricle anatomy following stage 1 palliation: Physiologic correlates and response to treatment. Congenital Heart Disease. 2017.

McGrattan KEM, H.; McKelvey, K.; DeToma, A.; Clemmens, C.; Hill, E.; Martin-Harris, B. Changes in infant swallow function throughout the videofluoroscopic swallow study. Dysphagia. 2017;32:839

Pados, B. P., J.; Dodrill, P. (2019). Know the flow: milk flow rates from bottle nipples used in the hospital and after discharge. Adv Neonatal Care, 19(1), 32-41.

Schrank, W., Al-Sayed, L., Beahm, P., & Thach, B. (1998). Feeding responses to free-flow formula in term and preterm infants. J Pediatr., 132(3), 426-430.

Koenig JS, Davies AM, Thach BT. Coordination of breathing, sucking, and swallowing during bottle feeding in human infants. J Appl Physiol. 1985;69(5):1623-9.

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