Can We Ignore Laryngeal Penetration?

A recent retrospective study (DR Duncan et al. JPGN 2019; 68: 218-24) makes it clear that laryngeal penetration is an important finding when identified on a swallow study. The authors reviewed charts from 137 subjects (mean age 9 months) who had laryngeal penetration but not aspiration with a video swallow study (VSS).

Key findings:

  • 40% of patients with laryngeal penetration receiving thickening of feeds as treatment, 15% had a change in flow rate.  60% were maintained on thin liquids.
  • Thickening feeds was significantly associated with improvement in symptoms with OR 41.8.  91% of subjects with thickening had symptom improvement compared to 19% among group with no feeding intervention.
  • Subjects receiving a feeding intervention (thickening or change in flow rate) had decreased total  and pulmonary hospitalizations.  In contrast, in patients who did not have a feeding intervention, no significant decrease in hospitalization was noted. These data are tabulated in Table 3.  It is worth noting that those who had feeding intervention had higher risk of admission prior to feeding intervention, 0.69 compared to 0.53 for non-intervention group. Afterwards, the feeding intervention group  risk was  0.40 compared to 0.45 for the non-intervention group.
  • On followup VSS, 26% had evidence of aspiration.

One key point is that those with deep penetration were much more likely to have their feeds thickened/adjusted.

My take: This study makes it clear that all symptomatic children with laryngeal penetration should have adjustment in their feedings, most often thickening of their feeds.   These interventions appear to lower hospitalizations and are needed because in many cases the swallow dysfunction does not resolve or worsens.

Related blog posts:

Georgia Aquarium

Something Useful for Apparent Life-Threatening Events (ALTEs)

In many cases of Apparent Life-Threatening Events (ALTEs) (also called Brief Resolved Unexplained Events, BRUEs) in infants, the exact reasons are unclear.  Sometimes these events are blamed on reflux despite studies indicating this is unlikely in the vast majority (see links at bottom of post).

A recent study (DR Duncan, J Amirault, PD Mitchell, K Larson, RL Rosen. JPGN 2017; 65: 168-73) finds that oropharyngeal dysphagia is correlated with ALTEs.

In this retrospective study which took place between 2012-15, the authors reviewed all patients admitted with ALTE.  They excluded infants with underlying diseases that included known neurologic impairment, congenital heart disease, and other congenital anomalies.

Demographics:

  • Median age 49 days
  • Color change: blue 65%, pale 8%, red 10%, none 17%
  • URI symptoms: 23%
  • Relationship to feeds: during 20%, after 35%, none 45%
  • Appeared well in ED 86%

Key findings:

  • Video fluoroscopic swallow study (VFSS) [also called oropharyngeal motility swallow study] was obtained in 29%.  In this group, 73% (n=40) had evidence of aspiration or penetration.
  • 26% of patients who had clinical feeding evaluation and VFSS were ascribed as having no oropharyngeal dysphagia prior to detecting aspiration on VFSS.
  • “Of all of the diagnostic tests ordered on patients with  ALTEs, the VFSS had the highest rate of abnormalities.”

Conclusion (from authors): “Oropharyngeal dysphagia with aspiration is the most common diagnosis identified in infants presenting with ALTEs.  The algorithm for ALTE should be revised to include an assessment of VFSS as clinical feeding evaluations are inadequate to assess for aspiration.”

Related blog post: What to do with ALTEs

Also, an except and link from NASPGHAN Consensus guidelines on GERD (2009)

  • In premature infants, a relationship between GER (i.e. reflux) and pathologic apnea and/or bradycardia has not been established. Despite a lack of convincing evidence, if pathological apnea occurs in the face of pre- existing reflux, then the following two statements are the most common features:
  • Although reflux causes physiologic apnea, it causes pathologic apneic episodes in only a very small number of newborns and infants.
  • When reflux causes pathological apnea, the infant is more likely to be awake and the apnea is more likely to be obstructive in nature.
  • A diagnosis of an acute life-threatening event (ALTE) warrants consideration of causes other than GER (i.e. reflux).Reflux of gastric acid seems to be related to ALTEs (episodes of combinations of apnea, color change, change in muscle tone, choking, and gagging) in < 5 % of infants with ALTE. 
  • Link: Gastroesophageal Reflux Disease in the Pediatric  – NASPGHAN.o

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