4/18/2017 Disclosures • Financial: Mercy Medical Center (employment) Pediatric Dysphagia: • Non-financial: No relevant disclosures Evidence into Practice • Content: Pictures and videos of breastfeeding to follow! Emily Mayfield, MA, CCC-SLP, BCS-S, IBCLC No photos or videos please! Mayfield ICCD 2017 Mayfield ICCD 2017 Outline for Today Evidence Based Practice: what is it? • Evidence Based Practice • Goal= integrate these three • Anatomy & physiology factors to deliver high-quality service • Breastfeeding Basics • Dynamic process • Assessment principles • Allows for individualized care • Aspiration: current information & theories • Intervention principles • Time for questions Mayfield ISHA 2015 Mayfield, ISHA 2014 Evidence Based Practice: What are the Evidence Based Practice: why do we need it? (perceived) barriers? • Crucial for the sustainability of • Time our profession • Access • ASHA Code of Ethics • Research reading skills • And…it’s the best thing for our • ASHA tutorials patients and families! • Check out dysphagiagrandrounds.com! • Resistance to practice changes • Available research to read Mayfield, ISHA 2014 Mayfield, ISHA 2014 1 4/18/2017 Evidence Based Practice: ASHA Practice Portal How do we get there? • External scientific evidence • Where to find • Free/open access • www.doaj.org • Possible library access • Great analysis of topics via ASHA SIG 13 Perspectives • How to evaluate • ASHA website • EBP Tutorials • Evidence maps • http://www.cebm.net/critical-appraisal/ • Databases such as PEDro • Share the load • Form journal groups Mayfield, ISHA 2014 Mayfield, ISHA 2014 Anatomy Anatomy www.new-vis.com Mayfield ICCD 2017 Mayfield ICCD 2017 Anatomy Anatomy • Vocal fold composition • Arytenoid length Monnier, P., Bernath, M. A., Chollet-Rivier, M., Cotting, J., George, M., & Perez, M. H. (2011). Pediatric airway surgery: Management of laryngotracheal stenosis in infants and children. Pediatric Airway Surgery: Management of Laryngotracheal Stenosis in Infants and Children. http://doi.org/10.1007/978-3-642-13535-4 Mayfield ICCD 2017 Mayfield ICCD 2017 2 4/18/2017 Anatomical Deviations of the Larynx: Newborn & Adult Larynx Laryngomalacia • Laryngomalacia • Softening of laryngeal tissue • Typically symptoms present at birth or within first month • Inspiratory stridor • Difficulty feeding • Apnea/cyanosis • Etiology • Anatomic? • Inflammatory? http://cursoenarm.net/UPTODATE/contents/mobipreview.htm? http://www.entusa.com/larynx_photo.htm • Neurologic? 29/15/29939 Mayfield ICCD 2017 Mayfield ICCD 2017 Laryngomalacia Laryngomalacia • Management • Depends on severity • Manage the associated dysphagia • Typically resolves without intervention before 2 years of age • Reflux management • May require surgical intervention if severely impacting breathing/feeding Simons, J. P., Greenberg, L. L., Mehta, D. K., Fabio, A., Maguire, R. C., & Mandell, D. L. (2016). Laryngomalacia and swallowing function in children. The Laryngoscope, 126(2), 478–484. http://doi.org/10.1002/lary.25440 Mayfield ICCD 2017 Mayfield ICCD 2017 Anatomical Deviations of the Larynx: Laryngomalacia Laryngeal Cleft • Laryngomalacia endoscopic view • Congenital malformation • Benjamin, B., & Inglis, A. (1989). • Abnormal communication Minor congenital laryngeal between the posterior clefts: Diagnosis and larynx/trachea and the classification. Annals of Otology, esophagus Rhinology and Laryngology, 98(6), 417-420. Benjamin, B., & Inglis, A. (1989). Minor congenital laryngeal clefts: Diagnosis and classification. Annals of Otology, Rhinology and Laryngology, 98(6), 417-420. Mayfield ICCD 2017 Mayfield ICCD 2017 Picture: GI Motility online 3 4/18/2017 Laryngeal Cleft: Symptoms • Possible overt symptoms • Stridor • Hoarse cry • Coughing/choking with feedings • Cyanosis • Can be associated with other congenital anomalies or occur in isolation Chien, W., Ashland, J., Haver, K., Hardy, S. C., Curren, P., & Hartnick, C. J. (2006). Type 1 laryngeal cleft: Establishing a functional diagnostic and management algorithm. International Journal of Pediatric Otorhinolaryngology, 70(12), 2073– Mayfield ICCD 2017 2079. Mayfield ICCD 2017 Laryngeal Cleft: Symptoms Laryngeal Cleft: Diagnosis • Clinical presentation suspicious for cleft • Multi-disciplinary • Penetration/aspiration despite intact timing and lack of other • Collaboration amongst multiple professionals oropharyngeal pathophysiology • May include chest CT, broncho-alveolar lavage • But may also be co-occurring with other issues • • Penetration/aspiration despite typical neurodevelopment Referral to ENT • • Persistent, unexplained pulmonary issues Flexible laryngoscopy • • Penetration/aspiration typically appears to occur between the Direct/rigid scope in OR with palpation of inter-arytenoid space arytenoids • Penetration/aspiration that is persistent despite interventions Chien et al., 2006; Rahbar et al., 2006; Williams et al., 2011; Neubauer, Rosenthal, Mayfield ICCD 2017 Wooten III, Zdanski, & Drake, 2013 Mayfield ICCD 2017 . Laryngeal Cleft: Management Laryngeal Cleft: Surgical Management • Conservative • Injection laryngoplasty • Suture repair • Diet modification/swallow maneuvers based on swallow study • On-going assessment to try to wean • Reflux management • “Wait and see” • Surgical • Open or endoscopic • Gel injection or suture repair WARNING: Intra-operative video, Chien et al 2006, Ojha et al 2014 there’s blood! Mayfield ICCD 2017 Mayfield ICCD 2017 4 4/18/2017 Post-operative Dysphagia Management Swallow physiology • Typically wait at least 6-8 weeks post repair for repeat swallow study • Pediatrics: Phase model • Some advocate for clinical weaning/monitoring with repeat VFSS only as • Anticipatory Phase necessary if pt had no co-morbidities and symptomatic aspiration • Oral Preparatory Phase • (Wentland et al., 2016)(Hersh et al., 2016) • Oral Transit Phase • Pharyngeal Phase • Dysphagia may persist post-operatively • Esophageal Phase* • Neurodevelopmental compromise strongest predictor of continued need for • Leopold & Kagel, 1997; Logemann 1998 thickened liquids or NPO (Osborn et al., 2014) • Useful for organizing thoughts & guiding differential diagnosis • Infants: Add layer of suck/swallow/breathe Mayfield ICCD 2017 Mayfield ICCD 2017 Suck/Swallow/Breathe Physiology: Sucking Suck/Swallow/Breathe Physiology: Sucking • Efficient sucking is comprised of both suction & expression (compression) • (Lau & Kusnierczyk2001; Cannon et al 2016, Elad et al 2014; Geddes, Chadwick, Kent, Garbin, & Hartmann, 2010) Elad, D., Kozlovsky, P., Blum, O., Laine, A. F., Po, M. J., Botzer, E., … Ben Sira, L. (2014). Biomechanics of milk extraction during breast-feeding. Proceedings of the National Academy of Sciences of the United States of America, 111(14), 5230–5. Mayfield ICCD 2017 Mayfield ICCD 2017 Suck/Swallow/Breathe Physiology: Sucking Suck/Swallow/Breathe Physiology: Sucking • Breastfeeding vs bottle feeding • Muscle activation • Bottle feeding: ↑ buccinators & orbicularis oris • Breastfeeding: ↑ Mentalis, masseter, temporalis, M Pterygoid Ardran, Kemo, & Lind, 1958; Sakalidis et al., 2012; Geddes et al, 2008; Gomes 1996; Inoue, 1995; Sakashita 1996; Nyvquist 2001 Mayfield ICCD 2017 Mayfield ICCD 2017 5 4/18/2017 Suck/Swallow/Breathe Suck/Swallow/Breathe Physiology: Sucking Physiology: Swallowing • Swallowing • Sucking • Tongue base pressure (Rommel 2006) • Expression develops before • Pharyngeal clearance consistent use of suction (Lau et • Shortening & contraction present (Rommel 2006, 2011) al, 2000) • Adequate valving needed • Reduced pharyngeal peak pressure above the UES which disappears with increasing age (Rommel 2011) • Airway protection** • Pharyngo-esophageal sphincter opening • UES relaxation found to be less complete at time of maximum proximal pharyngeal contraction, improved with age (Rommel 2011) • UES resting tone increases with age (Jadcherla 2005) Mayfield ICCD 2017 Mayfield ICCD 2017 Suck/Swallow/Breathe Physiology: Swallowing Airway Protection • Esophageal motility • Esophageal function: Peristalsis & aerodigestive protection • Hyolaryngeal positioning • Amplitude of esophageal peristalsis increases with maturation (Gupta • Vestibule closure 2009) • Epiglottic inversion? Mayfield ICCD 2017 Epiglottic Inversion Videoswallow: Epiglottic Inversion? • Rommel 2002, Rommel 2006 • No consistent epiglottic tilting until after 5 years of age • Epiglottis moved an average 34°, range of 9°-49° • Mean age of participants was 18 months, range 2-30 months • Gosa 2012 & Gosa, Suiter, & Kahane 2014 • Absence of full epiglottic tilting during swallows of infants (age range 1 week-3 months) • Anterior movement of arytenoids was sufficient for laryngeal closure Mayfield ICCD 2017 Mayfield ICCD 2017 6 4/18/2017 Suck/Swallow/Breathe Physiology: Breathing Suck/Swallow/Breathe Coordination • Swallow Apnea • S/S/B coordination requires • Nasal airflow maintained during complex neural control sucking, swallow apnea required • Respiratory phase coordination of during swallow swallow apnea • I-I, I-E, E-E, E-I, P (Martin et al, 1994) • Term infants: E-E then I-E most dominant (Kelly et al, 2007) Mizuno, K., & Ueda, A. (2003). The maturation and coordination of sucking, swallowing, and respiration in preterm infants. Journal of Pediatrics, 142(1), 36–40. Mayfield ICCD 2017 Mayfield ICCD 2017 Suck/Swallow/Breathe Physiology: Breathing Suck/Swallow/Breathe Physiology: Breathing • Healthy preterm infants: • I-I and P most dominant (Lau et al, 2003), difference not significant when taking 6-8 oral feedings • Pattern matures