One important concern that prolongs hospitalisation in neonates is feeding and swallowing disorders – dysphagia. The incidence of feeding disorders and dysphagia is significant in preterm infants (26%) and is double that of the general population (13%). Dysphagia is widely prevalent (up to 90%) in patients with neurological disorders.
It is assumed that the incidence of feeding and swallowing disorders is increasing because of the improved survival rates of children with complex and medically fragile conditions and the improved longevity of persons with dysphagia that develops during childhood.
In the USA, an estimated 116,000 new-born infants are daily discharged from short-stay hospitals with a diagnosis of feeding and swallowing problems, according to the National Hospital Discharge Survey from the CDC (National Centre for Health Statistics, 2010).
Prevalence is estimated to be 30%–80% for children with developmental disorders.
Clinicians and parents are faced with long-term feeding and swallowing strategies in patients who are unsuccessful with oral feeds. Often, these decisions include exclusive chronic gavage feeding and more invasive and lifestyle-changing feeding methods such as gastrostomy placement.
Neonatal Feeding disorders are problems with a range of feeding activities that may or may not include problems with swallowing.
Feeding disorders can be characterised by one or more of the following behaviours:
- Avoiding or restricting one’s oral feeding intake.
- Displaying disruptive or inappropriate mealtime behaviours for developmental level
- Experiencing less than optimal growth (Arvedson, 2008)
Neonatal dysphagia (dys = abnormal, phagia = swallowing), can occur in one or more of the four phases of swallowing and can result in aspiration—the passage of liquid, or saliva into the trachea—and retrograde flow of formula/breastmilk into the nasal cavity.
Neonatal feeding and swallowing disorders represent a major global problem, and consequences of dysfunctional feeding and swallowing patterns carry over into infancy and toddler age groups. Growth, development, and independent feeding and swallowing skills are all delayed among high-risk infants. Such a group comprises premature birth, low-birth-weight, congenital anomalies, structural abnormalities, perinatal asphyxia, postsurgical, neurological problems, metabolic disorders, genetic syndromes, GI disorder and sepsis categories. The long-term consequences of feeding and swallowing disorders can include:
- Oral food aversion;
- Aspiration pneumonia and/or compromised pulmonary status;
- Gastrointestinal complications such as motility disorders, constipation, and diarrhea;
- Poor weight gains velocity and/or undernutrition;
- Rumination disorder;
- Ongoing need for enteral (gastrointestinal) or parenteral (intravenous) nutrition;
- Psychosocial effects on the infant and his or her family; and
- Feeding and swallowing problems that persist into childhood and adulthood, including the risk for choking, malnutrition, or undernutrition.
Signs and symptoms
Signs and symptoms vary based on the phase(s) affected and the infant’s age and developmental level. They may include the following:
- Coughing and/or choking during or after swallowing.
- Watery eyes during feeding.
- Breathing difficulties when feeding that might be signalled by: increased respiratory rate; Bradycardia or tachycardia; cyanosis; apnea; frequent stopping due to uncoordinated suck-swallow-breath pattern; and desaturation.
- Decreased responsiveness during feeding.
- Difficulty initiating swallowing.
- Difficulty managing own secretions.
- Disengagement/refusal shown turning head away from feeding bottle or/and breast.
- Frequent congestion, particularly after meals.
- Frequent respiratory illnesses.
- Slight or spike fever after meals.
- Loss of liquid from the mouth; labial spillage.
- Loss of liquid from the nose; nasal regurgitation.
- Noisy or wet vocal quality during and after eating.
- Taking longer to finish feedings.
- Taking only small amounts of the feedings.
- Vomiting (more than typical spit-up for infants).
- Chest wheezing.
- Audible stridor during feedings.
As first, a bedside feeding and swallowing assessment is done by a specialized speech language pathologist. The bedside evaluation for infants’ birth to one year of age—including those in the NICU—includes evaluation of pre-feeding skills and reflexes, assessment of readiness for oral feeding, evaluation of nutritive and non-nutritive sucking abilities, and evaluation of breast- and bottle-feeding ability.
The Speech Language Pathologist should have extensive knowledge of embryology, pre-natal and perinatal development, and medical issues common to the preterm and medically fragile new-born as well as knowledge of typical early infant development.
A referral to the appropriate medical professional should be made when anatomical or physiological abnormalities are found during the clinical evaluation.
If further objective assessment is needed, an instrumental swallowing assessment can be performed such as videofluoroscopy swallow study (VFSS) or/and fibreoptic endoscopic evaluation of swallowing (FEES).
VFSS is considered the gold standard exam for studying swallowing and its dysfunction. It is used to determine feeding safety. Pharyngo-esophageal-manometry is emerging as a complementary technique to VFSS to provide information on swallowing dynamics in patients. VFSS is designed to evaluate the oropharyngeal and esophageal anatomy pertinent to swallowing during brief exposure to fluoroscopy.
Oral feeding is commonly recommended based on the safe passage of contrast during fluoroscopic observation. Radiological findings that are considered unsafe for oral feeding include nasopharyngeal reflux, laryngeal penetration, aspiration, pooling, or delayed clearance.
Fibreoptic endoscopic evaluation of swallowing (FEES) is also a first choice method for studying swallowing disorders. It offers various advantages: easy to use, very well tolerated, allows bedside examination, is economic, no contrast used and no radiation exposure.
Both VFSS & FEES could be sometimes used as complementary diagnosis instruments.
Treatment and management: A multidisciplinary approach
Neonatal Feeding and Swallowing dysfunction leading to aspiration presents major diagnostic and therapeutic challenges that often require the efforts of a coordinated multidisciplinary team consisting of the family/caregiver, neonatologist, speech language pathologists (SLP) with expertise in feeding and swallowing, selected paediatric subspecialists (pulmonologist, gastroenterologist, otolaryngologist, neurologist, and developmental paediatricians), clinical psychologists, lactation consultant, dietician and radiologists, and a dedicated neonatal nursing team. The approach to the management of neonatal feeding disorders and dysphagia is therefore dependent on primary and secondary symptoms, feeding and growth patterns, identifying the systems or target organs of dysfunction, and clinicopathologic correlation. Such approaches therefore form the basis for individualized therapies. Additional medical and rehabilitation specialists may be included, depending on the type of facility, the professional expertise needed, and the specific population being served. The Speech Language Pathologist who specialises in feeding and swallowing disorders typically co-leads with the treating physician and the professional care team in the clinical and hospital settings.
The Speech Language Pathologist would aim his/her therapy at short term plan and long-term plan that can be carried on during the patient’s childhood.
Short term plan focuses on facilitating the development of feeding skills in the neonate, and assisting the infant in achieving stability at each level which should be viewed as important steps leading to oral ingestion.
The treatment in NICU would include (but not limited to) the following:
- Communication: SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infant’s communication signals and behaviours (Autonomic system; Movement; State; Attention).
- Readiness for oral feeding: SLPs will help improve the infant’s ability to come into and maintain awake states and to coordinate breathing with sucking and swallowing and the presence or absence of apnea.
- Interventions that would facilitate early feeding and/or promote readiness for feeding include kangaroo mother care (KMC), non-nutritive sucking (NNS), and feeding protocols.
Other interventions that would immediately improve patient’s oral feedings (according to each case aetiology and severity) includes:
- Proper positioning while the infant is in an incubator or crib is important in encouraging physiological stability and mature neural development and organization.
- Changing positioning during breastfeeds.
- Paced feeding techniques can be used with both breastfeeding and bottle feeding.
- Changing bottle nipples (shape, size and flow rate), usually depends on infant’s sucking strength and viscosity of the liquid.
- Practice oral and sensory stimulation with infants who cannot yet bottle or breast feed.
- Non-nutritive sucking stimulation which is aimed at strengthening the suck and providing a more rhythmic suck pattern.
- Tube weening (for infants who are being fed through a tube).
- Thickening liquids.
- Stimulation of better laryngeal elevation and closure through tactile-palpation exercises.
In severe cases, the infant may need to meet the nutrition and hydration needs through enteral feeds (NGT, PEG, PEJ, TPN) or dual feedings (oral feed top up with enteral feed) while continuing to have feeding and swallowing therapy.
For some cases the feeding and swallowing therapy can be part of ongoing long-term rehabilitation plan and would continue after being discharged from the NICU. These patients will be treated in an outpatient setting.