A Case of Severe Neonatal Dysphagia

A Case of Severe Neonatal Dysphagia:
Experience and Reason
The Contemporary Management of Aerodigestive Disease in Children
2nd Aerodigestive Meeting
Vanderbilt University, Nashville, TN
Friday, November 7, 2014 at 11:15-12:15 PM
Sudarshan R. Jadcherla, MD
Professor of Pediatrics
Associate Division Chief of Neonatology, Academics
Divisions of Neonatology, Pediatric Gastroenterology and Nutrition
Director, The Neonatal and Infant Feeding Disorders Program
Principal Investigator, Innovative Research on Feeding Disorders Program
Program Director, Advance Fellowship in Infant Aerodigestive Disorders Program
Outline
• Case History with Relevance to Neonatal Dysphagia
• Approach to Diagnosis • Therapies and Outcomes
• Scientific Reasoning Symptoms, Signs and Procedures
 Full term born infant, lethal congenital heart disease underwent Domino Heart Transplant. Recovery was gradual and complete
 Severe multiple life threatening events requiring intubations, failed extubation, Prolong ICU stay and monitoring, Normal Cardio‐Respiratory functions otherwise
 Severe Feeding difficulties, GE‐reflux, Emesis, Dysphagia, Aspiration, Choking spells with Oral feeding attempts, Aspiration at Upper GI and Video‐fluoroscopy swallow study  Arching and Irritability, Symptoms with Intragastric Feeding, Refusing Oral Feeds, No response to H2 antagonists for acid suppression. Infant on metoclopramide already.
 Medical, ICU, Cardiac and Speech Therapy teams: Consideration for Gastro‐Jejunal feeds, Tracheostomy and Fundoplication
 Feeding Failure and Parents reluctant for these procedures 
Summarizing Reasoning for Feeding Failure
 Prolonged ICU Care, Mechanistic Continuous Intragastric or 



Transpyloric feeds, No motivation to Feeding, Lack of Normal Bio‐rhythms
Major Intra‐thoracic Cardiac Surgery, Inflammation, Organ Distortion, Edema and Scarring Painful procedures, Aversion to oral stimuli
Anorexia and lack of thirst, IV fluids, Concurrent medical conditions and Drug side‐effects
 Growth Failure, 3.8 kg at 13 weeks
How can fix all these problems?
Gut motility sequences at an oral feeding session
Study 1, 51 wks PMA, 3.8 Kg Catheter
Pharynx
Respiration
EMG
100
Pharynx
0
100
UES
0
100
P‐Eso
Irregular
Swallow
0
100
Irregular
Swallow
M‐Eso
0
100
LES
Diaphragm
D‐Eso
0
100
LES
0
100
Stomach
Stomach
5 s
0
mmHg
Domino heart transplant, severe GERD, multiple ALTE requiring intubation
Mal‐adaptation: Esophageal stimulus and Respiratory symptoms
300
Px‐Inf.
0
300
M‐Eso‐Inf.
Regular Respiration
Regular Respiration
Infusion
0
Respiration
Irregular respiration
EMG
Cough
100
Pharynx
Cough
Apnea
0
100
UES
0
100
UES low resting pressure
P‐Eso
0
100
Clearing PP
M‐Eso
0
100
Incomplete PP
PP
D‐Eso
0
100
LES
0
100
Stomach
LES Relaxation
0
EKG
LESR
LES Relaxation
Feeding Management Strategies








Treatment of GER, Acid suppressive therapy with PPI
Avoidance of Metoclopramide Continuous gavage feeds – Simulated bolus feeds – Bolus feeds Postural adaptation and rotation, Minimizing Sensory Stimuli, Sensory modification
Consistent occupational therapy, Pacing, Posture, oromotor stimulation, Pacifier, Kangaroo Care, Non‐nutritive sucking with feeds
Permissive volume restriction possibly stimulating thirst, Hunger manipulation, Positive reinforcement
Introduce Oral feeds, Aim for Quality of feeding session, Regulated flow of feeds, Slow feeds, Feeding session for ~30 min
Close monitoring for bradycardias or desaturation
 Outcomes:  Full PO feeding achieved
 Averted G‐tube, Tracheostomy, and Fundoplication Scientific Reasoning: Gut motility sequences Modified during Oral Feeding Study 1, 51 wks PMA, 3.8 Kg Study 2, 60 wks PMA, 4.7 Kg
Catheter
Pharynx
Respiration
EMG
100
Pharynx
0
100
UES
0
100
P‐Eso
Irregular
Swallow
Suck
0
100
Irregular
Swallow
M‐Eso
Well Coordinated Swallow
0
100
LES
Diaphragm
Suck
D‐Eso
0
100
LES
0
100
Stomach
Stomach
5 s
10 s
0
mmHg
Domino heart transplant, severe GERD, multiple ALTE requiring intubation
Same infant on full PO feeds
Scientific Reasoning: Role of pH‐Impedance Studies in Clarifying Refluxate and Symptoms
Jadcherla et al. JPEN J Parenter Enteral Nutr 2012 Scientific Reasoning: Symptom distribution
5%
49%
46%
UES
PX
P<0.001
29%
PE
33%
Esophagus
P=NS
30%
P<0.001
27%
27%
P=NS
Refluxate
P=NS
25%
DE
 Sensory (irritability, arching, pain) symptoms were similar
43%
ME
LES
P<0.001
38%
 Respiratory symptoms (cough, bradycardia, desaturation, grunting, gagging) increased with more proximal extent of acid
 Movement symptoms were greater with esophageal exposure
48%
Respiratory Symptoms
Sensory Symptoms
Movements
Jadcherla SR et al, Am J Gastroenterol 2008 Scientific Reasoning: Mapping the Pharyngeal‐Airway Reflex Interaction circuits
Jadcherla et al. Am J Gastroenterology 2009
Arching & Irritability, Desaturation and Bradycardia
Auto regulation and peristalsis

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