Risk profiles of infants [greater than or equal to] 32 weeks' gestational age with oropharyngeal and oesophageal dysphagia in neonatal care.
A three-group comparative study design was used. MBS data were prospectively collected and participants were assigned to the categories OPD, OD and no dysphagia. The study was conducted in a 29-bed NICU and high care in an urban, tertiary-care hospital, where expressed breastmilk via cup feeding followed by breastfeeding is promoted. Non-probability convenience sampling  was used to select as many participants as possible within the study's time limit. Prospective participants could be of any gender, present with any neonatal condition, but had to be [greater than or equal to]32 weeks' gestational age and in the NICU or high care. The sample included 49 participants with slightly more males (n=26; 53%) than females (n=23; 47%). The mean birth weight was 2.11 kg (standard deviation (SD) 0.74 kg; range 0.95-3.64 kg). The mean gestational age was 35.53 (SD 2.95; range 32-42) weeks. The participants' chronological age at data collection was 10.73 (SD 9.36; range 2-49) days.
A risk assessment checklist  was used to record pre- and peri-natal risks. A neonatal feeding assessment scale was used to observe feeding performance. MBS examinations were conducted in the lateral view to diagnose the presence and type of dysphagia. A SYSCO 19' version Multi DiagnostEleva FD screening machine (Philips, Netherlands/Holland) was used. The classification of dysphagia was guided by symptoms described by Arvedson and Brodsky.  The following symptoms were considered indicative of OPD: poor bolus formation, liquid spilling from the mouth, liquid adhering to the tongue or hard palate or that entered the sulci, piecemeal deglutition, delayed oral and/or pharyngeal transit time, aspiration before/after swallowing, pooling in the valleculae and pyriform sinuses and/ or pharyngeal recesses, velopharyngeal incoordination, reduced pharyngeal motility and laryngeal penetration. OD symptoms included cricopharyngeal dysfunction, reduced oesophageal motility, GOR, tracheo-oesophageal fistula, oesophagitis and obstruction of the oesophagus. 
Ethical clearance was granted by the Faculty of Health Sciences and the Faculty of Humanities of the University of Pretoria. Informed consent was obtained from all parents. Data were collected by a qualified speech-language therapist and three undergraduate speech-language therapy students trained in the procedures. Participants' medical records were reviewed and a structured interview was conducted with the parents. Thereafter, the mothers were observed feeding their infants. All participants were scheduled for an MBS examination within 8 days of initial contact. Data were collected prospectively until at least ten participants with no dysphagia were included as to allow statistical comparison between the three groups. MBS examinations were performed by two independent speech-language therapists experienced in the procedure in infants. The MBS team was blind to the participants' medical history and feeding observations. The MBS procedure was conducted according to recommendations for paediatric assessments.  Infants were positioned in a stable position at 45[degrees], and a thin barium mixture was presented in a bottle. Participants with positive MBS results received feeding intervention. Data from the three groups of participants were analysed. Association of discrete risk factors and dysphagia were determined using the Fisher's exact test and the relative risk ratio (RRR) from a multinomial logistic regression. Although the sample was small, it was deemed valuable to identify which dysphagia type (OPD or OD) showed a significant association with a certain risk factor. Differences between OPD and OD and continuous risk factors were assessed using a one-way analysis of variance (ANOVA). Following the ANOVA, a pair-wise comparison was conducted with Bonferroni adjustments. Associations of >0.05 were deemed significant.
From the total of 49 participants, 11 (22.5%) infants had no dysphagia, while 13 (26.5%) presented with OPD and the majority had OD (n=25 or 51%). Potential risks were grouped into categories that were kept constant across two tables, with Table 1 indicating discrete data and Table 2 showing continuous data tested for associations. Factors that showed no significance in this sample of participants with a mean gestational age of 35.53 weeks, included gestational age, birth weight, poor weight gain, number of days in incubator, Apgar score, meconium aspiration, RDS, patent ductus arteriosus and other congenital heart conditions, intraventricular haemorrhage, meningitis, septicaemia, hyperbilirubinaemia, congenital conditions such as craniofacial deformities, slow feeding, increased duration of tube feeding, refusing feeds and gagging and vomiting. It could be that the sample was too small to indicate correlations between some of these conditions and OPD and OD.
Prenatal and delivery factors
A statistically significant correlation between intrauterine growth restriction (IUGR) and OD (p=0.047), premature rupture of membranes (PROM) and OD (p=0.029) was found (Table 1). The RRR indicated that participants with OD were 5.73 more times likely to present with IUGR.
Participants with OPD were significantly older (p=0.007) and remained longer in the NICU (p=0.003) than those without dysphagia (Table 2). Both these findings were supported by significant Bonferroni adjustments. Statistically significant associations between the three groups of dysphagia with regard to respiratory support and medications received (Table 1) could not be analysed further as data were not sufficient.
Feeding and related factors
Statistically significant results were found for the remainder of feeding and related characteristics: Participants with OPD were likely to be fed via feeding tubes (p=0.02) and experience difficulties with breastfeeding (p=0.002). Results showed that nutritive sucking difficulties were significantly associated with OD (p=0.042). According to Table 1, both types of dysphagia were associated with choking (p=0.007), positing of milk (p=0.034) and hyperextension during feeding (p=0.026). Due to insufficient data only some risks for feeding could be analysed further and were found to differentiate between OPD and OD. The RRR for tube feeding and breastfeeding difficulties were strong, indicating that participants with OPD were 8.89 times more likely to be fed with a tube and 7 times more likely to experience breastfeeding difficulties. The RRR indicated that participants with OD were 5.25 times more likely to present with nutritive sucking difficulties.
In this sample of 49 participants, 51% presented with OD and 26.5% presented with OPD. When compared with an MBS diagnosis of OD or OPD, only a few clinical factors were found to be significantly associated with the two types of dysphagia in the sample of mostly late preterm infants (mean gestational age 35.53 weeks). The participants with OPD were in the NICU for longer and were older than participants with OD and no dysphagia. The correlation between increased time in the NICU and increased chronological age with both types of dysphagia is logical as infants that are seriously ill and born preterm may require longer hospitalisation.  These two seemingly similar risk factors (days in NICU and chronological age) differ, as some infants may have been born before arrival at the hospital and would therefore have spent fewer days in NICU than their age in days. The results show that those with dysphagia were not discharged early from the NICU. The purpose of early dysphagia intervention would be to prevent a lengthy NICU stay. OPD was also associated more with tube feeding than OD. While tube feeding is often the initial approach to manage feeding difficulties, it can also prolong dysphagia in preterm infants, delay treatment, negatively influence oral feeding and may increase GOR. [2,11] Problematic breastfeeding was associated more with OPD. This is consistent with the various symptoms that may be present during feeding of an infant with dysphagia. [2,5] Hyperextension during feeding influences the alignment of pharyngeal structures and places infants at risk for aspiration, a symptom of OPD.  Stressful mealtimes and fussiness are associated with dysphagia.  IUGR was associated with OD, indicating that the smaller the infant, the more likely it will present with dysphagia. Infants born small-for-gestational age are at increased risk of respiratory illnesses, including BPD and RDS, and longer use of ventilator support and oxygen supplementation.  The frequency of GOR, a condition associated with OD, is increased in infants with BPD due to an increase in positive abdominal pressure.  BPD and RDS have a known association with dysphagia, [3-5] which may further explain this result. Participants with OD were significantly more likely to present clinically with nutritive sucking difficulties than those with OPD, which is in itself a symptom of possible OPD. The reason for not observing sucking difficulties in participants with OPD may be that 76.92% of those with OPD were feeding via a tube (Table 1), thereby masking any sucking difficulties that may have been present. Only 33.33% of participants with OD were feeding via a tube, thereby allowing observations of nutritive sucking in more infants than in the OPD group. PROM is associated with OD in the sample, which may indicate an indirect risk. Preterm PROM accounts for 30-40% of preterm births and is associated with RDS in infants,  both of which have been associated with dysphagia. Both IUGR and nutritive sucking difficulties possibly indicate maturational problems found in participants with OD. It has been suggested that GOR, a condition associated with OD, is often a consequence of lower oesophageal sphincter immaturity.  Table 3 provides a summary of statistically significant factors associated with OD and OPD. The small sample size and the exclusion of extremely preterm neonates from the sample could have contributed to the few associations found.
Apart from preterm birth, OPD and OD showed distinct risk profiles that were tested against the MBS results of dysphagia in this sample of mostly late preterm infants. Although an MBS is the ideal, knowledge of the risk profiles of OPD and OD may enable personnel and speech-language therapists in the NICU and high care to identify, assess and treat infants with dysphagia timeously. Risk factors found in this study may be used as a starting point for the development of an instrument to assist in the early identification of dysphagia, which would be valuable in resource-poor settings. A larger sample is required to determine if the data can be used to indicate OPD and OD in other clinical settings.
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C Pike, BComm Path; M Pike, BComm Path; A Kritzinger, DPhil; E Kruger, MComm Path; M Viviers, MComm Path
Department of Speech-Language Pathology and Audiology, Faculty of Humanities, University of Pretoria, South Africa
Corresponding author: E Kruger (firstname.lastname@example.org)
Table 1. Discrete data of risks associated with different types of dysphagia Normal (n=11), OD (n=25), Risk factor % (n) % (n) Prenatal IUGR 18.20 (2) 56.00 (14) and C-section 63.60 (7) 68.00 (17) delivery Preterm PROM 36.40 (4) 4.00 (1) factors Respiratory Respiratory 9.09 (1) 0 (0) factors support Perinatal Neonatal 0 (0) 0 (0) conditions convulsions and Medications 54.55 (6) 57.50 (21) treatment received during hospitalisation Feeding Fussy during 0 (0) 0 (0) and related feedings factors Breathing 0 (0) 0 (0) difficulties during/after feeding Rooting reflex 100 (11) 66.67 (16) present Feeding tube 27.27 (3) 33.33 (8) Problematic 20.00 (2) 5.26 (1) breastfeeding Choking 0 (0) 20.83 (5) Positing of milk 0 (0) 12.50 (3) during/after feeding Hyperextension 0 (0) 0 (0) during feeding Nutritive sucking 36.36 (4) 75.00 (18) difficulties OPD (n=13), Fisher's exact Risk factor % (n) p-value Prenatal IUGR 53.90 (7) 0.089 and C-section 30.80 (4) 0.091 delivery Preterm PROM 15.40 (2) 0.030 * factors Respiratory Respiratory 23.08 (3) 0.036 * factors support Perinatal Neonatal 15.40 (2) 0.113 conditions convulsions and Medications 100 (13) 0.012 * treatment received during hospitalisation Feeding Fussy during 15.38 (5) 0.118 and related feedings factors Breathing 15.38 (2) 0.118 difficulties during/after feeding Rooting reflex 76.92 (10) 0.097 present Feeding tube 76.92 (10) 0.020 * Problematic 63.64 (7) 0.002 * breastfeeding Choking 53.85 (7) 0.007 * Positing of milk 38.46 (5) 0.034 * during/after feeding Hyperextension 23.08 (3) 0.026 * during feeding Nutritive sucking 41.67 (5) 0.042 * difficulties Dysphagia Risk factor type Prenatal IUGR OD and OPD delivery C-section OD factors OPD Preterm PROM OD OPD Respiratory Respiratory Insufficient data factors support for further analysis Perinatal Neonatal Insufficient data conditions convulsions for further and analysis treatment Medications Insufficient data received during for further hospitalisation analysis Feeding Fussy during Insufficient data and related feedings for further factors analysis Breathing Insufficient data difficulties for further during/after analysis feeding Rooting reflex Insufficient data present for further analysis Feeding tube OD OPD Problematic OD breastfeeding OPD Choking Insufficient data for further analysis Positing of milk Insufficient data during/after for further feeding analysis Hyperextension Insufficient data during feeding for further analysis Nutritive sucking OD difficulties OPD Risk factor RRR Prenatal IUGR 5.73 and 5.25 delivery C-section 1.21 factors 0.25 Preterm PROM 0.07 0.32 Respiratory Respiratory Insufficient data factors support for further analysis Perinatal Neonatal Insufficient data conditions convulsions for further and analysis treatment Medications Insufficient data received during for further hospitalisation analysis Feeding Fussy during Insufficient data and related feedings for further factors analysis Breathing Insufficient data difficulties for further during/after analysis feeding Rooting reflex Insufficient data present for further analysis Feeding tube 1.33 8.89 Problematic 0.22 breastfeeding 7 Choking Insufficient data for further analysis Positing of milk Insufficient data during/after for further feeding analysis Hyperextension Insufficient data during feeding for further analysis Nutritive sucking 5.25 difficulties 1.25 Risk factor 95% CI Prenatal IUGR 1.02-32.10 and 0.80-34.43 delivery C-section 0.27-5.38 factors 0.05-1.39 Preterm PROM 0.01-0.76 0.05-2.22 Respiratory Respiratory Insufficient data factors support for further analysis Perinatal Neonatal Insufficient data conditions convulsions for further and analysis treatment Medications Insufficient data received during for further hospitalisation analysis Feeding Fussy during Insufficient data and related feedings for further factors analysis Breathing Insufficient data difficulties for further during/after analysis feeding Rooting reflex Insufficient data present for further analysis Feeding tube 0.28-6.44 1.40-56.57 Problematic 0.02-2.82 breastfeeding 0.97-50.57 Choking Insufficient data for further analysis Positing of milk Insufficient data during/after for further feeding analysis Hyperextension Insufficient data during feeding for further analysis Nutritive sucking 1.13-24.42 difficulties 0.23-6.71 Risk factor p-value Prenatal IUGR 0.047 * and 0.084 delivery C-section 0.798 factors 0.114 Preterm PROM 0.029 * 0.248 Respiratory Respiratory Insufficient data factors support for further analysis Perinatal Neonatal Insufficient data conditions convulsions for further and analysis treatment Medications Insufficient data received during for further hospitalisation analysis Feeding Fussy during Insufficient data and related feedings for further factors analysis Breathing Insufficient data difficulties for further during/after analysis feeding Rooting reflex Insufficient data present for further analysis Feeding tube 0.72 0.021 * Problematic 0.246 breastfeeding 0.054 * Choking Insufficient data for further analysis Positing of milk Insufficient data during/after for further feeding analysis Hyperextension Insufficient data during feeding for further analysis Nutritive sucking 0.034 * difficulties 0.795 CI = confidence interval; C-section = caesarean section. * Statistically significant. Table 2. Continuous data of risks associated with different types of dysphagia Results after Bonferroni Fisher's adjustments, exact compared with Risk factor Groups Mean (SD) p-value no dysphagia Chronological Normal 5.73 (3.07) 0.004 * -- age (days) OD 10.20 (8.01) 0.084 OPD 16.00 (12.70) 0.003 * Days in NICU Normal 5.73 (3.04) 0.01 * -- OD 9.54 (7.20) 0.118 OPD 15.31 (12.98) 0.007 * * Statistically significant. Table 3. Risk factors according to types of dysphagia Factors associated with OPD Factors associated with OD Increased chronological age IUGR Increased stay in the NICU Nutritive sucking difficulties Tube feeding Preterm PROM Problematic breastfeeding
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|Author:||Pike, C.; Pike, M.; Kritzinger, A.; Kruger, E.; Viviers, M.|
|Publication:||South African Journal of Child Health|
|Date:||Jul 1, 2016|
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