September 2019 HSC Section 1 Congenital and Pediatric Problems

TABLE I. Modified Barium Swallow Study Findings.

Aspiration Among Patients Tested

Silent Aspiration Among Patients With Aspiration

Tested

Overall

1,286

440 of 1,286 (34.2%)

393 of 440 (89.3%)

Thin fluids

1,189

379 of 1,189 (31.8%)

335 of 379 (88.4%)

Thickened fluids

591

203 of 591 (34.3%)

179 of 203 (88.2%)

Puree

803

38 of 803 (4.7%)

32 of 38 (84.2%)

Solid food

511

5 of 511 (1.0%)

4 of 5 (80.0%)

of cooperation from many children. Modified barium swallow is largely considered the gold standard for investigating swallowing discoordination in both adults and children. 2 It is commonly used to evaluate dyspha- gia and aspiration in children with laryngeal cleft, deter- mine the need for surgical repair, and assess the outcome of surgery. 13–15 During a MBS study, the patient ingests thin and thick barium-impregnated test fluids and/or pureed and solid foods mixed with barium. Bolus flow and swallowing physiology are observed dur- ing videofluoroscopy, which helps identify the presence, type, and severity of discoordination. In addition, a com- plete medical, developmental, social, family, and feeding history must be taken to fully evaluate the patient. Because silent aspiration may occur without obvi- ous signs of distress, this condition may go undetected for long periods of time and result in chronic airway dis- ease, including bronchiectasis. In the present study, we examine a large heterogeneous group of pediatric patients to determine the prevalence of silent aspiration in children and identify which diagnoses may be associ- ated with this finding. We aim to provide insight into which patients are at risk and should undergo an MBS to identify or rule out silent aspiration. MATERIALS AND METHODS Institutional review board approval at Boston Children’s Hospital (Boston, MA) was obtained for this study. Medical records of all pediatric patients (under the age of 18) who underwent an MBS study in 2015 were reviewed. Patient age, gender, medical diagnoses (including otolaryngologic, neurologic, genetic, and syn- dromic diagnoses), and associated symptoms were collected. Speech-language pathologists reviewed all MBS studies performed in 2015 using the 8-point Penetration-Aspiration (PA) scale to identify the presence and type of aspiration with different textures of food material. Findings of overt aspiration (6 or 7 on the PA scale), silent aspiration (PA 8), penetration only (PA 2–5), and normal swallowing function (PA 1) were recorded. Modified barium swallow studies were performed in the radiology department with a radiologist and speech- language pathologist present. The patients were offered thin and thick barium-impregnated test liquids and/or pureed and solid foods mixed with barium. We compared demographics and clinical characteristics of patients with silent aspiration (PA 8) and patients without any aspiration (PA 1) using Chi-square or Fisher’s exact test for cat- egorical variables and Wilcoxon rank sum test for continuous variables. Similarly, we compared clinical characteristics of patients with silent aspiration (PA 8) and patients with overt (nonsilent) aspiration (PA 6 or 7). Univariate and multivariate

analyses were performed to examine clinical factors associated with silent aspiration. Risk ratio (RR) and 95% confidence inter- val (CI) were estimated from the binomial regression model with a log-link function. We built a multivariable regression model using a backward selection procedure, with P < 0.05 as the retention criterion. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). Characteristics of All Patients Who Underwent MBS Study Among 1,286 unique patients who underwent MBS, 59% (n 5 754) were male. Median age was 1.4 years (interquartile range [IQR] 5 0.5–3.6 years). Reason for referral for MBS was most often suspicion of aspiration, feeding difficulties, or choking. There were 440 patients (34%) who demonstrated aspiration with any consistency (Table I). Among patients who aspirated, 393 patients (89%) demonstrated silent aspiration. Clinical characteristics of 393 (31%) patients with silent aspiration, 47 (4%) patients with overt aspiration, and 846 (66%) patients without aspiration are described in Table II. The following diagnoses were identified through retrospective chart review: airway disorders including laryngeal cleft, laryngomalacia, unilateral vocal fold paralysis (VFP), and bilateral vocal fold paralysis; neurologic issues including developmental delay, hypoto- nia, epilepsy/seizures, microcephaly/macrocephaly, cere- bral palsy, hereditary disorder, neuromuscular disorder, meningitis encephalitis, and brain trauma; syndromes of broad variety but most commonly Down syndrome; con- genital heart disease; and gastroesophageal reflux disease (GERD). Of the 1,286 patients who underwent MBS, 440 patients (34%) had neurologic disease, 401 (31%) had GERD, and 238 (19%) had a history of prematurity. Among 311 infants less than 6 months of age, 120 (39%) were found to display silent aspiration. Silent aspiration was documented in 51 of 124 patients (41%) with laryn- geal cleft and 56 of 138 patients (41%) with laryngomala- cia. Silent aspiration was documented in 15 of 28 patients (54%) with unilateral VFP and one of four patients (25%) with bilateral VFP. All patients with unilateral or bilat- eral VFP demonstrated silent aspiration or no aspiration at all. Silent aspiration was also documented in 165 of 440 patients (38%) with neurologic disease, 27 of 62 patients (44%) with Down syndrome, and 41 of 84 patients (49%) with congenital heart disease. Of 238 children with a his- tory of prematurity, 93 (39%) were found to aspirate and, RESULTS

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