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should also be considered. Jabbour and colleagues reported that 41% of infants with VFP required a gastrostomy tube. (12) In another series, 56% of infants with BVFP required a gastrostomy tube. (78) In another study, 55% of children with VFP after cardiothoracic surgery required a feeding tube – only regimen at the time of discharge. (35) In a meta analysis of children with UVFP after cardiothoracic surgery, there was a strong association with gastrostomy tube use at the time of discharge (odds ratio 7.3; 95% con fi dence interval 1.6 – 32.8). (20) Gastroesophageal Re fl ux Disease GERD is a common comorbidity with VFP. (25) It can exacerbate symptoms of VFP in infants, especially respira tory issues. Increased work of breathing from VFP may contribute to GERD through increased intrathoracic pres sure. In addition, GERD can contribute to respiratory dis tress through airway in fl ammation, aspiration, and apneic episodes. (79)(80) In addition, paradoxical vocal fold move ment that can sometimes mimic the appearance and symp toms of BVFP in infants is associated with GERD and appears to resolve when GERD is controlled. (81)(82) Phar macologic and nonpharmacologic management of GERD should be considered as well as a gastroenterology consul tation in recalcitrant cases. Counseling Parents and Caregivers All parents and caregivers should be counseled that while many cases of congenital and iatrogenic VFP do recover, it could take months to years and sometimes interventions are needed in the interim to maintain an adequate airway and safe feeding. A greater number of medical and surgical interventions, as well as longer hospital stay, can be expected in infants with a diagnosis of VFP. (31)(83) Infants with VFP may need to return to the hospital after discharge for feeding or weight gain issues. (84) All infants and children should be followed closely by an otolaryngologist as well as SLP, as indicated, until the VFP and all associated airway, swallow ing, and voice symptoms resolve. (83) Family members should be reassured that there are no known parental behaviors before or during pregnancy that increased the risk of their infant developing VFP. The cardiac, thoracic, and neck procedures that can result in iatrogenic RLN injury are rarely elective and are often life-saving, so parents should be supported to have no decisional regret about the surgery that may have resulted in the VFP. Many parents are concerned that their child may have no voice or never be able to safely eat by mouth, after they hear that their infant has VFP or aspiration. Parents should be reassured that although their child may need treatment to improve his/her

its effect lasts for 3 to 6 months. In older children, more permanent laryngeal procedures are considered for UVFP in addition to injection laryngoplasty. These include thyro plasty (placement of an implant to permanently medialize the immobile vocal fold) and laryngeal reinnervation (con necting a branch of the ansa cervicalis nerve to the RLN). Because these are permanent measures, usually at least 1 year is given for spontaneous recovery of the VFP before proceeding with surgery. The youngest reported ages are 2 years for thyroplasty and l year for laryngeal reinnervation. (74)(75) A 2015 systematic review found that injection laryngoplasty, thyroplasty, and laryngeal reinnervation are all safe and effective for managing pediatric dysphonia and dysphagia. However, unlike injection laryngoplasty, there have been no reports evaluating the bene fi t or safety of thyroplasty or laryngeal reinnervation in infants. Glottic Stenosis and Scarring In the presence of vocal fold immobility resulting from scarring, rather than paralysis, endoscopic scar division can be performed. In some instances, the degree of the scarring is too great or this surgical intervention is not medically appropriate for the infant. In these instances, tracheostomy with a delayed laryngotracheal reconstruction and decan nulation during early childhood can be considered. Dysphagia Though interventions for dysphagia are individualized and often determined by the type of dysphagia, comorbidities, and severity, the overarching priority is establishing safe and ef fi cient oral feeding while ensuring adequate nutrition and hydration. (76) Modi fi cations in viscosity of liquids (eg, thickened liquids either using commercial thickeners or antire fl ux formulas); altering nipple fl ow rate; and positional adjustments (eg, side-lying, semiupright, seated) (21)(43)(51) are some of the interventions that SLPs use in neonates with dysphagia. In more severe cases, where spontaneous recov ery is not achieved and modi fi cations are not successful in establishing safe oral feeding, long-term feeding alterna tives are recommended to mitigate the risk of aspiration and provide optimal nutrition and hydration. (12)(21)(43)(77) Reactive airway disease may develop from chronic aspira tion, and additional management with corticosteroids, bron chodilators, and in some cases, pulmonary evaluation may be necessary. Enteral access can begin with an orogastric or nasogas tric tube. When ongoing enteral access is needed, a gastrostomy tube should be considered. When concomitant GERD persists despite positioning and medical management, a gastrostomy-jejunostomy tube or Nissen fundoplication

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