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Dysphagia Outcomes Improvement in vocal fold movement does not always cor respond to an improvement in swallowing function. (88) In many infants and children, dysphagia can persist even after vocal fold movement recovers. (89) Conversely, many chil dren compensate well and their dysphagia resolves despite persistent VFP. (43)(78) In a series of infants with VFP and either a gastrostomy tube or modi fi ed oral feeding at hospital discharge, 52% achieved full oral feedings within a year. (84) Over the long-term, the prognosis for feeding orally is overall good, but not as good for those with a CNS etiology or comorbid developmental delays. (78)(88) Because of the multifactorial nature of dysphagia in infants with VFP, it is dif fi cult to predict dysphagia-related outcomes and ongoing dysphagia therapy is recommended until patients achieve safe and stable feeding. Dysphonia Outcomes The impacts of dysphonia can come to the forefront once the child enters school. In a series of 57 formerly preterm chil dren presenting with voice abnormalities, 63% were diag nosed with VFP. (90) Interventions to manage dysphonia include voice therapy, injection laryngoplasty, thyroplasty, and laryngeal reinnervation. All of these interventions play a larger role in management of dysphonia in children com pared with prelingual infants. Persistent hoarseness or a weak voice can have signi fi cant school, social, con fi dence, and occupational impacts if not addressed. Long-term Follow-up Infants with VFP require serial laryngoscopy to ensure an adequate airway and document recovery of vocal fold move ment. These infants require ongoing monitoring by their pediatrician, otolaryngologist, and SLP to manage any per sistent breathing, swallowing, and voice issues, if vocal fold movement does not recover. The main goals of this mon itoring are to limit the impact on the overall health of the child and improve quality of life. Affected patients should follow up with otolaryngology at 3- to 6-month intervals, until symptoms resolve or stabilize, and then annually if the VFP persists. In a series of children with VFP after cardiac surgery, only 22% to 61% had any follow-up with otolaryn gology after discharge. (23)(91) A concerted team effort is necessary to ensure appropriate specialty follow-up care, especially because these infants have prolonged hospital stays and complex medical care. The primary care clinician should closely monitor the infant growth to assess for failure to thrive as well as respiratory, developmental, and school related issues.

voice, VFP will not prevent the child from developing speech and being able to talk. Permanent inability to feed orally is very unusual for isolated VFP.

PROGNOSIS AND FOLLOW-UP

VFP carries signi fi cant morbidity and usually predicts a need for several subsequent interventions, including surgeries. Associated health-care costs can be high for patients with VFP.

Expectations for Resolution of VFP VFP that is attributable to an iatrogenic nerve transection is not expected to recover. However, VFP that results from traction, thermal exposure, or an idiopathic cause may spontaneously recover. Recovery can be partial or complete. In most cases, spontaneous recovery is expected to occur within 1 year; however, there have been cases of recovery after intervals of up to 11 years. (9)(83) Median time to recovery is 4 to 6months. (3)(83) In reviews of all causes of VFP, recovery occurred in 24% to 64% of affected patients. (3)(9)(10)(12) After cardio thoracic surgery, 3% to 29% of patients recovered. (3) (23)(43)(83) In general, iatrogenic VFP is less likely to recover. Over time, children with UVFP may experience resolution of voice and swallowing issues either because of recovery of vocal fold movement or because of compensation from the contra lateral vocal fold to achieve glottic closure. (85) The prognosis for recovery from VFP appears to depend mostly on the cause of the VFP. Among cardiothoracic surgeries, repair of hypoplastic left heart syndrome, which requires extensive aortic arch reconstruction and multiple surgeries, is associated with poor prognosis for recovery. (83) Preterm and low-birthweight infants who have VFP after PDA ligation have a lower incidence of recovery than full term and normal weight infants. (86) In one series, all cases of right-sided VFP after ECMO cannulation resolved. (87) In a series of infants with type I and II Arnold-Chiari malforma tions, half recovered and this was after bony decompression in all but 1 case. (59) Spontaneous resolution of congenital BVFP has been reported in 61% to 64% of cases. (55)(57)(58) Children with comorbid conditions have worse functional outcomes in the setting of BVFP. (58) In general, iatrogenic injury has a lower incidence of resolution compared with idiopathic VFP. However, a systematic review showed that infants with VFP in the setting of a traumatic birth, either because of fetal position or assistive measures, had the highest reported incidence of VFP resolution (80%), which was even higher than idiopathic cases of VFP (57%). (38)

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