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FUTURE DIRECTIONS AND AREAS FOR RESEARCH

series have shown a good positive predictive value for return of vocal fold movement in infants when volitional activity is present. (99)(100)(101)(102) This information can be used to counsel family members about the likelihood of the return of vocal foldmovement and can be integrated into the decision making process before surgical management of VFP. The role of this evaluation in infants still needs to be established. So far, laryngeal surgeries and onabotulinum toxin A injections to improve the glottic airway in infants with BVFP have shown promise for good short-term airway, voice, and swallowing outcomes. Ongoing follow-up of these proce dures is needed to establish their long-term effects and ensure that the airway results are lasting, and delayed-onset voice and swallowing problems do not occur. Overall, more long-term follow-up studies are needed to better understand the ideal management of VFP in the neonatal period. This review is based on relevant clinical research evidence of varying strength. There are no randomized controlled trials evaluating management for VFP in infants to date. Most of the evidence on this topic is from single-center retrospective case series (Oxford Centre for Evidence-Based Medicine [OCEBM] level 4) and a few large administrative database analyses (OCEBM level 2 – 3). Systematic reviews (OCEBM level 2) exist on the topics of comparing idiopathic to birth trauma – related VFP, (38) surgical management of pediatric UVFP, (74) incidence and outcomes of left VFP in extremely premature infants after PDA ligation, (19) and characteristics of neonatal BVFP. (58) Systematic reviews with meta-analysis exist on the topics of incidence of UVFP after cardiothoracic surgery (20) and incidence, associated risk factors, and associated morbidities of VFP after PDA ligation. (28) American Board of Pediatrics Neonatal-Perinatal Content Speci fi cations • Know the various causes of stridor in the newborn and how to assess severity. • Know the indications for and the complications of tracheostomies. • Know the evaluation and medical and/or surgical management and associated potential complications or adverse effects of such management for a preterm infant with a patent ductus arteriosus. • Know the indications for and limitations of various neuroimaging studies and be able to recognize normal and abnormal structures and changes during development and growth. EVIDENCE SUMMARY

Although some advocate for universal evaluation of infants after cardiothoracic surgery to detect all cases of VFP, this may not be feasible or appropriate in all clinical situations. Liu and colleagues have evaluated a smartphone decibel meter with 90% sensitivity for normal vocal fold movement when the cry is greater than 90 dB and 90% speci fi city for VFP when the cry is less than 75 dB. (92) This will not screen effectively for BVFP, because the cry is often normal in these cases, but usually BVFP becomes clinically evident from respiratory symptoms. More studies are needed to con fi rm if this or other screening tests are appropriate to determine which infants require further assessments for VFP. Although fl exible laryngoscopy is the gold standard for diagnosing VFP in infants, it does irritate infants, which may contribute to cardiopulmonary collapse in susceptible infants. The use of ultrasonography to detect VFP was fi rst described in 1997 by Friedman. (93) This approach is of interest because it is noninvasive and does not require radiation or sedation. More recently, laryngeal ultrasonography has shown good correlation with fl exible laryngoscopy for detecting UVFP in infants after cardiac surgery. (22)(94)(95) Sensitivity has been reported to be 84% to 100% and speci fi city 80% to 95%. (22)(93)(95) Although there may be less physiologic impact compared with fl exible laryngoscopy, vocal fold move ment and closure are not always clear on ultrasonography. (22)(94)(95) Ultrasonography is also an emerging technique for evaluating dysphagia. (96)(97)(98) However, its applica tion for dysphagia in infants has not yet been reported. Because ultrasonography is noninvasive and free of radiation, further evaluation of it to assess VFP and dysphagia in infants could lead to a broader use of this modality. Because fl exible laryngoscopy, FEES, and VFSS are not readily available every where, the use of ultrasonography may have a large impact in lower resource settings. Although it is well-established in the adult literature that VFSS and FEES are reliable and valid tools for evaluating the physiology and function of swallowing, studies in infants are limited. Few studies have examined the usefulness of FEES in the population of infants with VFP as a compre hensive stand-alone instrumental assessment for establish ing the safety and ef fi cacy of breast and bottle feeding. Laryngeal electromyography (EMG) can be used to prog nosticate recovery of vocal fold movement, but its use is not standardized in infants. It is used more commonly for adults with VFP. Laryngeal EMG usually requires the collaboration of otolaryngology and neurology to place the electrodes and interpret the results. In this technique, an EMG electrode is placed in the muscle of the vocal fold, which requires general anesthesia in infants, and therefore limits its application. Small

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