Arquivo da categoria: Neonatology/ Pediatrics

Characterization of the transition technique from enteral tube feeding to breastfeeding in preterm newborns

Andréa Monteiro Correia Medeiros, et al.

J. Soc. Bras. Fonoaudiol. [online]. 2011, vol.23, n.1, pp. 57-65.

PURPOSE: To verify the corrected gestational age when oral feeding (breast half full) and exclusive breastfeeding were initiated in preterm newborns submitted to the transition technique from enteral feeding directly to breastfeeding, and time spent (in days) under speech-language pathology intervention until discharge. METHODS: Study participants were 35 preterm infants (PTI) divided into two groups. Group 1 (G1) was composed by 22 PTI who did not present any important medical complications during hospitalization, and Group 2 (G2) comprised 13 PTI with a history of major medical complications. The following data were recorded: gestational age at birth, birth weight, weight and corrected gestational age during speech-language pathology evaluation, corrected gestational age when started oral feeding, number of days stimulated through the non-nutritive sucking (NNS) technique, corrected gestational age when oral feeding started and when they were discharged from speech-language pathology intervention, and total number of days under speech-language pathology intervention. RESULTS: No differences were found between the groups (G1 and G2) for any of the analyzed parameters. In general, oral feeding started with an average of 36 weeks corrected gestational age. Exclusive oral feeding occurred with an average of 36.6 weeks corrected gestational age. In average, speech-language pathology intervention lasted 12.3 days, and the NNS technique in “gloved finger” or “empty breast” lasted an average of 4.54 days. CONCLUSION: The technique allowed the PTI to be discharged in exclusive breastfeeding at a corrected gestational age corresponding to that of healthy term newborns

Palavras-chave : Infant; premature; Enteral nutrition; Breastfeeding; Intensive care; neonatal; Gestational age.

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Caracterização da técnica de transição da alimentação por sonda enteral para seio materno em recém-nascidos prematuros

Andréa Monteiro Correia Medeiros, et al.

J. Soc. Bras. Fonoaudiol. [online]. 2011, vol.23, n.1, pp. 57-65.

OBJETIVO: Verificar a idade gestacional corrigida do início da dieta por via oral (mama parcialmente cheia) e da alimentação exclusiva em seio materno e o tempo dispendido (em dias) de atendimento fonoaudiológico para alta de recém-nascidos prematuros submetidos à técnica da transição da alimentação enteral direta para o seio materno. MÉTODOS: Fizeram parte do estudo 35 recém-nascidos prematuros (RNPT) divididos em dois grupos. O Grupo 1 (G1) foi composto por 22 RNPT que não apresentaram intercorrências médicas importantes durante a internação e o Grupo 2 (G2) por 13 RNPT com histórico de intercorrências médicas importantes. Foram registrados os seguintes dados: idade gestacional ao nascimento, peso ao nascimento, peso do recém-nascido e idade gestacional corrigida durante avaliação fonoaudiológica, idade gestacional corrigida no momento do início da alimentação por via oral, número de dias em que o recém-nascido realizou a técnica de sucção não nutritiva, idade gestacional corrigida no momento do início da alimentação por via oral exclusiva e da alta fonoaudiológica, e o número total de dias de atendimento fonoaudiológico. RESULTADOS: Não houve diferença entre os grupos (G1 e G2) para nenhum dos parâmetros analisados. De maneira geral, o início da oferta por via oral ocorreu com média de idade gestacional corrigida de 36 semanas. A alimentação por via oral exclusiva ocorreu com média de 36,6 semanas de idade gestacional corrigida. A média de dias de atendimento fonoaudiológico total foi de 12,3, sendo que o treino de sucção não nutritiva (SNN) em “dedo enluvado” ou “mama vazia” durou em média 4,54 dias. CONCLUSÃO: A técnica possibilitou a alta hospitalar do recém-nascido prematuro com alimentação exclusiva em seio materno em idade gestacional corrigida correspondente a do recém-nascido termo e saudável

Palavras-chave : Prematuro; Nutrição enteral; Aleitamento materno; Terapia intensiva neonatal; Idade gestacional.

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Staff workload and adverse events during mechanical ventilation in neonatal intensive care units

Lamy Filho, Fernando et al.

J. Pediatr. (Rio J.) [online]. 2011, vol.87, n.6, pp. 487-492.

OBJECTIVE: To investigate a possible association between the intensity of staff workload and intermediate adverse events, such as accidental extubation, obstruction of the endotracheal tube, and accidental disconnection of the ventilator circuit, during neonatal mechanical ventilation in high-risk neonatal units. METHOD: This prospective cohort study analyzed data of 543 newborns from public neonatal intensive care units (NICUs) in the city of São Luís, state of Maranhão, Northeastern Brazil, for 6 months, during which 136 newborns were submitted to mechanical ventilation in 1,108 shifts and were observed a total of 4,554 times. RESULTS: Adverse events occurred 117 times during this period. The associations between workload and adverse events were analyzed by means of generalized estimating equations. The adjustment variables were: birth weight, gender, maternity unit, Clinical Risk Index for Babies score, and care demand, the latter measured by the Northern Neonatal Network Scale. The larger the number of newborns classified by care demand (NCCD) per nurse and nursing technician, the more likely the occurrence of intermediate adverse events linked to mechanical ventilation. A number of NCCD > 22 per nurse (relative risk [RR] = 2.86) and > 4.8 per auxiliary nurse (RR = 3.41) was associated with a higher prevalence of intermediate adverse events. CONCLUSIONS: The workload of NICU professionals seems to interfere with the intermediate results of neonatal care and thus should be taken into consideration when evaluating NICU outcomes.

Palavras-chave : Neonatal intensive care; workload; artificial ventilation.

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Carga de trabalho de profissionais da saúde e eventos adversos durante ventilação mecânica em unidades de terapia intensiva neonatal

Lamy Filho, Fernando et al.

J. Pediatr. (Rio J.) [online]. 2011, vol.87, n.6, pp. 487-492.

OBJETIVO: Investigar uma possível associação entre a carga de trabalho de profissionais da saúde e eventos adversos intermediários, tais como extubação acidental, obstrução do tubo endotraqueal e desconexão acidental do circuito do ventilador, durante ventilação mecânica neonatal em unidades neonatais de alto risco. MÉTODO: Este estudo de coorte prospectiva analisou os dados referentes a 543 recém-nascidos de unidades de terapia intensiva neonatal (UTINs) de São Luís (MA) por 6 meses, durante os quais 136 recém-nascidos foram submetidos a ventilação mecânica em 1.108 turnos e foram observados 4.554 vezes. RESULTADOS: Ocorreram eventos adversos 117 vezes durante esse período. As associações entre carga de trabalho e eventos adversos foram analisadas por meio de equações de estimação generalizada. As variáveis de ajuste foram: peso de nascimento, gênero, maternidade estudada, pontuação no índice de risco clínico para bebês (clinical risk index for babies) e demanda de cuidados, determinada pela escala desenvolvida pela Northern Neonatal Network. Quanto maior o número de recém-nascidos classificados de acordo com a demanda de cuidados (RCDCs) por enfermeiro e técnico em enfermagem, maior a probabilidade da ocorrência de eventos adversos intermediários relacionados à ventilação mecânica. Um número de RCDCs > 22 por enfermeiro [risco relativo (RR) = 2,86] e > 4,8 por enfermeiro auxiliar (RR = 3,41) esteve associado a uma maior prevalência de eventos adversos intermediários. CONCLUSÕES: A carga de trabalho dos profissionais de UTINs parece interferir nos resultados intermediários do cuidado neonatal e, portanto, deve ser levada em conta na avaliação dos desfechos na UTIN.

Palavras-chave : Terapia intensiva neonatal; carga de trabalho; ventilação artificial.

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Experience of using electromyography of genioglossus in the investigation of paediatric dysphagia

 

Vijayakumar K, Rockett J, Ryan M, Harris R, Pitt M, Devile C.

Dev Med Child Neurol. 2012 Oct 25. doi: 10.1111/j.1469-8749.2012.04431.x. [Epub ahead of print]

Abstract

Aim  The aim of the study was to assess, retrospectively, the utility of genioglossus electromyography (gEMG) in evaluating children with suspected neurogenic feeding and swallowing difficulties. Method  Children who were evaluated using gEMG at a tertiary paediatric neurology dysphagia service were reviewed. Data were analysed by the presence/absence of neurogenic changes on gEMG and the method of feeding at their most recent follow-up. Results  The study group comprised 59 individuals (36 males, 23 females; median age 20mo; range 1mo-15y). The study cohort included individuals with heterogeneous neurological phenotypes (n=40), craniofacial syndrome (n=10), and congenital bulbar palsy (n=9). gEMG identified 35 out of 59 (60%) with neurogenic changes. At follow-up, 24 individuals were on oral feeds and 35 were on alternative methods of feeding (nasogastric /gastrostomy). Eight out of 24 children on oral feeds showed neurogenic changes compared with 27 out of 35 on alternative feeds. χ(2) analysis of feeding method at follow-up and the presence or absence of neurogenic change on EMG was highly significant (p≤0.002). When confounding factors for alternative feeds were accounted for on univariate analysis, the neurogenic changes, severe gastro-oesophageal reflux disease, and respiratory comorbidities were statistically significant in predicting the alternative feeding, whereas growth failure and behavioural difficulties were not significant confounders. Moreover, multiple logistic regression analysis revealed that the neurogenic changes were independently predictive of an alternative method of feeding after adjusting for other confounders with an odds ratio of 29.6 (95% confidence interval 3.97-220; p<0.007). Conclusion  gEMG is a valuable complementary tool in the evaluation of children with neurogenic dysphagia as the degree of severity is independently correlated with long-term feeding outcomes.

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Gastroesophageal Reflux, Esophageal Function, Gastric Emptying, and the Relationship to Dysphagia before and after Antireflux Surgery in Children

 

Loots C, van Herwaarden MY, Benninga MA, Vanderzee DC, van Wijk MP, Omari TI.

J Pediatr. 2012 Oct 25. doi:pii: S0022-3476(12)01003-7. 10.1016/j.jpeds.2012.08.045. [Epub ahead of print]

Abstract

OBJECTIVES:

To assess gastroesophageal reflux (GER), esophageal motility, and gastric emptying in children before and after laparoscopic fundoplication and to identify functional measures associated with postoperative dysphagia.

STUDY DESIGN:

Combined impedance-manometry, 24-hour pH-impedance, and gastric-emptying breath tests were performed before and after laparoscopic anterior partial fundoplication. Impedance-manometry studies were analyzed with the use of conventional analysis methods and a novel automated impedance manometry (AIM) analysis.

RESULTS:

Children with therapy resistent GER disease (n = 25) were assessed before fundoplication, of whom 10 (median age 6.4 years; range, 1.1-17.1 years; 7 male; 4 with neurologic impairment) underwent fundoplication. GER episodes reduced from 97 (69-172) to 66 (18-87)/24 hours (P = .012). Peristaltic contractions were unaltered. Complete lower esophageal sphincter relaxations decreased after fundoplication (92% [76%-100%] vs 65% [29%-91%], P = .038). Four (40%) patients developed postoperative dysphagia, which was transient in 2. In those patients, preoperative gastric emptying was delayed compared with patients without postoperative dysphagia, 96 minutes (71-104 minutes) versus 48 minutes (26-68 minutes), P = .032, and AIM analysis derived dysphagia risk index was greater (56 [15-105] vs 2 [2-6] P = .016). Two patients underwent a repeat fundoplication.

DISCUSSION:

Fundoplication in children reduced GER without altering esophageal motility. Four patients who developed dysphagia demonstrated slower gastric emptying and greater dysplasia risk index preoperatively. AIM analysis may allow detection of subtle esophageal abnormalities potentially leading to postoperative dysphagia.

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Restriction of oral intake of water for aspiration lung disease in children.

Weir K, McMahon S, Chang AB.

Cochrane Database Syst Rev. 2012 Sep 12;9:CD005303. doi:

Abstract

BACKGROUND:

Primary aspiration of food and fluid is commonly seen in children with feeding and swallowing difficulties associated with a range of diseases and complex medical conditions. Respiratory sequelae and pneumonia are known to be associated with primary aspiration of ingested material, however causality between primary aspiration of specific food and fluid types and pulmonary effects in children is yet to be established in controlled trials. The relative pulmonary morbidity of aspiration of ingested food and fluid materials versus other causes of respiratory disease such as viral and bacterial causes, secondary aspiration of gastrointestinal contents and predisposing lung conditions such as chronic neonatal lung disease in a developing immune system is also unclear. Current management decisions for children who aspirate have to optimise oral nutrition and hydration, while reducing the risk of aspiration to preserve pulmonary integrity. This generally includes restricting aspirated food or fluids and providing texture-modified diets and thickened fluids. Young children frequently refuse thickened fluids providing a management dilemma for both families and health professionals.

OBJECTIVES:

Our objective was to evaluate the efficacy of restriction of oral water ingestion on the pulmonary status of children with thin fluid aspiration demonstrated on a modified barium swallow study.

SEARCH METHODS:

The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Collaborative Review Group Specialised Register, MEDLINE, EMBASE and CINAHL databases were searched by the Cochrane Airways Group. The latest search was performed in May 2102.

SELECTION CRITERIA:

All randomised controlled trials comparing restriction of oral intake of water with unlimited oral water ingestion were eligible to be included.

DATA COLLECTION AND ANALYSIS:

Results of searches were reviewed against a pre-determined criteria for inclusion. No eligible trials were identified for a paediatric population and thus no data were available for analysis. One trial in an adult population was identified and reported.

MAIN RESULTS:

No randomised controlled trials examining the efficacy of restriction of oral intake of water in the management of children with thin fluid aspiration were found. In a single study in an adult population with stroke, no significant differences were seen between a control group of oral water restriction and the experimental group of unlimited oral water ingestion on outcomes such as pneumonia, total oral fluid intake and dehydration.

AUTHORS’ CONCLUSIONS:

There are no trials that have adequately evaluated the pulmonary effects of allowing or restricting oral water ingestion in children known to have primary aspiration of thin fluids. Thus, there is currently an absence of evidence to support a strict approach of full restriction of oral intake of water or support a more liberal approach of allowing oral water ingestion in children with primary aspiration of thin fluids.

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Pediatric feeding and swallowing disorders after bone marrow transplant

Buringrud JL, Redle EE, Cowen SE.

J Pediatr Hematol Oncol. 2012 Aug;34(6):436-41.

Abstract

Reduced oral intake is a known complication of bone marrow transplant (BMT) and may result in short-term tube feedings. Although most children return to typical eating habits, a subgroup of children requires intervention. The focus of the current investigation was to retrospectively identify the incidence and characteristics of feeding and swallowing disorders in pediatric patients during the first 100 days after BMT and to determine what factors contribute to feeding/swallowing disorders past the BMT acute phase (100+ d). The charts of 292 sequential patients undergoing BMT were reviewed. Seventy-two children (25%) were referred for feeding and/or swallowing intervention with a mean age of 78.6 months (SD=±63.4). Sixteen patients underwent instrumental evaluation with swallowing dysfunction identified in 50% (n=8) of the patients. Oral-motor dysfunction was reported in 33% (n=24) and feeding disorders occurred in 61% (n=44) of the patients referred for treatment. This single-institution review describes the impact of this interruption in the first 100 days after transplant on feeding and swallowing and determined what factors place a child at an increased risk for requiring tube feeding for 100+ days after transplant. The type of BMT, the use of a tube during the first 100 days, and the age were all significant predictors of requiring a tube when considered together for the individual patient. Children who do not require a tube in the first 100 days are significantly less likely to require one in future, approximately 85% less likely to require one whereas children receiving an autologous transplant are approximately 70% less likely to require a tube than children receiving an allogenic transplant. Providers should consider an intervention for younger children undergoing BMT to help maintain or facilitate the development of their feeding and swallowing skills. This may lead to improved feeding outcome in the pediatric BMT population.

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Incidence and clinical presentation of dysarthria and dysphagia in the acute setting following paediatric traumatic brain injury

Child Care Health Dev. 2010 Jan;36(1):44-53. Epub 2009 Mar 23.

Abstract

BACKGROUND:

A lack of data on dysarthria and dysphagia outcomes for children following traumatic brain injury (TBI) limits our clinical evidence base, and poses daily challenges for the speech language pathologist (SLP) managing this group. The present study aimed to examine dysarthria and dysphagia incidence and the clinical presentation of children with these disorders in the acute phase following TBI.

METHODS:

Incidence and characteristics were determined via a comprehensive retrospective medical chart review of children consecutively referred to a tertiary paediatric hospital over an 8-year period. Cases (n= 22 dysarthria, n= 72 dysphagia) and matched controls were compared across ancillary variables (e.g. age, severity of TBI, motor impairment).

RESULTS:

Incidence across the entire cohort was low [i.e. dysarthria (1.2%, 22/1895), dysphagia (3.8%, 72/1895)], but was markedly higher for the sub-category of children with severe TBI [e.g. dysphagia (76%, 63/83)]. Speech deficits were reported across respiration, phonation, resonance, articulation and prosody. Swallowing deficits included reduced lip closure, delayed swallow initiation, wet voice and coughing. Language and swallowing deficits were often co-morbid with dysarthria. Motor impairment was frequently co-morbid with both dysarthria and dysphagia. Cases had longer periods of hospitalization, ventilation and supplementary feeding compared with controls.

CONCLUSION:

Despite the low incidence of dysarthria and dysphagia across the entire TBI cohort, this sub-group may place longer-term burden on SLP services, having prolonged periods of ventilation, extended periods of hospitalization and a complex co-morbid clinical presentation compared with controls. The prevalence of co-morbid communication and swallowing impairments suggests a need for integrated rather than single discipline (i.e. dysphagia stream only) SLP services.

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Interventions for oropharyngeal dysphagia in children with neurological impairment

Morgan AT, Dodrill P, Ward EC.

Cochrane Database Syst Rev. 2012 Oct 17;10:CD009456. doi: 10.1002/14651858.CD009456.pub2.

Abstract

BACKGROUND:

Oropharyngeal dysphagia encompasses problems with the oral preparatory phase of swallowing (chewing and preparing the food), oral phase (moving the food or fluid posteriorly through the oral cavity with the tongue into the back of the throat) and pharyngeal phase (swallowing the food or fluid and moving it through the pharynx to the oesophagus). Populations of children with neurological impairment who commonly experience dysphagia include, but are not limited to, those with acquired brain impairment (for example, cerebral palsy, traumatic brain injury, stroke), genetic syndromes (for example, Down syndrome, Rett syndrome) and degenerative conditions (for example, myotonic dystrophy).

OBJECTIVES:

To examine the effectiveness of interventions for oropharyngeal dysphagia in children with neurological impairment.

SEARCH METHODS:

We searched the following electronic databases in October 2011: CENTRAL 2011(3), MEDLINE (1948 to September Week 4 2011), EMBASE (1980 to 2011 Week 40)
, CINAHL (1937 to current)
, ERIC (1966 to current), PsycINFO (1806 to October Week 1 2011), Science Citation Index (1970 to 7 October 2011), Social Science Citation Index (1970 to 7 October 2011), Cochrane Database of Systematic Reviews, 2011(3), DARE 2011(3), Current Controlled Trials (ISRCTN Register) (15 October 2011), ClinicalTrials.gov (15 October 2011) and WHO ICTRP (15 October 2011). We searched for dissertations and theses using Networked Digital Library of Theses and Dissertations, Australasian Digital Theses Program and DART-Europe E-theses Portal (11 October 2011). Finally, additional references were also obtained from reference lists from articles.

SELECTION CRITERIA:

The review included randomised controlled trials and quasi-randomised controlled trials for children with oropharyngeal dysphagia and neurological impairment.

DATA COLLECTION AND ANALYSIS:

All three review authors (AM, PD and EW) independently screened titles and abstracts for inclusion and discussed results. In cases of uncertainty over whether an abstract met inclusion criterion, review authors obtained the full-text article and independently evaluated each paper for inclusion. The data were categorised for comparisons depending on the nature of the control group (for example, oral sensorimotor treatment versus no treatment). Effectiveness of the oropharyngeal dysphagia intervention was assessed by considering primary outcomes of physiological functions of the oropharyngeal mechanism for swallowing (for example, lip seal maintenance), the presence of chest infection and pneumonia, and diet consistency a child is able to consume. Secondary outcomes were changes in growth, child’s level of participation in the mealtime routine and the level of parent or carer stress associated with feeding.

MAIN RESULTS:

Three studies met the inclusion criteria for the review. Two studies were based on oral sensorimotor interventions for participants with cerebral palsy compared to standard care and a third study trialled lip strengthening exercises for children with myotonic dystrophy type 1 compared to no treatment (Sjogreen 2010). A meta-analysis combining results across the three studies was not possible because one of the studies had participants with a different condition, and the remaining two, although using oral sensorimotor treatments, used vastly different approaches with different intensities and durations. The decision not to combine these was in line with our protocol. In this review, we present the results from individual studies for four outcomes: physiological functions of the oropharyngeal mechanism for swallowing, the presence of chest infection and pneumonia, diet consistency, and changes in growth. However, it is not possible to reach definitive conclusions on the effectiveness of particular interventions for oropharyngeal dysphagia based on these studies. One study had a high risk of attrition bias owing to missing data, had statistically significant differences (in weight) across experimental and control groups at baseline, and did not describe other aspects of the trial sufficiently to enable assessment of other potential risks of bias. Another study was at high risk of detection bias as some outcomes were assessed by parents who knew whether their child was in the intervention or control group. The third study overall seemed to be at low risk of bias, but like the other two studies, suffered from a small sample size.

AUTHORS’ CONCLUSIONS:

The review demonstrates that there is currently insufficient high-quality evidence from randomised controlled trials or quasi-randomised controlled trials to provide conclusive results about the effectiveness of any particular type of oral-motor therapy for children with neurological impairment. There is an urgent need for larger-scale (appropriately statistically powered), randomised trials to evaluate the efficacy of interventions for oropharyngeal dysphagia.

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