Evaluation and management of neonatal dysphagia: impact of pharyngoesophageal motility studies and multidisciplinary feeding strategy

Abstract

Background and objectives: Abnormal swallowing (dysphagia) among neonates is commonly evaluated using the videofluoroscopic swallow study (VSS). Radiological findings considered high risk for administration of oral feeding include nasopharyngeal reflux, laryngeal penetration, aspiration, or pooling. Our aims were to determine pharyngoesophageal motility correlates in neonates with dysphagia and the impact of multidisciplinary feeding strategy.

Methods: Twenty dysphagic neonates (mean gestation +/- standard deviation [SD] = 30.9 +/- 4.9 weeks; median 31.1 weeks; range = 23.7-38.6 weeks) with abnormal VSS results were evaluated at 49.9 +/- 16.5 weeks (median 41.36 weeks) postmenstrual age. The subjects underwent a swallow-integrated pharyngoesophageal motility assessment of basal and adaptive swallowing reflexes using a micromanometry catheter and pneumohydraulic water perfusion system. Based on observations during the motility study, multidisciplinary feeding strategies were applied and included postural adaptation, sensory modification, hunger manipulation, and operant conditioning methods. To discriminate pharyngoesophageal manometry correlates between oral feeders and tube feeders, data were stratified based on the primary feeding method at discharge, oral feeding versus tube feeding.

Results: At discharge, 15 of 20 dysphagic neonates achieved oral feeding success, and the rest required chronic tube feeding. Pharyngoesophageal manometry correlates were significantly different (P < 0.05) between the primary oral feeders versus the chronic tube feeders for swallow frequency, swallow propagation, presence of adaptive peristaltic reflexes, oral feeding challenge test results, and upper esophageal sphincter tone. VSS results or disease characteristics had little effect on the feeding outcomes (P = NS).

Conclusions: Swallow-integrated esophageal motility studies permit prolonged evaluation of swallowing reflexes and responses to stimuli under controlled conditions at cribside. The dysfunctional neuromotor mechanisms may be responsible for neonatal dysphagia or its consequences. Manometry may be a better predictor than VSS in identifying patients who are likely to succeed in vigorous intervention programs.

Conflict of interest statement

The authors report no conflicts of interest.

Figures

FIG. 1

Video fluoroscopic swallow study parameters are compared between successful oral feeders and failures (P= NS, chi square).

FIG. 2

(A) Charting swallow-integrated pharyngoesophageal motility study in an infant with feeding success describing propagation of spontaneous dry swallow, wet swallow–induced primary peristalsis, and oral feeding challenge test. (B) Charting similar data in an infant with feeding failure describing failed propagation of dry swallow, response failure to wet swallow, and poor response to oral feeds. EMG = electromyography; UES = upper esophageal sphincter; PE = proximal esophagus; ME = mid esophagus; DE = distal esophagus; LES = lower esophageal sphincter.