A Case of Severe Neonatal Dysphagia: Experience and Reason

Transcription

1 A Case of Severe Neonatal Dysphagia: Experience and Reason The Contemporary Management of Aerodigestive Disease in Children 2 nd Aerodigestive Meeting Vanderbilt University, Nashville, TN Friday, November 7, 214 at 11:15-12:15 PM Sudarshan R. Jadcherla, MD Professor of Pediatrics Associate Division Chief of Neonatology, Academics Divisions of Neonatology, Pediatric Gastroenterology and Nutrition Director, The Neonatal and Infant Feeding Disorders Program Principal Investigator, Innovative Research on Feeding Disorders Program Program Director, Advance Fellowship in Infant Aerodigestive Disorders Program

2 Outline Case History with Relevance to Neonatal Dysphagia Approach to Diagnosis Therapies and Outcomes Scientific Reasoning

3 Symptoms, Signs and Procedures Full term born infant, lethal congenital heart disease underwent Domino Heart Transplant. Recovery was gradual and complete Severe multiple life threatening events requiring intubations, failed extubation, Prolong ICU stay and monitoring, Normal Cardio Respiratory functions otherwise Severe Feeding difficulties, GE reflux, Emesis, Dysphagia, Aspiration, Choking spells with Oral feeding attempts, Aspiration at Upper GI and Video fluoroscopy swallow study Arching and Irritability, Symptoms with Intragastric Feeding, Refusing Oral Feeds, No response to H2 antagonists for acid suppression. Infant on metoclopramide already. Medical, ICU, Cardiac and Speech Therapy teams: Consideration for Gastro Jejunal feeds, Tracheostomy and Fundoplication Feeding Failure and Parents reluctant for these procedures

4 Summarizing Reasoning for Feeding Failure Prolonged ICU Care, Mechanistic Continuous Intragastric or Transpyloric feeds, No motivation to Feeding, Lack of Normal Bio rhythms Major Intra thoracic Cardiac Surgery, Inflammation, Organ Distortion, Edema and Scarring Painful procedures, Aversion to oral stimuli Anorexia and lack of thirst, IV fluids, Concurrent medical conditions and Drug side effects Growth Failure, 3.8 kg at 13 weeks How can fix all these problems?

5 Gut motility sequences at an oral feeding session Study 1, 51 wks PMA, 3.8 Kg Respiration Catheter Pharynx EMG Pharynx 1 Diaphragm Stomach 1 UES 1 P Eso 1 M Eso 1 D Eso 1 1 Stomach mmhg Irregular Swallow 5 s Irregular Swallow Domino heart transplant, severe GERD, multiple ALTE requiring intubation

6 Mal adaptation: Esophageal stimulus and Respiratory symptoms Px Inf. M Eso Inf. Respiration 3 3 Regular Respiration Infusion Regular Respiration EMG Irregular respiration Pharynx UES P Eso M Eso D Eso Stomach EKG Apnea UES low resting pressure Incomplete PP Relaxation R Cough Cough PP Relaxation Clearing PP

7 Feeding Management Strategies Treatment of GER, Acid suppressive therapy with PPI Avoidance of Metoclopramide Continuous gavage feeds Simulated bolus feeds Bolus feeds Postural adaptation and rotation, Minimizing Sensory Stimuli, Sensory modification Consistent occupational therapy, Pacing, Posture, oromotor stimulation, Pacifier, Kangaroo Care, Non nutritive sucking with feeds Permissive volume restriction possibly stimulating thirst, Hunger manipulation, Positive reinforcement Introduce Oral feeds, Aim for Quality of feeding session, Regulated flow of feeds, Slow feeds, Feeding session for ~3 min Close monitoring for bradycardias or desaturation Outcomes: Full PO feeding achieved Averted G tube, Tracheostomy, and Fundoplication

8 Scientific Reasoning: Gut motility sequences Modified during Oral Feeding Study 1, 51 wks PMA, 3.8 Kg Study 2, 6 wks PMA, 4.7 Kg Respiration Catheter Pharynx EMG Pharynx 1 Diaphragm Stomach 1 UES 1 P Eso 1 M Eso 1 D Eso 1 1 Stomach mmhg Irregular Swallow Irregular Swallow Suck 5 s 1 s Well Coordinated Swallow Suck Domino heart transplant, severe GERD, multiple ALTE requiring intubation Same infant on full PO feeds

9 Scientific Reasoning: Role of ph Impedance Studies in Clarifying Refluxate and Symptoms Jadcherla et al. JPEN J Parenter Enteral Nutr 212

10 Scientific Reasoning: Symptom distribution 5% UES PX 46% 29% 49% 38% P<.1 P<.1 Respiratory symptoms (cough, bradycardia, desaturation, grunting, gagging) increased with more proximal extent of acid PE 33% Esophagus 3% 27% P=NS P<.1 Sensory (irritability, arching, pain) symptoms were similar ME 43% Refluxate 25% 27% P=NS P=NS Movement symptoms were greater with esophageal exposure DE 48% Respiratory Symptoms Sensory Symptoms Movements Jadcherla SR et al, Am J Gastroenterol 28

11 Scientific Reasoning: Mapping the Pharyngeal Airway Reflex Interaction circuits Jadcherla et al. Am J Gastroenterology 29 Arching & Irritability, Desaturation and Bradycardia Auto regulation and peristalsis