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Infants admitted in the neonatal unit commonly present with feeding problems such as decreased oral intake and feeding intolerance. These infants may suffer from complex diseases such as prematurity or congenital malformations. The origin of these feeding problems may be disease-specific or may be secondary to many factors such as severity of the illness, concomitant medication and surgical interventions. "Healthy" preterm infants may have an immature nervous system leading to immature oral intake, and failure to coordinate sucking, swallowing and breathing. They may also have an immature motor gastro-intestinal function. Infants with bronchopulmonary dysplasia or central nervous system lesions are particularly prone to feeding problems. Recently, developmental changes in pharyngoesophageal physiology in the preterm infant were described explaining poor feeding in infants under 34 weeks. The physiology of distal esophageal motility has been described in healthy, preterm infants using water perfused manometry, but data on preterm infants with associated pathology are very limited.Term infants with severe congenital malformations also often present with feeding problems. In some cases, underlying respiratory, neurological or cardiac pathology impedes the ability to take oral feeds. In children with esophageal atresia, motility disorders are primarily due to the intrinsically disturbed development of the esophagus. End-to-end anastomosis of the esophagus can disturb vagal innervations, vascular supply or cause traction on the lower esophagus. In infants with congenital diaphragmatic hernia, multiple factors may play a role in the disturbed gastro-esophageal function leading to poor feeding. Development and position of lungs, stomach and lower gastrointestinal tracts are abnormal in those patients. Moreover, repositioning of the abdominal organs into the abdominal cavity can result in disorders based on numeric manometric parameters. For 15 years, we have had a unique setting of highly specialized clinical units focusing on pharyngeal as well esophageal dysphagia within the University Hospitals of Leuven. The current PhD project is part of an ongoing international collaboration between the KU Leuven (Experimental ORL, N Rommel) and the University of Adelaide, Australia (School of Paediatrics and Reproductive Health, T Omari) focusing on paediatric dysphagia. For three years, the clinical research has been expanded to adult dysphagia and become part of the Translational Research Centre for Gastrointestinal Disorders (TARGID). With this project we are now expanding the research to neonates.

Esophagogastric junction

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Background: Meconium intestinal obstructions in newborns can be caused by various pathologies such as meconium ileus, meconium obstruction of prematurity, meconium disease, and meconium plug syndrome. These are often mistaken as the same clinical entities; however, meconium ileus stands out through its association with the genetic disorder known as cystic fibrosis. In case of delayed diagnosis, the complete obstruction can progress to a complex form of meconium ileus, with numerous complications. The primary focus of the search was to emphasize on the necessity of a prompt diagnosis using diagnostic tools, and to react accordingly with an adequate therapeutic approach. Methods: PubMed database were searched for relevant articles. Results: Meconium ileus is a multifactorial pathology combining genetical, physiological and clinical elements. This includes a mutation of the cystic fibrosis transmembrane receptor gene, immaturity of a synchronized neuromuscular coordination to reach functional peristalsis, and the influence of maternal and infant-related risk factors. Meconium ileus initially presents with abdominal distention and emesis but can however rapidly progress to a complex form. This is best prevented integrating the following diagnostic tools: 1) clinical evaluation, 2) abdominal radiographs and/or 3) diatrizoate (Gastrografin®) enema. Following diagnosis, different therapeutical approaches, such as saline and N-acetylcysteine irrigation, glycerin suppositories, Gastrografin® enema and surgery, can be established depending on the clinical condition. Conclusion: By reaching a prompt diagnosis of meconium ileus, therapeutic measures can be taken which helps infants reach a more stable hemodynamic condition quickly with less invasive methods. Furthermore, immediate diagnose also contributes to prevent infant morbidity and mortality.

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Neonatal care has dramatically improved over the past decades. This has led to an increased survival of preterm infants. Common co-morbidities associated with prematurity are bronchopulmonary dysplasia, intraventricular hemorrhage and periventricular leukomalacia. Preterm infants with these co-morbidities often have disturbed oral feeding skills. Our aim is to review the prevalence, risk factors and pathogenesis of these feeding problems in preterm infants with these co-morbidities. We will also explore the relation between bronchopulmonary dysplasia and gastro-esophageal reflux. PubMed was searched for articles. Afterwards the chain sampling technique was used for more articles. To attain safe oral feeding, the coordination of sucking, swallowing and breathing is essential. This coordination is immature in all preterm infants and is even more disturbed in infants with bronchopulmonary dysplasia or brain injuries. The prevalence of the feeding problems in infants with these co-morbidities is unknown. In infants with bronchopulmonary dysplasia the coordination of sucking, swallowing and breathing is disturbed. This is due to an irregular breathing pattern, weak sucking pressure and less frequent swallowing. Moreover, oral hypersensitivity and aversion arise caused by multiple negative facial manipulations. The correlation between gastro-esophageal reflux and bronchopulmonary dysplasia is still uncertain. In preterm infants with an intraventricular hemorrhage or periventricular leukomalacia, the sucking and swallowing are impeded. This is probably due to dysfunction of the central pattern generators in the brainstem that regulate the complex sucking-swallowing-breathing processes. Also, the risk for oral aversion is higher in these infants with a complicated neonatal period. This results in a delayed achievement of full oral feeding in infants with bronchopulmonary dysplasia or intraventricular hemorrhage, usually around 38 weeks postmenstrual age. This is respectively 11 and 9 days later compared to healthy preterm infants. We conclude that medical follow-up and nutritional support are important to maintain adequate intake in preterm infants with associated co-morbidities. This is necessary to ensure normal growth and to support neurodevelopment in these patients at risk.

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Congenital heart disease (CHD) is a common birth defect with an increasing survival rate due to improved neonatal care. However, neonatal care is still challenged because of the higher prevalence of associated comorbidities in infants with CHD including feeding difficulties and impaired nutritional intake. Feeding difficulties are associated with a variety of problems such as impaired safety and efficiency of swallowing, behavioral troubles, and cardiorespiratory deficits. A large proportion of the infants with CHD is capable of exclusive oral feeding. However, oral feeding difficulties may lead to unsafe and inadequate oral intake, requiring implementation of tube feeding for some infants. Tube feeding can control the nutritional intake, but is associated with risks and complications that need to be taken in account. Furthermore, feeding is related to other factors such as surgical interventions. Surgery can enhance or deteriorate the feeding of the infant with CHD depending on factors such as the type of surgery and gestational age. Surgery can also cause vocal cord dysfunction which in turn leads to additional feeding difficulties. Hence, feeding is multifactorial influenced which complicates a simple conclusion. This narrative review provides an overview of the current evidence of feeding in infants with CHD.

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Objective : This scoping review aims to identify the available scientific evidence for infantile swallowing disorders in neurological diseases such as Intracranial Haemorrhage (ICH), Arterial Ischemic Stroke (AIS) and Hypoxic Ischemic Encephalopathy (HIE). The following aspects of swallowing disorders will be investigated: the (a) prevalence, (b) types of swallowing/feeding issues, (c) diagnostic tools, (d) available treatment options and (e) the involvement of the multidisciplinary healthcare team. Methods: The study design presumed upon the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines. A structured search strategy was conducted in five databases and one register system, pertaining to three concepts: swallowing/feeding disorders, infants and neurological disorders. Results: The search strategy yield an aggregate of 5,110 articles and 25 out of them met the inclusion criteria. The available evidence about swallowing disorders was analysed in three main categories according to the occurring disease in infants: 1. Intracranial Haemorrhage (ICH), 2. Arterial Ischemic Stroke (AIS) and 3. Hypoxic Ischemic Encephalopathy (HIE). The prevalence of swallowing disorders in ICH and AIS is documented in the majority of the relevant articles included but it is rarely discussed in HIE. The most common clinical presentations in neonates or infants are vomiting and poor sucking in ICH, aspiration/high risk for aspiration and gastroesophageal reflux in AIS. Aspiration, sucking/breastfeeding difficulties and persistent feeding impairment are mostly presented in HIE. Limited data are found for ICH and the diagnostic evaluation of swallowing problems. However, instrumental evaluation is often utilized. The literature does not identify any available means of assessment in AIS. When investigating deglutitive impairment in HIE population, both clinical and instrumental means are indicated; VFSS, pharyngo-esophageal and/or esophageal manometry and the Penetration Aspiration Scale (PAS) are most often employed. Alternative feeding methods such as nasogastric/gastrostomy tube are the predominant means of dysphagia management. Diet modification is also reported in AIS intervention plans. Oral stimulation is frequently mentioned in HIE treatment options. Overall, paediatric neurologists and Speech and Language Pathologists (SLPs) are reported to be the prevailing healthcare professionals in the multidisciplinary team recruitment. The complicity of the multidisciplinary healthcare team is not extensively identified in the literature. Conclusion : This scoping review indicates that deglutitive issues are present in the neonatal neurological diseases. There is only limited data available on swallowing issues in ICH and AIS population. In the case of HIE, there is limited evidence for the manifestations, the assessment and the intervention methods. The contribution of the multidisciplinary healthcare team to dysphagia management is lacking in literature. These research findings underline the importance of further investigation to analyse the nature of feeding problems, enrich dysphagia toolkit and identify the best ways for dysphagia management in infants with neurological impairment.