Cervical Auscultation and Feeding with the Paediatric Population

1. Cervical Auscultation and Feeding with the Paediatric Population Evidence Based Practice Acute Paediatric Feeding Group 2007

2. December 2007 EBP Extravaganza - Acute Paediatric Feeding 2 Paediatric Feeding Acute Group Members 2007 Valerie Gent Melissa Parkin Colleen Links Debbie Alverez Jana Carr Kate Hodge Anne Rosten Kimberley Achurch Rachel Hampshire Brodie Warren

3. December 2007 EBP Extravaganza - Acute Paediatric Feeding 3 Clinical Question �.. The process Initially we began with the clinical question: �Does cervical auscultation improve the identification of suck/swallow/breathe in-coordination in neonates/infants?� We wanted to look at this to gain information of the breathing and co-ordination of sucking patterns of the �good� vs the �not so good� feeders. We would then be able to look at the effects of pacing, how this affects their respiratory rate and how, using CA that we can become more reliable.We wanted to look at this to gain information of the breathing and co-ordination of sucking patterns of the �good� vs the �not so good� feeders. We would then be able to look at the effects of pacing, how this affects their respiratory rate and how, using CA that we can become more reliable.

4. December 2007 EBP Extravaganza - Acute Paediatric Feeding 4 Clinical Question �.. The process Too specific? Other studies have looked at CA in adult dysphagia Limited number of articles What did we really want from the evidence�.?

5. December 2007 EBP Extravaganza - Acute Paediatric Feeding 5 Clinical Question Is Cervical Auscultation an applicable tool to use with infants to describe feeding?

6. December 2007 EBP Extravaganza - Acute Paediatric Feeding 6 Various ways to gain evidence Online searches � e.g Ovid, Pubmed, Medline Article reference list from previous CA courses members had attended Contact with �No Fuss Feeding & Swallowing Centre� (formerly the PERO clinic) QLD We then were ready to perform CAP�s on the articles that �appeared� to answer our clinical question

7. December 2007 EBP Extravaganza - Acute Paediatric Feeding 7 Is Cervical Auscultation an applicable tool to use with infants to describe feeding? Vice at al. (1990) �Cervical auscultation of suckle feeding in newborn infants Found swallow & breath sounds were distinctively patterned Each breath consisted of an expiration and inspiration sequence Initial and final discrete sounds before and after bolus transit were evident The control group data was not included Therefore difficult to describe/define what constituted a feeding difficulty

8. December 2007 EBP Extravaganza - Acute Paediatric Feeding 8 Is Cervical Auscultation an applicable tool to use with infants to describe feeding? Vice at al (1995). �Correlation of cervical auscultation with physiological recording during suckle feeding in newborn infants 3 different types of swallow patterns were distinguished Initial and final discrete sounds before and after bolus transit was evident Discrete sounds may vary in association with differences in swallow-respiration patterns Limited number and type of subjects - 9 �normal subjects� no comparison of the swallowing patterns to difficult feeders Combined CA with physiological recordings � CA not isolated, therefore difficulty to replicate in everyday clinical situations

9. December 2007 EBP Extravaganza - Acute Paediatric Feeding 9 Is Cervical Auscultation an applicable tool to use with infants to describe feeding? Reynolds et al. (2002) � Cervical accelerometry in preterm infants 12 subjects, no control group An accelerometer rather than a stethoscope was used Initial discrete sound = not clear what physiological swallow even this represented Postulated swallow-associated sounds become more uniform with maturation Proposed that this method could be used to track maturation in infant feeding and predict infants who will experience difficulty in coordinating the various processes needed for successful feeding 3.2.2 Accelerometer The accelerometer is a neck mounted sensor which is held in place by a lightly adhesive strip. It has a wide frequency response range and can be obtained in miniature unobtrusive formats. It is vibrated by the "epidermal vibrations caused by internal sounds and vibrations reaching the surface where it is attached" (Kuhn, 1995), i.e. it responds to the movements of internal organs. The acoustic information the accelerometer provides, whist not 'sounding' like a swallow mediated by CA, appears closely related to the discrete swallow sounds detected on the neck by a stethoscope or a microphone. 3.2.2 Accelerometer The accelerometer is a neck mounted sensor which is held in place by a lightly adhesive strip. It has a wide frequency response range and can be obtained in miniature unobtrusive formats. It is vibrated by the "epidermal vibrations caused by internal sounds and vibrations reaching the surface where it is attached" (Kuhn, 1995), i.e. it responds to the movements of internal organs. The acoustic information the accelerometer provides, whist not 'sounding' like a swallow mediated by CA, appears closely related to the discrete swallow sounds detected on the neck by a stethoscope or a microphone.

10. December 2007 EBP Extravaganza - Acute Paediatric Feeding 10 Is Cervical Auscultation an applicable tool to use with infants to describe feeding? Da Nobrega et al, (2004) �Acoustic study of swallowing behaviour in premature infants during tube-bottle feeding and bottle feeding Postulated that all swallowing behaviours during bottle transition for preterm infants were significantly different. Concluded that the duration of respiration period during transition to bottle feeding was necessarily larger for preterm infants and therefore more recuperation time between groups of swallows was needed. Did not really assess the applicability of cervical auscultation vs other methods Limited study:- i.e. no control, randomization and limited number of subjects � therefore ?reliability of study

11. December 2007 EBP Extravaganza - Acute Paediatric Feeding 11 WAKE UP TIME������.. ? ?

12. December 2007 EBP Extravaganza - Acute Paediatric Feeding 12 SUMMARY �what we found Predominantly Level IV evidence Methodology different in ALL studies - & use of high technology, research equipment Difficult to replicate in everyday clinical practice Limited subjects in study designs Lack of control subjects Found it difficult to answer our specific question

13. December 2007 EBP Extravaganza - Acute Paediatric Feeding 13 Limitations of CA in general Lefton-Greif & Loughlin, (1996) Specialized Studies in paediatric dysphagia LIMITATIONS: Limited ability to detect aspiration events Interpretation is listener dependent � inter-rater reliability still questionable Correlations between sounds heard and specific swallowing events is often not known Does not display structures so that reasons Underlying impairment are not defined.

14. December 2007 EBP Extravaganza - Acute Paediatric Feeding 14 Advantages of CA Easy, available, non invasive and cost-efficient No radiation exposure, can sample swallowing repeatedly and for prolonged periods NO �contrast� required, uses real food or liquid

15. December 2007 EBP Extravaganza - Acute Paediatric Feeding 15 SUMMARY � Overall limited research in the area of paediatric dysphagia CA still remains to have a place in our �bag� of clinical tools to augment a clinical assessment or review of feeding progress Non-invasive for paediatric population is a BIG PLUS! ? More research is needed in this area ?

16. December 2007 EBP Extravaganza - Acute Paediatric Feeding 16 Where to from here�.? Benchmarking projects:- Service delivery Treatment methods FTE�s in NICU - submission to RHW Fussy eaters policy Teats in the NICU

17. December 2007 EBP Extravaganza - Acute Paediatric Feeding 17 Contacts and 2008 Brodie Warren - New EBP leader for 2008 John Hunter Children�s Hospital Meeting every two months (6 times a year) CIAP web-site - Information of questions and where meetings will be held Brodie.Warren@hnehealth.nsw.gov.au Sophie.Egan@sesiahs.health.nsw.gov.au Project discussion and information gathering�

18. December 2007 EBP Extravaganza - Acute Paediatric Feeding 18 References Vice Fl, Heinz JM, Giuriati G, Hood M. Bosma JF. Cervical auscultation of suckle feeding in newborn infants. Developmental medicine & Child Neurology. 32 (9):760-8, 1990 Sept. Vice FL, Blamford O, Heinz JM, Bosma JF. Correlation of cervical auscultation with physiological recording during suckle-feeding in newborn infants. Developmental Medicine & child Neurology. 37(2): 167-79, 1995 Feb Da Nobrega, L, Boiron M, Henrot A, Saliba E. (2004) Acoustic study of swallowing behaviour in premature infants during tube-bottle feeding and bottle feeding period. Early Human Development, 78, (2004) 53 � 60. Reynolds EW, Vice FL, Bosma JF, Gewolb IH, (2002) Cervical accelerometry in preterm infants Development Medical Child Neuorology. Sep; 44 (9):587 � 92 Gewolb IH, Bosma JF, Reynolds EW, Vice FL Integration of suck swallow rhythms in preterm infants with and without pulmonary dysplasia. Development Medicine & Child Neuroology, (2003), May; 45 (5):344-8. Reynolds EW Vice FL Gewolb IH, Cervical accelerometry in preterm infants with and without pulmonary dysplasia. Developmental Medicine & Child Neurology, (2003), May; 45 (5):442-446.

19. December 2007 EBP Extravaganza - Acute Paediatric Feeding 19 References Leslie P, Drinnan MJ, Finn P, Ford GA, Wilson JA, (2004) Reliability and validity of cervical auscultation: a controlled comparison using videofluroscopy, Dysphagia, 19 (4): 231-40. 2004 Lau c, Smith EO, Schanler RJ, (2003) Coordination of suck-swallow and swallow respiration in pres-term infants. Acta Paediatrica. (2003) 92 (6): 721-7, 2003. Singhi S. Bhalla AK. Bhandari A. Narang A, Counting respiratory rate in infants under 2 months: comparison between observation and auscultation. Annals of Tropical paedaitrics. 23 920: 135-8, 2003 Jun. Lefton-Grief and Loughlin (1996) Specialized studies in pediatric dysphagia.� Seminars in Speech and Language, 17(4): 311-29. Comrie and Helm (1997) Common feeding problems in the intensive care nursery: maturation, organization, evaluation and management strategies.� Seminars in Speech & Language, 18(3): 239-59

20. December 2007 EBP Extravaganza - Acute Paediatric Feeding 20 With thanks�

21. December 2007 EBP Extravaganza - Acute Paediatric Feeding 21 Have an enjoyable�

22. December 2007 EBP Extravaganza - Acute Paediatric Feeding 22 FUN�

23. December 2007 EBP Extravaganza - Acute Paediatric Feeding 23 Safe�

24. December 2007 EBP Extravaganza - Acute Paediatric Feeding 24 Christmas

25. December 2007 EBP Extravaganza - Acute Paediatric Feeding 25 Everyone! ?