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 Sophie Egan Senior Paediatric Speech Pathologist The Wollongong Hospital Sophie.Egan@sesiahs.health.nsw.gov.au

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

5. Clinical Question Is Cervical Auscultation an applicable tool to use with infants to describe feeding? 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 thePERO clinic) QLD • We then were ready to perform CAP’s on the articles that “appeared” to answer our clinical question 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 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 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 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 EBP Extravaganza - Acute Paediatric Feeding

11. WAKE UP TIME………………..  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 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. 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 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  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 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… 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 infantsDevelopment 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. 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 EBP Extravaganza - Acute Paediatric Feeding

20. With thanks… EBP Extravaganza - Acute Paediatric Feeding

21. Have an enjoyable… EBP Extravaganza - Acute Paediatric Feeding

22. FUN… EBP Extravaganza - Acute Paediatric Feeding

23. Safe… EBP Extravaganza - Acute Paediatric Feeding

24. Christmas EBP Extravaganza - Acute Paediatric Feeding

25. Everyone! EBP Extravaganza - Acute Paediatric Feeding