Objective To quantify and compare maximal extent (height) of acid reflux events (AREs) on symptom generation in dysphagic neonates. Methods Dysphagic neonates (N=53), born at 30 ± 5.3 wks gestation, underwent 24-hour pH-impedance study for the evaluation of troublesome symptoms purported to be due to gastroesophageal reflux disease (GERD). AREs (pH < 4 for > 4 seconds) detected by impedance (Z) were categorized by maximal extent as refluxate reaching distal (Z6, Z5), middle (Z4, Z3), or proximal (Z2, Z1) impedance channels. AREs reaching the pH sensor only were categorized as distal. Symptom correlation (%, symptom index (SI), symptom sensitivity index (SSI), and symptom associated probability (SAP)) and temporal characteristics (clearance times) of AREs were analyzed using linear mixed and GEE models comparing height categories presented as mean ± SEM, median (IQR), and OR (95% CI). Results Of the 2003 AREs: 1) distal extent AREs (n=1642) had increased frequency (p < 0.05), decreased ACT (p<0.05), and decreased acidity (p<0.05), 2) in middle and proximal AREs, acid clearance was longer than bolus clearance, p < 0.01, and 3) the odds of having cardiorespiratory (cough or sneeze) symptoms are increased with proximal and middle AREs (p<0.05). Conclusion Most proximal ascent of AREs into middle or proximal esophagus likely activates protective aerodigestive reflexes (peristalsis) or vigilant states to facilitate bolus and chemical clearance. Heightened esophageal sensitivity, acid neutralization delays, or clearance mechanism delays may accentuate multi-systemic troublesome symptoms.
Background Development of pharyngo-esophageal protective reflexes among infants with hypoxic ischemic encephalopathy (HIE) is unclear. Our aim was to distinguish these reflexes from controls and examine the maturational changes in HIE infants. Methods We evaluated 14 HIE infants (7 males) at 41.4±0.6 (HIE Time-1) and 46.5±0.6 (HIE Time-2) weeks postmenstrual age (PMA). 7 controls (3 males) were evaluated at 43.5 ± 1.3 weeks PMA. Graded pharyngeal stimulation with liquids (0.1, 0.3, 0.5 mL in triplicate) concurrent with high resolution manometry were used to analyze sensory-motor components of pharyngeal reflexive swallowing (PRS), upper esophageal sphincter (UES) contractile reflex (PUCR), and esophageal body characteristics. Linear mixed and generalized estimating equation models were used for comparison among groups. Key Results Compared to controls, HIE infants (Time-1 and Time-2) exhibited decreased number of pharyngeal peaks and latency to terminal swallow. HIE Time-1 infants showed increased UES resting tone and distal latency, compared to controls and HIE Time-2. Contractile vigor was increasingly abnormal during maturation, compared to healthy controls. Threshold volumes and frequency distribution of primary responses (PRS: PUCR: None) were not significant among all groups. Conclusions & Inferences Compared to controls, HIE infants display significant hypertonicity of skeletal muscle components, impairment of pharyngeal provocation induced reflexes and smooth muscle contractile vigor, reflecting poor propagation with maturation. These mechanisms may be responsible for inadequate clearance of secretions, ascending refluxate, and oropharyngeal bolus in HIE infants.
Aim Although the coordination of sucking and swallowing is critical for successful oral intake in neonates, the mechanisms that facilitate this coordination are not well understood. This investigation sought to clarify the mechanisms that facilitate this coordination, by comparing sucks that were coordinated with swallows and sucks that were completed in isolation. Methods Ten neonates with a median gestational age of 28.2 weeks, ranging from 27.0-35.0 weeks, were recruited from the neonatal nurseries at Nationwide Children's Hospital, Columbus, Ohio, USA. They were evaluated while bottle-feeding at term gestation for differences in characteristics between sucks that were coupled and not coupled with swallows. Suction was evaluated using an intraoral pressure transducer and swallows were identified using a micro-manometry pharyngeal catheter. Linear mixed models were applied to distinguish sucking characteristics. Results Suction exhibited an anti-phase relationship with the generation and release of positive pharyngeal pressure during the swallow. Coupled sucks had lower suction generation and release rates (p<0.0001), lower suction amplitude (p=0.004), longer suction duration (p<0.0001) and higher milk ejection pressure (p<0.0001). Conclusion The coordination of unique sucking and swallowing movement patterns may be achieved by the infant adapting to the sucking kinematics around the lingual patterns that facilitate the pharyngeal swallow.
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