Restriction of oral intake of water for aspiration lung disease in children
ABSTRACT Primary aspiration of food and fluid is commonly seen in children with feeding and swallowing difficulties associated with a range of diseases and complex medical conditions. Respiratory sequelae and pneumonia are known to be associated with primary aspiration of ingested material, however causality between primary aspiration of specific food and fluid types and pulmonary effects in children is yet to be established in controlled trials. The relative pulmonary morbidity of aspiration of ingested food and fluid materials versus other causes of respiratory disease such as viral and bacterial causes, secondary aspiration of gastrointestinal contents and predisposing lung conditions such as chronic neonatal lung disease in a developing immune system is also unclear. Current management decisions for children who aspirate have to optimise oral nutrition and hydration, while reducing the risk of aspiration to preserve pulmonary integrity. This generally includes restricting aspirated food or fluids and providing texture-modified diets and thickened fluids. Young children frequently refuse thickened fluids providing a management dilemma for both families and health professionals.
Our objective was to evaluate the efficacy of restriction of oral water ingestion on the pulmonary status of children with thin fluid aspiration demonstrated on a modified barium swallow study.
The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Collaborative Review Group Specialised Register, MEDLINE, EMBASE and CINAHL databases were searched by the Cochrane Airways Group. The latest search was performed in January 2005.
All randomised controlled trials comparing restriction of oral intake of water with unlimited oral water ingestion were eligible to be included.
Results of searches were reviewed against a pre-determined criteria for inclusion. No eligible trials were identified for a paediatric population and thus no data were available for analysis. One trial in an adult population was identified and reported.
No randomised controlled trials examining the efficacy of restriction of oral intake of water in the management of children with thin fluid aspiration were found. In a single study in an adult population with stroke, no significant differences were seen between a control group of oral water restriction and the experimental group of unlimited oral water ingestion on outcomes such as pneumonia, total oral fluid intake and dehydration.
There are no trials that have adequately evaluated the pulmonary effects of allowing or restricting oral water ingestion in children known to have primary aspiration of thin fluids. Thus, there is currently an absence of evidence to support a strict approach of full restriction of oral intake of water or support a more liberal approach of allowing oral water ingestion in children with primary aspiration of thin fluids.
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ABSTRACT: 2012 Clinical Nutrition Week Focused Learning Session Aspiration during swallowing was long thought to have a direct causal link with aspiration pneumonia and chronic lung disease. In fact, most teaching programs for a variety of disciplines teach this as a fact. Unfortunately, accepting the causal link between aspiration and lower respiratory tract infections, may lead to feeding treatment plans that are disproportionate to the problem and do not consider the holistic care of the affected child and family. Let us consider what is known about aspiration and its consequences in children. Who aspirates? Children with neurodevelopmental problems, preterm infants, children with anatomic abnormalities of their aerodigestive tracts are all at increased risk of aspiration. The typical picture of a child who aspirates is one with a host of medical problems who has a neurodevelopmental problem like cerebral palsy who has difficulty both with food processing, as well as swallowing. Children with milder impairments, such as, Down Syndrome and Fetal Alcohol Syndrome also are more prone to aspiration. Aspiration during swallowing can be seen in children with typical development (Skeikh et al 2001). In addition, a clustering of cases in typical children with indigenous heritage has been described but is not yet fully understood (Rempel et al 2011) What about the causal relationship of aspiration and pneumonia? Several authors have looked at children who aspirate and the relationship with pneumonia. Weir et al (2007) suggested in her review of children with aspiration during swallowing that a fluoroscopic swallowing study might over-estimate the impact of aspiration in relation to other known factors that are associated with pneumonia. In this group of children, aspiration and pneumonia were not related when they controlled for other factors that could contribute to pneumonia: the factors of importance for development of pneumonia were history of lower respiratory tract infection, cough, mechanical ventilation, oxygen requirement, asthma, Down Syndrome and gastroesophageal reflux. Similarly, Rempel et al 2011 demonstrated that children who demonstrated aspiration during swallowing more likely to have pneumonia only if they had other risk factors for pneumonia. Langmore et al (1998) had a similar finding in adult patients who developed aspiration pneumonia: independent factors correlated with aspiration pneumonia included dependent for feeding, dental caries, smoking and multiple medical diagnoses.
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ABSTRACT: While many factors that contribute to the occurrence of lower respiratory tract infections (LRTI) in Canadian indigenous children have been described, the role of aspiration during swallowing has not been explored in these children. Because of an increase in referrals of indigenous children from our catchment area (Manitoba, North Western Ontario, and Nunavut) for assessment of aspiration during swallowing, we retrospectively reviewed the clinical records of 325 consecutive children undergoing videofluoroscopic swallowing studies (VFSS) to evaluate which factors, including indigenous heritage and LRTI, were associated with aspiration during swallowing. Our sample had an overrepresentation of indigenous children (35% compared to 23% in the catchment area). These children were more likely to aspirate during swallowing (P = 0.001) and to have experienced an LRTI prior to the VFSS (P = 0.000). When separating the children who aspirated into two groups based on indigenous heritage, the indigenous children were more likely to have had an LRTI (P = 0.028) than the other children in the sample. With logistic regression analysis, significant correlations between indigenous heritage, LRTI (P = 0.000), and aspiration (P = 0.009) were found. When aspiration during swallowing was the factor of interest, it correlated with both LRTI (P = 0.001) and the presence of congested upper airway noises after eating (P = 0.000). These upper airway noises were strongly associated with aspiration in indigenous children (P = 0.004). While prospective data are required to determine if the correlations seen in this retrospective review will remain robust, indigenous children were more likely to aspirate during swallowing and have LRTI in this sample. Whether aspiration during swallowing is related to environmental, ethnic, or biological factors in indigenous children remains to be determined, but the association between aspiration and congested upper airway noises after eating may assist in the early diagnosis of aspiration during swallowing, and thereby enable timely intervention to decrease aspiration risk in children already at risk of repeated LRTI due to a number of other confounding factors.Pediatric Pulmonology 05/2011; 46(12):1240-6. DOI:10.1002/ppul.21489 · 2.38 Impact Factor
Article: Aspiration lung disease.[Show abstract] [Hide abstract]
ABSTRACT: The term aspiration lung disease describes several clinical syndromes, with massive aspiration and chronic lung aspiration being at two extremes of the clinical spectrum. Over the years, significant advances have been made in understanding the mechanisms underlying dysphagia, gastroesophageal function, and airway protective reflexes and new diagnostic techniques have been introduced. Despite this, characterizing the presence or absence of aspiration, and under what circumstances a child might be aspirating what, is extremely challenging. Many children are still not adequately diagnosed or treated for aspiration until permanent lung damage has occurred. A multidisciplinary approach is mandatory for a correct diagnosis in addition to timely and appropriate care.Pediatric Clinics of North America 03/2009; 56(1):173-90, xi. DOI:10.1016/j.pcl.2008.10.013 · 2.20 Impact Factor