#445 - [Journal Club] - 📌 Are we missing dysphagia in very preterm infants before they leave the NICU?

How often are we missing dysphagia in our most vulnerable NICU patients? In this episode of Journal Club, Daphna reviews a retrospective cohort study from the Journal of Perinatology examining the incidence and risk factors of dysphagia confirmed by flexible endoscopic evaluation of swallowing (FEES) in very preterm and very low birth weight infants. Among infants showing persistent feeding difficulties at 38 weeks post-menstrual age, laryngeal penetration was detected in all infants who underwent FEES, and tracheal aspiration in nearly 60%. Ben and Daphna discuss whether we are naming dysphagia for what it is, whether earlier instrumental assessment could change outcomes, and what it means for families to finally understand why their baby is struggling to feed.

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Incidence and factors associated with dysphagia in infants born very preterm or very low birth weight. Reynolds J, Suterwala M, Desai S, Chiruvolu A.J Perinatol. 2026 Apr 29. doi: 10.1038/s41372-026-02701-1. Online ahead of print.PMID: 42056238

Transcript

Ben Courchia (00:00.774) Hello everybody, welcome back to The Incubator Podcast. We're back for Journal Club. Daphna, good morning. How are you?

Daphna Yasova Barbeau (00:05.422) Good morning. How are you doing?

Ben Courchia (00:07.686) I'm doing alright. Can't complain.

Daphna Yasova Barbeau (00:15.310) I'll do the announcements this morning, which actually fits nicely with my journal club topic this week. I just wanted to mention the Gravens Conference. We've talked about it before, and they wanted to highlight that they are moving both the date and location this year. It's June 16th to 18th, with a pre-conference day on June 15th entitled Reimagining the NICU 3.0. It's located at the University of Notre Dame. The conference title this year is Sensitive Issues in Sensational Times. That should get people excited.

I've shared before that I love the Gravens Conference. It's a truly multidisciplinary conference covering trauma-informed care, family-centered care, and developmental care. There is so much to learn beyond your specific area of expertise in neonatology. Whether you focus on hemodynamics, bronchopulmonary dysplasia (BPD), the patent ductus arteriosus (PDA), nephrology, or anything else, the conversations about how we interact with families, with each other, and with babies will optimize everyone's work.

There is a discount code for Incubator listeners. You can register either in-person or virtually this year. The discount code is SPECIAL10 to receive a 10% discount.

Ben Courchia (02:08.762) Thank you to the Gravens organizing committee for making that happen for our listeners. Budgeting for conferences is not easy, so any discount is always welcome.

Daphna Yasova Barbeau (02:25.454) And credit to them this year. They offered scholarships for trainees, for nurses, and for therapists. And they are really on the forefront of providing paid conference registration, transportation, and lodging for parents to attend. Really impressive.

Moving along, I have an article from the Journal of Perinatology entitled "Incidence and Factors Associated with Dysphagia in Infants Born Very Preterm or Very Low Birth Weight." This comes out of Texas, lead author Jenny Reynolds and senior author Arpita Chiruvolo.

We did a trivia night with Dr. Brown's and had a full segment on feeding in the NICU. It was striking how little people understood about feeding, even though we are all prescribing it and discussing it on rounds every day. So I think it's important to highlight the prevalence of neonatal dysphagia. Difficulty with feeding and swallowing has been reported to range from 23% in preterm infants, 28% in extremely low birth weight infants, and 27 to 46% in extremely preterm infants. These feeding difficulties can lead to long-term adverse outcomes and further complicate already medically complex babies, impacting both health and development. Feeding is not just nutrition and not just developmental care. It is really both.

How do we assess feeding in the NICU? It typically begins with a clinical feeding evaluation including medical history, oral motor examination, and feeding and swallowing skill assessment. This is typically done by bedside nurses and speech-language professionals. However, clinical feeding evaluation may not fully predict aspiration. Two additional instrumental assessment tools exist: the video fluoroscopic swallow study (VFSS) and the flexible endoscopic evaluation of swallowing (FEES). These are the two most common instrumental tools used in infants.

The VFSS provides real-time imaging of the oral, pharyngeal, and upper esophageal phases of swallowing as the infant consumes barium liquids in a sidelying position on an inclined wedge or upright in a chair, directly evaluating disruptions in swallowing physiology. The FEES is also available for evaluating pharyngeal swallowing in both breastfed and bottle-fed infants. Advantages of FEES in the preterm population include no radiation exposure, the ability to be done at bedside, the use of breast milk or formula rather than barium, direct visualization of anatomy, and a longer assessment window that allows for evaluation of fatigue. Sometimes babies do well for the first few minutes and then begin to make errors as they tire. FEES also allows you to see the response to treatment strategies in real time, such as whether thickening feeds or changing the bottle makes a difference.

Daphna Yasova Barbeau (06:30.434) The purpose of this retrospective cohort study was to look at the incidence of dysphagia confirmed by FEES in the NICU, not just by clinical description. They also wanted to examine maternal characteristics and infant morbidities associated with dysphagia, and look at the frequency of therapeutic interventions at discharge in very preterm infants (less than 32 weeks) or very low birth weight infants (less than 1,500 grams).

It was a retrospective cohort study of infants born very preterm or very low birth weight between 2019 and 2021, conducted at an urban level four maternity hospital. Their NICU cares for approximately 125 very preterm or very low birth weight infants per year. All infants received a clinical bedside evaluation and follow-up interventions from either a speech-language pathologist (SLP) or an occupational therapist (OT). In many units, one type of therapist provides many types of intervention, and it is worth noting that here.

The neonatal therapist completes the clinical bedside evaluation during bottle and/or breastfeeding based on the mother's feeding goal, once the infant begins oral feeds. Oral feeding is reassessed at least weekly based on individual needs. Per their protocol, if an infant continues to exhibit feeding difficulties or poor feeding progression around 38 weeks post-menstrual age (PMA), the team proceeds with a FEES to obtain more detailed information about dysphagia. Criteria for performing FEES included being 38 weeks PMA or above, consistent signs of feeding difficulty despite compensatory strategies such as positioning, pacing, or an extra slow-flow nipple, regression or plateau in oral feeding progress, baseline physiologic stability, and respiratory support of no more than 2 liters per minute of nasal cannula. In their unit, the FEES is performed by an SLP as the endoscopist and a second neonatal therapist as the feeder during the exam.

Ben Courchia (09:06.222) And FEES stands for flexible endoscopic evaluation of swallowing.

Daphna Yasova Barbeau (09:09.858) That's right. That's why you need multiple hands for this evaluation. Upon completion, an ENT reviews the FEES video to assess upper airway anatomy and physiology and make further recommendations if needed.

Diagnosis of dysphagia on FEES was made if the infant had either laryngeal penetration with or without aspiration on thin liquids. To clarify: laryngeal penetration is defined as passage of material into the laryngeal vestibule that does not pass below the vocal cords, whereas aspiration is defined as entry into the trachea below the level of the vocal cords.

On to the results. During the two-year study period, 190 very preterm or very low birth weight infants were admitted to the NICU. After excluding 32 infants, 158 were included in the study. All 158 received the bedside clinical exam by the certified neonatal therapist per protocol. Of those 158, 40 infants (25%) met the criteria for FEES evaluation at around 38 weeks PMA, with documented consistent signs of feeding difficulty with regression or plateau despite feeding strategies.

All 40 infants with a FEES-confirmed diagnosis of dysphagia were compared to 118 infants with no dysphagia as the control group. There were no significant differences in maternal characteristics between the two groups. Median gestational age and birth weight were significantly lower in infants who developed dysphagia. Looking at Table 2, the gestational age range in infants with dysphagia was 25.8 to 29.3 weeks (mean approximately 28 weeks), versus 28.4 to 31 weeks (mean approximately 30 weeks) in infants without dysphagia.

Logistic regression adjusting for birth weight and gestational age showed that infants with dysphagia had an increased incidence of other morbidities, including BPD and intracranial hemorrhage. Multiple regression analysis adjusting for both birth weight and gestational age showed that dysphagia was significantly associated with higher central line days and longer hospital length of stay.

The median PMA at the time of FEES was 38.4 weeks. Laryngeal penetration was detected in all 40 infants who underwent FEES. Among those, tracheal aspiration was detected in 23 infants (57%). Three infants (approximately 7.5%) were discharged home with a G-tube, and 38 infants (95%) required thickened feeds upon discharge.

Daphna Yasova Barbeau (13:40.722) I think this data is alarming. At 38 weeks, babies who were showing clinical signs of feeding difficulty were found to have laryngeal penetration on FEES. Nearly 60% were aspirating. That is potentially very clinically significant.

One thing I was actually pleased to see is that approximately 7% were discharged with G-tubes, which means the team was able to intervene in the vast majority of babies and get them to where they needed to go without a G-tube. That is exciting. But 95% required thickened feeds at discharge, which is worth noting given that thickened feeds have fallen in and out of favor.

I wonder how many babies would benefit from these kinds of assessments but are simply not getting a FEES to characterize their dysphagia. I also think it would help families. We often say "your baby just isn't there yet" or "they haven't figured it out yet." But what specific skill is your baby actually struggling with? What are the risks? And for the bedside nurses, parents, or whoever is feeding, this reframes the conversation. It is not about just making the baby do it. This baby has a medically documented incoordination. I think having more information would be valuable for everyone on the team, and raises the question of whether we are continuing to push babies who may actually be aspirating.

Ben Courchia (14:24.272) It is a very interesting study. It is rare that we review a retrospective study, but this raises a real conundrum in the NICU. Setting aside the potential for residual confounding, what strikes me is that we almost never document dysphagia. I am becoming a bit of a note police in our unit about this. There are babies who clearly have dysphagia, and I wonder if we actually named it and called it what it is, whether that would prompt us to pursue a modified barium swallow study or FEES earlier. In this paper, FEES was done at around 38 weeks PMA, but I feel like in our practice we tend to get there much later. And I wonder whether that happens because we wait until we are frustrated with lack of progress rather than acting on an earlier naming of the problem. Would we order it sooner if the word dysphagia appeared in every daily note?

Daphna Yasova Barbeau (15:43.055) Exactly. Part of it is also whether we are treating dysphagia as expected or normal for this type of baby given their degree of immaturity. And there is some degree of that. Some babies just figure it out. Others do not. But labeling it and saying it is not that your baby is lazy or not getting it right, they have a medical incoordination, I think that helps everyone on the team. It changes the conversation from "just keep trying" to asking: do we keep pushing a baby who may be aspirating with every trial, or do we find out early what the risk actually is and intervene appropriately? There are always those babies who have a real setback when oral feeding is advanced too aggressively. This will definitely make me rethink those babies who are near term corrected and still struggling.

Ben Courchia (16:55.186) Thank you.

Daphna Yasova Barbeau (16:56.515) Thank you.