Mini-symposium: Oesophageal Atresia and Tracheo-oesophageal FistulaFeeding Difficulties in Children with Esophageal Atresia
Introduction
Esophageal atresia, with or without tracheoesophageal fistula (TEF), is a congenital anomaly of the esophagus affecting one in every 2500-3000 live births [1]. Infant survival of this condition is high, with reported survival rates of over 90% [2]. However, gastrointestinal and respiratory complications are well documented in children, adolescents and adults with repaired EA [3], [4], [5], [6], [7], [8], [9]. Feeding disorders in children with esophageal atresia are common in clinical practice but the literature supporting these observations is limited. Between 6% and 52% of patients have some abnormalities of feeding [7], [10], [11]. The majority of studies focus on esophageal abnormalities as source of feeding difficulties. There are no prospective studies on oropharyngeal dysfunction or aerodigestive abnormalities in patients with esophageal atresia.
Section snippets
Overview of Feeding Difficulties
Feeding difficulties have been described in patients with EA. Puntis et al., [11] first characterized feeding difficulties in 124 children with EA. Compared to healthy controls, children born with EA were significantly more likely to eat slowly, refuse meals, cough or choke during eating and vomit with meals. Chetcuti et al., [12] described similar feeding difficulties in childhood, but noted that overall, these difficulties lessen with age, with < 10% of patients age 15 or older reporting
Esophageal dysphagia as a cause for feeding difficulty
Dysphagia is a common complaint in patients with EA and causes include dysmotility, anatomic lesions, esophageal outlet obstruction and esophageal inflammation. The reported prevalence of dysphagia in patients with EA ranges from 38% to 85% [3], [8], [9], [12], [16], [17]. A recent systematic review and meta-analysis by Connor et al. found an overall pooled estimated prevalence of 50.3% (95% CI 35.7 – 64.8) [5]. The evaluation of dysphagia involves (1) an esophagram to assess for strictures or,
Diagnosis of Aspiration
There are many different methods of diagnosing oropharyngeal dysphagia and all of them are complementary with no clear gold standard test. Studies have suggested that the agreement between studies is poor. Baikie et al. for example, studied the agreement between three tests for aspiration – barium videofluoroscopy, salivagram and milk scan - in 63 children with cerebral palsy [35]. The authors found that overall agreement between the tests was poor, with a maximum kappa of 0.20 suggesting that
Management of oropharyngeal dysphagia with aspiration
Many causes of aspiration improve over time and thus management decisions regarding feeding must be made in the context of the likelihood of improvement in aspiration. Management goals include: reduction of aspiration during swallowing, reducing full column reflux into the oropharynx and continuation of oral feeding to maintain skills. While there are no studies on the management of aspiration in children with EA, conclusions can be drawn from the available literature in other populations.
Discussion
Feeding difficulties are common in patients with repaired EA. In this review, we investigate the mechanisms for abnormal feeding in these patients. Esophageal dysphagia is well-described in patients with EA and is often due to anatomic abnormalities such as strictures, esophageal dysmotility or mucosal inflammation. While respiratory symptoms are highly prevalent in patients with EA, there are very few studies evaluating oropharyngeal dysfunction in this population. Aspiration is an
Funding Source
This work was supported by the Translational Research Program at Children's Hospital Boston and NIH NIDDK R01 DK097112. It was funded by the NASPGHAN/ASTRA research award for disorders of the upper tract.
Financial Disclosures
None.
Educational Aims
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To describe the mechanism of esophageal dysphagia and oropharyngeal dysphagia/aspiration as mechanisms for feeding difficulties in patients with esophageal atresia
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To highlight the prevalence of respiratory symptoms in patients with esophageal atresia
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To review methods for diagnosing aspiration
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To discuss treatment strategies for management of aspiration
Directions for Future Research
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To characterize oropharyngeal dysphagia and aspiration in patients with esophageal atresia.
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To investigate the relationship between aspiration, respiratory symptoms and feeding difficulties in patients with esophageal atresia.
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To determine the best method of diagnosing aspiration in patients with repaired esophageal atresia.
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To optimize management of aspiration in patients with esophageal atresia.
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Cited by (40)
Magnamosis for long gap esophageal atresia: Minimally invasive “fatal attraction”
2023, Journal of Pediatric SurgeryCitation Excerpt :One patient experienced “secondary” oral aversion after dilation related esophageal fissuring. Recently, Mahoney et al. reported oral aversion with a prevalence between 38% and 85% in patients with EA [17]. However, no data is currently available on feeding and swallowing acquisition in patients treated with magnamosis.
Parents’ experiences of feeding children born with oesophageal atresia/tracheo-oesophageal fistula
2022, Journal of Pediatric SurgeryFear, isolation and the importance of support: A qualitative study of parents' experiences of feeding a child born with esophageal atresia
2022, Journal of Pediatric NursingCitation Excerpt :Research has also shown that whilst feeding difficulties in patients with typical EA might be mild, patients with more complex EA tend to experience significant feeding difficulties (Baird et al., 2015). Possible causes for feeding and swallowing difficulties are likely to be multifactorial and interacting, including abnormal functioning of the esophagus, such as gastroesophageal reflux, esophageal dysmotility or narrowing (Mahoney & Rosen, 2016; Ramsay & Birnbaum, 2013); psychological trauma related to aversive and intrusive oral events (Pham et al., 2021); parental factors, such as parental age, educational level and employment status (Sdravou et al., 2020); and feeding practices (Greer et al., 2008). Current recommendations highlight the need for early intervention and a specialist multidisciplinary team approach (Mahoney & Rosen, 2016; Menzies et al., 2017; Ramsay & Birnbaum, 2013).
Acupuncture for dysphagia after surgery for Esophageal Atresia with tracheoesophageal fistula: A case report
2021, World Journal of Acupuncture - MoxibustionEvaluation of pulmonary complications and affecting factors in children for repaired esophageal atresia and tracheoesophageal fistula
2021, Respiratory MedicineCitation Excerpt :Recently, glutathione and miRNA-21 levels were significantly lower in exhaled breath condensate of patients with EA, showing that airway inflammation may lead to many respiratory symptoms [38,39]. Long-term esophageal motility disorders and swallowing dysfunction are observed in 50.3% of the patients who underwent surgery due to esophageal anomalies [11,30–34]. Many studies have shown that the frequency of chronic cough, frequent pneumonia, and malnutrition increased due to swallowing dysfunction and aspiration.
Nutritional Status in Adolescents with Esophageal Atresia
2020, Journal of Pediatrics