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Vol.29, No.1 Winter/Spring 2019

NYU Winthrop’s Neonatal Breakthroughs

New Diagnostic Approach Improves Upon Detection of Common Feeding Problem, While Cold Milk “Startles” Infant’s Swallowing Movements to Improve Them

NYU Winthrop’s Neonatal Intensive Care Unit (NICU) is ranked among the best in the world regarding overall survival of extremely premature babies. That’s when compared to more than 800 NICUs by the prestigious Vermont Oxford Registry Network, an authority on the measurement of care and outcomes for high-risk infants worldwide. Now, with a novel new approach for detecting a common swallowing and feeding dysfunction, dysphagia, our results should improve even further.

Preterm infant

Dysphagia impacts 30–70% of very-low-birth-weight preterm infants and can result in serious consequences when milk, rather than reaching an infant’s stomach, goes down the wrong way and penetrates the airway (trachea). This can be devastating to fragile, immature lungs and lead to problems such as pneumonia, lung inflammation, and growth compromise. Fortunately, Nazeeh Hanna, MD, Chief of the Division of Neonatology, and his research team have developed a novel diagnostic method for detecting dysphagia that has proven so safe and successful that NYU Winthrop determined it could not withhold using the technique in the NICU, even though the approach is still under study. The technique employs a dual diagnostic approach that involves FEES and VFSS (see descriptions below) done simultaneously. NYU Winthrop is believed to be the only medical center in the U.S. – and possibly the world – employing this new dual approach, which the Hospital believes will soon become a standard of care.

“Our dual diagnostic approach is a major advancement in detecting potential health risks among the most vulnerable of the preterm infant population,” said Dr. Hanna. “We expect our discoveries to prompt a paradigm shift in approaches to diagnosing and treating dysphagia in preterm infants, immediately providing clinicians with improved techniques, methodologies, and applications that can impact clinical practice in NICUs throughout the country. These changes in standards of care may improve neonatal outcomes and decrease medical costs.”

Previously, there were limited diagnostic tools for detecting dysphagia in preterm infants. FEES and VFSS, independent of one another, were helpful diagnostic tools but had several limitations. VFSS is short for Video Fluoroscopy Swallow Study, or X-ray fluoroscopy, and it has to be done in a radiology suite. Previously, this was the only available tool to study a preterm infant’s ability to swallow safely, but it is not without shortcomings. The main disadvantage is the use of radiation, which means that it cannot be used repeatedly despite the infant developing and changing from week to week. Other disadvantages include an inability to use during breastfeeding and associated risks to transporting a sick, preterm infant to a radiology suite.

The other diagnostic tool, Fiberoptic Endoscopic Evaluation of Swallowing, or FEES, is a bedside portable endoscopy test that has been around for decades for use in evaluating dysphagia in adult patients, but it has rarely been evaluated in neonates. NYU Winthrop’s preliminary data showed that FEES identified dysphagia in 69% of all swallows compared with 60% for VFSS, and when combined, the two diagnostic tools gave an even more comprehensive picture of the infant feeding issue, yielding more specific and sensitive information than obtained through just one test. NYU Winthrop now uses the two tests for initial screenings of preterm infants, after which follow-up tests can use FEES-only for updating information as the baby further develops.

NYU Winthrop has, at the same time, placed into effect a new therapy for dysphagia that the Hospital’s research proved groundbreaking – feeding the preterm infant cold milk. The Hospital’s research showed that cold milk startles the pharynx (at the back of the mouth), triggering the brain to initiate more efficient swallowing movements.

When it comes to preterm infants with dysphagia, NYU Winthrop’s research turns on its head the age-old tradition of warming up milk for a baby.

A similar cold feeding approach has been used for some time in adult stroke and throat-cancer patients who suffer degradation in swallowing capabilities but has not previously been a standard for the infant population.

“Feeding a preterm infant cold milk startles the infant’s swallowing mechanism, just as a person might be startled if someone puts an ice cube to their skin, prompting the baby’s swallowing efforts to be much more effective,” added Dr. Hanna.”

NYU Winthrop’s Division of Neonatal Medicine has shown cold liquid to be very effective in short-duration feedings, reducing dysphagia occurrences from 71% to 26%. These results were published in Dysphagia, a multidisciplinary journal devoted to swallowing and its disorders, with the research titled “Short-Term Effects of Cold Liquids on the Pharyngeal Swallow in Preterm Infants with Dysphagia: A Pilot Study.” Currently, Dr. Hanna’s research team is investigating the effects of an entire cold-feed on feeding performance. Dr. Hanna expects this research to establish cold milk as a novel therapeutic option to manage dysphagia in preterm infants.

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