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Scott Webb: The Pediatric Aerodigestive and Airway Reconstruction team at Stanford Children's Health works together to streamline all parts of patient care, constantly striving to provide the best outcome for each patient. And today, we are discussing pediatric aspiration, a condition that can be difficult to diagnose, but if left untreated, it can lead to respiratory symptoms and lung injury.

And joining me today to discuss the diagnosis and treatment options for aspiration and how the multidisciplinary team at Stanford Children's Health can help children and families is Dr. Douglas Sidell. He's an Associate Professor of Otolaryngology and Director of the Lucile Packard Children's Hospital Center for Pediatric Voice and Swallowing Disorders and Pediatric Aerodigestive and Airway Reconstruction. And I'm also joined by Jenna Bernstein. She's a speech language pathologist at Stanford Children's Health.

This is Peds Talks from Stanford Children's Health. I'm Scott Webb. So I want to thank you both for joining me. And Dr. Sidell, I know you've been on before, so you're a bit of a pro at this. As we get rolling here, what is aspiration? And is it always a problem?

Dr. Douglas Sidell: Thanks, Scott. I think aspiration is a topic that's important to both our patients and their parents, but also other providers. It's amazing how often people kind of throw that word around. And there isn't always a clear diagnosis of aspiration, even when the word aspiration or the diagnosis of aspiration is given.

But specifically, aspiration occurs when food or liquid that tended to be swallowed and to enter the digestive tract actually enters the airway. And it's specifically defined on swallow studies when food or liquid passes through the level of the vocal cords. You know, of course, the concern here is that if you have a fluid or a solid, which really isn't supposed to be there ends up in the trachea and to some degree under some circumstances, the lungs. When aspiration happens, it may not only be food or drink like milk or water, but it can also be saliva, from unknown bodies or gastric reflux coming up from the stomach.

It's important I think to note that everyone aspirates a little bit naturally and our own bodies can actually take this. For example, our lungs, I think they do a pretty darn good job. We don't give them the credit they deserve for handling, you know, the secretions that we aspirate in very low quantities, for example, when we sleep. But if children aspirate either in larger quantities or on a chronic basis, it can become a big problem. And Jenna Bernstein on with us today, one of our top speech pathologists who specializes in swallowing disorders, I think could tell you a little bit more about the way this can affect children.

Jenna Bernstein: I think we have kind of a good start about, you know, what is aspiration and the real question that we ask from a, you know, feeding therapy speech-language pathology standpoint is how much aspiration is too much aspiration for any one child. And I think that's really variable kind of weighing the pulmonary health, weighing the growth trajectory, but also weighing what does feeding look like overall for this family. I think we'll delve a little bit more into that today and how we specifically assess.

Scott Webb: Yeah, we definitely will. And, Dr. Sidell, how do children with pathologic or chronic aspiration present? What kinds of symptoms do they have?

Dr. Douglas Sidell: Great question. And I don't mean to be vague about this, but I think this really can vary a great deal and it depends in some part at least on why the kids are aspirating. Some children may have very few symptoms and may not have clinical response when the actual aspiration occurs, something we call silent aspiration. This may only come to clinical attention on say a chest x-ray or in situations where a child may be diagnosed with something like asthma that doesn't respond as we would expect to the medical therapy for asthma.

And under other circumstances, we have kids who may cough or splutter when they're drinking and response to the liquid going in the wrong direction, or they may get some sort of a wet or gurgling noise either during or after they eat or drink. And some children, they come to clinical attention because they've got repeated infections or pneumonias, or just regular old colds that lasts much longer than they should under normal circumstances. And of course, like anything, I think there can be a blend of these possible presentations in any single child.

I think the important thing here to remember is that many of the symptoms of aspiration are not highly specific and they may be suggestive of several different pathologies or things that could be going on with that child. And not every cough during drinking or noisy breathing after a feed is aspiration. And that's something that we often tell other people who are referring patients to us. And we also know that not every long cold is representative of lung injury. This makes aspiration, I think something that may not be overtly easy to diagnose clinically, but it's always very important to consider. So just considering aspiration is an important first step in managing any child who may have aspiration going on.

Scott Webb: Yeah. And you mentioned diagnosis. So Jenna, back to you. What kinds of studies can you do to diagnose aspiration?

Jenna Bernstein: There are a number of different avenues we can take. And at Stanford Children's Health, we're lucky to have access to all of the avenues in which to really diagnose aspiration. So generally, we start with a clinical feeding evaluation and what this entails is getting a good kind of case history, typically an observation of the child eating and drinking so that we can try to identify, you know, any of those subtle signs that Dr. Sidell had mentioned that might suggest to us, you know, maybe aspiration is on the differential for this child. From there, if there is a concern, there are two instrumental assessments that we generally turn towards.

One is a or a videofluoroscopic swallow study or VFSS. And that is a study done in collaboration with radiology, where we add a contrast agent called barium to the child's liquids and solids. And we really watch them swallowing under this video x-ray and that allows us to see where the food and liquid is going and is any of that food or liquid going below the level of the vocal cords aspiration.

The other study that we do is something that, you know, Dr. Sidell and I do in collaboration at Stanford Children's and that is called the FEES, the fiberoptic endoscopic evaluation of swallowing. And what that entails is feeding a child while Dr. Sidell is passing a flexible laryngoscope. And that allows us to look at the voice box from above and see whether any food or liquid is getting into the area that it shouldn't be, the larynx. And Dr. Sidell can kind of add a little bit more onto that. We often are in the office doing these together.

Dr. Douglas Sidell: I think that's very important, Jenna. And, you know, we both know that when kids they're not protecting their airway well, and by that, I mean, they don't have a coordinated closure of the larynx, for example, when things that aren't supposed to go into it are in the neighborhood and they're at risk of aspirating anything. And like we talked about before, this could be reflux from below or anything coming from the mouth above. And it also could be a result of kids not really timing or coordinating their swallowing and breathing.

And as an otolaryngologist, I really like using the endoscopic swallow evaluation because it gives me an excellent amount of information about the function and the appearance of the larynx. It's not the appropriate study for every child, but it allows me and you to identify most of the laryngeal pathology with a fairly high sensitivity.

And I like to think of these studies, both the fluoroscopic or x-ray swallow study and the endoscopic swallow study kind of like a Venn diagram. You have both studies that have some overlap and they can tell us a lot of the same information, but they also have their own important benefits, you know, one over the other.

Under certain circumstances, I think we can add to our global evaluation by performing a combined laryngoscopy and bronchoscopy as well in the operating room. This allows us to actually feel the larynx for anatomic abnormalities that we can't see with a flexible scope in the clinic. And we can also look further down the airway into the trachea.

At Stanford Children's health, this is one of the things that's frequently performed by our aerodigestive team, and that allows us to combine specialties under one anesthetic. So our GI specialist can look at the GI tract in children, for example, with reflux or motility issues, and the pulmonologist can look in the lungs and I can look and feel the larynx and central airway. And so putting all of these things together, it gives us a pretty good understanding about how kids are, not only swallowing, but what their anatomy looks like and feels like often in real time.

Scott Webb: And Jenna, how is aspiration treated?

Jenna Bernstein: Yeah, I think when we look at aspiration, we can treat it in a number of different ways. And that's really patient dependent. So as Dr. Sidell touched on, ideally, you know, if there's multiple components going on, this child would be followed in a multidisciplinary fashion. And we typically do that here at Stanford Children's Health.

From the feeding specific standpoint, we usually try to implement some type of intervention that will slow down the flow of food or liquid to allow that child time to close off their airway, to prevent aspiration. For a young infant, that might look something like changing the positioning that they're feeding in, changing the flow rate of the nipple that they're feeding with or providing pacing, giving them breaks intermittently throughout the feed. For the older child, this might look something like changing the cup that they're drinking from. Maybe we look at a straw cup that has a slower flow, for example, or we work on taking single sips at a time.

Ideally, we would look at one of these strategies as kind of a first step, but sometimes that's not enough to prevent aspiration from happening. And so the other kind of tools in our toolbox that we often look at are thickening liquids. Another strategy that we use is to slow down the flow of whatever that child is eating or drinking to ideally allow them more time to protect their airway when they're swallowing.

Oftentimes, it's a combination of all three of these things, positioning, pacing, and thickening. But it really is patient-specific.

Scott Webb: Yeah. And Dr. Sidell, when we talk about the tools in the toolbox, you know, to use Jenna's words, are there any causes of aspiration that can be fixed with a surgery or an operation?

Dr. Douglas Sidell: I would say that there are many ways to treat aspiration surgically, but it really does depend on the anatomic problem that we're dealing with. When we do have an anatomic problem, it's almost always, you know, combined with some of the other non-surgical treatments that Jenna has discussed as well, and so we're frequently combining those with a surgical intervention.

Some examples, I can give you where surgical intervention is needed could include things like vocal fold immobility. Now, the vocal folds are the same thing as the vocal cords and they close at the appropriate time. And this is one of the most protective and important protective mechanisms of the airway. Unilateral or one-sided vocal cord immobility is a very common process where one of the vocal cords doesn't move well and the larynx can't close completely. So as a reminder, you know, the only thing we want passing in and out of the larynx is air. And when one vocal fold doesn't move well, this allows for frequently liquids to move through the larynx and into the airway when we're swallowing. This is treatable when you have one of the vocal folds not moving with these temporary injections that we do. And this is a very brief procedure which uses an injectable implant to move the vocal fold medially or towards the midline. And that's a static procedure. It doesn't cause the vocal fold to actually move functionally. It just pushes it towards the middle, so the other vocal fold can touch it and close the larynx completely.

This is, as I mentioned, a temporary implant and temporary, because many of the times when we have vocal fold immobility, depending on the etiology of the problem itself, those vocal folds will start to move again. So we don't want to do anything permanent to the larynx if the problem itself is temporary.

We also have long-term solutions to this problem as well if the vocal fold immobility is permanent and those involve more permanent implants or procedures that involve the nerves of the neck and the larynx. We also have other problems just to name a few like a laryngeal or laryngotracheal cleft, as well as a tracheoesophageal fistula. And these can be fixed. We see these frequently at Stanford Children's Health and they both represent abnormal communications or continuity that go between the GI tract and the airway. And so because you have these holes there, you know, surgical closure is possible.

But I do want to reiterate that even with these anatomic abnormalities, when they do exist, they may not be the only thing that's influencing the swallow function or dysfunction. Problems that affect the coordination and the timing of the swallow may also exist in children with these anatomic problems, especially if the kids are born prematurely or if they have another syndrome. And you have to really consider these things, they have to be taken into account. Because if you treat the anatomic problem that may help, but it may not be the complete solution and you have to be ready for this stuff or you may miss something very important.

Scott Webb: Yeah, definitely. And Jenna, back to you, what's the long-term prognosis for aspiration?

Jenna Bernstein: The good news is that the long-term prognosis is actually quite good for these patients. As long as we identify what's going on early and we prevent any negative kind of sequelae that can result from that. So if we meet a child when they're an infant, maybe two, three months old, and we find, you know, aspiration for this child, it's problematic and we can implement some of those strategies that we discussed.

We can make sure, as Dr. Sidell touched on, that we're not missing anything anatomical that might be contributing to this child's aspiration. The outcomes are quite good. And there will be a point in that child's life, it may be later on when they're 2, 3, 4, when they might no longer need to use some of those strategies that we discussed.

The swallowing overall is a super complex mechanism, but what we know about it is that it tends to improve with growth, with maturation, with safe swallowing practice. And so with all the tools that we currently have, if we can identify early and then implement some of those strategies, we see children who are really thriving on a totally regular diet with minimal intervention as they approach childhood.

Scott Webb: Yeah, you can see how and when early intervention would be so key. And Dr. Sidell, as we get close to wrapping up, this is for other providers and I wanted to ask you for pediatricians, when should they be referring to the specialists like yourself?

Dr. Douglas Sidell: I think a swallowing dysfunction is a lot more common than we actually appreciate. And it doesn't always mean, you know, a lifelong process where we have long-term complications, et cetera. But if any pediatrician suspects that swallowing dysfunction is a component of that child's either lung problems, frequent illnesses or difficulty with feeding, we would love to see them earlier rather than later, just as you mentioned. I think if we see somebody earlier, it gives us more opportunity to actually, you know, provide support to the families. Even if we're telling them that nothing is wrong, I think that that can be reassuring that we're doing something safe.

It also plugs them into our clinics, you know, early, and so we have the ability to be really an open door access point in case things actually do change or get worse over time. And I'd love to add to what Jenna mentioned when she was talking about that long-term prognosis of aspiration being very good. It is tough work as a parent and as a physician to work with a child who is aspirating, because it does require a lot of patience along the way. And we see these families and their children at different intervals, depending on what the actual problem or issue is. But we never just thicken the liquids and forget about them or place a nasal tube and walk away. We are constantly re-evaluating, supporting the families and working on whatever the child can do from a feeding and swallowing standpoint to maintain a safe and functional and maturing swallow over time.

Scott Webb: Well, as I said, I've had a chance to speak with you before, Dr. Sidell, and great having you on, Jenna. The work that you all are doing at the Pediatric Aerodigestive and Airway Reconstruction Center at Stanford Children's Health is really amazing. And I'm enjoying these conversations and learning so much and glad we could do one today for other providers. Thanks for your time and your expertise, and you both stay well.

Dr. Douglas Sidell: Thanks. I appreciate it.

Scott Webb: For more information, go to aerodigestive.stanfordchildren.org. And this is Peds Talks from Stanford Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.