Consideration of Cough Reflex Development When Ordering Modified Barium Swallow Studies in Infants


Infants < 51 weeks post-menstrual age (< 51 PMA) are often referred for modified barium swallow (MBS) studies for suspected silent aspiration (SA) given a possible association between SA and aspiration pneumonia. Infants this young are unlikely to have developed a mature laryngeal cough reflex, most likely rendering SA an expected finding in those who aspirate. The aims of this retrospective review were to (1) determine if SA resolves in a significant proportion of infants around the expected emergence of the laryngeal cough reflex, (2) determine which factors or characteristics are associated with and without SA resolution in these infants, and (3) determine if SA, or any aspiration, is associated with increased rates of lower respiratory infection (including aspiration pneumonia) in these infants. Results from the chart review revealed that 79/148 (53.4%) infants had SA on MBS < 51 PMA. 16/48 (33.3%) infants assessed for SA by the time of the expected emergence of the cough reflex had resolution. SA resolution was less common in infants with obstructive sleep apnea (p = 0.037). A total of 50/70 (71.4%) infants with a follow-up MBS had eventual SA resolution. Aspiration was not significantly associated with LRI, including aspiration pneumonia. The results suggested that the laryngeal cough reflex might develop later than reported in the literature and there is no association between aspiration and LRI. These findings may indicate that age should be considered before ordering an MBS solely to assess for SA in this population. The study provides preliminary evidence for future prospective research regarding SA resolution.

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  1. 1.

    Newman LA, Keckley C, Petersen MC, Hamner A. Swallowing function and medical diagnoses in infants suspected of dysphagia. Pediatrics. 2001;1:108.

    Google Scholar 

  2. 2.

    Rommel N, De Meyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. 2003;37(1):75–84.

    PubMed  Article  Google Scholar 

  3. 3.

    Tutor JD, Gosa MM. Dysphagia and aspiration in children. Pediatr Pulmonol. 2012;47(4):321–37.

    PubMed  Article  Google Scholar 

  4. 4.

    Thach BT. Maturation and transformation of reflexes that protect the laryngeal airway from liquid aspiration from fetal to adult life. Am J Med. 2001;111(8)(suppl 1):69S–77S.

    Google Scholar 

  5. 5.

    Thach BT. Maturation of cough and other reflexes that protect the fetal and neonatal airway. Pulm Pharmacol Ther. 2006;20:365–70.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  6. 6.

    Polverino HM, Polverino F, Fasolino M, Andò F, De Blasio AA. Anatomy and neuro-pathophysiology of the cough reflex arc. Multidisciplinary Respiratory Medicine. 2012;7:5.

    PubMed  PubMed Central  Article  Google Scholar 

  7. 7.

    Fuller R, Jackson D. Physiology and treatment of cough. Thorax. 1990;45(6):425–30.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  8. 8.

    Miller HC, Proud GO, Behrle FC. Variation in the gag, cough, and swallow reflexes and tone of the vocal cords as determined by direct laryngoscopy in newborn infants. Yale J Biol Med. 1952;24(4):284–91.

    CAS  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Casazza GC, Graham ME, Asfour FC, O'Gorman M, Skirko JD. Aspiration in the otherwise healthy Infant-Is there a natural course for improvement? Laryngoscope. 2019.

    PubMed  Article  Google Scholar 

  10. 10.

    Johnson P, Salisbury DM, Storey AT. Apnea induced by stimulation of sensory receptors in the larynx. Symposium on Development of Upper Respiratory Anatomy and Function. Implications for Sudden Infant Death Syndrome; US Department of Health, Education and Welfare. 1975;160–185.

  11. 11.

    Harding R, Johnson P, Johnston BE, McClelland MF, Wilkinson AR. Cardiovascular changes in newborn lambs during apnea induced by stimulation of laryngeal receptors with water. J Physiol. 1976;256(1):35P–6P.

    CAS  PubMed  Google Scholar 

  12. 12.

    Harding R, Johnson P, McCelland ME. Liquid-sensitive laryngeal receptors in the developing sheep, cat and monkey. J Physiol. 1978;277(1):409–22.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  13. 13.

    Lucier GE, Storey AT, Sessle BJ. Effects of upper respiratory tract stimuli on neonatal respiration: reflex and single neuron analyses in the kitten. Biol Neonate. 1979;35(1–2):82–9.

    CAS  PubMed  Article  Google Scholar 

  14. 14.

    Boggs DF, Bartlett D Jr. Chemical specificity of a laryngeal apneic reflex in puppies. J Appl Physiol Respirat Environ Exerc Physiol. 1982;53(2):455–62.

    CAS  Google Scholar 

  15. 15.

    Storey AT. A functional analysis of sensory units innervating epiglottis and larynx. Exp Neurol. 1968;20(3):366–83.

    CAS  PubMed  Article  Google Scholar 

  16. 16.

    Storey AT, Johnson P. Laryngeal water receptors initiating apnea in the lamb. Exp Neurol. 1975;47(1):42–55.

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    Pickens DL, Schefft G, Thach BT. Prolonged apnea associated with upper airway protective reflexes in apnea of prematurity. Am Rev Respir Dis. 1988;137(1):113–8.

    CAS  PubMed  Article  Google Scholar 

  18. 18.

    Pickens DL, Schefft GL, Thach BT. Pharyngeal fluid clearance and aspiration prevention mechanisms in sleeping infants. J Appl Physiol. 1989;66(3):1164–71.

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Davies AM, Koenig JS, Thach BT. Upper airway chemoreflex responses to saline and water in preterm infants. J Appl Physiol. 1988;64(4):1412–20.

    CAS  PubMed  Article  Google Scholar 

  20. 20.

    Davies AM, Koenig JS, Thach BT. Characteristics of upper airway chemoreflex prolonged apnea in human infants. Am Rev Respir Dis. 1989;139(3):668–73.

    CAS  PubMed  Article  Google Scholar 

  21. 21.

    Jadcherla SR, Hasenstab KA, Shaker R, Castile RG. Mechanisms of cough provocation and cough resolution in neonates with bronchopulmonary dysplasia. Pediatr Res. 2015;78:462–9.

    PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Chang AB. The physiology of cough. Paed Resp Rev. 2006;7(1):2–8.

    Google Scholar 

  23. 23.

    Ferguson NF, Estis J, Evans K, Dagenais PA, VanHangehan J. A retrospective examination of prandial aspiration in preterm infants. Perspect Swallowing Swallowing Disord (Dysphagia). 2015;24:162–74.

    Article  Google Scholar 

  24. 24.

    Gosa MM, Suiter DM, Kahane JC. Reliability for identification of a select set of temporal and physiologic features of infant swallows. Dysphagia. 2015;30(3):365–72.

    PubMed  Article  Google Scholar 

  25. 25.

    Jadcherla SR, Stoner E, Gupta A, et al. Evaluation and management of neonatal dysphagia: impact of pharyngoesophageal motility studies and multidisciplinary feeding strategy. J Pediatr Gastroenterol Nutri. 2009;48(2):186–92.

    Article  Google Scholar 

  26. 26.

    Arvedson JC, Lefton-Greif MA. Instrumental assessment of pediatric dysphagia. Semin Speech Lang. 2017;38(2):135–46.

    PubMed  Article  Google Scholar 

  27. 27.

    Langmore S, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia. 1998;13:69–81.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Greenough A, Milner AD. Neonatal Respiratory Disorders. 2nd ed. London: CRC Press; 2003.

    Book  Google Scholar 

  29. 29.

    Weir K, McMahon S, Barry L, Ware R, Masters IB, Chang AB. Oropharyngeal aspiration and pneumonia in children. Pediatr Pulmonol. 2007;42(11):1024–31.

    PubMed  Article  Google Scholar 

  30. 30.

    Weir KA, McMahon S, Taylor S, Chang AB. Oropharyngeal aspiration and silent aspiration in children. Chest. 2011;140(3):589–97.

    PubMed  Article  Google Scholar 

  31. 31.

    American Academy of Pediatrics—Policy statement. Age terminology during the perinatal period. Pediatrics. 2004;114(5):1362–1364.

    Google Scholar 

  32. 32.

    Delaney A, Arvedson J. Development of swallowing and feeding: Prenatal through first year of life. Dev Disabil Res Rev. 2008;14(2):105–17.

    PubMed  Article  Google Scholar 

  33. 33.

    Davis NL, Liu A, Rhein L. Feeding immaturity in preterm neonates: Risk factors for laryngeal aspiration and timing of maturation. Journal of Pediatric Gastroenterology, Hepatology, and Nutrition. 2015;57(6):735–40.

    Article  Google Scholar 

  34. 34.

    Weir KA, McMahon SM, Long G. Radiation doses to children during modified barium swallow studies. Pediatr Radiol. 2007;37(3):283–90.

    PubMed  Article  Google Scholar 

  35. 35.

    Hersh C, Wentland C, Sally S, et al. Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review. Int J Pediatr Otorhinolaryngol. 2016;89:92–6.

    PubMed  Article  Google Scholar 

  36. 36.

    Gabriel S, Eckel LJ, DeLone DR, et al. Pilot study of radiation dose reduction for pediatric head CT in evaluation of ventricular size. Am J Neuroradiol. 2014;35(12):2237–42.

    CAS  PubMed  Article  Google Scholar 

  37. 37.

    International Commission on Radiological Protection (ICRP). Radiation and your patient: A guide for medical practitioners. A web module produced by Committee 3 of the International Commission on Radiological Protection. 2009;1–17.

  38. 38.

    Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol. 2006;36(2):121–5.

    PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    United Nations Scientific Committee on the Effects of Atomic Radiation. Sources, Effects, and Risks of Ionizing Radiation. UNSCEAR. Report. Volume II, Scientific Annex B: Effects of radiation exposure of children. 2013;1–283

  40. 40.

    Rajaraman P, Simpson J, Neta G, Berrington de Gonzalez A, Ansell P, Linet MS, Ron E, Roman E. Early life exposure to diagnostic radiation and ultrasound scans and risk of childhood cancer: case-control study. BMJ. 2011;342:d472.

    PubMed  PubMed Central  Article  Google Scholar 

  41. 41.

    Mahieu LM, Buitenweg N, Beutels P, De Dooy JJ. Additional hospital stay and charges due to hospital-acquired infections in a neonatal intensive care unit. J Hosp Infect. 2001;47:223–9.

    CAS  PubMed  Article  Google Scholar 

  42. 42.

    Hodek J, von der Schulenburg JM, Mittendorf T. Measuring economic consequences of preterm birth - Methodological recommendations for the evaluation of personal burden on children and their caregivers. Health Economics Review. 2011;1(6):1–10.

    Google Scholar 

  43. 43.

    Mazurek Melnyk B, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, Stone PW, Small L, Tu X, Gross SJ. Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit program: A randomized, controlled trial. Pediatrics. 2006;118(5):e1414–e14271427.

    Article  Google Scholar 

  44. 44.

    Miles MS, Holditch-Davis D, Burchinal P, Nelson D. Distress and growth outcomes in mothers of medically fragile infants. Nurs Res. 1999;48(3):129–40.

    CAS  PubMed  Article  Google Scholar 

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Balest, A.L., White, K.E., Shaffer, A.D. et al. Consideration of Cough Reflex Development When Ordering Modified Barium Swallow Studies in Infants. Dysphagia 35, 533–541 (2020).

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  • Infants
  • Modified barium swallow study
  • Aspiration pneumonia
  • Silent aspiration
  • Dysphagia
  • Deglutition
  • Deglutition disorders