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Original Investigation
November 9, 2017

A Systematic Process for Weaning Children With Aspiration From Thickened Fluids

Author Affiliations
  • 1Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. Published online November 9, 2017. doi:10.1001/jamaoto.2017.1917
Key Points

Question  Can a systematic weaning process (SWP) be safely and effectively implemented to gradually wean children off of thickened fluids?

Findings  In a case series of 50 pediatric patients with aspiration who underwent the SWP, most patients tolerated a reduction in thickeners and a full wean to a thin-fluid diet. Children required a mean of 0.7 videofluoroscopic swallow studies from the time of presentation to completion of the SWP.

Meaning  The SWP uses incremental steps to gradually reduce fluid thickness based on a patient’s clinical response, which may allow the swallowing mechanism to adapt to consistent change over time.

Abstract

Importance  Thickening of fluids is a common strategy for feeding patients with oropharyngeal dysphagia but has known risks and should be stopped once it is safe to do so. Weaning children from thickened fluids safely can be challenging, and novel methods are required.

Objective  To describe the use of a systematic weaning process (SWP) for children who received thickened liquids owing to oropharyngeal dysphagia and identified risk of aspiration.

Design, Setting, and Participants  Retrospective case series (2010 to 2015) at a tertiary care center of 50 children with documented aspiration by clinical swallowing assessment, airway evaluation, and videofluoroscopic swallow study with at least 4 months of follow-up. All patients were initially receiving thickened fluids. A 10% reduction in thickness was made every 2 weeks based on clinical symptoms. Caregivers progressed to the next incremental level if there were no signs or symptoms of aspiration.

Main Outcomes and Measures  Number of patients weaned to a thin-fluid diet.

Results  Of 50 children (32 [64%] male; median [interquartile range] age, 0.7 [1.0] y at presentation and 1.8 [1.3] y at start of wean) using the SWP, 44 (88%) were able to reduce the amount of thickener used. A successful wean from thickened fluids to thin fluids was completed in 39 (78%). The mean (SD) duration of a successful wean was 0.9 (0.6) years. Five patients tolerated a reduction in thickener but not a full wean to thin fluids. For 6 patients, weaning failed and they continued to receive thickened fluids. Of those whose weaning failed, 2 patients developed pneumonia. Of the 39 successfully weaned patients, 14 (36%) experienced a temporary stall but eventually tolerated thin fluids. Only 2 (5%) developed pneumonia while all other successfully weaned patients (n = 37 [95%]) did not experience any substantial respiratory issues. Overall, 46 (92%) of children required 2 or fewer videofluoroscopic swallow study evaluations.

Conclusions and Relevance  Patients with oropharyngeal dysphagia and aspiration should be gradually weaned off of thickened fluids. The SWP uses small incremental steps to gradually reduce the amount of thickener. Using this method, most children tolerated a reduction in thickeners and a thin-fluid diet. The SWP presents a safe and effective way of gradually returning children to a more normal diet.

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