Objective. Respiratory illnesses may cause feeding difficulties in infants. We studied the safety of oral feeding during respiratory syncytial viral (RSV) bronchiolitis in previously healthy infants.
Methods. Twelve previously healthy infants (3–12 months) with RSV bronchiolitis underwent barium swallow studies during the acute phase of illness. Those with abnormal studies underwent repeat studies 2 to 4 weeks later.
Results. The initial barium studies revealed aspiration in 3 infants. All repeat studies, performed 2 to 4 weeks later, were normal.
Conclusions. Even previously healthy infants may be at risk of aspiration during RSV bronchiolitis.
Respiratory syncytial virus (RSV) is the major cause of bronchiolitis in infants. In the acute phase, bronchiolitis is often associated with fever, nasal discharge, irritability, tachypnea, wheezing, and feeding problems.1 Traditional wisdom, based on experience with premature infants, has dictated that there may be a risk of aspiration from feeding during respiratory distress; however, validated, specific feeding guidelines for infants during RSV bronchiolitis are not available. We investigated the safety of oral feeding during RSV bronchiolitis in previously healthy infants.
The study was conducted in a prospective manner over a period of 2 years comprising 3 RSV seasons. Infants presenting with classical clinical features of bronchiolitis and confirmation of RSV with the rapid antigen testing by enzyme-linked immunosorbent assay were considered for inclusion in the study. For inclusion in the study the infants had to be born full-term, previously healthy, and neurologically intact. In addition, entry criteria allowed inclusion of only those infants who were reported to have a reduced oral intake, feeding problems, and regurgitation but were well hydrated, clinically stable and able to consume oral feeds. Infants, who were born prematurely, had a prior history of failure to thrive or feeding problems, with an underlying cardiopulmonary condition or oropharyngeal anomaly were excluded. Infants with transcutaneous oxygen saturation <93% while being on room air and respiratory rate of >70 breaths per minute were also excluded. Twelve infants (range: 3–12 months; mean: 7.1 ± 3.5 months) with RSV bronchiolitis for 3 to 12 days (mean: 6.9 ± 2.4 days) fulfilled all entry criteria and formed the study group. All infants included in the study underwent a barium swallow study using half-diluted barium to assess suck-swallow mechanism in view of feeding difficulty and regurgitation. Specific instructions were provided to the radiologist to look for evidence of aspiration, anatomic anomalies, and gastroesophageal reflux. Barium was administered through a feeding bottle with the mother in attendance. If the barium study revealed evidence of laryngeal or tracheal penetration followed by eventual coughing up of barium, the infants were placed on thickened feeds ie, the regular formula (.67 kcal/mL, or 20 kcal/oz) was thickened with rice cereal in the concentration of 1 to 1.5 tablespoonfuls per 30 mL. Nasogastric tube feeds were recommended if the barium study revealed aspiration. Infants with abnormal barium studies underwent a repeat barium study in 2 to 4 weeks. No medications were prescribed.
The initial barium studies were abnormal in 8 of the 12 infants. Laryngeal or tracheal penetration of barium, with eventual clearance by coughing, was observed in 2 and 3 infants, respectively. Aspiration of barium was observed in 3 of 12 infants. The studies were normal in 4 of 12 infants (Fig 1). Six infants had evidence of gastroesophageal reflux.
The 5 infants with laryngeal or tracheal penetration were effectively managed with thickened feeds. Two of 3 infants with aspiration were fed through a nasogastric tube until their repeat barium study was performed. The parents of the third infant with aspiration refused tube feeds and he was managed with very thickened feeds (2 tablespoonfuls of rice cereal per 30 mL of formula). The feeding change was well tolerated by all infants. The energy intake increased because of the higher energy density of feeds. No complications or adverse outcomes were encountered either immediately or on follow-up.
Repeat barium studies were performed at 2 to 4 weeks (mean: 2.9 ± .8 weeks) after the initial study in the 8 infants with abnormalities in the initial study. All 8 repeat barium studies were normal (Fig 1). For the purpose of establishing a historical control we reviewed similar barium studies from a group of 22 neurologically intact infants being evaluated for apnea and gastroesophageal reflux. None of them showed aspiration, tracheal or laryngeal penetration in any infant.
Our study showed that abnormalities in swallowing occurred in previously healthy infants during the acute phase of RSV bronchiolitis despite appearing clinically stable. These findings did not correlate with any predictable clinical parameter and these abnormalities were completely reversible within a few weeks.
We do not think that the percentage of abnormality noted in our study (ie, 3 of 12 infants aspirated) may necessarily translate into the fact that globally 25% of all children with RSV bronchiolitis will aspirate. There may be an unavoidable bias in patient selection such that the percentage represented in our results may be higher because we included only those infants who had feeding difficulties and actively sought medical attention. The fact still remains that “some' or ”few' previously healthy infants with RSV bronchiolitis, who look clinically stable, do aspirate during the acute phase. This fact is important and needs to be addressed. Further, the symptoms of aspiration may be indistinguishable from those of RSV bronchiolitis. This may give an erroneous impression about the severity of bronchiolitis or its duration ie, an infant with mild RSV bronchiolitis and aspiration may give the impression of having severe RSV bronchiolitis with prolonged symptoms. This could affect proper treatment and unduly prolong illness. Oral feeding may then become an important confounding variable in assessing outcome of RSV bronchiolitis in clinical and research settings. So far, oral feeding has not been recognized as a confounding variable in any such study. Another concern is that aspiration in small infants may lead to food protein sensitization, abnormal mechanisms of neural control, and chronic airway dysfunction2 leading to chronic hyperreactivity of airways or reactive airway disease. This may provide yet another mechanism of increased reactivity of airways following RSV bronchiolitis; an already controversial issue.3
RSV bronchiolitis is a common problem in infants and there are no established feeding guidelines for infants during this illness. There is clearly a risk of aspiration during RSV bronchiolitis even in infants who appear clinically stable. Clinical researchers need to consider oral feeding as a confounding variable and primary care physicians need to be specifically aware of this problem with a higher index of suspicion. Our study identifies the problem but the optimal feeding strategy remains to be established. A simple intervention like the use thickened feeds during the acute phase of RSV bronchiolitis, especially in infants with feeding difficulties, needs to be considered. Such feeds would be safer to swallow because bolus formation would be easier and would also benefit gastroesophageal reflux. Infants who persist to have feeding difficulties or respiratory distress could merit further evaluation with a barium swallow study using different consistencies.
- Received April 22, 1999.
- Accepted September 10, 1999.
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An oral presentation of this data was made at the 1997 annual meeting of the American College of Chest Physicians and published as an abstract in Chest 1997;112:30S.
- RSV =
- respiratory syncytial virus
- ↵Welliver RC, Cherry JD. Bronchiolitis and infectious asthma. In: Feigin RD, Cherry JD, eds. Pediatric Infectious Disease. Philadelphia, PA: WB Saunders; 1992:245–254
- ↵Folkerts G, Busse WW, Nijkamp FP, Sorkness R, Gern JE. Virus-induced airway hyperresponsiveness and asthma. Am J Respir Crit Care Med. 1998;157:1708–1720
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