Masterclass 6 - The Multidisciplinary Approach to Aerodigestive Problems in Children

Aerodigestive disorders are diseases of the pharynx, larynx, trachea, bronchi, lung, and or upper digestive tract that may affect the respiratory, swallowing functions and or growth of the child. The case nature is complex. Compare with adults, the neonates and infants have a unique upper airway and feeding mechanism, which formed a special group of patients in this area. A group of experts, experienced in this age group is required. Multidisciplinary consultations and investigations are required. Timely access to surgical, social resources is beneficial. The case co-ordinator could be a doctor or a nurse, the team included doctor experts in respirology, gastrointestinology, neonatology, respiratory nurses, speech therapist, occupational therapist, dietitian, physiotherapist, medical social worker and pharmacist. We also consult paediatric surgeon, otolaryngologist as needed. Going through the case intake, investigations and an interdisciplinary discussion, we can offer a unified care plan to the carer. Patients could be benefited by the structured approach.

The presentation will introduce the major roles of Speech Therapists in the KWH Paediatric Aerodigestive Team and focus on the general management of dysphagia and feeding disorders in paediatric patients. To provide patient-oriented services, multi-disciplines are recruited in the aerodigestive team, including doctors, nurses, dietitians, physiotherapists, occupational therapists and medical social workers etc. 
Speech therapists will carry out bedside swallowing assessment. Instrumental assessments, namely Videofluoroscopic Swallow Study (VFSS) and Fiberoptic Endoscopic Examination of Swallowing (FEES) will be provided to obtain an objective and precise diagnosis if indicated for further case management. The presentation will be followed by describing the treatment objectives, such as modifying current diets, improving oro-motor functions and educating caregivers in assistive feeding. The special considerations in the management of patients with aerodigestive concerns will be highlighted as well.
The presentation will be concluded by case sharing from past experiences. Questions from the floor will be addressed. 

Children with aerodigestive disorder usually involve structural and functional airway and upper gastrointestinal tract disease, lung disease due to congenital or developmental abnormality or injury, swallowing dysfunction, feeding problems, genetic diseases, and neurodevelopmental disability. The care model of paediatric aerodigestive patient require multi-disciplinary collaboration. From physiotherapist perspective, respiratory care, tongue tie screening, neurodevelopmental training, and establishing proper exercise habit would be our major role. Treatment program includes tailor made sputum clearance techniques, education of proper breathing pattern, orofacial myofunctional therapy for management of tongue-tie or to improve tongue strength, neurodevelopmental training, postural education as well as exercise prescription to enhance healthy growth and satisfactory cardiopulmonary fitness. 

Occupational Therapist (OT) has been as one of the key members in Paediatric Aerodigestive Service Team in Kwong Wah Hospital since its establishment in the year 2015. Under care coordination by respiratory and gastrointestinal specialists, OT plays important roles in assessment & training of oral motor function, breathing coordination and developmental delay; providing advice on positioning method and proper use of feeding utensils to facilitate achievement of full oral feeding. Besides early intervention in neonatal intensive care unit and special care baby unit, OT supports home discharge by providing necessary carer education on feeding skills, compliant use of home respiratory support equipment; prescription and adaptation of positioning and mobility devices for infants/children with special needs. Home assessment and environmental adaptation always contributes to maintain sustainable home care and to relieve carer stress on handling babies/children with both respiratory and feeding dysfunctions or even more. OT continues to work closely with parents or caregivers during out-patient phase to remediate problems of weaning diet and behavioral feeding issues that would probably emerge when children with aerodigestive dysfunction are growing up. Behavioral intervention promotes love and attachment between parents and babies/children to handle feeding difficulties in different phases of child development, not only for fulfillment of their physiological need, but also guiding them to having healthy social development, independence in their self-care and self-regulation.

Aerodigestive problems include a variety of conditions that affect the respiratory and digestive systems. Children with such conditions may have issues with their breathing, feeding, swallowing or growth. Nutritional deficiencies are commonly seen in aerodigestive population due to alternations in intake, losses and metabolism.
Kwong Wah Hospital adopts a multi-disciplinary approach in management of aerodigestive problems in children. Dietitian is one of the multi-disciplinary team members working closely with doctor, nurse, occupational therapist, pharmacist, physiotherapist and speech therapist throughout the care for patients. 
Dietitian will carry out nutrition assessment, sometimes jointly with speech therapist, on a child's diet history and related feeding behaviours in order to identify the nutritional need, deficiencies and problems. Particular focus will be on intake of energy, protein, fluid and other micronutrients such as vitamin D and calcium. The nutrition intervention and feeding plan will be discussed at multi-disciplinary team meeting to ensure it incorporates the inputs from other disciplines in terms of the child's developmental stage, medical needs, and oro-motor function etc. The progress and outcomes of nutrition intervention will be monitored and evaluated regularly during the child's clinical admission for multi-disciplinary assessment and meeting. Outcome measurements include growth velocity and the adequacy of nutrients from oral diet and/or tube feeding. For those who require intensive nutrition care, dietetic out-patient clinic will also be arranged between the clinical admissions.