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Podcast Transcript: Challenges and Innovations in Pediatric Dysphagia Management

with Dr. Nikhila Raol

In this episode of BackTable ENT, Dr. Gopi Shah and Dr. Nikhila Raol, pediatric otolaryngologist at Children’s Healthcare of Atlanta and Associate Professor at Emory University, discuss management of pediatric dysphagia. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Pediatric Dysphagia: An Interdisciplinary Challenge

(2) Age-Based Presentations of Pediatric Dysphagia

(3) Medical Conditions Associated with Pediatric Dysphagia

(4) The Role of Questionnaires in Pediatric Dysphagia Research

(5) Examining the Pediatric Patient with Dysphagia

(6) Imaging & Labs for Dysphagia

(7) The Pediatric Dysphagia Team

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Challenges and Innovations in Pediatric Dysphagia Management with Dr. Nikhila Raol on the BackTable ENT Podcast)

Ep 132 Challenges and Innovations in Pediatric Dysphagia Management with Dr. Nikhila Raol

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[Dr. Gopi Shah]
This week on the BackTable podcast.

[Dr. Nikhila Raol]
I would just encourage everybody to do is just keep in mind how vulnerable these parents are. When we think about what happens down the road with these kids with regards to whether they're getting sick or whether the kids have aversive behaviors, some of that is driven by what the parents are doing. Because we're relying so much on the families to execute the plan, to report symptoms, to not force feed kids, to do those types of things, I would just have a lot of empathy for these families as you are working your way through the treatment and try not to be dismissive.

[Dr. Gopi Shah]
Hello everyone and welcome to the BackTable ENT podcast where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice.

[Dr. Gopi Shah]
My name is Gopi Shah and I'm a pediatric ENT, and I have a very brilliant guest today. I have Dr. Nikhila Raol. She's a pediatric ENT and associate professor of otolaryngology at Emory University in Georgia. She practices at Children's Health of Atlanta and is here today to talk to us about pediatric dysphagia. Welcome to the show, Nikhila.

[Dr. Nikhila Raol]
Thanks so much, Gopi. I'm excited to be here.

[Dr. Gopi Shah]
Tell us a little bit about yourself and your practice.

[Dr. Nikhila Raol]
Okay, yes. I trained mostly in Texas and after my fellowship in Boston, I came down to Atlanta to join Children's Health Care of Atlanta. I spent a couple of extra years in Boston doing my Master of Public Health. When I was shaping my practice, I really wanted to develop a niche that was applicable to population health level. I know when talking to my mentors and whatnot, I had an airway interest, but one of them had said, what about chronic swallowing issues? That's just something that we don't have enough data on and have enough people really working on from a research perspective. I really got interested in that. I started in a smaller population with the congenital heart disease patients and have really expanded into kids with feeding and swallowing difficulties of all types. The other part of my practice is primarily in refractory sleep apnea. I primarily focus on sleep and swallow issues in kids.

[Dr. Gopi Shah]
The MPH program, that was you did after your fellowship?

[Dr. Nikhila Raol]
Yes, I did that after my clinical year. I had an inkling that I wanted to do it when I started fellowship, but I had a wonderful mentor and my fellowship director. He really encouraged me to think outside the box from a research perspective and pushing the field perspective. That's really what drove me to move forward with getting that additional training.

(1) Pediatric Dysphagia: An Interdisciplinary Challenge

[Dr. Gopi Shah]
That's amazing. Tell us a little bit about how patients present to you guys. Tell us a little bit about the clinic at CHOA.

[Dr. Nikhila Raol]
Yes. We're super unique and I am really spoiled. I'm going to say this from my perspective, but I hope one day you can duplicate this anywhere. Obviously, aerodigestive clinics are pretty common now, especially in freestanding children's hospitals and academic centers. We have both an aerodigestive clinic and a dysphagia management clinic, and we affectionately call it Aerolite. It was born actually out of our behavioral feeding program, which is one of only, I think now, I think there's 14 or 15 around the country. Those really focused on kids who had something called ARFID or avoidant restrictive food intake disorder, which if you follow the literature now, a few years ago, there was a diagnosis that encompassed all of it called pediatric feeding disorder. We have the dysphagia kids, but also the behavioral kids. We really wanted to have a more focused clinic, especially for these infants, these really small kids.

Maybe they didn't have the pulmonary issues as yet, but we wanted to have a place for them to go. Maybe they were being discharged with an NG tube, or maybe they were breastfeeding and are having coughing and choking, things like that. We started this clinic. It's ENT, GI, speech, and nutrition. If they really have airway issues, they have those pulmonary complications, then we shunt them over to aerodigestive and vice versa. Sometimes those patients will come back over to our dysphagia management clinic. Luckily, I'm in both clinics. That certainly helps.

Now, when we talk about how patients present to us, we get a whole range of types of patients. When I first started, it was typically like coughing and choking with feeding, or had a swallow study that was abnormal, and the typical ways that aero kids get to us. Now, I see a lot of kids are like, the parents just say. "They don't look comfortable when they're feeding," or "something just seems off." It may or may not be aspiration per se, but I had started to think of dysphagia as much more of a continuum. Dysphagia is just difficulty swallowing. It doesn't necessarily mean it's going the wrong way. That has really changed how our patients come in to our practice. Really, it's typically kids who have some dysfunctional feeding. These kids are getting some medical workup if they were going into the behavioral side anyway. If they seem to have some difficulty with the actual process of chewing and swallowing and things like that, then they'll get shunted into our clinic.

[Dr. Gopi Shah]
Who's making the referrals primarily to you? Are some of the families finding you independently? Because I would imagine some of the families have probably seen several providers, and there's still some sort of discomfort at mealtime. It's just stressful for everybody. Nobody's enjoying it. How are the referrals to you?

[Dr. Nikhila Raol]
Yes, you nailed it on the head. We get some, they started coming from the speech pathologists who were doing the initial evaluations. Some of them were just clinical evaluations, and some of them were swallow studies. I will back up and say that the impetus for this clinic was really based on the need for a FEES clinic. Then it just blew up into this wonderful multidisciplinary clinic where we just look at every aspect of feeding. We'll get, a lot of them come from the speech-language pathologists after evaluations. Then we get a fair number from community providers who just don't know where else to send the kids. Then we do get some self-referrals because of word of mouth.

[Dr. Gopi Shah]
Tell me about percentage by age. Sounds like this initially started out maybe just for infants, but then if it's like, some of the behavioral stuff, you get older kids, toddlers, kids, adolescents, what's the breakdown in terms of age?

[Dr. Nikhila Raol]
The majority are under one, but we also get a fair number of kids who have been worked up for all the routine stuff. Even some who get, they've had their major workup done through the air digestive clinic and they've been stabilized. They're healthy. They're no longer having all those major medical issues, but then they're coming to us to see what can we do to normalize their swallowing? Just because we sometimes have a little different perspective. A fresh pair of eyes. I would say the majority are still under one, but we get those kids who are in the two to five range. Then sometimes we'll actually get these much older kids who they tell us something doesn't feel right. Those are great kids for our clinic because we can actually be pretty creative with how we work them up and then what kinds of interventions we're offering from both a strategies perspective and then even from a surgical perspective.

(2) Age-Based Presentations of Pediatric Dysphagia

[Dr. Gopi Shah]
You just said worked up for routine stuff, a routine workup. Tell me sort of what is the routine stuff that, on everybody's initial list, I guess, and the routine workup, what do they come in with already? What have you already, what have they already ruled out?

[Dr. Nikhila Raol]
Yes, pretty much everybody has had, let's say they're coming from a different set of providers. A lot of times they've already had triple endoscopy looking for a cleft. They've had swallow studies. They may have already had a cleft injection. They may have had something – you know, when I was training, I feel like we really focused a lot on do they have a laryngeal cleft? Do they have vocal fold paralysis? These very surgical things.

[Dr. Gopi Shah]
Anatomic reasons.

[Dr. Nikhila Raol]
Exactly. Exactly. It's like, it's obvious this is what's happening. They just didn't, that didn't fix it. Again, typically they've had video fluoroscopic swallow studies, not necessarily a FEES. Because I think where I practice, because of what we've created, a FEES is almost standard of care in a lot of these patients. I don't think that's necessarily true everywhere. Because, obviously, FEES are time-consuming and they can be difficult to perform. I think you have to have the right team for that. Really, it's like swallow study, triple endoscopy, some type of intervention like cleft injection, or even sometimes cleft repair. They've been worked up for eosinophilic esophagitis. They've been looked at for tracheobronchomalacia, things like that once you've checked those boxes, that's often when they just need a different set of eyes and some thinking outside the box, I think.

[Dr. Gopi Shah]
Yes, that's interesting. Tell me the difference in sort of symptoms or patient presentation from the infant side to like the toddler. For the infants, I've always been curious, how different is it maybe under three to six months to your nine to twelve-month infants?

[Dr. Nikhila Raol]
Yes. Three to six months, I think, or under three months, I think it's most commonly we're seeing these kids who are breastfed and coughing and choking with breastfeeding and may have some typical latch issues. I will say, I know it's super controversial and we're not going to get into the big tongue-tie conversation here, but I think that's one where some of these families when they come to us at that age range, they are having difficulty breastfeeding or they already had procedures done, like they went somewhere and got their tongue tie clipped and it didn't fix them. We're looking at what else could it be. Certainly, something that's impairing the suck, swallow, breathe mechanism is really common. I would say the two most common things we probably see are laryngomalacia and ankyloglossia in that age group, which doesn't mean that we always have to do surgery.

We have a brilliant speech-language pathologist in our clinic. She's just amazing because she is actually also now IBCLC certified, so she has the lactation consultant knowledge and the speech-language pathologist knowledge. She's been doing this for 15, 20 years. We really think about ways to allow the child to, allow them to use strategies to really optimize their feeding without saying, "oh, this automatically needs surgery." That may be things like side-lying or pacing or even mom, if they're breastfeeding, reclining back and feeding and things that, help the kiddo, just allow them to mature without condemning them to an intervention immediately. All these parents who come to us are really desperate, right? That's, I think, what we have to think about in feeding, just as you said, it is such a huge part of life when we think about our own kids, how much we watch them while they're eating throughout all the, many stages of life until probably until they leave our houses. Yes.

[Dr. Gopi Shah]
Every holiday is surrounded by meals, the food, like, "what are we going to eat?"

[Dr. Nikhila Raol]
Absolutely. Absolutely. I really think of these families as a very vulnerable population. I try to be careful about recommending surgery or saying that, "oh, this is going to be an instant fix.", because even surgery, even after that, you do often need to do more than that, whether it's therapy or other strategies to optimize your feeding. Yes, I think that's really important when you're thinking about these families is to just keep in mind how vulnerable the parents are, especially when the kids are under three months.

[Dr. Gopi Shah]
Then once they get to like, nine to twelve months, are these the babies that they were fine with breast milk, but now we're trying solids or, "well, they always had something going on, but they slid by and now it's an issue"?

[Dr. Nikhila Raol]
Yes, I think you touched on both types of presentations that we see. Sometimes we'll see that they were just getting by okay, and now they're introducing the spoon and they can't really maneuver things well in their mouth. They may be coughing and choking on these things, or they may just be refusing. I think one extreme case I can actually think of is a kid who came to the behavioral program around eleven months of age and it had some breastfeeding issues early on, but not an obvious tongue tie that I think someone would say, "oh, just clip it and it'll fix everything." It had begun to refuse feedings, had an NG tube placed, ended up coming to the program because it was refusing solids, all these things, and actually ultimately got a G tube. At the same time that they got the G tube, because our astute speech-language pathologist said, "it just seems like they can't lateralize their tongue well with purees and stuff, other solids that they're taking."

We said, "Okay, they're already going under for the G tube, let's just clip it and see if it fixes it." Literally in the feeding program, the next three meals, they were already taking much more by mouth and the behaviors we think of like packing and interior expulsion and things like that, that we don't normally think about for a typical dysphagia aspiration type of stuff, that significantly improved. You do get that stuff in the history early on if you ask for it, but at that time it doesn't necessarily seem like a big issue because there's no obvious anatomic issue that we can just say, "oh, this will fix everything." Now I once had someone say to me, dysphagia is not an emergency. Absolutely, I agree with that statement, but I do think of it as somewhat of an urgency because now I see these kids in the whole spectrum of pediatric feeding disorder when if we don't manage the dysphagia early, then it starts to become behavioral in nature because it doesn't feel good. It's either a lot of work to feed or it's going the wrong way or things like that has really changed how I support these families and also the urgency with which we do something for them.

[Dr. Gopi Shah]
Every once in a while, especially if it's a newborn, the first four to six weeks, you worry about weight and failure to thrive. Do you have babies like that and to where you're like, maybe you need to go to the ER. Are there any red flags that you can tell us about?

[Dr. Nikhila Raol]
Yes. I would say definitely weight is a big issue. We trend weight really closely. We also look at if they have severe nasal congestion and that could be, we think about rhinitis of infancy and things like that typically like we do as otolaryngologists. We find that sometimes if they're not strong, like their oral skills are not strong enough, they could actually have some nasopharyngeal regurgitation because they're not pushing the liquid down with enough force or they're not controlling it well enough that some of it actually goes up their nose.

Then of course, with like laryngomalacia and suck, swallow, breathe and things like that, those are going to affect their ability to gain weight. Sometimes what we do is if we feel really like a kiddo is, it's not appropriate for outpatient management. There's not time, we do think of it as more urgent or emergent. We will send them to get admitted and get an NG tube placed with the plan for doing as much workup or intervention as we can as an inpatient. Then just making sure that the kid has adequate nutrition with the feeding tube, but also working up all of the potential causes so that hopefully the feeding tube is very much temporary.

[Dr. Gopi Shah]
Yes. Talking to one of my partners in Dallas, Felicity [Lenes-Voit], when I saw what she was on for a tongue tie, feeding is important to her. She sees a lot of the feeding kids. Every once in a while, she would have these infants in clinic and it's a hard call to make do you admit, do you not admit? Fortunately, we have good pediatric colleagues that can talk us through it or the hospitalists that are, "yes, that makes sense" or, no. Tell me about some of your older kids. By then, can we say, this is definitely not a liquids issue because y'all got through formula and milk, or wait a second, no, you can still have liquid aspiration on thins or, it's not always going to be solids and textures at that age. Tell me about that group.

[Dr. Nikhila Raol]
Yes. I think that group that we see, some of those referrals come from pulmonology where it's like they have a diagnosis of asthma or something like that, or they're not sick per se. There's something that's a little bit off and they just happen to get a swallow study and the parents are totally surprised when they get these findings. That's one of those I think you can send to either aero digestive or a dysphagia-specific clinic.

In those cases, the nice thing is the kids often tell us what's wrong and they're pretty, in our world, we think of it as part of the treatment process and part of the decision-making as to do we want to do intervention or do we want to therapy or whatnot because they can participate a little better. we often use, in all ages, we often use a thickener wean. I don't know how much that's used everywhere, but that's just one example. I'm thinking of a strategy in our older kids that sometimes we'll use that we let them tell us when, if they're switching the thickness of the liquids as we're weaning, you can say, "this doesn't feel good. This is going the wrong way." They'll actually tell their parents, they'll start refusing. I think that's where refusal behaviors are probably more evident because the kids are telling the parents that this doesn't feel good. We really make them part of the treatment process.

The other thing that in those older groups that I love is when we do a FEES, they're often more compliant or participatory. We can try some different things and they'll talk with us about, "hey, this doesn't feel good or this they're not screaming and crying. We can try some different things with them." I wouldn't rule out that it's a liquid issue. It still could be. It's just that, again, they were limping along and this was incidentally found because they had these other symptoms.

(3) Medical Conditions Associated with Pediatric Dysphagia

[Dr. Gopi Shah]
Yes. Tell me about some of the comorbidities some of the patients have. You'd mentioned the cardiac kids. What other medical comorbidities do some of the patients have and what percent are otherwise no past medical history?

[Dr. Nikhila Raol]
We are a last step for a lot of these people. We do see kids who have no other issues, but probably the routine consult we get are going to be your cardiac kids, premature kids, and that includes BPD type of stuff. The respiratory component is affecting them, but also just straight-up preemies who maybe don't have lung disease, but don't have the skills either. Their oral skills didn't develop appropriately. We see a fair number of kids with some hypotonia, but often these are the kids who are like maybe your Down's kids or CP kids who are functional enough to eat something by mouth, but maybe need some strategies or maybe even an intervention to get them over the hump.

I will say I've seen some kids with the deep inter-arytenoid notches in the Down's population who for our normal kid, this may not have caused issues, but for these particular kids, they are causing issues because they have oral control problems also. I think you definitely think of those kids with comorbidities in a little bit different way, right? You don't just say, oh, anatomically, there's nothing obvious. You think of it more as, well, it's a second hit with what they already have. Maybe you'll be a little more aggressive in trying something to take away that minor anatomic issue.

[Dr. Gopi Shah]
Yes. that's interesting. Tell me about the cardiac kids because when I think of the cardiac kids, I think of vocal cord weakness, paralysis. Is that only a part of the cardiac? Tell me a little bit about that? Because I think of this anatomic issue, but it sounds like there's more to it.

[Dr. Nikhila Raol]
Yes, absolutely. I will say when I first started down this whole journey, we started with the vocal fold paralysis patients. That was our first group of patients that we actually, my research started with screening for vocal fold motion impairment and how that affects NG tube placement and how that affects their feeding in the long-term. What we found was that there's a lot of kids in the cardiac population who the dysphagia and the vocal fold issues are often separate. Actually, there's a nice paper from the Texas Children's Group, Julina Ongkasuwan, and she's done some great work in the cardiac population as well, and has actually shown that there are kids with aspiration whose vocal folds are just fine.

We know some of it's sensory, some of it's skill, and I suspect that even if the recurrent laryngeal nerve is not cut, there are some sensory branches also that are affecting the sensation, and that is something that we definitely see just takes time to recover. We also see aversion in those kids for sure. I know it's scary for the cardiac team to say, "let's let them try," because this is a population where one hit can be devastating, right, can be life-threatening if they aspirate once. They tend to be a little heavier-handed with saying NPO, whereas we try our best to not make kids NPO. That's one of the things that I'd really change is like, just let them do something, even if it's water, even something, so they're not losing those skills.

The cardiac kids, I would say, have all the same potential causes for swallowing and feeding difficulties that any other kid has. It's just that it probably impacts them more because they're also dealing with the cardiac defect. I'm certainly like laryngomalacia and vocal fold paralysis, ankyloglossia, laryngeal cleft, all those same things, but sometimes it's really just endurance. We try to slowly ramp them up, and maybe we don't have to do anything. I've seen plenty of kids where the vocal fold motion did not return to normal, but the feeding did, or the dysphagia resolved. We had a good systematic review a few years ago that shows that resolution of vocal fold motion or movement impairment is not directly linked to resolution of dysphagia. I think it's important to remember that.

Now, I would also argue that if you have kids who are going to be NPO, and you have a cardiac unit that is a little more willing to be aggressive with trying to not make them NPO, Seidel's group out of Stanford showed that you can inject these kids really early, and 70% of those kids are able to liberalize their diet. Maybe just as a temporary measure until they get stronger, until they figure out swallowing, whether or not the vocal fold movement recovers, you can consider that. Perhaps that will avoid some of the aversion issues later down the road, because they've been able to continue to eat by mouth.

(4) The Role of Questionnaires in Pediatric Dysphagia Research

[Dr. Gopi Shah]
That's cool. Tell me about questionnaires. Do you use questionnaires in this clinic? Is it age-dependent? Do we have that in peds, like a peds dysphagia questionnaire?

[Dr. Nikhila Raol]
Yes. There are actually a fair number of questionnaires out there. Now, I will be totally honest. I haven't been as good with using questionnaires as I would like to be, but some of the ones that we have used are the feeding swallowing impact survey, and that one's out of Hopkins. It's Maureen Lefton-Grief's work. If you want to read good peds dysphagia stuff that, not necessarily out of ENT, but it's out of the speech world, I would really encourage people to look at the speech literature.

Because I think as a laryngologist, if you specialize in dysphagia or if you see patients with dysphagia period, really knowing their literature is just as important as knowing our literature, because I think we're more than just a surgical specialty. We definitely do the medical side too. She's developed this nice survey that we will use as much as if I can remember to, but feeding swallowing impact survey is a good one. I like to use the functional oral intake scale or the FOIS to track a patient's progress. That was actually developed for adult stroke patients, but it's the same principle. You get graded on the scale of, are you completely tube dependent? Do you need modification of your diet? Are you completely normally orally fed?

I think that's nice just to see how patients are progressing. There is the SwallQual or the Swallowing Quality of Life Survey, which is, again, in adult patients, but you can adapt it for pediatric patients. I've talked to some colleagues who have done that. I know Derek Lamb has used that in his aerodigestive clinic up in Oregon. The other group that has some nice surveys is if you go on the Feeding Matters website, they're a wonderful organization that really is just focused on improving outcomes and efficacy for pediatric feeding disorder. They're great. They have some nice surveys on there that you can use for all different age groups. There is a survey for breastfed babies only, for breast and bottle fed, for bottle fed, and then getting into your pediatric group. I love those surveys because they look not only at the swallowing component, but also the feeding component. It's a holistic way of looking at feeding and making sure we're not missing some of these other symptoms that might actually be tipping us off. There's a component of dysphagia, but not necessarily specifically choking and gagging with feedings or recurrent pulmonary infections or things like that.

[Dr. Gopi Shah]
The whole questionnaire and survey things, in terms of how to use it, I have the same, not just remembering to make sure they fill it out, but where do I hold that information and how accessible is it for me to look back and compare can make it so that using a survey, sometimes you're like, "I need to follow this," but that'll be a podcast at a different time. We'll find somebody that's got a system.

[Dr. Nikhila Raol]
Yes. There are people who have gotten really good at it. If you're good at EPIC, if, we have EPIC, and I'm sure a lot of places do, but I think the best way is to incorporate it into that because honestly we do it by paper and that's why it's not consistent.

(5) Examining the Pediatric Patient with Dysphagia

[Dr. Gopi Shah]
Tell me about your exam. The patients in your clinic, what's your head and neck exam like?

[Dr. Nikhila Raol]
I do a routine otolaryngology exam, but when I focus on, when I'm doing my initial exam, I'll look at tongue motion, lateralization, where the frenulum inserts into the tongue. I will tell you, I strongly dislike the terms anterior and posterior ankyloglossia. I just look at for the kid, how much free tongue do they have and how much can they move it around? Then I'll look at the palate, how high arch the palate is. I'll look at the tonsils because tonsils can definitely impact feeding. I think that has been understudied. Honestly, I can only think of one study off the top of my head that was done subjectively with parents saying that swallowing improved when their tonsils were, kids had their tonsils removed for other reasons, but they did get better.

Those are my routine things that I'll look at. Obviously, I look at the palate, look for, if there could be submucous cleft or bifidity of the uvula. If you come see me in clinic, you're probably going to get a FEES. That's what's become a part of our exam and workup. The initial regular physical exam focuses a lot on the oral cavity and oropharynx. I'll also look in the nasal cavity and see, do they have significantly narrowed nasal passages? Do they look very congested, as that can definitely impact the ability to coordinate sucking, swallowing, and breathing.

[Dr. Gopi Shah]
Do you have any tips or tricks for the under three month, under five month with nasal congestion, like those babies come in and it's like, "okay, do lots of saline." Do you throw some Nasonex out of, is it reflux? How do you manage that?

[Dr. Nikhila Raol]
I will typically, and I am not as scared to try some nasal steroids to tell you the truth. I will typically do a three to five-day trial of the dexamethasone eye drops and just say one drop on each side twice a day for three to five days. Usually I'll go up to five days, but I won't do beyond that. It's for us, it's just a trial to see is the nasal congestion one of the biggest reasons for this feeding issues, swallowing issues, is it really, they can't breathe through their nose? From a reflux standpoint, I have had kids who, where reflux is really impacting it. I know that reflux can come all the way up, but I don't typically prescribe reflux meds anymore. I will get my GI colleagues to weigh in and I strongly feel that we know it's not benign giving a reflux medication.

If you look at the NASPGAN and ESPGAN, which are the gastroenterology organizations for North America and Europe, if you look at their guidelines, they do not advocate for doing reflux medications in these young babies. Not to say that reflux isn't problematic, but they would advocate trying different things first. Again, I'm lucky to work with some great GI colleagues who can help guide it, but I will try those nasal steroid drops. If parents tell me that they get more congested during a feed, and let's say when I do my scope exam, I'm seeing, or when I'm doing the feed is really I'm seeing like liquid come up the nose or things like that. If there looks like any tethering of the tongue, I'll have a low threshold to clip honestly, because if it's low risk and the parents are on board, they're okay with that. I tell them, “we can try it. It may not fix it, but we do have some data that suggests, or some at least anecdotal data that suggests this might help."

I have a very thorough conversation with the families if we're going to consider that intervention, but maybe not under three months, but around six to seven months, I'm not scared to try Flonase, to tell you the truth. I know, and I always tell the parents it's not FDA-approved in this age group, but kids typically do well, and we're not going to leave it on indefinitely. We have a plan to come off of it. I think this is where shared decision-making is super important in this population and what are the goals for the family. I try not to ignore nasal congestion. We do try to be a little more aggressive than just saline and suction. Now, I will say that this is all in addition to the saline and suction. I think some nice tools have come on the market, beyond just the bulb suction or NoseFrida. There are some these electrically powered suction.

[Dr. Gopi Shah]
Or Dr. Noze Best. Steve Gowdy's.

[Dr. Nikhila Raol]
Dr. Noze Best, yes. Full disclosure, that's my boss. I'm not trying to promote, but I know he's been on the show with you.

[Dr. Gopi Shah]
Yes, he has about cleft care, and on entrepreneurship, and the device, and his story.

[Dr. Nikhila Raol]
I think that that's a great temporizing measure that's still more aggressive, than just saying, wait it out, but not as aggressive as trying medication or surgical intervention. I think there's a lot of options besides just saying, that's sorry. This will just get better.

[Dr. Gopi Shah]
In terms of a nasal steroid spray for fulminates, how long do you have them trial it for? Then what's the long-term plan for some of these babies?

[Dr. Nikhila Raol]
Typically, I tell them to do at least for four to six weeks. We know after two weeks is when you really get the maximum effect, and we'll see if there is any improvement. When they get to the nine to ten month range, I will consider the impact of the adenoids. If they have no adenoid tissue, that's one thing, but if they have some enlargement, I will offer that if we're taking them to the operating for anything else, they're snoring significantly.

Now, one thing I always tell my residents, I've also changed it in how I do my exam, is that when I'm listening to kids breathe, coarse stridor can also sound like stertor. We might think it's nasal congestion, but it could actually be some arytenoid floppiness that sounds exactly the same. That's where doing a FEES can be helpful because when the kids are crying really hard, and they're contracting everything, you might not see that vibration of the arytenoids and that floppiness. Then when you ask them to do another task, like feed while we're scoping them, that might actually be more evident.

That's one thing I always tell people, it may seem like it's all up here, but it could actually be coming from here because that space is just so small.

[Dr. Gopi Shah]
If the Flonase, let's say it works, how long then? Is it like a three to six month thing, a three month thing or?

[Dr. Nikhila Raol]
Yes, I usually say three months, and then let's try coming off of it. Hopefully, that has given them enough time to grow. We're introducing other foods then. We're also introducing different positions for feeding. They're not laying back, they're sitting up more often, they have their stronger oral tone, so that, hopefully, if there was a little bit of nasopharyngeal reflux, that's not happening so much anymore, and things like that. About three months. I usually don't go beyond three months in these really young kids.

[Dr. Gopi Shah]
All right. Let's talk about the FEES. Tell us sort of what is your setup like? What are some of the tricks or tips that you have that seem to work with you? If you can't see, how do when to stop, or temporize the situation?

[Dr. Nikhila Raol]
I think, the most important thing is to have a really good speech language pathologist who is comfortable with FEES, and not just comfortable with FEES, but comfortable with kids being uncomfortable during the exam. We've seen that at least in infants under one, under maybe 10 months and under, we can typically get them to calm enough to get something in them. You might have to wait two or three minutes for them to calm down. Don't give up. That's the biggest advice I would give you is don't give up too quick. You have to prep the families for this too.

We do allow parents, if they're comfortable, to stay in the exam room with us. I always advocate for the parent, unless we're breastfeeding, for the parent not being a part of the feeding. I don't like to associate that, I don't like the kids to have that association as much as possible. On our good days, when we have two SLPs available, one will hold the baby, I will drop the scope, and then the other will feed the baby. If we don't, then we'll involve the parents if we don't have another choice, if we only have one SLP available. We always make sure the parent is comfortable with being the bad guy a little bit.

We do use green dye. I know some other places have talked about using a white dye because of how it sticks to the surrounding tissues. We like the green, it has worked well for us. When we're doing breastfeeding FEES, you can either come from in front of the baby, or come over the shoulder of mom, whatever is more ergonomically feasible for you. Then we'll usually let the baby start feeding first, and then we'll pull off, put a little green dye either in the mouth or on the nipple, mom's nipple, and then let them start feeding again.

Now, it doesn't always work, the green doesn't always make it where we want it to. Even the breast milk has some color to it, so it's usually enough for us to be able to see. Worst case scenario, if we cannot get a baby to calm down, we do take a little liquid in a syringe, and we'll squirt it into the cheek, and then that forces them to control it as best as we can. We always note all of these things on our documentation, so we know, this is not a natural way the baby feeds, it's squirting something in their mouth.

It can help us identify potentially a site of entry. When we're doing bottle feeding, we'll try multiple different thicknesses, we'll try different nipple flow rates, and then if the baby's old enough, we'll try some purees. like I said, the two keys are having patience and having a good SLP. Then if you just cannot get good information, they're just not cooperating, we'll just pull the scope out and do a clinical evaluation.

You were talking about when you can't see. Usually, when you can't see, at least in my experience, it's one of two things. One, it's the baby just can't hold still enough, and those days I'll say, ah, the baby won, we lost. We lost this battle. Maybe that happens about 15%, 20% of the time.

[Dr. Gopi Shah]
It's going to happen.

[Dr. Nikhila Raol]
The other thing that I do, I should say there's two other things that will affect that. One is secretions. We do have suction handy, and we'll try to clear the secretions as much as we can. That actually might impact my management, I might actually think of giving them medication for secretion control. If I see nasopharyngeal regurgitation, that can cloud my scope. Just for those people who don't do a lot of FEES, just for your knowledge, when we're doing a FEES, you can't actually see what's happening during the swallow because the pharyngeal muscles all squeeze the camera. We use what's happening before and after really, to guide our next steps.

As far as not seeing anything, that's usually one of those three things, baby is just not staying still enough and is moving around way too much, there's a bunch of secretions, or you're having regurgitation, which is clouding your camera, which is also super useful information.

[Dr. Gopi Shah]
On the FEES, in terms of what you're looking for and documenting, pulling of secretions, pulling of residual milk or whatever you fed them, sensation, tell me about what you document.

[Dr. Nikhila Raol]
Starting with just insertion of the camera, if babies are not that reactive when we put it in, we do start to think of neuro issues because how many babies are going to be comfortable with you just shoving a scope down their nose?

[Dr. Gopi Shah]
Even babies are going to feel that.

[Dr. Nikhila Raol]
Exactly. Now, if a baby has an NG tube in, I will actually put the camera in on the same side as the NG and just follow the NG down. I know it seems like you're taking up too much space in there, but it's better than taking up both sides. The camera goes down so nicely if you're just following the NG tube. Then when we get to the back, the things I'm typically looking for, as I said already, I'm looking at nasal regurg, I'm looking at residue, I'm looking at timing. If you're having premature spillage, why are they having premature spillage? Is it an oral control issue? Is it simply a immaturity issue? Is it hypotonia? Those are the types of things that we'll think of. I'll also look at the anatomic components.

I have some kids who, they might outgrow their laryngomalacia from a stridor perspective, from a breathing perspective, but then when I do the FEES, I might see that their arytenoids are actually a little floppy, and it drags the liquid in with the arytenoid flopping in. That is not impeding the airway, but this is actually an anatomic conduit into the larynx or into the glottis and the trachea.

The other thing I've seen with laryngomalacia is if you have tight AE folds, and maybe not so tight that the epiglottis is so curled that it's narrowing the supraglottis, but tight enough where you're not getting epiglottic inversion, and it sits, I think of it as, in my call, we call it a red carpet entry into the larynx. It's like the liquid just comes straight down from the tongue, straight through that little funnel, and goes directly into the glottis. Those are some of the things I'm looking at.

The nice thing about, we think about, is the cleft really the issue? We definitely can see inter-arytenoid penetrations beautifully. That makes me comfortable in saying, hey, if I need to take you for a DLB, I'm going to inject that. It might not be the only because, but I think that you'll see some improvement. I have a little more confidence when I see just like-- because we see these deep notches and things like that all the time, we're like, is it really the issue? I don't know, but if I have a FEES that has shown me inter-arytenoid penetrations, I feel more confident.

The other things that we might see is retrograde movement through the cricopharyngeus or pulling, like not lack of opening for the cricopharyngeus. I'm also looking at post-cricoid cushion that might be impeding liquid entering the esophagus. Lots of things that we couple it with the video fluoroscopic swallow study results, and I feel like we get a really nice complete picture.

(6) Imaging & Labs for Dysphagia

[Dr. Gopi Shah]
That was going to be my next question. The patient comes in, you get a thorough history, do your exam, you do the FEES. Do they all get a video swallow, or who are the kids then also need that in addition? I understand that you have different information from both, but let's get into that a little bit.

[Dr. Nikhila Raol]
If it's a breastfeeding baby, I'm honestly not going to rely on my video swallow, mainly because it's not fair to the kid. They don't have any practice with a bottle. Actually, that's not their primary mode of feeding, and so it's rare. Now, if I'm really concerned, and let's say, we're trying to see if the way to keep this kid safe is to switch them from breastfeeding to bottle feeding because we can do more issues with flow rate control, and thickening, and nipple changes, things like that, then I will have them start practicing on the bottle. After they've had a little practice with the bottle, then I'll get the videofluoroscopic swallow study. In our institution it takes about six to eight weeks to get one, so by the time we order one, and they've had enough time to practice, then we get it.

If I have a child who is, if we're not talking about breastfeeding, they're bottle feeding or they are using straws, and cups, and other modalities, and we just couldn't get enough information from the FEES, then we'll get one. If they didn't tolerate it well, or their timing is so good that during the white out, I can't see anything and there's no residual, there's no premature spillage, anything like that, and I really need to know if this is going down the wrong way, then those are the other kids that would get a videofluoroscopic swallow study.

Most of our kids have come to us after already having one, unless they're the breastfeeding only babies.

[Dr. Gopi Shah]
Then do you ever get bariums, like if you see something at the cricoid, is that who you get a barium, or is this where GI steps in?

[Dr. Nikhila Raol]
Yes. What we'll try and do if we need to get a barium esophagus, if we're seeing retrograde movement, or we're seeing the cricoid fringe just looks like it may not be opening, we'll just get them together. We'll do the videofluoroscopic swallow study, and we ask them to just get the barium esophagram at the same time. That's the nice thing about having GI right there, and we often we'll turn it into an upper GI series. We'll just follow it all the way through.

Again, having that multidisciplinary mindset right at the beginning is helpful because you're limiting the number of exams they're getting, and the amount of radiation that they're exposed to, things like that. We'll definitely get that if we have worry about past the larynx.

[Dr. Gopi Shah]
When we think of swallowing, we think of function, and so the workup is mostly functional, like a FEES, or video swallow. Is there any role for labs? Do you ever get labs? Is there any role for that?

[Dr. Nikhila Raol]
I think most of our lab issues are going to be when we're worried about FPIES, or anything like allergy mediated, or when we're talking about our eosinophilic esophagitis kids. Again, we're looking at allergy mediated, or eosinophil mediated mechanisms. Other labs, because we're in a feeding setting, we will do some nutrition workup to make sure there's no deficiencies. Those are the primary things I would say we look at from a lab standpoint.

From a dysphagia perspective, I wouldn't say we’re routinely have a bunch of labs we look at, except from a GI pathology perspective. If we're worried about neuromuscular issues, the thing that we often will look at is myasthenia gravis is one thing that we will think about. We'll talk to neurology, and we might send off some labs for that, but otherwise, I wouldn't say we routinely get labs.

[Dr. Gopi Shah]
Then in terms of other imaging modalities like CT chest, CT neck, an MRI brain, are those ever indicated, and who are you thinking about?

[Dr. Nikhila Raol]
Absolutely. I would say if we're talking about CT chest, those kids are in our Aerodigestive clinic. Sometimes we use those when we have concern for any vascular compression that might be causing those noisy breathing, and dysphasia and whatnot. If we're worried about vascular compression, now mind you, these kids have typically already had a endoscopy, like a flex bronc or DLB, and we have suspicion. The other times that we have used it is if we have parents who are a little bit in denial of what's going on, and they really are nervous about intervention, and they really think their kids are okay. The CT chest, when we see those signs of long-term impact of the chronic aspiration, then they seem more willing to be more aggressive with management.

MRI brain is a great question. I don't usually get MRI brains until kids are at least two years old, and that's for two reasons. One is the yield is not super high, although we just had a retrospective series that was published that showed that Chiari or abnormality at the brainstem is definitely more common in these kids with dysphasia, but it's still not that common.

The willingness or how enthusiastic neurosurgery is to intervene is fairly low because it's a huge procedure. You're talking about shunting these kids often. If you are seeing a little bit of prominence of the cerebellar tonsils, is that enough to say it might fix the dysphasia because it might not. You might go through this big procedure, and they still have dysphasia issues. We've had a couple of success stories of kids who had Chiari, and then had a neurosurgical intervention and got better, but it's not a sure bet that that's going to fix it.

It's just typically in my kids who are two years of age, have not had any response to any other interventions, and maybe you're seeing other signs like a bunch of pharyngeal residue, or other delays that maybe are making you think this could be a primary neuro issue. That's when we start thinking about a brain MRI.

[Dr. Gopi Shah]
That's always a hard one because it also requires sedation, so, overall, what's it going to gain me?

[Dr. Nikhila Raol]
I will see sometimes if they've never had an airway evaluation under anesthesia, and they are older when they came to me, and they have some other concerns, sometimes the parents will ask if we can coordinate the MRI and the endoscopy, and when we can do it, we'll do it. Because like you said, it's additional sedation, and always trying to avoid that in the piece patients, for sure.

[Dr. Gopi Shah]
In terms of the triple scopes, let's say the patient comes to you, and they've had the triple scope. When do you consider repeating it, and what information do you want prior triple scope? What is something the outside ENT can make sure that they've either snapped a photo of, or checked for on the scope?

[Dr. Nikhila Raol]
I would say the two things from an otolaryngology perspective, that you always look back at the pictures for-- First of all, always take pictures, so that we can see if you're referring to us or anybody who's maybe in a aerodigestive type setting. We all have different interpretations, I think, of what a meaningful deep notch or a cleft looks like. If I feel like what someone else called not a cleft or not a deep notch, and didn't do any intervention, and oftentimes I'll have then done a FEES and seen inter-arytenoid penetrations, or we just don't really have any other sources, I might take that kid back, and go ahead and inject and see.

I've had some families just say, "can you just go ahead and repair it, even if we're not sure. Can you just repair it, if you feel like it's deep," and I will. It's rare that we're doing that immediately, but if it's already their second endoscopy, I'll have a much lower threshold to do that if the families ask.

The other thing I'll look at is, as I was saying about laryngomalacia. Sometimes we do those DLBs, and their aryepiglottic folds look a little tight, but they don't necessarily have the classic laryngomalacia symptoms, then I would have a lower threshold. Especially if I have a FEES that shows some of those things I was talking about, like that entry through the epiglottis, or a little bit of redundancy of their arytenoid. I would take them back to say this might help.

I will say that often if I'm doing anything from a laryngomalacia standpoint, I'm also injecting the inter-arytenoid region, mainly because I have a hypothesis out. Again, I haven't tested this systematically, but I feel like there is some relationship between arytenoid floppiness or redundancy, and deficiency of the inter-arytenoid musculature. I felt a little validated when I went to the aerodigestive meeting this year, and Gresham Richter actually brought this up too.

He's done some good work in laryngomalacia, so he felt like there could be a connection there. I was like, "yes, I'm not crazy."

Often, those are the probably the two things that, at least anatomically, I would go back and look for, that maybe there's difference in perspective from otolaryngologist to otolaryngologist.

There are some other functional things that we might do in the interim if we saw issues with cricopharyngeal relaxation, or we did manometry, or things like that. I might do a cricopharyngeal Botox, if I think that it's a tongue movement issue. I would take them back, and repeat the DLB or triple or double endoscopy, and also just clip their tongue tie at the same time because we already have them under for something else. I think those are the things to think about, whether you are in an aerodigestive setting or not, just to check those off your list.

(7) The Pediatric Dysphagia Team

[Dr. Gopi Shah]
Then, you have your GI and your speech pathologist who's also a lactation specialist certified, they're with you. For those of us who practice, they come into our general peds clinic or general ENT clinic. When should we start consulting our subspecialists, and is there an order in your mind?

I found myself consulting speech right away, especially in my younger-- anytime actually, for dysphagia. Then in my younger ones, I would pretty much get GI onboard pretty early, specifically for the reflux stuff because again, like you said, the reflux meds, is this where we want to start, not start? Then for pulm, sometimes I'm like, did I consult them too late? Because I didn't have a frank aspiration history, but is there something else going on? How do you organize that in your mind?

[Dr. Nikhila Raol]
I 100% agree with you that every kid who has swallowing issues, you need a speech partner. You need an SLP working with you on it, because again, we are surgeons, and everything is not a surgical problem when it comes to dysphagia. I would say, there's probably more things that aren't a surgical problem than are a surgical problem. Having a great SLP as part of your team is critical. I'd say that's the most critical.

Now, involving GI, it's hard because as we know, especially in pediatric settings, it is not easy to get appointments. Wait times are long. I think that if you are thinking about taking a child to the operating room, you absolutely should get GI involved because you're going to want to know, do they want to scope the kid? That's one thing.

We've had some under one-year-old kids who have been diagnosed with eosinophilic esophagitis. I think that to me is probably the one where I would say, get them involved. At least ask them, if they want to join you. Then other times, you're right, from a reflux perspective, you may not necessarily need to send them to GI, but I at least get GI's opinion if I'm considering starting reflux meds. I make sure they have GI follow up, so that if I'm starting it, then GI will see them, and see if there's been any improvement. Do we need to continue it? Do they need any other workup for true reflux issues?

Oftentimes, though, if you're working with speech, we try thickening first. Rachel Rosen's group out of Boston Children's has wonderful work on that, how thickening is actually a better start than automatically starting reflux meds. If you are practicing by yourself, without a multidisciplinary team for all these kids, I would say get SLP on board for every patient that with dysphagia, and then have a good GI colleague who you can turn to where you might just curbside them for some of these kids. Also, if you're considering like some of your more conservative measures haven't worked, like thickening, pacing, nipple change, things like that, and you're thinking about being a little more aggressive with regards to intervention, you can ask them to join you for evaluation if needed.

You're talking about pulm. I don't think pulm is necessary in every kid, unless they've had any kind of pulm history, like those kids who come in with viral infections, and that's what triggers their dysphagia, or it's the first time you notice the dysphagia. Those kids, I typically do have pulm involved because they've been started on Flovent or Budesonide, nebulizers, things like that. You want to make sure they're optimized from a lung health standpoint, so you can be a little more aggressive or a little bit more trial and error from a dysphagia perspective because, obviously, you want to protect the lungs at all costs for sure.

Then if they have a frank pulmonary issue, then we're going to get them involved, for sure.

[Dr. Gopi Shah]
In terms of medical and surgical therapies, we've talked about nasal congestion, saline, nasal steroid sprays, and suctioning. We've talked about tongue tie, and looking at the tongue, and where the attachment is. We've talked about reflux and GI. We've talked about a little bit, and again, each one of these things can be its own two-hour podcast that we've talked a little bit about. Laryngeal cleft, and inject, repair, again, that's another topic, which we should do another time. You also mentioned the cricoid and the potential for Botox. We talked about speech path, and feeding therapy, whether it's pacing, changing the nipple size.

What else am I missing in the sort of tools, or potential therapies that you can provide these patients?

(8) Behavioral Treatment for Feeding Disorders
[Dr. Nikhila Raol]
From a behavioral perspective, I think that's the biggest one that we are lucky to have. I would say, that if you have that luxury that we have, if you really have kids who are having refusal behaviors, that you have them plugged in to a behavioral feeding program. If you don't have that, that's okay, but you want your feeding therapist to be comfortable with managing the aversion component too, and we've actually done that.

Our psychologists have gone out, and educated some of the community folks who are associated with our system, but not at the main campus, have educated them on how to manage some of the behavioral stuff. You are working on their refusal behaviors, while also advancing their diet. I think that's the other component that we as otolaryngologists, we will just chalk it up, because it's not surgical. We can't just fix it. I totally understand that.

Again, I'm spoiled because I get 30 minutes to an hour with each of these patients, which is probably what they need, not a 15-minute visit, like a routine visit. I would just run through all those things in your brain and say, maybe I need to also involve this person to get on that quickly, and not let it get any worse.

[Dr. Gopi Shah]
That's great. As we start to round it out, Nikhila, any other final thoughts or pearls for our audience on pediatric dysphagia? Because I find it to be such a hard topic, and just keeping it organized in my head of sort of how to manage it, that this is super helpful just to see, understand how you think about it.

[Dr. Nikhila Raol]
Sometimes when I'm talking, I get like one thought leads to the next thought of how when I'm thinking about these patients, so you're right. A lot of these topics we could talk about it for 45 minutes to an hour by themselves. I think if when you approach a patient with dysphagia, I think the first thing we need to do is figure out their urgency. The second thing you should figure out is the parents' goals. Then the third thing that I would just encourage everybody to do is just keep in mind how vulnerable these parents are.

When we think about what happens down the road with these kids with regards to whether they're getting sick, or whether the kids have aversive behaviors, some of that is driven by what the parents are doing. The parent is just as much the patient, in my mind, with these families. That's true for a lot of pediatric diagnoses, we know that, but because we're relying so much on the families to execute the plan, to report symptoms, to not force feed kids, to do those types of things, I would just have a lot of empathy for these families as you are working your way through the treatment, and try not to be dismissive.

Honestly, if it feels like you've done everything in your power, it's fine to send them to somebody else for a fresh pair of eyes. That's okay. That doesn't mean you've lost. I definitely even have, even though we are often the last stop, I'm not afraid to say, I just have one of my colleagues just say, what do you think of this? I've done this and this, is there something else that I'm missing? Do I just need to give them time? For the better a part of valor, say, I'm going to stop with all the interventions, let them grow, let them mature, let them learn. That's okay. That's not defeat. We may not be able to get it perfect, but if we've done something to make this things better for this child and for this family, I've learned to take that as a win.

I think of dysphagia a lot of times as a marathon, not a sprint. Don't be defeated, or don't feel defeated, if you haven't fixed it in one go.

[Dr. Gopi Shah]
Can we tell the audience about your Fulbright? Is that okay?

[Dr. Nikhila Raol]
Yes.

[Dr. Gopi Shah]
Congratulations. I'm super excited. It's a big deal. Nikhila has a Fulbright coming up in India. Tell us a little bit about your project, and what you plan to do? It's amazing.

[Dr. Nikhila Raol]
Thank you. I'm really excited. As I probably talked about tongue tie more on this show than most people think of in dysphagia, but it's primarily because in our minds, at least we think of it as a little bit of a novel target. We feel like it contributes to pharyngeal dysphagia. I think one of the things that we see in our country, in the U S and a lot of Western countries is, gosh, tongue tie is so controversial, and there's so much bias. Some people really believe it's an issue, and other people will just say, no, it's not never an issue. It's very difficult to do observational work here on that topic.

I'm going to India in a country where, or I should say in a state, I'm going specifically to a state in the South central part of India called Telangana, which in that state they have over double the rate of exclusive breastfeeding at six months, but they really don't think of tongue tie as an issue. They're traditionally taught that ankyloglossia does not really impact breastfeeding. I'm just going to do observational work, and see when these kids do have ankyloglossia, what's happening with them. Then whether they do or don't have ankyloglossia, what are the tools, or what are the special factors, specific factors that allow a mother to continue breastfeeding for six months or more?

You all probably know now that WHO and AAP recommend two years, which is pretty impressive, but it's a long time, but at least six months for the health benefits. I'm just going to see what happens if you don't treat it, and hopefully, we can bring back those findings, and have a more balanced approach and discussion about ankyloglossia in this country.

[Dr. Gopi Shah]
That's amazing. Oh, congratulations.

[Dr. Nikhila Raol]
Thank you.

[Dr. Gopi Shah]
I can't wait to hear about your experience, and basically, come back what you teach us in our field. It's super awesome.

[Dr. Nikhila Raol]
Thank you so much.

Podcast Contributors

Dr. Nikhila Raol

Dr. Nikhila Raol is a pediatric otolaryngologist at Emory University School of Medicine.

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 26). Ep. 132 – Challenges and Innovations in Pediatric Dysphagia Management [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.