Swallowing frequency
This novel study investigated the relationship between daily swallowing frequency and pneumonia in patients with severe CP. Swallowing frequencies in daily life were distributed over a wide range from 1 to 111 times per hour. While the previously reported minimum and maximum swallowing frequencies differed from our results, previous studies on elderly and healthy participants also observed individual differences in the daily swallowing frequency (203–1008 times per day Lear et al. [
27] 2–76 times per hour Tanaka et al. [
28]). This is similar to the individual differences we observed in patients with CP.
Swallowing frequency may be affected by various factors, specifically wakefulness, sleep depth, saliva volume, and drooling [
29‐
35]. Our objective was to measure the daily swallowing frequency during non-meal times. While the participants included those with poor wakefulness or drowsiness, we considered these to be among the factors that contributed to their “regular state” and may affect the swallowing frequency. Thus, we did not use the aforementioned factors as the exclusion criteria. However, we acquired three measurements to check for variation in the swallowing frequency within individuals in states that included these factors. The ICC results of the intra-rater correlation assessments displayed a high degree of correlation.
Therefore, the swallowing frequency of each participant varied little on a daily basis, that is, it remained constant. The lack of extreme variability in the daily swallowing frequency within each participant was useful as an indicator for functional or risk assessment.
The attending physicians determined the presence of pneumonia based on the medical records and the results of various clinical and imaging examinations. It is difficult to confirm whether all cases were of the aspiration type based on its definition [
36], which is a limitation of this study. Despite the variations in severity, all patients had CP with reduced swallowing functions. Hence, it is probable that aspiration was involved in causing pneumonia.
The swallowing frequency in patients with pneumonia in the previous year was significantly lower than that in patients without a history. Moreover, the multivariate analysis established an association between reduced swallowing frequency and pneumonia. Reduced swallowing frequency supposedly affects swallowing functions through the disuse of swallowing-related organs or secondary sarcopenia of the related muscles. Reduced swallowing frequency among the study participants indicated that their swallowing-related organs were moving less frequently, and a chronic state was likely to cause disuse or sarcopenia. A previous study primarily involving the elderly reported that those with aspiration (aspirators) exhibited greater loss of lingual and suprahyoid muscle strength and mass than the regular age-related decline [
37‐
39]. The geniohyoid muscle is involved in elevating the larynx and is particularly prone to disuse and sarcopenia. Moreover, limitations on oral feeding promote (cause) atrophy of this muscle [
40]. Functional decline in the muscles involved in elevating the larynx could be a direct cause of aspiration during the swallowing motion, which eventually hinders the appropriate timing and the amount of opening to the esophagus. Despite the patients having severe CP, we anticipated that they could experience a similar phenomenon as the elderly participants. Therefore, the decrease in the daily swallowing frequency could promote a functional decline in the swallowing-related muscles over the long term. This, in turn, could eventually result in aspiration-mediated pneumonia. Further studies are required to determine whether swallowing frequency causes the disuse of swallowing-related muscles.
Reduced swallowing frequency can increase the risk of aspiration. In CP cases, pneumonia is caused by the aspiration of food [
17,
41], saliva, pharyngeal secretions [
15,
42], and refluxed contents of the stomach and esophagus, including gastric acid [
17,
42]. Swallowing movement is an airway defense mechanism that clears particles that have flowed into or accumulated in the pharynx by directing them to the esophagus and preventing them from entering the pharynx. This defense mechanism is effective against the anterograde aspiration of ingested food and secreted saliva and the retrograde aspiration of reflux substances [
19]. Therefore, swallowing frequency reflects the state of the defense mechanism against aspiration. Previous studies [
21,
22] on the elderly have reported that cases with reduced swallowing frequency have increased retention of secretions in the pharynx and greater food aspiration. In addition, reduced swallowing frequency is likely to increase the risk of aspiration. In the present study, the above-mentioned mechanism contributed to the decrease in the swallowing frequency and the history of pneumonia. Our results suggested that reduced swallowing frequency increases the risk of aspiration, even in patients with CP. In addition, the degree of swallowing frequency may be a useful index for the effective functioning of the airway defense mechanism against aspiration. However, the patients in this study were a group of individuals with a decline in swallowing function, and it was not possible to evaluate the presence or absence of aspiration by instrumental evaluation of swallowing in a few patients. Therefore, further consideration is needed to clarify these findings.
Considering the difficulty in evaluating the daily swallowing status with standard swallowing function tests, such as video fluoroscopy and video endoscopy, the frequency of swallowing may be a useful index for evaluating decreased swallowing function and the risk of pneumonia in children with disabilities who are prone to aspiration of reflux substances. Appropriate assessments are imperative for the management of food-related issues. The safe and continuous maintenance of oral feeding is essential for increasing survival prognosis and improving the quality of life of patients with CP and reduced swallowing function.
While we examined the association between swallowing frequency and history of pneumonia, further investigation is required to determine whether swallowing frequency can predict the onset of pneumonia. We intend to conduct a prospective study to determine the appropriate cutoff values for swallowing frequency and consider the effects of aspiration and reflux using instrumental evaluations of these symptoms.