2017 Sec 1 Green Book

J. Carter et al./International Journal of Pediatric Otorhinolaryngology 86 (2016) 256–261

Contents

1. Consensus objectives ....................................................................................................................................................................................................................................... 257 2. Target population .............................................................................................................................................................................................................................................. 257 3. Intended users ................................................................................................................................................................................................................................................... 257 4. Methods ............................................................................................................................................................................................................................................................... 257 4.1. Abbreviations ........................................................................................................................................................................................................................................ 257 5. Recommendations and justification ........................................................................................................................................................................................................... 257 6. Disclaimer ............................................................................................................................................................................................................................................................ 257 6.1. Section 1: evaluation and treatment considerations .............................................................................................................................................................. 257 6.2. Section 2: initial presentation algorithm .................................................................................................................................................................................... 257 6.3. Section 3: comprehensive care algorithm .................................................................................................................................................................................. 257 6.4. Section 4: management of the difficult to feed infant with laryngomalacia ................................................................................................................. 259 6.5. Section 5: post-surgical treatment algorithm and persistent laryngomalacia .............................................................................................................. 259 6.6. Section 6: recommendations for acid suppression therapy ................................................................................................................................................. 259 Conflict of interest ............................................................................................................................................................................................................................................ 261 Acknowledgements .......................................................................................................................................................................................................................................... 261

• Section 5 : post-surgical treatment algorithm • Section 6 : recommendations for acid suppression therapy

1. Consensus objectives

To provide recommendations for the comprehensive manage- ment of young infants who present with signs or symptoms concerning for laryngomalacia.

6. Disclaimer

Members of the International Pediatric ORL Group (IPOG) pre- pared this report. Consensus recommendations are based on the collective opinion of the members of this group. Any person seeking to apply or consult the report is expected to use independent medical judgment in the context of individual patient and institutional circumstances.

2. Target population

Pediatric patients with signs concerning for laryngomalacia.

3. Intended users

These consensus recommendations are intended to:

6.1. Section 1 : evaluation and treatment considerations

1. Provide initial care and triage recommendations for primary care practitioners and other health care providers who commonly evaluate young infants with noisy breathing. 2. Provide comprehensive care recommendations for otolaryngolo- gists who manage young infants with laryngomalacia.

The members of the IPOG identified five frequently debated eval- uation and treatment considerations in the management of laryngomalacia. Variation in practice among the current group members remains, and the purpose of this section is to provide a list of reasonable options based on expert opinion ( Table 1 ).

4. Methods

6.2. Section 2 : initial presentation algorithm

Expert opinion by the members of the International Pediatric Oto- laryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the manage- ment of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein rep- resent the second publication by the group.

The initial presentation algorithm is designed to guide the initial evaluation of the infant presenting with inspiratory stridor. This may vary depending on what type of medical care setting the infant presents in. Urgency of referral to an otolaryngologist is guided by severity of disease. Those with more severe disease may warrant expedited referral and those who have significant apnea/desaturations and/or inability to feed may warrant inpa- tient admission. Those infants who may be aspirating and/or have pulmonary disease may benefit from chest x-ray to further evaluate this. Flexible fiberoptic laryngoscopy (FFL) by an otolar- yngologist is important to confirm the diagnosis. Those infants whose laryngoscopy findings are not commensurate with the severity of their symptoms may benefit from airway films to screen for a secondary airway lesion. Further recommendations are detailed in Fig. 1 . The algorithm in Fig. 2 was designed to guide treatment for the infant that has been diagnosed with laryngomalacia, confirmed by FFL. This algorithm stratifies management decisions based on disease severity. The group suggests that the provider should recognize the presence of co-morbidities (see Fig. 2 ) that may lead to sub- optimal outcomes. Additionally, supraglottoplasty should be carefully considered in those with neurologic disease whose aspiration could 6.3. Section 3 : comprehensive care algorithm

4.1. Abbreviations

AP, anterior and posterior; CXR, chest x-ray; FEES, fiberoptic en- doscopic evaluation of swallowing; FFL, flexible fiberoptic laryngoscopy; H2RA, histamine-2 blocker; IPOG, International Pe- diatric Otolaryngology Group; MRI, magnetic resonance imaging; PPI, proton pump inhibitor; VFSS, video fluoroscopic swallow study.

5. Recommendations and justification

The recommendations are outlined in the following appendices

• Section 1 : evaluation and treatment considerations • Section 2 : initial presentation algorithm • Section 3 : comprehensive care algorithm • Section 4 : management of the difficult to feed infant with laryngomalacia

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