JOMS study: New treatment algorithm recommended for babies born with tiny jaws

January 2, 2019

ROSEMONT, Ill. – Evaluation and treatment of infants born with severely undersized lower jaws vary among doctors, but common practices could define best practices, according to a study published in the January issue of the Journal of Oral and Maxillofacial Surgery.

Researchers propose an algorithm for early management of Robin sequence, a condition in which Infants have a tiny lower jaw, allowing their tongue to compromise their airway and impair feeding.

The study published in the official journal of the American Association of Oral and Maxillofacial Surgeons (AAOMS) involved 193 doctors from 20 countries – 80 percent were surgeons – who answered survey questions about evaluation and early treatment of infants with Robin sequence, as well as two cases to evaluate how they would handle clinical scenarios. The first case was a newborn with nonsyndromic Robin sequence, moderate airway obstruction and feeding impairment. The second case was an infant with syndromic Robin sequence and severe airway obstruction needing intubation in the delivery room.

Variations were found among clinical groups. However, the investigations found that, “Despite variation in the evaluation and treatment of infants with RS (Robin sequence), this international and multispecialty survey showed trends that could represent best practices.”

The proposed algorithm presents diagnosis and early treatment based on consultations, feeding evaluation, sleep study and airway evaluation. Such factors as obstructive sleep apnea, airway anomalies and feeding could determine treatment, according to the algorithm.

“This study showed a marked difference in the management of infants with RS between U.S. and non-U.S. physicians,” researchers wrote. “Non-U.S. physicians tended to spend more time trialing non-operative treatments and were less likely to recommend an airway operation compared with U.S. respondents.” The authors hypothesize this is driven by “differences in healthcare systems and maternity leave allowances, because delaying an airway operation is likely associated with longer hospitalization.”

In addition, surgeons and non-surgeons vary in how they evaluate and treat these patients, but the results were statistically irrelevant, according to the study. Surgeons tend to ask for an airway evaluation, consult with a geneticist, conduct diagnostic imaging and recommend airway surgery earlier. Non-surgeons are more likely to place nasogastric tubes earlier, perhaps due to more attention to eating and nutrition, the authors stated.

Furthermore, providers with a high volume of new infants with the condition are more likely to recommend consultation with a craniofacial surgeon and a sleep study during early treatment. These doctors also were more likely to propose surgery to treat airway obstruction earlier and less likely to insert a tube in the nasal passageway, possibly because doctors who have more resources and background with the condition are more likely to operate sooner.

The authors of “Early Management of Infants With Robin Sequence: An International Survey and Algorithm” are: Cory M. Resnick, DMD, M.D. (Harvard School of Dental Medicine, Harvard Medical School and Boston Children’s Hospital), Joshua LeVine (Harvard School of Dental Medicine), Carly E.  Calabrese, MPH (Boston Children’s Hospital), Bonnie L. Padwa, DMD, M.D. (Harvard School of Dental Medicine and Boston Children’s Hospital), and Anne Hansen, M.D., MPH, and Umakanth Katwa, M.D. (Harvard Medical School).  

The full article can be accessed at www.JOMS.org/article/S0278-2391(18)30506-8/fulltext.