From the Guidelines
High flow oxygen therapy does not significantly increase aspiration risk in pediatric patients when used appropriately. Children on high flow nasal cannula (HFNC) can generally be fed orally with caution, but individual assessment is essential. For stable patients on HFNC with flow rates below 2 L/kg/min who are alert, have intact swallowing function, and no respiratory distress, oral feeding can typically proceed safely 1. However, children with increased work of breathing, altered mental status, flow rates above 2 L/kg/min, or those requiring CPAP/BiPAP may need feeding modifications or temporary NPO status with alternative nutrition routes.
The physiological reason for minimal aspiration risk is that properly fitted HFNC systems don't significantly increase gastric distension or compromise protective airway reflexes. When initiating oral feeding, start with small amounts of thicker liquids while monitoring for coughing, choking, or oxygen desaturation. If the child shows signs of feeding difficulty, immediately stop oral intake and consult with the healthcare team about alternative feeding methods such as nasogastric tubes. Regular reassessment of aspiration risk is necessary as the child's clinical condition changes.
Some studies have shown that high-flow nasal cannula therapy may offer several advantages compared with NIV, including better tolerance and dead space reduction 1. However, the main consideration in pediatric patients is to prioritize their safety and minimize the risk of aspiration, and high flow oxygen therapy can be a viable option when used judiciously.
Key considerations for pediatric patients on high flow oxygen therapy include:
- Individual assessment of aspiration risk
- Monitoring for signs of feeding difficulty
- Regular reassessment of clinical condition
- Use of properly fitted HFNC systems
- Avoidance of high flow rates above 2 L/kg/min
- Alternative feeding methods for high-risk patients.
From the Research
Pediatric Aspiration Risk while on High Flow
- The risk of aspiration in pediatric patients on high-flow nasal cannula (HFNC) therapy is a concern, but there is limited direct evidence addressing this specific issue 2, 3, 4, 5, 6.
- However, studies have investigated the use of HFNC in pediatric patients, including its effectiveness, safety, and potential complications 2, 3, 4, 5, 6.
- A study published in 2021 found that the implementation of an HFNC protocol in a pediatric ICU decreased the duration of HFNC therapy and the length of stay in the ICU and hospital, without increasing the risk of aspiration or other complications 5.
- Another study published in 2020 discussed the use of HFNC and noninvasive ventilation in pediatric emergency medicine, including the potential risks and benefits, but did not specifically address aspiration risk 3.
- A 2025 study evaluated the diagnosis and treatment response of patients receiving HFNC therapy in the pediatric emergency department and found that HFNC therapy was effective in most pediatric patients with respiratory distress, but did not report on aspiration risk 4.
- A 2018 survey of pediatric respiratory therapists found that there was no consensus on the definition of HFNC, how to set initial flow, or how to make adjustments, which may impact the risk of aspiration 6.
Factors Affecting Aspiration Risk
- The presence of chronic disease and abnormal chest radiography findings have been identified as independent risk factors for treatment failure, which may include aspiration, in pediatric patients receiving HFNC therapy 4.
- The duration of HFNC therapy and the presence of allergic disease have been found to be protective factors against treatment failure, including aspiration 4.
- The use of aerosol therapy during HFNC has been reported, but the impact on aspiration risk is not well understood 6.
Clinical Implications
- Clinicians should be aware of the potential risks and benefits of HFNC therapy in pediatric patients, including the risk of aspiration 2, 3, 4, 5, 6.
- The implementation of an HFNC protocol and the use of objective respiratory scores may help to minimize the risk of aspiration and other complications 5.
- Further research is needed to fully understand the risk of aspiration in pediatric patients on HFNC therapy and to develop evidence-based guidelines for its use 2, 3, 4, 5, 6.