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Pediatric Dysphagia Evidence Map
Assessment

Clinical Examination

 


 
 
 

External Scientific Evidence

  

Evidence-Based Practice Guidelines

Feeding Problems of Infants and Toddlers
Bernard-Bonnin, A. C. (2006).
Canadian Family Physician, 52, 1247-1251
.
Added: July 2011
 
Description
This guideline provides recommendations regarding the diagnosis and management of feeding problems in young children. Populations included, but were not limited to, children with behavioral feeding disorders, craniofacial anomalies and neurodevelopmental disabilities. Levels of evidence are provided for recommendations throughout the text. Level I evidence requires at least one well done randomized controlled trial, systematic review, or meta-analysis. Level II evidence requires at least one (preferably more than one) comparison trial, non-randomized cohort, case-control, or epidemiologic study. Level III evidence is based on expert opinion or consensus statements. 
 
Recommendations
  • When evaluating feeding disorders the following key elements should be considered:
    • “How is the problem manifested?
    • Is the child suffering from any disease?
    • Have the child’s weight and development been affected?
    • What is the emotional climate like during the child’s meals?
    • Are there any great stress factors in the family?” (p. 1248).
  • Medical history should include investigation of development, e.g., “antenatal and perinatal history” (p. 1248), family history, diet and dietary changes, feeding characteristics, e.g., “route and time of administration” (p. 1248) and “feeding position” (p. 1248), strategies previously used, and environments and behaviors at mealtimes.
  • An assessment of parent-child interaction should be completed during feeding. “Positive interactions, such as eye contact, reciprocal vocalizations, praise and touch, and negative interactions, such as forced feeding, coaxing, threatening, and children’s disruptive behavior (turning the head away from food, throwing food) should be noted” (p. 1249).
  • Additionally, assessment should document behavior prior to the presentation of food. Specifically, behaviors such as prompting, reinforcement and consequences should be noted.
 
   
 
New York State Department of Health, Early Intervention Program; U.S. Department of Education
 
Clinical Practice Guideline: Report of the Recommendations. Down Syndrome, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2006).
Albany (NY): NYS Department of Health, Publication No. 4959, 292 pages.
 
 
Added: July 2011
 
Description
This guideline provides recommendations pertaining to the assessment and intervention of young children with Down syndrome. The intended audiences for this guideline include families and professionals. Of particular importance to speech-language pathologists and audiologists are recommendations regarding assessment and management of communication, cognition, social relationships, oral-motor feeding, and hearing. The recommendations are classified A, B, C, D1 or D2, based on the strength and quality of evidence. Level A recommendations are considered “strong evidence” based on high quality evidence from two or more efficacy studies. Level B recommendations are considered “moderate evidence" and based on evidence from at least one high quality efficacy study. Level C recommendations are "limited evidence" and based on evidence from at least one efficacy study with moderate quality or applicability to the topic.  Level D1 and D2 are consensus recommendations. Level D1 recommendations are consensus panel opinion based on information not meeting criteria for evidence in systematic reviews and Level D2 recommendations are based on information where a systematic review has not been done. 
 
Recommendations
  • Children with Down syndrome should be assessed for oral sensorimotor and feeding problems. Assessment should include:
    • "Physical examination and thorough medical and feeding history;
    • Observation of interaction patterns between child and primary feeders, including observation of trial feeding, body posture and positioning effects,
    • Oral-motor examination, including:
      • Presence/absence of oral reflexes
      • Structure and praxis of lips, tongue, palate
      • Oral sensation
      • Laryngeal function (voice production)
      • Control of oral secretions
      • Respiratory control
      • Swallowing function (including effect on nutrition intake and need for measures to prevent aspiration)
      • Oral postural control;
    • Parents knowledge about the progression of introducing solid foods to the child’s diet;
    • Indications for specialized studies (such as videofluoroscopy)" (Level D2)
  • The following assessment tests may aid in assessing oral-motor and feeding:
    • The Neonatal Oral-Motor Feeding Scale
    • The Pre-Speech Assessment Scale
    • Schedule for Oral-Motor Assessment  (Level D2)

» See full summary and quality ratings 

 
 
New York State Department of Health, Early Intervention Program; U.S. Department of Education
 
Clinical Practice Guideline: Report of the Recommendations. Motor Disorders, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2006).
Albany (NY): NYS Department of Health, Publication No. 4962, 322 pages.
 
 
Added: July 2011
 
Description
This guideline provides recommendations regarding assessment and intervention for young children with developmental motor disorders and cerebral palsy, a static central nervous system disorder.  The target audiences for this guideline are parents and professionals. The recommendations are classified A, B, C, D1 or D2, based on the strength and quality of evidence. Level A recommendations are considered “strong evidence” based on high quality evidence from two or more efficacy studies. Level B recommendations are considered “moderate evidence" and based on evidence from at least one high quality efficacy study. Level C recommendations are "limited evidence" and based on evidence from at least one efficacy study with moderate quality or applicability to the topic.  Level D1 and D2 are consensus recommendations. Level D1 recommendations are consensus panel opinion based on information not meeting criteria for evidence in systematic reviews and Level D2 recommendations are based on information where a systematic review has not been done. 
 
Recommendations
  • No standardized assessment test or scale is recommended for universal use to assess oral motor skills in children with cerebral palsy. Assessment instruments may include:
    • Neonatal Oral-Motor Assessment Scale;
    • Pre-Feeding Skills: A Comprehensive Resource for Feeding Development;
    • Schedule for Oral-Motor Assessment;
    • The Multidisciplinary Feeding Profile (Evidence Level D2) (p. 74).
  • Assess feeding in a natural environment; feeding position; lip, tongue, and jaw actions during feeding; fine motor skills; efficiencies with varying textures; time to clear the oral cavity; mastication skills; and coordination of breathing and swallowing during feeding. (Evidence Level D2) (pp. 72-73).
  • Signs of impairment to watch for during the initial oral-motor feeding assessment include: increased heart rate or loss of breath, excessive coughing during or after meal, gagging, spitting, tongue thrust, squirming or withdrawal, and oral loss of liquid (Evidence Level D2) (pp. 72-73).

» See full summary and quality ratings 

 
 
Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
 
Royal College of Speech and Language Therapists Clinical Guidelines: 5.8 Disorders of Feeding, Eating, Drinking & Swallowing (Dysphagia)
Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.
 
Added: July 2011
 
Description
This guideline provides recommendations for the assessment and management of swallowing disorders in children and adults. This guideline is intended for speech-language pathologists. Populations included, but were not limited to, stroke, traumatic brain injury, autism spectrum disorder, cerebral palsy, Parkinson’s disease and head and neck cancer. Each recommendation is graded A (requires at least one randomized controlled trial), B (requires at least one well-conducted clinical study), or C (requires evidence from expert committee reports). 
 
Recommendations
  • “Subsequent to information gathering, the Speech & Language Therapist will make a judgment with regard to whether they proceed in assessing the individual with food and liquid” (Level C Evidence) (p. 64).
  • The SLP will consider the swallowing impairment within the context of the individual’s overall development, emotional and behavioral well-being, current status, prognosis, and setting and may determine that intervention is not appropriate at a given time (Level C Evidence) (p. 67).
  • “For an individual who has a tracheostomy, it is physiologically contraindicated to assess or feed with the cuff inflated. However, in rare circumstances, a team decision may be taken to feed with the cuff inflated. Where a tracheostomy is sited, the individual should have a swallow assessment following the same principles as discussed above, having the adjunct of:
    • Blue dye added to secretion and food and liquid
    • Cuff deflation" (p. 66).
  • "The individual swallow will be assessed using a speaking valve to determine if there is an improvement in safety and efficiency” (Level B Evidence) (p. 66).
  • The following aspects should be considered during the clinical evaluation:
    • Case history
    • Oro-facial examination
    • Vocal tract function
    • Motor skills, posture, and tone
    • Nutrition/hydration
    • Respiratory status
    • Gastro-oesophageal reflux
    • Secretion management
    • Tracheostomy
    • Cognitive level
    • Alertness level
    • Medications
    • Oral hygiene
    • Dental health
    • Dietary preferences
    • Participation
    • Feeding patterns
    • Emotional state, mood, and behavior (Level C Evidence) (p. 64).
  • The speech-language pathologist (SLP) should observe the individual (and feeding support persons) while eating and drinking and take note of:
    • Mealtime interaction
    • Positioning
    • Bolus size
    • Pacing and presentation
    • Utensils
    • The environment (Level B Evidence) (p. 64).
 
 
 
 
 
Evidence-Based Systematic Reviews
Clinimetrics of Measures of Oropharyngeal Dysphagia for Preschool Children with Cerebral Palsy and Neurodevelopmental Disabilities: A Systematic Review
Benfer, K. A., Weir, K. A., et al. (2012).
Developmental Medicine and Child Neurology, 54(9), 784-795.
Added: April 2013

Description
This is a review of the published literature investigating the psychometric properties and clinical usefulness of objective measures of oropharyngeal dysphagia (OPD) in children with cerebral palsy (CP).

Conclusions

  • Nine measures were identified. It was difficult to compare the measures since they varied in stated purpose and domain.

  • Overall the validity of the included measures was limited primarily because of a lack of a commonly accepted theoretical foundation to describe OPD in children with CP.

  • The reliability of most of the measures was considered to be good however further studies with greater methodological rigor and larger sample sizes are needed.

  • The clinical utility of many of the measures was compromised because there was no published manual detailing the procedures to ensure consistent use.

  • Overall, there are few measures with demonstrated psychometric properties  for children with CP.

  • "The SOMA [Schedule for Oral Motor Assessment] and FFAm [Functional Feeding Assessment-modified] had the strongest psychometric properties of validity and reliability, and were most suitable for use in a research context" (p. 794).

  • "The SOMA and DDS [Dysphagia Disorders Survey] had the strongest clinical utility to support clinical decision-making" (p. 794).

» See full summary and quality ratings



A Review of Psychometric Properties of Feeding Assessment Tools Used in Neonates
Howe, T. H., Lin, K. C., et al. (2008).
Journal of Obstetric, Gynecologic & Neonatal Nursing, 37(3), 338-349.
Added: April 2013

Description
This is a systematic review of the published scientific literature investigating the psychometric properties of neonatal clinical feeding assessment tools.

Conclusions

  • Seven tools were identified including:

    • Early Feeding Skills (EFS)

    • Infant Breastfeeding Assessment Tool (IBFAT)

    • LATCH

    • Mother-Baby Assessment (MBA)

    • Neonatal Oral-Motor Assessment (NOMAS)

    • Preterm Infant Breastfeeding Behavior Scale (PIBBS)

    • Systematic Assessment of the Infant at Breast (SAIB)

  • The review raised several key concerns regarding the identified tools. First, the tools did not agree about what components constituted successful feeding behaviors. Second, the sample sizes of the studies were small and the selected participants did not fully represent the target population thus limiting their generalizability. Third, only one of the tools (NOMAS) examined internal consistency and responsiveness. These two properties are necessary if the tool is to be used to track changes over time.

  • The authors concluded that "a psychometrically sound neonate feeding assessment tool has not yet been empirically validated" (p. 347).

» See full summary and quality ratings



Clinical Practice: Swallowing Problems in Cerebral Palsy
Erasmus, C. E., van Hulst, K., et al. (2012).
European Journal of Pediatrics, 171(3), 409-14.
Added: September 2012

Description
This review discusses the pathophysiology, clinical features, assessment, and management of swallowing problems in children with cerebral palsy (CP). 

Conclusions
Speech language pathologists may be involved with the swallowing assessment of children with cerebral palsy as part of a multidisciplinary team. Recommendations for evaluation based on expert opinion include:

  • Assess respiratory status

  • Collect medical, social-emotional, and medication history

  • Evaluate for presence of gastro-oesophageal reflux

  • Evaluate the safety of the feeding program and consider nasotube feeding

  • Conduct neurological examination

  • Examine orofacial structures and consider specialist ENT evaluation

  • Examine oral hygiene, occlusion, teeth, posture and head control, mouth closure, and lip seal

  • Consider the consistency, size, and texture of the food bolus, consider the positioning of the patient, and determine the appropriateness of swallow manoeuvres

  • Evaluate oropharyngeal swallowing stage

  • Assess speech and communication

  • Evaluate secretion management and consider drooling treatment

  • Consider use of videofluoroscopy to detect silent aspiration and evaluate swallowing with various bolus types

» See full summary and quality ratings



Instruments for Assessing Readiness to Commence Suck Feeds in Preterm Infants: Effects on Time to Establish Full Oral Feeding and Duration of Hospitalisation
Crowe, L., Chang, A., et al. (2012).
Cochrane Database of Systematic Reviews (4).

This review meets the criteria for a high-quality evidence-based systematic review.
Added: September 2012

Description
This is a systematic review of randomized or quasi-randomized controlled trials investigating the effects of using a specialized feeding readiness assessment instrument compared to no instrument or another instrument on time to establish full oral feeds and hospitalization duration in preterm infants.

Conclusions
"There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population" (p. 2).

» See full summary and quality ratings



 
Sucking and Swallowing in Infants and Diagnostic Tools
da Costa, S. P., van den Engel-Hoek, L., et al. (2008).
Journal of Perinatology, 28(4), 247-57.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: September 2012

Description
This is a review of journal articles pertaining to the development of sucking and swallowing in infants, diagnostic tools to assess the coordination of sucking, swallowing, and breathing, and prognostic impacts of poor sucking and swallowing on later neurodevelopmental outcomes.

Conclusions
Several research tools have been developed to assess sucking behavior; however these tools are limited to the measurement of only a subset of relevant aspects of sucking behavior and to assessment of only bottle feeding or breastfeeding, but not both. These tools also require expensive/complicated measuring equipment. The research supporting these tools has been conducted with a small sample size and often without a control group or validity testing. There is a need for the development of a user-friendly, reliable, and noninvasive tool to assess breastfeeding and bottle feeding in infants.

» See full summary and quality ratings



Feeding Disorders in Food Allergic Children
Haas, A. M. (2010).
Current Allergy and Asthma Reports, 10(4), 258-64.
Added: September 2012

Description
This is a review of the published literature investigating feeding difficulties and disorders in children with food allergies.

Conclusions

  • "Assessment should include analysis of the complex interplay of developmental function experiences and learning gathered via caregiver interview, a mealtime observation of preferred and nonpreferred foods, and analysis of overall development " (p. 261).

  • "In addition to observations regarding oral motor and oral sensory function, observations should be made regarding muscle tone, postural alignment and stability, breathing, global sensory processing, communication, and their resultant impact on feeding and mealtimes" (p. 261).

» See full summary and quality ratings



 

Clinical Expertise/Expert Opinion

 
Consensus Guidelines  
NHS Quality Improvement Scotland
 
Best Practice Statement: Caring for the Child/Young Person with a Tracheostomy
NHS Quality Improvement Scotland. (2008).
Edinburgh (Scotland): NHS Quality Improvement Scotland, 68 pages
 
Added: July 2011
 
Description
This guideline provides recommendations for the management of children and adolescents with a tracheostomy. This guideline is intended for healthcare professionals involved in the multidisciplinary care of these children. 
 
Recommendations
  • “The presence of a tracheostomy tube may impair swallowing with increased risk of aspiration” (p. 10).
  • Speech-language pathologists should assess swallowing, "including first gathering relevant information from the multidisciplinary team, and recognize when to involve the dietitian" (p. 10).
  • "The assessment should be carried out along with the child/young person’s nurse” (p. 10).
 
 
 
American Speech-Language-Hearing Association
 
Guidelines for Speech-Language Pathologists Providing Swallowing and Feeding Services in Schools
American Speech-Language-Hearing Association. (2007).
Retrieved from: http://www.asha.org/docs/html/GL2007-00276.html.
 
 
Added: July 2011
 
Description
This ASHA guideline addresses the issues, models, and procedures for management of students with swallowing and feeding disorders in the school setting. 
 
Recommendations
  • “A parent/guardian interview is an important source of information regarding such factors as medical history, mealtime environment, and cultural factors in the home” (p. 15).
  • “The teacher interview includes gathering information about how the student’s dysphagia affects his or her academic progress and ability to participate in extracurricular activities. Following the screening, a comprehensive, interdisciplinary swallowing and feeding evaluation may occur” (p. 15).
 
 
 
American Speech-Language-Hearing Association
 
Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Guidelines
American Speech-Language-Hearing Association. (2005).
Retrieved from: http://www.asha.org/docs/html/GL2005-00060.html.
 
 
Added: July 2011
 
Description
This is a guideline providing recommendations on the roles and responsibilities of speech-language pathologists (SLPs) providing care in the Neonatal Intensive Care Unit (NICU). Recommendations are provided pertaining to assessment and management of communication, feeding, and swallowing of infants. 
 
Recommendations
  • A standard pediatric clinical examination includes taking a history, physical examination, developmental assessment, observation of nonnutritive and nutritive sucking, and determination, along with a multidisciplinary team, of readiness for oral feeding.
  • “Readiness for oral feeding in the preterm infant is associated with the infant’s ability to achieve and maintain awake states, to coordinate breathing with sucking and swallowing and the presence of apnea” (p. 9).
 
 
 
American Speech-Language-Hearing Association
 
Preferred Practice Patterns for the Profession of Speech-Language Pathology
American Speech-Language-Hearing Association. (2004).
Retrieved from: http://www.asha.org/docs/html/PP2004-00191.html.
 
 
Added: July 2011
 
Description
This Preferred Practice Patterns for the Profession of Speech-Language Pathology document is a description of recommended practice for many areas of assessment and management in the scope of practice for SLPs. The guiding principles for each clinical service are discussed in terms of service provider, expected outcome, clinical indication, clinical processing, setting, equipment, safety precautions, and documentation. 
 
Recommendations
  • “Swallowing screening is conducted in a clinical or natural environment conducive to obtaining valid screening results.” Settings may include bedside, home, or hospice.
  • Swallowing screening may involve:
    • Interview/questionnaire
    • Observation of signs and symptoms
    • Observation of typical feeding/eating situation
    • Formulation of recommendation and referral for full swallowing or other evaluation if appropriate
    • Communication of the results and recommendations to the multidisciplinary team
  • Evaluation may be static or dynamic and includes:
    • Relevant case history, including medical and educational history and socioeconomic, cultural, and linguistic background
    • Observation of auditory, visual, motor, and cognitive status
    • Observation of orofacial myofunctional patterns
    • Standardized oropharyngeal myofunctional assessment
    • Standardized and nonstandardized assessments of facial muscles and structures, posture, control, and reflexes, as well as functional assessment of feeding and swallowing (including suckling, sucking, mastication, oral containment, and bolus manipulation), and assessment of airway function and saliva function. Behavioral factors, such as acceptance of pacifier, nipple, utensil, and foods/liquids of different textures should also be assessed.
    • Assessment of the form and function of the facial and pharyngeal structures
    • Assessment of oral/nasal airways pertaining to orofacial myofunction patterns, swallowing or speech using perceptual and instrumental procedures
    • Instrumental diagnostic procedures such as videofluoroscopic swallow study, endoscopic evaluation of swallowing, and ultrasound with consideration for positioning, presentation, and viscosity.
    • Articulation
    • Collaboration with other professionals including physicians and dental specialists
    • Interdisciplinary and family collaboration and interaction
    • Follow-up services 
 
 
 
American Speech-Language-Hearing Association
 
Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders: Technical Report
American Speech-Language-Hearing Association. (2001).
Retrieved from: http://www.asha.org/docs/html/TR2001-00150.html.
 
 
Added: July 2011
 
Description
This ASHA position statement provides information regarding the role of the SLP in evaluation and management of children and adults with feeding and swallowing disorders and discusses the scope and rationale for SLP services. 
 
Recommendations
  • The “clinical” or “bedside” examination of swallowing is typically the first step of a comprehensive swallowing evaluation and generally consists of four components:
    1. Case history and interviews with the patient, family, and other professionals
    2. Assessment of oral motor structures and function
    3. Assessment of speech and vocal quality
    4. Assessment of the individual’s skills and functional ability in a natural environment and adequacy of airway protection and coordination of respiration and swallowing
  • It may also assess the impact of altering the bolus or introducing compensatory techniques on the individual’s swallowing function.
  • Functional rating scales may provide additional information regarding the individual’s perceptions and quality of life.

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Client/Patient/Caregiver Perspectives

 
No information was found pertaining to client/patient/caregiver perspectives.
 
 
 




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