Assessing and Managing Pediatric Dysphagia

Educational Objectives

The goal of this program is to improve the diagnosis and treatment of pediatric dysphagia. After hearing and assimilating this program, the clinician will be better able to:

1. Explain how dysphagia affects pediatric feeding disorder domains.
2. Optimize use of the videofluoroscopic swallow study in children with dysphagia.
3. Assess effectiveness of the Penetration-Aspiration Scale based on data.

Summary

Feeding and swallowing: feeding is a broad term encompassing all aspects of eating and drinking, including swallowing, mealtime behaviors related to food, and environmental influences; swallowing is the technical term for deglutition, which starts after food or liquid enters the mouth and involves different parts of the throat and esophagus; all children with swallowing problems also have feeding issues; some children, eg, those with sensory issues or autism spectrum disorder, may face feeding problems that are not directly related to swallowing itself

Pediatric dysphagia: factors to consider while evaluating dysphagia include diagnostic conditions, comorbidities, previous feeding experiences, and environmental and social determinants; pediatric patients have distinct medical conditions that differ from adults, eg, prematurity, bronchopulmonary dysplasia, chronic lung disease; diseases affect children differently than adults; medical advancements have resulted in more children surviving with conditions, eg, congenital heart disease or spinal muscular atrophy, which may also lead to dysphagia; some children may experience dysphagia because of new infectious diseases, eg, long-term COVID or Zika virus infection

Challenges in pediatric dysphagia research: the age range of pediatric patients is vast, but the overall population is relatively small; conducting research is difficult because of small sample sizes, heterogeneous populations, and limited availability of suitable controls; ethical concerns arise when designing research studies with children, eg, using a placebo control group may be considered unethical; growth and development can make it difficult to isolate the effects of the intervention being studied; medical advancements have likely led to a cohort of children with increasingly complex conditions who may also experience dysphagia; this makes it difficult to compare current patient populations to those studied in the past; researchers often rely on caregivers' reports for a child's medical history, which can be influenced by the caregiver's understanding, expectations, and socioeconomic background; obtaining informed consent becomes more complex as children mature; children's anatomy and physiology are constantly changing at a rapid and uneven pace, making it difficult to establish clear benchmarks for “normal” swallowing function in different age groups; certain developmental milestones are linked to specific anatomic changes in the vocal tract; researchers need to consider these age-specific factors when evaluating swallowing function

Development: children with typical development have the ability to adjust their swallowing based on several factors, eg, head position, mouth opening, and food consistency; as they grow, children gradually learn to handle a wider variety of foods and textures and eventually multitask by eating and drinking simultaneously; events that disrupt typical development can lead to difficulties in acquiring proper feeding skills; infants need to learn essential feeding behaviors like recognizing hunger cues and accepting spoon feeding; a child who misses these crucial learning opportunities during development might face long-term challenges; the use of imaging techniques raises concerns about potential risks to a child's developing organs because of radiation exposure; researchers need to consider the necessity and frequency of such procedures; children, especially those with chronic health conditions, may have varying levels of cooperation because of past experiences or simply not being in the mood

Standardization: Martin Donner defined dysphagia as a symptom, not a disease, that can affect any part of the swallowing tract; there are significant gaps in knowledge when it comes to caring for children with dysphagia; current clinical and instrumental evaluations lack uniformity and clear terminology; the goal of standardization is to minimize unnecessary or excessive variability; benefits in health care include safety, reproducibility, transparency, and quality across different clinical centers, reduction in medical errors, and improved clinical decision making; clear terminology reduces ambiguity in diagnoses and treatment plans; streamlining processes and eliminating unnecessary variations has the potential to lower health care costs

Drawbacks: standardization may eliminate necessary variations in care, overlooking a patient's unique needs and strengths; focusing on a standardized “average” level of care could discourage providers from developing new or improved approaches; standards are based on the knowledge available at the time of their development; dissemination and implementation of new knowledge may be delayed

Clinical evaluation: the rationale and techniques have remained relatively unchanged for the past 4 to 5 decades; the evaluation is global, not instrumental, and does not provide the benefit of direct visualization; initial evaluation helps determine if the patient has dysphagia and identifies potential causes; it establishes a baseline of function and helps evaluate the effectiveness of interventions, eg, introducing spoon feeding; the evaluation process also helps build a relationship with the child's caregivers

Terminology: pediatric feeding disorder (PFD) is defined as impaired swallowing that is not age-appropriate and is associated with any of the 4 interactive domains, medical, feeding, psychosocial, or nutritional; an aerodigestive patient is a child who has multiple interrelated congenital and/or acquired conditions that affect the airway, breathing, feeding, swallowing, or growth; symptoms can vary, so early diagnosis and intervention are crucial

Multidisciplinary management: different specialists are needed to address specific issues a child may face, such as respiratory, airway, digestive, feeding, and swallowing problems; in a study (Alexander et al [2021]), 25 children (median age of 20 mo) were evaluated, and it was found that all of them had ≥1 issue in the PFD domains

Role of the clinician: is to determine whether dysphagia is present and if it contributes to the child's current symptoms; the clinician must also identify specific underlying conditions that affect feeding and swallowing development; furthermore, they should implement evidence-based interventions to reduce the impact of the feeding and swallowing disorder without causing new problems; recent studies suggest that there is a lack of strong evidence to prove the accuracy of clinical evaluations in detecting oropharyngeal aspiration in children; clinical evaluations remain valuable in determining the need for, the timing, and the type of evaluation; the clinician should establish a connection between the clinical presentation and instrumental findings; the choice of examination depends on the reason for doing it; diagnostic and management needs require direct visualization of structures and functions not seen on clinical evaluation; the choice of diagnostic test depends on the loci of the swallowing problems and the child's ability or willingness to cooperate; the test should be performed when potential information could affect diagnostic or management decision-making

Radiologic evaluation: in 1983, Dr. Jeri Logemann introduced the modified barium swallow study or the videofluoroscopic swallow study (VFSS), which was originally used to assess aspiration; VFSS is now used for identifying reasons for aspiration, determining the type and severity of dysphagia, evaluating sensory and motor function related to swallowing, and defining treatment targets; Dr. Heather Bonilha conducted a study on the effect of excessive radiation exposure in children undergoing VFSS examinations; the skill of the clinician performing the VFSS can be a source of variability; less experienced clinicians may tend to perform the studies more frequently, potentially resulting in inconsistencies in the results; studies suggest longer examination times because of concerns about missing crucial information; evidence shows that more consistent treatment recommendations are made when the findings address physiologic impairments, rather than solely focusing on the location of the swallowed material; institutional variations in patient selection, fluoroscopy duration, barium consistency employed, criteria for stopping the examination, and examination repetition frequency may contribute to inconsistency in evaluations

Treatment recommendations: VFSS results often lack clear treatment recommendations, leaving clinicians unsure how to advise families on feeding strategies; it is advisable not to use pass/fail terminology; instead, the clinician may describe the underlying physiologic issues to parents; protocols designed for adults may not be suitable for children; children often cannot swallow on command or handle single swallows, unlike adults; shorter fluoroscopy times are achievable in children, thereby minimizing radiation exposure; children's swallowing systems are constantly developing, adding another layer of complexity to interpreting VFSS results

Unresolved questions: it is unclear when to perform a VFSS, eg, during acute illness; there are also uncertainties about which contrast materials to use, quantities, and standardization; there is a lack of consensus on optimal positioning during the exam, and disagreements on frame rates, magnification levels, and the number of swallows needed; variability in examination duration (1-8 min), and reporting with inconsistent definitions for observed physiologic features during the examination exist; there are no standard metrics for reporting or interpreting results, nor is there a clear understanding of what constitutes meaningful clinical outcomes; resource wastage and increased radiation exposure are consequences of such variabilities

Strategies for reducing radiation exposure: identify children for whom VFSS is appropriate; collimate the x-ray field to the area of interest; use magnification judiciously; 30 frames per second (FPS) is currently the optimal frame rate; 15 FPS is inadequate for judging the presence and depth of thin liquid penetration; minimize fluoroscopy times; use intermittent fluoroscopy to capture essential findings; end the examination when the necessary information is obtained or when additional information is unlikely; plan repeat examinations strategically based on anticipated changes in the child's condition, rather than using arbitrary time intervals

Penetration-Aspiration Scale (PAS): was developed for adults who had dysphagia after a stroke; it classifies airway protection during a single swallow; fluctuations in swallowing were not captured, and sequential swallows were not described; the PAS provides information about the depth and response to airway invasion, but only if the aspiration is captured; the PAS does not provide information on the cause of penetration and aspiration, the severity of dysphagia, the presence of related swallowing impairments, the most important physiologic targets, whether swallowing function meets nutritional needs, and future swallowing function or aspiration risk; studies have shown changes in PAS scores after specific interventions in adults with well-defined conditions; PAS scores at the extreme ends of the range have the most agreement among clinicians, with less agreement in midrange scores; barriers to the usefulness of PAS scores include variability in methods, variable populations, variations in scoring, and inappropriate frame rates

Simplified scoring systems: some use a simplified 3-level scale of normal, penetration to vocal folds, and aspiration below vocal folds; it is difficult to apply the full scale to infants; the simplified scale may provide a greater number of responses but less information

Strategies for improvement: provide definitions; perform prospective well-defined studies; use consistent protocols with standardized frame rates; train examiners; determine optimal intervals between examinations to balance information gathering with radiation exposure concerns

Measurement tool for VFSS (BaByVFSSImP): is a system currently being developed by the speaker’s group; it clearly defines each of the 21 components in terms of bolus location at the time of swallow initiation; locations the examiner should focus on are specified; scoring is done at a specific point in swallowing; it addresses the issue that swallows with the same PAS scores may be very different physiologically; the system requires specific training; neither adult nor pediatric prior training translated into accurate identification of relevant findings

Readings

Alexander E, Armellino A, Buchholtz J, et al. Assessing pediatric feeding disorders by domain in complex aerodigestive patients. Cureus. 2021;13(8):e17409. doi:10.7759/cureus.17409; Borders JC, Brates D. Use of the penetration-aspiration scale in dysphagia research: A systematic review. Dysphagia. 2020;35(4):583-597. doi:10.1007/s00455-019-10064-3; Goday PS, Huh SY, Silverman A, et al. Pediatric feeding disorder: Consensus definition and conceptual framework. J Pediatr Gastroenterol Nutr. 2019;68(1):124-129. doi:10.1097/MPG.0000000000002188; Lawlor CM, Choi S. Diagnosis and management of pediatric dysphagia: A review. JAMA Otolaryngol Head Neck Surg. 2020;146(2):183-191. doi:10.1001/jamaoto.2019.3622; Lee JW, Randall DR, Evangelista LM, et al. Subjective assessment of videofluoroscopic swallow studies. Otolaryngol Head Neck Surg. 2017;156(5):901-905. doi:10.1177/0194599817691276; Martin-Harris B, Canon CL, Bonilha HS, et al. Best practices in modified barium swallow studies. Am J Speech Lang Pathol. 2020;29(2S):1078-1093. doi:10.1044/2020_AJSLP-19-00189; Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehabil Clin N Am. 2008;19(4):691-vii. doi:10.1016/j.pmr.2008.06.001; Pagnamenta E, Longhurst L, Breaks A, et al. Research priorities to improve the health of children and adults with dysphagia: A National Institute of Health Research and Royal College of Speech and Language Therapists research priority setting partnership. BMJ Open. 2022;12(1):e049459. doi:10.1136/bmjopen-2021-049459.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Lefton-Greif was recorded at the 51st SENTAC Annual Meeting, held November 30 to December 2, 2023, in Charleston, SC, and presented by The Society of Ear Nose and Throat Advancement in Children. For information on upcoming CME activities from this presenter, please visit www.sentac.org. Audio Digest thanks the speakers and The Society of Ear Nose and Throat Advancement in Children for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

OT571701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

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To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

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Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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