Disclosures and Support

MA Lefton-Greif, Ph.D., CCC-SLP, BRS-SNationwide Children's Hospital Annual Neonatal Conference

May 24, 2013

1

Pediatric Feeding and Swallowing Problems: Let’s Figure it Out

Maureen A. Lefton-Greif, PhD, CCC-SLP, BRS-SAssociate Professor, Dept. of Pediatrics and Otolaryngology Head and

Neck Surgery, and Physical Medicine + RehabilitationJohns Hopkins University School of Medicine

Nationwide Children's Hospital Annual Neonatal Conference

May 24, 2013

Disclosures and Support

Pearsons (http://www.speechandlanguage.com/) for Pediatric Videofluoroscopic Swallow Studies (1998)

NIDCD, 5R01DC011290-02, Standardization of videofluoroscopic swallow studies for bottle-fed children, p ,2011 – 2015

What is the cause of the problem?

How can it be fixed?

When will it be fixed?

Questions You Will Be AskedHow Are Feeding and Swallowing Disorders Evaluated and Treated?

By a multidisciplinary team - best means of establishing

a diagnosis and providing treatment

Team members may include but are not limited to our

colleagues from neonatology, speech-language

pathology, otolaryngology, nutrition, nursing,

gastroenterology, pulmonary, developmental

pediatrics, psychology, occupational therapy,

physical therapy, early intervention programs,

and caregivers

Post-Natal Feeding/Swallowing Development

“Normal feeding and swallowing

development is ‘biopsychosocial’ process

th t i l hild th i i dthat involves children, their caregivers, and

a host of other factors (e.g., culture,

professionals)”.

Stevenson & Allaire, 1991

F di

…linked during infancy and early

childhood

SwallowingFeeding

• Difficulty with anyaspect of eating or drinking, including swallowing.

Swallowing

• Process of deglutition that occurs after liquids or foods enter the mouth.

• Involves any or all phases of deglutition


May 24, 2013

2

Disruptions that ….

occur early in life may result in long-term

feeding problems or exacerbate pre-existing

swallowing problems

Some NICU Graduates:

Have an increased risk of dysphagia

(e.g., secondary to IVH/ PVL or neurologic

involvement) and /orinvolvement) and /or

decreased tolerance to sequelae associated

with dysphagia (e.g., BPD / CLD-P, increased

growth/nutrition needs)

Attainment of Oral Feeding

Most healthy premature infants attain oral feedings by median age of 34 - 38 weeks

Modifying Characteristics

Younger GA at birth (≤ 28 weeks)

Lower BW’s: ≤1000 grams

CLD and duration of ventilation/ CPAP

GER

Practice, practice, practiceAmaizu et al, 2008; Jadchurla et al, 2010; Lemmons et al, 2001; Pickler et al 2009;

Simpson et al 2002

Feeding Outcomes

After d/c infants w/ CLD with feeding challenges and increased risk for long term growth challenges1

At 1 month CA at home, infants with “mild” CLD continued to have desaturations during feeds, took longer to eat, and had less volume intake than infants w/o CLD2

Singer et al, 1992;Wood et al, 2003

NICU Graduates and Feeding Problems

Approximately 31% of w/ feeding difficulties

before 1 year of age1

Former preemies account for ≈ 40% of children Former preemies account for ≈ 40% of children

referred to out patient specialty clinic for feeding

or growth concerns1

Incidence:19% - 80%2-4

1Hawdon,2000; 2 Cerro et al, 2002; 3 Mathiesen et al, 2000; 4 Sweet et al, 2003

Persistent Feeding Difficulties: Presentation to Out Patient Clinics

38% born preterm

74% with developmental delay

Persistent feeding difficulties were likely to be Persistent feeding difficulties were likely to be

a combination of chronic respiratory

compromise and neurologic involvement ,

both of which may be more fully expressed

with maturation

Burklow et al ,2002


May 24, 2013

3

F di

…linked during infancy and early

childhood

SwallowingFeeding

• Difficulty with anyaspect of eating or drinking, including swallowing.

Swallowing

• Process of deglutition that occurs after liquids or foods enter the mouth.

• Involves any or all phases of deglutition

Swallowing Development

Pharyngeal Swallowing

True Sucking

Efficient Swallowing Full TermSwallowing

10 - 12.5 wksSucking

18 - 24 wksSwallowing34 - 36+ wks

Full Term Infant

Fetal Swallowing

Grassi, R. et al. Am. J. Roentgenol. 2005

Attainment of oral feeding does not depend on the present of a fully mature suck-swallow pattern –suggesting that as with acquisition of other motor milestone, learning continues to occur.

Bringham. J Child Neuol, 2009

Swallowing is Critical for Survival

Swallowing is critical to lung

protection because airway because airway

and food food pathways share

the pharynx

Levels of Airway Protection

1. Swallow

Cough

Mucociliary action

Immune system

Swallow = Primary means of airway protection


May 24, 2013

4

Post-Natal Swallowing

Seems “simple”

requires coordination

of multiple structures in

th th th t dthe mouth, throat, and

esophagus

coordinated with

breathing

600 - 900 times daily1

1 Lear et al.,1964

Primary Functions of Post-Natal Swallowing

Direct food, liquid, & saliva from the mouth to

the stomach while keeping airway protected

Provide enough of the right types of liquids & Provide enough of the right types of liquids &

foods for:

adults to stay healthy

children to grow and develop

In other words, Feeding/Swallowing must be ….

Safe

Adequate (hydration & nutrition)

Enjoyable

Corollary- Swallowing Must Must Adapt to:

Alterations in anatomic relationships of pharyngeal structures due to Normal developmental changes, including aging

Changes in head & neck posture Changes in head & neck posture alterations in anatomic relationships of pharynx

Developmentally appropriate changes in nutritional intake e.g., Changes in liquid/food characteristics,

volume, & temperature

Four Phases of Swallowing

Oral preparatory

Oral

Pharyngeal

Esophageal

Normal Swallowing: Infant


May 24, 2013

5

Swallowing Dysfunction or Oropharyngeal Dysphagia

dysphagia (dǐs-fā’ jē-ă)

[G. dys, difficult + G. phagein, to eat]

Inability to swallow or difficulty swallowing

“Dysphagia is not a

disease. Rather it is a

symptom of a disease

that may be affecting

any part of theany part of the

swallowing tract from

the mouth to the

stomach.”

Donner,1986

Phases of Swallowing: Localized Disruptions

Oral preparatory

OralOral

Pharyngeal

Esophageal

Adapted from: Arvedson JC + Lefton-Greif MA, 1998

Prolonged feeding

Sucking problems - bottle

feeding

Oral / Oral Preparatory Phase:Bolus Formation/Transit Problems

feeding

Drooling

Difficulty chewing

Difficulty clearing mouth


Pharyngeal Phase:Airway Protection Problems

Penetration / aspiration

Impaired airway clearance (e.g., silent aspiration)aspiration)

Poor pharyngeal clearance

± aspiration

Prolonged mealtimes



May 24, 2013

6

Pharyngeal Phase: Aspiration Esophageal Phase: Transit & Airway Protection Problems

Incomplete or inefficient

bolus passage

Stricture or web

Disruption of peristalsis

Retrograde aspiration


When Feeding/Swallowing Problem is Suspected…

Clinic or Bedside

Evaluation

What is a Clinic or Bedside Swallowing Evaluation?

Global feeding/swallowing evaluation without

the any instrumental swallowing assessment

Therefore, evaluation without the benefit of

direct visualization of the swallowing

mechanism

Feeding/Swallowing History: Three Key Areas to Probe

Is it safe?

Is it enough ? Is it enough ?

Is it enjoyable vs. stressful?

Is it Safe?

Are there signs of respiratory problems with

feeding?

Coughing, rapid or noisy breathing, a gurglyCoughing, rapid or noisy breathing, a gurgly

voice, or nasal congestion that increase with

meal progression?

Signs may be age/developmentally specific


May 24, 2013

7

Is it Safe?

Patterns

Timing

Types of intake

Frequency

Are there unexplained respiratory problems in

the setting of difficult mealtimes?

Dangerous Periods for Aspiration

Brief period just before and immediately

after birth

Neonatal aspiration syndromes associated

with significant morbidity and mortality

Recurrent aspiration during first two

years of life

Thach, 2001

Potential Impact of Swallowing Problems in Children

Impairments/Consequences Associated

with Aspiration

Respiratory compromisep y p

Acute (e.g., coughing/choking) –

bedside/clinic observations

Chronic pulmonary disease

Total #

Anatomic & Physiologic Changes:Post-Natal Human Lung Growth

n = 36 males, 20 females,

6 weeks - 14 years

Total #of

Alveoli

Is it Adequate?

How long does it take to feed your child?

Longer than 30 minutes (NICU: 20 – 30 mins)

Is your child gaining weight?

NICU has guidelines

After d/c, no weight gain for 2 - 3 months is

comparable to weight loss in adults

Older children, when was the last time your

child’s clothing size changed (not only for

length)?

Inadequate Nutrition, Why?

Areas to Probe


May 24, 2013

8

Inadequate Intake

Food offered but child does not take enough

Dysphagia

Problems sucking

O t d f tiOromotor dysfunction

Behavioral feeding problem/refusal

Developmental / experience

Altered oromotor sensitivity

Pain and conditioned aversionAdapted from: Jaffe AC, 2001

Potential Conditions Associated with Inadequate Intake:

Dysphagia

or

Oromotor

• Prematurity + assoc. complications• Anatomic, structural, or craniofacial

abnormalities Cleft lip/palate, Pierre RobinOromotor

Dysfunction• Neurologic condition / incoordination CNS defects, cerebral palsy

• Neuromuscular disease / weakness SMA, muscular dystrophies

• Chronic lung disease• Stamina Cardiac conditions

Inadequate Nutrition

Food offered and child takes enough, and then…

Emesis

Gastroesophageal refluxGastroesophageal reflux

Malrotation

Increased intracranial pressure

Jaffe AC, 2001

Inadequate Intake: After NICU Discharge

Not offered enough or the “right types” food

Environmental/ social factors

Education / information lacking

( P fit b t d l t l kill(e.g., Poor fit between developmental skills

and foods offered)

Adapted from: Jaffe AC, 2001


Impairments/Consequences Associated

with Nutrition Compromise

Inadequate growth and nutritional intake Inadequate growth and nutritional intake

Adverse development / CNS growth

Potential Impact of Fetal and Infant Malnourishment …

Behavioral and cognitive deficits

Slower language development

Slower fine motor development

Lower IQ’s

Poorer school performance


May 24, 2013

9

Appropriate and Enjoyable,vs. Stressful?

Are meal times stressful for child and/or

caregivers?

Neurologic based skill & safety issues?Neurologic based skill & safety issues?

Behavior and / or sensory issues?


Stressful Mealtimes

Multiple levels/types of disruptions in child /

caregiver interactionscaregiver interactions

What is the cause of the problem?

How can it be fixed?

When will it be fixed?

Questions

Answer: When the dysphagia resolves

enough for the child to “tolerate” the

sequalea associated with the swallowing

dysfunction

Who Should be Referred for a Clinic / Bedside Evaluation?

Who Should be Referred? Children presenting with….

Conditions placing them at high risk for dysphagia with concomitant aspiration

Pediatric Populations at Increased Risk of Dysphagia

Anatomic or structural

anomalies

Congenital

Preterm + low birth

weights

Cardiopulmonaryg

Acquired

Neurologic conditions

Cardiopulmonary

disease

Medically fragile

Misc.


May 24, 2013

10

Who Should be Referred? Children presenting with….

Conditions placing them at high risk for

dysphagia with concomitant aspiration

Children ith s/s s ggesti e of orophar ngeal Children with s/s suggestive of oropharyngeal

dysphagia

Respiratory

Nutrition

Difficult / stressful meals

What Happens During a Feeding/Swallowing Evaluation

History

Physical examination

Observation of mealtime

Clinic or

Bedside

Response

Non-nutritive or nutritive

Evaluation

Goals of a Bedside / Clinical Evaluation …

ID nature and extent of possible dysphagia -

an accurate diagnosis is essential for

appropriate treatment

Establish baseline of mealtime behaviors

Child’s responsiveness to oral stimulation and

feeding

Child’s “ability” to protect the airway

Caregiver-child interactions

Goals of a Bedside / Clinical Evaluation …

ID the safest & most efficient liquid and food

consistencies for oral feeding, to whatever

extent possible

Introduce therapeutic modifications

ID other necessary evaluations

Goals of a Clinical Evaluation …

Formulate hypothesis re: practicality of oral

feeding and / or recommend alternative

methods for nutritional managementmethods for nutritional management

ID factors that may modify a child’s response

or ability to tolerate the consequences of any

swallowing problem

Host Characteristics

•Diagnostic condition(s)

•Co-morbidities

Age / Timing of Exposure

• Growth and development

• Susceptibility to injury

Factors that Determine / Modify the Impact of the Swallowing Dysfunction

Environmental / Social Factors

• Feeding techniques

• Health care access and management

• Exposure to environmental stressors

•Severity of dysphagia

Adapted: Lefton-Greif + McGrath-Morrow 2007


May 24, 2013

11

Goals of a Clinical Evaluation …

Determine if an instrumental evaluation is

needed

Phases of swallowing – which examination

Ability AND willingness of child to cooperate

…and if needed, how to increase likelihood of

cooperation and reduce risks associated with

exam


• Diagnostic condition(s)

• Co-morbidities

• Severity of dysphagia

Factors that Determine / Modify the Impact of Dysfunctional Swallowing

Severity of dysphagia




anomalies

Congenital

Preterm + low birth

weights

Cardiopulmonaryg

Acquired


Cardiopulmonary

disease

Medically fragile

Misc.

Factors Determining Impact of Anatomic / Structural Conditions on Swallowing

Location, location, location

Extent of impairment

Prognosis, treatment

Presence of other anomalies or co-morbidities

e.g., isolated palatal cleft vs. cleft associated with a craniofacial syndrome

Brown, Lefton-Greif, Ishman, 2010

Four Anatomic /Structural Sites of Associated with Dysphagia

A. Nose and nasopharynx

B. Oral cavity and oral

pharynx

C. Hypopharynx and larynx

D. Trachea and esophagus

Brown, Lefton-Greif, & Ishman, 2010



anomalies

Congenital

Preterm + low birth

weights

Cardiopulmonaryg

Acquired


Cardiopulmonary

disease

Medically fragile

Misc.


May 24, 2013

12

Factors Determining Impact of Neurologic Conditions on Swallowing

Location, location, location

Extent of impairment

Prognosisg

Presence of other anomalies or co-

morbidities

e.g., seizures, CLD



anomalies

Congenital

Preterm + low birth

weights

Cardiopulmonaryg

Acquired


Cardiopulmonary

disease

Medically fragile

Misc.

Potential Diagnostic Influences

Acute Chronic

Static Progressive

Anatomic

N l i

Impact of Potential Diagnostic Factors: Dysphagic Characteristics

ifest

atio

n Prognosis

Neurologic

Medical Status

Developmental + Oral-Motor Status

External to Child

Man

i

Adapted from Rogers, 1996



• Co-morbidities












What Happens During a Feeding/Swallowing Evaluation

History


Observation of mealtime

Clinic or

Bedside

Response

Non-nutritive or nutritive

Instrumental assessment?

Evaluation

Bedside/Clinic Evaluation: To…

Determine need for, timing of, and type of

instrumental evaluation

Phases of swallowing

Ability AND willingness of child to

cooperate


May 24, 2013

13

Instrumental Evaluation?????

When? There’s a need for…

Direct visualization of structures not seen on

clinic evaluation for diagnostic or management

informationinformation

Which one? Determined on basis of….

Host characteristics - phases of swallowing?

Ability of child to cooperate?

When? Timing for when info would be most

helpful

Routes of Aspiration

Direct from swallowing

Indirect from regurgitation

Direct from swallowing

Indirect from regurgitation

Direct + indirect

Communication between Communication between

airway & GI tract (e.g., airway & GI tract (e.g.,

TEF)TEF)

Direct + indirect

Communication between Communication between

airway & GI tract (e.g., airway & GI tract (e.g.,

TEF)TEF)

Instrumental Assessment Procedures

Upper Gastrointestinal Examination (UGI)

Flexible Endoscopic Evaluation of Swallowing

(FEES)(FEES)

Videofluoroscopic Swallow Study (VFSS)

Potential Candidates for FEES Clinic: Children who …

Are NPO or taking too little to participate in

VFSS

Have structural or suspected structural p

abnormalities

Have abnormal VFSS + question re: airway /

respiratory interaction

Need repeated exams

Langmore, 2001

Aspiration of Saliva on FEES


May 24, 2013

14

Instrumental Assessment Procedures

Upper Gastrointestinal Examination (UGI)

Flexible Endoscopic Evaluation of Swallowing

(FEES)(FEES)

Videofluoroscopic Swallow Study (VFSS)

Modified Barium Swallow Study (MBS) orVideofluoroscopic Swallow Study

(VFSS)

The MBS is designed to assess not only whether the patient is aspirating, but also the reason for the aspiration, so appropriate treatment can be initiated

Logemann, 1983

VFSS Aims: 2013

Define physiologic swallow function

Facilitate diagnostic decision-making

“Stress” the system to delineate specific Stress the system to delineate specific

impairment(s)

Identify intervention strategies to aid in

making management decisions/plan

VFSS: Known Limitations

Involves radiation

Not a true simulation of a real meal

Not the evaluation for bolus formation

Not a chewing evaluation

Brief view of frequent + repetitive task

Not an evaluation of esophageal function

(only upper esophagus)

Follow Same Steps for AllVFSS’s

Decision to carry out exam

Planning

Carrying it out

Reading/Reviewing Findings

Interpreting Findings

Making management decisions relative to the

“whole child”

Documenting Arvedson + Lefton-Greif, 1998

VFSS Procedure

Decision: yes / no Planning

Carrying it out

Reading/Reviewing

Interpreting Findings

Management decisions re total child

Documenting


May 24, 2013

15

Decisions for VFSS are Based Upon….

Suspicion of oropharyngeal dysphagia

AND

Diagnostic or management needs which would be clarified by VFSS findingsbe clarified by VFSS findings

AND

Child who is ready, willing, and able to participate

AND

Findings will make a differenceAdapted from Arvedson + Lefton-Greif, 1998

Criteria for VFSS Examination

Risk for aspiration by history or observation

Prior aspiration pneumonia

Suspicion of pharyngeal/laryngeal problem on Suspicion of pharyngeal/laryngeal problem on

basis of underlying condition/ presentations

Need to define oral, pharyngeal, & upper

esophageal structures/functions for

management

Ready, Willing & Able to Participate

Stable medical and health status

Cardio-pulmonary stability

Nutritional stability

Alert, calm state

Ability to tolerate bolus feeds

Non-nutritive suck (NNS)NNS is pre-requisite, NOT guarantee

of successful oral feeding

Findings Make a Difference

Benefits > Risks associated with radiation

Determined by defining which questions can

be answered by completing a VFSSbe answered by completing a VFSS

Don’t Order Tests that

.DAM Principle

Don’t Affect Management

(Huda, 2012)

Principles for Repeat VFSS

Same as for initial VFSS

Information needed for

Definition of etiology or diagnosis

Guide for management decisions

NOT some arbitrary time interval

Child should be at baseline (e.g., not ill)


May 24, 2013

16

VFSS Procedure

Decisions: yes / no

PlanningC Carrying it out

Reading

Interpreting

DocumentingArvedson + Lefton-Greif, 1998

As Low as Reasonably

Achievable

ALARA:

Practice mandate adhering to the principle

of keeping radiation dose to patients and

personnel as low as possible.

Tolbert D, et al, American College of Radiology 1996

Radiation Concerns in Children1

Young children are particularly sensitive to

the effects of ionizing radiation

Inherently greater radiosensitivity than Inherently greater radiosensitivity than

adults since they have a higher proportion

of dividing cells

More remaining years of life for

development of radiation-induced cancers

1Brenner and Hall, 2007

VFSS Procedure: Planning

Contrast preparation (mixed with

food/liquid)

Utensil selection

Order of liquid & food presentations

Other considerations

Suction

Monitors

Preparation of Tube Feeder: NPO

Child should demonstrate some level of oral

intake, at least for therapeutic “taste trials”

NG tube - remove in most instances

Amount per bolus: 2 to 3 cc Amount per bolus: 2 to 3 cc

(1 cc ≈ saliva swallow)

Less than 10 -15 cc., need to question validity

& reliability

Medication schedules maintained or in some

cases, adjusted as needed

VFSS Procedure

Decisions: yes / no

Planning

Carrying it outCarrying it out Reading

Interpreting



May 24, 2013

17

General:Radiation Safety Considerations

Focus on addressing specific questions

Short AND infrequent exams - limit “fluoro” time

Careful collimation– try to avoid orbits of eyes

Appropriate shielding – all in radiology suite

Engage cooperation, to whatever extent possible

Duration of Radiation Exposure During VFSS

Source of Information

PopulationMean Range

90 childrenWeir, et al.1* x = 1.57 yrs;

.03 - 15.83 yrs2.47 ± 0.81 0.08 to 4.60

Unpublished225 bottle-fed

childrenx = 0.54 yrs

1.21 0.29 - 2.15

1 Pediatric Radiology 2007;37:283-290 * pulsed 15f /sec.

2 Unpublished 2009

Child-Specific:Radiation Safety Considerations

Remember that incomplete or poorevaluation is a waste of x-ray exposure

Use continuous (30 fps) not pulse fl (<30 f )1fluoroscopy (<30 fps)1

Failure to detect supraglottic penetration & aspiration, especially on liquids has been documented in children

Use magnification, if needed

1 Cohen, 2008

VFSS Procedure

Child-Specific:Radiation Safety Considerations

Know when to terminate VFSS

Needed information obtained

Not likely to get informationNot likely to get information

VFSS Procedure

Decisions: yes / no

Planning

Carrying it outCa y g t out

Reading = what you see Interpreting



May 24, 2013

18

Penetration (Supraglottic)

Entry of secretions or

ingesta into the larynx

ABOVE th t lABOVE the true vocal

folds.Penetration

Laryngeal Penetration: UGI (6 wk male)

Delzell et al, Pediatr Radiolo 1999, 29:763

Aspiration

Penetration

AspirationAspiration

What is the relationship

between penetration and

aspiration?

Landmark for Deep Penetration

Deep Penetration

Friedman & Frazier: Dysphagia 2000, 15:153

Deep Penetration

What’s known about the pen-asp relationship in children?

Relationship bet. depth of penetration &

aspiration1

85% children (n = 125, 7 days -19 yrs) w/ deep

laryngeal pen → asp

Temporal relationship2

Asp. occurs later than laryngeal pen. on VFSS

1st pen = 50.77 sec

1st asp = 65.41sec.1Friedman & Frazier, 20002 Newman et al, 2001


May 24, 2013

19

MYTH

Swallowing is “ safe” because infant had penetration without any obvious aspiration

Consider:

Frame rate

Whether a “representative” feeding was imaged

Child’s ability to tolerate aspiration

Levels of Airway Protection

1. Swallow

Cough

Mucociliary action

Immune system

Swallow = Primary means of airway protection

Silent Aspiration

Aspiration without any

external behavioral

signs such as

coughing or choking.

If aspiration is “silent” by is it a problem?

Primary airway response to aspiration is

absent – lack of airway clearance

Caregivers keep feeding children because

primary “signal” of feeding difficulty is absent

How common is silent aspiration?

Population Age Range(Years)

% pts. with aspiration

Young peds 0 - 5 89 - 100

Older peds + adults

5 - 55 71 - 94

Varied Median 65 51 - 58

Very old > 90 73 - 88

“Normal” Aspiration

Health adults - asleep and patients with

depressed levels consciousness1

Volume: 0.1- 0.2 mL2

1 Huxley et al, 1978, 2Gleeson et al,1997


May 24, 2013

20

Myth: Aspiration Can Be Ruled Out

ASK:

Why? – Why is aspiration/swallowing dysfunction suspected?

Wh ? Wh t t f th t lik lWhere? What parts of the system are likely to be involved?

What? What action will be taken if aspiration is present

How much? Frequency? Amount?

Assumptions about Aspiration: Oropharyngeal Dysphagia vs. Normal

Occurs more frequently - chronicity

Occurs in greater amounts

Occurs with a wider variety of “materials”

Liquids + foods vs. saliva

GER?

Aspiration on VFSS Findings

PassPass FailFail

Image of aspiration does not tell:

• Reasons for aspiration

• Presence of related swallowing impairments that

• Increase the likelihood of other aspiration events –regardless of capturing or not capturing an aspiration event

• Interfere with meeting nutrition goals

• Whether or what a person can eat or drink safely

• Ability of person to tolerate aspiration

Image of aspiration does not tell:

• The meaning or significance of aspiration – on future exams or from other institutions

• “If” and “when” a VFSS should be repeated

Current State of Art

• No objective measures for biomarkers of status or change

• No consistency in how examinations are conducted or reported – hinders interpretation and probably contributes to increased x-ray exposure for many children

Standardization of VideofluoroscopicSwallow Studies in Bottle-Fed Children

Goals of this project are to develop and test

a standardized measurement tool and

scoring schema for the quantification of

swallowing impairment in bottle-fed

children


May 24, 2013

21

Standardization of Interpretation of VFSS Images: Why?

Enable objective characterization and

tracking of the natural history of swallowing

impairments

Provide outcome measures for interventions

in dysphagia

Serve as biomarker for clinical trials for

children with diagnostic conditions associated

with dysphagia

Standardization of Interpretation of VFSS Images is Essential for….

Decreasing variability in exchange of

patient information

Standardizing VFSS practices

Potentially reducing unnecessary

exposure to radiation

0

1

2

3

Aim1: Develop Peds Tool

Empirically reduce components for the tool into a reliable, parsimonious, and clinically relevant set based on measures of rater

li bilit d f t l i f ll ireliability and factor analysis following examination and scoring of 300 VFSS exams by trained SLPs at two clinical sites

Synchronized VFSS + 3-D Animation


May 24, 2013

22

iVFSS Tool: Number of Sucks to Form Bolus for Swallowing

Old

0 = Sucking 1 - 3 times

1 = Sucking 4 - 6 times

2 = Sucking 6+ times

New

1 = Sucking 1 time

2 = Sucking 2 times

3 = Sucking 3 times

3 = Sucking without liquid flow from nipple

4 = Sucking 4 times

5 = Sucking 5 times

6 = Sucking 6 or more times

7 = Sucking without liquid flow from nipple

Differences for domain component scores of swallowing impairment between thin and thick liquid consistencies (n = 25)

Domain Selected Components

ConsistencyRelated

Differences in Impairment s

Lower impairment scores*

(No. of pts.)

Description (No. of pts.) Thin Thick

OralNo. of sucks to form bolus 2 2 0Oral residue after each suck/swallow burst

4 2 2

O lOral-Pharyngeal

TransitLocation of bolus initiation 5 0 5

PharyngealPalatal-Pharyngeal Approximation/palatal integrity

2 0 2

Tongue base retraction 4 2 2

Bolus/Airway Relationships

Timing of airway entry 6 0 6Penetration-aspiration 12 1 11Amount of aspiration 6 0 6Frequency of aspiration 6 0 6

* Lower score = better function

Re: The Airway, the Real Question:

How much aspiration istoo much?

Follow Same Steps for AllVFSS’s

Decision to carry out exam – yes or no

Planning

Carrying it out

Reading images

Interpreting findings

Making management decisions

re: “whole child”

Arvedson + Lefton-Greif, 1998



• Co-morbidities












VFSS: Interpretation & Recommendations for Each Child

Underlying diagnostic conditions (history)

Clinical examination


Clinical findings – observation of feeding

Phase of swallowing (structure & function)

Physiologic reasons for findings


May 24, 2013

23

VFSS: Interpretation & Recommendations for Each Child

Summary of swallowing function

Risk of aspiration

Risk of nutrition / hydration compromiseRisk of nutrition / hydration compromise

Ability to tolerate impact of dysphagia

(prognosis statement needed)

Short term

Long term

Recommendations After VFSS

Changes in route of nutrition/hydration

Nutrition guidelines

Position & posture changes

Alterations of food textures, temperatures

Utensil changes

Changes in feeding schedule & pacing

Oral sensorimotor program with food

Nonnutritive oral sensorimotor program

VFSS Procedure

Decisions: yes / no

Planning

Carrying it out

Reading

Interpreting

Documenting

Arvedson + Lefton-Greif, 1998

Documenting VFSS Findings

Findings & interpretations are discussed with

other team members to develop a plan that

addresses child’s global & specific oraladdresses child s global & specific oral

feeding deficits as well as caregiver goals

Case Presentations

Standardization of Videofluoroscopic Swallow Studies in Bottle-Fed Children, Thanks to….

Johns HopkinsMarilee C. Allen, M.D.Karla AuYeung, MDKathryn A. Carson, ScMJ. Michael Collaco, MD

MUSC

Bonnie Martin-Harris, PhD.Diane Andrews, MSJulie Blair, MSLucinda Halstead, MDJ. Michael Collaco, MD

Elizabeth Cristafalo, MDRenee Flax-Goldenberg, MDStacey L. Ishman, MDSharon McGrath-Morrow, MDJenny Wright, B.S.

uc da a s ead,Jeanne G. Hill, MDThomas C. Hulsey, MSPH, ScDMichelle M. Macias, MDJohn Sandidge, MADavid R. White, MD


May 24, 2013

24

The Standardization of Videofluoroscopic Swallow Studies in Bottle-Fed Children is funded by Grant 5R01DC011290-02 from the National Institute on Deafness and Other Communication Disorders.

Documents

Disclosures and Support