DEVELOPMENTAL DISABILITIES

RESEARCH REVIEWS 14: 118 127 (2008)

ASSESSMENT OF PEDIATRIC DYSPHAGIA AND

FEEDING DISORDERS: CLINICAL AND
INSTRUMENTAL APPROACHES
Joan C. Arvedson*
Childrens Hospital of Wisconsin-Milwaukee, Medical College of Wisconsin-Milwaukee, Milwaukee, Wisconsin

Assessment of infants and children with dysphagia (swallowing INTERDISCIPLINARY FEEDING/SWALLOWING

problems) and feeding disorders involves significantly more considerations TEAM APPROACH
than a clinical observation of a feeding. In addition to the status of feed-
ing in the child, considerations include health status, broad environment,
An interdisciplinary approach allows for coordinated
parentchild interactions, and parental concerns. Interdisciplinary team consultation with focus on the whole child (and caregivers)
approaches allow for coordinated global assessment and management who may have multiple interrelated health and developmental
decisions. Underlying etiologies or diagnoses must be delineated to every issues. Individuals involved in the problem solving have
extent possible because treatment will vary according to history and cur- opportunities to provide patient care and case coordination
rent status in light of all factors that are often interrelated in complex
ways. A holistic approach to evaluation is stressed with a primary goal that is difficult to obtain when professionals function inde-
for every child to receive adequate nutrition and hydration without pendently. Of course, not all disciplines are needed for all chil-
health complications and with no stress to child or to caregiver. Instru- dren, and as children change over time, primary team players
mental swallow examinations that aid in defining physiological swallow- may change as well. These kinds of teams demonstrate several
ing status are needed for some children. Successful oral feeding must be
measured in quality of meal time experiences with best possible oral
important characteristics that include (1) a shared group phi-
sensorimotor skills and safe swallowing while not jeopardizing a childs losophy related to diagnostic approaches and management pro-
functional health status or the parentchild relationship. ' 2008 Wiley-Liss, Inc. tocols, (2) team leadership with organization for evaluation
Dev Disabil Res Rev 2008;14:118127. and sharing information, (3) collegial interaction among var-
ied specialists, and (4) time commitment for the labor inten-
Key Words: infant; child; swallowing; feeding; assessment; evaluation sive nature of this kind of work [Brodsky and Arvedson,
2002,a].
Interdisciplinary teams may be in medical settings or in
school-based settings [ASHA, 2007]. School-based team mem-
bers work closely with medical team colleagues so that find-
ings from all evaluations or assessments can be incorporated
into appropriate coordinated recommendations. Physician
INTRODUCTION input is of utmost importance in the development of manage-

C
omprehensive assessment of infants and children with ment plans and for monitoring the health status of children.
dysphagia and feeding disorders involves considerations Treatment options vary by history, physical examination, find-
of the broad environment, parentchild interactions, ings during clinical feeding evaluations, and instrumental swal-
parental concerns, and health status of the child. All of those lowing evaluations. To set the stage for evaluating infants and
factors must be taken into account by professionals in order to young children with feeding and swallowing disorders, a few
make optimal management decisions for every child to assure operational definitions are in order.
that nutrition and hydration needs are met for adequate
growth. It is not enough to determine the levels of oral senso- Operational Definitions
rimotor skills and safety of swallowing in isolation.
Professionals involved in assessment and management of ! Feeding disorders: Problems in a broad range of eating
infants and children with swallowing and feeding problems
activities that may or may not be accompanied by a
must have adequate knowledge and skills about associated
health conditions and specific feeding/swallowing issues.
Improper diagnoses and management decisions increase risk
*Correspondence to: Joan C. Arvedson, Childrens Hospital of Wisconsin-
for poor nutrition and health outcomes. In contrast, thorough Milwaukee, Medical College of Wisconsin-Milwaukee, Milwaukee, WI.
problem solving and interdisciplinary management can E-mail: [email protected]
enhance the lives of children and their caregivers. Children Received 23 May 2008; Accepted 23 May 2008
Published online in Wiley InterScience (www.interscience.wiley.com).
and families are better served by an interdisciplinary team than DOI: 10.1002/ddrr.17
by a single discipline in isolation [Arvedson et al., 2002].
' 2008 Wiley -Liss, Inc.
 difficulty with swallowing food muscular conditions, orthopedic for 12.7% of 4.14 million births in the
and liquid. Feeding disorders conditions (body function United States in 20042005, which rep-
may be characterized by food level). resents an increase of 20% since 1990
refusal, disruptive mealtime [Hamilton et al., 2007]. The survival
With this approach, the first considera-
behavior, rigid food prefer- rate of preterm infants delivered at
tion in a clinical feeding evaluation is
ences, less than optimal growth, <1,000 g (extremely low birth weight)
the childs level of participation in meal-
and failure to master self-feed- increased from 65 to 90% from 1987 to
time environments.
ing skills expected for develop- 2000. The survival rate of micropree-
Other dimensions to consider
mental levels. mies (<600 g) increased from 30 to
! Swallowing disorders (dysphagia):
include functioning and disability (body
55% in that same time period. Inci-
functions, body structures, and activities
Problems in one or more dence of cerebral palsy (CP) is higher
and participation), contextual factors
phases of the swallow that in infants born between 24 and 26
(environmentalexternal to an individ-
include (1) oral phase: (a) bolus weeks (20%) than those delivered at 32
uals control), and personal factors
formation (from time food or weeks gestation (4%) [Ancel et al.,
(unique to each person, such as past ex-
liquid enters the mouth until it 2006].
perience or background) [WHO, 2001;
begins to move over the tongue Children with a wide range of
Threats, 2006]. Details on the ICF can
in the oral cavity), and (b) oral disabilities who are seen by feeding and
be found at http://www.who.int/classi-
(transit of bolus posteriorly over swallowing specialists frequently are
fications/icf/en/. Clinicians are urged
the tongue ending with initia- classified as failure to thrive (slow
to familiarize themselves with these
tion (trigger) of the pharyngeal weight gain). Children who are slow to
concepts that are pertinent to evaluating
swallow); (2) initiation of the gain weight are at particular risk for
the status of each individual with fol-
swallow (under voluntary neu- both feeding problems (60%) and devel-
low-up recommendations based on par-
ral control); (3) pharyngeal opmental delays (55%) [Raynor and
ticipation as the initial and highest prior-
phase (involuntary neural con- Rudolf, 1996; Wright and Birks, 2000].
ity with oral skills and feeding.
trol) from the initiation of the Children with CP are at high risk for
swallow to end when the bolus feeding and swallowing problems. Prev-
moves through the cricopha- INCIDENCE AND PREVALENCE alence of feeding problems is less in
ryngeal juncture into the esoph- OF FEEDING/SWALLOWING children with hemiplegia and diplegia
agus); and (4) esophageal phase DISORDERS (2530%) compared with children who
(begins with opening of the Feeding-related concerns are have spastic quadriplegia or extrapyra-
upper esophageal sphincter among the most common issues in pre- midal CP (5075%) [Stallings et al.,
through the lower esophageal school children who are brought to pri- 1993a,b; Dahl et al., 1996; Reilly et al.,
sphincter). Particular concern mary health care professionals by 1996]. Ongoing growth analysis and de-
relates to timing and coordina- parents. Given the range of diagnostic velopmental assessments are important
tion deficits that may result in labels applied to these disorders by var- components of the process in identifica-
aspiration. ied specialists, it is not surprising that tion of infants at high risk for feeding
! Aspiration: Passage of any mate- incidence figures vary considerably and swallowing disorders.
rial (e.g., food, liquid, saliva) [Casey, 1999; Chatoor, 2002]. Some
below the level of the true children with feeding disorders have no
vocal folds into the trachea. swallowing related concerns. The FEEDING AND FEEDING
! Silent aspiration: No cough, broader context of family and society DISORDERS IN THE CONTEXT
choke, or other signs of prob- should be addressed as a preliminary OF FAMILY AND SOCIETY:
lems when food or liquid enters step in the assessment prior to focusing CASE FOR A RELATIONAL
the trachea. on childrens skills and safety for oral DISORDER BETWEEN PARENT
feeding. AND CHILD
Incidence of feeding disorders is A child with signs of a feeding
CLINICAL EVALUATION BASED
estimated to be 2545% of typically disorder more prominent than a swal-
ON WORLD HEALTH
developing children and up to 80% of lowing disorder will be served better
ORGANIZATION (WHO)
children with developmental disabilities with the family in the context of a
CONCEPTS
[Linscheid et al., 2003]. The incidence multiaxial diagnosis rather than an initial
A comprehensive evaluation includes
of dysphagia (swallowing disorders) is focus on the childs status and needs
information related to participation (so-
unknown, although it seems clear that [American Psychiatric Association
ciety level), activities (person level), and
the incidence of swallowing dysfunction (APA), 2000]. This kind of diagnosis
impairment (body function level)
is increasing [Burklow et al., 1998; includes the child (with medical, devel-
[WHO, 1997; Arvedson et al., 2002]:
Hawdon et al., 2000; Marlow, 2001; opmental, and behavioral characteris-
! social and physical mealtime Newman et al., 2001; Ancel et al., tics), the parent, the parentchild rela-
environments where the child 2006]. Improved survival rates of chil- tionship, and the social and nutritional
participates, e.g., home, school, dren with history of prematurity (birth context of feeding [Davies et al., 2006].
restaurants (society level); at <37 weeks gestation), low birth Davies et al. [2006] proposed diagnostic
! childs activity limitations dur- weight, and complex medical condi- criteria for a Feeding Disorder
ing mealtime, e.g., self-feeding tions provide at least a partial explana- Between Parent and Child that span a
abilities, adaptive equipment tion for the increasing incidence of range of interactions, attitudes, and
needs (person level); swallowing disorders [Martin et al., expectations that are not meant to be
! underlying deficits, e.g., motor 2005; Hamilton et al., 2007]. Preterm mutually exclusive or hierarchical. These
skills, respiratory status, neuro- births (<37 weeks gestation) accounted criteria include:
Dev Disabil Res Rev ! ASSESSMENT OF PEDIATRIC DYSPHAGIA ! ARVEDSON 119
 ! acknowledgement of contribu- intended to be inclusive. The answers because it is so stressful. Forced
tions from both parent and to these questions do not define the feeding can result when parents
child; problem, but they can help identify get stressed with children who
! reflection of interactive nature infants and children in need of a com- are difficult to feed. Forced
of the feeding relationship; prehensive evaluation and they may also feeding then leads to additional
! management of diversity of provide useful information in the his- complications that may include
feeding disorders and avoidance tory part of an assessment [e.g., Arved- inadequate weight gain,
of subtyping with multiple eat- son and Rogers, 1993, 1997]: increased food refusals, and in
ing eccentricities by setting up severe cases, global behavior
a single diagnosis and then dif- ! How long does it take to feed maladaptations.
ferentiating through a multiaxial the child? If parents report ! Has the child slowed or stopped
diagnosis; more than about 2530 min on gaining weight in the previous
! explicit use of multiaxial diag- a regular basis, there might be a 23 months? Particularly in the
nosis to reflect the multideter- serious problem. Prolonged first 2 years of life, steady and
mined nature of feeding disor- feeding duration for infants and appropriate weight gain is
ders; children of all ages is a primary expected and critical for brain
! distinguishing between a feed- marker of feeding problems and development along with overall
ing problem possibly amenable points to a need for further growth. Lack of weight gain in
to education and early problem investigation. a young child is like a weight
solving and the established or ! Is the child totally dependent loss in older children or adults.
entrenched feeding disorder on others for feeding? Does ! Are there any signs of respira-
requiring systematic diagnosis the child do some assisted tory distress? For example, a
and treatment. feeding or some independent child may become increasingly
feeding? Children who are not congested as a meal pro-
This proposal specifies that a diagnosis
feeding independently, but gresses. There may be a gurgly
of a feeding disorder between parent
should be on the basis of age voice quality. Rapid or catch
and child must show established or
and overall developmental up (panting) breathing may be
entrenched problems that emerged prior
skills, typically present with seen in an infant taking a nipple
to the childs developmental age of 6
significant neuromotor disabil- feeding. Respiratory issues can
years. Problems must have lasted for at
ities (e.g., CP). These children be related to aspiration with
least 1 month. No exclusionary criteria
frequently show a high proba- oral feedings in some instances.
are involved. Deficits that are acknowl-
bility for silent aspiration with ! Does the child vomit regularly?
edged as having an impact on the feed-
oral feeding [Rogers et al., When? Under what circum-
ing include medical, psychosocial, de-
1994]. Although there are stances does the vomiting
velopmental (e.g., gross and fine motor
exceptions, children who occur? Can parents estimate the
skills, oral sensorimotor skills, cognitive
maintain upright position with volume per event? Vomiting
and language levels of function), eco-
good head control and hand- tends to be a negative experi-
nomic, and other systemic problems
to-mouth skills for self-feeding ence for most children. How-
[Davies et al., 2006]. Attention to mul-
usually have better coordina- ever, some children with neu-
tiple influences is essential in order for
tion for safe swallowing. rological impairment and gas-
successful diagnosis and treatment of ! Does the child refuse food? troesophageal reflux (GER)
children with feeding disorders. Aware-
Food refusals can occur for a may not vomit at all [Wilson
ness of these children and their families
variety of reasons that include, et al., 2006].
may arise from various sources to
but are not limited to, physio- ! Does the child get irritable or
include primary care physicians, educa-
logical based problems [e.g., become lethargic during meal-
tors, and other medical and educational
airway or gastrointestinal (GI) times? Irritability may signal GI
professionals. Referrals are then made
factors], oral sensorimotor defi- discomfort, airway problems, or
to specialists with the appropriate
cits, or disordered parentchild behavioral issues. Lethargy or
knowledge and experience to delineate
interactions. Refusals occur in sleepiness may result from fa-
the complex issues and make manage-
multiple ways. Some children tigue, sedating medications
ment plans with parents and other pri-
clamp their mouths shut and (e.g., anticonvulsants, muscle
mary caregivers as integral team mem-
turn the head away when a relaxants), or recurrent seizures.
bers.
spoon approaches their mouth;
others hit at the spoon or the
WHO NEEDS A FEEDING/ feeders arm; still others may ASSESSMENT PROCESS:
SWALLOWING EVALUATION? spit food out; and in some INFANTS AND CHILDREN
Physicians, nurses, and other pro- instances, children may vomit WITH FEEDING AND
fessionals who do not carry out com- purposefully. SWALLOWING DISORDERS
prehensive clinical feeding and swallow- ! Are mealtimes stressful? Meal- Assessment of infants and young chil-
ing assessments may find the following times may be stressful for a va- dren with signs and symptoms of feed-
questions helpful to determine whether riety of reasons. Regardless of ing and/or swallowing disorders is likely
a child has signs of a feeding or swal- the reasons, follow-up investi- to encompass multiple dimensions that
lowing problem that should be followed gations are needed. Parents may include, but may not be limited to: (a)
up by a specialist(s). This list of ques- say, I dread every meal. We review of family, medical, developmen-
tions provides some examples and is not take turns feeding our child tal, and feeding history; (b) physical ex-
120 Dev Disabil Res Rev ! ASSESSMENT OF PEDIATRIC DYSPHAGIA ! ARVEDSON
 provide systematic observations of infant
Table 1. Assessments of Infant Oral Sensorimotor feeding (e.g., Table 1). Multiple scales
Function for Feeding and check lists, although not standar-
dized, enable clinicians to systematize
Assessment Description observations of children [e.g., Arvedson
Bottle/breast feeding: Neonatal Oral Motor Checklists of behaviors in categories of normal, et al., 2002, pp 324329; Kenny et al.,
Assessment Scale (NOMAS) [Palmer et al., disorganized, and dysfunctional tongue and jaw 1989; Jelm, 1990; Coster et al., 1998;
1993] movement Koontz-Lowman and Lane, 1999;
Systematic Assessment of the Infant at the Observations related to alignment, areolar grasp, Reilly et al., 2000]. Instrumental swal-
Breast (SAIB) [Association of Womens areolar compression, and audible swallowing
Health, Obstetric, and Neonatal Nurses,
low assessments may be recommended
1990] as the next step in a comprehensive
Preterm Infant Breast-feeding Behavior Diary by mother: rooting, amount of breast in evaluation of feeding and swallowing.
Scale (PIBBS) [Nyqvist et al., 1996] mouth, latching, sucking, sucking bursts,
swallowing, state, letdown, and time Physical Examination (Prefeeding
Breastfeeding evaluation [Tobin, 1996]for Purpose: identify when a mother would benefit
term infant from lactation support. List of expectations for Assessment)
feedings Regardless of age and feeding
Bottle feeding: Feeding flow sheet Observations for state, respiratory rate, heart rate, expectations, the observer notes at
[Vandenberg, 1990] nipple, form of nutrition, position, coordination, rest posture and position, with the
support quantity, and duration changes over time
Infant feeding evaluation [Swigert, 1998] Not standardized evaluation: means of documenting
realization that underlying tone and
a variety of observations, including infant strength are particularly important fac-
responses to attempted interventions. Devised for tors in consideration of oral feeding
birth to 4 months, components for preterm or ill safety. Prefeeding observations are made
infant not specified to note deviations from normal expect-
Reproduced with permission from Rogers and Arvedson, MRDD Res Rev, 2005, 11, 79, ! Wiley. ations and include [Arvedson and Rog-
ers, 1993]:
amination (prefeeding assessment); (c) ! disorders affecting hunger/ ! child and parent interactions;
clinical feeding and swallowing evalua- appetite, food-seeking behav- ! posture, position, and move-
tion; (d) other considerations (e.g., so- iors, and ingestion; ment patterns (head, neck and
matic growth patterns, neurodevelop- ! anatomic and physiological trunk focus);
mental status, orofacial structures, car- abnormalities of the orophar- ! respiratory patterns (e.g.,
diopulmonary, and other GI function). ynx, larynx, and trachea (con- breathing rate, effort, nose/
For children with concerns related to genital and/or acquired); mouth);
safety of swallow function and need to ! anatomic and physiological ! overall responsiveness, tempera-
define the pharyngeal phase of swallow- abnormalities of esophagus; ment, affect;
ing, a recommendation will be made ! respiratory tract disorders that ! alertness and ability to sustain
for an instrumental swallowing evalua- affect suckingswallowing attention to tasks;
tion (to be discussed later in this arti- breathing coordination; ! response to sensory stimulation
cle). In some cases, other diagnostic ! central nervous system and to include tactile, visual, audi-
tests may be ordered by physicians neuromuscular disorders; tory, smell;
(beyond the scope of this article). ! cardiovascular (congenital heart ! self-regulation and self-calming
disease, congestive heart fail- abilities.
Review of Family, Medical, ure);
Developmental, and Feeding ! inflammatory disorders and mu- Oral Structure and Function
History cosal infections that may cause Assessment
The clinical evaluation of infants dysphagia; Thorough examination of oral struc-
and children begins with a review of ! miscellaneous disorders that tures and function must be made before
family, medical, developmental, and may affect feeding and swallow- introducing liquid to an infant: observa-
feeding history as the first step in ing, e.g., Prader-Willi syn- tions are made regarding symmetry or
addressing feeding and swallowing prob- drome, hypothyroidism, some asymmetry of facial features, lip and jaw
lems. History is typically obtained from craniofacial anomalies, xerosto- position, palate shape and height,
medical charts, medical and educational mia, allergies, and lipid and lip- tongue position in the oral cavity and
professionals, parents, and other caregiv- oprotein metabolism disorders. movement patterns, oral reflexes and
ers. Prenatal, birth, and neonatal history nonnutritive sucking (NNS) in young
can yield possible clues to etiologies of infants, and laryngeal function as noted
feeding and swallowing problems Clinical Feeding and Swallowing by voice quality. For example, breathy
[Arvedson et al., 2002, pp 324330]. Assessment voice makes one suspicious of possible
Knowledgeable professionals consider The oral sensorimotor and feeding unilateral vocal fold paralysis/paresis.
various categories for diagnostic condi- assessment typically consists of a physical Weak or uncoordinated NNS would
tions that may underlie feeding and examination (prefeeding assessment), indicate lack of readiness for nipple
swallowing issues. Disorders and abnor- oral structure and function examination, feeding sufficient to meet nutrition
malities of swallowing and feeding are and feeding observation. Assessments needs. Drooling after the age of 5 years
categorized in various ways [e.g., Rog- for breast-feeding and bottle feeding of suggests a need for a comprehensive
ers et al., 2002; Link and Rudolph, neonates and young infants have not work-up [Brodsky and Arvedson,
2003]: been standardized, but a few assessments 2002,c]. Detailed descriptions of facili-
Dev Disabil Res Rev ! ASSESSMENT OF PEDIATRIC DYSPHAGIA ! ARVEDSON 121
 nent to readiness to accept new textures
Table 2. Examples of Observations That May Relate to Cranial [e.g., Illingworth and Lister, 1964].
Nerve (CN) Function During Feeding Assessment of Transitional Children are likely to be ready for
Feeders or Older Children chewable food even when they have
not mastered all gradations of pureed
CN Stimulus Typical Response Deficit Response textures [Gisel, 1991; Green et al.,
V Food on tongue Mastication Bolus not formed
1997]. Expectations for chewing skills
VII Sucking Lip pursing to Lip seal not attained are made in relation to normal develop-
latch on nipple ment, which reemphasizes the need for
Food on lower lip Lip closure Limited or no lip movement all feeding and swallowing specialists to
Smile Lip retraction Lack of retraction or asymmetry know normal development exceedingly
IX,X Food in posterior Swallow initiated Delayed initiation of pharyngeal
oral cavity <2 sec swallow well. A childs failure to close lips
XII Food on tongue Tongue shaping Tongue lacking elevation and around a spoon, reduced tongue action
with pointing thinning; excessive thrusting; to form a bolus, and delay in trigger or
and protruding atrophy initiation of a pharyngeal swallow all
Source: Adapted from Arvedson et al. [2002].
may be indications of cranial nerve defi-
cits. Observations provide information
related to possible oral sensory versus
oral motor disorders. Many children
tating oral feeding in preterm infants the infants best interests if the infant is have both types, but may show a
in the NICU can be found in other observed for only the first few minutes preponderance of one over the other
sources [e.g., McCain, 2003; Rogers of an oral feeding. (Table 3).
and Arvedson, 2005; Delaney and Older infants and children: The A fundamental question that must
Arvedson, 2008]. Intraoral inspection feeding observation is made with a fa- be answered by the end of the clinical
may be held until after the feeding ob- miliar feeder holding an infant as typi- feeding assessment is: Can this child eat
servation with children who may be cally as would be done at home, or and drink safely strictly orally? If the
wary about someone getting in their with a child in a high chair or other answer is yes, modifications may
face. It is helpful to have children in seating system. These observations are include, but are not limited to:
their typical state for meal times in attempts to simulate as closely as possi- ! posture and position alterations;
order to get the most useful observation ble the regular feeding environment and ! taste, texture, and temperature
of eating and drinking. routine as carried out at home. Obser-
changes of food or liquid;
vations are made about the parent and ! broader based sensory and
Feeding Observation child interactions around feeding. The
motor interventions;
Newborn infants: Cardiorespiratory child is observed for specific aspects of ! scheduling of meal and snack
status must be stable. A calm alert state oral sensorimotor function that can be
times to facilitate hunger;
is desirable for anticipation of feeding related to function of cranial nerves V, ! structure and routines at meal
with minimal stress to the infant. NNS VII, IX, X, and XII with a few exam-
times to improve parentchild
is assessed, even though adequate NNS ples in Table 2. Inferences are made
interactions as well as behav-
is not sufficient to predict adequacy of regarding time to produce swallows and
ioral responses of the child.
oral feeding abilities. If an infant does whether a child appears to make multi-
not demonstrate rhythmic and strong ple swallows to clear a single bolus. If the answer is no or if there are
NNS, it is not likely that she will be Textures may be varied, usually starting signs of concern regarding safety of
ready to suck, swallow, and coordinate with a texture or consistency that is fa- swallowing that may include risks for
breathing to take enough breast milk or miliar to the child and then offering a aspiration, follow-up instrumental eval-
formula to meet nutrition and hydra- food that may be more difficult, accord- uation is warranted. One can only make
tion needs. An infant who is anticipated ing to parents. Other attributes of food inferences regarding pharyngeal and
to be an oral feeder should be observed and liquid that can be varied include upper esophageal phases of swallowing
for at least 1520 min. Efficient feeding taste and temperature. It is of interest by clinic examination/observation
is accomplished in 1520 min or maxi- that children who have not experienced regardless of the experience, knowledge,
mum 30 min for most typical infants. typical development of oral feeding in and astuteness of a specific clinician.
Length of feeding times among preterm the first year of life often require addi-
infants fed according to their cues and tional time to accept textured food and OTHER CONSIDERATIONS
tolerance range from 10 to 30 min with to make developmentally appropriate In addition to the clinical evalua-
none fed longer than 30 min [McCain, gains. They often prefer sour and tart tion of feeding and swallowing, the cli-
2003]. Some infants may take a few flavors over bland food. They also may nician should focus on somatic growth
minutes to warm up. If the feeding prefer finger foods that they handle in- patterns, neurodevelopmental status,
observation is stopped after 5 min, an dependently, rather than have someone orofacial structures, cardiopulmonary
erroneous impression might be made. else spoon feed them. Children have and other GI function.
On the other hand, an infant may start shown that they are more likely to have
out well, become disorganized, and feeding difficulties when lumps are Somatic Growth
show signs of fatigue as the feeding pro- introduced at or after 10 months of age Thorough nutrition assessment is
gresses. This pattern is not uncommon than when lumps are introduced earlier critical with various methods available.
in infants with cardiac abnormalities or than 10 months [e.g., Northstone et al., Advances in nutrition assessment can be
neurogenic dysphagia. Management 2001]. Age estimates relate to critical found in several recent excellent reviews
decisions would not likely be made in and sensory periods that appear perti- [e.g., Kirby and Noel, 2007]. No single
122 Dev Disabil Res Rev ! ASSESSMENT OF PEDIATRIC DYSPHAGIA ! ARVEDSON
 Asymmetry of facial features may be a
Table 3. Attributes of Children with Primarily Oral Sensory vs. sign of a unilateral stroke or some other
Primarily Oral Motor Disorders neurological insult. Knowledge of syn-
dromes and anomalies is basic to con-
Primary Motor Disorder Primary Sensory Disorder sideration of impact on swallowing and
Inefficient sucking and swallowing at breast Nipple confusion from breast- to bottle- feeding for both short- and long-term
or bottle feeding prognoses.
Taste differentiation noted with liquids in Lack of taste differentiation of liquids in
bottle bottle despite intact sucking Cardiopulmonary Examination
Inefficiency or incoordination with all Efficiency with liquids better than with solid
textures foods
Airway stability is a prerequisite
Food swallowed whole when given mixed Sorts out food of different textures, for successful oral feeding. The cardio-
textures e.g., fruit piece in yoghurt pulmonary examination may reveal signs
Difficulty manipulating bolus of food on Food held under tongue or in cheek to of dysphagia and possible chronic aspi-
tongue; loss of food out mouth or avoid swallowing ration. The complexity of patients at
pocketed in cheeks
Vomitingnot texture specific Vomitingcertain textures risk for aspiration makes it difficult to
Gagging noted after food moves through Gagging noted when food approaches or sort out the various factors that contrib-
oral cavity touches lip or tongue ute to aspiration in children. This area
Gagging with liquid or solid after swallow Gagging prominent with solids; normal is one where interdisciplinary evaluation
initiated or triggered swallow with liquids
Toleration of others fingers in mouth Toleration of ones own fingers in mouth,
is mandatory [Brodsky and Arvedson,
but not others 2002,a]. Numerous diagnostic condi-
Acceptance of teething toys, but not able to No mouthing of toys tions and comorbidities associated with
bite them or maintain them in the mouth dysphagia and respiratory consequences
No problems with toothbrushing Refusal of toothbrushing arise from the pulmonary and neurolog-
Source: Palmer and Heyman [1993]. Adapted from Arvedson et al. [2002], p 295. ical systems, genetic conditions, and
others that include congenital heart dis-
ease, immunodeficiencies, and trauma.
Additional examples can be found in
measure fulfills all requirements for nication disorders and mental retarda- the work of Lefton-Greif and McGrath-
assessing nutrition status in infants and tion. A thorough neurological history Morrow [2007]. Infants may exhibit
young children. Multiple measures may and examination is essential in identify- signs of apnea and bradycardia with
be needed. All children deserve ing and treating the vast range of nerv- swallowing dysfunction [e.g., Guillemi-
adequate nourishment so that they can ous system disorders and neuromuscular nault et al., 1984; Loughlin and Lefton-
grow and develop fully to meet their diseases that are associated with feeding Greif, 1994]. A child who requires as-
potential in all functional domains. and swallowing disorders. sistance for feeding and is neurologically
impaired is at high risk for silent aspira-
Neurodevelopmental Examination Upper Airway and Orofacial tion with oral feeding [Arvedson et al.,
Each childs neurodevelopmental Examination 1994; Rogers et al., 1994a,b]. Children
status must be determined as feeding Alterations of orofacial structures with intractable seizures and treated
and swallowing intervention plans need are common with some congenital syn- with vagal nerve stimulation may be at
to be tailored to a childs developmental dromes and craniofacial anomalies. Na- increased risk for aspiration with no
levels of function, not to chronologic sopharyngeal obstruction can occur observable response [Lundgren et al.,
age. Methods of evaluation and scales with choanal atresia or stenosis, nasal 1998]. Other signs include recurrent
can be incorporated for cognitive and polyps, or foreign bodies and often dis- pneumonia, undernutrition (failure to
language levels, with healthcare pro- rupt infant nipple feeding at the breast thrive), and radiographic signs of
viders being aware of strengths and or bottle. Open mouth posture may be chronic lung injury [Bauer et al., 1993].
weaknesses of various measures an indication of limitations in nasal Children with tracheostomy vary signif-
[Rossman et al., 1994; Macias et al., breathing, hypotonia, or some combi- icantly in their degree of swallowing
1998; Voigt et al., 2003; Vincer et al., nation of factors. With midline defects difficulties. The degree of difficulty is
2005]. Sensory and motor skills need to such as cleft palate, food and liquid may likely related more to the underlying
be evaluated with differentiation of pri- get into the nasopharynx. In some reasons for the tracheostomy than to
marily oral sensory deficits versus pri- instances, liquid or food may come out the presence of the tracheostomy tube
marily oral motor deficits [Palmer and the nose. Tonsil and adenoid hypertro- itself [Arvedson and Brodsky, 1992] and
Heyman, 1993] (Table 3). Most chil- phy may result in partial airway obstruc- duration of the tracheostomy tube in
dren tend to demonstrate some aspects tion with mouth breathing and snoring. toddlers [Abraham and Wolf, 2000]. It
of both sensory and motor deficits, In some instances, solid food may get is important to sort out chronic (at least
although it is not unusual for children caught in palatine or lingual tonsils and 4 weeks in duration) respiratory mani-
to have a strong tendency to one or the can interfere with swallowing. Improve- festations of dysfunctional swallowing
other. Additional resources for these ment has been noted following tonsil- from episodic events that are temporally
areas of assessment include the works of lectomy in a small sample of children related to feedings [e.g., Matsuse et al.,
Blanche et al. [1995], Case-Smith and with neurological impairment [Conley 1998; Thach, 2005].
Humphrey [2000], and Morris and Klein et al., 1996]. Mandibular hypoplasia The type and extent of respiratory
[2000]. Risk factors in the development with retracted tongue posture can inter- presentations and effects can vary by
of behavioral food refusal and mainte- fere with resting respiration that may multiple interacting factors that include
nance of maladaptive feeding behaviors become more problematic with oral age, presence of comorbidities, fre-
after periods of illness include commu- feeding, as in Pierre Robin sequence. quency of aspiration, and type of aspi-
Dev Disabil Res Rev ! ASSESSMENT OF PEDIATRIC DYSPHAGIA ! ARVEDSON 123
rated materials. The primary unan- ing regarding management of feeding tion of nasal, pharyngeal, and laryngeal
swered question prompts continued and swallowing problems. structures (including true and false vocal
need for research: How much aspiration folds). Tonsils and any other mass can
of what for how long can be tolerated INSTRUMENTAL EVALUATION be seen readily. Secretions may be seen
by an individual before chronic lung OF SWALLOWING in pharyngeal recesses or in the laryn-
disease is an issue? A variety of proce- Imaging studies that allow for vis- geal vestibule. When a child swallows, a
dures can be used for delineating respi- ualization of some aspects of oral, pha- white out occurs as the epiglottis tilts
ratory status and whether swallowing ryngeal, and upper esophageal phases of upon initiation (trigger) of the pharyn-
dysfunction is an underlying cause or swallowing include: Videofluoroscopic geal swallow. The area comes into view
whether the pulmonary dysfunction swallow study (VFSS), fiberoptic endo- immediately after the initiation of the
may underlie the dysphagia. Criteria for scopic evaluation of swallowing (FEES), swallow, allowing for visualization of
specific tests and descriptions of proce- FEES with sensory testing (FEES-ST), any residue in valleculae, pyriform
dures can be found elsewhere. Again a and ultrasonography (US). Although sinuses, posterior pharyngeal wall, la-
team approach is stressed with professio- US is not used routinely in most clinical ryngeal vestibule, and at times it may be
nals communicating across specialties settings, it is a valuable research tool possible to see aspirated material below
and with parents. that provides useful data while visualiz- the level of the true vocal folds. How-
ing aspects of the oral and pharyngeal ever, the inability to visualize the entire
phases of swallowing. A brief discussion dynamic swallowing sequence is a draw-
GI Examination of US, FEES/FEES-ST, and VFSS fol- back of this evaluation. Advantages
GER, the passage of gastric con- lows. include: no radiation exposure, position
tents into the esophagus, is common in of patient is flexible, observation of
normal infants with a frequency of re- Ultrasonography structures, sensory component, can be
gurgitation as high as 67% at 4 months US uses reflected sound as an repeated frequently, and it is readily
of age [Nelson et al., 1997]. The etiol- imaging tool, which has been applied available in most medical settings.
ogy in infants is primarily anatomic and to visualize temporal relationships
a function of a liquid diet, low esopha- between movement patterns of oral and Videofluoroscopic Swallow Study
geal capacitance, minimal length of sub- pharyngeal structures in fetal swallowing The VFSS is the primary instru-
diaphragmatic esophagus, and supine [Petrikovsky et al., 1996; Miller et al., mental examination to provide dynamic
positioning [Kirby and Noel, 2007]. 2003, 2006; Grassi et al., 2005], prema- imaging of oral, pharyngeal, and upper
This benign infantile GER seldom ture infants [Miller and Kang, 2007], esophageal phases of swallowing. The
results in esophagitis or airway irritation young infants [Bosma et al., 1990], and lateral view is standard. The anteropos-
since the regurgitated breast milk or in older children and adults [e.g., terior view is used in some instances,
formula is nonacidic. However, infants Shawker et al., 1984; Fanucci et al., particularly when asymmetry is noted
and children with GER disease 1994; Yang et al., 1997]. and for view of palatine tonsils. The
(GERD) may present with signs that esophagus is scanned only for transit of
result from pain, airway irritation, or Fiberoptic Endoscopic Evaluation a bolus. If a comprehensive examination
feeding disorder. The North American of Swallowing with Sensory Testing of esophageal structure and function is
Society for Pediatric Gastroenterology, The flexible (fiberoptic) endo- needed, an esophagram or in some
Hepatology, and Nutrition (NASP- scopic examination of swallowing allows instances an upper GI study is com-
GHAN) [Rudolph et al., 2001] has for visualization of events occurring im- pleted.
published guidelines for evaluation and mediately before and immediately after For purposes of the radiographic
management of GERD. Eosinophilic the pharyngeal swallow. It was devel- examination of swallowing, it must be
esophagitis (EE or EoE), an inflamma- oped as an adjunct to VFSS and clinical remembered that this examination cap-
tory disease of the esophagus, may examination of swallowing function in tures only a brief window in time and
mimic the signs of GERD [Noel and adults. It can be performed safely in it does not simulate a real meal. The
Tipnis, 2006]. EE is often associated persons of all ages including premature primary purpose is to define the pha-
with food allergy and atopy [Noel infants [Willging, 1995; Willging et al., ryngeal phase of swallowing, not just to
et al., 2004], and unrelated to acid ex- 1996; Willging and Thompson, 2005]. determine whether a child aspirates
posure. Diagnosis requires endoscopy The sensory testing component uses an [Arvedson and Lefton-Greif, 1998].
and is made by histologic confirmation air pulse stimulus of mechanoreceptors Oral tongue propulsion of boluses into
of mucosal changes [Gupta et al., 1997; within the larynx (FEES-ST). Coopera- the pharynx has an impact on pharyn-
Lim et al., 2004]. Treatments involve tion can be obtained in nearly all chil- geal function. This examination pro-
dietary changes and medications [Mar- dren. No cases of laryngospasm or re- vides structural and functional findings
kowitz et al., 2003; Konikoff et al., spiratory compromise have been that can be related to varied swallowing
2006]. Overall, adequate management encountered [Willging and Thompson, disorders (Table 4). When aspiration is
of GI tract disorders that may also 2005]. FEES may be an adjunct to observed, the clinician must note
include motility problems along with VFSS in some instances [Bastian, 1991]. whether the aspiration occurred before,
the conditions described above is an Technology advances in recent years during, or after swallows and on what
important underpinning for potential of make it feasible to integrate FEES with texture(s) or consistencies. The findings
successful oral feeding in those children VFSS with the same patient. must be related to possible swallow
who have safe swallowing. To interpret FEES-ST is carried out best by a problems or disorders, since manage-
findings of infants and childrens oral pediatric otolaryngologist and speech- ment decisions are based on the
feeding during a clinical feeding assess- language pathologist working as a team. problems that are identified. Details
ment, knowledge regarding all related The flexible endoscopic tube is passed regarding criteria for referral for VFSS,
interactive systems aids in decision mak- transnasally, which allows for visualiza- preparation of infants and children, pro-
124 Dev Disabil Res Rev ! ASSESSMENT OF PEDIATRIC DYSPHAGIA ! ARVEDSON
 served best through an interdisciplinary
Table 4. Selected Videofluoroscopic Swallow Study Findings and team approach with considerations to
Common Swallow Disorders include the WHO identification of the
ICF as a potential framework for coding
Radiographic Finding (Sign) Possible Common functional status and for standardizing
Swallowing Disorder
language to describe health and health-
Bolus formation related domains. Consideration of feed-
Loss of food or liquid out mouth ; closure ing problems in young children as a
Material in anterior sulcus ; lip tension or tone parentchild relational disorder provides
Material in lateral sulcus ; buccal tension or tone
Material pushed out with tongue Tongue thrust, ; tongue control
a basis for incorporating those concepts
Limited/immature chewing ; jaw and tongue control into a comprehensive management plan.
>three sucks per swallow (nipple) ; suck strength/coordination Evaluation has been discussed in a holis-
Oral transit tic framework that has the potential to
Searching tongue movements Apraxia of swallow, ; oral sensation facilitate the best possible safety and
Forward tongue to move bolus Tongue thrust
Material remains in anterior sulcus ; lip tone, ; tongue control function of feeding for all children
Material remains in lateral sulcus ; tongue movement/strength whether it be with a goal for total oral
Material remains on tongue ; tongue movement/strength feeding or a goal that includes supple-
Material remains on hard palate ; tongue strength; high/narrow palate mental tube feedings to assure that
Limited tongue movement ; tongue coordination, disorganized
anteroposterior movement
nutrition and hydration needs are met,
Tongue-palate contact incomplete ; tongue elevation while facilitating oral feeding in ways
Oral transit (>3 s) Delayed oral transit that will not jeopardize a childs health.
Pharyngeal phase initiation (trigger) Every child deserves to receive adequate
Material in valleculae preinitiation If brief, no delay in pharyngeal initiation nutrition and hydration without stress
Material in pyriform sinuses preinitiation Delayed pharyngeal initiation
Material in/on tonsil tissue Tonsils blocking bolus transit, delayed to child or to caregiver. Successful oral
pharyngeal initiation feeding must be measured in quality of
Material on posterior pharyngeal wall Delayed pharyngeal phase initiation meal time experiences with best possi-
Pharyngeal phase ble skills while not jeopardizing a childs
Nasopharyngeal backflow/reflux ; velopharyngeal closure, ; UES opening
Penetration to underside of superior Incoordination, ; pharyngeal contraction
functional health status or the parent
part of epiglottis child relationship. n
Penetration into airway entrance ; closure of airway entrance
Residue after swallows in valleculae ; tongue base retraction
Residue in pyriform sinuses ; pharyngeal contractions, ; UES
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