Dysphagia

DOI 10.1007/s00455-015-9667-5

REVIEW ARTICLE

Systematic Review: Non-Instrumental Swallowing and Feeding

Assessments in Pediatrics
Dani-Ella Heckathorn1 • Renée Speyer1,2 • Jessica Taylor1 • Reinie Cordier3

Received: 11 May 2015 / Accepted: 25 October 2015

 Springer Science+Business Media New York 2015

Abstract There is a high incidence of parental reporting of scoring or interpreting scores. There is high variability
abnormal swallowing and feeding function and the negative among the many assessments available to clinicians in the
impacts thereof on children. As such there is a need for well area of feeding and swallowing function in pediatrics. There
validated assessments in the area of pediatric swallowing and appears to be limited information available on the validity
feeding. While instrumental assessments are well validated, and reliability of these assessments. Thus, most assessments
there is limited information available to guide the selection need to be used with caution. Further research is needed to
and use of non-instrumental assessments for swallowing and evaluate the psychometric properties of the assessments.
feeding function. The aim of this study was to identify and
report on non-instrumental assessments available to clini- Abbreviations
cians for pediatric swallowing and/or feeding function in AEPS Assessment, Evaluation, and Programming
order to support clinical decision making. A systematic lit- System for Infants and Children—Second
erature search was performed by two independent reviewers Edition
using Medline and Embase databases, to find non-instru- ASD Autism spectrum disorder
mental assessments for pediatric swallowing and feeding AYCE About Your Child’s Eating
function. Published assessments were also included in the BAMBI Brief Autism Mealtime Behavior Inventory
study by searching well-known publishers and relevant BAMF-OMD Brief Assessment of Motor Function (Oral
feeding and swallowing textbooks. Assessments were sum- Motor Deglutition scale)
marized and evaluated according to respondent type, target BASOFF Behavioral assessment scale of oral
populations, assessment design, domains of assessment and functions in feeding
scoring. Thirty assessments were included in the final BED Bedside Evaluation of Dysphagia—
review. All assessments had either caregiver or clinician Revised Edition
respondents. There was high variability in target popula- CCITSN Carolina Curriculum for Infants and
tions, assessment designs and areas of assessment. Twenty- Toddlers with Special Needs
four of the 30 assessments did not provide instruction for CCTI Colorado Childhood Temperament Inventory
CEBI Children’s Eating Behavior Inventory
CEBQ Children’s Eating Behavior Questionnaire
& Renée Speyer CFQ Child Feeding Questionnaire
[email protected] CMFBQ Child Mealtime Feeding Behavior
1 Questionnaire
College of Healthcare Sciences, James Cook University,
Townsville, QLD 4811, Australia CTCAE Common Terminology Criteria for
2 Adverse Events
Department of Otorhinolaryngology and Head and Neck
Surgery, Leiden University Medical Center, Leiden, DASH-3 Developmental Assessment for Individuals
The Netherlands with Severe Disabilities—Third Edition
3
School of Occupational Therapy and Social Work, Curtin DAYC-2 Developmental Assessment of Young
University, Perth, WA, Australia Children—Second Edition

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DEP Dysphagia Evaluation Protocol linked to poorer patient outcomes including higher rates of
DDS Dysphagia Disorder Survey or Dysphagia malnutrition [3], higher mortality rates [4, 5], increased
Disorders Survey medical complications [6, 7], longer hospitalisations [4, 7,
DINE Dyadic Interaction Nomenclature for Eating 8], poorer immune responses [6], higher support required
DSFS Drooling Severity and Frequency Scale post hospital discharge [6, 7], and overall poorer quality of
EFS Early Feeding Skills Assessment life (QoL) [4, 6]. In addition to the poor health outcomes
FES Family Environment Scale that are associated with swallowing difficulties, pediatric
FDA-2 Frenchay Dysarthria Assessment—Second populations, face physical, and developmental challenges if
Edition their nutritional and caloric intake is not sufficient [9–13].
FSQ Feeding and Swallowing Questionnaire In addition to swallowing difficulties, children may also
FSQ Feeding Strategies Questionnaire be at risk of reduced nutrition and caloric intake due to
GVA Gisel Video Assessment feeding difficulties. Feeding difficulties in pediatrics may
IFSQ Infant Feeding Style Questionnaire be broadly defined as difficulties eating adequately which
IFTI Infant-Toddler and Family Instrument may result in reduced absorption or consumption of food,
MFP Multidisciplinary Feeding Profile impacting on physical and/or psychosocial function [14].
NOMAS Neonatal Oral-Motor Assessment Scale Feeding difficulties in children or infants have been asso-
NR Not Reported ciated with negative parent–child interactions, anxiety,
OAG Oral Assessment Guide for children and stress, social avoidance, and specific fears (phobias) [15–
young people 18].
OD Oropharyngeal Dysphagia Studies have previously estimated that around 20–45 %
OMAS Oral Motor Assessment Scale of parents within the general population report that their
PASSFP Pediatric Assessment Scale for Severe children have some form of feeding or swallowing diffi-
Feeding Problems culty [19–22], and that between 3 and 10 % of children
PIBBS Preterm Infant Breastfeeding Behavior have significant swallowing or feeding difficulties resulting
Scale (revised) in significant health or developmental consequences [23].
PMAS Parent Mealtime Action Scale Swallowing and feeding difficulties are also projected to
PRISMA Preferred Reporting Items for Systematic increase due to improved survival rates of infants born
Reviews and Meta-Analyses (PRISMA) prematurely or with complex medical conditions [19].
PSAS Pre-Speech Assessment Scale Given the high rates of swallowing and feeding difficulties
QoL Quality of Life and the negative consequences of these conditions, it is
SAFE Swallowing Ability and Function important to use assessments with sound psychometric
Evaluation properties in order to support early identification and
SAIB Systematic Assessment of the Infant at optimize treatment outcomes [19, 24–28]. Current evi-
Breast dence for swallowing and feeding difficulties in pediatric
SOMA Schedule for Oral Motor Assessment populations recommends the use of a multidisciplinary
STEP-Child Screening Tool of Feeding Problems, team approach for both conducting comprehensive
modified for children assessments and delivery of interventions [19, 25, 29]. The
SWAL-QoL Swallowing Quality of Life Questionnaire use of videofluoroscopy and fiberoptic endoscopic evalu-
(adapted for use with pediatric patients) ation of swallowing to assess swallow function (or dys-
function) is well supported in the literature [6, 27–31].
However, there is a lack of discussion and support for the
use of standardized, psychometrically sound measures of
swallowing or feeding function, such as non-instrumental
Introduction assessments, which can augment or serve as alternatives to
instrumental assessment in order to reduce unnecessary
Oropharyngeal dysphagia can refer to problems with cost and the use of invasive procedures [32–36].
chewing and preparing food, transporting a bolus from the This systematic review is a first step in addressing the
oral cavity to the back of the tongue, moving food into the need to identify and report on the characteristics of non-
esophagus, or unsafe and inefficient swallowing [1]. The instrumental assessments in the areas of both pediatric
term oropharyngeal dysphagia is not commonly used in swallowing and feeding functions that are available to
pediatric populations as oropharyngeal and esophageal clinicians. The terms swallowing and feeding function (i.e.,
dysfunction are intrinsically linked in this population [2]. normal swallowing and feeding) and swallowing and
Swallowing dysfunction in the general population has been feeding dysfunction (i.e., swallowing and feeding

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Table 1 Search strategy: pediatric swallowing or feeding assessment

Search type Database Search terms Limitations Abstracts
identified

Mesh/Thesaurus Medline (‘‘Deglutition Disorders’’ OR ‘‘Deglutition’’ OR ‘‘Feeding and Eating Disorders None applied 923
terms of Childhood’’ OR ‘‘Eating Disorders’’ OR ‘‘Feeding Behavior’’) AND
(‘‘Questionnaires’’ OR ‘‘Health Surveys’’) AND (‘‘Child’’ OR ‘‘Infant’’)
Embase dysphagia/OR eating disorder/OR feeding disorder/) AND questionnaire/OR None applied 759
health survey/) AND (child/OR infant/)
Free text Medline (questionnaire* or survey*) AND (swallow* or dysphag* or deglut* or feed*) Year: 712
AND (child* or toddler* or infant* or schoolchild* or youth* or baby or babies 2012-Current
or pediatr* or paediatr* or neonat* or newborn* or postneonat* or postnat* or
suckling* or juvenile*)
Embase (swallowing disorder* OR deglut* OR feed* OR eating disorder*) AND Year: 498
(questionnaire* OR survey*) AND (child* OR toddler* OR infant* OR 2012-Current
schoolchild* OR yout* OR baby OR babies OR pediatr* OR paediatr* OR
neonat* OR newborn* OR postneonat* OR postnat* OR suckling* OR
juvenile*)
Total abstracts 2892
Total abstracts 2201
(duplicates
removed)

Table 2 Inclusion and exclusion criteria for abstract and original article selection
Inclusion criteria Exclusion criteria

Describes the use of a non-instrumental assessment Does not refer to an assessment in the methodology
Refers to swallowing/feeding function/dysfunction Refers only to instrumental assessments
Includes assessment of the pediatric or neonatal Refers only to the assessment of conditions not related to swallowing or feeding
population
Refers only to conditions of a psychological origin (e.g., anorexia nervosa)
Assessment is used on non-human populations
Only includes adult participants

difficulties or disorders) are used throughout this manu- Reference lists of included articles were also searched for
script and include behavioral aspects of feeding. further publications and assessments. Eligibility of publi-
cations was appraised independently by both reviewers;
consensus was reached through discussion where there was
disagreement on eligibility.
Methods The non-instrumental assessments were then identified
by searching for the original, first publication that descri-
This review was performed according to the Preferred bed the selected assessment, and when this failed, by
Reporting Items for Systematic Reviews and Meta-Anal- contacting the authors directly. To ensure that the search
yses (PRISMA) statement [37]. A systematic literature was comprehensive, well-known publishers for assessment
search was conducted using Medline and Embase online tools and textbooks around the topic of pediatric swal-
databases (Table 1). From this search, all appropriate lowing or feeding were also searched so as to capture rel-
journal abstracts up to June 2013 were included. Both evant assessments that have been published in sources other
databases were searched using medical subject headings than research databases. The assessments were then con-
(MeSH) or Thesaurus terms and free text. Two independent sidered for eligibility according to inclusion and exclusion
abstract reviewers selected abstracts and original publica- criteria as listed in Table 3. For assessments to be included,
tions of non-instrumental assessments according to the they were required to (a) have at least 50 % of the items
inclusion and exclusion criteria as described in Table 2. related to swallowing or feeding; (b) be designed for use

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Table 3 Inclusion and exclusion criteria for assessments

Inclusion criteria Exclusion criteria

50 % or more of the assessment items (or items of a subtest) are The study population is not human
swallowing/feeding related
Populations include those aged 0–18 years The assessment is used for instrumental assessment (e.g. observation
tool for videofluoroscopy or video recording)
Any aspect of swallowing/feeding is investigated (excluding psychogenic The assessment is a surveya
conditions, but including behavioural and oral intake)
Assesses observations or reported history The assessment is used for guiding case history taking only
May be completed by a clinician or parent/caregiver The assessment is not published in English
Less than 50 % of the assessment items relate to swallowing/feeding
The assessment investigates oesophageal dysphagia, pain or
mucositis
The assessment investigates adult populations only
The assessment investigates psychogenic swallowing/feeding
difficulties only
The assessment investigates obesity only
a
Survey is defined as an assessment designed to collect data of a target population group, rather than for a specific individual [38]

with pediatric populations; and (c) needed to be of a non- swallowing function in children of various aetiologies in
instrumental assessment design (i.e., the assessment was not various domains of feeding or swallowing functioning (see
used in instrumental assessment processes or for retro- Table 5).
spective video assessment). Guidelines for clinicians for
case history taking and surveys were excluded. Eligibility Respondents and Assessment Style
of these assessments and analysis of the characteristics and
assessment domains were independently appraised by two The assessments were designed to be completed by two
reviewers, who again reached consensus through discus- types of respondents: caregivers (Table 6) or clinicians
sion. Figure 1 provides an overview of the process of (Table 7). Of the 30 included assessments, 11 were iden-
inclusion according to the PRISMA flow diagram [39]. tified as caregiver assessments; 9 of which took a case
history style approach to asking questions and two focused
on observation instead (Table 6). Eighteen assessments
Results were designed to be completed by clinicians; these
assessments all used clinical observations of swallowing or
Systematic Literature Search feeding function or set clinical tasks (Table 7). One
assessment could be completed by either caregivers or
The systematic searches in Medline and Embase yielded clinicians and utilised a case history style of assessment
2201 records. A total of 76 original non-instrumental (Table 8).
assessments were retrieved from the database, publisher,
and textbook searches and the reference lists of the inclu- Target Populations
ded articles. The assessments were evaluated using the
inclusion criteria for assessments (Table 3). While all assessments were developed to investigate
Of the 76 assessments, 46 were excluded as they did not swallowing or feeding function in pediatric populations,
meet the inclusion criteria (see Table 4). The 46 assess- various target groups (including diagnostic and age groups)
ments were excluded for the following reasons: 27 were were identified (Tables 6, 7 and 8). Nine assessments were
excluded as less than 50 % of the assessment items were developed to assess the swallowing and feeding difficulty
not related to feeding and/or swallowing; 6 assessments did of infants and children from birth to 2 years with no
not assess the target population of children or infants; and specific illness: Clinical Evaluation of Pediatric Dysphagia
13 assessments were excluded as they did not meet the [40], Clinical Feeding Evaluation of Infants [82], Clinic/
requirements for non-instrumental assessments. A total of Bedside Oral-Sensorimotor Feeding Assessment Work-
30 non-instrumental assessments were identified as meet- sheet [81], Developmental Pre-Feeding Checklists [65],
ing all inclusion criteria as they investigated feeding or Early Feeding Skills Assessment (EFS) [84], Oral Motor

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Records identified through Medline Records identified through Embase

Idenficaon
search search
(n = 923) MESH terms (n = 759) Thesaurus terms
(n = 712) Free text (n = 498) Free text

Records after duplicates removed

(n = 2201)
Abstracts excluded due to
exclusion criteria
(n = 1994)
Records screened
(n = 2201)

Articles excluded due to

Screening

exclusion criteria
Full-text articles screened (n= 141)
for assessment (n = 207)

Number assessments
Number of (articles) after duplicates
assessments removed
(reference lists) (n = 66)
(n = 8)
Eligibility

Excluded: Surveys
(n = 21)

Number of
assessments Excluded: Oesophageal
Number of assessments disorders
(publishers and
(all sources) (n = 3)
textbooks)
(n = 111)
(n = 37)

Excluded: Unable to obtain

Number of assessments copies of the assessment
evaluated for eligibility (n= 11)
Included

(n = 76)

Assessments excluded due

Total assessments
to exclusion criteria
included in analysis
(n = 46)
(n = 30)

Fig. 1 Flow diagram of the reviewing process according to PRISMA. Study flow diagram showing the process of inclusion for assessments. The
flow diagram follows the structure as recommended by PRISMA [39]

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Table 4 Overview of excluded non-instrumental assessment tools for swallowing and feeding function in children (n = 46)
Assessment Acronyma Inclusion criteria Exclusion criteria

Assessment, Evaluation, and Programming AEPS Suitable for children and infants Less than 50 % swallowing/feeding
System for Infants and Children, Second related
Edition (Brookes Publishing)
Assessment of cranial nerves [40] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses neurology only
Breastfeeding evaluation [41] NR Suitable for infants Not an assessment: educational tool
with information on normal
feeding behaviours
Bedside examination/Cranial nerve NR Assesses swallow safety Not used with target population
examination [42] (children or infants)
Bedside Evaluation of Dysphagia—revised BED Assesses swallowing function Not used with target population
edition (Pro-ed) [43] (children or infants)
Carolina Curriculum for Infants and Toddlers CCITSN Suitable for toddlers and infants Less than 50 % swallowing/feeding
with Special Needs (brookes publishing) [44] related
Checklist of items for dysphagia screening [45] NR Assesses swallowing function Not used with target population
(children or infants)
Child Mealtime Feeding Behavior CMFBQ Suitable for children aged 3;0–6;0 Less than 50 % swallowing/feeding
Questionnaire [46] related
Assesses parental behaviours and
problem solving primarily
Child Feeding Questionnaire [47] CFQ Questionnaire for children Less than 50 % swallowing/feeding
related
Assesses factors related to obesity,
rather than child’s swallowing/
feeding function
Children’s Eating Behaviour Questionnaire CEBQ Suitable for children aged 2;0–7;0 Less than 50 % swallowing/feeding
[48] related
Assesses behaviours related to
obesity, rather than swallowing/
feeding function
Colorado Childhood Temperament Inventory CCTI Suitable for children aged 0;5–9;0 Less than 50 % swallowing/feeding
[49] related
Assesses the child’s temperament
Common Terminology Criteria for Adverse CTCAE Single item related to swallow function Less than 50 % swallowing/feeding
Events (Previously: National Cancer related
Institute—Common Toxicity Criteria) [50]
Cranial nerve examination [51] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses neurology and physiology
only
Developmental Assessment for Individuals DASH-3 Suitable for children aged 0;6-adulthood Less than 50 % swallowing/feeding
with Severe Disabilities—Third Edition related
(Pro-ed) [52]
Developmental Assessment of Young DAYC-2 Suitable for children aged birth-5;0 Less than 50 % swallowing/feeding
Children—Second Edition (Pro-ed) [53] related
Developmental checklist [54] NR Checklist for children with achondroplasia, Less than 50 % swallowing/feeding
beginning prior to 15 months, until last related
developmental milestone is met
Drooling rating scale [55] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses severity and frequency of
drooling, rather than swallowing/
feeding function

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Table 4 continued
Assessment Acronyma Inclusion criteria Exclusion criteria

Drooling Severity and Frequency Scale [56] DSFS Assessment for children Less than 50 % swallowing/feeding
related
Assesses severity and frequency of
drooling, rather than swallowing/
feeding function
Dyadic Interaction Nomenclature for Eating DINE Items behaviour related with some Not a questionnaire-style assessment:
[57] consideration for environment and assessment via video
feeding
Dysphagia Evaluation Protocol (Pearson) [58] DEP Assesses swallowing function Not used with target population
(children or infants)
Family Environment Scale [59] FES Assesses mealtime environment Less than 50 % swallowing/feeding
related
Assesses family social environment
with little related to moments of
feeding
FEES Protocol, revised [60] NR Suitable for children Not a questionnaire-style assessment:
assessment via video
Frenchay Dysarthria Assessment—second FDA-2 Assesses swallowing function Not used with target population
edition (Pro-ed) [61] (children or infants)
Less than 50 % swallowing/feeding
related
Gisel Video Assessment [62] GVA Assess children’s feeding abilities and Not a questionnaire-style assessment:
behaviours assessment via video
History information [40] NR Suitable for children Not a questionnaire-style assessment:
open ended questions to guide case
history taking
Infant Feeding Style Questionnaire [63] IFSQ Suitable for children aged 0;3–1;8 Less than 50 % swallowing/feeding
related
Assesses parental behaviours and
beliefs around mealtimes
Infant-comprehensive dysphagia examination NR Suitable for assessing feeding in infants Not a questionnaire-style assessment:
[42] guide for clinicians for case history
taking
Infant-Toddler and Family Instrument (Brookes IFTI Suitable for infants Less than 50 % swallowing/feeding
Publishing) [64] related
Mealtime assessment guide [65] NR Assesses children’s mealtime environment Not an assessment
Oral Assessment Guide for children and young OAG Designed for children Less than 50 % swallowing/feeding
people [66] related
Assesses health of child’s oral
structures, and physiology rather
than swallowing/feeding function
Oral motor and speech assessment [67] NR Suitable for people aged 2;6–21;5 Less than 50 % swallowing/feeding
related
Assesses oral motor skills related to
communication not feeding
Oral secretion [55] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses production and control of
saliva, rather than swallowing/
feeding function
Parent mealtime questionnaire: eating and NR Assesses children’s mealtime environment Not a questionnaire-style assessment:
drinking [65] guide for clinicians for case history
taking

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Table 4 continued
Assessment Acronyma Inclusion criteria Exclusion criteria

Parent mealtime questionnaire: tube feedings NR Assesses children’s feeding needs Not a questionnaire-style assessment:
and beginning oral feeding [65] guide for clinicians for case history
taking
Pediatric dysphagia case history form and NR Suitable for children Not a questionnaire-style assessment:
caregiver questionnaire [68] guide for clinicians for case history
taking
Pediatric dysphagia case history form and NR Suitable for infants Not a questionnaire-style assessment:
caregiver questionnaire–Infant 0–6 months guide for clinicians for case history
[68] taking
Parent Mealtime Action Scale [69] PMAS Assesses children’s mealtime environment Less than 50 % swallowing/feeding
related
Assessment designed to investigate
factors related to obesity
Assesses parental behaviours around
mealtimes rather than child
Parental questionnaire (pre-surgery NR Suitable for children aged 0;9–4;9 Less than 50 % swallowing/feeding
macroglossia) [70] related
Investigates impact of macroglossia
including but not focused on
swallowing/feeding function
Post saliva surgery form [55] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses ability to control saliva,
rather than swallowing/feeding
function
Reflux [65] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses gastroesphageal reflux only
Saliva control assessment [55] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses ability to control saliva,
rather than swallowing/feeding
function
Saliva control assessment Form [71] NR Suitable for children Less than 50 % swallowing/feeding
related
Assesses ability to control saliva,
rather than swallowing/feeding
function
Swallowing Ability and Function Evaluation SAFE Assesses swallowing function Not used with target population
(Pro-ed) [72] (children or infants)
Swallowing disorders treatment complete kit— NR Assesses swallowing function Not used with target population
second edition (Pro-ed) [73] (children or infants)
Swallowing Quality of Life Questionnaire SWAL- Questionnaire for children Assesses parent’s (QoL), rather than
(adapted for use with pediatric patients) [74] QoLb the child
Videofluorographic examination of swallowing NR Suitable for children Not a questionnaire-style assessment:
[45] assessment via video
a
Acronyms have been used throughout the article where possible, for assessments without acronyms, full names have been used
b
While the authors referred to this assessment using the same abbreviation (SWAL-QoL) as the adult version of this assessment, these two
assessments are not identical. The listed assessment has been modified in order to assess the quality of life of the parents of children with feeding
disorders

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 Table 5 Overview of included non-instrumental assessment tools for swallowing and feeding function in children (n = 30)
Assessment Acronyma Inclusion criteria

About Your Child’s Eating [75] AYCE Majority of items related to behaviours around mealtimes
Behavior focused feeding assessment [76] NR Majority of items related to behaviours around mealtimes as well as feeding function and sensory aspects to
feeding
Behavioral assessment scale of oral functions in feeding [77] BASOFF Majority of items related to oral motor and feeding function
Brief Assessment of Motor Function (Oral Motor Deglutition BAMF- Oral motor scale for deglutition related to oral motor and feeding level of functioning
scale) [78] OMD
Brief Autism Mealtime Behavior Inventory [79] BAMBI Majority of items feeding behaviour and feeding sensation related
Children’s Eating Behavior Inventory [80] CEBI Majority of items related to feeding and behaviour around mealtimes
Clinic/Bedside oral-sensorimotor feeding assessment worksheet NR Majority of items related to oral motor skills, feeding function and some case history
[81]
Clinical evaluation of pediatric dysphagia [40] NR Majority of items related to physical structures involved in feeding, feeding and swallowing function and oral
motor skills
Clinical feeding evaluation of infants [82] NR Majority of items related to early feeding skills and reflexes
Developmental pre-feeding checklists [65] NR Majority of items related to expected feeding skills for developmental stages
Dysphagia Disorder Survey [83] DDS Majority of Items oral motor and feeding related
Early Feeding Skills Assessment [84] EFS Majority of items related to early feeding skills
Eating profile [85] NR Majority of items related to behaviour and environmental factors of feeding
Feeding and Swallowing Questionnaire [86] FSQb Majority of items related to feeding for children with complex feeding needs
Feeding assessment [87] NR Majority of Items related to feeding environment with consideration of some QoL factors
Feeding questionnaire [88] NR Majority of items related to feeding of infants
Feeding Strategies Questionnaire [89] FSQb Majority of items related to behaviours around mealtimes
Mealtime behavior questionnaire [90] NR Majority of Items related to child feeding behaviours
Multidisciplinary Feeding Profile [91] MFP Majority of items feeding related over many different domains
Neonatal Oral-Motor Assessment Scale [92] NOMAS Majority of items related to motor functioning of jaw and tongue during feeding
Oral motor and feeding evaluation [77] NR Majority of items related to oral motor skills and feeding skills
Oral Motor Assessment Scale [93] OMAS Items related to oral-motor functioning and movements
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

Parental feeding questionnaire [94] NR Majority of items related to behaviour around mealtimes and oral intake
Pediatric Assessment Scale for Severe Feeding Problems [95] PASSFP Majority of items feeding related for children with severe feeding difficulties
Pediatric dysphagia clinical evaluation [68] NR Majority of items related to required physiology/neurology for feeding and feeding function with trials
Pre-Speech Assessment Scale [96] PSAS Majority of Items feeding and oral-motor related
Preterm Infant Breastfeeding Behavior Scale (revised) [97] PIBBS Majority of items related to early feeding skills and reflexes
Schedule for Oral Motor Assessment [98] SOMA Majority of items related to oral motor and feeding function
Screening Tool of Feeding Problems, modified for children [99] STEP– Majority of items sensation of feeding and feeding behaviour related
Child
Systematic Assessment of the Infant at Breast [100] SAIB Majority of items related to early feeding skills and positioning.
a
Acronyms have been used throughout the article where possible, for assessments without acronyms, full names have been used
b

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These two assessments have been referred to by their full title throughout this manuscript as they have been designated the same acronym by their respective authors
 Table 6 Characteristics of non-instrumental assessment tools for swallowing and feeding function in children: Completed by parents/caregivers (n = 11)
Assessment (alphabetical Assessment Target population (age) Scale titles Number of scales Response options Cut off (Normal Time
order) format (number of items) (total number of items); vs. Abnormal)

123
Range of score

About Your Child’s History Children with chronic Negative interactions (6) 3 (15); Range:15–75 5-point ordinal scale NR NR
Eating (AYCE) [75] illnesses (8;0–18;11) Positive interactions (4)
Neutral situations (5)
Brief Autism Mealtime Observations Children with ASD Feeding behaviours (18) 1 (18); Range: 18–90 5-point scale NR NR
Behavior Inventory (3;0–11;11)
(BAMBI) [79]
Children’s Eating History Children with eating and Child (28) 2 (40; Range Total Eating Mixed: 5-point ordinal NR Approximately
Behavior Inventory mealtime disorders Parent (8 or 12 dependent on Problem score: scale (some negatively 15 min
(CEBI) [80] (2;0–12;11) presence of spouse in family) 40–200) scored), Binary scoring
Range perceived
problems: 0–40
Eating profile [85] History Children with ASD Child identification (12) 12 (157); Range: NR Mixed: 3/4/5-point ordinal NA NR
(3;0–12;11) and their Dietary history of the child (16) scales, Binary scoring,
parents Multiple options
Child health (8)
Family dietary history (7)
Child mealtime behaviours (23)
Food preferences (19)
Autonomy with eating (11)
Behaviours outside mealtime (12)
Impact on daily life (8)
Strategies used to resolve
difficulties encountered at
mealtime (31)
Communication abilities (8)
Socio–economic factors (2)
Feeding and swallowing History Children with CP Feeding and swallowing skills 1 (18); Range: NR Mixed: Binary, Open NR NR
questionnaire [86] (0;11–4;10) (18) ended, VAS
Feeding assessment [87] History Children with PKU Feeding environment (13) 1 (13); Range: NR Mixed: 4/11-point ordinal NR NR
(1;0–5;11) scales, Multiple options,
Open ended
Feeding Questionnaire History Infants born prematurely: Feeding behaviours (17) 1 (19); Range: NR Mixed: 3/4/5-point ordinal NR NR
[88] 25–36 weeks gestation scales, Binary scoring
(Measured at 0;3, 0;6
and 1;0)
Feeding strategies History Children (2;0–6;11) Strategies used during mealtimes 1 (40); Range: 40–200 5-point ordinal scale NR NR
questionnaire [89] by parents (40)
Mealtime behavior Observations Children (2;0–6;11) Mealtime behaviours (33) 1 (33); Range: 33–165 5-point ordinal scale Normal \100 NR
questionnaire [90] Abnormal C100
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…
 Table 6 continued
Assessment (alphabetical Assessment Target population (age) Scale titles Number of scales Response options Cut off (Normal Time
order) format (number of items) (total number of items); vs. Abnormal)
Range of score

Parental feeding History Children with feeding Parental feeding/perception 4(23); Range: NR Mixed: 4-point ordinal NR NR
questionnaire [94] disorders (0;6–3;0) of child’s feeding (4) scale, Binary scoring
Mealtime behaviour (11)
Food refusal and struggle for
control (6)
Neophobia (2)
Screening Tool of History Children with ASD Chewing problems (3) 6 (15 frequency, 15 3-point ordinal scale Rapid Eating: 0–1 NR
Feeding Problems, or other conditions Rapid Eating (3) severity); Food Refusal: 0-1
modified for children (2;0–18;11) Range Chewing
(STEP-child) [99] Food refusal (3) Food Selectivity: 1–2
problems: 0–9 (each
Food Selectivity (2) frequency and severity) Vomiting: 0–1
Vomiting (2) Range Rapid eating: 0–9 Stealing food: 0–1
Stealing food (2) (each frequency and Scores for both frequency
severity) and severity of difficulties
Range Food refusal: 0–9
(each frequency and
severity)
Range Food selectivity:
0–6 (each frequency
and severity)
Range Vomiting: 0–6
(each frequency and
severity)
Range Stealing food: 0–6
(each frequency and
severity)
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

123
 Table 7 Characteristics of non-instrumental assessment tools for swallowing and feeding function in children: Completed by clinicians (n = 18)
Assessment (alphabetical Assessment Target population (age) Scale titles (number of items) Number of scales (total Response options Cut off Time
order) format number of items); (Normal vs.

123
Range of score Abnormal)

Behavior focused feeding Observations Unspecified General development and 6 (104) Range: NR Mixed: Binary, Multiple NR NR
assessment [76] and history (assumed &2;0–12;0) background (5) options, Open ended
Feeding history (7)
Feeding environment used most
often for meals (11)
Mealtime habits (5)
Current feeding problems (47)
Feeding techniques (29)
Behavioral Assessment Scale Observations Children with severe to Assessment of oral motor skills 1 (14); Range: 14–84 6-point ordinal scale NR NR
of Oral Functions in Feeding profound developmental relating to feeding ability (14)
(BASOFF) [77] delays (0;10–21;6)
Brief Assessment of Motor Observations Children (0;6–20;0) Articulation (10) 2 (1); Range: 0–10 per 11-point ordinal scale NR \5 min if parent is present,
Function (Oral Motor Oral motor deglutition (10) scale according to description 10–15 min if parents are
Deglutition scale) (BAMF- of maximum motor absent
OMD) [78] performance during
deglutition
Clinic/Bedside Oral- Observations Unspecified Presenting problem (6) 14 (99) Rang: NR Mixed: 3/4/5/6-point NR NR
Sensorimotor Feeding (assumed & 0;6–6;0) Reasons for referral (7) ordinal scale,
Assessment Worksheet [81] Binary Scoring, Multiple
Developmental levels (6)
Options, Open ended,
Position for feeding (1)
Ratio Scale
Posture for feeding (1)
Primary feeders (1)
Liquid (2)
food textures (1)
Enjoyment/Behaviour during
mealtimes (1)
Related interfering patterns (3)
General problems (6)
Oral-motor function during
feeding (62)
Problem summary (1)
PO feeding summary (1)
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…
 Table 7 continued
Assessment (alphabetical Assessment Target population (age) Scale titles (number of items) Number of scales (total Response options Cut off Time
order) format number of items); (Normal vs.
Range of score Abnormal)

Clinical evaluation of Observations Unspecified Physiologic status (8) 8 (114) Range: NR Mixed: 3/4/7-point ordinal NR NR
pediatric dysphagia [40] (assumed & 0;0–2;0) Stress cues During Feeding (5) scale, Binary scoring,
Multiple options, Open
general postural control/tone
ended, Ratio scale
(16)
Oral structure and function (43)
Cranial nerve screening (4)
Swallowing/feeding evaluation
(16)
Presentation information (14)
Oral-motor/swallowing Patterns
(8)
Clinical feeding evaluation Observations Infants State(6) 6 (63); Range: NR Mixed: 3/4/6-point ordinal NR NR
of infants [82] Motor Control (6) scales, Binary scoring,
Multiple options, Open
Tactile (5)
ended, Ratio scale
Oral-Motor (7)
Suck Swallow Breathe (21)
Physiologic Control (23)
Developmental Pre-Feeding Observations Infants: 0;1–2;0 1 month (7) 15 (82) Range: NR 3-point ordinal NR, assumed developmental age of
Checklists [65] 3 months (6) to adjust the child
according to
4–6 months (1)
5 months (1)
5 or 6 months (3)
6 months (11)
7 months (3)
8 months (2)
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

9 months (9)
10 months (1)
12 months (11)
15 months (5)
18 months (8)
21 months (1)
24 months (13)
NR

123
 Table 7 continued
Assessment (alphabetical Assessment Target population (age) Scale titles (number of items) Number of scales (total Response options Cut off Time
order) format number of items); (Normal vs.

123
Range of score Abnormal)

Dysphagia Disorder Survey Observations Children with Related factors (7) 2(15); Range Related Binary Scoring NR 10–15 min
(DDS) [83] developmental Feeding/swallowing Factors: 0–7
disabilities (2–21 years) competency (8) Range Swallowing/
feeding competency:
0–8
Early Feeding Skills Observations Infants Oral feeding readiness (5): If 3 (35); Range: NR Mixed: Oral Feeding NR NR
Assessment (EFS) [84] patient fails this domain cease Readiness: Binary
assessment Oral Feeding Skills: 3/4-
Oral feeding skills (26) point scales
Oral feeding tolerance (4) Oral Feeding Tolerance:
Binary
Multidisciplinary Feeding Observations Children with Physical/Neurological (11) 6 (136); Range: Mixed: 3/4/5/6-point NR 30–45 min
Profile (MFP) [91] neurological disability Oral-facial structure (23) 184–583 ordinal scales,
(6;0–18;11) Binary scoring, Multiple
Oral-facial sensory inputs (4)
options
Oral-facial motor function (22)
Ventilation/phonation (4)
Functional feeding assessment
(72)
Neonatal Oral-Motor Observations Neonates born Jaw (13) 2 (26); Range: NR Binary scoring NR NR
Assessment Scale prematurely to Tongue (13)
(NOMAS) [92] 8 weeks corrected
Oral Motor Assessment Scale Observations Children with CP Oral motor skills (7) 1 (7); Range: 0–21 3-point ordinal scale Normal = 21 NR
(OMAS) [93] (3;0–13;11) Abnormal \21
Oral Motor and Feeding Observations Unspecified History (81) 2 (150) Range: NR Mixed: 2/3/4-point ordinal NR NR
Evaluation [77] and History (assumed & 0;0–2;0) Physical examination (69) scale, Binary scoring,
Multiple options, Open
ended, Ratio scale
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…
 Table 7 continued
Assessment (alphabetical Assessment Target population (age) Scale titles (number of items) Number of scales (total Response options Cut off Time
order) format number of items); (Normal vs.
Range of score Abnormal)

Pediatric Dysphagia Clinical Observations Unspecified Alertness (3) 14 (144) Range: NR Mixed: 2/3/4/7-point NR NR
Evaluation [68] (assumed & 0;6–6;0) Physiologic status (12) ordinal scale, Binary
Scoring, Interval scale,
Primitive reflexes (10)
Multiple options, Open
Abnormal reflexes (3) ended, Ratio scale
Physical Strength, stability and
posture (6)
Oral-facial structures (35)
Feeding presentation (15)
Sucking observations (19)
Spoon feeding observations (10)
Cup feeding observations (11)
Bite/chew observations (8)
Swallow observations (4)
Stimulability (1)
Recommendations (7)
Pre-Speech Assessment Scale Observations Children with CP Feeding Behaviour (4) 6 (27 positive, 27 Both positive and negative Positive score 24 months = 24 points)
(PSAS) [96] or other significant Sucking (3) negative scores); scores ordinal scales should be Negative score:
disabilities (0;0–2;1) Range Positive score (number of points varies equal to age
Swallowing (5) Normal = 0
per item: 0–25 per item) in months
Biting/chewing (4) (e.g. Atypical: [0
Range Negative score
Respiration/phonation (6)
per item: 0–9
Sound play (5)
Positive and negative scores are
recorded for each item.
Positive scores represent the
presence of normally
developing skills. Negative
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

scores represent the presence

of behaviours not present in
typically developing children
2‘–3 h
Preterm Infant Breastfeeding Observations Infants (both term Breast feeding behaviours (12) 1 (8); Range: NR Mixed: 3/5/8-point ordinal NR NR
Behavior Scale (revised) and pre term) scales, Binary scoring,
(PIBBS) [97] Multiple options, Ratio
scales

123
 Table 7 continued
Assessment (alphabetical Assessment Target population (age) Scale titles (number of items) Number of scales (total Response options Cut off Time
order) format number of items); (Normal vs.

123
Range of score Abnormal)

Schedule for Oral Motor Observations Infants (0;8–2;0) Puree (14) 4 (113); Range Mixed: Binary scoring, Puree: normal Assessment: 15–20 min
Assessment (SOMA) [98] Semi-solid (13) Puree: 0–9 Multiple choice, Open \3 Scoring: 10–20 min
Range Solids: 0–9 ended, Ratio Scales Semi Solids:
Solid (14)
Range Cracker: 0–22 normal \4
Cracker (26)
Range Bottle: 0–9 Solids: normal
Bottle (14)
\4
Trainer cup (19) Range Trainer cup:
0–14 Cracker:
Cup (13) normal \9
Range Cup: 0–9
Bottle: normal
\5
Trainer Cup:
normal \5
Cup: normal
\5
Systematic Assessment of the Observations Infants Alignment (5) 4 (18); Range: NR Binary scoring NR NR
Infant at Breast (SAIB) Areolar grasp (8)
[100]
Areolar compression (2)
Swallow (3)
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

Table 8 Characteristics of non-instrumental assessment tools for swallowing and feeding function in children: Completed by parents/caregivers
or clinicians (n = 1)
Assessment (alphabetical Assessment Target population Scale titles (number Number of scales Response Cut off Time
order) format (age) of items) (total number of options (Normal
items); Range of vs.
score Abnormal)

Pediatric Assessment History Infants ([0;4) with If patient fails Part A 1 (15); Range: 0–66 Mixed: 5/6- Normal 5 min
Scale for Severe severe feeding of the tool, do not point ordinal [37
Feeding Problems problems who conduct scale,
(PASSFP) [95] feed orally assessment. Multiple
Feeding and options
swallowing skills
(15)

and Feeding Evaluation [77], Pediatric Dysphagia Clinical Child’s Eating (AYCE) [75], and one assessment was
Evaluation [68], Schedule for Oral Motor Assessment developed to assess swallowing or feeding difficulties in
(SOMA) [98], and Systematic Assessment of the Infant at children with phenylketonuria as the target population:
Breast (SAIB) [100]. Three assessments were developed to Feeding Assessment [87].
assess swallowing and feeding function in infants born Age ranges for all the assessment varied greatly, ranging
prematurely: Feeding Questionnaire [88], Neonatal Oral- from birth of premature infants to adults (Fig. 2). Twelve
Motor Assessment Scale (NOMAS) [92], and Preterm assessments targeted infants and children between birth and
Infant Breastfeeding Behavior Scale (revised) (PIBBS) 2 years of age (only); a time where typically developing
[97]. One assessment was specifically developed to inves- children are still developing their ability to swallow and feed
tigate infants (of unspecified gestational ages) with severe [1]: Clinical Evaluation of Pediatric Dysphagia, Clinical
swallowing and feeding difficulties: Pediatric Assessment Feeding Evaluation of Infants, Developmental Pre-Feeding
Scale for Severe Feeding Problems (PASSFP) [95]. Checklists, EFS, Feeding Questionnaire, NOMAS, Oral
Six assessments were developed to assess children with Motor and Feeding Evaluation, PASSFP, PSAS, PIBBS,
no specified illnesses other than having potential swal- SOMA, and SAIB. Seven assessments investigated swal-
lowing or feeding difficulties: Behavior Focused Feeding lowing and feeding function in a range of ages beginning
Assessment [76], Brief Assessment of Motor Function within 0–2 years and continuing up to childhood or adult-
(Oral Motor Deglutition scale) (BAMF-OMD) [78], Chil- hood: BASOFF, BAMF- OMD, Clinic/Bedside Oral-Sen-
dren’s Eating Behavior Inventory (CEBI) [80], Feeding sorimotor Feeding Assessment Worksheet, Feeding and
Strategies Questionnaire [89], Mealtime Behavior Ques- Swallowing Questionnaire, Feeding Assessment, Parental
tionnaire [90], and Parental Feeding Questionnaire [94]. Feeding questionnaire, and Pediatric Dysphagia Clinical
Three assessments were developed to assess swallowing or Evaluation. Finally, 11 assessments investigated swallowing
feeding difficulties in children with autism spectrum dis- or feeding function in populations with ages beginning in
orders (ASD) as the target population: BAMBI, Eating early childhood and extending through to middle childhood
Profile [85], and Screening Tool of Feeding Problems, or up to adulthood: Behavior Focused Feeding Assessment,
modified for children (STEP-Child) [99]. Four assessments BAMBI, CEBI, Eating Profile, Feeding Strategies Ques-
were developed to assess swallowing and feeding diffi- tionnaire, Mealtime Behavior Questionnaire, OMAS,
culties in children with cerebral palsy (CP) or other neu- AYCE, DDS, MFP, and STEP-Child.
rological conditions as the target populations: Feeding and
Swallowing Questionnaire [86], Multidisciplinary Feeding Assessment Design
Profile (MFP) [91], Oral Motor Assessment Scale (OMAS)
[93], and Pre-Speech Assessment Scale (PSAS) [96]. Two There were many different response options used in the
assessments were developed to assess swallowing or assessments including binary scoring, ordinal scales, ratio
feeding function in children with ‘‘developmental delay’’ scales, visual analogue scales (VAS), questions with mul-
as the target population: behavioral assessment scale of tiple options, and open questions; 17 of the 30 assessments
oral functions in feeding (BASOFF) [77] and Dysphagia used a combination of multiple response options (Tables 6,
Disorder Survey (DDS) [83]. One assessment was devel- 7, 8). The length of assessments also varied; one assess-
oped to assess swallowing or feeding difficulties in children ment consisted of a single scale and seven items (OMAS),
with chronic illnesses as the target population: About Your while another had 12 subscales and 157 items (Eating

123
 D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

Fig. 2 Overview of non-instrumental assessment tools for swallowing and feeding function in children: Age ranges are shown for each
assessment. Arrows indicate assessments with age ranges extending higher than 18 years. Where no specific ages were given, the terms used
within the text have been provided (where possible) and estimates of appropriate ages have been given according to the authors’ discretion

Profile) (Tables 6, 7, 8). Twenty-three of the 30 assess- Questionnaire, NOMAS, Oral Motor and Feeding Evalua-
ments did not specify the time required to administer the tion, Parental Feeding Questionnaire, Pediatric Dysphagia
assessment; however, the administration times that were Clinical Evaluation, PIBBS, and SAIB. The remaining
reported ranged from 5 min (BAMF-OMD and PASSFP) to eight assessments provided no instruction for interpretation
2 ‘–3 h (PSAS). of the results.

Assessment Domains
Scoring
The following assessment domains were identified: oral
Six assessments provided instruction for scoring and were motor skills, behaviors related to swallowing or feeding
designed with cut-off scores to distinguish between normal function, environmental factors related to functional
versus abnormal swallowing or feeding function: Mealtime swallowing and feeding, physical swallowing or feeding
Behavior Questionnaire, OMAS, PSAS, PASSFP, SOMA, skills, QoL in relation to swallowing or feeding difficulties,
and STEP-Child. Sixteen of the 30 assessments used and sensory aspects of swallowing or feeding function
qualitative descriptors rather than a numerical scoring (Table 9). Twenty-three assessments included items
system: Behavior Focused Feeding Assessment, Clinical specific to the domain of swallowing or feeding skills, 17
Evaluation of Pediatric Dysphagia, Clinical Feeding assessments included items specific to oral-motor skills, 10
Evaluation of Infants, Clinic/Bedside Oral-Sensorimotor included items specific to behavioral aspects of swallowing
Feeding Assessment Worksheet, Developmental Pre- or feeding, six included items specific to environmental
Feeding Checklists, Eating Profile, EFS, Feeding and aspects of swallowing and feeding, five included items
Swallowing Questionnaire, Feeding Assessment, Feeding related to sensory aspects of swallowing or feeding, and

123
D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

Table 9 Overview of non-instrumental assessment tools for swallowing and feeding function in children: Assessment domains
Assessment Assessment domains
Oral Behavioural Environmental Feeding/ QoL Sensory Additional areas of
motor swallowing assessment

About Your Child’s Eating (AYCE) [75] d

Behavior Focused Feeding Assessment [76] d s d s
Behavioral Assessment Scale of Oral d d
Functions in Feeding (BASOFF) [77]
Brief Assessment of Motor Function (Oral d d
Motor Deglutition scale) (BAMF-OMD)
[78]
Brief Autism Mealtime Behavior Inventory d s
(BAMBI) [79]
Children’s Eating Behavior Inventory (CEBI) d s d QoL of parents
[80]
Clinic/Bedside Oral-Sensorimotor Feeding d d History of feeding
Assessment Worksheet [81]
Clinical Evaluation of Pediatric Dysphagia d d Anatomical structures,
[40] physiological stability
Clinical Feeding Evaluation of Infants [82] d d Physiological stability during
feeding
Developmental Pre-Feeding Checklists [65] d
Dysphagia Disorder Survey (DDS) [83] d s s d
Early Feeding Skills Assessment (EFS) [84] d d
Eating Profile [85] d d
Feeding and Swallowing Questionnaire [86] d
Feeding Assessment [87] d s
Feeding Questionnaire [88] d
Feeding Strategies Questionnaire [89] d
Mealtime Behavior Questionnaire [90] d
Multidisciplinary Feeding Profile (MFP) [91] d d d Neurological and anatomical
Neonatal Oral-Motor Assessment Scale d d
(NOMAS) [92]
Oral Motor and Feeding Evaluation [77] d d Physical examination
Oral Motor Assessment Scale (OMAS) [93] d d
Parental Feeding Questionnaire [94] s d
Pediatric Assessment Scale for Severe d s d s s
Feeding Problems (PASSFP) [95]
Pediatric Dysphagia Clinical Evaluation [68] d d Physical examination
Pre-Speech Assessment Scale (PSAS) [96] s d
Preterm Infant Breastfeeding Behavior Scale d d
(revised) (PIBBS) [97]
Schedule for Oral Motor Assessment (SOMA) s d
[98]
Screening Tool of Feeding Problems, d s s
modified for children (STEP-Child) [99]
Systematic Assessment of the Infant at Breast d d Alignment and positioning of
(SAIB) [100] infant during breastfeeding
d Denotes categories comprising a major portion of the assessment
s Denotes categories present but only comprising a minor portion of the assessment

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 D.-E. Heckathorn et al: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments…

two included items specific to QoL aspects of swallowing standardized appraisal tool that is valid and reliable itself,
or feeding. Twenty-three of the 30 assessments covered such as the consensus-based standards for the selection of
more than one domain, with two of the assessments cov- health measurement instruments (COSMIN) in order to
ering four of the six domains. inform clinicians about the reliability and validity of the
assessments that they use [102, 103].
With so little research into the reliability and validity of
Discussion existing assessments, it would be beneficial to prioritise
research on developing the psychometric characteristics of
Variations Among Assessments existing assessments to build this area of research to a
higher, more rigorous, and evidence-based standing.
The swallowing and feeding assessments included in this Selecting the most robust clinical assessments based on the
review demonstrated variability in terms of target popula- quality of its psychometric properties will result in more
tions, the design of each assessment, and the assessment sound clinical reasoning, selecting appropriate interven-
domains. This variation likely reflects the need to capture a tions based on valid and reliable assessment scores, and
wide range of children with swallowing or feeding diffi- greater confidence in documenting clinical progress and
culties across multiple domains (e.g., a combination of changes over time [104].
behavioral and sensory difficulties) and who have multiple
risk factors (e.g., neurological conditions and a develop-
mental disorder) [27, 101]. As a result, the variation among
Conclusion
these assessments reflects the diversity and complexity of
the target populations and is also likely to reflect the
Many non-instrumental assessments are available to clini-
diversity of both the professionals involved and their
cians to evaluate swallowing and feeding function in
clinical settings, each with their unique approach to clinical
pediatric populations. These assessments vary widely in
practice and resource restrictions (such as availability of
design, assessment domains, and target groups or popula-
time, equipment, or finances).
tions. A lack of instruction for use and interpretation of
assessment scores was evident, indicating that many of
Validity and Reliability
these assessments may be at risk for inconsistent use and
misinterpretation of results. This review highlights char-
The aim of this report was to provide clinicians with an
acteristics of the assessments for clinicians to support them
overview of a broad range of non-instrumental swallowing
in selecting appropriate assessments for clinical practice.
and feeding assessments. While this manuscript does not
This paper also highlights the need for future research to
investigate the psychometric quality of the assessments, the
comprehensively evaluate the quality of psychometric
review of the assessments made it apparent that there is a
properties of the retrieved assessments as many tools
proliferation of feeding assessments that have been devel-
appeared to lack robust data on their reliability and valid-
oped for infants and children with limited research inves-
ity. As the use of assessments without known psychometric
tigating the quality of the psychometric properties of these
properties may result in outcome data that are not evi-
assessments. This gap became apparent with the lack of
dence-based and cannot be interpreted correctly, a psy-
information available to support standardized interpretation
chometric review will assist in guiding future choices in the
of many of the assessment scores, and also in a lack of
assessment and treatment planning.
consideration for validity and reliability of many of the
assessments during their development. Compliance with Ethical Standards
It is also concerning to note that many assessments
within this review appear not to have been assessed for Conflict of interest The authors declare that they have no conflict
of interest.
validity and reliability within the populations they are
being used, raising the question as to whether they should
be used at all. A recent psychometric review has been
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