INTRODUCTION
The act of swallowing is one of the most complex bodily functions and
involves seamless co-ordination of voluntary and involuntary
neuromuscular activities resulting in the propagation of liquid and food
boluses from the mouth through the pharynx and into the esophagus. A
wide array of structural and developmental disorders in childhood are
associated with swallowing dysfunction. This can lead to aspiration of
foreign material into the lung, predisposing to respiratory morbidity
and sometimes mortality,1 in children
with2 and without3, 4 underlying
neurological abnormalities. Adequate diagnosis and treatment of
disordered swallow is paramount to avoid aspiration, safeguard adequate
nutritional intake and hydration whilst minimizing health complications
and stress to the child and caregiver. Clinical feeding evaluations
(CFE) of children with suspected aspiration play an important role in
the diagnosis of swallowing disorders and identification of those who
require intervention and further instrumental
assessment.5 CFE are the domain of occupational
therapists (OT) or speech and language therapists (SLT). The therapist
first inspects the face and oropharynx for anatomic abnormalities. Next,
a variety of different textures are offered and the swallowing process
is closely observed, auscultating for respiratory sounds, paying
attention to the voice quality, cough and respiratory distress. In many
cases this evaluation and training is considered sufficient,
particularly when there are clear overt symptoms on testing and these
improve following intervention. These children are often not referred
for further evaluation.
Video fluoroscopy swallow studies (VFSS) are considered the gold
standard for the assessment of swallow and are best performed for
children following CFE by collaboration between the OT or SLT and the
pediatric radiologist.6 Using a variety of
radiolabeled textures, precise information is obtained about anatomy as
well as function, including oro-pharyngeal transit time, pharyngeal
motility and pooling of material in the vallecula and pyriform sinuses.
Textures posing the least aspiration risk to the child are identified.
However, VFSS is resource intensive, and considerable doses of radiation
are administered.
Whilst CFE offer a first indication of the child’s ability to swallow
secretions and different food textures, this may be insufficient in
cases with higher morbidity or when there is uncertainty regarding the
safety of a particular food texture. Overt aspirations (OA) may be
readily identified by CFE, but silent aspirations (SA), the passage of
food stuff below the cords without a corresponding protective cough
reflex, are more difficult to diagnose clinically.5,6Recent studies suggest that CFE may not adequately predict aspiration
risk in children7 and that the sensitivity and
specificity of CFE are decreased when compared with
VFSS.8
The aim of the present study was to determine the reliability of the CFE
in making a diagnosis of overt and silent aspiration compared with VFSS
in children. Additional aims were to describe the impact of CFE and VFSS
on feeding recommendations and evaluate clinical status one year post
VFSS and feeding intervention, as compared to one year prior to VFSS.