Clinical feeding evaluation
All children were initially assessed clinically by the OT, following referral from a number of sources, including hospital departments, outpatient clinics and community settings. The case notes of those assessments were reviewed by an experienced OT for this study. The eight-point penetration-aspiration score, validated and previously used in children10, 11 was converted into a simplified format, as previously described,6 to facilitate comparison between CFE and VFSS and calculation of the predictive value of CFE with respect to the presence of suspected overt or silent aspirations, as compared to the VFSS gold standard (table 1). For this purpose, penetration was regarded as no aspiration. The presence of aspirations was noted separately for each texture trialed. However, in the final diagnosis, aspiration referred to a positive finding for one or more food textures. Silent aspiration (SA) was suspected and scored clinically when there were anamnestic clues and subtle signs, such as a wet/ phlegmy vocal quality, lack of speech, a decrease in alertness, drooling, difficulty controlling secretions and an absent gag reflex.12