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.