20Q: Evaluation and Management of Pediatric Dysphagia

From the Desk of Ann Kummer

It gives me great pleasure to introduce this article on Pediatric Dysphagia, written by my colleague and good friend, Dr. Claire Miller, PhD, MHA, CCC-SLP.  I have had the privilege of working closely with Dr. Miller for over 30 years at Cincinnati Children’s Hospital Medical Center. As such, I am very familiar with her strong reputation as a master clinician and also her incredible reputation as a talented educator, mentor, and author. Through her research and also through her multiple publications and presentations, Claire has brought national and international recognition to the dysphagia program and the Interdisciplinary Feeding Team at Cincinnati Children’s.

Here is more information about Dr. Claire Miller:

Dr. Miller holds a clinical and research position in the Division of Speech-Language Pathology and also serves as the Program Director of the Aerodigestive and Esophageal Center at Cincinnati Children’s Hospital Medical Center, which includes the Interdisciplinary Feeding Team. She is a field service associate professor- affiliate in the Department of Otolaryngology-Head and Neck Surgery at the University of Cincinnati College of Medicine and is an assistant professor - affiliate in the Department of Communication Sciences and Disorders at the University of Cincinnati.  Dr. Miller’s research and clinical interests are in the area of pediatric dysphagia, with a focus on instrumental swallowing assessment and clinical management of infants and children with congenital and acquired airway anomalies. She has authored numerous publications and is a co-author of the textbook entitled Medical Speech-Language Pathology: A Desk Reference, 4^th Edition.  She has presented nationally and internationally on aspects of pediatric dysphagia and as such, is highly respected as one of the world’s experts in this area.

In this course, Dr. Miller presents an overview of pediatric dysphagia with a specific focus on the role of the speech-language pathologist in the assessment and treatment of infants and children with dysphagia. Clinical protocols for clinical and instrumental assessments are reviewed and the options for treatment interventions are summarized. 

This article is interesting, well written and very informative.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q:  Evaluation and Management of Pediatric Dysphagia

Claire Kane Miller

1. What is pediatric dysphagia and what is the role of the speech-language pathologist?

Dysphagia, (dis-ˈfā-j(ē-)ə), according to the Merriam-Webster Dictionary, means difficulty in swallowing. Dysphagia may occur at any age, or in any of the phases of the swallow, which are generally referred to as the oral phase (preparation and transfer of food for swallowing), the pharyngeal phase (trigger of the swallow response with simultaneous closure of the airway) and the esophageal phase (transfer of the food to the stomach). Dysphagia is not a specific diagnosis or disease. Rather, it is a symptom caused by an underlying disease, disorder, structural abnormality, or condition.  

Short term dysphagia may occur in typically developing infants and children. For example, some children may have trouble with the transition from breastfeeding to bottle-feeding, or have difficulty progressing from pureed baby food to solid food textures. The incidence, prevalence, and complexity of dysphagia sharply increases in children with issues that affect the necessary structures and neurologic functions for efficient and safe feeding and swallowing (Bhattacharyya, 2015).  Such children may have difficulty achieving enough intake to sustain growth, or have swallowing difficulties that result in aspiration (food or liquid into the lungs).

How did speech-language pathologists (SLPs) get involved with the assessment and treatment of dysphagia in the first place? The speech-language pathologist’s expertise in the oropharyngeal components of speech and vocal production led to the application of this knowledge to adult dysphagic patients beginning in the late 1970s (Miller & Groher, 1993). Pioneering research by Dr. Jeri Logemann, SLP and her collaborations with both otolaryngology and gastroenterology laid the foundation for the role of the SLP in the management of dysphagia. Over the past several decades, SLPs have taken on a primary role in the clinical, instrumental, and management approaches to dysphagia in adults and children.  The pediatric SLP is recognized as an important member of the multidisciplinary team managing dysphagia in a range of patients and settings, which include the neonatal intensive care unit (NICU), the pediatric intensive care unit (PICU), rehabilitation units, school settings, and in the home.

2. What causes pediatric dysphagia?

Dysphagia in the pediatric population is becoming more common, particularly in children with chronic medical conditions (Hawdon, Beauregard, Slattery, & Kennedy, 2000). A major factor is the improved medical technology and ability to care for children born prematurely, or with complex medical conditions.  The causes of dysphagia are multiple and include neurologic, structural, cardiorespiratory, metabolic, sensory, and/or behavioral factors.

• Neurologic issues affect the sensory and motor functions of the central nervous system that are essential for swallowing. Traumatic brain injury, congenital brain malformations, brain tumors, or pediatric cerebrovascular accidents (CVAs) are neurologic causes of dysphagia.
• Any type of structural abnormality in the mouth, palate, pharynx, larynx, or esophagus may affect the functional aspects of feeding, and interfere with adequate airway protection during the swallow. Examples include conditions such as craniofacial anomalies or laryngeal anomalies (i.e. laryngeal cleft).
• Cardiorespiratory conditions affect endurance required for intake of adequate volume during feeding.  Such conditions include congenital structural or functional heart defects, and respiratory conditions such as cystic fibrosis or chronic lung disease. In addition, the coordination required between respiration and swallowing to prevent aspiration (entry of food or liquid into the airway) may be compromised.
• Underlying problems with metabolism may affect appetite and contribute to the development of feeding aversion and refusal.
• Sensory processing disorder (SPD) affects the child’s ability to interpret oral sensory input and integrate information and may affect the development of efficient feeding and swallowing skills  
• Behavioral etiologies such as disordered feeding interactions between the caregiver and the child, or behavioral issues that perpetuate food refusal, or texture selectivity. Choking episodes which may lead to swallowing phobia, and persistent avoidance of eating, or unusual behaviors such as extended chewing, or preference for certain textures.

3. What happens during the SLP’s clinical evaluation of dysphagia? What test(s) should I use?

The clinical oral motor feeding assessment is generally the first step in the overall diagnostic evaluation of dysphagia. The clinical assessment provides the basis for: (1) consideration of medical and developmental history on the feeding issues; (2) direct observation of oral sensorimotor skills and caregiver-child interactions during feeding; and (3) documentation of clinical signs and symptoms of possible swallowing dysfunction that threaten the safety and efficiency of feeding.

There is no single standardized assessment protocol that covers all aspects of pediatric dysphagia, given the diversity of age ranges and conditions. Assessment tools are geared toward specific conditions and age domains, and clinicians should be aware that further evaluation of the validity and reliability of some currently available assessments is necessary (Heckathorn, Speyer, Taylor, & Cordier, 2016). Suggested clinical templates for infants and children (developed by expert consensus) are available on the American Speech and Hearing Association (ASHA) website (www.asha.org).  

During the clinical assessment, the clinician performs an oral mechanism exam. Resting tone and posture, and the range and strength of oral motor movements necessary for feeding are assessed. Clinical signs and symptoms of possible swallow dysfunction during feeding are documented, including coughing, choking, color changes, changes in respiratory rate, wet or congested sounds, wet vocal quality, and decreased oxygen saturations. As the safety and efficiency of the swallow cannot be determined by the clinical evaluation alone, the clinical signs of swallowing dysfunction prompt referral for an instrumental study.

4. What is the SLP’s role in the instrumental assessment of swallowing, and what assessments are used?  

The instrumental assessments that are most often used for swallowing analysis in infants and children are the videofluoroscopic swallowing study (VFSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES). High-resolution pharyngeal manometry (HRPM) is an additional option. The SLP has an important role in each of these examinations.

The SLP typically works collaboratively with a radiologist during the VFSS. The VFSS provides a view of the oral, pharyngeal, and cervical (upper) esophageal phases of the swallow. Visualization of the swallow helps to identify the type of swallowing impairment present. The patient’s reaction to abnormalities in the swallowing process can be identified, and most importantly, therapeutic strategies can be introduced during the study to improve the efficiency and/or safety of the swallowing process. The VFSS requires that the child be able to ingest enough oral volume for a representative study, which is sometimes not realistic for patients who accept very limited volumes of liquid or food orally.

Pediatric FEES may be done independently by the SLP, or collaboratively with a pediatric otolaryngologist. During FEES, the transnasal passage of an endoscope allows anatomy and swallowing function to be viewed. The child’s ability to manage secretions, liquids, and solids can be assessed. The FEES study may be an adjunct or replacement study to the VFSS for children with negligible oral intake who are not able to undergo the VFSS. Performing FEES independently is within the scope of practice for the speech-language pathologist; however, rules differ between states as to the SLP’s role as the endoscopist.

High-resolution pharyngeal manometry (HRPM) for swallowing is a way to evaluate the pressure aspects of the swallow. Given that the movement of food or liquid during the swallow is a pressure-driven process, the analysis of the pressure components of the swallow provides significant insight into the nature of the swallowing problem. The use of HRPM is also within the scope of the SLP. Though it has been used most often in a research context, clinical use is becoming more widespread.

5. What other studies might be part of the workup of pediatric dysphagia? What should speech-language pathologists know?

The evaluation of pediatric dysphagia often involves multiple tests and procedures that do not involve the SLP. However, the SLP should have some general awareness about the components of the medical diagnostic workup. Endoscopic evaluations performed under anesthesia include microlaryngoscopy and bronchoscopy (MLB) and esophagogastroendoscopy (EGD) to rule out anatomic abnormalities such as laryngeal clefts, masses, or fistulas. Gastric emptying scans are a type of test that determine how quickly food and liquid are emptied from the stomach. Impedance studies detect the movement of food or liquid through the esophagus and the effectiveness of clearance. Esophageal pH monitoring measures the frequency and duration of acid reflux episodes. High-resolution chest CT provides information about pulmonary injury as a result of chronic aspiration.

6. What is an interdisciplinary feeding team, and when is it needed?

The input and expertise of multiple services is often necessary during evaluation and management of infants and children with dysphagia. The navigation between multiple different appointments and services can be overwhelming and frustrating to the family. The communication between services can be disjointed, leaving caregivers with the responsibility to relay information regarding findings and recommendations. A coordinated interdisciplinary team approach consolidates patient appointments, streamlines communication between services, and ultimately helps to coordinate care (McComish et al., 2016; Miller et al., 2001)  

Though interdisciplinary feeding team membership and evaluation protocol may vary by setting and patient condition, the overarching goal is to use an interdisciplinary approach to achieve the best outcome and quality of life for infants and children with pediatric dysphagia.

The typical organizational structure of an interdisciplinary feeding team includes a medical director and membership of multiple services, such as Gastroenterology, Otolaryngology, Nursing, Speech Pathology, Nutrition Therapy, Occupational Therapy, Social Work, and Psychology.  A developmental pediatrician, pediatric dentist, physiatrist, radiologist, and pediatric surgeon may also be members of the team. An administrative infrastructure for triage of referrals, multidisciplinary scheduling, and for generation of team reports and communications is necessary.

7. What is habilitation vs rehabilitation of pediatric dysphagia?

The terms habilitation and rehabilitation both refer to the act of learning skills.  The key difference is that rehabilitation refers to regaining skills that have been lost, whereas habilitation refers to learning new skills. In contrast to the adult who may undergo rehabilitation following a stroke to regain the skills needed for efficient oral intake and safe swallowing, an infant or child may not yet have developed the necessary sensorimotor skill set. For example, medical and physiologic factors may preclude infants and children from exposure to oral feeding during critical or sensitive learning periods for skill acquisition (Harris & Mason, 2017).  In such circumstances, the focus of treatment is upon providing compensatory strategies for eliciting (habilitating) the skills that emerge in the typical oral sensorimotor skill sequence, such as developing a suck-swallow on a pacifier, and then learning to coordinate the suck-swallow sequence during bottle feeding.

8. What are direct versus indirect dysphagia treatment approaches?

Treatment of dysphagia consists of both indirect and direct approaches. Direct treatment approaches involve rehabilitative maneuvers or specific exercises to change the physiology of the swallow. Examples include maneuvers such as head rotation, chin flexion, or a head tilt to modify the pathway of food or liquid as it is swallowed, or the use of an “effortful” swallow strategy to help with clearance of food or liquid. The use of direct maneuvers and exercises requires comprehension of directions, which is not always possible in children for developmental and/or cognitive reasons. Indirect strategies refer to compensatory techniques to eliminate symptoms of dysphagia and to improve the safety and efficiency of feeding/swallowing. Most of the dysphagia treatment in pediatric patients is compensatory in nature and include modification of positioning during feeding, the use of sensory input to help facilitate motor action, the use of specific equipment, and the use of differing consistencies of food and liquid. The therapist and the family work together to problem-solve options in the context of the treatment session.

9. How do the roles of the SLP and the occupational therapist differ in the evaluation and management of dysphagia?

Collaboration between the SLP and the occupational therapist (OT) is often beneficial in the evaluation and management of dysphagia. The OT is involved in the habilitation and rehabilitation of basic life skills, or “occupations” which include gross motor skills, fine motor skills, and daily living skills including feeding. OTs can help to improve postural stability, which facilitates safe feeding and swallowing. Speech-language pathologists have specialized training in head and neck anatomy and the oropharyngeal aspects of feeding and swallowing. The knowledge and skills from each discipline facilitates a team approach in the care of dysphagia patients. For example, the OT can address position and posture, adaptive feeding equipment, and the sensory issues that might be underlying feeding difficulty. The SLP may focus on bolus type (texture, flavor, temperature), method of delivery (slow flow nipple, fast flow nipple), or the use of either direct or indirect dysphagia treatment strategies. Often the SLP and OT can collaborate during an evaluation or treatment session to meet discipline-specific goals. For example, the OT may set a goal for independent feeding ability, while the SLP goal may be focused on strategies for safe and efficient feeding using direct or compensatory feeding techniques.

10. What is a Sensory Processing Disorder (SPD), and how does SPD affect feeding?

Sensory processing disorder (SPD) is a complex disorder that may affect both children and adults. It is estimated that 30% of children with disabilities and 5-10% of the population without disabilities experience atypical responses to sensory stimuli (Schaaf, (Schaaf et al., 2010). SPD involves one or more of the sensory systems (auditory, visual, tactile, olfactory, and taste). Individuals may over-respond or under-respond to sensory input, excessively seek sensory experiences, have difficulty discriminating sensations, or respond to sensory input in an atypical manner. The symptoms of SPD are reported to be more varied in children with autism spectrum disorder (ASD) as compared to typically developing children, affect multiple sensory systems, and impact upon many activities of daily living, including mealtime.

Children with sensory avoidant behavior display are hypervigilant, fearful, and anxious about perceived “threats” in the environment. For example, the presentation of foods that are out of a “preferred” range in terms of texture, or specific brand type may evoke a strong reaction. Sensory-seeking children tend to maintain a heightened state of arousal, become overexcited in response to stimulation, and demonstrate impulsivity. When eating, such children may demonstrate a tendency to over-fill their mouth with food, and/or exhibit extreme taste preferences for certain items, such as foods that are exceptionally spicy, sour, salty, or crunchy. In contrast, children with sensory discrimination challenges may have difficulty differentiating the sensations of being hungry or full and demonstrate poor awareness of food residue in the mouth, or the need to chew thoroughly prior to swallowing.

11. What are the types of intervention approaches for sensory processing disorders?

Models of intervention (SPD) include both individual therapy and group therapy designs that might involve co-treatment by both a speech-language pathologist and an occupational therapist. The use of play is the hallmark of a sensory integrative approach to treatment (Schaaf & Nightlinger, 2007). The child is actively engaged in sensory-based activities, with the goal of facilitating adaptive and organized responses to sensory inputs and environments. For example, the sensory qualities of food can be experienced through a variety of play interactions that do not involve eating the food initially. The exposures to food in a play context offer opportunities for olfactory exposure, visual exposure, and tactile exposure (touching or stirring the food). Food “play” should be separate from the meal or snack, so that the expectation is clear that the child is not expected to eat any volume of the food. As the child becomes familiar with the smell, texture, sight, and perhaps even the taste of the food through a sensory play experience, the food (or similar food) can be introduced as part of the meal or snack.

12. What types of behavioral interventions are used in feeding therapy?

Behavioral feeding problems range in severity, and include inappropriate mealtime behaviors (throwing foods, spitting), persistent food refusal, eating too fast or too slow, or gagging, choking, and possibly vomiting in response to non-preferred foods. The Diagnostic and Statistical Manual of Mental Disorders (5^th ed, DSM-V) provides the specific diagnostic criteria for the identification of behavioral feeding problems (Attia, Becker, Bryant-Waugh et al., 2013). Effective treatment of behavioral feeding problems requires the knowledge of behavioral principles and behavior interventions. The SLP may work in tandem with a pediatric psychologist who has expertise in applying behavioral principles to guide interventions. Behavioral interventions are based on learning principles and focus on strengthening certain behaviors while altering other (undesirable) behaviors. Behavioral intervention programs occur in the inpatient and outpatient day treatment settings. An inpatient admission for behavioral feeding treatment is advantageous in that intensive treatment frequency is possible. However, inpatient admissions may not be feasible or necessary in all cases.

13. How are social stories™ used in feeding therapy?

A “social story” is a treatment approach often used in language therapy that uses an individualized story to provide guidance for responses in a social situation (Kokina & Kern, 2010). The overall purpose is to help the child understand the parts of an upcoming situation that may be stressful (for example, visiting the dentist, or taking a taste or touching a new food in feeding therapy). Simple, descriptive and directive sentences are used within the story to provide the who, what, when, where, and why of the situation, and the target behavior. The story includes images and words that describe what will happen and sentences that give the child options for acceptable responses. For example, a social story might be used prior to feeding therapy to provide a simple explanation of what will happen in sequence, ending with a final activity that is reinforcing, such as time for play or a special story. The sequence of activities in the feeding session include specifics, such as the choices that will be made between foods, the number of bites required, and choices. For example, if a child is asked to touch or taste a non-preferred food (descriptive), possible responses are given (directives). “If I feel like gagging, I can take a deep breath, and ask for more time” or “If I put the food to my lips, and want to get it off, I can wipe it away with a napkin.”

14. What is the International Dysphagia Diet Standardization Initiative (IDDSI) all about?

Historically, there has been much variation in how food textures and liquids are described across settings. In 2012, a committee was formed to develop international standardized terminology and descriptors for the foods and liquids commonly used for patients with dysphagia. The International Dysphagia Diet Standardization Initiative (IDDSI) was developed by the committee as a global standard that uses standardized terminology and definitions to describe thickened liquids and modified food textures for dysphagic individuals of all ages, all cultures, and in all care settings (Steele et al., 2018). The IDDSI framework consists of a continuum of 8 levels (0-7) whereby liquids are measured from Levels 0-4, and foods are measured from Levels 3-7. Liquids are described as thin (0), slightly thick (1), mildly thick (2), moderately thick (3), and extremely thick (4). Foods are described as liquidized (3), pureed (4), minced and moist (5), soft and bite-sized (6) and regular (7), or regular easy to chew (7e).

15.  What issues need to be considered when using thickened liquids as a treatment strategy?

Thickening liquid has been one of the most commonly used intervention strategies for persons with dysphagia across the lifespan. For example, infants and children who demonstrate oral control issues, or a delayed swallowing response, benefit from the slower transit time of thickened liquid. The thicker liquid is easier to control orally, and the slower transit of the liquid may lessen the chance of liquid aspiration. However, there are potential problems with the use of thickened liquids. The use of gum-based thickeners adds volume, but no calories, and therefore, an infant must ingest more fluid volume to achieve the same calorie and nutrient intake. In contrast, if rice cereal is used as a thickening agent, it is possible that the infant may ingest too much of certain nutrients, such as iron. Therefore, it is essential that the SLP confer with the managing physician prior to making recommendations about thickening liquid.

16. What types of ethical issues could arise in the management of pediatric dysphagia?

The primary ethical principles used in health care, and a model of decision-making that incorporates both ethical theory and principles can be applied to dysphagia care (Lefton-Greif, 2001). Guardian and/or child preference, cultural preferences, and quality of life are all factors that influence decision-making.  In pediatric dysphagia, ethical issues may arise when considering the efficacy of treatment, or the safety of continuing to recommend oral feeding, even in minimal amounts. For example, children with degenerative conditions or profound neurologic impairment may have swallowing deficits that will not improve with traditional rehabilitative or compensatory treatment. Continued treatment may be strongly desired by the patient or the family, yet the efficacy of continued treatment must be addressed.   In some cases, patients wish to continue oral feeding, even when their condition is worsening, and there are known issues with aspiration that may eventually cause severe respiratory illness. In the patient or family’s perspective, being able to take even a small amount of food or liquid orally increases the quality of a life that may have changed drastically because of medical condition. With such severe compromises in swallow function, decisions about the next “right” steps for oral feeding are not always clear. Knowledge and use of an ethical decision-making process enables the “best” resolution for difficult situations in which there are essentially no “right” or “wrong” solutions.

17. Where are we with developing evidence-based practice strategies in pediatric dysphagia?

Selection of the “right” treatment approach is guided by the types of issues that infant or child demonstrates, and by the available evidence to support an approach. Evidence-based decision making (EBDM) integrates the best clinical or research evidence available, clinical expertise, and patient and family values. This approach helps clinicians, patients, and families make evidence-based care decisions during the diagnostic and therapeutic process. Evidence to guide practice in pediatric dysphagia is continually evolving, and it is important for clinicians to be aware of the developments in the field, and the best evidence available. The ASHA practice portal https://www.asha.org/practice-portal/ makes it easy for busy practicing clinicians to find the best evidence available for dysphagia evaluation and treatment. Evidence maps to assist with evidence-based decision making, templates and tools for documentation, and links to pertinent licensure laws are available.

18. What kind of training do SLPs receive in their undergraduate and graduate training programs? Does an SLP need to be “certified” to treat dysphagic patients?

Given that evaluation and treatment of swallowing disorders is included in the scope of practice for SLPs, a graduate-level course in dysphagia is an essential part of the graduate curriculum in speech-language pathology (ASHA, 2007). The updated version of the Graduate Curriculum on Swallowing and Swallowing Disorders (Adult and Pediatric Dysphagia) (ASHA, 2007) is intended to serve as a model for university programs.

There is no special certification required to evaluate and treat patients with dysphagia, ASHA formally recognizes independent specialty certification boards who have met criteria as outlined by the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). Specialty certification for swallowing is available through the American Board of Swallowing and Swallowing Disorders. Requirements for applicants include ASHA certification, documentation of continuing education that relates to dysphagia within the last 3 years, post-certification clinical experience, and advanced skill documentation.

19. How can we ensure and maintain competency in pediatric dysphagia evaluation and treatment?

The Dysphagia Competency Verification Tool (DCVT) is a recently developed tool for verification of clinical competency in dysphagia. The DVCT is available on the ASHA Practice Portal: www.asha.org/Practice-Portal/Templates/.  A DCVT user guide is also posted on the portal, which provides an overview of the tool in addition to rating and implementation guidelines.  The DCVT consists of competency sections to confirm knowledge and skills for dysphagia clinical evaluation and management competency, videofluoroscopic swallowing studies (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), and high-resolution manometry (HRM). The DVCT can be used by clinical managers and supervisors to evaluate and document clinical competence in dysphagia, or as a resource for new clinicians for self-assessment and identification of growth opportunities. The DVCT is free and customizable – it can be adapted for graduate students, clinical fellows, newly hired SLPs, and for verification of competency maintenance for experienced staff SLPs.

20.  What are the future areas of research in the field of pediatric dysphagia? What are functional outcome measures?

The field of dysphagia has many opportunities for continued research of both physiologic outcomes (objective measures of swallowing function pre and post-treatment) and functional outcomes (skills important to everyday living). Though research has been accumulating in the field, there is much yet to be learned. Continued standardization of evaluation and treatment protocols will allow for meaningful objective measurement of our outcomes and will guide future practice. In addition, the impact of our treatment on the infant or child’s level of functioning need to be studied. As described in the International Classification of Functioning, Disability and Health (ICF), functional outcomes address the individual’s ability to function in the environment. In the area of dysphagia, the functional goal may include the family’s ability to care or engage in an activity with their child (eating); the child’s ability to participate in functional activities (e.g. social events, lunch, and snack time at school); and the activity settings (social, cultural). In pediatric dysphagia treatment, a functional outcome measure often reflects the goal of treatment on the child or family’s quality of life. The targeted outcome may be the child’s ability to function in everyday activities such as eating and drinking, even in a limited way.