Deglutition and respiration: development, coordination, and practical implications

Understanding Dysphagia Care in Pakistan: A Survey of Current Speech Language Therapy Practice

Dysphagia affects individuals across all ages and has pervasive and potentially life-threatening consequences. Individuals with dysphagia are assessed and treated by speech and language therapists (SLTs), however, little attention has been paid to their practices in Pakistan. This study aimed to explore SLTs practices for dysphagia assessment, signs and symptoms observed during evaluation, and management strategies, alongside barriers and facilitators to service delivery in Pakistan. A 45-item survey was distributed to SLTs online. Responses were received from 101 participants and analyzed descriptively, and open-text responses were analyzed using content analysis. Results revealed that 65.3% SLTs worked across the lifespan, and most (79.4%) had dysphagia-related experience of five years or less. SLTs were an active workforce engaged with varying ages, disorders, and settings, yet dysphagia contributed to a small caseload percentage for most. Analyses found informal clinical exams were more frequently used than instrumental assessments. A variety of service provision facilitators were described, such as supportive teams and accessible resources, and responses about barriers revealed gaps in awareness, education, and guidance. This exploratory study presents novel and unexplored data which provides a deeper understanding of dysphagia-related care in Pakistan.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA.

SEARCH METHODS

Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision).

AUTHORS' CONCLUSIONS

There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.

Eating and drinking ability and nutritional status in adults with cerebral palsy

AIM

To describe eating and drinking ability in adults with cerebral palsy (CP) relative to sex, age, subtype, and severity of gross motor and hand function and nutritional status.

METHOD

This was a cross-sectional study based on data of 2035 adults with CP, median age 26 years (range 18-78 years). The Eating and Drinking Ability Classification System (EDACS), Gross Motor Function Classification System (GMFCS), and Manual Ability Classification System (MACS) were used in addition to subtype, body weight, height, body mass index (BMI), skin fold thickness, and gastrostomy. Linear regression models were used to estimate associations between body weight and the other variables.

RESULTS

More than half of the adults (52.5%) eat and drink safely and 32.4% have dysphagia with limitations to eating and drinking safety. Weight, height, and BMI decreased with increasing EDACS levels. In EDACS level V, 86% had a gastrostomy, 23.4% in EDACS levels III to V were underweight, whereas 42.3% in EDACS levels I to II had a BMI over 25, indicating overweight or obesity. Increasing EDACS levels and need of support during meals were associated with lower body weight.

INTERPRETATION

Adults with CP should be routinely screened and treated for dysphagia to avoid nutritional complications. Being dependent on others during mealtimes is a risk factor for low body weight.

Effect of oromotor exercises on feeding in children with cerebral palsy: systematic review

Background

Feeding problems are prevalent in children with cerebral palsy (CP). Oromotor exercises (OME) should be started as soon as possible to enhance chewing and drooling. Oromotor exercises consist of active exercises, passive exercises, and sensory stimulation. The purpose of this review is to evaluate the effectiveness of oromotor exercises on feeding, chewing, and drooling in children with CP.

Body

The American Academy for Cerebral Palsy and Developmental Medicine and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology were used to conduct a systematic review. Four databases (PubMed, Cochrane Library, PEDro, and Google Scholar) were searched; this review includes seven articles, participants were 173 participants ranging in age from 18 months to 18 years. Articles were assessed according to their level of evidence and quality assessment was done by AACPDM, PEDro scale, and JBI scale. Due to the heterogeneity across included studies, descriptive analysis was performed on all of them. Primary outcomes were chewing and drooling. Results showed the effectiveness of OME in improving drooling, but with weak evidence while not effective in improving chewing.

Conclusion

High-quality studies are required to develop a firm judgment on the influence of oromotor exercises on feeding. The current level of evidence to support the effectiveness of oromotor exercises in children with CP is currently insufficient.

Nutrition and growth in infants with established bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) remains the most common late morbidity of preterm birth. Ongoing clinical care and research have largely focused on the pathogenesis and prevention of BPD in preterm infants. However, preterm infants who develop BPD have significant medical needs that persist throughout their neonatal intensive care unit course and continue post-discharge, including those associated with growth and nutrition. The objective of this manuscript was to provide a review on nutrition and growth in infants with established BPD after discharge from the hospital and to identify the knowledge and research gaps to provide direction for future studies.

Feeding of children with tracheostomy at hospital discharge

ABSTRACT Purpose: to describe the work of speech-language-hearing therapists and verify which was the most prevalent feeding method in the sample studied. Methods: a descriptive observational study based on data surveyed from medical records. The following variables were used: age, medical diagnosis, hospital ward, feeding method before and after the tracheostomy, time of speech-language-hearing care, and speech-language-hearing discharge. The data were submitted to descriptive statistical analysis with the appropriate tests to compare the categorical variables. All infants and children with tracheostomy performed either before or during hospital stay between July 2017 and July 2018, who received speech-language-hearing care upon request of the physician, were included. Results: a total of 51 children took part in the study, most of whom were males (56.9%), with a median age of 12 months, ranging from 1 month to 12 years old at the time of the speech-language-hearing assessment. The feeding methods at hospital discharge were described as follows: full oral feeding (37%), partial oral feeding (25.5%), nasogastric/nasoenteral tube (19.6%), and gastrostomy (17.6%). Conclusion: the full oral diet of tracheostomized children was the most prevalent feeding method at hospital speech-language-hearing discharge.

Quantitative video-fluoroscopic analysis of swallowing in infants

OBJECTIVES

To utilize objective, quantitative videofluoroscopic swallow measures to profile swallowing in infants and to determine the likelihood of objective swallow measures to predict risk of swallow impairments such as airway violation, reflux and post swallow residue.

STUDY DESIGN

Our single center retrospective observational study used a cohort of 146 bottle-fed infants (0-9 months) referred for VFSS with any kind of feeding related concern. Frame-by-frame analysis of 20-s video loops of mid-feed sucking was completed to obtain quantitative timing, displacement and coordination measures as well as presence of other findings including aspiration, residue and naso-pharyngeal reflux (NPR) and esophago-pharyngeal reflux (EPR). Spearman correlation, Mann-Whitney U test and binomial logistic regression were conducted to determine statistical associations between swallow measures and binary reporting of swallow impairments.

RESULTS

Videofluoroscopic data of 146 infants were reviewed and analyzed. 49% of infants demonstrated at least one penetration or aspiration event. Total pharyngeal transit time (TPT) and suck-swallow ratio were associated with aspiration (p < .05). Infants with >3 sucks per swallow had significantly longer TPT and their risk of aspiration was greater than those with <3 sucks per swallow (RR 1.23, 95% CI 0.43-8.507, p = .03). Pharyngeal constriction ratio (PCR) and bolus clearance ratio (BCR) were associated with residue, NPR and EPR (p < .05).

CONCLUSION

Objective measures provide clinicians with reliable timing and displacement data even in the very young. These measures correlate with swallowing safety and may help to identify enhanced risk in some infants, which may influence management recommendations.

A Multidisciplinary Approach to Pediatric Feeding Disorders: Roles of the Speech-Language Pathologist and Behavioral Psychologist

Purpose Pediatric feeding disorders (PFDs) present as a complex clinical challenge because of the heterogeneous underlying etiologies and their impact on health, safety, growth, and psychosocial development. A multidisciplinary team approach is essential for accurate diagnosis and prompt interventions to lessen the burdens associated with PFDs. The role of the speech-language pathologist (SLP) as a member of the multidisciplinary team will be highlighted. Method This clinical focus article reviews the definition of PFDs and pertinent literature on factors that contribute to the development of PFDs, the accurate diagnosis, and current interventions for infants and children. As part of the multidisciplinary team, the SLP has an integral role in determining whether a child cannot or will not eat and working with the team to identify and carryout appropriate interventions. Collaboration between SLPs and psychologists/behavioral specialists in conjunction with the parents/caregivers as part of the multidisciplinary team is essential to the advancement of therapeutic goals. Conclusions Due to their complex nature, the successful management of PFDs is only possible with the care and expertise of a multidisciplinary team, which includes parents/caregivers. SLPs are important members of these multidisciplinary teams and provide valuable input for the accurate identification and effective remediation of PFDs.

Bronchopulmonary dysplasia: what are its links to COPD?

Emerging evidence suggests that adverse early life events can affect long-term health trajectories throughout life. Preterm birth, in particular, is a significant early life event that affects approximately 10% of live births. Worldwide, prematurity is the number one cause of death in children less than 5 years of age and has been shown to disrupt normal lung development with lasting effects into adult life. Along with impaired lung development, interventions used to support gas exchange and other sequelae of prematurity can lead to the development of bronchopulmonary dysplasia (BPD). BPD is a chronic respiratory disease of infancy characterized by alveolar simplification, small airways disease, and pulmonary vascular changes. Although many survivors of BPD improve with age, survivors of BPD often have chronic lung disease characterized by airflow obstruction and intermittent pulmonary exacerbations. Long-term lung function trajectories as measured by FEV1 can be lower in children and adults with a history BPD. In this review, we discuss the epidemiology and manifestations of BPD and its long-term consequences throughout childhood and into adulthood. Available evidence suggests that disrupted lung development, genetic susceptibility and subsequent environment and infectious events that occur in prenatal and postnatal life likely increase the predisposition of children with BPD to develop early onset chronic obstructive pulmonary disease (COPD). The reviews of this paper are available via the supplemental material section.

Impact of road proximity on infants and children with bronchopulmonary dysplasia

INTRODUCTION

Infants born prematurely are at high risk for morbidities, including lung disease (bronchopulmonary dysplasia [BPD]). Little is known regarding environmental factors that can impact outcomes in BPD. We sought to assess the role of traffic-related air pollution (TRAP) on respiratory outcomes in BPD.

METHODS

A total of 784 subjects were included from the Johns Hopkins BPD clinic. Caregivers completed questionnaires on environmental exposures and respiratory outcomes (acute care use and chronic symptoms). Distance to the nearest major roadway was derived from subjects' geocoded residential addresses.

RESULTS

Approximately half of the subjects (53.8%) lived within 500 m of a major roadway. Subjects who lived within 500 m of a major roadway were more likely to be non-white (P = .006), have a lower estimated household income (P < .001) and live in more densely populated zip codes (P < .001) than those who lived further than 500 m away. For every 1 km increase in distance between residence and roadway, the likelihood of activity limitations decreased by 35% (P = .005). No differences in acute care use were seen with proximity to major roadways.

CONCLUSIONS

Proximity to a major roadway was associated with chronic respiratory symptoms, such as activity limitations (eg, dyspnea), and tended to be associated with nighttime symptoms as well. Self-reported minorities and families with lower estimated household incomes may be more likely to be exposed to TRAP. Further research is necessary to define the effects of TRAP versus other sources of indoor and outdoor air pollution as well as to determine the best ways of combatting pollution-related respiratory morbidities.

Development and validation of a screening tool for feeding/swallowing difficulties and undernutrition in children with cerebral palsy

AIM

To develop and validate a screening tool for feeding/swallowing difficulties and/or undernutrition in children with cerebral palsy (CP).

METHOD

This cross-sectional, observational study included 89 children with CP (63 males, 26 females; median age 6y 0mo; interquartile range 4y 0mo-8y 11mo), across all Gross Motor Function Classification System levels. Children with feeding tubes were excluded. Children were classified as well-nourished or moderately to severely undernourished, using the paediatric Subjective Global Nutrition Assessment. Eating and drinking abilities were classified using the Eating and Drinking Ability Classification System (EDACS) from mealtime observation and videofluoroscopic swallow studies when indicated. Parents/caregivers answered 33 screening questions regarding their child's feeding/swallowing abilities and nutritional status. The diagnostic ability of each question for identifying children with feeding/swallowing difficulties and undernutrition was calculated and the combination of questions with the highest sensitivity and specificity identified.

RESULTS

Feeding difficulties impacted on swallow safety in 26 children (29%) and 26 children (29%) were moderately or severely undernourished. The 4-item final tool had high sensitivity and specificity for identifying children with feeding/swallowing difficulties (81% and 79% respectively) and undernutrition (72% and 75% respectively). The tool successfully identified 100 per cent of children with severe undernutrition and 100 per cent of those classified as EDACS level IV or V.

INTERPRETATION

Screening for feeding/swallowing difficulties and undernutrition will enable early identification, assessment, and management for those children in need.

WHAT THIS PAPER ADDS

A screening tool with high sensitivities and specificities for identifying children with feeding/swallowing difficulties and undernutrition. The tool identified 100 per cent of children with severe undernutrition. The tool identified 100 per cent of children in Eating and Drinking Ability Classification System levels IV or V.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Management of the risk of bronchoaspiration in patients with oropharyngeal dysphagia

ABSTRACT Objective: to manage the risk of bronchoaspiration in patients with oropharyngeal dysphagia through signalizing plates in the hospital bed. Methods: a descriptive, quantitative study, developed in the medical clinic I (diagnostic investigation), medical clinic II (infectology / pneumology), surgical clinics and intensive care unit of the University Hospital of the Federal University of Sergipe, from February to August 2017. It was composed of patients in the age group ≥ 18 years of age, of both sexes, diagnosed with oropharyngeal dysphagia, based on the application of the adapted protocol of clinical evaluation in the hospital bed and instrumental examination of swallowing, when pertinent. Following the clinical evaluation and identification of the risk of bronchoaspiration due to oropharyngeal dysphagia, the signs were inserted at the hospital bed by the speech therapist. Results: the study included 43 patients at risk of bronchoaspiration due to oropharyngeal dysphagia, average age of 53.7 ± 3.53 years old, with 51.1% (n = 22) females and 48.9% (n = 21) males. A predominance of neuropathies (53.4%) and severe neurogenic oropharyngeal dysphagia (37.2%) was observed. The intensive care unit stood out with 44.18% (n = 19) of the application of signs of risk of bronchoaspiration. Conclusion: the management of bronchoaspiration risk has been shown to be a promising measure to reduce adverse events, which affect the patient's safety and consequently the quality of care in the hospital environment, as well as a possible strategy for measuring respiratory complications triggered by aspiration of oropharyngeal contents.

The Effect of Additives for Reflux or Dysphagia Management on Osmolality in Ready-to-Feed Preterm Formula: Practice Implications

BACKGROUND

A common osmolality threshold for feedings is to stay <450 mOsm/kg for normal infants. Preterm formulas are frequently modified to improve growth, modify nutrition, and manage gastroesophageal reflux (GER) or dysphagia. Relationships between osmolality and additives to ready-to-feed preterm formulas are unclear. Our aims were to evaluate and compare the effects of caloric density, thickening agent recipes, and supplements to ready-to-feed preterm formula on osmolality.

METHODS

A freezing point osmometer was used to measure the osmolality of 47 preterm infant formula combinations with varying caloric densities (ready-to-feed 22 and 30 cal/oz), thickening agents (rice vs oatmeal cereal), thickener amounts (0.0, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 tsp/oz), and combinations of supplements (saline, iron, vitamin D, or multivitamin). Ten samples per combination were tested using a 10-μL pipette. Comparisons were made using analysis of variance and t-tests for group and pair-wise comparisons, respectively.

RESULTS

A total of 470 osmolality samples were analyzed: (1) raters had high agreement (r = 0.98; P < .001); (2) for every 0.5 tsp/oz of thickener, the osmolality increases by 30 mOsm/kg (P < .001); (3) osmolality was higher with the oatmeal (vs rice) thickening agent (P < .001); and (4) vitamin and electrolyte supplement combinations increase osmolality.

CONCLUSIONS

Alteration of ready-to-feed preterm formulas may significantly increase osmolality and have unintended consequences. Caution and monitoring should be exercised with modifying ready-to-feed preterm formulas for regurgitation, rumination, GER, dysphagia, feeding intolerance, or emesis. This study supports the concept of achieving volume tolerance before further manipulation of additives.

Dysphagia and associated clinical markers in neurologically intact children with respiratory disease

OBJECTIVE

The identification of oropharyngeal aspiration is paramount since it can have negative consequences on a compromised respiratory status. Our hypothesis was that dysphagia in neurologically intact children with respiratory disease is associated to specific clinical markers.

STUDY DESIGN

Using the medical files we conducted a retrospective, observational cohort study on children admitted to the pediatric hospital unit due to respiratory disease. We collected data on specific parameters of a clinical swallowing assessment and dysphagia was classified according to the Dysphagia Management Staging Scale. We also included the following clinical markers: age, days of hospitalization, need for orotracheal intubation (OTI), duration of orotracheal intubation (in hours), number of previous hospital admissions due to respiratory disease, number of previous hospital admissions due to other causes, and previous orotracheal intubations.

RESULTS

The final study sample consisted of 102 patients (mean age of 5.88 months). For the purposes of statistical analysis, the patients were grouped according to the classification of dysphagia (ie, no dysphagia, mild dysphagia, and moderate-severe dysphagia). Data analysis indicated that the clinical markers of orotracheal intubation (P = 0.042), duration of orotracheal intubation (P = 0.025), and days of hospitalization (P = 0.037) were significant in children with moderate-severe dysphagia.

CONCLUSIONS

Our data indicate that neurologically intact children with respiratory disease who were submitted to prolonged OTI (ie, over 48 h) should be prioritized for receiving a detailed swallowing assessment.

Novel Mealtime Duration Measures: Reliability and Preliminary Associations With Clinical Feeding and Swallowing Performance in Self-Feeding Children With Cerebral Palsy

PURPOSE

The purpose of this study is to examine (a) the reliability of newly developed measures of mealtime duration and (b) their relationship to clinical feeding/swallowing performance in children with spastic cerebral palsy (SCP).

METHOD

Seventeen self-feeding children (9 boys, 8 girls) with SCP (age range = 5;1 [years;months] to 17;6, Gross Motor Function Classification System range = I-IV) were assessed during mealtimes using the Dysphagia Disorder Survey (DDS; Sheppard, Hochman, & Baer, 2014). Children were divided into 2 groups, children with primarily unilateral or bilateral brain involvement. Duration measures included mealtime duration and total sip/bite duration for each bolus type (liquid and solid).

RESULTS

Excellent intra- and inter-rater reliability for all duration measures was observed (intraclass correlation coefficient [ICC] = 1.00 and 0.955, respectively, for mealtime duration; ICC = 1.00 and 0.963, respectively, for solid/bite duration; ICC = 1.00 and 0.957, respectively, for liquid/sip duration). Positive correlations were found between total mealtime duration and DDS Part 1, rs = .514 [.045-.797], p = .035; Part 2, rs = .528 [.064-.804], p = .029; and total scores, rs = .665 [.271-.868], p = .004, and between total solid/bite duration and DDS Part 1, rs = .579 [.137-.828], p = .015; Part 2, rs = .620 [.199-.847], p = .007; and total scores, rs = .762 [.444-.909], p < .001. Children with unilateral brain involvement exhibited significantly lower DDS total (p = .049) and Part 2 scores (p = .026), indicating better feeding/swallowing performance/skills. They also had shorter mealtime duration (p = .019) and solid/bite duration (p = .025) compared with children with bilateral involvement.

CONCLUSIONS

Our new mealtime duration measures are reliable and correlate with feeding/swallowing performance in a sample of self-feeding children with SCP. Therefore, they may be useful supplements to feeding/swallowing assessments for this population.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.5715076.

Oropharyngeal Dysphagia and Cerebral Palsy

OBJECTIVES

To determine the progression of oropharyngeal dysphagia (OPD) in preschool-aged children with cerebral palsy (CP) according to gross motor function. It was hypothesized that fewer children would have OPD at 60 months compared with 18 to 24 months (predominately Gross Motor Function Classification System [GMFCS] I-II).

METHODS

Longitudinal population-based cohort of 179 children (confirmed CP diagnosis, born in Queensland in 2006-2009, aged 18-60 months at study entry [mean = 34.1 months ± 11.9; 111 boys; GMFCS I = 46.6%, II = 12.9%, III = 15.7%, IV = 10.1%, and V = 14.6%]). Children had a maximum of 3 assessments (median = 3, total n = 423 assessments). OPD was classified by using the Dysphagia Disorders Survey part 2 and rated from video by a certified pediatric speech pathologist. GMFCS was used to classify children's gross motor function.

RESULTS

OPD prevalence reduced from 79.7% at 18 to 24 months to 43.5% at 60 months. There were decreasing odds of OPD with increasing age (odds ratio [OR] = 0.92 [95% confidence interval (CI) 0.90 to 0.95]; P < .001) and increasing odds with poorer gross motor function (OR = 6.2 [95% CI 3.6 to 10.6]; P < .001). This reduction was significant for children with ambulatory CP (GMFCS I-II, OR = 0.93 [95% CI 0.90 to 0.96]; P < .001) but not significant for children from GMFCS III to V (OR [III] = 1.0 [95% CI 0.9 to 1.1]; P = .897; OR [IV-V] = 1.0 [95% CI 1.0 to 1.1]; P = .366).

CONCLUSIONS

Half of the OPD present in children with CP between 18 and 24 months resolved by 60 months, with improvement most common in GMFCS I to II. To more accurately detect and target intervention at children with persisting OPD at 60 months, we suggest using a more conservative cut point of 6 out of 22 on the Dysphagia Disorders Survey for assessments between 18 and 48 months.

Parent perception of the impact of using thickened fluids in children with dysphagia

BACKGROUND

Oropharyngeal dysphagia occurs in children without known neurological disorders, increasing their risk for respiratory problems and inadequate intake. Clinicians may recommend thickening nutritive fluids; however, there is little research regarding the impact of thickening nutritive fluids on clinical outcomes in children.

METHODS

We used a parental reporting tool to determine whether parents identified changes in signs of dysphagia or volume of intake when thickened fluids were incorporated into an individualized feeding program for dysphagic children without known neurological problems. Fifty-five children diagnosed with dysphagia, for whom thickened fluids had been recommended per radiographic and clinical exam, qualified for the study. Parents of 44 children (24 females, 20 males) aged 2 weeks to 14 months completed baseline and post-thickening (within 90 days) rating scales.

RESULTS

Compared to baseline, parents reported significant decreases in the frequency of apnea (W = -219, P < 0.0001, r = 0.399), congestion (W = -450, P < 0.0001, r = 0.579), coughing/choking with drinking (W = -485, P < 0.0001, r = 0.603), resistance to feeding (W = -344.5, P < 0.0001, r = 0.476), vomiting during feeding (W = -409, P < 0.0001, r = 0.565), and wheezing (W = -337, P < 0.001, r = 0.449). For those children whose parents initially reported inadequate levels of intake, there was a significant (Z = 3.15, P = 0.0029, r = 0.47) increase (+49.63 mm) in the rated adequacy of liquid intake, as well as a significant increase (+1.41 oz.) in the estimated volume per feeding (Z = 224, P = 0.29, r = 0.33).

CONCLUSION

These results provide information for clinicians and physicians to incorporate when considering the use of thickened fluids in the dysphagia management of children without a known neurological diagnosis.

Neurologic Evaluation in Children With Laryngeal Cleft

Importance

Referral to a neurologist and imaging play important roles in the management of laryngeal cleft. Swallowing involves a complex series of neuromuscular interactions, and aspiration can result from anatomical causes (eg, laryngeal cleft), neuromuscular disorders, or some combination thereof. To date, no protocols or guidelines exist to identify which patients with laryngeal cleft should undergo neuroimaging studies and/or consultation with a neurologist.

Objective

To establish guidelines for neurologic evaluation and imaging techniques to identify or rule out neuromuscular dysfunction in children with laryngeal cleft.

Design

Retrospective review of the medical records of 242 patients who were diagnosed with laryngeal cleft at a tertiary children's hospital between March 1, 1998, and July 6, 2015. Based on this review, an algorithm to guide management of laryngeal cleft is proposed.

Main Outcomes and Measures

Data extracted from patient medical records included the type of laryngeal cleft, details of neurologic referral, results of neuroimaging studies, and objective swallow study outcomes.

Results

Of the 242 patients, 142 were male and 100 were female. Mean age at the time of data analysis was 8.7 years (range, 10 months to 25 years), and there were 164 type I clefts, 64 type II, 13 type III, and 1 type IV. In all, 86 patients (35.5%) were referred to a neurologist; among these, 33 (38.4%) had examination findings indicative of neuromuscular dysfunction or dyscoordination (eg, hypotonia, spasticity, or weakness). Abnormal findings were identified in 32 of 50 patients (64.0%) who underwent brain imaging. Neurosurgical intervention was necessary in 3 patients diagnosed with Chiari malformation and in 1 patient with an intraventricular tumor detected on neuroimaging.

Conclusions and Relevance

A substantial proportion of patients with laryngeal cleft have coexistent neuromuscular dysfunction as a likely contributing factor to dysphagia and aspiration. Collaboration with a neurologist and appropriate neuroimaging may provide diagnostic and prognostic information in this subset of patients. At times, imaging will identify critical congenital malformations that require surgical treatment.

PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy

OBJECTIVES

Cerebral palsy (CP) remains the world's most common childhood physical disability with total annual costs of care and lost well-being of $A3.87b. The PREDICT-CP (NHMRC 1077257 Partnership Project: Comprehensive surveillance to PREDICT outcomes for school age children with CP) study will investigate the influence of brain structure, body composition, dietary intake, oropharyngeal function, habitual physical activity, musculoskeletal development (hip status, bone health) and muscle performance on motor attainment, cognition, executive function, communication, participation, quality of life and related health resource use costs. The PREDICT-CP cohort provides further follow-up at 8-12 years of two overlapping preschool-age cohorts examined from 1.5 to 5 years (NHMRC 465128 motor and brain development; NHMRC 569605 growth, nutrition and physical activity).

METHODS AND ANALYSES

This population-based cohort study undertakes state-wide surveillance of 245 children with CP born in Queensland (birth years 2006-2009). Children will be classified for Gross Motor Function Classification System; Manual Ability Classification System, Communication Function Classification System and Eating and Drinking Ability Classification System. Outcomes include gross motor function, musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function, communication difficulties, oropharyngeal dysphagia, dietary intake and body composition, participation, parent-reported and child-reported quality of life and medical and allied health resource use. These detailed phenotypical data will be compared with brain macrostructure and microstructure using 3 Tesla MRI (3T MRI). Relationships between brain lesion severity and outcomes will be analysed using multilevel mixed-effects models.

ETHICS AND DISSEMINATION

The PREDICT-CP protocol is a prospectively registered and ethically accepted study protocol. The study combines data at 1.5-5 then 8-12 years of direct clinical assessment to enable prediction of outcomes and healthcare needs essential for tailoring interventions (eg, rehabilitation, orthopaedic surgery and nutritional supplements) and the projected healthcare utilisation.

TRIAL REGISTRATION NUMBER

ACTRN: 12616001488493.

The Eating and Drinking Ability Classification System in a population-based sample of preschool children with cerebral palsy

AIM

To determine (1) the reproducibility of the Eating and Drinking Ability Classification System (EDACS); (2) EDACS classification distribution in a population-based cohort with cerebral palsy (CP); and (3) the relationships between the EDACS and clinical mealtime assessment, other classifications, and health outcomes.

METHOD

This was a cross-sectional population-based cohort study of 170 children with CP at 3 years to 5 years (mean 57.6mo, standard deviation [SD] 8.3mo; 105 males, n=65 females). Functional abilities were representative of a population sample (Gross Motor Function Classification System level I=74, II=34, III=21, IV=18, V=23). The EDACS was the primary classification of mealtime function. The Dysphagia Disorders Survey was the clinical mealtime assessment. Gross motor function was classified using the Gross Motor Function Classification System.

RESULTS

EDACS classification had 88.3% intrarater agreement (κ=0.84, intraclass correlation coefficient=0.95; p<0.001) and 51.7% interrater agreement (κ=0.36, intraclass correlation coefficient=0.79; p<0.001). In total, 56.5% of children were classified as EDACS level I. There was a strong stepwise relationship between the Dysphagia Disorders Survey and EDACS (r=0.96, p<0.001). Parental stress (odds ratio=1.3, p=0.05) and feeding tubes (odds ratio=6.4, p<0.001) were significantly related to more limited function on the EDACS.

INTERPRETATION

The EDACS presents a viable adjunct to clinical assessment of feeding skills in children with CP for use in surveillance trials and clinical practice. A rating addendum would be a useful contribution to the tool to enhance reproducibility.

Oral stimulation for promoting oral feeding in preterm infants

BACKGROUND

Preterm infants (< 37 weeks' postmenstrual age) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge.

OBJECTIVES

To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.• Extremely preterm infants born at < 28 weeks' PMA.• Very preterm infants born from 28 to < 32 weeks' PMA.• Infants breast-fed exclusively.• Infants bottle-fed exclusively.• Infants who were both breast-fed and bottle-fed.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention in preterm infants and reporting at least one of the specified outcomes.

DATA COLLECTION AND ANALYSIS

One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model.

MAIN RESULTS

This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain.

AUTHORS' CONCLUSIONS

Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.

Respiratory motor training and neuromuscular plasticity in patients with chronic obstructive pulmonary disease: A pilot study

The objective of this study was to examine the feasibility of a full-scale investigation of the neurophysiological mechanisms of COPD-induced respiratory neuromuscular control deficits. Characterization of respiratory single- and multi-muscle activation patterns using surface electromyography (sEMG) were assessed along with functional measures at baseline and following 21±2 (mean±SD) sessions of respiratory motor training (RMT) performed during a one-month period in four patients with GOLD stage II or III COPD. Pre-training, the individuals with COPD showed significantly increased (p<0.05) overall respiratory muscle activity and disorganized multi-muscle activation patterns in association with lowered spirometrical measures and decreased fast- and slow-twitch fiber activity as compared to healthy controls (N=4). Following RMT, functional and respiratory sEMG activation outcomes during quite breathing and forced expiratory efforts were improved suggesting that functional improvements, induced by task-specific RMT, are evidence respiratory neuromuscular networks re-organization.

Suck, swallow and breathing coordination in infants with infantile colic

BACKGROUND

There appears to be a perception amongst parents and in popular literature that infantile colic is caused by feeding difficulties. Limited support for this perception is found in scientific literature. Whilst there is scientific evidence that suck, swallow and breathing are key components of successful feeding, these components and the coordination thereof in infants with colic have not been extensively researched.

OBJECTIVE

The objective of the study was to explore the suck, swallow and breathing coordination in infants with infantile colic and compare it with infants without the condition.

METHOD

An assessment protocol for suck, swallow and breathing coordination was compiled from literature. This protocol was performed on a research group of 50 infants, independently diagnosed with infantile colic, and a control group of 28 infants without the condition. All participants were from two rural towns in the North–West province, South Africa, selected with a snowball selection method and strict selection criteria. The study followed a static comparison group design.

RESULTS

A significant difference in the key components of feeding and the presence of colic in participants of four age categories were found. The correlation between postural control and the presence of infantile colic were sustained in participants from 2–19 weeks old.

CONCLUSION

Suck, swallow and breathing were found to be significantly associated with infantile colic. The findings should be investigated further. It appears that speech-language therapists may play an expanding role in infantile colic.

Pediatric Dysphagia: Physiology, Assessment, and Management

Infancy and childhood represent a time of unparalleled physical growth and cognitive development. In order for infants and children to reach their linear and neurological growth potential, they must be able to reliably and safely consume sufficient energy and nutrients. Swallowing difficulties (dysphagia) in pediatric populations can have a detrimental effect on dietary intake and, thus, growth and development. As a result, it is imperative to accurately identify and appropriately manage dysphagia in pediatric populations. This article provides an overview of dysphagia in children, as well as common causes of childhood swallowing difficulties, populations at risk for pediatric dysphagia, techniques used to assess swallowing in pediatric patients, and the current treatment options available for infants and children with dysphagia.

Clinical signs suggestive of pharyngeal dysphagia in preschool children with cerebral palsy

This study aimed to determine the discriminative validity, reproducibility, and prevalence of clinical signs suggestive of pharyngeal dysphagia according to gross motor function in children with cerebral palsy (CP). It was a cross-sectional population-based study of 130 children diagnosed with CP at 18-36 months (mean=27.4, 81 males) and 40 children with typical development (TD, mean=26.2, 18 males). Sixteen signs suggestive of pharyngeal phase impairment were directly observed in a videoed mealtime by a speech pathologist, and reported by parents on a questionnaire. Gross motor function was classified using the Gross Motor Function Classification System. The study found that 67.7% of children had clinical signs, and this increased with poorer gross motor function (OR=1.7, p<0.01). Parents reported clinical signs in 46.2% of children, with 60% agreement with direct clinical mealtime assessment (kappa=0.2, p<0.01). The most common signs on direct assessment were coughing (44.7%), multiple swallows (25.2%), gurgly voice (20.3%), wet breathing (18.7%) and gagging (11.4%). 37.5% of children with TD had clinical signs, mostly observed on fluids. Dysphagia cut-points were modified to exclude a single cough on fluids, with a modified prevalence estimate proposed as 50.8%. Clinical signs suggestive of pharyngeal dysphagia are common in children with CP, even those with ambulatory CP. Parent-report on 16 specific signs remains a feasible screening method. While coughing was consistently identified by clinicians, it may not reflect children's regular performance, and was not sufficiently discriminative in children aged 18-36 months.

Safety and Efficacy of Oral Feeding in Infants with BPD on Nasal CPAP

Safety and efficacy of oral feeding was examined in infants with bronchopulmonary dysplasia (BPD) on nasal continuous positive airway pressure (NCPAP). We hypothesized that repetitive oral feeding enhances aero-digestive outcomes and reduces resource utilization. Data from infants with BPD (37-42 weeks post menstrual age) that were orally fed while on NCPAP (n = 26) were compared with those that were exclusively gavage fed on NCPAP (n = 27). Subject assignment was random and physician practice based. Specifically, we compared the differences in aero-digestive milestones, resource utilization, and safety metrics. Demographic characteristics such as gender distribution, gestational age, and birth weight, clinical characteristics such as frequency of intraventricular hemorrhage and patent ductus arteriosus needing surgical ligation were similar in both groups (p > 0.05). Characteristics of respiratory support and airway milestones were similar in both groups (p > 0.05). However, infants in NCPAP-oral fed group had earlier acquisition of full oral feeding milestone by 17 days (median) versus infants who were not orally fed during NCPAP (p < 0.05). Discharge weights and the frequency of gastrostomy tube placement were also similar in both groups (p > 0.05). There were no tracheostomies in either group. There was no incidence of clinically significant aspiration pneumonia in infants during the period of the oral feeding while on NCPAP. Controlled introduction of oral feedings in infants with BPD during NCPAP is safe and may accelerate the acquisition of oral feeding milestones.

Variation in the timing and frequency of sucking and swallowing over an entire feeding session in the infant pig Sus scrofa

Feeding is a rhythmic behavior that consists of several component cycle types. How the timing of these cycles changes over a complete feeding sequence is not well known. To test the hypothesis that cycle frequency/duration changes as a function of time spent feeding, we examined complete feeding sequences in six infant pigs, using EMG of mylohyoid and thyrohyoid as cycle markers. We measured the instantaneous frequency of sucking and of swallowing cycles in 19 sequences. Each sequence contained three qualitatively distinctive phases of sucking frequency. Phase 1 started with cycles at a very high frequency and quickly dropped to a more constant level with low variation, which characterized phase 2. Phase 3 had a steady level of frequency but was interspersed with a number of high- or low-frequency cycles. Each phase differed from the others in patterns of within-phase variation and among-phase variation. Phase 2 had the least variation, and phase 3 had the largest range of frequencies. The number of sucks per swallow also differed among phases. These patterns, which characterize normative feeding, could indicate a physiologic basis in satiation. In human infant clinical studies, where data collection is often limited, these results indicated the utility of collecting data in different phases. Finally, these results can be used as a template or pattern with which to assess clinically compromised infants.

Dysphagia and aspiration in children

Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.

Longitudinal cohort protocol study of oropharyngeal dysphagia: relationships to gross motor attainment, growth and nutritional status in preschool children with cerebral palsy

INTRODUCTION

The prevalence of oropharyngeal dysphagia (OPD) in children with cerebral palsy (CP) is estimated to be between 19% and 99%. OPD can impact on children's growth, nutrition and overall health. Despite the growing recognition of the extent and significance of health issues relating to OPD in children with CP, lack of knowledge of its profile in this subpopulation remains. This study aims to investigate the relationship between OPD, attainment of gross motor skills, growth and nutritional status in young children with CP at and between two crucial age points, 18-24 and 36 months, corrected age.

METHODS AND ANALYSIS

This prospective longitudinal population-based study aims to recruit a total of 200 children with CP born in Queensland, Australia between 1 September 2006 and 31 December 2009 (60 per birth-year). Outcomes include clinically assessed OPD (Schedule for Oral Motor Assessment, Dysphagia Disorders Survey, Pre-Speech Assessment Scale, signs suggestive of pharyngeal phase impairment, Thomas-Stonell and Greenberg Saliva Severity Scale), parent-reported OPD on a feeding questionnaire, gross motor skills (Gross Motor Function Measure, Gross Motor Function Classification System and motor type), growth and nutritional status (linear growth and body composition) and dietary intake (3 day food record). The strength of relationship between outcome and exposure variables will be analysed using regression modelling with ORs and relative risk ratios.

ETHICS AND DISSEMINATION

This protocol describes a study that provides the first large population-based study of OPD in a representative sample of preschool children with CP, using direct clinical assessment. Ethics has been obtained through the University of Queensland Medical Research Ethics Committee, the Children's Health Services District Ethics Committee, and at other regional and organisational ethics committees. Results are planned to be disseminated in six papers submitted to peer reviewed journals, and presentations at relevant international conferences.

An Oral, Motor, Medical, and Behavioral Approach to Pediatric Feeding and Swallowing Disorders: An Interdisciplinary Model

Feeding and swallowing problems are reported in 10-25% of all children, 40-70% in premature infants, and 70-90% in children with medical/developmental delays (Graham, 1985; Rogers & Arvedson, 2005; Sullivan et al., 2000). The etiologies of feeding disorders are as varied as the multiple disciplines, approaches, and interventions available. This paper illustrates, through case presentation, an interdisciplinary feeding team model that incorporates an oral, motor, medical, and behavioral approach to treating children with feeding disorders.

Evaluating service delivery for speech and swallowing problems following paediatric brain injury: an international survey

RATIONALE, AIMS AND OBJECTIVES

Little is documented about contemporary management of speech and swallowing disorders associated with paediatric acquired brain injury (ABI). It is therefore challenging for clinicians in this field to benchmark their clinical management against current evidence or practices undertaken in other centres. To address this issue, we aimed to provide much-needed baseline data on speech and language pathology management of speech and swallowing disorders associated with childhood ABI. Key objectives were to: (i) determine whether clinicians use formalized referral criteria, clinical guidelines, protocols or care pathways; and (ii) to document the specific assessment and treatment approaches used.

METHODS

Speech and language pathology managers and clinicians at 31 major paediatric rehabilitation centres across Australia, New Zealand, the UK and Ireland were invited to participate in an online survey.

RESULTS

Fifty-one speech and language pathologists responded representing 26 centres (84% response rate). Routine referrals of ABI patients to speech and language pathology occurred relatively infrequently in these centres (12%). Centres utilized assessment protocols (23%) and guidelines (35%) more frequently than treatment guidelines (8%). Multidisciplinary care pathways were applied by 31%. Most centres used adult-based motor speech assessments and informal ('in-house developed') swallowing assessment tools.

CONCLUSIONS

The limited use of referral criteria, protocols, care pathways and guidelines invites the possibility of unequal care, and less than optimal outcomes. Reliance on adult-based or in-house assessments is inappropriate, yet frequently a necessity due to an absence of paediatric-specific tools in this field. Further research is required in parallel with the formation of consensus groups to support the development of: (i) paediatric-specific assessment tools and management approaches; and (ii) clinical protocols and guidelines.

Oropharyngeal aspiration and silent aspiration in children

BACKGROUND

Limited information exists about the nature of and factors associated with oropharyngeal aspiration (OPA) and silent aspiration (SA) in children. A prospective study was undertaken to determine the factors associated with fluoroscopically identified OPA and SA.

METHODS

Three hundred children presenting with feeding difficulties underwent a videofluoroscopic swallow study (VFSS) for evaluation of swallowing. Swallowing performance on each food and fluid consistency was rated using the penetration-aspiration scale, and children were classified into the following groups: OPA, SA, overt aspiration (OA), and no aspiration (NA).

RESULTS

OPA occurred in 34% of children; of these, 81% had SA. SA was significantly associated with neurologic impairment (OR, 4.65; 95% CI, 2.26-9.54), developmental delay (OR, 4.62; 95% CI, 2.28-9.35), aspiration lung disease (OR, 3.22; 95% CI, 1.29-8.05), and enteral feeding (OR, 2.03; 95% CI, 1.04-3.62). Similar results were found for OPA. Children with SA were more likely to have neurologic disease (OR, 4.1; 95% CI, 1.1-15.8) than those with OA. Age or gender differences, gastroesophageal reflux disease, recurrent respiratory tract infections, and asthma were no more likely to occur in children with OPA, SA, or OA.

CONCLUSIONS

SA is very common in children with feeding difficulties and is most likely to occur in children with a neurologic problem. Limited medical diagnoses distinguished between aspirators (OPA, SA) and those with NA. VFSS should be performed in children with feeding difficulties and diagnoses of neurologic impairment, cerebral palsy, aspiration lung disease, and/or enteral feeding because of the increased likelihood of SA.