A comparison of clinical and radiological assessments in paediatric dysphagia during the transitional feeding period

Abstract

The purpose of this investigation was to compare two assessment techniques, the Clinical Feeding Evaluation (CFE) and the Videofluoroscopic Swallow Study (VFSS), in their ability to document the nature of swallowing impairment, identify aspiration, determine level of feeding activity limitation and make feeding recommendations for children in the transitional feeding stage.Design. A prospective case series.Participants. Data was collected on 20 consecutive infants and children, aged from three months to three years of age, who presented for evaluation at the Videofluoroscopic Swallow Clinic at a tertiary hospital.Procedure. Participants were scheduled for CFE prior to their radiological evaluation. The CFE was conducted by the primary clinician and included a case history and parent interview, a pre-feeding evaluation, oral sensorimotor assessment and clinical feeding trial. Participants then underwent a VFSS conducted by a second clinician, blinded to the results of the CFE. The participants then attended an appointment with the primary clinician, who had results of both the CFE and VFSS, to determine a management plan. The nature of the information from both the CFE and VFSS was analysed.A penetration-aspiration rating was assigned at two points, following the CFE and following the VFSS. Measures of swallowing impairment, feeding limitation and feeding recommendations were made at three points, following the CFE ('CFE only' condition), following the VFSS ('VFSS only' condition) and following information from both assessments ('Combined' condition). The individual assessments (CFE and VFSS) were compared with the Combined condition to determine which individual assessment most influenced the final outcome for the swallowing impairment and feeding limitation measures and feeding recommendations.Results. The CFE provided the most information regarding medical complexity of the children. Analysis of medical information revealed this population of infants to be medically complex with an average of 2.9 medical conditions. Children on non-oral or combined feeding methods generally had a higher number of conditions (Mean = 3.5) than those on full oral intake (Mean = 2.1). The VFSS demonstrated superior ability to detect laryngeal penetration and aspiration, particularly with fluid textures. The CFE and VFSS showed good agreement in determining a rating for presence or absence of penetration/aspiration on puree (k= 1.000), semisolid (92%) and solid (100%) textures, but poor agreement on thin fluid (zc = . 118) and thick fluids (k= -.132). The CFE had the highest agreement with the Combined condition when determining the level of severity for oral phase impairment (r= 0.925) and feeding limitation (r= 0.803), while the VFSS had the highest agreement with the Combined condition (t=0.948) for pharyngeal phase impairment. When making feeding recommendations, the CFE had the highest agreement with final recommendations for semisolid (zc = 0.700) and chewable solid (k = 1.000) textures, while the VFSS influenced final recommendations regarding thin (zc = 0.800) and thickened fluid (zc = 0.900) textures. Both assessments were similar in determining recommendations for feeding method (oral, combined oral and tube feeding, or non-oral) (zc =0.500 respectively) and puree textures (95%).Conclusions. Feeding and swallowing difficulties in medically complex infants and children during the transitional feeding period require comprehensive evaluation. The nature of information about feeding and swallowing dysfunction from both assessments was complementary and not redundant. An optimal assessment battery should include both the clinical feeding evaluation and video fluoroscopic swallow study to adequately determine swallowing impairments and feeding limitation and to make appropriate feeding recommendations. The use of only one assessment for the young, medically complex child presenting with dysphagia could lead to inaccurate diagnosis and subsequent management recommendations.