Paediatric dysphagia - Position statements
European Society for Swallowing Disorders
,
Celia Harding, Margaret Walshe, Pascale Fichaux Bourin, Virginie Woisard
3rd ESSD Congress, Malmö Sweden 12-14 September 2013
Plan…
• Definition
• Categories
• Guidelines for assessment and management
First of all several definitions have to be stated
Definitions
• In paediatric dysphagia:
– Swallowing disorders
– Feeding disorders
Swallowing Disorders (SD) is the term used in this position
statement because Oropharyngeal Dysphagia (OD) in
paediatrics and oesophageal dysfunction are intrinsically
linked so this term does not include feeding disorders
Definitions:
The different stages in paediatric development
• Newborn: infant born at term, with a birth weight of around
3.5 kg
• Preterm
‒ By age: (define PMA or GA)
• Extremely pre-term is below 28 weeks
• Very preterm is 28 – 32 weeks
• Moderate / late pre-term is 32-37 weeks
‒ By weight: : Less than 2.5kg
• VLBW = 1.0kg – 1.5kg
• ELBW = up to 1.0kg
The American Academy of Paediatrics (2004) recognised this
problem over a decade ago with a call for consistency in the
use of definitions to describe the length of gestation and age
in neonates.
Definitions:
The different stages in paediatric development
• Neonate: a baby who is aged 28 days and below
• Infants: under 2 years of age
• Children: under 18 years of age
The American Academy of Paediatrics (2004) recognised this
problem over a decade ago with a call for consistency in the
use of definitions to describe the length of gestation and age
in neonates.
Proposition Plan for each category
• The main points of the problem (the main aetiologies, the
prognostic factors …)
• Statement on screening
• Statement on assessment
• Statement on management of disorders and complications
• Statement on the multidisciplinary team
Swallowing disorders in Preterm
Screening and assessment
• When:
‒ At the time of transition from tube feeding to oral
feeding, readiness for oral feeding must be assessed
using a valid and reliable clinical tool. Currently there
is no consensus for a specific instrument.
‒ Screening should be performed during the first 2 years
of life by use of paediatric checklist of children’s eating
difficulties and a feeding observation.
‒ In case of swallowing disorders where aspiration is
suspected an instrumental evaluation has to be
performed.
Screening and assessment
• How:
– Observation of infant states, sucking, feeding skills during
meal (breast or bottle feeding) and parent-infant
interactions
‒ In NICU (neonatal intensive care unit) assessment has to
be performed using a Developmental Care approach (Als
1984): morbidity, behavior, sucking, feeding skills
‒ After leaving neonatal care the screening should be
performed by the infant’s pediatrician preferably during a
routine visit by a meal observation
‒ Instrumental assessment should be used judiciously
‒ Validated feeding scales are recommended
‒ Changes in infant feeding should be reported using
validated scoring systems
Management
• In NICU: there is no consensus regarding specific
sensorimotor interventions
‒
‒
Oral and non-oral sensorimotor interventions
appear to improve oral feeding performance in
preterm infants and could shorten the transition
time to independent oral feeding in preterm infants.
The modality of intra-oral stimulations are discussed
because oral hypersensitivity or defensiveness are
very common during the first life in preterm and may
interfere feeding skills’ development.
Management
• After leaving hospital these infants remain at risk,
therefore:
‒
Education on feeding and swallowing should be
provided by a specialist multi-disciplinary team.
It is important to help families
‒
•
•
•
to understand better what are swallowing disorders
to manage difficulties already present
to prevent feeding skills delay and aversive feeding
behavior
Swallowing disorders in Infant
Problem
• Main points
– SD may be secondary to disease but also to immaturity, so
the diagnosis is an ongoing process.
– Management of swallowing disorders and nutrition must
be aggressive and immediate, because of the reduced
nutritional reserve which impedes the weight gain and
growth, reduces the defence mechanism against infection,
and can influence the infant’s psychomotor and
intellectual development.
– SD in infants affects not only somatic development but
also oromotor and psychomotor maturation.
• Main causes may be: neurologic, anatomic, secondary to
systemic illness or to resolved medical conditions, a genetic
syndrome, psycho-behavioural
• Low birthweight infants are at high risk of SD
Multidetermined disorders / Multiaxial diagnosis
Screening
• Screening is not systematic but determined by
diagnosis such as cleft palate, Pierre Robin
sequence, Prader Willi Syndrome, low
birthweight, perinatal stroke…
• Screening will be performed by observation of
a meal
• In case of neurologic disease this screening
may be planned regularly for instance twice
during the first year of life and a minimum of
once a year after.
• When aspiration is suspected a swallowing
assessment has to be done
Assessment
• How:
– In all cases, the diagnosis must be thorough and accurate.
– The clinical evaluation of SD is an evolving process including
swallowing disorders and the ensuing consequences.
– The assessment tool focusing on swallowing may be:
• a feeding test or meal observation with validated scales
• an instrumental assessment with FEES, or videofluoroscopy
– Appropriate timing for follow up testing is required with
videofluorscopy before 2 years of age and with FEES for the
older child if necessary.
– The assessment for ensuing consequences consist of the follow
up of health and nutritional status, neurodevelopmental skills
and mother-infant interactions with validated scales.
Assessment
• When:
– For neonates and infants, with unknown pathology , an
assessment is indicated when immature sucking skills,
poor endurance for oral feeding and risk of aspiration
(RGO, Bronchitis..) are noticed.
– The clinical evaluation of SD being an evolving process,
once management decisions are made clinicians and
caregivers should monitor the infants.
– During follow up, validated scales to measure skills should
be used along side instrumental evaluation.
– The frequency of follow up assessments decrease with the
infant’s age; the main stages being weaning development
and prelinguistic acquisition about 8 and 18 months.
Management
• Parents are the first caregivers as they are involved in the
diagnosis and the management of the disorders
• Precursors are the same as for preterm infants
• If oral feeding is impossible, education is required on:
– prevention of saliva’s aspiration
– Improving oral skills despite the lack of oral-feeding experiences with
sensorimotor stimulations ( flavour, smell, chewing toys…)
– The Speech and Language Therapist can support the development of
these skills
• In cases of modified food textures, caregivers and health
providers have to compensate for the lack of sensation and
for the impact of chewing and speech-motor acquisitions.
• It is recognized that thickeners and modified texture diets
have some risks and it is important that the multi-disciplinary
team work together to minimize the impact of these
(dehydration, constipation, reduced appetite)
Swallowing disorders in Children
Problematic
• The main points
– Psychological maturation and feeding behavioural
disorders are critical during this period
– Anatomical changes and growth can impact on swallowing
skills and increase difficulties e.g. cerebral palsy,
myopathies…
• The main causes of SD
–
–
–
–
–
–
Tumour
Neurological disorders
Neurodegenerative diseases
Respiratory disorders
Digestive disorders
Disorders of the ear, nose and throat
Screening
• There is no systematic Screening
• In a population at risk, screening should be
performed each year of life by a check list of
children’s eating difficulties and/ or a feeding
observation and should also involved a specific
follow up of nutritional status
• In an acute situation, more in depth screening and
assessment must be performed
Assessment
• When:
– Specific symptoms of dysphagia
– Recurrent pneumonia without aetiology
– Failure to thrive
– Behavioural feeding disorders e.g. Limited food
texture tolerance, high level of food refusal, high
level of parental stress managing the meal time
– Severe acquired disorders
Assessment
• How:
– The assessment tool focusing on swallowing may be
an instrumental assessment with FEES, or
videofluoroscopy
– Manometry and or impedance testing may be
indicated when a reflux or UOS dysfunction are
suspected
– These instrumental assessments have to be
performed after a specific clinical evaluation
Management
• Psychological dimension +++ Interaction
child/parents
• Dietetic approach / nutritional status for
growth needs
• Swallowing Re-education
Guidelines for assessment
Clinical assessment
• Oro-pharyngeal evaluation of:
– Oromotor skills with validated scales such as
• NOMAS® (neonatal oral-motor assessment scale) for
infant before 1 month of life
• POSP ® (Oromotor assessment)
• SOMA ® for infants after 8 months
– Feeding observation should collect:
•
•
•
•
duration of the meal
calorific intake
amount taken and milk-volume
interaction during the meal
Instrumental assessment
• FEES provides a dynamic view of the
pharyngo-larynx during:
– Respiration
– Crying or phonation
– Saliva management
– Swallowing.
• VFS is unable to test sensitivity but can show:
– Aspiration
– Oesophageal motility.
– Adaptations (e.g. modified textures, specific strategies to
support the child etc…) and
– Positioning to minimise risk
Multi-disciplinary Team
• It is recognized that due to the complex nature of SD in
children, team-working is essential to minimize the health and
psychosocial risks
• The MDT should include a range of professional (e.g.
Paediatrician, SLT, Physiotherapist, Occupational therapist,
Dietitian, Specialist nurse, Respiratory therapist, Clinical
psychologist, Specialist doctors (when appropriate), Dentist,
Social worker, education professionals), Carers, and Parents
• Programmes for children with SD need to be written by the
MDT and agreed by all involved. In addition all programmes
need to be re-evaluated regularly
• Programmes need to consider a child’s activity and
participation
References
• Arvedson JC, Brodski L. 2002 Pediatic swallowing and
feeding: Assessment and management II edition
Thomson Learning
• Schindler O., Ruoppolo G. Schindler A.
2011.Deglutilogia II edition Omega edizioni
• Lau C et al. 2000
• Mizuno K. and Ueda A. 2003
• Premji et al, 2004
• McCain et al, 2001
• Als ,1984