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Characteristics of dysphagia in children with cerebral palsy
Abstract and Figures
Videofluoroscopic modified barium swallow (VMBS) examinations may provide clinically relevant information regarding deglutition in children with cerebral palsy and dysphagia. A retrospective review of clinical evaluations and VMBS studies on 90 consecutive children with cerebral palsy and dysphagia was completed. Most children were referred because of concerns regarding airway protection during oral feedings. Most children had multiple disabilities and 93% were nonambulatory. The majority of children were totally dependent for oral feedings (80%). Oral and pharyngeal phase abnormalities were present in almost all patients. Abnormalities of deglutition were observed only while swallowing specific food textures in the majority of patients. Aspiration of specific food textures was significantly more common than aspiration of all food textures (p
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... The rates of CP are higher in children born preterm, small for gestational age, and with congenital malformations [42,56,57] than with uncomplicated term birth. Characteristics of swallowing deficits are variable and silent aspiration is common [58,59]. However, the magnitude of swallowing impairments is related closely or in large part to motor function [55,[60][61][62]. ...
Feeding/swallowing and airway protection are complex functions, essential for survival, and continue to evolve throughout the lifetime. Medical and surgical advances across the globe have improved the long-term survival of medically complex children at the cost of increasing comorbidities, including dysfunctional swallowing (dysphagia). Dysphagia is prominent in children with histories of preterm birth, neurologic and neuromuscular diagnoses, developmental delays, and aerodigestive disorders; and is associated with medical, health, and neurodevelopmental problems; and long-term socioeconomic, caregiver, health system, and social burdens. Despite these survival and population trends, data on global prevalence of childhood dysphagia and associated burdens are limited, and practice variations are common. This article reviews current global population and resource-dependent influences on current trends for children with dysphagia, disparities in the availability and access to specialized multidisciplinary care, and potential impacts on burdens. A patient example will illustrate some questions to be considered and decision-making options in relation to age and development, availability and accessibility to resources, as well as diverse cultures and family values. Precise recognition of feeding/swallowing disorders and follow-up intervention are enhanced by awareness and knowledge of global disparities in resources. Initiatives are needed, which address geographic and economic barriers to providing optimal care to children with dysphagia.
... Although the feeding and swallowing skills and difficulties of children with CP have been described (e.g., Arvedson, 2013;Benfer et al., 2013Benfer et al., , 2016Benfer et al., , 2017Gisel & Alphonce, 1995;Mishra et al., 2019;Rogers et al., 1994;Yilmaz et al., 2004), most research in this area has used a cross-sectional design and examined children at one time point. Some longitudinal studies focusing on identifying changes over long periods of time (6-month to 1-year intervals or more) have been published and have offered insights on early predictors of clinical dysphagia and growth (e.g., preschool children: Benfer et al., 2016Benfer et al., , 2017Clancy & Hustad, 2011;Motion et al., 2002;school-age children and adolescents: Nystrand et al., 2014). ...
Purpose:
We aimed to examine the day-to-day variability of feeding and swallowing performance and mealtime duration in school-age self-feeding children with spastic cerebral palsy (SCP) across 15 days.
Method:
Thirteen children with SCP (ages 5;10 [years;months]-17;6) participated. Children were divided into unilateral (UCP, n = 6) and bilateral (BCP, n = 7) SCP groups. Feeding/swallowing assessments using the Dysphagia Disorder Survey (DDS) were conducted and total mealtime durations (TMDs) were calculated for all days. DDS Part 1 (factors related to feeding) and DDS Part 2 (signs of oropharyngeal difficulties) components were rated. Mixed-effects models were used to compare group means and estimate between- and within-subject variances in each group. Likelihood ratio tests were used to determine best covariance structure and compare variance types across groups.
Results:
Within-subject variance for all three variables, DDS Part 1, 2, and TMD, across days was larger in the BCP group than the UCP group (Part 1: p = .0036, Part 2: p = .0002, and TMD: p = .0005) and the between-subject variance was larger in the BCP group for DDS Part 2 (p = .0362). The UCP group presented with lower (milder) DDS scores (Part 1: p = .0160; Part 2: p = .0141) and shorter TMD (p = .0077) than the BCP group across days. Furthermore, both groups exhibited greater variability in DDS Part 2 than 1 (p < .0001).
Conclusion:
These preliminary results emphasize the need to account for day-to-day variability when evaluating swallowing especially in children with BCP and provide preliminary ranges of performance that could be useful for clinical prognosis and future treatment research.
Supplemental material:
https://doi.org/10.23641/asha.21669611.
... Eating and drinking are complex sensory motor activities, which can be described in four phases-oral preparatory, oral (propulsive), pharyngeal, and esophageal-of swallowing (24). Persons with CP can have impairments in any of the four phases of swallowing (25)(26)(27)(28)(29). Persons with ID have been reported to exhibit higher incidences of eating too fast, swallowing whole, and taking an unbalanced diet (30,31). ...
In Japan, fees for nutritional management (NM) was introduced in April 2009 to improve nutritional care for persons with disabilities residing in welfare facilities. The present study aimed to clarify (1) the nutritional status as well as eating-related functions and behaviors of such residents and (2) status of incorporating claim fees for NM and oral maintenance in facilities supporting persons with disabilities. This cross-sectional study approached 2,510 welfare facilities for persons with disabilities across Japan. Anonymous questionnaire surveys were conducted in August 2018. Among the 1,543 responses, 1,538 (61.3%) were valid for analysis. The median number of residents in a facility was 50. Among all residents (n=80,322), 16.9% were underweight (body mass index [BMI]<18.5) and 14.5% were obese (BMI≥25.0). Of the residents, 38.9% adjusted food form and 15.2% had eating behavior-related problems. In total, 723 (47.0%) and 54 (3.5%) facilities, claimed the fees for NM and oral maintenance, respectively. The main reasons for not implementing the claim fees for NM was the lack of time for nutritional care and management (NCM; 30.2%), absence of a registered dietitian (29.3%), and difficulty in assessing swallowing function (24.1%). Our results revealed that the implementation rates of claim fees for NM and oral maintenance were low despite most respondents having problems with the double burden of malnutrition and necessity of oral care, suggesting the importance of securing time for NCM, appointing registered dietitians, and evaluating swallowing function.
... The rate of aspiration detection using the aforementioned methods is much higher than that using other evaluation methods, even in patients with CP [10]. However, the prevalence of aspiration varies widely from 31 to 97% in such cases, despite the use of standard swallowing function tests [11][12][13]. In addition, the relationship between aspiration detected by examination and the incidence of pneumonia is reportedly low in older adults and patients with CP [14,15]. ...
Background
Aspiration pneumonia is a major complication that occurs in patients with severe cerebral palsy and is associated with their survival prognosis, necessitating appropriate assessment and response. We focused on swallowing frequency as an index of daily swallowing function due to the difficulty in evaluating the risk of pneumonia. The swallowing motion protects the airway by safely directing the food, saliva, and secretions accumulated in the pharynx into the esophagus to prevent aspiration and entry into the trachea. Thus, swallowing frequency may be correlated with the incidence of pneumonia. In this study, we aimed to investigate the relationship between swallowing frequency and history of pneumonia in patients with severe cerebral palsy.
Methods
Fifty-seven patients with cerebral palsy were included in this study. Swallowing frequency was measured three times for each patient on separate days, and the reproducibility was examined by calculating the intraclass correlation coefficient. Further, the relationship between swallowing frequency and history of pneumonia was investigated using multivariate logistic regression analysis.
Results
While swallowing frequency differed between participants, it was constant within individuals (intraclass correlation coefficient: 0.941). Furthermore, the swallowing frequencies per hour were 12.2 ± 12.2 and 27.0 ± 20.4 in the patient groups with and without a history of pneumonia, respectively ( P < 0.001). Swallowing frequency (odds ratio: 10.489, 95% confidence interval: 2.706–40.663, P = 0.001) was significantly associated with the incidence of pneumonia in the previous year.
Conclusions
Swallowing frequency could be used as an index for assessing the risk of dysphagia and pneumonia in patients with severe cerebral palsy.
... These findings partially validate previous work focused on younger age groups and/or other CP subtypes (Benfer et al., 2013(Benfer et al., , 2014Kantarcigil et al., 2016;Mishra et al., 2018). Overall, in children with CP, feeding and swallowing development is known to occur within an abnormally developing system, and swallowing deficits may affect all or some of the swallowing phases and are often present from birth (e.g., Benfer et al., 2013;Calis et al., 2008;Love et al., 1980;Mishra et al., 2019;Rogers et al., 1994). However, it has also been documented that children with GMFCS Levels I and II (i.e., milder gross motor involvement) are likely to show improvements or fully functional feeding and swallowing skills by age (Benfer et al., 2017). ...
Purpose
Our purpose was to start examining clinical swallowing and motor speech skills of school-age children with unilateral cerebral palsy (UCP) compared to typically developing children (TDC), how these skills relate to each other, and whether they are predicted by clinical/demographic data (age, birth history, lesion type, etc.).
Method
Seventeen children with UCP and 17 TDC (7–12 years old) participated in this cross-sectional study. Feeding/swallowing skills were evaluated using the Dysphagia Disorder Survey (DDS) and a normalized measure of mealtime efficiency (normalized mealtime duration, i.e., nMD). Motor speech was assessed via speech intelligibility and speech rate measures using the Test of Children's Speech Plus. Analyses included nonparametric bootstrapping, correlation analysis, and multiple regression.
Results
Children with UCP exhibited more severe (higher) DDS scores ( p = .0096, Part 1; p = .0132, Part 2) and reduced speech rate than TDC ( p = .0120). Furthermore, in children with UCP, total DDS scores were moderately negatively correlated with speech intelligibility (words: r = −.6162, p = .0086; sentences: r = −.60792, p = .0096). Expressive language scores were the only significant predictor of feeding and swallowing performance, and receptive language scores were the only significant predictor of motor speech skills.
Conclusions
Swallowing and motor speech skills can be affected in school-age children with UCP, with wide variability of performance also noted. Preliminary cross-system interactions between swallowing, speech, and language are observed and might support the complex relationships between these domains. Further understanding these relationships in this population could have prognostic and/or therapeutic value and warrants further study.
Background:
The Pediatric Eating Assessment Tool (PEDI-EAT-10) is a reliable and valid tool for rapid identification of dysphagia in patients aged 18 months to 18 years.
Aims:
To translate and adapt the PEDI-EAT-10 into the Italian language and evaluate its validity and reliability.
Methods & procedures:
The translation and cross-cultural adaptation of the tool consisted of five stages: initial translation, synthesis of the translations, back translation, expert committee evaluation and test of the prefinal version. The internal consistency of the translated tool was analysed in a clinical group composed of 200 patients with special healthcare needs aged between 18 months and 18 years. They were consecutively enrolled at the Rare Disease Unit, Paediatrics Department, Fondazione Policlinico Agostino Gemelli-IRCCS, Rome. For test-retest reliability, 50 caregivers filled in the PEDI-EAT-10 questionnaire for a second time after a 2-week period. Construct validity was established by comparing data obtained from patients with data from healthy participants (n = 200). The study was approved by the local ethics committee.
Outcomes & results:
Psychometric data obtained from patients (104 M; mean age = 8.08 ± 4.85 years; median age = 7 years) showed satisfactory internal consistency (Cronbach's α = 0.89) and test-retest reliability (Pearson r = 0.99; Spearman r = 0.96). A total of 30% of children were classified as having a high risk of penetration/aspiration. The Italian PEDI-EAT-10 mean total score of the clinical group was significantly different from that resulting from healthy participants.
Conclusions & implications:
The PEDI-EAT-10 was successfully translated into Italian, validated and found to be a reliable one-page rapid screening tool to identify dysphagia in children and adolescents with special needs.
What this paper adds:
What is already known on the subject The PEDI-EAT-10 is a valid and reliable quick discriminative paediatric tool for identifying penetration/aspiration risks. What this paper adds to the existing knowledge In the present study we successfully translated and adapted the PEDI-EAT-10 into the Italian language. What are the potential or actual clinical implications of this work? This translation and adaptation increase access to valid feeding and swallowing assessment for children of Italian-speaking families. In addition, the I-PEDI-EAT-10 can suggest further assessment of patients' swallowing abilities.
Objective: To describe the profile of patients undergoing a gastrostomy, the recommendations and outcome of this insertion in a Pediatric Teaching Hospital. Method: This was a retrospective, quantitative, and descriptive study that researched the records of patients who underwent a gastrostomy between January 2010 and December 2012. Results: The diseases and conditions most frequent were chronic infantile encephalopathy (77.5%), pneumonia (67.5%), seizures (57.5%), and malnutrition (42.5%). Although most patients presented a history of dysphagia (62.5%), oral feeding was observed most frequently as the most common form of nutrition, before the gastrostomy insertion (42.5%), followed by nasoenteric tube (40%). The introduction of nutrition by gastrostomy was successful and occurred an average of 2.82 (± 1.19) days after insertion. Six months after their gastrostomy, 80% of patients continued feeding only through this access tube and only 2.5% had removed the gastrostomy; 45% of the participants had gastrostomy complications, with extravasation of gastric material (15%) and local inflammation (15%) being the most frequent. Conclusion: The profile of patients undergoing gastrostomy is mostly of individuals with neurological and respiratory diseases, without respiratory support, of the male gender, and feeding by oral cavity or nasoenteric tube for a prolonged period. The main recommendation criteria were dysphagia and neurological diseases. Regarding the outcome, the introduction of nutrition by gastrostomy was successful; most individuals remained with this long-term nutritional support and the most common complications were gastric material extravasation and local inflammations
A clinical and research protocol was developed to compare the sensitivity and clinical value of videofluoroscopy with the traditional bedside clinical evaluation in the evaluation of children's swallowing dysfunction. The bedside and videofluoroscopic evaluations of 33 children were reviewed retrospectively. Our findings indicated that recommendations for feeding changed for 14 of the children as a result of the information gained from videofluoroscopic evaluation. The results suggest that videofluoroscopy provides therapists with more objective evidence than a bedside evaluation for determining the etiology of swallowing dysfunction and directing the management or treatment of this dysfunction.
Signs of respiratory distress including coughing, choking, and gagging are not uncommon during oral feedings in patients with severe dysphagia. Aspiration pneumonia and chronic lung disease are recognized complications. Pulse oximetry, respiratory inductance plethysmography, and nasal airflow measurement by thermistors are accurate noninvasive methods of monitoring cardiopulmonary adaptation during oral feedings in patients with severe dysphagia. We report significant, previously unrecognized, acquired hypoxemia during oral feedings in two patients with severe cerebral palsy and one with multiple sclerosis. The episodes of hypoxemia occurred only while swallowing specific food textures. Periods of hypoxemia most probably resulted from aspiration during oral feedings. Cardiopulmonary adaptation may prove to be an important consideration in decisions regarding the method and advisability of continued oral feedings in patients with severe dysphagia.
y clinical observation and the cinefluorographic method, oral functions were investigated during deglutition in five children with cerebral palsy. From the results of this study, the following conclusions were drawn. By the clinical observation based upon the physiological evaluation criteria, absence of lip function, inadequacy of tongue movement, and loss of basic reflexes were assured. From the qualitative analysis of cinefluorographic pictures, lack of mobility of anterior and dorsal portion of tongue, depression of tongue root, drooling of barium liquid, incompetency of soft palate movement, and poor mobility of posterior pharyngeal wall were confirmed. The cinefluorographic results proved that the clinical observation had the following limitations., it might suggest only the abnormal pattern in the first phase, especially at the primary stage, but the conditions during the late stage of the first phase and the whole second phase were difficult to be assessed. In order to know the time relationship between the structural movements and the passage of bolus, the selected time points were defined. The cinefluorographic data revealed the dysfunction of tongue and soft palate, the inconsistency of time relationship, and the loss of coordination between the structures. The abnormal patterns of deglutition were ascertained during both the first and the second phase, in which the former was marked. In addition, the compensatory efforts were scarcely observed between the structures. The deglutition pattern in children with cerebral palsy might suggest that it was the palsy type of deglutition and the more complex type of abnormal function.
The respiratory inductance plethysmograph was used to analyse the ventilatory cycle during drinking, chewing and swallowing of normal and cerebral-palsied children aged between five and 12 years. 33 children were divided equally into three groups: normal, spastic CP and athetoid CP. A few of the children with spastic CP and over half of those with athetoid CP were unable to perform the 'big breath' task. In the remaining trials, the children with CP held their breath for a shorter time than normal children. Many children with CP required multiple swallows to consume 5mL of liquid. In the majority of trials, normal children swallowed liquids at or near the peak of inspiration, whereas the children with CP did not. Supplementary swallows and solid-bolus swallows occurred at any point in the ventilatory cycle in all groups. The children with CP had a greater need to inspire at the end of liquid tasks, especially during the 75mL task.
Our purpose here is to review abnormalities of the first two phases of swallowing. The most frequent symptoms of abnormal oral or pharyngeal swallowing include difficulty initiating swallowing, cervical dysphagia, nasal regurgitation, coughing, and choking. Generally, abnormal oral or pharyngeal swallowing function is associated with high cervical dysphagia in the upper neck, whereas the abnormal esophageal motor function or obstructive morphology may be in the retrosternal area or lower neck
Ten patients aged from nine months to 24 years with severe physical and intellectual impairments who had feeding difficulties were investigated by videofluoroscopy of repeated modified barium swallows. In all but one case the swallow reflex was delayed, and seven had poor and inefficient pharyngeal peristalsis. Four aspirated large amounts and three small amounts, all tending to do so with pastes rather than liquids. Recommendations, based on the videofluoroscopic findings, included changes in body and head position and consistency of food and of feeding technique. There were noticeable improvements in meal‐time behaviour and reduced coughing and choking.
RÉSUMÉ
Investigations vidéofluoroscopiques des troubles alimentaires chez les polyhandicapés Dix patients âgés de neuf mois à 24 ans, présentant des troubles graves physiques et intellectuels et ayant des difficultés d'alimentation ont étéétudiés par vidéofluoroscopie de bouchées de baryte, répétées et modifiées. Dans tous les cas sauf un, le réflexe de déglutition était retardé et dans sept cas, le péristaltisme pharyngéétait pauvre et inefficace. Quatre sujets absorbaient de larges bouchées, trois de petites quantités, tous faisant mieux avec une consistance pâteuse plutôt que liquide. Les conseils, établis à partir des données de la vidéofluoroscopie, comprennent un changement de la position du corps et de la téte, un contrôle de la consistence de la nourriture et de la technique alimentaire. Des progrès notables furent obtenus dans le comportement aux repas, une réduction de la toux et des fausses routes.
ZUSAMMENFASSUNG
Videofluoroskopische Untersuchungen bei Fütterungsschwierigkeiten von Kindern mit multiplen Behinderungen
Bei 10 Patienten im Alter zwischen neun Monaten und 24 Jahren mit schweren physikalischen und intellektuellen Behinderungen wurden wegen bestehender Fütterungsschwierigkeiten wiederholte modifizierte Bariumschlucke videoskopisch untersucht. Bei alien außer einem war der Schluckreflex verzögert und sieben hatten eine schlechte und ineffektive pharyngeale Peristaltik. Vier aspirierten große Mengen und drei kleine Mengen, alle tendierten jedoch eher bei Breien als bei Flüssigkeiten zur Aspiration Aufgrund der videofluoroskopischen Befunde wurde empfohlen, die Körper‐ und Kopfhaltung, die Konsistenz der Nahrung und die Fütterungsmethoden zu verändern. Es resultierten ein deutlich besseres Eßverhalten und weniger Husten‐ und Erstickungsanfälle.
RESUMEN
Investigación videofluoroscópica de las alteraciones de la alimentación en niños con diversas invalideces
Diez pacientes de nueve meses a 24 años con graves alteraciones físicas e intelectuales fueron investigados por medio de la videofluoroscopia de la deglución, repetidamente modificada, de papilla de bario. En todos los casos menos uno el reflejo de deglución estaba retrasado y siete tenían una paristalsis faríngea pobre e ineficaz. Cuatro aspiraban mucho y otros poco, y todos téndían a hacerlo con papillas más que con líquidos. Las recomendaciones basadas en los hallazgos videofluoroscópicos incluían cambios en la posición del cuerpo y la cabeza, en la consistencia del alimento y en la ténica de la alimentación. Se observó una notable mejoría en el comportamiento en las comidas y se redujeron la tos y el atragantamiento.