Paediatric dysphagia - Position statements European Society for Swallowing Disorders

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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

• In paediatric dysphagia:– Swallowing disorders– Feeding disorders

Definitions

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

• 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

Definitions:The different stages in paediatric development

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.

• Neonate: a baby who is aged 28 days and below• Infants: under 2 years of age• Children: under 18 years of age

Definitions:The different stages in paediatric development

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

• 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

Screening and assessment

• 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

Management

Swallowing disorders in Infant

• 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

Problem

Multidetermined disorders / Multiaxial diagnosis

• 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

Screening

• 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.

Assessment

• 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)

Management

Swallowing disorders in Children

• 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

Problematic

• 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

Screening

• 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

Assessment

Management

• Psychological dimension +++ Interaction child/parents

• Dietetic approach / nutritional status for growth needs

• Swallowing Re-education

Guidelines for 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

Clinical 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

Instrumental assessment

• 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

Multi-disciplinary Team

• 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

References