Perspectives on Swallowing and Swallowing Disorders (Dysphagia)
Volume 24, February 2015, Copyright © 2015 American Speech-Language-Hearing Association
Special Considerations for the Pediatric Population Relating
to a Swallow Screen Versus Clinical Swallow or
Instrumental Evaluation
Amy L. Delaney
Masters Family Speech and Hearing Center, Children’s Hospital of Wisconsin
Milwaukee, WI
Clinical & Translational Science Institute & Otolaryngology, Medical College of Wisconsin
Milwaukee, WI
Financial Disclosure: Amy L. Delaney is speech-language pathology program specialist at
Children’s Hospital of Wisconsin and adjunct assistant professor in the Department of Clinical &
Transitional Science Institute & Otolaryngology at Medical College of Wisconsin.
Nonfinancial Disclosure: Amy L. Delaney has previously published in the subject area.
Abstract
Careful consideration should be taken to determine how a swallow screen could be
implemented in the pediatric population. A variety of factors to be considered include: age,
developmental level, feeding experience of the child, diagnosis, the status of the child’s
dysphagia, and the setting where the patient is treated. A swallow screen might be feasible
in specific situations in the pediatric population to identify aspiration risk in those with a
change in normal swallow status. Yet, more research is needed to improve the accurate
identification for the pediatric population of aspiration risk and other signs of dysphagia
that warrant an instrumental assessment. While risk for aspiration is a concern in this
population, it is not the only concern due to the dynamic changes in feeding and swallowing
performance that occur throughout childhood. These dynamic changes require a thorough
clinical observation that neither a swallow screening nor instrumental assessment can
provide the clinician. Thus, the clinical swallow evaluation (CSE) remains the most
comprehensive tool available to assess oral feeding skill development and function, as well as,
to identify risk factors for not only aspiration, but for other aspects of dysphagia, which may
warrant an instrumental assessment.
There is debate in speech-language pathology about the utility of a swallow screen to
determine aspiration risk rather than use of a clinical swallow evaluation (CSE) or direct referral to
instrumental assessment. In healthcare, screening tests are generally used in healthy individuals
to identify those at increased risk of having a disease or disorder, and to determine need for further
testing such as implemented in mammography or colonoscopy (Evans, Galen, & Britt, 2005; Grimes
& Schultz, 2002). Swallow screens are currently used in adults who have suffered an event leading
to concern for aspiration. An example of a formal swallow screen is a procedure such as a 3-ounce
water challenge (Suiter & Leder, 2008; Suiter, Leder, & Karas, 2009). A failed screening is when a
patient is unable to consume the prescribed volume without interruption, coughing, choking, or wet
vocal quality during or within the one-minute following completion of the task. The procedure is
assessing for aspiration risk to reduce unnecessary instrumental swallow evaluations. Studies have
consistently revealed high sensitivity for determining the absence of aspiration with thin liquids with
a passed screening, but low specificity and a high false-positive rate for determining presence of
aspiration with a failed screening. More than one-half of those who failed the screening did not
aspirate during fiberoptic endoscopic evaluation of swallowing (FEES) instrumental assessment
(Suiter & Leder, 2008; Suiter et al., 2009). These findings were replicated in a pediatric population
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with 77% (34/56) of children who failed the screening were not found to aspirate on instrumental
evaluation (Suiter et al., 2009).
There could be several reasons why a failed screening did not result in presence of
aspiration during instrumental assessment for the pediatric cohort. First, different tasks were
used, as sequential swallowing of a three ounce volume of liquid was used during the screening
versus discrete swallows of three individual 5 ml boluses used during the instrumental assessment.
Second, the inability to consume the prescribed volume was not a strong indication of aspiration.
Third, the child does not aspirate every time he/she drinks. Finally, the instrumental assessment
revealed absence of aspiration at the time of testing, but aspiration may indeed occur at some
other time during the feeding.
Though over referral to instrumental assessment is of concern for an adult patient, it is
more concerning for the pediatric patient and further investigation is required to improve the
sensitivity and specificity of a swallow screen. Extra consideration needs to be made in the
frequency of radiation exposure, the risks of exposure in an infant or young child, and the ability
of a child to complete the instrumental assessment. Some children may refuse to complete the
swallow study due to the presence of barium in the food. Others will not tolerate placement of a
scope. If the need for instrumental assessment is identified but unable to be conducted due to the
above concerns, a CSE is often still warranted to make more global recommendations until the
time where instrumental assessment is able to be conducted. Additionally, feeding and swallowing
problems may progress over the course of a mealtime and fluoroscopy does not afford the amount
of time necessary to observe changes over time due to reduced endurance. While FEES has no
time limitation, the oral phase is not visible, and in the pediatric population, thorough observation
of the oral phase is critical.
Aspiration risk is of great concern in pediatrics; it is not the only concern. In infants
and young children in particular, there is great concern for feeding-related problems. These
feeding-related problems may never place a child at risk for aspiration. Children with a feeding
disorder consume a diet that is inappropriate for their age. Feeding disorders fall into categories
such as failure to advance textures at developmentally appropriate times, failure to advance in
methods of eating (utensils or self-feeding), selective or restrictive diet, and inadequate volume of
intake to support growth and/or nutrition (Levine et al., 2011; Phalen, 2013; Romano, Hartman,
Privitera, Cardile, & Shamir, 2014; Rudolph, 1994). The etiology of these issues can be related
to oral-sensory dysfunction, oral-motor dysfunction, global incoordination or weakness, poor
appetite, poor mealtime structure and routine or negative parent-child interactions due to a range
of medical conditions (Davis et al., 2013; Phalen, 2013; Rommel, De Meyer, Feenstra, & Veereman-
Wauters, 2003; Rudolph, 1994). Evaluation of feeding-related problems requires a CSE. The CSE
allows for identification of the specific features during a mealtime that may increase aspiration risk,
and other signs of dysphagia, so that these issues can be evaluated with appropriate therapeutic
trials during an instrumental assessment when appropriate.
Perhaps a formal swallow screen is not necessary. In the pediatric population, informal
screenings occur frequently by pediatricians, nurses, parents, and daycare providers. Yet, the
currently available literature does not delineate which risk factors warrant an instrumental
assessment alone, a CSE alone, or a combination of methods. Use of best evidence-based information
about feeding and swallowing development and age-specific expectations could be as accurate in
identifying the need for further assessment as a swallow screening due to the child’s dynamically
changing system. There are a number of factors to be considered when making a decision on
use of a formal swallow screen, CSE, or direct referral to instrumental assessment. These factors
include: age, development, feeding experience, diagnosis, status of dysphagia, and setting. Table 1
outlines the factors that should be considered for implementation of a swallow screen within the
pediatric population.
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Age
The age of a child plays a substantial role in decision-making about the utility of a swallow
screen versus CSE or instrumental assessment. Anatomic and physiologic changes that occur
throughout childhood create the basis of change in feeding performance. These age-specific changes
dictate differences in feeding and swallowing performance that include feeding method (breast, bottle,
cup, utensil type and size, self/independent feeding), diet (texture, bolus size, nutrition/hydration
needs, volume per texture, volume per method, volume per meal, food choices) and environmental
controls (frequency of feedings, timing of feedings, mealtime duration, position of child, location,
compliance). Each of these factors must be considered when determining criteria for a screening.
For example, the amount of liquid that is reasonable to take at one time without interruption
and the criteria that would be appropriate for failing children of different ages needs to be defined
(see reviews by Delaney & Arvedson, 2008; Delaney & Rudolph, 2012). An infant would be more
likely than a toddler to complete a prescribed volume for a swallow screen based on normal
expectations of sequential swallowing by bottle, but the volume would be dependent by age and
weight. As children wean from the bottle, consumption of liquids shifts away from large volumes at
one time without interruption. The chances of children failing a screening would increase due to
normal changes in feeding practices and out of lack of compliance due to age rather than due to a
swallowing problem. A limited number of studies have been published of typically-developing
children regarding performance for bolus sizes of liquids and foods, sip size, discrete versus sequential
swallowing, texture advancement, and chewing efficiency (see review by Delaney & Rudolph, 2012).
These limited age-specific expectations make it difficult to standardize one screening tool for all
children. Even scarcer are studies reporting feeding and swallowing outcomes of children of different
ages with developmental and/or medical issues.
Healthy, typically developing children under 3 years of age are a very heterogeneous group
given that oral feeding skills, abilities, and swallowing expectations are constantly changing
(Delaney & Rudolph, 2012; Gisel, 1991; Green et al., 1997; Wilson & Green, 2009). Abilities are
expected to change by the week and month, rather than years or decades. Oral feeding skill
acquisition stabilizes in typical children by 3 years of age. Ongoing refinement continues into
preschool or even school-aged years (Green, et al., 1997; Wilson & Green, 2009). The duration of
this refinement phase is unknown. Once skills stabilize and compliance for the screening task by a
child is reasonable, a swallow screen for children might be feasible. However, once development,
medical status, or changes in feeding experience exist, the criteria for the screening would need to
be reconsidered.
Development and Feeding Experience
Oral feeding skills and abilities are closely tied to development and feeding experiences
and the focus in pediatrics is largely on habilitation of a child with a feeding and swallowing
mechanism that has never functioned normally. The developmental level of a child can predict
feeding expectations. A child with global development delay would be expected to have feeding
skills commensurate with overall developmental levels. Usually major concern for aspiration risk
is not present in a child with a primary developmental delay. A child with a domain-specific
development delay is more difficult to categorize (e.g., do isolated delays in walking indicate delays
in chewing or aspiration risk?). Usually major concern for aspiration risk is still not present but
if the delay coincides with a medical diagnosis there may be increased risk. Refer to Table 1.
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Table 1. Factors Under Consideration for a Pediatric Swallow Screen.
Variables Considerations Potential for
screening
Age Preterm
Infant Varying expectations based on No
Toddler age and development
School age More consistent expectations Possible
Teen depending on status
Development Typical Age specific expectations, at certain age easy to determine Possible at
change in status and increased risk based certain age
Not typical Global deficit Reasonable to expect delays in Possible at
oral feeding skills but does not certain
mean risk for aspiration; difficult developmental
to know when feeding level
progression is complete to set
expectations
Domain specific deficit Which domain best dictates oral Possible,
(other than feeding) feeding skill levels? dependent on
domain
Oral-motor/Feeding/ Varying factors, may benefit from Possible
Swallowing deficit only screening
Feeding Typical Normal age of onset At certain age easy to determine Possible at
experience and progression change in status and increased certain age
risk based on status
None Never eaten by mouth Will fail screen but not indication No
or limited intake of risk for aspiration; likely high
false-positive
Delayed Delayed onset of oral If typical progression is simply Possible at
eating delayed then at certain age or certain
developmental level could likely developmental
do a screen level
Altered Periods of NPO or Difficult to know when feeding No
regression; atypical progression is complete to set
progression; combo of expectations; would likely fail due
PO and tube to low or inconsistent intake/
acceptance
Diagnosis Medical Genetic Highly dependent on primary Possible
Neuro diagnosis, concomitant diagnoses
Cardio/Respir and severity
Ortho
GI
No medical If young infant, might be first Possible
diagnosis indication of underlying medical
or development issue; no red
flags for etiology or risk factor
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Status of Acute Highly dependent on Not necessarily true reflections of Possible
dysphagia status other factors skills; possible transient problem;
may resolve and SLP never needed;
rescreening possible for hospital
setting; dependent on age
Chronic Highly dependent on Likely multifactorial and complex No
status other factors
Setting Inpatient Acute Benefit of h/p, medical exam, i/o Possible for
Chronic monitoring, rescreening possible, certain units
Rehab consistent providers available for
training, diagnosis and risk
factors might be more evident;
certain units may be possible
Outpatient Hospital Certain units may be possible, Possible
Clinic rescreening may not be possible;
inconsistent training
Community PCP office Often little/no medical No
Early intervention information, diverse knowledge;
School difficult to train and have
Daycare consistent decision-making;
Home rescreening may not be possible
Developmental and medical issues will alter a child’s feeding experience such that age is no
longer a primary indicator used to determine the possibility of a swallow screen. Children may
have a protracted developmental phase of skill acquisition based on chronic illness, long hospital
stays, or developmental issues. Delays in introduction of new foods are missed leading to lack of
skill development during these critical periods in infancy. Children may have experienced normal
onset and frequency of feedings in infancy but had aversive experiences due to varied medical/
surgical procedures such as oral suctioning, intubation, and other oral procedures leading to oral
defensiveness. Other children have little to no feeding experience and dramatic delays in onset
of eating due to extreme prematurity or complex medical situations that create different feeding
expectations.
Diagnosis
The number of underlying diagnoses a child has complicates the decision-making as to
whether a swallow screen versus a CSE is sufficient to determine when to conduct an instrumental
assessment. A child may present with an isolated delay in feeding milestones without a medical
diagnosis or obvious aspiration risk due to a developmental delay. These feeding difficulties may be
the first indication of an underlying medical or developmental condition that has not yet been
diagnosed (Dahl & Kristiansson, 1987; Drewett & Young, 1998; Mizuno & Ueda, 2005). In these
cases, a CSE is more beneficial than a swallow screen. An infant or young child with isolated
chronic respiratory issues (Lefton-Greif, Carroll, & Loughlin, 2006; Mercado-Deane et al., 2001),
children with neuroimpairment (Arvedson, Rogers, Buck, Smart, & Msall, 1994; van den Engel-
Hoek et al., 2013), and children with severe traumatic brain injury (Morgan, Mageandran, &
Mei, 2009), may need direct referral to an instrumental assessment based on increased risk for
pharyngeal dysfunction and aspiration. Children with certain medical diagnoses are already
known to be at increased risk of feeding and swallowing problems that may benefit from both a
CSE and instrumental assessment without the need for a swallow screen. Although the range and
extent are variable, some well known patient groups include patients with cardiac defect (Mussatto
et al., 2014), Down Syndrome (Kumin & Bahr, 1999), structural anomalies (de Vries et al., 2014)
and pulmonary issues (Hawdon, Beauregard, Slattery, & Kennedy, 2000). A child of the same age
and feeding experience with multiple diagnoses (e.g., such as a child with prematurity, grade IV
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intraventricular bleed, bronchopulmonary dysplasia, and cardiac defect) will have very different
expectations in swallowing performance than a child with isolated gastroesophageal reflux and
would not likely benefit from a screening.
While risk factors for aspiration and other signs of dysphagia are reported, prevalence of
aspiration risk by diagnosis is not clearly defined in pediatrics. First, the criteria to diagnose a
child with a feeding disorder or aspiration risk and dysphagia vary by discipline. A child may
get a diagnosis of a feeding disorder or dysphagia by a dietitian based on poor growth (Sermet-
Gaudelus et al., 2000), by a psychologist based on negative mealtime behaviors (Benjasuwantep,
Chaithirayanon, & Eiamudomkan, 2013; Schreck & Williams, 2005), or by a physician in a child
who needs supplemental tube feeding (Mussatto et al., 2014) even though the child has no aspiration
risk. Describing and quantifying risk factors and outcomes by diagnosis is difficult such that
children with picky eating, without any aspiration risk or dysphagia, and those dependent on
supplemental tube feeding, due to significant aspiration, might be categorized together. Thus,
screening for aspiration risk by diagnosis alone can introduce a great deal of confounding factors.
Status of Dysphagia
The acute or chronic nature of the feeding and swallowing problems is another important
consideration. In an older child who experiences a change in their normal swallowing status
following a medical event, a swallow screen could be warranted. Changes in swallow status during
an acute event may be transient and resolve on its own (e.g., onset of coughing during drinking
with upper respiratory infection; resection of brain tumor; or decline in intake of solids for two
weeks following a choking episode) or may have a more predictable course of dysphagia. A child
with chronic dysphagia may not benefit from a screening as the problems are likely multifaceted.
The child may be unable to complete the task or an instrumental assessment based on age,
development, or feeding experience. However, a child placed on thickened liquids due to aspiration
with cough response might benefit a swallow screen to determine the potential of an upgrade in
diet to avoid further instrumental evaluation.
Setting
The perspective of the individual clinician, and the context from which their perspective is
rooted, is a key factor in potential to reach consensus on this topic. The considerations revolve
around the opportunity to perform a screening, the process of what the screening entails, and
when to use the available screen or refer for full assessment (CSE or instrumental assessment).
These decisions will differ for those working an inpatient hospital setting, an outpatient hospital,
or within the community. There may be opportunities to implement a screening procedure for a
patient admitted to a particular hospital or unit. Children admitted to certain units of a hospital
might present with a particular diagnosis that creates high-risk or more predictable swallowing
problems and a swallow screen would help delineate those at risk for aspiration and in need
of an instrumental assessment. There are more consistent providers in hospital units for training
on the screening measure and the ability to consult with a speech-language pathologist (SLP) to
help determine which type of evaluation is appropriate (Warner, Suiter, Nystrom, Poskus, & Leder,
2013). More timely and consistent decision-making is afforded in this setting, with detailed medical
information, close monitoring, and the opportunity for supplemental feeding readily available, if
needed. The patient is easily accessible for more than one observation allowing for rescreening, if
deemed necessary, and there is more opportunity as a team to decide what is best for the patient.
There are fewer opportunities to implement a formal screening procedure for a patient
presenting to an outpatient clinic or in the community where providers may have very diverse
backgrounds and perspectives. While children presenting to a specialty clinic may have more
specific risk factors for dysphagia, children presenting to a community clinic may have less specific,
more diverse, or no risk factors at all, increasing the difficulty of decision-making particularly
if the child fails the screening. Comprehensive medical information may not be available and
the opportunity to monitor and rescreen the child is not easily accomplished. Formal training
procedures of staff by an SLP could be difficult, as most community clinics do not have clinicians
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on-site. The setting can provide unique opportunities and could be a key variable in consideration
in the implementation of a swallow screen.
Summary
The decision-making regarding implementing a swallow screen in the pediatric population
has multiple variables to be considered. There are concomitant factors that increase the complexity
of decision-making and decrease the likelihood that a formal swallow screening would be a viable
option in the pediatric population as a whole. Yet, certain circumstances might afford contemplation
of a swallow screen. As a starting point, the criteria for a swallow screen would need to start with
the age of a child and their feeding experience. If a child is older than the age when skill acquisition
has stabilized and when that child has had normal feeding and swallowing development, criteria
could be established. In children with developmental delays or complex medical situations, age and
experience no longer remains the primary determination of criteria.
These complex and dynamic changes in feeding that occur from birth into childhood continue
to require a comprehensive clinical swallow evaluation. With extensive training in anatomy,
physiology, and development, SLPs are best suited to make educated decisions about feeding and
swallowing abilities, as well as, the benefit and timing of instrumental assessment. The CSE
affords the clinician time, flexibility, and intervention trials that a swallow screen or instrumental
swallow study does not. Data are desperately needed to determine accurate and reliable risk
factors for aspiration, and other signs of dysphagia, that requires confirmation by instrumental
assessment. Identifying these risk factors must include age, development, experience, diagnoses,
status of dysphagia, and setting. Thoughtful discussion with all of these variables in mind might
lead to some consensus and future research direction in speech-language pathology on how to
screen and evaluate aspiration risk and other signs of dysphagia in the pediatric population.
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History:
Received October 7, 2014
Revised January 9, 2015
Accepted January 12, 2015
doi:10.1044/sasd24.1.26
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