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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_936_Библиотеки_им_академика_М_И_Перельмана
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Pediatric Clinical
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Feeding Assessment
Anna Miles
While there are common themes
between an adult clinical swallowing evaluation and a pediatric clinical
feeding assessment, there are more differences than similarities. Like adult
dysphagia, pediatric feeding difficulties are a symptom of a vast range of
medical conditions and developmental
disorders (Table 14–1). These etiologies differ from those of adulthood and
old age. Children are also constantly
developing, and any clinical feeding
assessment must take cognizance of
this dynamic adapting system. Pediatric feeding difficulties lead to malnutrition, dehydration, failure to thrive,
respiratory complications, and distress
and reduced quality of life for child and
family (Lefton-Greif & McGrath-Morrow, 2007; Loughlin, 1989). In children,
the long-term adverse consequences of
aspiration (including recurrent chest
infections, tracheal and bronchial granuloma, stenosis, bronchitis, bronchiectasis, empyema, respiratory failure) are
life limiting and life threatening and
require careful investigation (Tutor &
Gosa, 2012; Tutor & Schoumacher, 2003)
(Table 14–2). While a detailed case history, oral examination, and structured
meal observation remain critical, the
opinions of, and mealtime interactions
with, parents also bear great significance. This chapter will provide an
overview of the components of a pediatric clinical feeding assessment covering neonates through to older childhood. For simplicity throughout the
chapter, “child” will be used to describe
the full spectrum of childhood from
prematurity to adulthood rather than
distinguishing between neonate, infant,
toddler, and child.
A pediatric clinical feeding assessment should be a comprehensive,
systematic, biopsychosocial evaluation. Instrumental assessments including flexible endoscopic evaluation of
swallowing (FEES) and/or a videofluoroscopic swallow study/dynamic
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Table 14–1. Pediatric Etiologies Associated with Feeding Problems
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• Prematurity
•
Central nervous system disorders (e.g., cerebral palsy, brain malformations,
brain tumors)
Cranial nerve, peripheral nerve, and muscle disorders (e.g., Moebius syndrome,
•
spinal muscular atrophy, muscular dystrophies, myotonic dystrophy, myasthenia
gravis)
•
Chromosomal abnormalities (e.g., Down syndrome)
•
Genetics structural conditions (e.g., Pierre Robin, cleft palate)
Metabolic disorders (e.g., hypoglycemia, pituitary and hypothalamic disorders,
•
inborn errors of metabolism)
• Gastrointestinal diseases (e.g., esophageal stenosis, hiatal hernia,
gastroesophageal reflux)
•
Cardiorespiratory compromise (e.g., congenital heart disorders, chronic lung
diseases)
• Inflammatory diseases (e.g., children in pain with arthritic disorders, juvenile
dermatomyositis)
• Medication side effects (e.g., hypotonia, drowsiness, nausea from oncology
medications)
• Sensory deprivation/overstimulation (e.g., prolonged ICU hospitalizations)
• Social-behavioral maladaptation (e.g., food refusal, child abuse)
Table 14–2. Signs of Aspiration in Children
Immediate Presentation Long-Term Presentation
Changes in respiration
Gagging
Vocal quality changes/wet respiratory
sounds
Swallows
Apnea with brachycardia
Cyanosis
Stridor
Hoarseness
Obstructive inspiratory efforts
Coughing
Choking
Change in skin color
Nasal flaring
Eye watering/eye blinking
Recurrent chest infections
Tracheal and bronchial granuloma
Stenosis
Bronchitis
Bronchiectasis
Empyema
Respiratory failure
Failure to thrive
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14. PEDIATRIC CLINICAL FEEDING ASSESSMENT
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swallow study (VFSS/DSS) may complement the clinical feeding assessment
and will be discussed later. A comprehensive feeding assessment typically
includes a medical history, feeding history, developmental history, oral sensorimotor assessment, caregiver interview, and meal observation.
INDICATIONS
Indications for a pediatric clinical feeding assessment include sucking difficulties, gagging, choking and/or coughing during meals, unexplained food
refusal, difficulties maintaining adequate caloric intake/adequate weight,
failure to thrive, recurrent pneumonias,
lengthy or distressed mealtimes, drooling, reflux, vomiting, regurgitation, or
high-risk medical diagnoses such as
cerebral palsy or cleft palate (Arvedson,
2008; Imhoff & Wigginton, 1991; Reilly
& Skuse, 1992; Wessel & Samour, 2005).
specialists in feeding, neurology, gastroenterology, and pulmonology; and
speech pathologists, physiotherapists,
occupational therapists, nutritionists/
dietitians, behavioral psychologists,
and social workers. It is critical that
the team communicates effectively to
ensure family and health professionals have a clear shared goal. There may
be times in the neonatal intensive care
unit (NICU), for example, where supplementary oxygen weaning is deemed
higher priority than nasogastric tube
feeding weaning. While, at other times,
tube feeding may be a barrier to discharge in a family desperate to return
home to their extended family, and
increasing oral feeds may take highest
priority. Regular interprofessional team
ward rounds and meetings are essential
for united, comprehensive assessment
and management.
TOOLS
TEAM APPROACH
The pediatric clinical feeding assessment must be approached by an
interprofessional team (Manikam &
Perman, 2000). Team members bring
different expertise to the medical, surgical, sensorimotor, and behavioral management of the child (McComish et al.,
2016) and depending on the individual
child’s needs may include physicians,
including specialty physicians such
as pediatric otolaryngologists, pediatric gastroenterologists, developmental
pediatricians, pediatric neurologists,
pediatric pulmonologists, pediatric
radiologists, and pediatric psychiatrists; nurses, including clinical nurse
There are many assessment tools available to clinicians, and these are often
population specific. These include
screening tools, observational checklists, and assessment protocols as
well as parent questionnaires. An upto-date systematic review of screening tools published in 2021 found 44
studies detailing unique screeners and
another 20 studies further validating
these screeners (Litchford et al., 2021).
They concluded that there are many
effective tools available to detect feeding dysfunction. This provides a great
resource for clinicians when deciding
on a screening tool for their specific
workplace.
Systematic reviews in pediatric feed-
ing assessment have become extremely
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
popular in recent years and provide
detailed critical appraisal of the currently available assessment protocols
(Calvo et al., 2016; Heckathorn et al.,
2016; Jaafar et al., 2019; Litchford et
al., 2021; Myer et al., 2016; Poppert et al.,
2015; Tsu-Hsin Howe et al., 2008). Commonly reported tools include Schedule
for Oral Motor Assessment (SOMA)
(Reilly et al., 2000), the Pediatric Evaluation of Disability Inventory (PEDI)
(Haley et al., 1992), Oral-Motor/Feeding Rating Scale (Jelm, 1990), Multidisciplinary Feeding Profile (Kenny et al.,
1989), Parental Feeding Questionnaire
(Tauman et al., 2011), Dysphagia Disorders Survey (DDS) (Sheppard et al.,
2014), and the Pediatric Eating Assessment Tool (Pedi-EAT) (Thoyre et al.,
2014). A recent systematic review offers
a critical appraisal of parent report
instruments for assessing feeding difficulties specifically in children with neurological conditions (Jaafar et al., 2018).
Six parent-report instruments met the
authors’ inclusion criteria: (a) Screening
Tool of Feeding Problems, (b) Paediatric Eating Assessment Tool, (c) Paediatric Assessment Scale for Severe Feeding Problems, (d) Montreal Children’s
Hospital Feeding Scale, (e) Children’s
Eating Behaviour Inventory, and (f) Behavioural Paediatric Feeding Assessment Scale (BPFAS). This wide range
of options may seem overwhelming,
but clinicians are likely to pick different assessment tools for different work
settings, and it would not be unusual to
routinely use multiple assessment tools
for different populations, ages, and situations. The important message is to
take a multipronged, comprehensive
approach to understanding the child
and their feeding.
CASE HISTORY
A thorough data collection should occur
before evaluating the child
a team discussion about the purpose/
goal of evaluation to ensure continuity of communication with family and
an appropriately focused assessment.
Unique to the pediatric population, a
review of the child’s educational and
therapeutic records is necessary as
well as an investigation of the complex
nature of parent-child interactions and
their influence on feeding and swallowing behaviors.
— including
Medical History
The pediatric swallowing team must
evaluate the perinatal and neonatal
history, medical diagnoses, previous
hospitalizations, and any significant
illnesses — focusing on organic precursors or causes of feeding problems.
The perinatal and neonatal history
may provide information detailing any
fetal hypoxia, the child’s response after
delivery, prematurity, any significant
congenital anomalies, and any major illness during the first few months of life.
Congenital anomalies, central nervous
system insults, or chronic illnesses may
affect the child’s ability to eat orally. For
example, respiratory problems may
make it difficult for the child to breathe
comfortably during feeding and lead
to an increased risk of aspiration, congenital cardiac problems often lead
to increased calorie requirements for
growth but fatigue makes feeding difficult, and gastroesophageal reflux from
whatever cause may result in discomfort when feeding as well as increase
14. PEDIATRIC CLINICAL FEEDING ASSESSMENT
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the risk of aspiration. Neurological
problems, whatever the origin (congenital or acquired, central or peripheral
nervous system or muscle diseases),
may interfere with the development of
normal oral-motor skills, resulting in
oral/pharyngeal/laryngeal/esophageal sensorimotor deficits as well as
impacting on optimal positioning and
self-feeding abilities. Prolonged NICU
hospitalizations, especially if there
have been repeated or prolonged tracheal intubations, frequent changes of
feeding tubes, and frequent episodes of
oropharyngeal or tracheal suction, may
lead to sensory processing disorders
resulting in hypersensitivity, sensory
defensiveness, and food selectivity/
refusal. Structural abnormalities such
as micrognathia, cleft palate, tongue
tie, and laryngomalacia must be considered as well as dental problems in
older children.
Attention must be given to the
chronic, improving, or deteriorating
nature of the child’s medical diagnoses, including the presence of seizures
or other conditions where abilities may
fluctuate. Previous hospitalizations
and significant illnesses can influence
or disrupt the child’s developmental
skills, including feeding skills. Respiratory conditions and/or illnesses may be
a contributor to the feeding difficulties
but may also indicate acute or chronic
aspiration.
A detailed developmental history
may provide insight into whether the
feeding difficulties are in line with
global development and establish the
child’s current developmental stage
(American Speech-Language-Hearing
Association, 2008). Current health status and current medications should
be noted. The American Speech-Language-Hearing Association (ASHA)
has developed comprehensive, consensus-based templates for pediatric
feeding history and clinical evaluation
(https://www.asha.org/siteassets/
practice-portal/pediatric-cse-template
.pdf). These may be useful for the clinical team to ensure all relevant information has been collated.
Family Interview
As with all patient-centered, successful
clinical practice, building a relationship with family and understanding a
family’s situation is important. Is there
good family support? Is there stress/
anxiety around mealtimes? What is the
understanding of the pediatric feeding
disorder by the family? Are there differences of understanding and opinion
within the family unit? It may be useful to probe into the feeding history of
parents and siblings
medical history but also eating habits,
food avoidance/selectivity or eating
disorders.
A parent perspective of the medical
history, sleep, nutrition, patterns of illness, weight maintenance, and feeding
history is useful as well as a description of a typical mealtime and/or a
typical day. Parents can provide critical
information about sensory processing
issues. It’s important to explore signs of
sensory over- or underresponsiveness,
overfrequent face/hand washing or
repulsion of face/hand washing, food/
texture avoidance, and/or adverse
reactions to food smells. Sensory craving should be explored, for example,
hot or cold temperature preferences,
— not only family
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
textural preferences (i.e., crunchy foods),
or strong flavor preferences.
Nutritional History
Nutritional Status
Food diaries completed by the primary
caregiver provide vital information
regarding quantity as well as range
of food eaten. For children with food
refusal and/or selectivity concerns, a
comprehensive food preference inventory may be required. Behavior-based
assessments include About Your Child’s
Eating–Revised (AYCE-R) (Davies et
al., 2007), the Behavioral Pediatric Feeding Assessment Scale (BPFAS) (Criss &
Napier-Philips, 2001), Children’s Eating
Behavior Inventory–Revised (CEBI-R)
(Archer et al., 1991), the Picky Eating
Questionnaire (Kaurer et al., 2015), or
the Brief Autism Mealtime Behavior
Inventory (BAMBI) (Lukens & Linscheid, 2008).
A review of the child’s current nutritional status should include laboratory tests, anthropometric measures
(including a review of growth), and an
assessment of nutrition-focused physical findings, which may impact their
nutritional status such as appetite and
gastrointestinal symptoms. Laboratory
tests can help define nutritional deficiencies. The most readily available
screening tests are the complete blood
count and a chemistry panel. Acomplete blood count may reveal concerns
such as iron-deficiency anemia or
altered immune status. The chemistry
panel may reveal electrolyte abnormalities (i.e., sodium and chloride) and
protein deficiency (i.e., a low albumin
and total protein). Anthropometric
measures may include weight, height,
triceps skinfold thickness, and mid-arm
circumference as a serial indicator of
body fat and muscle mass (American
Academy of Pediatrics, Committee on
Nutrition, 2020).
Growth Charts
Growth charts can be a good determinant of a child’s nutritional status. Prolonged inadequate caloric intake results
in a child nutritionally failing to thrive.
A child is defined as having failure to
thrive when (a) weight-to-length ratio
(body mass index [BMI]) is <5% for age
and gender, (b) the weight is <5% for
age and gender, or (c) the weight percentage has decreased two standard
deviations or more below the norm.
In 1977, in the United States, growth
charts were developed by the National
Center for Health Statistics in collaboration with the Centers for Disease Control and Prevention (CDC), based on
data from national probability samples.
These have been revised over the years
as the U.S. population has grown and
changed, and the CDC now provides
both the World Health Organization
(WHO) growth standards for infants
0 to 2 years and the CDC growth charts
for children 2 years and older (https://
www.cdc.gov/growthcharts/) covering weight, length, BMI, and head
circumference.
It is important to remember that
the causes of failure to thrive may be
organic (physical cause), nonorganic
(psychosocial including child abuse), or
a combination of both. However, not all
growth patterns are strictly related to
nutrition. For example, chromosomal
disorders such as Down syndrome
require use of specific growth charts,
14. PEDIATRIC CLINICAL FEEDING ASSESSMENT
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and genetic disorders include many
children with deviant growth patterns, both restricted growth such as
Russell-Silver syndrome and increased
growth such as Beckwith-Wiedemann
syndrome. Intrauterine insults, such as
fetal alcohol syndrome and intrauterine
infections, may result in poor intrauterine and postnatal growth and health.
There are many reasons why a child’s
weight, height, weight for height ratio,
and head circumference may be less
than the fifth percentile for age and
gender. But remember, the family’s own
growth pattern needs to be taken into
account. Some children under the fifth
percentile are normal. It is the growth
trajectory that is often more important.
Feeding History
Feeding history is usually elicited from
the parent, nurse, caregiver, or teacher.
Multiple accounts can be useful as children often respond differently to different people, and an individual caregiver’s perceptions can differ (Reilly &
Skuse, 1992). Feeding history should
include past methods and patterns of
feeding from birth onward, including
transitions to new foods/textures. It is
useful to know when the feeding problem began, what medical and social
circumstances existed at the time, and
the course of progression. Although a
physiological-based feeding impairment is important to assess and treat,
for many children, the feeding difficulties may be behavioral, including
food selectivity and food refusal. These
problems can result in the same severity of medical consequences, including
growth retardation, malnutrition, and
social difficulties (Chatter, 2002). The
interview with parents should cover
food choices and mealtime behaviors as
well as physiological signs and symptoms. The current feeding status needs
to include the parent’s perception of
the feeding difficulties and a thorough
description of the child’s mealtimes,
including the method and schedule of
feeding. Information gathered should
include type of food, amounts, textures,
temperatures, duration of feeding,
physical environment including seating and posture, family members usually present, the child’s behavior, and
any interventions attempted. A 24-hour
or, ideally, a 3-day dietary recall of the
child’s feeding routine and schedule
is helpful to assess individual nutritional patterns.
CLINICAL EXAMINATION/
OBSERVATION
The clinical team must observe the
full picture of the child even before
observing their competence when food
is introduced. An assessment of the
child’s general physical appearance
and oral sensorimotor abilities should
be completed.
Readiness for Feeding
Commonly used assessment tools for
oral feeding readiness and competence in the neonate include the Neonatal Oral-Motor Assessment Scale
(NOMAS) (Braun & Palmer, 1986),
Revised NOMAS (da Costa et al., 2016),
Early Feeding Skills Assessment (EFS)
(Thoyre et al., 2005), and Feeding Readiness Scale (Ludwig & Waitzman, 2007).
In children of all ages, the following
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
questions should be considered. Is the
child’s posture conducive to feeding?
How is their level of consciousness
— alert, sleepy, irritable? How is their
general tone
spastic (hypertonic)? Are these involuntary movements (dyskinesia)? Can the
child maintain alertness and attention
long enough for a full meal? Does the
child have the physiological maturation
for oral intake (heart range, respiration,
digestion) (Porges, 1996)? Is respiratory
state conducive to feeding? Is the child
interested in sucking/mealtimes?
— floppy (hypotonic) or
Behavior
Behavior can impact on feeding safety
and pleasure but may also direct the
clinical team to the root of a feeding
difficulty. Is the child alert, active, irritable, or apathetic? Irritability and apathy are commonly seen with malnutrition. Irritability may also be in response
to gastroenterological issues such as
reflux. Observe the child’s response to
food presentation and attitude toward
eating: Is the child hungry, cautious,
anxious, relaxed? Is this behavior in
direct response to food presentation or
to any other stimulus during the feeding? This is important as food refusal,
food selectivity, and disruptive behaviors can lead to poor feeding dynamics
between parent and child (American
Speech-Language-Hearing Association,
2008; McComish et al., 2016).
Global Development
Observe the child’s fine and gross
motor skills and muscle tone. Is the
child performing tasks at the expected
age, or is the child showing some developmental delay? Many children who
are developmentally delayed exhibit
some alteration in muscle tone, either
hypertonia, hypotonia, or mixed tone.
Both the child’s motor skills and muscle
tone influence their ability to eat and
feed independently.
Signs of Malnutrition
There are a number of signs of malnutrition to look out for. First, check
the skin for color, bruises, rashes, and
turgor. A pale color may indicate irondeficiency anemia. Bruising may be due
to vitamin K deficiency, but don’t forget
child abuse is a well-recognized cause
of failure to thrive. Essential fatty acids,
zinc, or vitamin deficiencies are known
to cause skin rashes. When inadequate
fluid intake accompanies poor caloric
intake, the skin and mucous membranes will be dry.
In rare situations, except in some
developing countries, we see signs of
more severe malnutrition. Loose skin
covering the decreased subcutaneous
fat indicates both a calorie and protein
inadequacy (marasmus). Excessive
fluid retention resulting in edema may
be due to insufficient protein intake
(kwashiorkor) or electrolyte imbalances. Check hair for texture, color, and
distribution. Hair that is brittle, pale
blond colored, and sparsely distributed is seen with protein malnutrition.
Check eyes for hydration status and
infection. Xerophthalmia, or dryness,
may be due to vitamin A deficiency.
Malnutrition can affect the immune
system and cause conjunctivitis (Kleiman & Warman, 1994).
ORAL SENSORY-MOTOR
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ASSESSMENT
14. PEDIATRIC CLINICAL FEEDING ASSESSMENT
n
Lip and jaw closure
n
Tongue mobility
333
The child’s oral sensory-motor and
feeding skills determine the types of
foods safely handled. During the first
3 years of life, the dramatic oromotor
and developmental feeding changes
have profound effects on the types of
food, textures, and feeding methods the
child can safely control. Developmental
feeding skills are affected by the child’s
gestational age. For example, preterm
infants frequently demonstrate generalized hypotonia and immature development of their suck/swallow/breathing,
thus affecting their feeding efficiency.
However, somewhere around 33 to 34
weeks’ gestation, the healthy growing
premature infant’s oromotor maturation allows for suck/swallow/breathing coordination and the introduction
of oral feedings (Casaer et al., 1982).
Some oral reflexes are common to all
ages, while other reflexes disappear
with maturity (Table 14–3). Clinicians
may find primitive reflexes still present
in an older child with neurological deficits, particularly cerebral palsy.
Birth to 4 Months
For term infants and premature infants whose postnatal age is corrected,
the following reflexes and responses
exist:
n
Rooting reflex
n
Suck reflex
n
Bite reflex
n
Gag reflex
n
Tongue protrusion reflex
n
Swallow reflex
The approach recommended for assessing oral sensory-motor skills is to
progress from the least frightening or
threatening (external touching of the
face and mouth) to the most threatening (internal inspection of the mouth).
When assessing these movements, start
with the rooting reflex. Elicit the reflex
by gently stroking the infant’s cheek.
The infant will turn their head toward
the touch with mouth open. The rooting reflex disappears between 3 and
5 months. The suck reflex is easily
assessed following the rooting reflex.
Alert the infant to your finger insertion
by progressive touch from cheek to lip,
then into the mouth. Gently insert finger with pad side up toward the hard
palate. An assessment of this nonnutritive sucking provides the clinician
with a measure of suck strength as well
as suck frequency and coordination.
Sucking should occur at a frequency
of two sucks per second (Arvedson
& Brodsky, 2002). During the sucking reflex, the tongue extends over
the gums or lips, with a motion moving from tongue tip to the back of the
tongue. A pulling pressure is felt with
the inserted finger being pulled to feel
the soft palate. The sucking reflex disappears at approximately 6 months.
When assessing the rooting or suck
reflexes, oral hypersensitivity may be
noted. For example, the infant may
demonstrate agitation, facial grimace,
arching, and gagging even with gentle
touching of the face. Oral hypersensitivity is defined as an aversion to touch
or to eating food by mouth and/or food
refusal of certain food types or textures.
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