HOW I...

PAEDIATRIC

HOW I INFORM MY
DECISIONS

DYSPHAGIA: QUESTIONS
IS PENETRATION DURING SWALLOWING A NORMAL OR ABNORMAL EVENT FOR CHILDREN? DOES IT INDICATE DYSPHAGIA OR RISK OF ASPIRATION? WHAT DO WE DO WHEN WE SEE IT - REMOVE ORAL FEEDING, PERHAPS UNNECESSARILY, OR CONTINUE IT, PERHAPS RISKING RESPIRATORY CONSEQUENCES? CHARLOTTE BUSWELL GOES IN SEARCH OF ANSWERS.
Jamie* (11 months) was developmentally and neurologically doing well for his age. He had however had several chest infections, some requiring hospital admissions. Investigations suggested aspiration may be the reason for his respiratory problems, and had excluded other possible causes. As each episode of respiratory illness appeared to relate to feeding he was by now nonorally fed. Jamies parents and paediatrician wanted detail on the safety of his swallow. Jamies videofluoroscopy showed that milk penetrated into his laryngeal vestibule during swallows. As he propelled milk through his pharynx and on past his larynx, a small volume momentarily flicked under his epiglottis penetrating into his laryngeal vestibule, but appeared to remain part of the bolus. It did not go as far as the vocal cords. The milk in his larynx cleared completely as the bolus continued on into his oesophagus. All other aspects of swallowing were normal and we did not observe any aspiration. However, we didnt know if the penetration suggested Jamie was at risk of aspirating on other swallows. We decided to trial non-oral feeding for 4 months, and respiratory symptoms reduced. Very gradually we reintroduced small volumes orally. The process of returning to full oral feeding was very slow with Jamie reluctant to accept food orally. So were we right to remove Jamies oral feeding? And does the presence of penetration suggest that changes should be made to the management of a childs feeding? Penetration (figure 1) in swallowing physiology occurs when food or drink passes into the laryngeal vestibule, but does not pass below the level of the vocal cords; if it passes below the level of the vocal cords this is aspiration. Figure 1 Penetration on videofluoroscopy (shown with parental consent) Figure 1 shows a series of frames from a videofluoroscopy showing penetration into the laryngeal vestibule during the pharyngeal stage of the swallow. The arrows show: (a) Liquid in the pharynx with the main part of the bolus in the valleculae (above the epiglottis), starting to pass into the laryngeal vestibule. (b) and (c) Liquid penetrating under the epiglottis and into the laryngeal vestibule as the bolus continues to pass through the pharynx (seen as a thin lining under the epiglottis). (d) the liquid clearing from the laryngeal vestibule and passing with the main part of the bolus on into the oesophagus.

PENETRATING

WHATEVER THE CLIENT GROUP, WHEN CARRYING OUT AN ASSESSMENT AND MAKING RECOMMENDATIONS FOR MANAGEMENT WE INTERPRET AND DRAW TOGETHER FINDINGS FROM CLIENT / CARER REPORTS, OBSERVATION, AND FORMAL SOMETIMES INSTRUMENTAL MEASURES. OUR TWO CONTRIBUTORS SPECIALISE IN WORKING WITH CHILDREN WITH DYSPHAGIA. HERE, THEY ASK CLINICAL QUESTIONS ABOUT THE SIGNIFICANCE OF PENETRATION AND RESPIRATORY DISORDERS, AND DESCRIBE HOW THEY WENT ABOUT FINDING ANSWERS. THEIR SUGGESTIONS FOR PRACTICE SHOW HOW IMPORTANT IT IS TO TRY TO LOOK AT THE WHOLE PICTURE AND TO REPORT EVIDENCE ACCURATELY, INCLUDING ANY UNCERTAINTY. INFORMED DECISIONS (1) PENETRATING QUESTIONS INFORMED DECISIONS (2) QUESTIONING ASSUMPTIONS
CHARLOTTE ANN BUSWELL IS A SPECIALIST SPEECH & LANGUAGE THERAPIST, CHILD DEVELOPMENT CENTRE, ROYAL VICTORIA INFIRMARY, QUEEN VICTORIA ROAD, NEWCASTLE UPON TYNE NE1 4LP, TEL. 0191 282 4701, E-MAIL CHARLOTTE.BUSWELL@NUTH.NHS.UK. REBECCA HOWARTH IS A SENIOR SPECIALIST SPEECH & LANGUAGE THERAPIST, MANCHESTER CHILDRENS HOSPITAL / CENTRAL MANCHESTER PCT, TEL. 0161 922 2135, E-MAIL REBECCA.HOWARTH@CMMC.NHS.UK.

24

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006

HOW I

The laryngeal vestibule (figure 2) is the space between the laryngeal inlet and the vestibular folds (Standring, 2004). During the swallow the larynx rises and the epiglottis lowers to direct food and liquid past the larynx towards the oesophagus. Figure 2 The interior of the larynx showing the laryngeal vestibule Aspiration has pulmonary consequences, although evidence on the relationship between the amount of aspiration and the pulmonary consequences is extremely limited (Cass et al., 2005). Children who both aspirate and have gastro oesophageal reflux are at particular risk of respiratory consequences (Morton et al.,1999). There is no evidence that penetration that clears and does not pass below the vocal cords and into the trachea has any pulmonary consequences. DeMatteo et al. (2005) compared clinical evaluation of swallowing in children with videofluoroscopy. Penetration and aspiration of fluids, but not of solids, was detected from their clinical evaluations, with coughing the best predictor. However other studies describe many children as not showing signs such as coughing or discomfort when they aspirate (Mirrett et al. 1994).

Figure 3 The 8-Point Penetration-Aspiration Scale (Rosenbek et al., 1996)

1. Material does not enter the airway 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway 4. Material enters the airway, contacts the vocal folds, and is ejected from the airway 5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway 6. Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort 8. Material enters the airway, passes below the vocal folds, and no effort is made to eject
(Reprinted from Rosenbek et al. (1996), p.94, Table 2 Final version of the 8-Point PenetrationAspiration Scale. With kind permission of Springer Science and Business Media.)

Increase sensitivity
When reporting on a videofluoroscopy we describe what is recorded during screening, together with observations such as any coughing and the childs cooperation. We are aware of limitations: are the swallows representative of how the child usually feeds? / the setting is not a real mealtime / the food has barium powder mixed into it / we are not seeing a whole meal. We go to great lengths to minimise these limitations and thus increase the sensitivity of the videofluoroscopy (how good it is at picking up children with a swallowing disorder), for example by having parents feeding their child, in the childs usual position, using food, cups and utensils from home. We describe each stage of the swallow oral preparatory, oral, pharyngeal and upper oesophageal and comment on the interaction between the stages; for example oral control was poor, resulting in liquid spilling into the pharynx. The 8-Point Penetration-Aspiration Scale (Rosenbek et al., 1996) (figure 3), gives definition to our descriptions of penetration and aspiration, and may enhance our rating reliability (Stoeckli et al., 2003). Reliability (or agreement) on rating videofluoroscopies is more consistent for some swallowing features than for others. Agreement varies between clinicians. Clinicians may also vary their rating of swallowing features on separate occasions. Of all swallowing features on videofluoroscopy, it is the presence or absence of penetration and aspiration that has the most agreement between observers (McCullough et al., 2001).

So, we can be accurate at identifying penetration from the videofluoroscopy tape, but what parents and colleagues want to know is, what is its significance? This prompted me to search for evidence, with the following questions in mind: 1. Is it normal for children to penetrate? 2. Is it normal at any age or does the pattern change as children get older? 3. If it isnt normal what does it mean does it suggest a risk of aspiration (that is, an aspiration that nearly happened)? If penetration is an indicator of aspiration then, to manage the risk, we may want to modify a childs oral intake by removing consistencies on which they showed penetration. However, this can itself carry potential risks. Thickening drinks can increase the effort of drinking and if, as a result, fluid intake becomes inadequate, we may have to resort to supplementary tube feeding for fluids. If we withdraw oral feeding it can be difficult to re-establish (Mason et al, 2005) and we can disrupt or change the dynamics of social interaction around feeding by introducing tube feedings. In view of this, we need to be as sure as we can be that the evidence used in decision making is as accurate as possible.

Including uncertainty
Decisions on continuing with or modifying oral feeding on the grounds of safety of the swallow are not made on only one piece of evidence or by one person. Rather, the multidisciplinary team with the parents consider the evidence from mealtime observations, investigations and history of chest health (Cass et al., 2005). Our responsibility is to integrate the videofluoroscopy findings with the mealtime observations and to be accurate in reporting and interpreting findings using the best available evidence. Where evidence is weak we have a responsibility to say so. By presenting evidence accurately, and including any uncertainty, parents can make an informed decision about their childs feeding. I found little in searches of databases and texts on penetration in children, and much of it contradictory. Terminology used to describe the depth of passage of material into the larynx was inconsistent across studies, which may account for some of the variations in findings. I also searched adult literature, although there are reservations about applying adult data to children as several aspects of the anatomy and physiology of swallowing differ. There are however more adult studies and evidence can be stronger as, for example, ethical permission for videofluoroscopies with healthy adults is more likely to be obtained.

1. Healthy Adults
In a study of 150 healthy adults (age range 20-79), each swallowing one large mouthful of barium contrast, Ekberg & Nylander (1982) observed penetration into the subepiglottic region of the laryngeal vestibule in eight participants (5.3%), but none into the supraglottic region. Robbins et al. (1999), looking at how the swallows in 98 healthy adults (age range 21-84) were distributed on the 8-Point Penetration-Aspiration Scale (figure 3), evaluated 2 to 4 swallows of 3ml boluses per participant much smaller than a usual adult bolus. Penetration was found to point 2 in 16.5% of the total swallows, to point 3 in 2.8% of swallows, and aspiration in one swallow in an elderly man. All others were to point 1.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006

25

HOW I

This evidence in adults is on a limited number of swallows. The Ekberg study on small volumes suggests that penetration occurs in healthy adults, but to high rather than low in the laryngeal vestibule.

nasogastric tube while continuing with small amounts of pures orally. Sarah will be reviewed in the videofluoroscopy clinic before deciding on whether she will need continued tube feeding.

2. Healthy Children
Arvedson & Lefton-Greif (1998) suggest that, in infants, penetration which clears may be seen on the first couple of swallows, but should be considered abnormal if the amount penetrated increases through a feed. Three studies evaluated children with upper gastrointestinal symptoms. In such studies the child lies down on their side, the pharyngeal stage of the first few swallows of liquid is screened and screening then moves down the oesophagus to the stomach. Only the first (Delzell et al 1999), specifically set out to look at whether penetration is seen in normal swallowing. Of the 34 children (ages 7 days to 16 months mean 4 months), 33 showed penetration; 16 of these penetrated in over half of their swallows, and a further 5 on every swallow. Delzell concluded penetration is a normal finding in infants and children who have no evidence of swallowing dysfunction (p.764). The second study (Newman et al., 1991), of 21 infants (ages 3 days to 170 days mean 50 days), looked at the initial 3 to 5 sucks and found that infants with normal swallowing did not show penetration into the supraglottic area. Neither of these two studies looked at healthy infants.They had all been referred because of gastrointestinal symptoms such as vomiting which can themselves be associated with swallowing problems (Mathisen et al., 1999). In the third study Mercado-Deane et al. (2001) examined the incidence of swallowing problems in 472 full-term infants (under 12 months), referred with vomiting and respiratory symptoms, but no other difficulties. All were first evaluated on upper gastrointestinal studies where laryngeal penetration was found in 19 (13%) of the infants. Videofluoroscopies were carried out on 16 of these 19 infants; 6 aspirated on videofluoroscopy.

Suggestions for practice

Taking the evidence into account, my suggestions for practice are: 1. If we see penetration without aspiration, point out that there is insufficient evidence on whether this is normal in children or not. 2. Report the volumes the child had, and at what point during a feed penetration or aspiration was seen. 3. Quantify the depth of penetration into the laryngeal vestibule; depending on the quality of the image, in practice this can be difficult. 4. Where clinical symptoms or respiratory investigations suggest aspiration, or where we see penetration, give an extended feed of the childs usual feed volume. Screen intermittently to see if the child progresses to aspirate later in the feed. Parents are good at judging when their child is about to reach the end of their bottle / drink; with their guidance we can ensure we screen their last swallows. 5. If planning an extended feed, discuss this with the radiologist at the outset so the videofluoroscopy can be completed within safe radiation exposure limits. 6. Allow for longer appointments as extended feeds take more time in the x-ray room. 7. Apply the evidence on using extended feeds to clinical evaluations it confirms the value of observing feeding across a meal, not just for a few swallows. 8. Not all children need to have an extended feed. Plan each childs videofluoroscopy around the information that it hopes to provide. Children with severe, complex swallowing disorders may only need to be screened during videofluoroscopy on a few initial swallows to describe their swallowing pattern. * Names have been changed. Charlotte Buswell is a specialist speech and language therapist employed by Newcastle upon Tyne Hospitals NHS Trust. She is on year 2 of the MSc in Speech and Swallowing Research, School of Surgical and Reproductive Sciences, University of Newcastle upon Tyne.

3. Children with dysphagia

I reviewed two studies that specifically looked at penetration in children with dysphagia. Newman et al. (2001) reviewed findings from 43 consecutive videofluoroscopies of dysphagic infants (ages 1 week - 11.5 months, mean-5.25 months), with a range of aetiologies. On 2oz of milk, 40% of infants penetrated; half of these infants also aspirated. Of the nine who aspirated, six had some swallows where they just penetrated. Penetration and aspiration did not occur in early swallows; rather penetration occurred at a mean of 50 seconds into the bottle, and aspiration at a mean of 60 seconds. Friedman & Frazier (2000) looked at depth of penetration in 125 childrens (7 days - 19 years) videofluoroscopies, on a range of consistencies. They defined deep penetration as material entering the lower one-third of the laryngeal vestibule, and moderate penetration as entering the upper twothirds. Moderate penetration was seen in 19% of the children, and in a further 31% deep penetration was seen. Aspiration was seen in 85% of the children who showed deep penetration. Deep penetration was associated with thin consistencies and a delay in initiating the swallow, but, interestingly, not with oral motor impairment. These authors conclude that deep penetration is predictive of aspiration in dysphagic children. My team now evaluates clients in the light of the evidence described, and is seeing benefits for clients and families. For example, Sarah* was referred for a videofluoroscopy at 8 months with respiratory illness, felt to be due to aspiration. We screened initial swallows on her bottle and found no penetration or aspiration. Extending the feed, we found that after around 50 mls she started to penetrate during swallows. Continuing with the bottle and screening intermittently, we saw silent aspiration. With this evidence of aspiration, together with that from the respiratory investigations, her parents were able to make a more informed decision about whether to continue to feed her orally with a liquid consistency. Had we followed our earlier practice and only evaluated the first part of her feeding on her bottle, the videofluoroscopy would have missed the penetration of milk and the subsequent aspiration. Her parents decided to give her fluids by

References

Arvedson, J.C. & Lefton-Greif, M.A. (1998) Pediatric Videofluoroscopic Swallow Studies. San Antonio, Texas: Communication Skill Builders. Cass, H., Wallis, C., Ryan, M., Reilly, S. & McHugh, K. (2005) Assessing pulmonary consequences of dysphagia in children with neurological disabilities: when to intervene?, Developmental Medicine & Child Neurology 47 (5), pp. 347-352. Delzell, P.B., Kraus, R.A., Gaisie, G. & Lerner, G.E. (1999) Laryngeal penetration: a predictor of aspiration in infants?, Pediatric Radiology 29 (10), pp. 762-5. DeMatteo, C., Matovich, D. & Hjartarson, A. (2005) Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties, Developmental Medicine & Child Neurology 47 (3), pp. 149-57. Ekberg, O. & Nylander, G. (1982). Cineradiography of the pharyngeal stage of deglutition in 150 individuals without dysphagia, British Journal of Radiology 55 (652), pp. 253-257. Friedman, B. & Frazier, J.B. (2000). Deep laryngeal penetration as a predictor of aspiration, Dysphagia 15 (3), pp. 153-8. Mason, S.J., Harris, G. & Blissett, J. (2005) Tube feeding in infancy: implications for the development of normal eating and drinking skills, Dysphagia 20 (1), pp. 46-61. Mathisen, B., Worrall, L., Masel, J., Wall, C. & Shepherd, R.W. (1999) Feeding problems in infants with gastro-oesophageal reflux disease: A controlled study, Journal of Paediatric Child Health 35 (2), pp. 163-169. McCullough, G. M., Wertz, R.T., Rosenbeck, J.C., Mills, R.H., Webb, W.G. & Ross, K.B. (2001) Inter- and intrajudge reliability for videofluoroscopic swallowing evaluation measures, Dysphagia 16 (2), pp. 110-118. Mercado-Deane, M.G., Burton, E.M., Harlow, S.A., Glover, A.S., Deane, D.A., Guill, M.F. & Hudson, V. (2001) Swallowing dysfunction in infants less than 1 year of age, Pediatric Radiology 31 (6), pp. 423-8. Mirrett, P. L., Riski, J.E., Glascott, J. & Johnson, V. (1994) Videofluoroscopic assessment of children with severe spastic cerebral palsy, Dysphagia 9 (3), pp. 174-179. Morton, R.E., Wheatley, R. & Minford, J. (1999) Respiratory tract infections due to direct and reflux aspiration in children with severe neurodisability, Developmental Medicine & Child Neurology 41 (5), pp. 329-334. Newman, L.A., Cleveland, R.H., Blickman, J.G., Hillman, R.E. & Jaramillo, D. (1991) Videofluoroscopic Analysis of the Infant Swallow, Investigative Radiology 26 (10), pp. 870-73. Newman, L.A., Keckley, C., Petersen, M.C. & Hamner, A. (2001) Swallowing function and medical diagnoses in infants suspected of dysphagia, Pediatrics 108 (6). Robbins, J.A., Coyle, J., Rosenbek, J., Roecker, E. & Wood, J. (1999) Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale, Dysphagia 14 (4), pp. 228-32. Rosenbek, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L. & Wood, J.L. (1996) A PenetrationAspiration Scale, Dysphagia 11 (2), pp. 93-98. Standring, S., Ed. (2004) Grays anatomy: the anatomical basis of clinical practice. Edinburgh: Elsiever Churchill Livingstone. Stoeckli, S.J., Huisman, T.A., Seifert, B. & Martin-Harris, B.J. (2003) Interrater reliability of videofluoroscopic swallow evaluation, Dysphagia 18 (1), pp. 53-57.

26

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006