The National Center for Evidence-Based Practice
in Communication Disorders
Home      Pediatric-Dysphagia-Assessment-Instrumental-Assessment-Videofluoroscopy

Pediatric Dysphagia Evidence Map
Instrumental Assessment

Videofluoroscopy

 


 

External Scientific Evidence

  

Evidence-Based Practice Guidelines
British Thoracic Society

British Thoracic Society Guideline for Respiratory Management of Children with Neuromuscular Weakness
Hull, J., Aniapravan, R., et al. (2012).
Thorax, 67 Suppl 1, i1-40.
Added: April 2013

Description

  • This guideline provides recommendations for the assessment and treatment of children with neuromuscular weakness (NMW). The target audiences of this guideline are healthcare professions who care for these children. The guideline provides graded evidence statements and recommendations. Evidence statements are graded as:

    • Level 1 (1-, 1+, 1++) - Meta-analyses/systematic reviews of randomized controlled trials (RCTs) or RCTs with low (1++) to high (1-) risk of bias.

    • Level 2  (2-, 2+, 2++) - Case control or cohort studies or a systematic review of such studies with a minimal (2++) or high (2-) risk of bias.

    • Level 3 - Non-analytic studies

    • Level 4 - Expert opinion

  • The recommendations included in the guideline are classified based on the strength and quality of evidence.

    • Grade A - Based on 1++ or 1+ evidence directly applicable to the target population and overall consistency of results.

    • Grade B - Based on 2++ evidence directly applicable to the target population or extrapolated evidence from studies classified as 1++ or 1+.

    • Grade C - Based on 2+ evidence directly applicable to the target population or extrapolated evidence from studies classified as 2++.

    • Grade D - Evidence level 3 or 4 extrapolated evidence from level 2 + studies.

    • Good Practice Point - Important practice points for which there is no or likely to be no evidence.

Recommendations
Children with NMW and a history of recurrent chest infections or swallowing difficulties should have "a feeding assessment by a speech and language therapist including a videofluoroscopy swallow assessment if the swallow is thought to be unsafe" (good practice point) (p. 1).

» See full summary and quality ratings



New York State Department of Health, Early Intervention Program; U.S. Department of Education
 
Clinical Practice Guideline: Report of the Recommendations. Motor Disorders, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2006).
Albany (NY): NYS Department of Health, Publication No. 4962, 322 pages
.
 
Added: July 2011
 
Description
This guideline provides recommendations regarding assessment and intervention for young children with developmental motor disorders and cerebral palsy, a static central nervous system disorder.  The target audiences for this guideline are parents and professionals. The recommendations are classified A, B, C, D1 or D2, based on the strength and quality of evidence. Level A recommendations are considered “strong evidence” based on high quality evidence from two or more efficacy studies. Level B recommendations are considered “moderate evidence" and based on evidence from at least one high quality efficacy study. Level C recommendations are "limited evidence" and based on evidence from at least one efficacy study with moderate quality or applicability to the topic.  Level D1 and D2 are consensus recommendations. Level D1 recommendations are consensus panel opinion based on information not meeting criteria for evidence in systematic reviews and Level D2 recommendations are based on information where a systematic review has not been done. 
 
Recommendations
Some children may need additional evaluation using instrumental assessments such as a videofluoroscopic swallow study (VFSS) or flexible endoscopic examination of swallowing (FEES) (Evidence Level D2) (pp. 68–75). 
 
 
 
 
Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
 
Royal College of Speech and Language Therapists Clinical Guidelines: 5.5 Cleft Palate & Velopharyngeal Abnormalities
Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.
 
Added: July 2011
 
Description
This guideline provides recommendations for the assessment and treatment of cleft palate and velopharyngeal abnormalities. The target audience for this guideline is speech-language pathologists. Recommendations are based on randomized controlled trials (Level A Evidence), well-conducted clinical studies (Level B Evidence), or expert opinion (Level C Evidence). 
 
Recommendations
Recommend differential diagnosis of velopharyngeal dysfunction with direct and indirect assessment tools which can include videofluoroscopy and perceptual evaluation, nasendoscopy, and acoustic and airflow measurements when possible (Level B Evidence). 
 
 
 
 
Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
 
Royal College of Speech and Language Therapists Clinical Guidelines: 5.8 Disorders of Feeding, Eating, Drinking & Swallowing (Dysphagia)
Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.
 
Added: July 2011
 
Description
This guideline provides recommendations for the assessment and management of swallowing disorders in children and adults. This guideline is intended for speech-language pathologists. Populations included, but were not limited to, stroke, traumatic brain injury, autism spectrum disorder, cerebral palsy, Parkinson’s disease and head and neck cancer. Each recommendation is graded A (requires at least one randomized controlled trial), B (requires at least one well-conducted clinical study), or C (requires evidence from expert committee reports). 
 
Recommendations
  • A videofluoroscopic or fibre-optic endoscopic evaluation of swallowing should be carried out if necessary (and if there are no clinical contraindications) to improve visualization of the upper aerodigestive tract, assess aspiration and residue, facilitate techniques and therapeutic strategies to reduce aspiration and improve swallowing efficiency, compare baseline and post-treatment function, and to further diagnose (Level A Evidence).
  • “Research has demonstrated poor inter-rater reliability in the interpretation of [Videofluoroscopic Evaluation of Swallowing (VFES)], and the Speech & Language Therapist should therefore exercise caution” (Level A Evidence) (p. 65).

» See full summary and quality ratings

 
 
 
 
Evidence-Based Systematic Reviews
Clinical Practice: Swallowing Problems in Cerebral Palsy
Erasmus, C. E., van Hulst, K., et al. (2012).
European Journal of Pediatrics, 171(3), 409-14.
Added: September 2012

Description
This review discusses the pathophysiology, clinical features, assessment, and management of swallowing problems in children with cerebral palsy (CP). 

Conclusions
Speech language pathologists may be involved with the swallowing assessment of children with cerebral palsy as part of a multidisciplinary team. Recommendations for evaluation based on expert opinion include:

  • Assess respiratory status

  • Collect medical, social-emotional, and medication history

  • Evaluate for presence of gastro-oesophageal reflux

  • Evaluate the safety of the feeding program and consider nasotube feeding

  • Conduct neurological examination

  • Examine orofacial structures and consider specialist ENT evaluation

  • Examine oral hygiene, occlusion, teeth, posture and head control, mouth closure, and lip seal

  • Consider the consistency, size, and texture of the food bolus, consider the positioning of the patient, and determine the appropriateness og swallow manoeuvres

  • Evaluate oropharyngeal swallowing stage

  • Assess speech and communication

  • Evaluate secretion management and consider drooling treatment

  • Consider use of videofluoroscopy to detect silent aspiration and evaluate swallowing with various bolus types

» See full summary and quality ratings


 
The Pros and Cons of Videofluoroscopic Assessment of Swallowing in Children
McNair, J., & Reilly, S. (2003).
Asia Pacific Journal of Speech, Language & Hearing, 8(2), 93-104.
 
 
Added: July 2011
 
Description
This is a review of the research investigating the use of videofluoroscopic swallowing assessment (VFSS) in children. Although other populations were not excluded, the majority of studies included in this review focused on children with cerebral palsy. 
 
Conclusions
  • “No studies have compared the results obtained from VFSS with any other instrumental technique used with children” (p. 102).
  • “To date… there has been no study demonstrating that performing VFSS results in better health outcomes for the child” (p. 102).
  • “Because we found no studies that compared VFSS with other instrumental or noninstrumental examinations, the claims regarding it being a ‘gold standard’ for use with children must be interpreted cautiously” (p. 103).
  • “It is our expert, clinical opinion that VFSS adds much to the diagnostic work-up…. We found no evidence to support the view that VFSS was harmful or was not cost-effective. No objective disadvantages of VFSS were identified” (p. 103).

» See full summary and quality ratings

 
 

Clinical Expertise/Expert Opinion

 
Consensus Guidelines  
American Speech-Language-Hearing Association
 
Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Guidelines
American Speech-Language-Hearing Association. (2005).
Retrieved from: http://www.asha.org/docs/html/GL2005-00060.html
 
Added: July 2011
 
Description
This is a guideline providing recommendations on the roles and responsibilities of speech-language pathologists (SLPs) providing care in the Neonatal Intensive Care Unit (NICU). Recommendations are provided pertaining to assessment and management of communication, feeding, and swallowing of infants. 
 
Recommendations
  • Instrumental swallowing assessment methods include, but are not limited to, videofluoroscopic swallow study (VFSS), endoscopy, and ultrasonography (US). 
  • Instrumental assessments such as scintigraphy and radionuclide milk scanning may differentiate aspiration resulting from swallowing from aspiration related to gastroesophageal reflux.
  • During instrumental assessment of swallowing, cardiac, respiratory, and oxygen saturation monitors may assist in determining any changes to physiologic or behavioral condition. Other signs include color changes, nasal flaring, and sucking/swallowing/breathing patterns. Cervical auscultation may also be useful to estimate timing of swallowing and assessment of breathing sounds.

» Access the document 

 
 
American Speech-Language-Hearing Association
 
Guidelines for Speech-Language Pathologists Performing Videofluoroscopic Swallowing Studies
American Speech-Language-Hearing Association. (2004).
Retrieved from: http://www.asha.org/docs/html/GL2004-00050.html.
 
 
Added: July 2011
 
Description
These ASHA guidelines detail the use of videofluoroscopic swallowing study (VFSS) in the assessment and management of children and adults with oral, pharyngeal, and upper esophageal dysphagia as well as offer training recommendations to obtain competency in performing VFSS. 
 
Recommendations
  • “The examination protocol for infants and young children should be appropriate for the child’s size and developmental status” (p. 13).
  • “Radiation exposure time needs to be minimized in the pediatric population. Radiation safety documents list lower exposure rates and allowable dose limits for infants and children (Brent, 1989; NCRP, 1977)” (p. 13).
  • The SLP should continuously monitor for clinical symptoms and signs of possible airway compromise during the examination (e.g., gagging, coughing, crying, choking, vomiting, back arching, congestion, and changes in oxygen desaturation and responsiveness).
  • “The swallowing protocol should include consistencies that are developmentally appropriate” (p. 14).
  • “For children who are developmentally ready for semi-solid and solid consistencies, multiple spoon feeding and solid intake trials should be observed” (p. 14).
  • Positioning equipment varies depending on the child’s condition and size. Efforts should be made to observe each child’s feeding and swallowing in a typical feeding position. The assessment protocol should include positional changes for bottle/nipple feeding and spoon feeding, modification of bolus rate, and alternation of liquids and solids to improve clearance.
  • The SLP should monitor for evidence of liquid/food evidence in the tracheostomy or evidence of food/liquid upon suctioning during instrumental assessment of children with tracheostomies.
  • The SLP should monitor for difficulty with coordination of a rhythmic suck swallow sequence with breathing during nipple feeding during the instrumental examination. The assessment should include initial sucking burst cycles and intermediate burst cycles in order to assess fatigue.
 
 
 
American Speech-Language-Hearing Association
 
Preferred Practice Patterns for the Profession of Speech-Language Pathology
American Speech-Language-Hearing Association. (2004).
Retrieved from: http://www.asha.org/docs/html/PP2004-00191.html
 
 
Added: July 2011
 
Description
This Preferred Practice Patterns for the Profession of Speech-Language Pathology document is a description of recommended practice for many areas of assessment and management in the scope of practice for SLPs. The guiding principles for each clinical service are discussed in terms of service provider, expected outcome, clinical indication, clinical processing, setting, equipment, safety precautions, and documentation. 
 
Recommendations
Evaluation may be static or dynamic and includes instrumental diagnostic procedures such as videofluoroscopic swallow study, endoscopic evaluation of swallowing, and ultrasound with consideration for positioning, presentation, and viscosity. 
 
 
 
 
American Speech-Language-Hearing Association
 
Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders: Technical Report
American Speech-Language-Hearing Association. (2001).
Retrieved from: http://www.asha.org/docs/html/TR2001-00150.html.
 
 
Added: July 2011
 
Description
This ASHA position statement provides information regarding the role of the SLP in evaluation and management of children and adults with feeding and swallowing disorders and discusses the scope and rationale for SLP services. 
 
Recommendations
  • “The methods used to examine swallowing function in pediatric patients include videofluoroscopic swallow study, endoscopic assessment of swallowing function, and ultrasonography. Scintigraphy or radionuclide milk scanning, is used to identify aspiration from swallowing or gastroesophageal reflux and to examine gastric emptying time” (p. 12).
  • Videofluoroscopy procedures must be age-appropriate in regard to positioning, presentation, and viscosity when performed with infants and children (Arvedson & Lefton-Greif, 1998). The interpretation of videofluoroscopic findings should also be age-appropriate and consider the differences in normal swallowing function between infants, children, and adults (Newman, Cleveland, Blickman, Hillman, & Jaramillo, 1991).
 
 
 
American Speech-Language-Hearing Association
 
Clinical Indicators for Instrumental Assessment of Dysphagia [Guidelines]
American Speech-Language-Hearing Association. (2000).
Retrieved from: http://www.asha.org/docs/html/GL2000-00047.html.
 
 
Added: July 2011
 
Description
This ASHA guideline provides recommended clinical indicators for the use of instrumental assessment when assessing swallowing in patients with oral, pharyngeal, or upper esophageal dysphagia. The guideline does not distinguish between pediatric and adult populations or distinguish by etiology. 
 
Recommendations
  • An instrumental examination is indicated when:
    • There are inconsistencies between the patient’s signs and symptoms and clinical examination findings;
    • Confirmation of a suspected medical diagnosis or differential diagnosis is necessary;
    • Oropharyngeal dysphagia could potentially be contributing to nutritional or pulmonary compromise;
    • There is a concern regarding the safety and efficiency of the swallow;
    • The patient is a candidate for swallowing rehabilitation and specific instrumental assessment results may guide management and treatment.
  • An instrumental examination may be indicated when:
    • The patient has a medical condition associated with a high risk for dysphagia (e.g., neurologic, pulmonary, gastrointestinal problem, head/neck radiotherapy, craniofacial abnormalities);
    • The patient has previously been diagnosed with dysphagia and a change in swallowing function is suspected;
    • The patient has a cognitive or communicative deficit that does not allow for completion of a clinical examination;
    • The patient has a chronic degenerative disease and oropharyngeal function may require assessment for appropriate management.
  • Instrumental examination is not indicated when:
    • Findings from the clinical examination do not identify dysphagia;
    • The patient is too medically unstable to tolerate an instrumental assessment;
    • The patient is unable to cooperate/participate in an instrumental assessment;
    • The results of the instrumental assessment will not change the patient’s clinical management. 
 
 
 

Client/Patient/Caregiver Perspectives

 
No information was found pertaining to client/patient/caregiver perspectives.
 
 
 



Use the images below to navigate to other sections of the Pediatric Dysphagia evidence map.