Evidence for your Practice: Feeding and swallowing assessment practices in Canada

Post by Stephanie Glegg, MSc, BSc(OT)

How do we support best practices in pediatric feeding and swallowing assessment in Canada? What are these best practices, how are they carried out, and who is involved? In what ways can we support the needs of these children in hospital and community clinics, or through telerehabilitation?

Sunny Hill Health Centre for Children’s Child Development & Rehabilitation Evidence Centre recently partnered with the Canadian Agency for Drugs and Technologies in Health (CADTH) to answer these questions by collaborating on an environmental scan of feeding assessment practices in pediatric health centres across Canada. CADTH conducted the environmental scan, which included a pan-Canadian survey, stakeholder consultation, and the publication of a CADTH Environmental Scan Report: Feeding and Swallowing Assessment Services for Pediatric Populations in Canada: Service Provision, Practice Models, and Assessment Tools (March 2017).

The goal of the environmental scan was to identify and to summarize Canadian pediatric feeding and swallowing assessment services. Key topics covered by the scan included:

• Practice models in place at the health centres surveyed
• Populations served
• Organization of services (e.g. feeding team-based vs. clinical program-based)
• Health professional involvement and scope of practice
• Assessment procedures in use and under consideration
• Practice guidelines, policies and procedures in use
• Outcome measures in use
• Required service provision for inpatient, outpatient, rehabilitation and teleconsultation populations
• The full findings can be accessed on the CADTH website.

The scan was preceded by the generation of three CADTH Rapid Response Reports that synthesized related evidence. Key messages are summarized below: 

1. Assessment of pediatric feeding and swallowing

• No evidence-based guidelines were identified in the reviewed literature for assessing feeding and swallowing in children
• One systematic review suggested limited evidence about the validity and reliability of non-instrumental measures of pediatric dysphagia (i.e. those that do not require specialized equipment)

2. Fiberoptic endoscopic evaluation of swallowing (FEES) for pediatric patients with dysphagia: Clinical effectiveness

• Two non-randomized studies were found that had conflicting evidence on the clinical effectiveness of FEES. One concluded that FEES was a useful management tool in children with dysphagia, while the other did not find a significant improvement of long-term feeding status in children with dysphagia evaluated by FEES. A third non-randomized study supported the use of the FEES to address the high error rate observed during clinical assessment.

3. Three-ounce water swallow challenge for oropharyngeal dysphagia: Diagnostic accuracy and guidelines.

• No relevant pediatric literature was identified.
• One non-randomized study of 25 male adults compared the water swallow challenge to videofluoroscopic swallow studies (VFSS). The authors concluded that the water swallow challenge was useful and valid for determining aspiration risk, with 100% sensitivity, 64% specificity, a 78% positive predictive value, and a 100% negative predictive value.
• A second non-randomized study of adults concluded that a combined approach to screening for aspiration risk that included the water swallow challenge and the Clinical Predictive Scale of Aspiration (CPSA) was useful and more efficient than relying on VFSS alone. The diagnostic accuracy of the water swallow challenge was determined to have 87.3% sensitivity and 42.3% specificity. 

A new toolkit, the Optimizing feeding and swallowing in children with physical and developmental disabilities handbook has also been developed by Holland-Bloorview’s Evidence to Care Team, which incorporates the findings of the environmental scan along with other key evidence. This toolkit was developed specifically for clinicians, and provides a framework to help guide decision making about the clinical assessment and management of feeding and swallowing issues in children with physical and developmental disabilities. 

Together, these resources form a foundation for understanding more clearly how feeding and swallowing assessment is and can be carried out across the country. This information can inform the development and refinement of feeding and swallowing assessment services in a range of clinical contexts, and will be of high interest to occupational therapists and other clinicians involved in this area of practice.