Evaluation of Swallow

Dysphagia is relatively common in children. A rate of 0.9% was found in children aged 3–17 [10], and incidence is higher in certain medically complex populations including those with cerebral palsy and craniofacial syndromes [11–13]. There has been a marked increase in diagnoses of dysphagia in the pediatric hospitalized population, from 0.08% in 1997 to 0.41% in 2012 [14]. While exact reasons for this are not clear, it is often attributed both to increased survival rates of extremely preterm infants and improved diagnosis of swallowing disorders. Often the SLP is the first contact a child with dysphagia has with the multidisciplinary team. Children may be referred directly to us for a swallow evaluation or for treatment of feeding or swallowing disorders, or we may care for the child in the NICU from birth. We have the benefit of being able to spend the time to get a comprehensive history and provide ongoing assessment in therapy sessions. The SLP has several methods of evaluating swallowing, including the clinical swallowing evaluation, flexible endoscopic evaluation of swallowing, and video fluoroscopic swallowing study, as well as less frequently used measures including manometry. These may be used in combination depending on the needs of the patient. According to ASHA, the role of the SLP in evaluation includes participating in determining the appropriateness of instrumental evaluation and follow-up, diagnosing pediatric oral and pharyngeal swallowing disorders, making appropriate referrals to other disciplines, and recommending a safe swallowing and feeding plan [9].

We require the expertise of others when evaluating and planning treatment beyond swallow recommendations for structural and functional deficits impacting swallowing, including (but not limited to) neurologic impairments, cerebral palsy (CP), sensory deficits, tracheoesophageal fistula, laryngeal cleft, acid reflux, esophageal dysmotility, laryngeal mobility impairment, and neurologic disorders.

Treatment of Dysphagia

SLPs on the multidisciplinary team as well as our colleagues working in more general outpatient settings, birth to three, and schools provide feeding and swallowing therapy to habilitate or rehabilitate swallowing and progress feeding skills. Feeding is defined as any aspect of eating or drinking and includes preparing food or liquid for intake, sucking or chewing, and swallowing [15]. Swallowing specifically refers to the complex processes involved in transporting solids, liquids, or saliva from the mouth to the digestive tract while maintaining airway protection [15]. Speech language pathologists are involved in evaluation and treatment of both.

A detailed description of all forms of feeding and swallowing therapy is beyond the scope of this chapter. Approaches to swallowing treatment may include positioning changes, changes in viscosity of bolus, changes in flow rate of bolus, maneuvers, sensory stimulation techniques, oral motor treatments, pacing, and cue-based feeding [15].

Evaluation of Voice

Incidence estimates of pediatric dysphonia are varied, ranging from 1.4% [10] to 26% [16]. Dysphonia rates in children are likely increasing for some of the same reasons dysphagia rates are increasing, and children are presenting with more complex etiologies of voice disorders, beyond benign lesions. As survival rates of children born extremely preterm, or with complex tracheal or laryngeal anomalies, increase, rates of hoarseness and the complexity of children seen in the voice clinic will increase. For example, 38% of a sample of children born extremely preterm were found to have moderate-severe dysphonia at school age, with only 6% having normal voice [17]. Speech language pathologists often work in collaboration with an ENT in diagnosis and evaluation of voice disorders. According to the ASHA scope of practice, SLPs can perform a comprehensive voice evaluation which includes clinical and instrumental evaluation, assess normal or abnormal vocal function, describe voice quality and function, diagnose a voice disorder, refer to appropriate professionals to provide diagnosis of the underlying cause of the voice disorder (e.g., nodules as a cause of dysphonia), and make referrals to other professionals for other medical, surgical, or behavioral evaluation [9]. We can perform perceptual, acoustic, and aerodynamic evaluation of vocal function. We can also visualize the larynx using rigid or flexible endoscopy with stroboscopy, as well as high-speed digital video imaging of the larynx, and provide skilled interpretation of structure and function based on this. We do not diagnose lesions but can identify and describe the parameters of laryngeal function based on these evaluations and contribute to planning treatment, whether it be behavioral, surgical, or a combination of the two. The voice evaluation is also an important time to assess for stimulability for change based on therapeutic probes.

Treatment of Dysphonia

SLPs in a voice clinic and in other settings plan and deliver skilled treatment to optimize vocal function given the current anatomy, provide pre- and postoperative therapy, and provide therapy to change ingrained vocal functional behaviors. A detailed discussion of the types of voice therapy provided is beyond the scope of this chapter but can be found in other sections of this book and in these and other resources [18–23].

Evaluation and Treatment of Breathing Disorders

Speech language pathologists are also experts in evaluation and management of laryngeal breathing disorders such as paradoxical vocal fold motion disorder, exercise-induced laryngomalacia, and chronic cough [9]. We can behaviorally and endoscopically evaluate laryngeal, pharyngeal, and respiratory function during breathing and provide interventions related to laryngeal sensitivity and control as well as optimizing respiratory coordination [24–28].

Conclusion

The benefits of working as a part of a multidisciplinary team cannot be overstated, for both clinician and patient. We are able to evaluate based on our areas of expertise and then discuss with other team members based on the findings of their specialized evaluations, providing optimal treatment for patients.