Abstract
Objective: (1) To establish an incidence figure for dysphagia in a population of pediatric traumatic brain injury (TBI) cases; (2) to provide descriptive data on the admitting characteristics, patterns of resolution, and outcomes of children with and without dysphagia after TBI; and (3) to identify any factors present at admission that may predict dysphagia.
Participants: A total of 1,145 children consecutively admitted to an acute care setting for traumatic brain injury between July 1995 and July 2000.
Main outcome measure: Medical parameters relating to dysphagia based on medical chart review.
Results: (1) Dysphagia incidence figure of 5.3% across all pediatric head injury admissions. Incidence figures of 68% for severe TBI, 15% for moderate TBI, and only 1% for mild brain injury. (2) Statistically significant differences were found between the dysphagic and nondysphagic subgroups on the variables of length of stay, length of ventilation, Glasgow Coma Scale (GCS), computed tomography classification, duration of speech pathology intervention, supplemental feeding duration, duration until initiation of oral intake (DIOF), duration to total oral intake (DTOF), and period of time from the initiation of intake until achievement of total oral intake (DI-TOF). (3) Significant predictive factors for dysphagia included GCS < 8.5 and a ventilation period in excess of 1.5 days.
Conclusion: The provision of incidence data and predictive factors for dysphagia will enable clinicians in acute care settings to allocate resources necessary to deal with the predicted number of dysphagia cases in a pediatric population, and assist in predicting patients who are at risk for dysphagia following TBI. Early detection of patients with swallowing dysfunction will be aided by these data, in turn helping to facilitate effective medical and speech pathology intervention via assisting the reduction of medical complications such as aspiration pneumonia.
RATIONING is now unavoidable in medical practice1 and is coupled with policy makers and managers promoting evidence-based clinical practice.2 Strong evidence, however, regarding effective pediatric health care strategies (for individuals or populations) is not available for a broad range of important issues.3 The drive for efficiency in health care is gaining momentum, but very little attention is focused on the equity of access to services.4 The clinical and administrative decisions that perpetuate inequitable patterns of referral and access to a range of rehabilitation care are not well known.5 A starting point for being able to determine the need for service provision in the traumatic brain injury (TBI) population is increased knowledge regarding the characteristics of the population.5
There are very few pediatric reports detailing the admitting characteristics, patterns of recovery, or outcomes of children with dysphagia.6,7 Nor are there data available on the prevalence of dysphagia in the pediatric population after TBI, despite the knowledge that recovery can be severely compromised by a swallowing impairment.8 Woratyla and colleagues9 noted that the secondary complication of pneumonia was present more frequently in patients with swallowing disorders and evidence of aspiration after TBI. Such secondary complications as aspiration pneumonia are widely recognized as a major contributing factor to mortality and morbidity in TBI.10,11
Despite the absence of data for the pediatric population, the incidence of dysphagia has been widely reported for the adult population after TBI. Established incidence figures, however, can be seen to vary greatly dependent upon whether the population studied comprised severe TBI patients, consecutive brain injury admissions, acute TBI patients, or patients in the rehabilitation phase of recovery (Table 1). For example, dysphagia incidence figures across consecutive traumatic brain injury admissions have been reported at 4.5%,12 in comparison with a figure of 65% for a severely brain-injured population.13 Halper and colleagues13 noted that, although the reported dysphagia incidence in the adult population was approximately 26% to 30% in the mid-late 1980s,12,14,15 recent figures have been reported as high as 61% for those admitted to an acute trauma center,16 and 41.6% for those admitted to a rehabilitation setting.17 Halper et al.13 indicated that these findings signal an increase in dysphagia incidence during recent times. One possible reason for the increase in dysphagia incidence for the adult population would be an increase in overall TBI admissions. However, international studies examining the incidence of TBI over approximately 10-15 years have indicated a decline in the incidence of TBI over time,18,19 rather than an increase. An alternate explanation could be improved detection methods for dysphagia, and increased awareness of dysphagia after TBI. The apparent increase of incidence figures in the adult population after TBI is of critical interest to the pediatric clinician, because the extent of dysphagia in children after TBI may have been underestimated to date.
The process of full recovery of oral feeding after TBI in children is dependent on many factors. Authors note that these factors may include the child's age, premorbid developmental status, neuropathology of injury, and clinical course after TBI.6,20 To date, however, although a number of authors have highlighted such factors as potential variables,6,20 no studies have systematically examined their impact on swallowing outcomes. Consequently, a further step in establishing evidence-based clinical practice is to identify the value of certain variables or predictive factors (e.g., Glasgow Coma Scale [GCS], ventilation period) for dysphagia. Establishment of such information will assist prioritization of treatment services, enable early assessment of those patients at risk for dysphagia, minimize risks and episodes of aspiration, maximize nutritional intake, and help provide the patient with the most appropriate form of supplemental feeding.16,21 A number of risk factors for abnormal swallowing and aspiration have been identified for the adult population after TBI, including lower admitting GCS scores (GCS 3, 4, or 5), lower admitting cognitive assessment scores (Ranchos Los Amigos Cognitive Scale levels of I or II), presence of a tracheostomy, duration of ventilation, underlying neuropathology as indicated by computed tomography (CT) results, and the length of stay in hospital.13,21 Only a few of these factors have been discussed in relation to the pediatric TBI population, including CT results and cognition level.6,7,20
In 1996-1997, approximately 2,135 (306 per 100,000) children in the state of Queensland were admitted to the hospital with TBI.22 As previously outlined, however, general outcomes, incidence figures, and predictive factors for dysphagia remain unknown for this population. Therefore, the present study aims to strengthen existing clinical knowledge regarding dysphagia in the pediatric population after TBI by providing a dysphagia incidence figure for an admitted population of pediatric TBI cases. Second, descriptive data on the admitting characteristics, patterns of resolution, and outcomes of these patients will be provided. Finally, the third aim involves the identification of any admitting factors that may be valuable predictors of dysphagia.