ISSUES of nutrition and hydration are particularly significant for the pediatric population. 1 Adequate nutrition is extremely important for children to ensure sufficient growth and development of all body systems. Consequently, the presence of dysphagia in the pediatric population may have a negative impact upon physical and intellectual development. 2,3 As the growth and maturation of oral-motor skills and swallowing parallel general neurological maturation, 3,4 any disruption of neurological functioning, as can occur subsequent to traumatic brain injury (TBI), may compromise oral-motor or feeding development in a child. Newman 3 stated that pediatric patients represent a unique diagnostic challenge, as they present with complications of dysphagia different from those in adults, including implications for growth and development.
Anecdotal and preliminary evidence in the literature to date supports that children with dysphagia subsequent to neurological damage may have difficulties with many areas of development, including cognition, oral-motor, fine, and gross motor skills, which may directly or indirectly affect feeding or swallowing behavior. 5 Of particular importance, only 2 articles have highlighted the impact of impaired cognitive status and behavioral impairment on swallowing function in the pediatric population post-TBI. 6,7 In regard to the adult population with TBI, Leopold and Kagel 8 first proposed the importance of cognitive and behavioral impairment for swallowing function, detailing the difference between factors affecting ingestion (including feeding behaviors such as aversive responses to food, impulsive eating, etc) and factors affecting deglutition (the physiological process). They later suggested that clinical assessment of feeding should therefore encompass 5 stages, as opposed to the standard 4 physiological levels of oral preparatory, oral, pharyngeal, and oesophageal. 9 The fifth, or anticipatory, stage was proposed to investigate the interaction of pre-oral-motor, cognitive, psychosocial, and somataesthetic components of the meal. 9 In light of the suggested impact of cognition on swallowing function in the pediatric population with TBI it would appear critical that this fifth stage of the swallowing process be routinely included in the assessment of dysphagia.
A thorough diagnosis of swallowing impairment following severe head injury in children requires both a clinical bedside examination (CBE) and a physiological assessment, typically a radiographic procedure. 1,6,10 In the literature to date, however, the dysphagic characteristics of the pediatric population with TBI have been defined predominantly through the use of radiographic measures. 6,7 Although such studies have contributed to the knowledge base regarding the physiological characteristics of the swallowing disorders of the pediatric population with TBI, there has been an absence of reports documenting the clinical characteristics. Gisel and Alphonce 11 proposed that to classify a child's feeding impairment, one must compare a child's skills to the basis of normal growth and oral-motor performance, investigating both eating efficiency and competence of oral-motor skills. Such analysis can be achieved only during a CBE, where issues of feeding endurance and developmental feeding behaviours can be clearly observed in a more natural feeding interaction. A child's experiences are integral to the development of eating behaviours. It is important for reinstating or maintaining feeding development that a child is physically and cognitively prepared for the feeding routine, and these aspects are clearly addressed during a CBE.
In particular, the clinical bedside assessment of swallowing can provide the clinician with an indication of the nature and severity of dysphagia, establish a baseline of oral-motor function, explore the impact of associated cognitive function, and enable noninvasive investigation of feeding options such as diet choice, use of compensatory feeding strategies, and optimal positioning for the child. 12 Early adjustments in diet, or changes in positioning determined from a CBE, can help reduce the risk of aspiration. 13 The CBE is also important for continual monitoring of the child's progress as it is a less expensive 14 and less invasive procedure compared to radiographic assessments. In summary, the CBE remains an extremely useful tool to assess and monitor dysphagia and to assist in determining optimal treatment or compensatory strategies to maximize oral feeding in children.
Despite recognition of the detailed information available from a CBE, there is presently an absence of systematic studies examining the clinical characteristics of post-TBI dysphagia in the pediatric population. It was therefore the aim of the present investigation to document the results of the initial clinical dysphagia assessments conducted with a group of pediatric patients with TBI referred to speech pathology in the acute stage postinjury. Through the use of a comprehensive clinical bedside assessment incorporating the anticipatory stage of the swallowing process, this preliminary study aimed to document the characteristics of cognitive status, nutritive and nonnutritive oromotor function, feeding function, dietary recommendations based on the acute CBE, and an indication of overall feeding severity. The clinical objective of this study was to provide clinicians with the first systematically documented patterns of behaviour observable on CBE that are characteristic of dysphagia in the pediatric population with TBI in the acute stage postinjury.
METHODS
Subject population
Inclusion criteria stipulated that all subjects presented with a moderate to severe TBI (Glasgow Coma Scale [GCS] 0-12) as diagnosed by a neurosurgeon/neurologist. Subjects were between 4 and 15 years of age for the purpose of eliminating neurodevelopmental considerations related to swallowing ability. Children younger than 4 years were excluded on the basis that the foundation adult oral skills are purported to be present by 3 years, including varied tongue movements and rotary chewing. 1 Permission for subject inclusion was obtained from the supervising medical consultant and the child's parent(s)/guardian.
Subjects included 14 children (7 males, 7 females) aged 4 years 1 month to 15 years, (M = 7 years 11 months, SD = 11 months) with moderate or severe TBI, systematically referred over a 2-year period from 2 major children's hospitals in Brisbane, Australia. Thirteen children had sustained a severe head injury, and 1 child (subject 13) had sustained a moderate head injury (GCS, M = 5.3, SD = 0.6, range = 3-10). Biographical data including computed tomography (CT) data and the aetiology of brain injury are detailed in Table 1. The admitting GCS score was rated by a neurologist/neurosurgeon. All 14 subjects were intubated and ventilated for an average of 3.5 days (SD = 0.7 days, range = 1-9). Subjects were referred to speech pathology at an average time of 9 days (SD = 1.6 days, range = 3-24) postinjury. No subject had a history of significant premorbid neurological, developmental, sensory, or structural deficits, or a significant history of nonspecific feeding/swallowing disorder, determined via: (a) medical chart review and discussion with appropriate multidisciplinary team members such as dieticians, psychologists, etc and (b) parental completion of a feeding case history from Feeding Assessment Resources Management. 15 Following the initial assessment, all children were referred for ongoing dysphagia management and rehabilitation.
Clinical bedside assessment procedure
The initial CBE was conducted while the patient was in the acute phase of recovery, directly following referral and determination of medical stability by the medical officer in charge. Medical stability was defined as a stable respiratory system; ability to tolerate an upright seating position for 10 minutes; a GCS score of greater than 11; and the ability to maintain a sufficient level of alertness to tolerate swallowing evaluation. The complete clinical bedside assessment took approximately 20 to 25 minutes. Overall, the CBE comprised a battery investigating cognitive status (Ranchos Los Amigos [RLA] Cognitive Scale), 16 nonfeeding oral-motor skill (Verbal Motor Production Assessment of Children, 17Frenchay Dysarthria Assessment [FDA] 18) oral-motor skill related to feeding (Schedule for Oral-Motor Assessment 19), a dysphagia severity rating (Paramatta Hospitals Assessment of Dysphagia20), and a feeding trial. A speech pathologist with greater than 5-years experience in the area of pediatric dysphagia conducted the assessment battery.
Cognitive assessment
Subject's cognitive status on initial assessment during the acute phase was rated with the RLA Cognitive Scale, 16 as previously used by Winstein 21 and Mackay et al. 22 The RLA consists of 8 levels ranging from level 1: No response (eg, unresponsive to any stimulus) to level 8: Purposeful appropriate (eg, alert, oriented, defects in stress tolerance, judgement, and abstract reasoning persist). The adult version of the RLA was used in the present study because of the limited normative data provided on the pediatric version of the scale. The adult version has been more widely applied in research, and in our experience is more commonly recognized in pediatric settings than in the pediatric version.
Oral-motor assessment-Nonnutritive
The oral-motor skills of the 14 subjects were tested with the Verbal Motor Production Assessment for Children (VMPAC) 17 and the FDA. 18 The VMPAC assesses the neuromotor integrity of the speech production mechanism, both at rest and during vegetative and volitional nonspeech and speech tasks. There are 3 main areas of assessment in the VMPAC: Global Motor Control, Focal Oromotor Control, and Sequencing. Hayden and Square 17 advocated the use of the VMPAC with a wide range of populations, including those with acquired brain injury with concurrent speech production disorder. While the VMPAC is not marketed as an assessment tool for oral-motor movement associated with swallowing impairment, it provides a reliable and valid method for examining oral-motor function in children. The Global Motor Control component of the assessment investigates neuromotor innervation to peripheral muscles in the torso, neck, head, and oro-facial region required for the efficient production of speech. 17 The Global Motor Control section also encompasses 2 subsections: General Motor Control, which assesses tone, respiration/phonation, reflexes, and vegetative functions; and Oromotor Integrity, which investigates muscular symmetry, smoothness of movement, and presence of abnormal movement. The Global Motor Control score is converted into a percentage (%) score that can be compared to normative data on a child of the same age. In this way an oral-motor impairment severity rating (within normal limits, mild, moderate, severe) can be determined.
The FDA 18 is an assessment of speech neuromuscular activity. It is divided into 8 major sections: reflex, respiration, lips, jaw, palate, laryngeal, tongue, and overall speech intelligibility. For the purpose of this study, only the first 7 sections were used. The intelligibility section was not required as the assessment was focusing on oral-motor skills for feeding, not for speech. Performance on each component is rated on a scale of severity from level a (normal function) to level e (no function). From the results, an average can be determined in each of the sections, allowing a severity rating of normal (level a), mild (level b), mild-moderate (level c), moderate (level d), or severe (level e) to be allocated. While the FDA is not normed for the pediatric population, previous research has found the FDA to be successfully applied to the pediatric population. 23,24 The FDA is useful in providing a clearer profile of deficits of the speech subsystems than is the VMPAC.
Oral-motor assessment-nutritive
The Schedule for Oral-motor Assessment (SOMA) 19 was designed primarily to assess a wide range of oral-motor skills in infants with a grossly intact neurological system, but it has been extended to children with both minor and major neurological impairment. The upper age limit in those children with developmental disability is to be determined largely by the extent of the subject's handicap, with the assessment being suitable for oral-motor assessment of children with general developmental abilities equivalent to a chronological age of 6 months to 2 years. 19
Seven oral-motor challenge (OMC) categories have been included, looking at the oral-motor control required for puree, semisolids, solids, cracker, liquid from a bottle, liquid from a trainer cup, and liquid from a cup. Each discrete oral movement is rated as normal or abnormal. The total number of abnormal ratings is calculated per OMC category (eg, puree) and compared to the rating criterion to determine whether a child has normal or abnormal function for that food category. For example, the breakdown of abnormal ratings required to attain an overall abnormal rating per OMC category is as follows: puree (>=4 abnormal ratings), semisolid (>=4 abnormal ratings), solids (>=4 abnormal ratings), cracker (>=9 abnormal ratings), and cup (>=5 abnormal ratings).
Feeding trial and diet recommendations
There are no standardized feeding assessments that can stand alone for the pediatric population. Relevant skill areas that are frequently reported to be required in a feeding trial were incorporated into an observation checklist in order to systematically record cognitive/behavioral and feeding deficits. 12,15,21,22,25 The feeding trial in the present study examined integrative functioning of the oral and facial structures as they relate directly to feeding. Issues of oral sensitivity, oral reflexes, pharyngeal discomfort, and eating efficiency were also addressed. Diet recommendations determined from the nonnutritive and nutritive oral-motor assessments and the feeding trial were recorded. Diet recommendations were determined based on (a) the safety of food/fluid intake and (b) the efficiency of food/fluid intake. The safest food and fluid consistencies were determined to be those consistencies with which the patient demonstrated no clinical signs of aspiration/swallowing discomfort (cough, wet voicing, throat clearing, etc). The efficiency of intake was determined by the amount of external facilitation required, or the amount of oral-motor labor demonstrated by the patient in eating/drinking the various food/fluid consistencies.
Dysphagia severity rating
The Parramatta Hospitals Assessment of Dysphagia (PHAD) 20 provides a quantifiable measure of the severity of dysphagia, requiring observation and assessment of 12 aspects of swallowing. The assessment incorporates severity ratings across alertness, respiration, auditory comprehension, verbal expression, oral-motor functioning (lips, tongue, soft palate), gag reflex, phonation, cough reflex, oral preparation, oral stage, pharyngeal stage, and food/fluid tolerance. Each element is rated on a scale of either 1 to 5, where 1 indicates no function and 5, normal function, or 2 to 10, where 2 indicates no function and 10, normal function. An overall severity rating can be determined by summing the subset scores to create an aggregate score out of 100, which is then classified by a dysphagia severity level, using a rating scale adapted from the third edition of the PHAD (1998). 20 The classification scale is as follows: nondysphagic (>95); mild dysphagia (>86-94); moderate dysphagia (>51-85); and severe dysphagia (<50).
RESULTS
Acute ratings for the (RLA) Cognitive Scale
The majority of subjects (57%, 8/14) were rated at an RLA score of III (localized response). The second most common rating was an RLA score of IV (confused/agitated), which was attained by 21.4% (3/14) of subjects. Two subjects (14.3%) were rated at V (confused, inappropriate, nonagitated), and 1 (7.14%) received an RLA rating of II (generalized response).
Acute swallowing characteristics for the VMPAC
Quantitative analysis of the total scores for the Global Motor Control subtest (incorporating both subcategories of General Motor Control and Oromotor Integrity) revealed that all 14 subjects had a severe oromotor impairment, with scores ranging between 4/20 and 6/20. A qualitative analysis of the oral-motor deficits identified in the pediatric subject population on the Global Motor Control subtest is summarized in Table 2. Qualitative analysis revealed that a high proportion of the TBI group present with tonal deficits, altered respiratory support, immature reflex patterns, and reduced oromotor integrity (see Table 2).
Acute swallowing characteristics for the FDA
The results of the FDA revealed deficits across all oromotor categories for the 14 patients. These primarily fell within the range of mild-moderate deficits for the categories of reflex, lip, jaw, and tongue function. However, respiratory and palatal functions were mainly mildly to moderately impaired, and laryngeal function ranged from mild-moderate to severely impaired for the majority of cases (see Table 3).
Acute swallowing characteristics for the SOMA
Overall ratings of normal/abnormal oral-motor function determined by the SOMA revealed that all 14 subjects (100%) demonstrated oral-motor dysfunction for the puree and semisolid food categories. However, only 92% (12/13) of subjects had abnormal oral-motor dysfunction for the solid food consistency, and 77% (10/13) of subjects demonstrated oral-motor dysfunction for the cracker category of the SOMA. Only 23% (3/13) of subjects presented with oral-motor dysfunction on the fluid/cup category. Percentage ratings for the population were taken out of only 13 subjects for the solid, cracker, and cup OMC categories as subject 12 was not assessed on these areas because of the severity of her dysphagia.
Subsequent qualitative analysis of subjects' DOM performance on each food trial category of the SOMA allowed for a profile of abilities based on the function of mandibular, lingual, and labial muscles in relation to the food consistency trialled. To aid interpretation all behaviours were recast into a negative format to clearly identify areas of deficit. A summary of performance on the SOMA can be seen in Table 4. Overall, reaction, liquid loss, sequencing, and initiation as well as aspects of lip, tongue, and jaw function were noted to be impaired in over 50% of the subject group (Table 4).
Acute clinical observations from the feeding trial
Clinical observations of the subjects noted during the feeding trial can be seen in Table 5. Results revealed a pattern of cognitive/behavioral deficits in greater than 50% of the group. Oral sensitivity was affected in almost a third, with abnormal reflexes noted in the majority of patients. Deficits were noted across the group in the oral preparatory, oral, and pharyngeal phases of swallowing. All subjects had reduced performance on indicators of eating efficiency. It is also necessary to note that while only one patient (7%) experienced a reduced level of alertness, this score must be interpreted with caution, given that a criterion for beginning the acute assessment was that the patient was alert and medically stable.
Diet recommendations based on CBE
All 14 subjects were recommended to remain on supplemental feeding, specifically nasogastric feeding as their primary source of nutrition and hydration, after the acute CBE. Of the 14 subjects, one child, subject 12, was recommended to remain nil by mouth, largely because she was unable to manage her own secretions. The remaining 13 subjects were able to have puree or thickened fluid trials in the presence of a speech pathologist only.
Acute swallowing characteristics for the PHAD
Subjects' acute total scores ranged from 27 to 60 on the PHAD, with a breakdown of scores based on severity ratings revealing that 64% (9/14) of subjects had a severe dysphagia, and the remaining 36% (5/14) of subjects had a moderate dysphagia.
DISCUSSION
As demonstrated by the present data, the clinical examination of swallowing for the pediatric patient in the acute stage post-TBI revealed a combination of multilevel deficits that both individually and in combination had a negative impact on swallowing competence and safety. In the acute phase, deficits in cognition, general motor, and oromotor integrity compromise the ability to manage oral intake. In light of the severity and extent of the subsystem deficits, all patients presented with a moderate or severe dysphagia. Subsequently, issues of control, efficiency, and safety resulted in the recommendation that all patients remain on nonoral nutrition, but supervised swallowing trials of puree consistency were commenced with the majority (13/14) of the group.
The 14 subjects in the present study demonstrated a range of cognitive levels at the point of the initial assessment, ranging from II (generalized response) to V (confused, inappropriate, nonagitated) on the RLACS. However, the majority of subjects were only at level III (localized response) at the time of clinical trials. All subjects were supplementally fed (nasogastric feeding) at the point of this initial assessment, with all 14 remaining on nonoral supplemental feeding postassessment. The finding of poor cognitive state in parallel with the inability to sustain oral intake in the present study agrees with previous findings in the adult literature. It has been documented that adults post-TBI are able to begin oral intake at RLA level IV, but are not eating a full oral diet until RLA level VI. 22 Based on the present data, it would appear that a comparable level of cognitive status may be necessary to enable full oral trials in the pediatric population.
Issues of behavioral control that were observed across the CBE assessments included delayed initiation of the feeding sequence in approximately half of the population in relation to semisolids, crackers, or fluids. That is, subjects did not attempt to approach the food or fluid within 2 seconds of presentation of the substance. A fifth of the population also demonstrated panic reactions on attempts to sequence cup drinking. Subjective assessment of general behavioral characteristics during the clinical bedside evaluation highlighted that the children were highly distractible and required constant refocusing back to the task of eating. A number of subjects were also agitated and uncooperative at times during the assessment. These cognitive/behavioral difficulties also manifested in the majority of children being unaware of their own swallowing/feeding problems, leading to potential heightened risk of aspiration due to poor behavioral control.
Field and Weiss 26 proposed that the ability to follow directions and subject judgment of the rate and amount of intake are affected by cognitive status. These cognitive-behavioral deficits contribute to dysphagia in unpredictable ways as swallowing initiation has a voluntary, as well as reflex, component. 26 Ylvisaker and Logemann 27 have stated that severe dysphagia may occur in the presence of a mild physiological deficit because of cognitive-behavioral factors. That the results of the present study indicated that all children had some form of impaired cognition/lack of awareness of their dysphagia is significant given that the severity of the dysphagia can be increased because of such factors. It is clearly imperative that the CBE investigates the preoral anticipatory stage of eating in order to identify the effect of cognitive status on the feeding process. In this way cognitive-behavioral factors can be identified and management strategies can be implemented to reduce the impact of such issues on dysphagia outcome. The present preliminary study provided the first prospective data investigating the relation between cognition and dysphagia in the pediatric population. However, the study is limited by the use of adult measures with children, the wide age range with potentially meaningful developmental differences between 5-year- and 14-year-olds, and the small number of participants. Further comprehensive studies are required using age-appropriate formalized assessments of cognition that address the unique developmental needs of children. In addition, larger subject numbers are needed in order to confidently state the interrelationship between these factors. The development of a "cognitive checklist" would also be a valuable contribution to clinical practice for speech pathologists working in the area of dysphagia in a pediatric population post-TBI.
Following adequate cognitive and behavioral functioning, optimal oral-motor ability is a second key element necessary for safe oral feeding. The initial requirement for functional oral-motor movement for feeding is adequate body stability to enable mobility of the cheeks, lips, jaw, and hyoid during chewing, drinking, and swallowing. 4,28 Changes in trunk and neck positioning have been found to affect directly oral and pharyngeal phases of swallowing, demonstrating the strength of the relation between body stability and oral-motor control. 29 The present study found that only 64% of the pediatric population post-TBI had stable and well-aligned head, neck, and trunk posture at rest. Furthermore, 100% of subjects had abnormal postural control and tone, and had unstable head, neck, and postural control for trunk movement, ambulation, or phonation. Subsequently, almost 80% of subjects were unable to orientate their head to the spoon. Given the severity of tonal and postural impairment, resulting in head and neck instability, it is not surprising that subjects in the present study had significant impairment of respiratory, lip, jaw, tongue, and laryngeal function.
Closely related to tone and postural control, children in the present study presented with a range of respiratory impairments. Respiratory deficits were largely mild during rest, but subjects were less able to compensate for respiratory difficulties during speech, with almost 90% of the population being unable to achieve respiration adequate for phonation. However, incomplete or poor laryngeal closure may also have contributed to the inability to phonate. McHenry 30 stated that laryngeal dysfunction is a common component of motor speech disorders after TBI in the adult population, with patterns of deficit reflective of slow or incomplete laryngeal valving. Pediatric subjects post-TBI in the present study experienced severe deficits of the laryngeal parameters of voicing, timing, pitch, and volume.
Further evidence of poor laryngeal closure demonstrated on the CBE was the presence of an inadequate or absent cough reflex. The reduction in the upward and forward movement of the larynx during swallowing noted in a number of children during the feeding trial is also significant, as it signals impairment in the protection of the laryngeal vestibule during swallowing. These issues of poor laryngeal movement/closure are concerning, given the potential consequence of aspiration. 31 However, in order to conclusively determine the presence of impaired laryngeal closure, instrumental assessment such as videofluoroscopic or fiberoptic endoscopic evaluation of swallowing are necessary.
The inability of the majority of patients to achieve phonation is also of note as it limits the number of clinical indicators of swallowing. The clinician is unable to determine the presence of food or fluid on the vocal folds via the existence of "wet" voicing when a patient is unable to voice. This is of particular concern in the TBI population who provide already limited indications of swallowing dysfunction, and are frequently regarded as being silent aspirators. 32 No subject in the present study demonstrated "wet voicing," but this result must be interpreted with caution given that a large proportion of subjects were unable to phonate. Two children reported a sticking feeling in the pharynx and 2 children also demonstrated throat clearing, both behaviours being indicative of pharyngeal impairment.
While oral/facial hypersensitivity was present in 36% of subjects, motor function was further reduced, with all 14 children demonstrating severely compromised oral-motor integrity. All 14 subjects lacked smoothness and range of movement of the mandibular, facial, labial, and lingual musculature. Two subjects displayed abnormal jaw reflexes, and all 14 subjects demonstrated abnormal patterns of tongue movement, or tongue reflexes. The presence of such abnormal reflex function signals a regression to more primitive movement patterns following the neurological damage incurred from TBI. Endurance of function was also reduced, with no subject being able to maintain tongue position against mild pressure without evidence of deterioration.
Impairment in facial tone was evident, with unequal articulatory structures on both sides of the midline at rest, inadequate contraction of oppositional facial muscles, and hyper and hypotonicity present. Reduced facial tone may lead to problems such as food collecting in the anterior or lateral sulci during chewing. 31 Such excessive oral residue places the patient at risk of passive loss of the food into the airway, or of actively inhaling the material. The overall reduction of oral-motor integrity disrupts the rhythmicity or sequencing of feeding, an integral part of oral-motor development.
The CBE revealed that lip function was impaired for both nutritive and nonnutritive tasks across the patent group. Nonnutritive oral-motor deficits included issues of reduced lip spread, seal, alternating movements, and lip function during speech. Nutritive deficits encompassed problems with lip seal, removing food from the spoon, and inactivity of the lips during sucking, munching, or chewing. Logemann 33 stated that impaired lip function, specifically poor lip seal, is typically related to food or liquid loss, and while these and excessive drooling are aesthetic issues, they are not likely to affect the physiology of deglutition. However, excessive food loss does place strain on the efficiency or endurance aspects of the mealtime, with longer mealtime duration required in order to consume sufficient oral intake. Reductions in feeding efficiency are of particular concern in the TBI population, where patients are already at risk of malnutrition subsequent to markedly increased nutritional demands to enable recovery.
With respect to the specific functioning of lip, tongue, and jaw, poor jaw stability and reduced tongue movement were the most significant oral-motor deficits for the present pediatric population post-TBI. These deficits may not only result in poor efficiency of the oral-motor system through inadequate oral preparation, but may also lead to aspiration. 12 Poor tongue control may lead to the bolus being poorly contained in the mouth, and food particles may fall prematurely into the pharynx. 31 Logemann 31 also highlighted that the posterior movement of the tongue plays a role in the swallow trigger, and any deterioration in posterior tongue movement may contribute to a delayed swallow trigger. Delayed swallow trigger has been reported as a frequent characteristic of dysphagia in instrumental studies of swallowing in the pediatric population post-TBI. 6,7
The prevalent finding of jaw instability in the present clinical study is of particular interest. While detailing impairment of lingual function, previous case studies of dysphagia have failed to comment on jaw stability or its potential impact on the feeding interaction. This would largely appear to be a consequence of the predominant use of instrumental VFS assessment for reporting the characteristics of dysphagia and oral-motor impairment. 6,7 In addition to the significance of jaw function on swallowing behaviour, the present finding also highlights the importance of a CBE for detecting the full range of oral-motor impairments. Although their strengths lie in other areas, instrumental assessments do not provide adequate opportunity to observe all aspects of oromotor function. As demonstrated by the present data, a thorough determination of oralmotor deficit through a CBE is integral to planning and implementing appropriate treatment goals.
Rhythmicity is another important aspect of oral-motor development, 28 and plays an important role in the oral preparatory and oral phases of swallowing. The tongue and jaw are primarily involved in the rhythmic aspects of feeding. Tongue movement develops from the primitive antero-posterior excursions to lateral movements, assisting in food placement between the teeth for chewing, and in moving food to the back of the tongue for swallowing. 28 Jaw movement also develops from wide vertical excursions into rotary movements for grinding hard foods.
CONCLUSION
The results of the clinical assessment of swallowing in the pediatric patients in the acute phase post-TBI revealed a pattern of impaired cognition, altered behaviour related to feeding, severe tonal and postural deficits, oromotor, respiratory, and laryngeal impairments, and oral sensitivity issues in the majority of the 14 cases. These preliminary findings demonstrate that the severe swallowing impairment in the pediatric population post-TBI is impacted upon by multilevel deficits involving more than the specific components of the swallowing mechanism. In light of the deficits identified, which could not be observed on videofluoroscopic investigation alone, the present study highlights the importance of the CBE in the assessment of dysphagia in the pediatric patient post-TBI in order to identify targets for intervention.
REFERENCES