Evaluacion de screening para disfagia en niños

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Original article

Assessment of feeding and swallowing in children: Validityand reliability of the Ability for Basic Feeding and Swallowing

Scale for Children (ABFS-C)

Anri Kamide a,⇑, Keiji Hashimoto a, Kohei Miyamura b, Manami Honda a

a Division of Rehabilitation Medicine and Developmental Evaluation Center, National Center for Child Health and Development, Japanb Tokyo Metropolitan Ohtsuka Hospital, Japan

Received 21 April 2014; received in revised form 14 August 2014; accepted 18 August 2014

Abstract

Objective: The purpose was to devise a dysphagia scale for disabled children that could be applied by various medical profession-als, family members, and personnel in treatment and education institutions and facilities for disabled children and to assess thevalidity and reliability of that scale, “Ability for Basic Feeding and Swallowing Scale for Children” (ABFS-C). Methods: Subjectswere 54 children (aged 2 months to 14 years and 7 months, median 14 months) who visited the National Center for Child Health andDevelopment from January 2012 to December 2013. They were examined using the Fujishima’s Grade of Feeding and SwallowingAbility (Fujishima’s Grade), the Functional Independence Measure for Children (WeeFIM) and the ABFS-C composed of 5 items(wakefulness, head control, hypersensitivity, oral motor and saliva control). Validity was evaluated according to correlations of theABFS-C with Fujishima’s Grade or WeeFIM. To assess interrater reliability, 17 children were assessed by a doctor and occupationaltherapist independently. Results: The ABFS-C scores and Fujishima’s Grade were correlated using Spearman rank correlation coef-

ficients. Fujishima’s Grade was significantly correlated with saliva control (R = 0.470) and the total ABFS-C scores (R = 0.322) butnot with wakefulness (R = 0.014), head control (R = 0.122), hypersensitivity (R = 0.009), or oral motor (R = 0.139). In addition,the total ABFS-C scores had a significant correlation with the total score of the WeeFIM ( R = 0.562), motor WeeFIM (R = 0.451),cognitive WeeFIM (R = 0,478), and the eating subscore of the WeeFIM (R = 0.460). Interrater reliability was demonstrated for allitems except hypersensitivity. Conclusions: There were significant correlations between the total ABFS-C scores and Fujishima’sGrade and WeeFIM, which suggested the need for comprehensive assessments rather than assessments of individual feeding andswallowing functions. To improve the reliability for hypersensitivity, the assessment process for hypersensitivity should be reviewed. 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

Keywords: Dysphagia; Children; ABFS-C; Clinical assessment scale

1. Introduction

Dysphagia rehabilitation in our country involvesmultiple professions engaged in the treatment of primar-

ily physically disabled children with cerebral palsy orneuromuscular disease. Recently, however, a widerrange of conditions such as developmental disordersand tube-feeding dependency have to be addressed

http://dx.doi.org/10.1016/j.braindev.2014.08.005

0387-7604/ 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

⇑ Corresponding author. Address: National Center for Child Health and Development, 10-1, Okura 2-chome, Setagaya-ku, Tokyo 157-8535,Japan. Fax: +81 (3) 3416 2222, +81 (3) 3416 0181.

E-mail address: [email protected] (A. Kamide).

www.elsevier.com/locate/braindev

Brain & Development 37 (2015) 508–514

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[1,2]. Children’s feeding and swallowing function isdeveloped not only through functional and morpholog-ical growth of oropharyngeal organs but also throughthe development of other organs and psychophysiologi-cal functions. Consequently, children with dysphagiacan be pathogenetically classified into those affected by

retardation of functional development and thoseaffected by a reduction of acquired function. Featuresof disability are thus so complicated that multiple assess-ments not only limited to the disease have to beperformed.

Neither here nor abroad, no satisfactory assessmentscale for childhood dysphagia has been established thatapplies a clinical assessment based on an interview andobservation with an auxiliary diagnosis using imagingmethods [3]. Items found in textbooks for clinical assess-ment are wide-ranging, specialized, and time-consuming. It is, therefore, desirable to develop anassessment scale that would allow those with diverse

roles, varying from family members to personnel inmedical treatment institutions and welfare facilities suchas those facilities serving disabled children to arrive at ashared understanding of dysphagia in disabled children.

We developed a feeding and swallowing function ver-sion of the Ability for Basic Movement Scale forChildren (ABMS-C) [4], which we had developed tobriefly assess the ability for movement in children. Inaddition, we verified the validity and reliability of thenew instrument.

2. Subjects and methods

2.1. Subjects

From January 2012 to December 2013, 54 pediatricpatients with dysphagia at the National Center for ChildHealth and Development newly received rehabilitation.There were 24 males and 30 females, and their medianage was 14 months (aged 2 months to 14 years and7 months). They were classified according to the primarypathogenesis as follows: organic, 17 (4, malignant dis-ease; 3, laryngeal paralysis; 3, laryngomalacia; 2, cheilo-gnathopalatoschisis; 2, gastroesophageal reflux; 1, clefttongue; 1, multiple malformation; 1, esophageal atresia);neurological, 28 (6, chromosome or genetic abnormal-ity; 3, cerebral palsy; 3, hydrocephalus; 3, history of liv-ing donor liver transplantation; 3, extremely low birthweight; 2, brain tumor; 2, epilepsy; 2, multiple malfor-mation; 1, cerebrovascular disease; 1, encephalitis; 1,hypoxic-ischemic encephalopathy; 1, history of cardiacsurgery); psychobehavioral, 5 (2, anorexia; 2, develop-mental disorder; 1 tube-feeding dependency afteroperations); and developmental, 4 (3, tube-feedingdependency due to inflammatory bowel disease; 1,history of cardiac surgery). They were classifiedby swallowing phases as follows: postural control

preparation phase, 6; oral preparatory phase, 10; oralphase, 4; pharyngeal phase, 32; and esophageal phase, 2.

This study was approved by the research ethics com-mittee of the National Center for Child Health andDevelopment. Informed consent was obtained fromfamily members of all of the children.

2.2. Methods

2.2.1. Ability for Basic Feeding and Swallowing Scale

(ABFS-C)

The ABFS-C is composed of 5 items pertaining to achild’s feeding and swallowing ability, i.e. wakefulness,head control, hypersensitivity, oral motor ability, andsaliva control. Each item was rated on a 4-point scalefrom 0 to 3. Fig. 1 shows assessment contents of theABFS-C.

“Wakefulness” is an index of food recognizabilityreflecting the patient’s general status prior to a feeding

and swallowing act. It is rated according to the GlasgowComa Scale as 0 in the case of failure to respond to painstimulation, as 1 if the patient is awakened by swayingof the body, as 2 if the patient is awakened by speech,or as 3 if the patient is awake without any stimulation.

“Head control” provides information on the patient’sdevelopment of motor activity in the feeding posture orthe severity of neurological symptoms. As in the case of the Ability for Basic Movement Scale for Children, [4]head control is graded as 0 if the neck is completelyunstable, as 1 if the neck follows when both shouldersare raised to 45 degrees, as 2 if the neck follows but stays

fixed for less than 10 s when both shoulders are raised to90 degrees, and as 3 if the neck is perfectly stable.

“Hypersensitivity” is a type of pediatric-specificdysesthesia and is an index of the degree of lack of expe-rience with feeding and swallowing. The patient is exam-ined for such dysesthesia by slow movement of theexaminer’s palm while touching the patient’s body sur-face in the order of the upper and lower limbs fromthe periphery to the center, the face, and around the lipsand oral cavity. Observation of changes in the patient’sfacial expression determines whether or not hypersensi-tivity is present. It is graded as 0 if hypersensitivity ispresent all over the body, as 1 if it is present aroundthe lips, as 2 if it is present in the oral cavity, and as 3if there is no hypersensitivity.

“Oral motor ability” serves as an index of the devel-opmental degree of tongue and lip motor function andthe severity of neurological symptoms. Around the timethat a child acquires food-holding ability, he/she canopen or close the lips. Later, the child can move the ton-gue back and forth or up and down, and then from sideto side. Subsequently, the child becomes able to volun-tarily protrude the tongue beyond the lips. Conse-quently, 0 represents the inability to close the lips ormove the tongue, 1 indicates lack of ability to move

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the tongue but the ability to close the lips, 2 denotes thattongue movement is limited to the inside of the oral cav-ity, and 3 signifies voluntary movement of the tonguebeyond the lips.

“Saliva control” is a risk index for aspiration that issurmised from saliva control and the amount of food res-idue in the pharynx. It is graded as 0 if the child is alwaysunable to swallow saliva, resulting in overflow of salivathat has pooled in the oral cavity from the lips; as 1 if pharyngeal secretions always make a gurgling sound,as 2 if pharyngeal secretions make a gurgling sound onlyafter oral stimulation (stimulation is selected from gumrubbing, gustatory stimuli, presentation of usual food,etc. depending on the child’s condition), and as 3 if thereare no gurgling sounds of pooled pharyngeal secretionsafter oral stimulation.

2.2.2. Validity

To explore the validity of the ABFS-C, we assessedthe patient’s feeding and swallowing ability, and whichwas scored according to the Fujishima’s Grade of Feed-ing and Swallowing Ability (Fujishima’s Grade) [5] and

the Food Intake LEVEL Scale (FILS) [6]. These scalesmeasure the severity of dysphagia by examining to whatdegree patients take food orally. They are primarilyapplied to adults and are used all over Japan. As theseinstruments did not include factors related to childhoodgrowth and development, we modified them so that theydescribed how the child took food in a form that corre-sponded to that by a normally developed child of thepatient’s age.

Fujishima’s Grade determines the severity of a swal-lowing disorder as necessary by using a videofluoroscop-ic swallow study (VFSS) or a fiberoptic endoscopic

evaluation of swallowing (FEES). Severity is rated asfollows: Grade 1, difficulty in swallowing or inabilityto swallow, no indication for swallow training; Grade2, indication only for basic swallow training; Grade 3,aspiration occurs less often when conditions are right,swallow training is feasible; Grade 4, feeding can beenjoyable; Grade 5, oral intake is partially possible (1or 2 meals); Grade 6, oral intake of 3 meals is possiblebut alternative nutritional therapy is required; Grade7, oral intake of easy-to-swallow food is possible at 3meals; Grade 8, oral intake is possible at 3 meals unlessfood is particularly hard to swallow; Grade 9, oralintake of regular meals is possible under clinical watchand guidance; and Grade 10, normal feeding and swal-lowing ability.

FILS determines the severity of dysphagia by judg-ment based on food forms and ratios of oral intakeson a daily basis. Ratings are as follows: Level 1, no swal-lowing training is performed except for oral care; Level2, swallowing training not using food is performed;Level 3, swallowing training using a small quantity of food is performed; Level 4, easy-to-swallow food less

than the quantity of a meal is ingested orally; Level 5,easy-to-swallow food is orally ingested in one to twomeals, but alternative nutrition (non-oral nutrition suchas tube feeding and drip infusion) is also given; Level 6,the patient is supported primarily by ingestion of easy-to-swallow food in three meals, but alternative nutritionis used as a complement; Level 7, easy-to-swallow foodis orally ingested in three meals and no alternative nutri-tion is given; Level 8, the patient eats three meals byexcluding food that is particularly difficult to swallow;Level 9, there is no dietary restriction, and the patientingests three meals orally, but medical considerations

score

wakefulness

head control

hypersensitivity

oral motor

saliva control

no response

to pain

stimulus

wakes up

when shaken wakes up

when called to

awake

no head control

can hold head up in line with can hold head up but not for 10 sec when

both shoulders are raised

90 degrees

body when bothshoulders are

raised 45

degrees can hold head up for10 sec when bothshoulders are raised

90 degrees

whole body

hypersensitive

to touch

does not like objects

touching lips

or mouth area

does not like objects

touching inside

the mouth

not hypersensitive

cannot close lips

or move tongue

can move lips

but cannot move

tongue

can close lips

and can move

tongue inside

the mouth only

can close lips

and can stick

tongue outside

the mouth

constantly droolingconstant throat

gurgling

throat gurgling

after stimulation

inside the mouth

no throat gurgling

after stimulation

inside the mouth

Fig. 1. ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children.

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are given; and Level 10, there is no dietary restriction,and the patient ingests three meals orally (normal). Inthe above assessment, we had the patient ingest regularfood consumed by normally developed children of thesame age (i.e. milk for a 3-mon-old baby, soft solid foodfor an 8-mon-old baby).

In addition, we assessed the patients’ disability statususing the Functional Independence Measure for Chil-dren (WeeFIM). It is an 18-item, 7-level ordinal scaleinstrument that measures a child’s consistent perfor-mance of essential daily functional skills. The 18 itemsare organized into 6 subscales of self-care (including eat-ing), sphincter control, transfers, locomotion, communi-cation, and social cognition. Total score of the motorWeeFIM consists of scores for the subscales of self-care,sphincter control, transfers, and locomotion. Totalscores of the cognitive WeeFIM consist of scores forthe subscales of communication and social cognition.

The Spearman rank method was employed to explore

correlations between items on the ABFS-C or totalscores of the ABFS-C and Fujishima’s Grade or theFILS in 54 pediatric patients. We similarly examinedthe strength of the association between items on theABFS-C or total scores of the ABFS-C and the totalscores of WeeFIM, motor WeeFIM, and cognitiveWeeFIM and the eating subscore in the motor WeeFIMin 31 children (12 boys, 19 girls; aged 2 months to7 years and 8 months, median 11 months). Statisticalsoftware used was SPSS Statistics 20.

2.2.3. Interrater reliability

Interrater reliability was evaluated employing exami-nation of 17 of the above-mentioned children (8 boys, 9girls; aged 3 months to 38 months, median 7 months).Assessment was made separately by a doctor and anoccupational therapist using the ABFS-C at the firstexamination to seek weighted k coefficients of resultantdata on individual items using the above-mentionedsoftware. Assessment dates differed at most by 1 week

between the doctor and occupational therapist involvedin the assessment. They were kept unaware of theircounterpart’s assessment scores during the study period.

2.2.4. Internal consistency

Internal consistency of the 5 items comprising the

ABFS-C was checked by Cronbach’s coefficient alpha(Cronbach’s A) in 54 pediatric patients.

3. Results

3.1. Validity

Whereas there was a significant correlation betweenFujishima’s Grade and saliva control (R = 0.470) orthe total score of the ABFS-C (R = 0.322), no obviouscorrelation was found between Fujishima’s Grade andwakefulness (R = 0.014), head control (R = 0.122),hypersensitivity (R = 0.009) or oral motor

(R = 0.134). Additionally, FILS had no significant cor-relation with total scores or each item of the ABFS-C(Table 1).

Results of the correlation coefficient analysis thatcompared scores of the ABFS-C and WeeFIM areshown in Table 2. The total score of the ABFS-Csignificantly correlated with the total score of the Wee-FIM (R = 0.562), motor WeeFIM (R = 0.451), cogni-tive WeeFIM (R = 0.478), and the eating subscore of WeeFIM (R = 0.460). In addition, the total score of the WeeFIM had a significant correlation with headcontrol (R = 0.423) and oral motor (R = 0.440), and

the eating subscore of WeeFIM had a significant corre-lation with oral motor (R = 0.373).

3.2. Interrater reliability

Scores on wakefulness and head control indicatedalmost perfect interrater reliability (weighted k = 1.0,weighted k = 0.889) while oral motor and saliva control

Table 1Correlations of total scores of the ABFS-C with Fujishima’s Grade or with FILS.

N = 54 Grade Level

Median Range r p r pWakefulness 3.00 0–3 0.014 0.918 0.225 0.102Head control 3.00 0–3 0.122 0.378 0.001 0.992Hypersensitivity 3.00 0–3 0.009 0.951 0.086 0.535Oral motor 0.00 0–3 0.134 0.335 0.043 0.760Saliva control 2.00 0–3 0.470** 0.000 0.331* 0.014Total score of ABFS-C 11.00 0–15 0.322* 0.018 0.098 0.480Grade 4.00 1–10 0.803** 0.000Level 5.00 1–10 0.803** 0.000

ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children.Fujishima’s Grade: Fujishima’s Grade of Feeding and Swallowing Ability.FILS: Food Intake LEVEL Scale.* p < 0.05.

** p < 0.01.


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had moderate correlations (weighted k = 0.500,weighted k = 0.502). On the other hand, hypersensitivityshowed no significant interrater reliability (weightedk = 0.016) (Table 3).

3.3. Internal consistency

The 5 items on the ABFS-C had appropriate internal

consistency (Cronbach’s A = 0.974).

4. Discussion

The prevalence of childhood dysphagia is estimatedto fall between 25% and 45% in typically developingchildren and between 33% and 80% of children withdevelopmental disability, [7] with an upward trendcurrently in place. There are more than a few verycomplicated and diversified structural, neurologicaland psychobehavioral abnormalities that occur in theprocess of growth and development [8]. Moreover, close

collaboration is required among disciplines to managedisabled children since a variety of professions as wellas facilities become engaged in their management inaccordance with changes that take place from infancy/childhood to school age/adulthood [1,2]. Consequently,an assessment scale is desired that can easily identify thewhole picture of dysphagia in a child so that informa-tion can be shared among disciplines. At present,however, in our country, individual facilities or commu-nities assess dysphagia in their own distinctive ways.

Decision tables for dysphagia rehabilitation levelsand aspiration risks, which are being used in some pedi-atric rehabilitation centers, are the easiest to use but

they have not been satisfactorily verified for reliabilityand validity [9]. An assessment approach proposed byMurayama et al. [10] was aimed at detecting aspirationin children with cerebral palsy and is therefore inappro-priate for assessment of children with other disabilities.A number of assessment methods for children have beenreported abroad [3,11–15]. A systematic review of 27papers published before 2012 [16] cited the Schedulefor Oral Motor Assessment (SOMA) [17] as an excellentassessment method with regard to reliability, validity,and clinical usefulness. This method was aimed atassessing oral motor function and distinguishes between

normal and abnormal function by determining whetherfeeding status for each of 5 food forms exceeded theminimum level. However, it is not commonly used inactual examinations because it is suitable only for dys-phasic children with issues of the oral phase. Thus, thereality is that there is no assessment method that is stan-dardized for comprehensive assessment and severityclassification with substantiation of reliability and valid-ity [11].

We therefore developed the ABFS-C to provide asimple scale that could easily assess pediatric dysphagiain daily life. One of the most useful points of the

Table 3Inter-rater reliability of each ABFS-C item by doctor and occupationaltherapist (OT).

N = 17 Reliability

Median Range Weighted j P

Wakefulness Doctor 3.00 0–3 1.0* 0.000OT 3.00 0–3

Head control Doctor 3.00 0–3 0.889** 0.000OT 3.00 0–3

Hypersensitivity Doctor 3.00 0–3 0.016 0.879OT 0.00 0–3

Oral motor Doctor 3.00 0–3 0.500* 0.006OT 3.00 0–3

Saliva control Doctor 1.00 0–3 0.502* 0.001

OT 1.00 0–3* p < 0.05.

** p < 0.01.

Table 2Correlations of total scores of the ABFS-C with WeeFIM.

N = 31 Wee FIM

Total score Motor WeeFIM Cognitive WeeFIM Eating subscore of motorWeeFIM

Median Range r p r p r p r p

Wakefulness 3.00 0–3 0.106 0.570 0.089 0.635 0.098 0.601 0.089 0.634Head control 3.00 0–3 0.423* 0.018 0.354 0.051 0.389* 0.031 0.354 0.051Hypersensitivity 3.00 0–3 0.071 0.705 0.004 0.984 0.029 0.878 0.009 0.964Oral motor 2.00 0–3 0.440* 0.013 0.359* 0.047 0.375* 0.038 0.373* 0.039Saliva control 2.00 0–3 0.222 0.231 0.281 0.125 0.147 0.429 0.288 0.116Total score of ABFS-C

11.00 0–15 0.562** 0.001 0.451* 0.011 0.478** 0.007 0.460** 0.009

ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children.WeeFIM: Functional Independence Measure for Children.* p < 0.05.

** p < 0.01.


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ABFS-C in comparison with other scales is that we caneasily record comprehensive ability regardless of differ-ent phases of feeding and swallowing, and then canmonitor the progress of the child’s ability without aVFSS or FEES.

Our results showed that total scores of the ABFS-C

had a significant correlation with Fujishima’s Grade,total scores of the WeeFIM, motor WeeFIM, cognitiveWeeFIM, and the eating subscore of the WeeFIM. The5 items on the ABFS-C had also appropriate internalconsistency. On the other hand, regarding items on theABFS-C, saliva control had a significant correlation withFujishima’s Grade but wakefulness, head control, hyper-sensitivity, and oral motor did not. In addition, therewere significant correlations between total scores of theWeeFIM and head control and oral motor. Oral motorhad the only significant correlation with the eating sub-score of the WeeFIM. Consequently, it was suggestedthat severity assessment required a more comprehensive

assessment including not only individual swallowingfunctions but also consciousness levels, sensation disor-ders and gross motor functions. FILS had no significantcorrelation with total scores of the ABFS-C or each of itsitems except saliva control. This difference from our find-ings with Fujishima’s Grade was because Fujishima’sGrade indicated how much the patient “can” do basedon a VFSS or FEES whereas FILS reflected the patients’“actual feeding action” according to the direction bytheir primary doctor [18]. Therefore, FILS was notalways determined with food forms suitable to thepatient’s feeding and swallowing ability probably result-

ing in a discrepancy between those levels and ABFS-Cscores. Moreover, since subjects differed in the causesof dysphagia, including causative diseases and disordersof the swallowing stages, it was suggested that the ABFS-C had the potential to be used to assess disabled childrenin general. Based on these results, we believe that theABFS-C is an effective assessment scale that reflects theseverity of pediatric dysphagia.

Interrater reliability of the ABFS-C was verified in 4items: wakefulness, head control, oral motor and salivacontrol. On the other hand, such reliability was notdemonstrated in hypersensitivity, which may have beenbecause we do not have a good scale for evaluatinghypersensitivity in the body, lips and oral cavity. Anexaminer whom the patient doesn’t know has difficultydistinguishing between hypersensitivity and psychologi-cal refusal, so there might have been differences in ratingbetween examiners. Since a past unpleasant experience,a fear of strangers, or emotional insecurity due to a longhospitalization may cause psychological refusal, itseemed necessary to revise results of the assessment afterhearing about the patient’s responses when touched by afamily member. In addition, since different sensory stim-uli other than touching with the examiner’s fingers,including touching with a pacifier, toothbrush or cup,

taste stimulus and thermal stimulus, may elicit differentresponses, examiners might have faced difficulty in deci-sion making. We thought that there was yet room forimprovement in the assessment procedure, includingunification of kinds of sensory stimuli.

Finally, several limitations of this study should be

mentioned. First, it remains necessary to explore theclinical utility of each item of the ABFS-C. We wouldlike to use the SOMA for validation in pediatric patientswith oral phase problems, and explore whether or notscores are properly allocated to each item and whetheror not developing processes are reflected in each age cat-egory using other international development evaluationscales such as the Ages & Stages Questionnaires (ASQ)or the Kinder Infant Development Scale (KIDs).Second, we have to revise the assessment procedurefor hypersensitivity and its wording. Finally, it is neces-sary to evaluate interrater reliability between profession-als and non-professionals. Then, we plan to accumulate

further cases and further revise this assessment tool.

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