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Dadich A, Samaranayake P, Hurriyet H, Elliot C. Process improvement of a paediatric feeding clinic. Heliyon 2024; 10:e23150. [PMID: 38163113 PMCID: PMC10756986 DOI: 10.1016/j.heliyon.2023.e23150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose The purpose of this study is to identify opportunities to improve processes within a paediatric feeding clinic to enhance timely patient access to healthcare through effective and efficient resource use. Design/methodology/approach The study involved three interrelated methods. First, de-identified feeding clinic data, collected over seven years, were analysed to understand patient appointments. Second, clinician workshops and the swim lane method were used to map feeding clinic processes. Third, root cause analysis was conducted to identify bottlenecks and identify improvement opportunities. Findings The results revealed three, poorly connected sub-processes within the feeding clinic - namely: the patient triaging and appointment scheduling or allocation process; the clinic reporting process; and the cancellation and rescheduling process. These sub-processes were poorly connected because of inadequate resources, few standardised processes, and limited coordination between the different processes. Consequently, patient appointments were typically delayed, and patient reports were not always completed in a timely manner. Processes within the paediatric feeding clinic could therefore be improved by using digital tools, patient portals and telehealth, online interventions, an automated appointment confirmation system, and/or an automated transcription of each appointment. Originality/value This is the first published study to apply business process management to a paediatric feeding clinic. By using three methods to clarify opportunities to improve clinic processes, it highlights the potential value of health information technology in this context. This evidence will enable health service managers to ensure that children with feeding difficulties have timely access to appropriate care.
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Affiliation(s)
- Ann Dadich
- School of Business, Western Sydney University, Australia
| | | | - Hilal Hurriyet
- School of Business, Western Sydney University, Australia
| | - Chris Elliot
- Department of Paediatrics, St George Hospital, Australia
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Hines M, Martens A, Zimmerman E. Infant Bottle-Feeding: A Prospective Study of Infant Physiology and Parental Report Metrics. Compr Child Adolesc Nurs 2023; 46:309-319. [PMID: 37498287 PMCID: PMC10592442 DOI: 10.1080/24694193.2023.2232457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/24/2023] [Indexed: 07/28/2023]
Abstract
The aim of this study was to examine associations between parent reports of bottle-feeding behaviors and infant non-nutritive suck (NNS) on a pacifier as well as oral feeding skills during bottle-feeding. A prospective study was conducted. Full-term infants with no prior diagnosed feeding disorders were recruited at 3-months. Parents reported their infant's bottle-feeding behaviors using the Neonatal Eating Assessment Tool-Bottle-Feeding (NeoEAT-Bottle-Feeding), consisting of five domains: Infant Regulation, Energy and Physiologic Stability, Gastrointestinal Tract Function, Sensory Responsiveness, and Compelling Symptoms of Problematic Feeding. Infant NNS was measured using a custom pacifier, pressure transducer device, which yields the following NNS variables: duration (sec), frequency (Hz), amplitude (cmH20), cycles per burst, cycle amount, and burst amount. The Oral Feeding Skills (OFS) scale was used to measure the initial volume, transfer volume, proficiency, and rate of milk transfer during bottle feeding. Fifty-two infants (58% male) with reported prior bottle experience completed this study. NeoEAT-Bottle-Feeding Total score was significantly positively associated with NNS burst duration and NNS cycles per burst. The NeoEAT-Bottle-Feeding Energy and Physiologic Stability domain was significantly positively correlated with NNS cycles per burst. NeoEAT-Bottle-Feeding Gastrointestinal Tract Function domain score was significantly positively correlated with NNS duration, amplitude, and cycles per burst. There were no significant associations between NeoEAT-Bottle-Feeding domains and the OFS scale. The findings demonstrate that parent reports of problematic feeding at 3 months of age are associated with aspects of infant NNS physiology and not with oral feeding metrics during bottle-feeding. Parent reports of bottle-feeding behaviors, particularly pertaining to gastrointestinal issues, were associated with aspects of infant NNS. These data together will allow for a more nuanced understanding of infant feeding and will be beneficial in determining if infants have a feeding delay.
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Affiliation(s)
- Morgan Hines
- Speech and Neurodevelopment lab, Department of Communication Sciences and Disorders, Northeastern University, 360 Huntington Avenue, Boston, MA 02115
| | - Alaina Martens
- Speech and Neurodevelopment lab, Department of Communication Sciences and Disorders, Northeastern University, 360 Huntington Avenue, Boston, MA 02115
| | - Emily Zimmerman
- Speech and Neurodevelopment lab, Department of Communication Sciences and Disorders, Northeastern University, 360 Huntington Avenue, Boston, MA 02115
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Slana N, Hočevar-Boltežar I, Kornhauser-Cerar L. Risk Factors for Feeding and Swallowing Disorders in Very Low Birth Weight Infants in Their Second Year of Life. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1536. [PMID: 36363492 PMCID: PMC9697318 DOI: 10.3390/medicina58111536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/09/2022] [Accepted: 10/24/2022] [Indexed: 10/07/2023]
Abstract
Background and Objectives: This study aimed to identify the prevalence of feeding and swallowing disorders (FSD) in very low birth weight (VLBW, 1500 g or less) infants in the first two years after discharge from the maternity hospital, their possible risk factors, and the consequences of them. Materials and Methods: A total of 117 preterm children with VLBW born between 2013 and 2015 were included. The data concerning possible FSD after discharge from the hospital were obtained through accessible medical documentation for the child and a short parental questionnaire. Results: FSD was reported in 32 (27.4%) infants following discharge from the hospital but in only five children (4.3%) at a mean age of four years. Four variables (birth gestational age less than 28 weeks, birth weight equal to or less than 1000 g, birth length below 33 cm, and start of oral feeding after the 34th gestational week) were identified as risk factors for FSD after discharge. However, only birth length remained a significant predictor after being included in a binary logistic regression model (p = 0.000). Abnormal oral sensitivity and a decrease in weight to under the 10th percentile were significantly more common in the FSD group at follow-up visits at the age of about 2 years. Conclusions: FSD was still present in more than one-quarter of VLBW infants after discharge from the maternity hospital but mostly disappeared within four years. A birth gestational age under 28 weeks, weight up to 1000 g, the late beginning of per oral feeding, and a birth length below 33 cm were determined to be significant predictive factors for FSD. Having a birth length below 33 cm was associated with an almost 6.5-fold increase in the odds of having persistent FSD after discharge from the hospital. FSD in the first years of life may have an impact on the child's further growth and development.
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Affiliation(s)
- Nuša Slana
- Department for (Re)Habilitation of Children, University Rehabilitation Institute Republic of Slovenia Soča, SI-1000 Ljubljana, Slovenia
- Department of Special Education and Rehabilitation, Faculty of Education, University of Ljubljana, SI-1000 Ljubljana, Slovenia
| | - Irena Hočevar-Boltežar
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Center Ljubljana, SI-1525 Ljubljana, Slovenia
- Department of Otorhinolaryngology and Cervicofacial Surgery, Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia
| | - Lilijana Kornhauser-Cerar
- Neonatal Intensive Care Unit, Department for Obstetrics and Gynaecology, Division for Perinatology, University Medical Center Ljubljana, SI-1525 Ljubljana, Slovenia
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Walton K, Daniel AI, Mahood Q, Vaz S, Law N, Unger SL, O'Connor DL. Eating Behaviors, Caregiver Feeding Interactions, and Dietary Patterns of Children Born Preterm: A Systematic Review and Meta-Analysis. Adv Nutr 2022; 13:875-912. [PMID: 35157009 PMCID: PMC9156386 DOI: 10.1093/advances/nmac017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/26/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Infants born preterm (<37 weeks of gestation) often experience feeding problems during hospitalization. Whether difficulties persist or have long-term sequelae on childhood eating is unclear. We aimed to describe the oromotor eating skills (e.g., chewing/swallowing), eating behaviors (e.g., food neophobia), food parenting practices (e.g., pressure to eat), and dietary patterns of preterm children during late infancy (6-12 mo) and early childhood (>12 mo-7 y) and to determine whether these differed from those of term-born peers. We identified 67 articles (57 unique studies) for inclusion. We used random-effects meta-analysis of proportions to examine the prevalence of oromotor eating skill and eating behavior challenges among preterm children, standard meta-analysis for comparisons with term-born peers, and the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of evidence. Forty-three percent (95% CI: 24%, 62%) of infants and 25% (95% CI: 17%, 33%) of children born preterm experienced oromotor eating difficulties and 16% (95% CI: 4%, 27%) and 20% (95% CI: 11%, 28%), respectively, exhibited challenging eating behaviors. During late infancy and early childhood, oromotor eating difficulties (OR: 2.86; 95% CI: 1.71, 4.77; I2 = 67.8%) and challenging eating behaviors (OR: 1.52; 95% CI: 1.11, 2.10; I2 = 0.0%) were more common in those born preterm than in those born term: however, the certainty of evidence was very low. Owing to the low number and heterogeneity of studies, we narratively reviewed literature on food parenting and dietary patterns. Mothers of preterm infants appeared to have heightened anxiety while feeding and utilized coercive food parenting practices; their infants reportedly received less human milk, started solid foods earlier, and had poorer diet quality than term-born peers. In conclusion, meta-analyses show preterm children experience frequent oromotor eating difficulties and challenging eating behaviors throughout the early years. Given preterm birth increases risk of later obesity and diet-related chronic disease, research examining the effects of caregiver-child interactions on subsequent diet is warranted. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020176063.
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Affiliation(s)
- Kathryn Walton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allison I Daniel
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Quenby Mahood
- Hospital Library & Archives, Learning Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Simone Vaz
- Department of Pediatrics, William Osler Health System, Brampton, Ontario, Canada
| | - Nicole Law
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sharon L Unger
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada,Paediatrics, Sinai Health, Toronto, Ontario, Canada,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Rodgers RF, Hines M, Martens A, Zimmerman E. Correlation between maternal eating disorder and early infant feeding regulation: a cross -sectional study. BMC Pregnancy Childbirth 2021; 21:838. [PMID: 34930160 PMCID: PMC8690522 DOI: 10.1186/s12884-021-04317-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background The post-partum period is a vulnerable time for mothers in terms of eating disorder symptoms and is critical for the establishment of feeding patterns in infants. This study aimed to investigate the relationships between maternal eating disorder symptoms and objective indices of feeding regulation at 3 months, as well as perceived breastfeeding self-efficacy. Methods A sample of n = 73 full-term mother-child dyads (44% female) participated in the study. Mothers self-reported eating disorder symptoms and breastfeeding self-efficacy and objective indices of infant feeding regulation were obtained in the home. Results Findings revealed the existence of relationships between higher maternal eating disorder symptoms, and objective indices of infant feeding regulation with substantial gender differences in the patterns emerging. Among mother-daughter dyads, maternal weight and shape concerns were associated with higher infant transfer volume and rate during bottle feeding. In contrast, among mother-son dyads, higher maternal eating disorder symptoms, including weight, shape, and eating concern, were associated with lower infant transfer volume and rate as well as lower levels of proficiency while taking their bottle. Conclusion Relationships emerged between higher maternal eating disorder symptoms and feeding regulation with substantial gender differences in these patterns. Additional research clarifying the underlying mechanisms of these associations is warranted and further efforts should be directed towards supporting mothers during the postpartum period.
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Affiliation(s)
- Rachel F Rodgers
- APPEAR, Department of Applied Educational Psychology, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA.,Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHRU Montpellier, 291 Av. du Doyen Gaston Giraud, 34000, Montpellier, France
| | - Morgan Hines
- Speech and Neurodevelopment Lab, Department of Communication Sciences and Disorders, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Alaina Martens
- Speech and Neurodevelopment Lab, Department of Communication Sciences and Disorders, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | - Emily Zimmerman
- Speech and Neurodevelopment Lab, Department of Communication Sciences and Disorders, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA.
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Dadich A, Hockey K, Kaplun C, Fleming C, Hopwood N, Moraby K, Elliot C. Clinician and carer moral concerns when caring for children who tube-feed. J Child Health Care 2021:13674935211052842. [PMID: 34696607 DOI: 10.1177/13674935211052842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Child healthcare can be vexed by moral concerns - this extends to the care of children who tube-feed. Children who tube-feed often receive care from family members and clinicians of various disciplines. Each brings expertise, experiences, values, and views to a situation, prioritising the child's needs while attending to those they deem important in potentially disparate ways. Their understanding of a situation is shaped by beliefs, feelings, and perceptions. How then are key decisions made about the care of a child who tube-feeds? This article explores clinicians' and carers' moral concerns when caring for children who tube-feed. Interviews with clinicians (n = 9) and carers (n = 9) clarified three findings: first, there are often disparate beliefs about the need for tube-feeding; second, tube-feeding can evoke strong emotions; and third, it can be difficult to normalise tube-feeding. This article demonstrates how challenges can emerge when relationships between clinicians and carers diverge. Furthermore, it establishes how an ethic of care can bring different interests together to bolster the relationships required to optimise feeding care and promote health outcomes among children who tube-feed and their carers. This requires improved dialogue between and among clinicians and carers to create shared understandings of what is, what should be, and how to benefit children who tube-feed.
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Affiliation(s)
- Ann Dadich
- School of Business, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Kaitlyn Hockey
- School of Business, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Cathy Kaplun
- School of Nursing and Midwifery, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Catharine Fleming
- School of Science and Health, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Nick Hopwood
- Faculty of Arts and Social Science, 1994University of Technology Sydney, Sydney, NSW, Australia
| | - Khadeejah Moraby
- SA Health, 1050Central Early Childhood and Families Service, Women's and Children's Health Network, Adelaide, SA, Australia
| | - Chris Elliot
- Department of Paediatrics, 90135Saint George Private Hospital, Kogarah, NSW, Australia
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Krishnamurthy R, Balasubramanium RK, Kamath N, Bhat KG. A Delphi survey based construction and validation of test for oropharyngeal dysphagia in Indian neonates. Int J Pediatr Otorhinolaryngol 2021; 140:110306. [PMID: 32829932 DOI: 10.1016/j.ijporl.2020.110306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND SLPs have a crucial need to depend on comprehensive clinical swallowing assessments to determine the presence of dysphagia in neonates. A comprehensive clinical swallowing assessment that is ethnoculturally sensitive may help to identify the presence and severity of swallowing problems in neonates. OBJECTIVE The study aimed to construct and validate the contents of a test for oropharyngeal dysphagia in Indian neonates (TOD-IN). METHOD The test for oropharyngeal dysphagia in Indian neonates (TOD-IN) was developed using the Delphi process. Five expert panelists served as participants; two rounds of electronic questionnaire-based survey was carried out to develop and validate the contents of TOD-IN. RESULTS Round one rendered descriptive data that was analyzed quantitatively and qualitatively. At the end of round one, panelists unequivocally agreed on the need for research to develop a validated assessment tool for dysphagia in Indian neonates. The second round dealt with establishing the face and content validity of the final version of TOD-IN. A unanimous consensus was obtained regarding the format, scoring system, and the construct of the final version of the tool. CONCLUSION Practicing clinicians in India are met with several challenges such as resource constraints, limited infrastructure, increasing caseload, and a lack of trained workforce. We believe that inexperienced clinicians will benefit from the structured guidance provided by TOD-IN in a restrained resource context where prioritization of patients is the key. Further studies investigating the psychometric properties of TOD-IN are in progress.
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Affiliation(s)
- Rahul Krishnamurthy
- Department of Audiology and Speech Language Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| | - Radish Kumar Balasubramanium
- Department of Audiology and Speech Language Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Nutan Kamath
- Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kamalakshi G Bhat
- Department of Pediatrics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Hill RR, Park J, Pados BF. Bottle-Feeding Challenges in Preterm-Born Infants in the First 7 Months of Life. Glob Pediatr Health 2020; 7:2333794X20952688. [PMID: 32953946 PMCID: PMC7479869 DOI: 10.1177/2333794x20952688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/03/2020] [Accepted: 07/24/2020] [Indexed: 11/30/2022] Open
Abstract
Preterm infants frequently experience oral feeding challenges while in the
neonatal intensive care unit, with research focusing on infant feeding during
this hospital stay. There is little data on symptoms of problematic feeding in
preterm-born infants in the months after discharge. The purpose of this study
was to describe symptoms of problematic bottle-feeding in the first 7 months of
life in infants born preterm, compared to full-term infants. Parents of infants
less than 7 months old completed an online survey that included the Neonatal
Eating Assessment Tool—Bottle-feeding and questions about the infant’s medical
and feeding history. General linear models were used to evaluate differences in
NeoEAT—Bottle-feeding total score and subscale scores by preterm category,
considering other significant factors. Very preterm infants had more symptoms of
problematic bottle-feeding than other infants. Current age, presence of
gastroesophageal reflux, and anomalies of the face/mouth were associated with
problematic bottle-feeding.
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Affiliation(s)
- Rebecca R. Hill
- MGH Institute of Health Professions,
Boston, MA, USA
- Rebecca R. Hill, DNP, FNP-C, MGH Institute
of Health Professions, 36 First Avenue, Boston, MA 02129, USA.
| | - Jinhee Park
- William F. Connell School of Nursing,
Boston College, Chestnut Hill, MA, USA
| | - Britt F. Pados
- William F. Connell School of Nursing,
Boston College, Chestnut Hill, MA, USA
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Martin-Harris B, Carson KA, Pinto JM, Lefton-Greif MA. BaByVFSSImP © A Novel Measurement Tool for Videofluoroscopic Assessment of Swallowing Impairment in Bottle-Fed Babies: Establishing a Standard. Dysphagia 2020; 35:90-98. [PMID: 30955137 PMCID: PMC6778717 DOI: 10.1007/s00455-019-10008-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/28/2019] [Indexed: 10/27/2022]
Abstract
AIM This investigation tested the construct validity of the first standardized assessment tool, the BaByVFSS Impairment Profile, (BaByVFSSImP©), developed for the quantification of swallowing observations made from videofluoroscopic swallow studies (VFSS) in bottle-fed babies. METHOD Construct validity of the measures was tested using descriptive methods and confirmatory factor analysis (CFA) of swallowing scores obtained from a cohort of bottle-fed babies (median age 3 months 1 day, interquartile range 1 month 4 days-7 months 4 days) sequentially referred for VFSS based on clinical signs, symptoms, or risk factors associated with dysphagia and/or aspiration. Main outcome measures were emergence of functional domains derived from swallowing component impairment scores. RESULTS Confirmatory factor analysis resulted in 21 significant components (factor loadings ≥ 0.5) grouping into five functional domains labeled for common contribution to overall swallowing function. The tool was organized into the BaByVFSSImP. Clinical relevance was explored using correlational analyses between domain scores, maximum penetration/aspiration scores, feeding status, and caregiver burden. INTERPRETATION Quantification of physiologic swallowing impairment captured by BaByVFSSImP holds promise for identification of physiologically based targets for intervention, clinical decisions regarding enteral feeding, and tracking the trajectory of swallowing impairment throughout development in young children.
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Affiliation(s)
- Bonnie Martin-Harris
- Department of Communication Sciences and Disorders, Department of Otolaryngology Head and Neck Surgery, Department of Radiation Oncology, School of Communication, Feinberg School of Medicine, Northwestern University, 2240 Campus Drive, Evanston, IL, 60208, USA.
- Department of Otolaryngology Head and Neck Surgery, Evelyn Trammell Institute for Voice and Swallowing, College of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA.
- Research Service, Edward Hines, Jr. VA Hospital, 5000 South 5th Avenue, Hines, IL, 60141, USA.
| | - Kathryn A Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Welch Center for Prevention, Epidemiology and Clinical Research, 2024 East Monument Street, Suite 2-500, Baltimore, MD, 21287, USA
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Jeanne M Pinto
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, The Johns Hopkins University School of Medicine, David M. Rubenstein Building, Suite 3070, 200 North Wolfe Street, Baltimore, MD, 21287, USA
| | - Maureen A Lefton-Greif
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, The Johns Hopkins University School of Medicine, David M. Rubenstein Building, Suite 3017, 200 North Wolfe Street, Baltimore, MD, 21287, USA
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
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