Assessment scale of the oral motor performance of children and adolescents with neurological damages

The oral behavior screener: a brief caregiver-completed measure of oral behaviors

INTRODUCTION

To date, there are no caregiver-reported screening measures of oral behaviors related to feeding. The goal of this study was to develop such a measure.

METHOD

Caregivers of 803 children referred to a feeding clinic and 188 comparison children reported their children's frequency of nine oral behaviors. These data were used to develop an Oral Behavior Screener (OBS). Both the psychometrics of the OBS and the relations between the OBS and child demographics were examined.

RESULTS

As expected, the clinical sample demonstrated more deficits in oral behaviors than the comparison sample. We also found special needs status and age were linked to the OBS summary score.

DISCUSSION

The OBS is a brief screener that can be used by clinicians to examine the need for further assessment, possible targets for intervention, oral behaviors often associated with feeding problems.

Effect of action observation training on the oral phase of swallowing in children with cerebral palsy: a pilot randomized controlled trial

Swallowing disorder is prevalent in children with cerebral palsy (CP), and previous studies have shown that motor-based programs benefit children with CP by facilitating motor learning. We hypothesized that action observation training (AOT) could enhance motor learning and improve the oral phase of swallowing in children. In this two-group parallel double-blind randomized controlled trial, the intervention group received AOT and sensorimotor therapy, while the control group received a sham and sensorimotor therapy. The function of the oral phase of swallowing, as the primary outcome, was measured pre-intervention, post-intervention, and at one month of follow-up. Secondary outcomes included reported symptoms of feeding problems and the impact of the child's swallowing disorder on the main caregiver, which were measured pre-intervention and post-intervention. The result of the Mann-Whitney U test showed a significant difference between the two groups in the function of the oral phase of swallowing after the intervention. Additionally, the intervention had a large effect size. However, no significant difference was found in the parent-reported scores of the feeding/swallowing impact survey and symptoms of feeding problems between the two groups. In conclusion, this pilot study provides preliminary evidence of the clinical efficacy of AOT as a safe neurorehabilitation method to improve the oral phase of swallowing in children with CP. However more studies are needed in the future.

Investigation of Assessment Tools in the Area of Pediatric Feeding Evaluation: A Mixed-Methods Study

IMPORTANCE

The new diagnostic code for pediatric feeding disorder (PFD) in the International Classification of Diseases, 10th edition, Clinical Modification, requires that occupational therapists and speech-language pathologists (SLPs) use valid and reliable assessment tools that capture the complexity of PFD.

OBJECTIVE

To determine current assessment tools that clinicians are using across the four domains of PFD: (1) medical factors, (2) nutrition factors, (3) feeding skill factors, and (4) psychosocial factors. A secondary objective was to obtain clinicians' perceptions of the assessment tools.

DESIGN

A mixed-methods study using survey research and focus groups.

SETTING

Online survey and virtual focus groups.

PARTICIPANTS

Occupational therapists and SLPs who identified as clinicians who treat PFDs.

RESULTS

The survey revealed that 65% of the clinicians (N = 445) used a nonstandardized assessment tool across the four domains of PFD. The focus groups (n = 26) revealed four resulting themes that expanded the survey results: (1) no one assessment tool works, (2) clinicians rely on self-created assessments, (3) it takes a team and collaboration, and (4) there are many issues with the current assessment of PFD.

CONCLUSIONS AND RELEVANCE

This study reveals the need for clinicians working with children with PFD to use feeding assessment tools with sound psychometric properties. The requirement for occupational therapists and SLPs to evaluate and treat dysphagia and disorders of feeding indicates the need to provide entry-level education on reliable and valid assessment tools that thoroughly evaluate all the domains of PFD. What This Article Adds: This article highlights current assessment tools used by occupational therapists and SLPs treating PFD and the need for more standardized procedures and tools to evaluate children across the four domains of PFD.

Generating Items for a Novel Bedside Dysphagia Screening Tool Post Acute Pediatric Stroke

Bedside dysphagia assessment protocols are not well developed in acute pediatric stroke unlike adults. The objective of this study was to identify items deemed relevant and feasible by expert consensus to inform the development of a bedside dysphagia screening tool for acute pediatric stroke. A two-phase study was conducted: (1) literature review and expert consultation generated a comprehensive list of dysphagia assessment items; (2) items were formatted in an online survey asking respondents opinion of relevance to acute pediatric stroke and feasibility for bedside administration by a trained health professional. The Dillman Tailored Design approach optimized response rate. Respondents were identified using the snowball method. Speech-language pathologists with > 2 years in pediatric dysphagia were invited to complete the survey. Demographic and practice variables were compared using univariate statistics. Item relevance and feasibility were made using binary or ordinal responses, combined to derive item-content validity indices (I-CVI) to guide item reduction. Items with I-CVI > 0.78 (excellent content validity) were moved forward to tool development. Of the 71 invited respondents, 57(80.3%) responded, of which 34(59.6%) were from North America. Sixty-one items were generated of which 4(6.6%) items were rated 'to keep'. These were face symmetry (I-CVI:0.89), salivary control (I-CVI:0.95), alertness (I-CVI:0.89) and choking (I-CVI:0.84). Of all respondents, 31(54.4%) endorsed swallowing trials, of which 25(80.6%) endorsed thin liquid by teaspoon (n = 17, 68%) or open cup (n = 20, 80%). We identified candidate items for bedside dysphagia screening with excellent content validity for acute pediatric stroke patients. Next steps include assessment of the psychometric value of each item in identifying dysphagia in children in the acute stage of recovery from stroke.

Effect of oral motor facilitation technique on oral motor and feeding skills in children with cerebral palsy : a case study

Background:

Deficiencies in oral motor function and feeding skills are common in children with cerebral palsy (CP). Oral motor therapy is a useful method to improve oral motor function and feeding skills. Oral motor facilitation technique (OMFT) is a newly designed comprehensive oral motor therapy, including postural control, sensory adaptation, breathing control, sensorimotor facilitation, and direct feeding.

Methods:

This study was performed to identify the effect of OMFT on oral motor function and feeding skills in children with CP. A total of 21 children with CP (3–10 years, GMFCS III–V) participated in 16 weeks (16 sessions) of OMFT. The effects on oral motor function and feeding skills were assessed using the Oral Motor Assessment Scale (OMAS) before the treatment, 8 and 16 weeks after OMFT. Data were analyzed using the Friedman test and post-hoc analysis.

Results:

Significant improvement was found in oral motor function and feeding skills including mouth closure, lip closure on the utensil, lip closure during deglutition, control of the food during swallowing, mastication, straw suction, and control of liquid during deglutition after OMFT. Mouth closure was the most effective and mastication was the least effective item. Sixteen weeks is more effective than 8 weeks of OMFT.

Conclusion:

OMFT could be an effective and useful oral motor therapy protocol to improve oral motor function and feeding skills in children with CP.

Paediatric oral sensorimotor interventions for chewing dysfunction: A scoping review

BACKGROUND

Chewing dysfunction can have adverse effects on growth, development and quality of life. There is a lack of evidence-based consensus guidelines for sensorimotor intervention. To address this, we need to understand the current state of the science in clinical sensorimotor interventions for paediatric chewing dysfunction and systematically plan a research agenda and priorities for the field.

AIMS

The purpose of this scoping review was to examine the extent, range and nature of evidence for oral sensorimotor interventions for paediatric chewing dysfunction.

METHODS & PROCEDURES

This scoping review entailed five phases that included: identification of the research question; identification of relevant studies; study selection; data charting; and collation, summarization and report of the results. Treatment studies that were peer-reviewed and written in English were included. All studies involved a paediatric population and included an oral sensorimotor and/or chewing intervention. Information regarding study design, population, intervention, comparator, outcome measures and findings were extracted.

MAIN CONTRIBUTION

Of the 21 studies included in this scoping review, 53% were specific to children with cerebral palsy. All interventions were multi-component in nature and the treatment studies included a range of study designs, but few were controlled trials with comparators. A wide variety of outcomes measures were used within and across studies to determine treatment effectiveness.

CONCLUSIONS & IMPLICATIONS

The findings suggest that in a small number of studies, sensorimotor interventions provide preliminary evidence for effectiveness in specific populations. These and other treatment protocols must be trialled in additional clinical populations and settings to improve the evidence base for sensorimotor treatment of paediatric chewing dysfunction. This review also serves to help prioritize research agendas and further motivates the need for consensus-based clinical guidelines for paediatric chewing treatment.

WHAT THIS PAPER ADDS

What is already known on the subject Paediatric feeding disorders are highly prevalent and children often have chewing dysfunction that results in significant negative consequences. We lack evidence-based sensorimotor treatment approaches for chewing dysfunction, which directly impacts the care clinicians can provide children. What this study adds to existing knowledge This scoping review is the first step in examining the literature to understand the current state of the science for oral sensorimotor interventions for paediatric chewing dysfunction. Few randomized controlled studies were identified and a majority included children with cerebral palsy. Most of the interventions were multi-component and included a variety of treatment approaches. What are the potential or actual clinical implications of this work? The results of this scoping review can be used as an initial reference for clinicians selecting treatment approaches for chewing dysfunction. It also serves to help prioritize research agendas and further motivates the need for consensus-based clinical guidelines for paediatric chewing treatment.

Parent-delivered interventions used at home to improve eating, drinking and swallowing in children with neurodisability: the FEEDS mixed-methods study

BACKGROUND

Eating, drinking and swallowing difficulties are common in young children with neurodisability. These difficulties may lead to inadequate calorie intake, which affects a child's nutrition, growth and general physical health.

OBJECTIVE

To examine which interventions are available that can be delivered at home by parents to improve eating, drinking and swallowing in young children with neurodisability and are suitable for investigation in pragmatic trials.

DESIGN

This was a mixed-methods study that included focus groups, surveys, an update of published systematic reviews of interventions, a systematic review of measurement properties of existing tools, evidence mapping, evidence synthesis, a Delphi survey and stakeholder workshops.

SETTING

The study was carried out in NHS hospitals, community services, family homes and schools.

PARTICIPANTS

Parents of children who had neurodisability and eating, drinking and swallowing difficulties. Professionals from health and education. Young people with eating, drinking and swallowing difficulties or young people who had previously experienced eating, drinking and swallowing difficulties.

DATA SOURCES

Literature reviews; national surveys of parents and professionals; focus groups with parents, young people and professionals; and stakeholder consultation workshops.

REVIEW METHODS

An update of published systematic reviews of interventions (searched July-August 2017), a mapping review (searched October 2017) and a systematic review of measurement properties using COnsensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) methodology (searched May 2018).

RESULTS

Significant limitations of the available research evidence regarding interventions and tools to measure outcomes were identified. A total of 947 people participated: 400 parents, 475 health professionals, 62 education professionals and 10 young people. The survey showed the wide range of interventions recommended by NHS health professionals, with parents and professionals reporting variability in the provision of these interventions. Parents and professionals considered 19 interventions as relevant because they modified eating, drinking and swallowing difficulties. Parents and professionals considered 10 outcomes as important to measure (including Nutrition, Growth and Health/safety); young people agreed that these were important outcomes. Stakeholder consultation workshops identified that project conclusions and recommendations made sense, were meaningful and were valued by parents and professionals. Parents and health professionals were positive about a proposed Focus on Early Eating, Drinking and Swallowing (FEEDS) toolkit of interventions that, through shared decision-making, could be recommended by health professionals and delivered by families.

LIMITATIONS

The national surveys included large numbers of parents and professionals but, as expected, these were not representative of the UK population of parents of children with eating, drinking and swallowing difficulties. Owing to the limitations of research evidence, pragmatic decisions were made about interventions that might be included in future research and outcomes that might be measured. For instance, the reviews of research found only weak or poor evidence to support the effectiveness of interventions. The review of outcome measures found only limited low-level evidence about their psychometric properties.

CONCLUSIONS

Opportunities and challenges for conducting clinical trials of the effectiveness of the FEEDS toolkit of interventions are described. Parents and professionals thought that implementation of the toolkit as part of usual NHS practice was appropriate. However, this would first require the toolkit to be operationalised through development as a complex intervention, taking account of constituent interventions, delivery strategies, implementation and manualisation. Subsequently, an evaluation of its clinical effectiveness and cost-effectiveness could be undertaken using appropriate research methods.

FUTURE WORK

Initial steps include FEEDS toolkit development and evaluation of its use in clinical practice, and identification of the most robust methods to measure valued outcomes, such as Nutrition and Growth.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10454425.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 22. See the NIHR Journals Library website for further project information.

Psychometric properties of the Persian version of the oral motor assessment scale in children and adolescents with cerebral palsy

The Oral Motor Assessment Scale (OMAS) is a diagnostic tool used to assess the oral motor skills in individuals with neurological and neuromuscular disorders. This assessment was developed by Brazilian researchers and for the first time, its validity and reliability was examined in Brazil. The purpose of the present study was to examine the validity and reliability of the adopted Persian version of the OMAS (OMAS-P) to assess the oral skills of Iranian individuals with cerebral palsy (CP). In this non-experimental descriptive-analytical study 120 people (60 children and adolescents with CP) aged 3 to 15 years and 60 healthy subjects) participated. The research was carried out in number of stages including translation and adaptation of the OMAS to Persian (OMAS-P) in a forward-backward way. The oral motor skills functionality of the 120 people was examined using the OMAS-P. To assess the repeatability and reliability of the OMAS-P the assessments was repeated on the participants with CP disorder after two weeks. Results corresponding to this study indicated a reasonable agreement (Kappa >0.7) for all the OMAS-P items. The mean values of the OMAS-P items were appreciably different between the two groups (p < 0.001). The Persian version of the OMAS (OMAS-P) indicated consistent psychometric properties and can be used as a reliable tool for oral motor skills assessment in people with CP. However, it seems that by specifying factors such as the time frame for the OMAS, the position of the child during assessment, and whether or not parents use facilitating techniques, the comprehensiveness and efficiency of the OMAS data will also upgrade.

Eye tracking metrics to screen and assess cognitive impairment in patients with neurological disorders

PURPOSE OF REVIEW

Eye tracking is a powerful method to investigate the relationship between behavior and neural mechanisms. In recent years, eye movement analysis has been used in patients with neurological disorders to assess cognitive function. In this review, we explore the latest eye tracking researches in neurological disorders that are commonly associated with cognitive deficits, specifically, amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD), Parkinson's disease (PD), multiple sclerosis (MS), and epilepsy. We focus on the application of ocular measures in these disorders, with the goal of understanding how eye tracking technology can be used in the clinical setting.

FINDINGS

Eye tracking tasks (especially saccadic tasks) are often used as an adjunct to traditional scales for cognitive assessment. Eye tracking data confirmed that executive dysfunction is common in PD and ALS, whereas AD and MS are characterized by attention deficits. Research in evaluating cognitive function in epilepsy using eye tracking is still in its early stages, but this approach has shown advantages as a sensitive quantitative method with high temporal and spatial resolution. Eye tracking technology can facilitate the assessment of cognitive impairment with higher temporal resolution and finer granularity than traditional cognitive assessment. Oculomotor data collected during cognitive tasks can provide insight into biological processes. Eye tracking provides a nonverbal and less cognitively demanding method of measuring disease progression in cognitively impaired patients.

Addition of Kinesio Taping of the orbicularis oris muscles to speech therapy rapidly improves drooling in children with neurological disorders

OBJECTIVE

To evaluate the effects of Kinesio Taping (KT) of the orbicularis oris muscles as an adjunct to standard therapy for drooling.

METHODS

Fifteen children with neurological disorders and drooling received speech therapy and twice-weekly KT of the orbicularis muscles over a 30-day period. Drooling was assessed by six parameters: impact on the life of the child and caregiver; severity of drooling; frequency of drooling; drooling volume (estimated by number of bibs used); salivary leak; and interlabial gap. Seven markers of oral motor skills were also assessed.

RESULTS

KT of the orbicularis oris region reduced the interlabial gap. All oral motor skills and almost all markers of drooling improved after 15 days of treatment.

CONCLUSION

In this sample of children with neurological disorders, adding KT of the orbicularis oris muscles to speech therapy caused rapid improvement in oral motor skills and drooling.

Labial Incompetence in Mobius Syndrome: LeFort I Impaction Case Report and Review of Management Strategies

Difficulty with speech intelligibility in Mobius syndrome patients due to bilabial incompetence is common yet rarely discussed. We present a patient with Mobius syndrome who underwent counterclockwise LeFort I impaction to improve her labial competence. In addition, we present a literature review of management strategies for labial incompetence correction in Mobius patients. At 7-year follow-up after LeFort 1 impaction, the patient reports improvement in speech intelligibility, specifically regarding the ability to pronounce bilabial consonants. This is the first published report of LeFort I impaction to improve labial competence and bilabial consonant pronunciation in a Mobius syndrome patient.

Psychometric Characteristics of Non-instrumental Swallowing and Feeding Assessments in Pediatrics: A Systematic Review Using COSMIN

As early diagnosis of swallowing and feeding difficulties in infants and children is of utmost importance, there is a need to evaluate the quality of the psychometric properties of pediatric assessments of swallowing and feeding. A systematic review was performed summarizing the psychometric properties of non-instrumental assessments for swallowing and feeding difficulties in pediatrics; no data were identified for the remaining twelve assessments. The COSMIN taxonomy and checklist were used to evaluate the methodological quality of 23 publications on psychometric properties. For each assessment, an overall quality score for each measurement property was determined. As psychometric data proved incomplete, conflicting or indeterminate for all assessments, only preliminary conclusions could be drawn; the most robust assessment based on current data is the dysphagia disorder survey (DDS). However, further research is needed to provide additional information on all psychometric properties for all assessments.

European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment

OBJECTIVES

Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment.

METHODS

Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.

Gingivitis and salivary osmolality in children with cerebral palsy

AIM

To investigate the influence of salivary osmolality on the occurrence of gingivitis in children with cerebral palsy (CP).

DESIGN

A total of 82 children with spastic CP were included in this cross-sectional study. Oral motor performance and gingival conditions were evaluated. Unstimulated saliva was collected using cotton swabs, and salivary osmolality was measured using a freezing point depression osmometer. Spearman's coefficient, receiver operating characteristic (ROC), and multiple logistic regression analyses were performed.

RESULTS

Strong correlation (r > 0.7) was determined among salivary osmolality, salivary flow rate, visible plaque, dental calculus, and the occurrence of gingivitis. The area under the ROC to predict the influence of salivary osmolality on the occurrence of gingivitis was 0.88 (95% CI 0.81-0.96; P < 0.001). The cutoff value of 84.5 for salivary osmolality presented good sensitivity and specificity, both higher than 77%. The proportion of children presenting salivary osmolality ≤84.5 mOsm/kgH₂ O and gingivitis was 22.5%, whereas for the group presenting osmolality >84.5 mOsm/kgH₂ O, the proportion of children with gingivitis was 77.5%. Salivary osmolality above 84.5 increased the likelihood of gingivitis fivefold, whereas each additional 0.1 mL of salivary flow reduced the likelihood of gingivitis by 97%.

CONCLUSION

Gingivitis occurs more frequently in children with CP showing increased values of salivary osmolality.

A telehealth approach to conducting clinical swallowing evaluations in children with cerebral palsy

BACKGROUND

Accurate and timely evaluation of dysphagia in children with cerebral palsy (CP) is critical. For children with limited access to quality healthcare, telehealth is an option; however, its reliability needs to be investigated.

AIM

To test the reliability of an asynchronous telehealth model for evaluating dysphagia in children with CP using a standardized clinical assessment.

METHODS AND PROCEDURES

Nineteen children (age range 6.9-17.5) were assessed at three mealtimes via the Dysphagia Disorder Survey (DDS) by three clinicians (face-to-face evaluations). Mealtimes were video-recorded to allow asynchronous evaluations by a remote clinician who also completed approximately 1/3 of face-to-face evaluations. Agreement was tested on DDS variables and dysphagia severity.

OUTCOMES AND RESULTS

Results revealed substantial to excellent agreement between face-to-face and remote assessments by the same rater (78-100%, KW=0.64-1) on all, but two variables (oral transport and oral pharyngeal swallow) and by different raters (69-89%, KW=0.6-0.86) on all but one variable (orienting). For dysphagia severity, intrarater agreement was excellent (100%, KW=1); interrater agreement was substantial (85%; KW=0.76).

CONCLUSIONS AND IMPLICATIONS

Asynchronous clinical swallowing evaluations using standardized tools have acceptable levels of agreement with face-to-face evaluations, and can be an alternative for children with limited access to expert swallowing care.

The nutritional state of children and adolescents with cerebral palsy is associated with oral motor dysfunction and social conditions: a cross sectional study

BACKGROUND

Cerebral palsy (CP) is the main cause of severe physical impairment during childhood and has commonly shown oral motor association. It has been considered as the main cause of the high prevalence of problems in children's nutrition. Respiration, chewing, swallowing, speaking and facial expressionare part of the orofacial motor functions and when affected they can interfere in children's well-being. The aim of this study was to correlate two methods of orofacial motor evaluation, analyze the influence of orofacial motor functional impairment on the nutritional status of children and adolescents with CP, and the association between socioeconomic factors.

METHODS

Seventy children and adolescents with CP were selected, age range 6-16 years and following the exclusion criteria previously determined; 129 normoreactive children (control group), sex and age-matched to patients with CP. For the orofacial motor analysis two evaluation instruments were applied, the "Oral Motor Assessment Scale" (OMAS) and "Nordic Orofacial Test-Screening" (NOT-S). The anthropometric evaluation was based on the World Health Organization (WHO) and followed the criteria recommended by the Brazilian Ministry of Health.

RESULTS

There was statistically significant correlation between the oral motor methods of evaluation (r = -0.439, p < 0.0001). Concerning the nutritional status evaluation, being overweight was associated with dystonic and mixed CP forms variables (p = 0.034), mother with no partnership (p = 0.045) and mild oral motor impairment (p = 0.028).

CONCLUSION

It could be concluded that, the weight's gain by children and adolescents might be favored by a better functional oral motor performance and social factors.

Validation of Clinical Observations of Mastication in Persons with ALS

Amyotrophic lateral sclerosis (ALS) is a progressive neurological disease that can result in difficulties with mastication leading to malnutrition, choking or aspiration, and reduced quality of life. When evaluating mastication, clinicians primarily observe spatial and temporal aspects of jaw motion. The reliability and validity of clinical observations for detecting jaw movement abnormalities is unknown. The purpose of this study is to determine the reliability and validity of clinician-based ratings of chewing performance in neuro-typical controls and persons with varying degrees of chewing impairments due to ALS. Adults chewed a solid food consistency while full-face video were recorded along with jaw kinematic data using a 3D optical motion capture system. Five experienced speech-language pathologists watched the videos and rated the spatial and temporal aspects of chewing performance. The jaw kinematic data served as the gold-standard for validating the clinicians' ratings. Results showed that the clinician-based rating of temporal aspects of chewing performance had strong inter-rater reliability and correlated well with comparable kinematic measures. In contrast, the reliability of rating the spatial and spatiotemporal aspects of chewing (i.e., range of motion of the jaw, consistency of the chewing pattern) was mixed. Specifically, ratings of range of motion were at best only moderately reliable. Ratings of chewing movement consistency were reliable but only weakly correlated with comparable measures of jaw kinematics. These findings suggest that clinician ratings of temporal aspects of chewing are appropriate for clinical use, whereas ratings of the spatial and spatiotemporal aspects of chewing may not be reliable or valid.

Dietary Intakes and Nutritional Issues in Neurologically Impaired Children

Neurologically impaired (NI) children are at increased risk of malnutrition due to several nutritional and non-nutritional factors. Among the nutritional factors, insufficient dietary intake as a consequence of feeding difficulties is one of the main issues. Feeding problems are frequently secondary to oropharyngeal dysphagia, which usually correlates with the severity of motor impairment and presents in around 90% of preschool children with cerebral palsy (CP) during the first year of life. Other nutritional factors are represented by excessive nutrient losses, often subsequent to gastroesophageal reflux and altered energy metabolism. Among the non-nutritional factors, the type and severity of neurological impairment, ambulatory status, the degree of cognitive impairment, and use of entiepileptic medication altogether concur to determination of nutritional status. With the present review, the current literature is discussed and a practical approach for nutritional assessment in NI children is proposed. Early identification and intervention of nutritional issues of NI children with a multidisciplinary approach is crucial to improve the overall health and quality of life of these complex children.

Teeth grinding, oral motor performance and maximal bite force in cerebral palsy children

AIM

Identify whether the degree of oral motor performance is related to the presence of teeth grinding and maximal bite force values in children with spastic cerebral palsy.

METHODS

Ninety-five spastic cerebral palsy children with and without teeth grinding, according to caregivers' reports, were submitted to a comprehensive oral motor performance evaluation during the feeding process using the Oral Motor Assessment Scale. Maximal bite force was measured using an electronic gnathodynamometer.

RESULTS

The teeth grinding group (n = 42) was younger, used anticonvulsant drugs, and was more frequently classified within the subfunctional oral motor performance category. Teeth grinding subfunctional spastic cerebral palsy children presented lower values of maximal bite force. The functional groups showing the presence or absence of teeth grinding presented higher values of maximal bite force compared with the subfunctional groups.

CONCLUSION

In spastic cerebral palsy children, teeth grinding is associated with the worse oral motor performance.

Oropharyngeal dysphagia in preschool children with cerebral palsy: oral phase impairments

PURPOSE

This study aimed to document the prevalence and patterns of oral phase oropharyngeal dysphagia (OPD) in preschool children with cerebral palsy (CP), and its association with mealtime duration, frequency and efficiency.

METHODS

Cross-sectional population-based cohort study of 130 children diagnosed with CP at 18-36 months ca (mean = 27.4 months, 81 males) and 40 children with typical development (mean = 26.2, 18 males). Functional abilities of children with CP were representative of a population sample (GMFCS I = 57, II = 15, III = 23, IV = 12, V = 23). Oral phase impairment was rated from video using the Dyspahgia Disorders Survey, Schedule for Oral Motor Impairment, and Pre-Speech Assessment Scale. Parent-report was collected on a feeding questionnaire. Mealtime frequency, duration and efficiency were calculated from a three day weighed food record completed by parents. Gross motor function was classified using the Gross Motor Function Classification System (GMFCS).

RESULTS

Overall, 93.8% of children had directly assessed oral phase impairments during eating or drinking, or in controlling saliva (78.5% with modified cut-points). Directly assessed oral phase impairments were associated with declining gross motor function, with children from GMFCS I having a 2-fold increased likelihood of oral phase impairment compared to the children with TD (OR = 2.0, p = 0.18), and all children from GMFCS II-V having oral phase impairments. Difficulty biting (70%), cleaning behaviours (70%) and chewing (65%) were the most common impairments on solids, and difficulty sipping from a cup (60%) for fluids. OPD severity and GMFCS were not related to mealtime frequency, duration or efficiency, although children on partial tube feeds had significantly reduced mealtime efficiency.

CONCLUSIONS

Oral phase impairments were common in preschool children with CP, with severity increasing stepwise with declining gross motor function. The prevalence and severity of oral phase impairments were significantly greater for most tasks when compared to children with typical development, even for those with mild CP. Children who were partially tube fed had significantly lower feeding efficiency, so this could be a useful early indicator of children needing supplementation to their nutrition (through increasing energy density of foods/fluids, or tube feeds).

Assessing salivary osmolality as a caries risk indicator in cerebral palsy children

BACKGROUND

Salivary osmolality reflects the hydration status of individuals with cerebral palsy (CP) necessary for an adequate unstimulated salivary flow rate.

AIM

To investigate whether salivary osmolality could serve as a potential indicator of caries risk in children with spastic CP by displaying a stronger association with caries occurrence than salivary flow rate.

DESIGN

The convenience sample consisted of 65 children with CP aged 6-13 years old. Unstimulated whole saliva was collected using cotton roll, and salivary osmolality was measured using a freezing point depression osmometer. The children's oral motor performance was evaluated during the feeding process using the Oral Motor Assessment Scale. Caries occurrence was also evaluated according the World Health Organization criteria.

RESULTS

Motor skills were significantly associated with caries experience. Regarding the salivary parameters, osmolality presented a stronger association with caries experience than did the salivary flow rate. Children with worse oral motor performance presented a higher rate of caries occurrence.

CONCLUSION

Osmolality exhibited a stronger association with caries occurrence than did salivary flow rate. This parameter, therefore, could be a potential caries risk indicator for spastic cerebral palsy children.

Inter-rater and intra-rater agreement on the Nordic Orofacial Test--Screening examination in children, adolescents and young adults with cerebral palsy

OBJECTIVE

To evaluate inter-rater and intra-rater agreement on the Nordic Orofacial Test-Screening (NOT-S) examination applied to children, adolescents and young adults with cerebral palsy (CP).

MATERIALS AND METHODS

Using the NOT-S examination, two speech and language pathologists independently assessed video recordings of 48 subjects with CP aged 5-22 years and representing all CP sub-diagnoses and levels of gross motor function and manual ability. Thirty-one subjects were reassessed. Fifteen out of 17 items in the NOT-S examination domains (1) Face at rest, (2) Nose breathing, (3) Facial expression, (4) Masticatory muscle and jaw function, (5) Oral motor function and (6) Speech were rated using a 'yes' (dysfunction observed)/'no' format, generating an overall score of 0-6.

RESULTS

Inter-rater agreement: Twelve out of 15 items and five out of six domains showed acceptable unweighted kappa values (κ = 0.46-1.00). The lowest kappa value was found for domain 4 (κ = -0.04), although it had high inter-rater agreement (92%). The linear weighted kappa value for the overall NOT-S examination score was 0.65 (95% CI = 0.49-0.82). Intra-rater agreement: All items and domains showed acceptable unweighted kappa values (items 0.58-1.00 and 0.59-1.00, domains 0.81-1.00 and 0.62-0.89) for both raters. The linear weighted kappa value for the overall NOT-S examination score was 0.81 (95% CI = 0.63-0.99) for rater A and 0.54 (95% CI = 0.25-0.82) for rater B.

CONCLUSIONS

The NOT-S examination has acceptable inter-rater and intra-rater agreement when used in young individuals with CP.

Experiência de cárie e osmolaridade salivar em crianças com paralisia cerebral

INTRODUÇÃO: Estudos têm demonstrado que quanto maior a severidade do dano neurológico em crianças com paralisia cerebral (PC), maior é o risco de doenças orais. OBJETIVO: Correlacionar a experiência de cárie com a osmolaridade salivar em crianças com PC. MATERIAL E MÉTODO: Participaram do estudo 99 crianças (9,2±2,3 anos) com PC, em tratamento reabilitacional. A saliva de repouso foi coletada no período matutino, utilizando rolos absorventes (Salivette®) por cinco minutos. A osmolaridade salivar foi medida por depressão do ponto de congelamento em osmômetro. As avaliações incluíram a experiência de cárie pelo índice de dentes cariados, perdidos e obturados (CPOD), e o motor oral durante o processo de alimentação da criança. Foram utilizados os testes Qui-quadrado, t de Student, Correlação de Spearman e razão de chances (OR), com nível de significância de 5%. RESULTADO: O grupo 1 (G1) foi composto por 41 crianças livres de cárie e o grupo 2 (G2), por 58 crianças com cárie (CPOD=3,5±2,7). Os grupos foram homogêneos para gênero (p=0,884) e idade (p=0,174). Entretanto, diferiram significantemente com relação à motricidade oral, apresentando G2 maiores porcentagens de crianças com motor oral subfuncional (p<0,001) e tetraparéticos (p=0,001). O G2 apresentou valores significantemente maiores (p<0,001) para osmolaridade (99,6±36,7mOsml) quando comparado ao G1 (76,7±15,9mOsml). Observou-se uma correlação significante entre osmolaridade e experiência de cárie (p<0,001). Apresentar osmolaridade superior a 76,7 (OR=5,18; 1,85 a 14,83) foi determinante individual de maior probabilidade de apresentar risco de cárie (CPOD>0). CONCLUSÃO: Maiores valores de osmolaridade salivar aumentam o risco de cárie em crianças com PC.

Oral motor assessment in individuals with Moebius syndrome

BACKGROUND

Moebius syndrome (MS) is a rare congenital condition that is characterised by facial hypomimia and congenital strabismus caused by complete or partial impairment of the 6th and 7th cranial nerves. MS may be further associated with other nerves or malformations, mainly involving the extremities. The objective of this study was to quantify the decrease in oral motor performance in people with MS compared with normoreactive individuals using the Oral Motor Assessment Scale (OMAS).

METHODS

The study group comprised 33 subjects between the ages of 2 and 20 years (average age: 10 ± 5 years) with MS along with 46 age- and gender-matched control subjects.

RESULTS

The study group displayed a lower average functional score than the control group (P < 0.0001). A significant lack of lip closure (P = 0.03) and anterior lingual seal during swallowing (P = 0.03) occurred in the study group; in most cases, the individuals with MS were classified as 'subfunctional'. In addition, individuals with MS in the older age group displayed better functional scores than those in the younger group (P = 0.05).

CONCLUSIONS

Functional damage to oral motor function in individuals with MS is evident, but differs among patients with respect to severity and the movements that are compromised. However, overall, improvements in the functional patterns of these individuals can be observed as they mature in age.

Clinimetrics of measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities: a systematic review

AIM

The aim of this study was to determine the psychometric properties and clinical utility of objective measures of oropharyngeal dysphagia (OPD) in children with cerebral palsy or neurodevelopmental disabilities aged 12 months to 5 years.

METHOD

Five electronic databases were searched to identify measures of OPD. The Consensus-based Standards for the Selection of Measurement Instruments (COSMIN) Checklist was used to assess psychometric properties and a Modified CanChild Outcome Rating Form was used for clinical utility.

RESULTS

Nine measures of OPD from 27 papers were assessed: the Brief Assessment of Motor Function - Oral Motor Deglutition Scale; the Behavioral Assessment Scale of Oral Functions in Feeding; the Dysphagia Disorders Survey; the Feeding Behaviour Scale; the Functional Feeding Assessment, modified; the Gisel Video Assessment; the Oral Motor Assessment Scale; the Pre-Speech Assessment Scale; and the Schedule for Oral Motor Assessment.

INTERPRETATION

The Schedule for Oral Motor Assessment and the Functional Feeding Assessment, modified, proved to be the strongest measures based on published psychometric properties of validity and reliability. The Schedule for Oral Motor Assessment and the Dysphagia Disorders Survey were found to have the strongest clinical utility. Further studies to test the psychometric properties of existing measures, in particular predictive validity, responsiveness, and test-retest reliability, would be beneficial for selecting an appropriate measure for both clinical and research contexts.

Longitudinal cohort protocol study of oropharyngeal dysphagia: relationships to gross motor attainment, growth and nutritional status in preschool children with cerebral palsy

INTRODUCTION

The prevalence of oropharyngeal dysphagia (OPD) in children with cerebral palsy (CP) is estimated to be between 19% and 99%. OPD can impact on children's growth, nutrition and overall health. Despite the growing recognition of the extent and significance of health issues relating to OPD in children with CP, lack of knowledge of its profile in this subpopulation remains. This study aims to investigate the relationship between OPD, attainment of gross motor skills, growth and nutritional status in young children with CP at and between two crucial age points, 18-24 and 36 months, corrected age.

METHODS AND ANALYSIS

This prospective longitudinal population-based study aims to recruit a total of 200 children with CP born in Queensland, Australia between 1 September 2006 and 31 December 2009 (60 per birth-year). Outcomes include clinically assessed OPD (Schedule for Oral Motor Assessment, Dysphagia Disorders Survey, Pre-Speech Assessment Scale, signs suggestive of pharyngeal phase impairment, Thomas-Stonell and Greenberg Saliva Severity Scale), parent-reported OPD on a feeding questionnaire, gross motor skills (Gross Motor Function Measure, Gross Motor Function Classification System and motor type), growth and nutritional status (linear growth and body composition) and dietary intake (3 day food record). The strength of relationship between outcome and exposure variables will be analysed using regression modelling with ORs and relative risk ratios.

ETHICS AND DISSEMINATION

This protocol describes a study that provides the first large population-based study of OPD in a representative sample of preschool children with CP, using direct clinical assessment. Ethics has been obtained through the University of Queensland Medical Research Ethics Committee, the Children's Health Services District Ethics Committee, and at other regional and organisational ethics committees. Results are planned to be disseminated in six papers submitted to peer reviewed journals, and presentations at relevant international conferences.

Manometric evaluation of oral function with a hand-held balloon probe

Tongue pressure measured with a disposable hand-held balloon probe has been used for assessing tongue function; however, no diagnostic standard for assessing other oral functions exists currently. In this study, to develop a method for multifactorial manometric evaluation of oral functions, 20 men and 20 women (21-32 years of age) were instructed to apply 7-s maximal voluntary muscular effort on a hand-held balloon probe placed against the anterior and lateral parts of the palate, buccal surface of the molars on the habitual chewing side and labial surface of the anterior teeth for measuring anterior and posterior tongue, cheek and lip pressures (LPs), respectively. Intra-session reproducibility was determined by three repeated measurements, and associations between the obtained and the conventional data on oral diadochokinesis were tested. The men exhibited higher values of all the pressure types. Further, both genders showed a positive correlation between anterior and posterior tongue pressures (PTPs) (P < 0·05), but only the women exhibited positive correlations between anterior tongue and cheek pressures, cheek and PTPs, anterior tongue and LPs, and cheek and LPs (P < 0·05). No statistically significant correlation was found between the pressures and the number of syllabic articulations, except between LP and the number of /pa/ articulations in the women (r = 0·524, P < 0·05). In conclusion, the balloon probe method enables objective manometric evaluation of oral functions and could be an effective tool for clinical epidemiological studies and evidence-based decision-making in nursing care.