Telepractice for pediatric Dysphagia: a case study

Exploring the diagnostic accuracy and applicability of the Gugging Swallowing Screen in children with feeding and/or swallowing disorders

BACKGROUND

The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia.

METHODS

Eighty-Greek-Cypriot children aged 3-12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre- and post-therapy) to each patient throughout 24 sessions of dysphagia therapy.

KEY RESULTS

The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test-retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool-10 (PEDI-EAT-10) total score (rs = -0.365), and inter-rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR- 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR- NA).

CONCLUSIONS & INFERENCES

The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed.

Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion

Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429-1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team's experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children's Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.

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.

Virtual nourishment: Paediatric feeding disorder management with telepractice amidst COVID-19: An allied health perspective

PURPOSE

The rapid adoption of telepractice services by health professionals was necessary to maintain service continuity for children with paediatric feeding disorders during the COVID-19 pandemic, during periods where in-person therapy was restricted. The aim of this study was to explore clinical perspectives and reflections on the use of telepractice for managing paediatric feeding disorders during the pandemic.

METHOD

A post-positivist qualitative approach using thematic analysis was adopted. This study seeks to understand participants' experiences and thoughts from allied health professionals from speech-language pathology, occupational therapy, and dietetics working with paediatric feeding in Western Australia. All participants delivered at least 10 telepractice sessions to children from birth to 12 years with a paediatric feeding disorder. Braun and Clarke's six-step thematic analysis process was used to analyse the data inductively.

RESULT

Eleven allied health professionals representing eight clinical settings in Western Australia, including speech-language pathology, occupational therapy, and dietetics, working with paediatric feeding were recruited. The results revealed four themes: families becoming the catalyst of change, clinician comfort over confidence, insights into authentic mealtimes, and the paradox of choice.

CONCLUSION

This study highlighted the need to build clinicians' confidence and competence, and the provision of service guidelines and training. Although many clinicians had positive experiences with telepractice, most returned to in-person delivery once COVID-19 restrictions were lifted, emphasising the importance of comfort in service delivery selection. We recognise that the findings of this study are constrained by the fact that it was conducted in a single geographical region and utilised a small qualitative sample. While telepractice was successful in managing paediatric feeding disorders, further development and implementation of telepractice guidelines are needed for telepractice to be a viable service delivery option for families and children with feeding disorders.

A time and cost analysis of speech pathology paediatric feeding services delivered in-person versus via telepractice

INTRODUCTION

Telepractice models of care have the potential to reduce the time and financial burdens that consumers may experience accessing healthcare services. The current study aimed to conduct a time and financial cost analysis of paediatric feeding appointments accessed via telepractice (using videoconferencing) compared to an in-person model.

METHODS

Parents of 44 children with paediatric feeding disorders (PFDs) residing in a metropolitan area completed three questionnaires relating to (a) demographics, (b) time and cost for in-person care and (c) time and cost for telepractice. Both cost questionnaires collected data required for direct and indirect costs comparisons (e.g. out-of-pocket costs associated with the appointment (direct), time away from usual duties (indirect)). Average number of services accessed by each participant, and PFD appointments conducted annually by the service, were collected from service statistics. Analysis involved cost minimisation and cost modelling from a societal perspective.

RESULTS

The telepractice appointment resulted in significant time (p = 0.007) and cost (AUD$95.09 per appointment, SD = AUD$64.47, p = < 0.0001) savings per family. The health service cost was equivalent for both models (AUD$58.25). Cost modelling identified cost savings of up to AUD$475.45 per family if 50% of appointments in a 10-session block were converted to telepractice. Potential cost savings of AUD$68,750.07 per annum to society could be realised if 50% of feeding appointments within the service were provided via telepractice.

DISCUSSION

The telepractice model offered both time and cost benefits. Future service re-design incorporating hybrid services (in-person and telepractice) will help optimise benefits and minimise burden for families accessing services for PFDs.

Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond

The COVID-19 pandemic drove rapid and widespread uptake of telepractice across all aspects of healthcare. The delivery of dysphagia care was no exception, with telepractice recognized as a service modality that could support social distancing/infection control, overcome service delivery challenges created by lockdowns/service closures, and address consumer concerns about attending in-person appointments. Now, almost two years since most services first rapidly deployed telepractice, it is time to reflect on the big picture, and consider how telepractice will continue as a service option that is sustained and integrated into mainstream dysphagia care. It is also timely to consider the research agenda needed to support this goal. To this end, in this paper we present 4 discussion topics, which raise key considerations for the current and future use of telepractice within adult and pediatric dysphagia services. These are (1) Dysphagia services must meet consumer and service needs; (2) Aspects of dysphagia services can be safely and reliably provided via telepractice; (3) Telepractice can be used in flexible ways to support the delivery of dysphagia services; and (4) Providing quality dysphagia services via telepractice requires planned implementation and evaluation. Then directions for future research are discussed. These considerations are presented to help shift perspectives away from viewing telepractice as simply a COVID-19 "interim-care solution". Rather, we encourage clinicians, services, and researchers to embrace a future of "integrated care", where traditional dysphagia services are combined with telepractice models, to enhance the quality of care provided to our clients.

Outcome Measures Following Tele-rehabilitation and Conventional Face to Face Rehabilitation in Paediatric Cochlear Implant Users during COVID-19 Pandemic: A Pilot Study in a Tertiary Care Setup

Background

Following the COVID-19 pandemic, majority of paediatric cochlear implantees (CI) lost follow ups for rehabilitation and tele-therapy was initiated. Present study thus compared the outcome measures of paediatric CI users on tele-therapy versus conventional face to face therapy following COVID-19 pandemic.

Method

Twenty seven unilateral paediatric cochlear implantees in the age range of 2–11 years were divided into two groups based on the therapy modality, viz, tele- and face-to-face therapy. Based on the hearing age, participants were further divided into three groups, viz, 0–2, 2–4, and greater than four years. A complete the test battery comprising Integrated Scales of Development, Speech Intelligibility Rating scale, and Revised Categorical Auditory Perception were administered. The speech & language test battery was performed prior to initiating the rehabilitation and post 12 months of rehabilitation.

Results

Results of the present study revealed that conventional rehabilitation had better outcomes compared to teletherapy. The rate of progress after one year of rehabilitation with respect to hearing-age showed a significant difference for the hearing-age group of 0–2 years across the domains of audition, speech and language.

Conclusion

The present study indicates that conventional method of the speech-language and auditory rehabilitation is far better compared to the tele rehabilitation services especially for those visiting tertiary care hospitals as most of them belong to lower and middle socioeconomic status. From the results, it can be delineated that with lesser hearing experience, paediatric CI users always need to initially enroll for conventional therapy for better speech-language and auditory outcomes.

Objective and Subjective Clinical Swallowing Outcomes via Telehealth: Reliability in Outpatient Clinical Practice

Purpose The COVID-19 pandemic has drastically increased the use of telehealth. Prior studies of telehealth clinical swallowing evaluations provide positive evidence for telemanagement of swallowing. However, the reliability of these measures in clinical practice, as opposed to well-controlled research conditions, remains unknown. This study aimed to investigate the reliability of outcome measures derived from clinical swallowing tele-evaluations in real-world clinical practice (e.g., variability in devices and Internet connectivity, lack of in-person clinician assistance, or remote patient/caregiver training). Method Seven raters asynchronously judged clinical swallowing tele-evaluations of 12 movement disorders patients. Outcomes included the Timed Water Swallow Test (TWST), Test of Masticating and Swallowing Solids (TOMASS), and common observations of oral intake. Statistical analyses were performed to examine inter- and intrarater reliability, as well as qualitative analyses exploring patient and clinician-specific factors impacting reliability. Results Forty-four trials were included for reliability analyses. All rater dyads demonstrated "good" to "excellent" interrater reliability for measures of the TWST (intraclass correlation coefficients [ICCs] ≥ .93) and observations of oral intake (≥ 77% agreement). The majority of TOMASS outcomes demonstrated "good" to "excellent" interrater reliability (ICCs ≥ .84), with the exception of the number of bites (ICCs = .43-.99) and swallows (ICCs = .21-.85). Immediate and delayed intrarater reliability were "excellent" for most raters across all tasks, ranging between ICCs of .63 and 1.00. Exploratory factors potentially impacting reliability included infrequent instances of suboptimal video quality, reduced camera stability, camera distance, and obstruction of the patient's mouth during tasks. Conclusions Subjective observations of oral intake and objective measures taken from the TWST and the TOMASS can be reliably measured via telehealth in clinical practice. Our results provide support for the feasibility and reliability of telehealth for outpatient clinical swallowing evaluations during COVID-19 and beyond. Supplemental Material https://doi.org/10.23641/asha.13661378.

Telehealth for Dysphagia Across the Life Span: Using Contemporary Evidence and Expertise to Guide Clinical Practice During and After COVID-19

Purpose Our aim was to critically review recent literature on the use of telehealth for dysphagia during the COVID-19 pandemic and enhance this information in order to provide evidence- and practice-based clinical guidance during and after the pandemic. Method We conducted a rapid systematized review to identify telehealth adaptations during COVID-19, according to peer-reviewed articles published from January to August 2020. Of the 40 articles identified, 11 met the inclusion criteria. Full-text reviews were completed by three raters, followed by qualitative synthesis of the results and description of practical recommendations for the use of telehealth for dysphagia. Results Seven articles were guidelines articles, three were editorials, and one was a narrative review. One article focused on telehealth and dysphagia during COVID-19. The remaining 10 mentioned telehealth in varying degrees while focusing on dysphagia management during the pandemic. No articles discussed pediatrics in depth. The most common procedure for which telehealth was recommended was the clinical swallowing assessment (8/11), followed by therapy (7/11). Six articles characterized telehealth as a second-tier service delivery option. Only one article included brief guidance on telehealth-specific factors, such as legal safeguards, safety, privacy, infrastructure, and facilitators. Conclusions Literature published during the pandemic on telehealth for dysphagia is extremely limited and guarded in endorsing telehealth as an equivalent service delivery model. We have presented prepandemic and emerging current evidence for the safety and reliability of dysphagia telemanagement, in combination with practical guidelines to facilitate the safe adoption of telehealth during and after the pandemic.

Validation of a Novel Wearable Electromyography Patch for Monitoring Submental Muscle Activity During Swallowing: A Randomized Crossover Trial

Purpose Surface electromyography (sEMG) is often used for biofeedback during swallowing rehabilitation. However, commercially available sEMG electrodes are not optimized for the head and neck area, have rigid form, and are mostly available in large medical centers. We developed an ultrathin, soft, and flexible sEMG patch, specifically designed to conform to the submental anatomy and which will be ultimately incorporated into a telehealth system. To validate this first-generation sEMG patch, we compared its safety, efficiency, and signal quality in monitoring submental muscle activity with that of widely used conventional sEMG electrodes. Method A randomized crossover design was used to compare the experimental sEMG patch with conventional (snap-on) sEMG electrodes. Participants completed the same experimental protocol with both electrodes in counterbalanced order. Swallow trials included five trials of 5- and 10-ml water. Comparisons were made on (a) signal-related factors: signal-to-noise ratio (SNR), baseline amplitude, normalized mean amplitude, and sEMG burst duration and (b) safety/preclinical factors: safety/adverse effects, efficiency of electrode placement, and satisfaction/comfort. Noninferiority and equivalence tests were used to examine signal-related factors. Paired t tests and descriptive statistics were used to examine safety/preclinical factors. Results Forty healthy adults participated (24 women, M _age = 67.5 years). Signal-related factors: SNR of the experimental patch was not inferior to the SNR of the conventional electrodes (p < .0056). Similarly, baseline amplitude obtained with the experimental patch was not inferior to that obtained with conventional electrodes (p < .0001). Finally, normalized amplitude values were equivalent across swallows (5 ml: p < .025; 10 ml: p < .0012), and sEMG burst duration was also equivalent (5 ml: p < .0001; 10 ml: p < .0001). Safety/preclinical factors: The experimental patch resulted in fewer mild adverse effects. Participant satisfaction was higher with the experimental patch (p = .0476, d = 0.226). Conclusions Our new wearable sEMG patch is equivalent with widely used conventional sEMG electrodes in terms of technical performance. In addition, our patch is safe, and healthy older adults are satisfied with it. With lessons learned from the current COVID-19 pandemic, efforts to develop optimal swallowing telerehabilitation devices are more urgent than ever. Upon further validation, this new technology has the potential to improve rehabilitation and telerehabilitation efforts for patients with dysphagia. Supplemental Material https://doi.org/10.23641/asha.12915509.

Dysphagia Care Across the Continuum: A Multidisciplinary Dysphagia Research Society Taskforce Report of Service-Delivery During the COVID-19 Global Pandemic

At the time of writing this paper, there are over 11 million reported cases of COVID-19 worldwide. Health professionals involved in dysphagia care are impacted by the COVID-19 pandemic in their day-to-day practices. Otolaryngologists, gastroenterologists, rehabilitation specialists, and speech-language pathologists are subject to virus exposure due to their proximity to the aerodigestive tract and reliance on aerosol-generating procedures in swallow assessments and interventions. Across the globe, professional societies and specialty associations are issuing recommendations about which procedures to use, when to use them, and how to reduce the risk of COVID-19 transmission during their use. Balancing safety for self, patients, and the public while maintaining adequate evidence-based dysphagia practices has become a significant challenge. This paper provides current evidence on COVID-19 transmission during commonly used dysphagia practices and provides recommendations for protection while conducting these procedures. The paper summarizes current understanding of dysphagia in patients with COVID-19 and draws on evidence for dysphagia interventions that can be provided without in-person consults and close proximity procedures including dysphagia screening and telehealth.

"It Takes a Whole Day, Even Though It's a One-Hour Appointment!" Factors Impacting Access to Pediatric Feeding Services

Feeding disorders can have a significant impact on children and their families. Access to supportive multidisciplinary care is central to improving outcomes; however, there are numerous factors that can impact service access. Using a mixed methods design, the current study examined parents' experiences and satisfaction with accessing a state-wide government-funded tertiary pediatric feeding clinic in Australia. Parents of 37 children (aged 7 weeks to 17 years) participated in the study, residing 6-1435 km from the service. Each completed questionnaires regarding satisfaction (Client Satisfaction Questionnaire-8 Child Services) and costs, and participated in a semi-structured interview. Costs were measured as both direct (e.g., accommodation) and indirect (measured as lost productivity) associated with accessing their feeding appointment. Results revealed parents were highly satisfied with their child's feeding services, but considerable impacts were reported in accessing the service with 85% of the group noting that attending their child's appointment took at least half a day. The total cost per appointment ranged between $53 and $508 Australian dollars. Interviews identified three main barrier themes: distance and travel, impact on daily activities (e.g., work, school), and parent perception of inaccurate representation of their child's feeding skills within the clinic environment. The issues raised were also tempered by an overarching theme of parental willingness to do "whatever was needed" to meet their child's needs, regardless of these barriers. Service providers should be cognizant of the factors that impact access for families and consider alternative service-delivery models where appropriate to help reduce family burden associated with accessing necessary care.

Developing the system architecture for conducting synchronous paediatric feeding assessments via telepractice

Introduction

Telepractice systems should be acceptable to users and meet end-user needs. Whilst the system requirements to conduct adult dysphagia assessments via telepractice are established, key differences exist between adult and paediatric swallowing assessments. This study was conducted to develop the system architecture required to conduct paediatric feeding assessments in patient homes via telepractice.

Methods

The study used a four-phase iterative design, informed by human-centred design principles. In Phase 1, two telepractice researchers and two paediatric feeding clinicians identified assessment tasks and explored potential system design solutions. Initial system testing was completed using clinical simulations (Phase 2). Live trials with 10 typically developing children were then conducted (Phase 3). Phase 4 involved user-centred feedback from clinicians and parents. Feedback from the development team, clinicians and parents was used to continuously refine the model.

Results

A combination of synchronous and asynchronous methods enabled all assessment components to be successfully completed. Clinician and parent feedback established the optimal technology (e.g. phone, tablet) and key camera positions necessary to optimise visual/auditory information for the online clinician. End-user feedback identified greater time efficiencies could be achieved through collecting some data (e.g. intra-oral pictures) via asynchronous methods prior to the session. Information sheets were deemed necessary to enhance the user experience. Clinicians and parents responded positively to the final system design.

Discussion

Modifications to standard videoconferencing were necessary to develop a clinically viable process for conducting paediatric feeding assessments in the home via telepractice. End-user feedback was integral to the design of the final model.

Telehealth for Dysphagia Rehabilitation: The Present and the Future

Dysphagia affects about nine million adults and half a million children annually in the United States alone, and its prevalence is only projected to increase as the baby boomer generation grows older. For many individuals who live in rural or underserved areas, accessing a speech-language pathologist (SLP) with expertise in dysphagia can be challenging. Telehealth appears to be a viable solution to address the needs of individuals living in these areas, and for patients and clinicians with mobility/access limitations. This article provides an overview of the current research evidence in dysphagia telehealth and identifies research and clinical practice gaps as well as potential solutions. Our aim is to provide foundational knowledge for dysphagia clinicians who are interested in entering the telehealth arena.

Case Reports: Trial Dysphagia Interventions Conducted via Telehealth

The diagnosis of dysphagia, defined as swallowing dysfunction or difficulty, is estimated to affect 40–60% of the institutionalized geriatric population, and is the leading cause of aspiration pneumonia, one of the primary contributors of geriatric mortality. In the United States, statistics suggest that at least 50% of these individuals have limited access to treatment due to mobility, distance, and socioeconomic constraints. While “tele-dysphagia intervention” – the delivery of dysphagia therapy services via telecommunications technology – may provide a solution, there is limited research investigating its validity or reliability. The following three case reports of individuals successfully participating in trial tele-dysphagia therapy sessions lend credibility to this service delivery approach, and highlight the need for future research.

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.