This article was published in Advance for Speech-Language Pathologists, November, 2004 , Vol. 14 •Issue 45 • Page 10. Advance gave permission to re-post. Original article can be accessed at:http://speech-language-pathology-audiology.advanceweb.com/Article/Fees-in-Pediatrics.aspx
Since Susan Langmore developed fiberoptic endoscopic evaluation of swallowing (FEES) in 1988, the use of endoscopy for the identification of oropharyngeal swallowing disorders has grown tremendously. The efficacy of the method is shown in the literature to correlate highly with videofluoroscopy in adults and pediatrics, providing the clinician with an additional objective evaluation to gain information.1-3 Several considerations must be made and questions raised when adapting the FEES exam for pediatric use.
The FEES exam offers several advantages, such as portability, flexibility with regards to positioning, time and length of exam, and, especially important for children, avoidance of exposure to radiation. While the FEES exam is an invasive procedure, it can be performed successfully with careful preparation and appropriate screening for candidacy.
Thus far, FEES has largely been used for adult patients in a variety of settings, including inpatient, outpatient and nursing homes. The use of nasoendoscopy for swallowing assessment is expanding into the infant and pediatric population. In some facilities the exam is performed by a physician who physically passes the scope while a speech-language pathologist feeds the child and interprets the exam. In other facilities the speech pathologist is independent in the passage of the endoscope and interpretation of the examination.
This leaves an important question for the speech-language pathologist. Should we, as clinicians, be passing the scope independently on pediatric and infant patients? Do we need the assistance of a physician?
At University of North Carolina (UNC) Hospitals, in Chapel Hill, we have successfully developed a training protocol for competency for our clinicians to perform pediatric FEES exams. The protocol includes both independent scope passage and interpretation by the speech-language pathologist. The suggested training to acquire competency includes participation in a FEES course and initial observation of the exam, followed by six scope passes on normal volunteers and 25 supervised scope passes on adult patients. The clinician then must observe five pediatric FEES and pass the scope on five pediatric patients with supervision from a privileged endoscopist. When we originally developed the protocol, we worked with our pediatric ENTs to gain experience with scope passing on infants and children.
The speech-language pathologist should have a thorough understanding of normal pediatric anatomy and function. “Knowledge of normal and abnormal velopharyngeal and laryngopharyngeal anatomy, as well as a thorough understanding of the developmental changes that occur in the swallowing process as the child matures, is key to successful implementation of FEES in pediatric patients,” according to C.J. Hartnick et al.4
One of the key differences we have encountered with our pediatric exams is that they require two people: a speech-language pathologist to pass the scope and someone to feed the child. This is unlike adult FEES, which often can be done independently by the clinician. The speech-language pathologist performing FEES on a pediatric patient requires assistance to stabilize the child to prevent him or her from pulling out the endoscope as well as a caregiver or experienced feeder to assist with feeding a potentially difficult feeder. Passage of the endoscope can be more difficult because of the smaller size of the nasal passages.4
Key considerations in the Pediatric FEES Protocol are equipment, reducing anxiety about the exam, feeding utensils, timing of the exam, increasing cooperation, positioning, observation, interpretation and special populations. The examination protocol should be modified to reflect the age and size of the child, the current and age-appropriate diet, and potential to tolerate the scoping process as well as willingness to eat orally with a scope passed transnasally. FEES equipment includes a pediatric endoscope and a standard FEES cart, which consists of a monitor, VCR, light source, camera and scope.
Parents, caregivers and older children should be educated about the procedure. Anxiety about the test may be decreased by exposing the patient to the examiners, doing the test in familiar surroundings, sitting the child on a parent’s lap, using distraction during portions of the exam, decreasing observers in the room, and giving the young patients control over some aspects of the exam, such as the choice of foods and who feeds them.5 Concerning feeding utensils, the study may include various nipples, utensils and consistencies deemed age or developmentally appropriate. Regarding timing of the exam, it may be helpful to withhold feeds two to four hours prior to the study to maximize hunger, feeding readiness and cooperation during the examination. Providing stimulus rewards such as verbal praise, clapping, bubbles, etc., to toddlers in order to increase acceptance of food and participation may be helpful and necessary to increase cooperation.
A benefit of FEES is being able to place children in their typical feeding position. Standard infant feeding positions include semi-upright or side-lying and require head, neck and trunk support. Older children typically are positioned upright. However, positioning may be dependent upon a child’s medical status, diagnosis and overall motor control.
The laryngeal and pharyngeal anatomy should be viewed prior to feeding with normal respiration. The initial suck/swallow/breathe sequence for infants should be viewed and typically will show a rapid sequence of swallows and white-outs (when the epiglottis obstructs the view). The feeder can use non-nutritive sucking in order to clear the pharynx, slow the flow rate, or impose breaks for the patient or to improve the view. The patient can be monitored for fatigue throughout the feeding session. All of these suggestions should be modified to meet the individual needs of a child.
As with all FEES procedures, aspiration before the swallow can be detected in real time. Evidence of aspiration during the swallow can only be inferred. The suck/swallow/breathe sequence is in constant motion for the infant who is sucking from a nipple with a continuous flow. Thus, the white-out period seen during the swallows is frequent due to the motion of the epiglottis.
This means the clinician primarily is observing coordination, rhythmic patterns, and whether penetration/aspiration is present at rest periods or imposed breaks. If the infant or child cries when the nipple is pulled away, there may be some difficulty with maintaining scope positioning and a clear view.
At this point, non-nutritive sucking may be helpful to re-establish a view of the laryngeal vestibule and vocal cords. Aspiration of secretions also can be seen and must be carefully analyzed, given that many times infants will build secretions with scope passage. The secretions sometimes sit within the laryngeal vestibule, making it difficult to distinguish pathological vs. normal conditions. The best method of delineating pathological vs. normal secretions seems to be based on the infant’s ability to rapidly clear the secretions reflexively with a sneeze or cough or through non-nutritive sucking.
Of course, not every child will tolerate a FEES exam because it is an invasive procedure. The most successful populations to perform FEES with, we have found, are in the NICU setting and among infants in general. The exam is performed at a feeding time, hunger often equates tolerance for the scope, and our physicians appreciate not having to transfer the infants to radiology. An added benefit is that we get a look at the child’s airway, which we then can share with our ENTs and pulmonologists when necessary.
Special consideration should be given to infants with NG tubes in place. Because young infants are nasal breathers during the feeding process, compromised breathing may result from a NG tube in one nares and an endoscope in the other. Removal of the NG tube may allow for a more successful exam.
Children ages 1-3 should be assessed for candidacy on an individual basis. This may include medical and cognitive status, cooperation level, and need for the exam. Toddlers over age 3 also can be good candidates for the FEES exam with careful preparation, which may include medical play therapy or discussion beforehand about the test.
The case of Baby B demonstrates how effective the FEES procedure can be. Baby B was a 3-month-old former preemie, fed via NG tube and oral feeds, who demonstrated aspiration during the swallow on two modified barium swallow exams. It was clear that she was aspirating a moderate amount during the swallow but unclear as to why.
She did not have a neurological diagnosis, appeared to have normal tone, and was eager to suck. A fiberoptic exam quickly revealed the problem: she had a polyp sitting above the upper esophageal sphincter (UES), most likely from chronic NG tube placement, that was funneling liquid into her airway. The polyp was not visible on X-ray. It was removed, and she was able to eat successfully without aspirating.
Currently, guidelines covering the topic of speech-language pathologists passing the scope are directed by individual states. In addition, the American Speech-Language-Hearing Association (ASHA) is in the process of writing guidelines on the subject of FEES.
The answer to the question of whether the speech-language pathologist should pass the scope on infants and children is yes, if your state allows speech-language pathologists to do so. Proceed with caution, get the proper training, and you will expand your ability to diagnose and treat these often complex and intriguing patients.
- Leder, S.B., Karas, D.E. (2000). Fiberoptic endoscopic evaluation of swallowing in the pediatric population, 1132-1136. Laryngoscope.
- Willging, J.P., Miller, C.K., Hogan, M.J., Rudolph, C.D. (1996). Fiberoptic endoscopic evaluation of swallowing in children: A preliminary report of 100 procedures. Dysphagia, 11: 2.
- Miller, C.K., Willging, J.P., Strife, J.L., Rudolph, C.D. (1994). Fiberoptic endoscopic examination of swallowing in infants and children with feeding disorders. Dysphagia, 9 (4): 266.
- Hartnick, C.J., Hartley, B.J., Miller, C., Willging, J.P. (2000). Pediatric fiberoptic endoscopic evaluation of swallowing. Annals of Otology, Rhinology & Laryngology, 109: 996-99.
- Migliore, L.E., Scoopo, F.J., Robey, K.L. (1999). Fiberoptic examination of swallowing in children and young adults with severe developmental disability. American Journal of Speech-Language Pathology, 8: 303-08.
Key Considerations for Training
• Become a privileged adult endoscopist first.
• Use a pediatric scope.
• Know normal anatomy and physiology of infants and children.
• Know normal oropharyngeal patterns in pediatrics.
• Choose patients very carefully.
• Train under an ENT or other experienced pediatric endoscopist.
• Follow protocol for scope passing and interpretation.
You can reach Krisi Brackett through this blog.
Brian Kanapkey is coordinator of the Voice Restoration and Swallowing Disorders Clinic at the University of North Carolina Hospitals ENT Clinic. He is also an adjunct faculty member in the Division of Speech and Hearing Sciences at UNC-Chapel Hill. He focuses on patients with laryngectomy/TEP, adult swallowing disorders and pediatric FEES. He can be contacted at (919) 966-8048 or by e-mail at firstname.lastname@example.org.