Feeding assessment and paediatric dysphagia — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in a general paediatric clinic. A six-year-old with severe cerebral palsy is reviewed for faltering growth and three admissions with pneumonia over the past year. Her parents describe mealtimes lasting over an hour, food refusal and drooling, but no coughing or choking. Her weight has fallen from the twenty-fifth to below the third centile. A bedside feed observed by the speech-language therapist appears quiet and cough-free. The team asks you to interpret the bedside finding, to decide whether aspiration is excluded, to choose and justify an instrumental test, to grade her feeding ability, and to outline the management. You have twelve minutes with the team and five minutes for examiner discussion. [7]

Information available on request

• Six years old, severe cerebral palsy, non-ambulant; three pneumonia admissions in the past year, chronic wet cough between episodes. [7]
• Mealtimes over an hour, food refusal, drooling, no reported coughing or choking with feeds; no cyanosis observed. [3]
• Weight fallen from the twenty-fifth to below the third centile over eighteen months; height centile also falling. [8]
• Bedside feed observed by speech-language therapist: quiet, no cough, no overt distress; some wetness to the voice noted afterwards. [3]
• Eating and Drinking Ability Classification System grade (on request): level four, indicating tube-feeding with limited oral intake. [9]

Tasks

1. Give your interpretation of the cough-free bedside feed and whether aspiration is excluded. Grade your confidence. [3]
2. Choose the instrumental test that best visualises aspiration and explain what it shows. [1]
3. Explain how the Eating and Drinking Ability Classification System informs the risk and the plan. [9]
4. Outline the multidisciplinary management, including the role of enteral feeding. [8]
5. Counsel the family on the outlook and on preserving safe oral feeding for pleasure. [7]

Marking anchors

Must-hit

• Recognises that the cough-free bedside feed does not exclude aspiration, because the clinical feeding evaluation has limited accuracy for detecting aspiration and cannot detect silent aspiration, and that the neurological injury that discoordinates the pharyngeal swallow also blunts the laryngeal cough reflex, so this child is aspirating silently and presenting through the chest and the growth chart. [3] [7]
• Chooses the videofluoroscopic swallow study as the test that best visualises aspiration, explaining that it images the barium bolus in real time and directly shows penetration, aspiration and residue including silent aspiration, which the bedside cannot see. [1]
• Uses the Eating and Drinking Ability Classification System to confirm that a high grade tracks with aspiration risk, and integrates this with the recurrent pneumonia and faltering growth to justify moving to a more intensive feeding plan. [9]

Merit

• Outlines a multidisciplinary plan with the paediatrician, speech-language therapist, dietitian, occupational therapist and physiotherapist, modifying texture on the IDDSI ladder, optimising posture and reflux, securing nutrition, and proceeding to a gastrostomy because oral intake is unsafe and insufficient, while preserving any safe consistency for pleasure; counsels the family that the outlook centres on protecting the lung and the growth. [8] [7]

Fail

• Reassures the family that the cough-free bedside feed excludes aspiration and treats only the pneumonia and the faltering growth without an instrumental study. [3]
• Attributes the recurrent pneumonia to asthma or recurrent infection, or the faltering growth to behaviour or neglect, without asking about the swallow or requesting a swallow study in this high-risk child. [7]