Feeding assessment and paediatric dysphagia — formative SAQs

SAQ 1 — The child with cerebral palsy and a cough-free feed (20 marks, ~15 minutes)

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. A bedside feed observed by the speech-language therapist appears quiet and cough-free. [7]

Questions

1. Give the most likely unifying diagnosis and explain why the absence of coughing does not exclude it. (5 marks) [3]
2. Outline the clinical feeding evaluation and state its key limitation. (5 marks) [3]
3. Which instrumental test best visualises aspiration, and what does it show that the bedside cannot? (4 marks) [1]
4. Explain how the Eating and Drinking Ability Classification System helps here. (3 marks) [9]
5. Outline the multidisciplinary management and the role of enteral feeding. (3 marks) [7]

Model answer (must-hit)

1. The most likely unifying diagnosis is oropharyngeal dysphagia with chronic, predominantly silent, aspiration. The absence of coughing does not exclude it because the neurological injury that discoordinates the pharyngeal swallow also blunts the laryngeal cough reflex, so the child aspirates without any outward sign, presenting through the chest with recurrent pneumonia and through faltering growth rather than through mealtime choking. [3]
2. The clinical feeding evaluation plots growth, takes the mealtime history of duration, refusal, drooling and chest symptoms, inspects the oral structures and tone, and observes the child taking age-appropriate consistencies for a delayed pharyngeal trigger, multiple swallows, a wet voice and residue. Its key limitation is that it cannot reliably detect aspiration and cannot detect silent aspiration, because it cannot see the bolus below the vocal cords. [3]
3. The videofluoroscopic swallow study best visualises aspiration. It images the child swallowing barium of several consistencies under X-ray in real time, showing the timing and coordination of the oral and pharyngeal phases and directly visualising penetration, aspiration and residue, including aspiration that is clinically silent at the bedside. [1]
4. The Eating and Drinking Ability Classification System grades how safely and efficiently a child eats and drinks in everyday life on a five-level scale, and its higher levels track closely with aspiration risk, so it both communicates the severity and triages the child toward instrumental assessment and a more intensive feeding plan. [9]
5. The management is multidisciplinary, with the paediatrician, speech-language therapist, dietitian, occupational therapist and physiotherapist modifying texture on the IDDSI ladder, optimising posture, pace and utensils, treating reflux, and securing nutrition. Because oral intake is unsafe and insufficient, a gastrostomy is the appropriate long-term route, preserving any safe consistency for pleasure. [7]