Introduction

Oropharyngeal dysphagia can refer to problems with chewing and preparing food, transporting a bolus from the oral cavity to the back of the tongue, moving food into the esophagus, or unsafe and inefficient swallowing [1]. The term oropharyngeal dysphagia is not commonly used in pediatric populations as oropharyngeal and esophageal dysfunction are intrinsically linked in this population [2]. Swallowing dysfunction in the general population has been linked to poorer patient outcomes including higher rates of malnutrition [3], higher mortality rates [4, 5], increased medical complications [6, 7], longer hospitalisations [4, 7, 8], poorer immune responses [6], higher support required post hospital discharge [6, 7], and overall poorer quality of life (QoL) [4, 6]. In addition to the poor health outcomes that are associated with swallowing difficulties, pediatric populations, face physical, and developmental challenges if their nutritional and caloric intake is not sufficient [9–13].

In addition to swallowing difficulties, children may also be at risk of reduced nutrition and caloric intake due to feeding difficulties. Feeding difficulties in pediatrics may be broadly defined as difficulties eating adequately which may result in reduced absorption or consumption of food, impacting on physical and/or psychosocial function [14]. Feeding difficulties in children or infants have been associated with negative parent–child interactions, anxiety, stress, social avoidance, and specific fears (phobias) [15–18].

Studies have previously estimated that around 20–45 % of parents within the general population report that their children have some form of feeding or swallowing difficulty [19–22], and that between 3 and 10 % of children have significant swallowing or feeding difficulties resulting in significant health or developmental consequences [23]. Swallowing and feeding difficulties are also projected to increase due to improved survival rates of infants born prematurely or with complex medical conditions [19]. Given the high rates of swallowing and feeding difficulties and the negative consequences of these conditions, it is important to use assessments with sound psychometric properties in order to support early identification and optimize treatment outcomes [19, 24–28]. Current evidence for swallowing and feeding difficulties in pediatric populations recommends the use of a multidisciplinary team approach for both conducting comprehensive assessments and delivery of interventions [19, 25, 29]. The use of videofluoroscopy and fiberoptic endoscopic evaluation of swallowing to assess swallow function (or dysfunction) is well supported in the literature [6, 27–31]. However, there is a lack of discussion and support for the use of standardized, psychometrically sound measures of swallowing or feeding function, such as non-instrumental assessments, which can augment or serve as alternatives to instrumental assessment in order to reduce unnecessary cost and the use of invasive procedures [32–36].

This systematic review is a first step in addressing the need to identify and report on the characteristics of non-instrumental assessments in the areas of both pediatric swallowing and feeding functions that are available to clinicians. The terms swallowing and feeding function (i.e., normal swallowing and feeding) and swallowing and feeding dysfunction (i.e., swallowing and feeding difficulties or disorders) are used throughout this manuscript and include behavioral aspects of feeding.

Methods

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [37]. A systematic literature search was conducted using Medline and Embase online databases (Table 1). From this search, all appropriate journal abstracts up to June 2013 were included. Both databases were searched using medical subject headings (MeSH) or Thesaurus terms and free text. Two independent abstract reviewers selected abstracts and original publications of non-instrumental assessments according to the inclusion and exclusion criteria as described in Table 2. Reference lists of included articles were also searched for further publications and assessments. Eligibility of publications was appraised independently by both reviewers; consensus was reached through discussion where there was disagreement on eligibility.

Table 1 Search strategy: pediatric swallowing or feeding assessment
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Table 2 Inclusion and exclusion criteria for abstract and original article selection
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The non-instrumental assessments were then identified by searching for the original, first publication that described the selected assessment, and when this failed, by contacting the authors directly. To ensure that the search was comprehensive, well-known publishers for assessment tools and textbooks around the topic of pediatric swallowing or feeding were also searched so as to capture relevant assessments that have been published in sources other than research databases. The assessments were then considered for eligibility according to inclusion and exclusion criteria as listed in Table 3. For assessments to be included, they were required to (a) have at least 50 % of the items related to swallowing or feeding; (b) be designed for use with pediatric populations; and (c) needed to be of a non-instrumental assessment design (i.e., the assessment was not used in instrumental assessment processes or for retrospective video assessment). Guidelines for clinicians for case history taking and surveys were excluded. Eligibility of these assessments and analysis of the characteristics and assessment domains were independently appraised by two reviewers, who again reached consensus through discussion. Figure 1 provides an overview of the process of inclusion according to the PRISMA flow diagram [39].

Table 3 Inclusion and exclusion criteria for assessments
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Fig. 1
figure 1

Flow diagram of the reviewing process according to PRISMA. Study flow diagram showing the process of inclusion for assessments. The flow diagram follows the structure as recommended by PRISMA [39]

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Results

Systematic Literature Search

The systematic searches in Medline and Embase yielded 2201 records. A total of 76 original non-instrumental assessments were retrieved from the database, publisher, and textbook searches and the reference lists of the included articles. The assessments were evaluated using the inclusion criteria for assessments (Table 3).

Of the 76 assessments, 46 were excluded as they did not meet the inclusion criteria (see Table 4). The 46 assessments were excluded for the following reasons: 27 were excluded as less than 50 % of the assessment items were not related to feeding and/or swallowing; 6 assessments did not assess the target population of children or infants; and 13 assessments were excluded as they did not meet the requirements for non-instrumental assessments. A total of 30 non-instrumental assessments were identified as meeting all inclusion criteria as they investigated feeding or swallowing function in children of various aetiologies in various domains of feeding or swallowing functioning (see Table 5).

Table 4 Overview of excluded non-instrumental assessment tools for swallowing and feeding function in children (n = 46)
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Table 5 Overview of included non-instrumental assessment tools for swallowing and feeding function in children (n = 30)
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Respondents and Assessment Style

The assessments were designed to be completed by two types of respondents: caregivers (Table 6) or clinicians (Table 7). Of the 30 included assessments, 11 were identified as caregiver assessments; 9 of which took a case history style approach to asking questions and two focused on observation instead (Table 6). Eighteen assessments were designed to be completed by clinicians; these assessments all used clinical observations of swallowing or feeding function or set clinical tasks (Table 7). One assessment could be completed by either caregivers or clinicians and utilised a case history style of assessment (Table 8).

Table 6 Characteristics of non-instrumental assessment tools for swallowing and feeding function in children: Completed by parents/caregivers (n = 11)
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Table 7 Characteristics of non-instrumental assessment tools for swallowing and feeding function in children: Completed by clinicians (n = 18)
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Table 8 Characteristics of non-instrumental assessment tools for swallowing and feeding function in children: Completed by parents/caregivers or clinicians (n = 1)
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Target Populations

While all assessments were developed to investigate swallowing or feeding function in pediatric populations, various target groups (including diagnostic and age groups) were identified (Tables 6, 7 and 8). Nine assessments were developed to assess the swallowing and feeding difficulty of infants and children from birth to 2 years with no specific illness: Clinical Evaluation of Pediatric Dysphagia [40], Clinical Feeding Evaluation of Infants [82], Clinic/Bedside Oral-Sensorimotor Feeding Assessment Worksheet [81], Developmental Pre-Feeding Checklists [65], Early Feeding Skills Assessment (EFS) [84], Oral Motor and Feeding Evaluation [77], Pediatric Dysphagia Clinical Evaluation [68], Schedule for Oral Motor Assessment (SOMA) [98], and Systematic Assessment of the Infant at Breast (SAIB) [100]. Three assessments were developed to assess swallowing and feeding function in infants born prematurely: Feeding Questionnaire [88], Neonatal Oral-Motor Assessment Scale (NOMAS) [92], and Preterm Infant Breastfeeding Behavior Scale (revised) (PIBBS) [97]. One assessment was specifically developed to investigate infants (of unspecified gestational ages) with severe swallowing and feeding difficulties: Pediatric Assessment Scale for Severe Feeding Problems (PASSFP) [95].

Six assessments were developed to assess children with no specified illnesses other than having potential swallowing or feeding difficulties: Behavior Focused Feeding Assessment [76], Brief Assessment of Motor Function (Oral Motor Deglutition scale) (BAMF-OMD) [78], Children’s Eating Behavior Inventory (CEBI) [80], Feeding Strategies Questionnaire [89], Mealtime Behavior Questionnaire [90], and Parental Feeding Questionnaire [94]. Three assessments were developed to assess swallowing or feeding difficulties in children with autism spectrum disorders (ASD) as the target population: BAMBI, Eating Profile [85], and Screening Tool of Feeding Problems, modified for children (STEP-Child) [99]. Four assessments were developed to assess swallowing and feeding difficulties in children with cerebral palsy (CP) or other neurological conditions as the target populations: Feeding and Swallowing Questionnaire [86], Multidisciplinary Feeding Profile (MFP) [91], Oral Motor Assessment Scale (OMAS) [93], and Pre-Speech Assessment Scale (PSAS) [96]. Two assessments were developed to assess swallowing or feeding function in children with “developmental delay” as the target population: behavioral assessment scale of oral functions in feeding (BASOFF) [77] and Dysphagia Disorder Survey (DDS) [83]. One assessment was developed to assess swallowing or feeding difficulties in children with chronic illnesses as the target population: About Your Child’s Eating (AYCE) [75], and one assessment was developed to assess swallowing or feeding difficulties in children with phenylketonuria as the target population: Feeding Assessment [87].

Age ranges for all the assessment varied greatly, ranging from birth of premature infants to adults (Fig. 2). Twelve assessments targeted infants and children between birth and 2 years of age (only); a time where typically developing children are still developing their ability to swallow and feed [1]: Clinical Evaluation of Pediatric Dysphagia, Clinical Feeding Evaluation of Infants, Developmental Pre-Feeding Checklists, EFS, Feeding Questionnaire, NOMAS, Oral Motor and Feeding Evaluation, PASSFP, PSAS, PIBBS, SOMA, and SAIB. Seven assessments investigated swallowing and feeding function in a range of ages beginning within 0–2 years and continuing up to childhood or adulthood: BASOFF, BAMF- OMD, Clinic/Bedside Oral-Sensorimotor Feeding Assessment Worksheet, Feeding and Swallowing Questionnaire, Feeding Assessment, Parental Feeding questionnaire, and Pediatric Dysphagia Clinical Evaluation. Finally, 11 assessments investigated swallowing or feeding function in populations with ages beginning in early childhood and extending through to middle childhood or up to adulthood: Behavior Focused Feeding Assessment, BAMBI, CEBI, Eating Profile, Feeding Strategies Questionnaire, Mealtime Behavior Questionnaire, OMAS, AYCE, DDS, MFP, and STEP-Child.

Fig. 2
figure 2

Overview of non-instrumental assessment tools for swallowing and feeding function in children: Age ranges are shown for each assessment. Arrows indicate assessments with age ranges extending higher than 18 years. Where no specific ages were given, the terms used within the text have been provided (where possible) and estimates of appropriate ages have been given according to the authors’ discretion

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Assessment Design

There were many different response options used in the assessments including binary scoring, ordinal scales, ratio scales, visual analogue scales (VAS), questions with multiple options, and open questions; 17 of the 30 assessments used a combination of multiple response options (Tables 6, 7, 8). The length of assessments also varied; one assessment consisted of a single scale and seven items (OMAS), while another had 12 subscales and 157 items (Eating Profile) (Tables 6, 7, 8). Twenty-three of the 30 assessments did not specify the time required to administer the assessment; however, the administration times that were reported ranged from 5 min (BAMF-OMD and PASSFP) to 2 ½–3 h (PSAS).

Table 9 Overview of non-instrumental assessment tools for swallowing and feeding function in children: Assessment domains
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Scoring

Six assessments provided instruction for scoring and were designed with cut-off scores to distinguish between normal versus abnormal swallowing or feeding function: Mealtime Behavior Questionnaire, OMAS, PSAS, PASSFP, SOMA, and STEP-Child. Sixteen of the 30 assessments used qualitative descriptors rather than a numerical scoring system: Behavior Focused Feeding Assessment, Clinical Evaluation of Pediatric Dysphagia, Clinical Feeding Evaluation of Infants, Clinic/Bedside Oral-Sensorimotor Feeding Assessment Worksheet, Developmental Pre-Feeding Checklists, Eating Profile, EFS, Feeding and Swallowing Questionnaire, Feeding Assessment, Feeding Questionnaire, NOMAS, Oral Motor and Feeding Evaluation, Parental Feeding Questionnaire, Pediatric Dysphagia Clinical Evaluation, PIBBS, and SAIB. The remaining eight assessments provided no instruction for interpretation of the results.

Assessment Domains

The following assessment domains were identified: oral motor skills, behaviors related to swallowing or feeding function, environmental factors related to functional swallowing and feeding, physical swallowing or feeding skills, QoL in relation to swallowing or feeding difficulties, and sensory aspects of swallowing or feeding function (Table 9). Twenty-three assessments included items specific to the domain of swallowing or feeding skills, 17 assessments included items specific to oral-motor skills, 10 included items specific to behavioral aspects of swallowing or feeding, six included items specific to environmental aspects of swallowing and feeding, five included items related to sensory aspects of swallowing or feeding, and two included items specific to QoL aspects of swallowing or feeding. Twenty-three of the 30 assessments covered more than one domain, with two of the assessments covering four of the six domains.

Discussion

Variations Among Assessments

The swallowing and feeding assessments included in this review demonstrated variability in terms of target populations, the design of each assessment, and the assessment domains. This variation likely reflects the need to capture a wide range of children with swallowing or feeding difficulties across multiple domains (e.g., a combination of behavioral and sensory difficulties) and who have multiple risk factors (e.g., neurological conditions and a developmental disorder) [27, 101]. As a result, the variation among these assessments reflects the diversity and complexity of the target populations and is also likely to reflect the diversity of both the professionals involved and their clinical settings, each with their unique approach to clinical practice and resource restrictions (such as availability of time, equipment, or finances).

Validity and Reliability

The aim of this report was to provide clinicians with an overview of a broad range of non-instrumental swallowing and feeding assessments. While this manuscript does not investigate the psychometric quality of the assessments, the review of the assessments made it apparent that there is a proliferation of feeding assessments that have been developed for infants and children with limited research investigating the quality of the psychometric properties of these assessments. This gap became apparent with the lack of information available to support standardized interpretation of many of the assessment scores, and also in a lack of consideration for validity and reliability of many of the assessments during their development.

It is also concerning to note that many assessments within this review appear not to have been assessed for validity and reliability within the populations they are being used, raising the question as to whether they should be used at all. A recent psychometric review has been conducted on the quality of psychometric properties of measures assessing swallowing function in children with CP and other neurological conditions [30]. However, more research is needed to cover areas of swallowing and/or feeding function in other populations. It is recommended that further evaluation of the quality of psychometric properties of these assessments is to be performed using a standardized appraisal tool that is valid and reliable itself, such as the consensus‐based standards for the selection of health measurement instruments (COSMIN) in order to inform clinicians about the reliability and validity of the assessments that they use [102, 103].

With so little research into the reliability and validity of existing assessments, it would be beneficial to prioritise research on developing the psychometric characteristics of existing assessments to build this area of research to a higher, more rigorous, and evidence-based standing. Selecting the most robust clinical assessments based on the quality of its psychometric properties will result in more sound clinical reasoning, selecting appropriate interventions based on valid and reliable assessment scores, and greater confidence in documenting clinical progress and changes over time [104].

Conclusion

Many non-instrumental assessments are available to clinicians to evaluate swallowing and feeding function in pediatric populations. These assessments vary widely in design, assessment domains, and target groups or populations. A lack of instruction for use and interpretation of assessment scores was evident, indicating that many of these assessments may be at risk for inconsistent use and misinterpretation of results. This review highlights characteristics of the assessments for clinicians to support them in selecting appropriate assessments for clinical practice. This paper also highlights the need for future research to comprehensively evaluate the quality of psychometric properties of the retrieved assessments as many tools appeared to lack robust data on their reliability and validity. As the use of assessments without known psychometric properties may result in outcome data that are not evidence-based and cannot be interpreted correctly, a psychometric review will assist in guiding future choices in the assessment and treatment planning.