RETURN TO ABSTRACT LISTING


Background
Radiologist involvement in the modified barium swallow study is common and often learned early in residency. In adults, dysphagia often occurs from muscular deconditioning or pathologies, related to obstructive lesions and/or associated therapies such as radiation or surgery. General radiologists are less likely to be involved in pediatric modified barium swallow studies, which are often performed predominantly with liquids of variable consistencies, with speech pathologists who have special training and expertise in pediatric dysphagia. Likewise, not all children's hospitals require the involvement of a radiologist during the examination. This educational exhibit describes the approach to the pediatric modified barium swallow study with respect to substances used, descriptions of abnormalities encountered, and recommendations provided by speech therapists using the study as a guide. Institution-specific protocols are depicted as a prototype for use at other facilities that may or may not have dedicated pediatric speech pathologists.

Educational Goals / Teaching Points
Orally administered consistencies are outlined with mapping of commonly accepted consistency terminology to commercially-available barium products used for children. Pediatric upper aerodigestive anatomy is shown. Oral, pharyngeal, and esophageal phases of the swallow mechanism are described with respect to specific pathologic processes in the pediatric population. The 8-point Penetration-Aspiration Scale (PAS) is defined. The Dysphagia Outcome and Severity Scale (DOSS) is detailed. Speech pathology recommendations for children are included with correlation to abnormalities encountered at specific phases of the swallow study are described with guidance from a speech pathologist trained in pediatric dysphagia.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
At our institution, regulations require that a physician perform fluoroscopy examinations on children. The International Dysphagia Diet Standardization Initiative describes a continuum of 8 consistencies in which drinks are scored from 0 to 4 and foods are measured from 3 to 7. Consistency is standardized using the flow rate through a 10-mL syringe, and commercially-available barium products denoted as honey and nectar consistency are mapped to the liquids scored 0 - 4 via standardized means. These consistencies are correlated to institution-wide accepted formula consistencies per policy and used in coordination with the modified barium swallow studies reviewed in real time by the radiologist and the speech pathologist. A pediatric-specific chair is required for young children. The 8-point PAS includes 4 levels (2 - 5) that describe penetration and 3 levels (6 - 8) that indicate aspiration at different severities. Dietary recommendations are described based on clinical scenarios.

Conclusion
There is more to the modified barium swallow study than just the determination of penetration and/or aspiration. Understanding the speech pathologist's approach to diagnosis and treatment of pediatric dysphagia is important for radiologists who provide supervision for pediatric modified barium swallow studies.