الفهرس 
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Abstract
Dysphagia is a condition in which one or more of the four phases of normal swallowing, namely the oral preparatory, oral propulsive, pharyngeal, and esophageal, are affected. In pediatric patients with dysphagia, aspiration, or inhaling of food, fluids, or even saliva into the lower airway, is possibly the most worrisome finding. In pediatric patients, recurrent respiratory difficulties were strongly linked to laryngopharyngeal penetration and aspiration. Because of the improved survival rates of premature newborns and children with severe medical problems, the frequency of dysphagia in children is on the rise. Pneumonia is a significant health illness that affects children under the age of five years, resulting in high mortality rates of 1-2 million fatalities each year in underdeveloped countries, with pneumonia accounting for around 8% of all pediatric hospitalizations.
The aim of the work is to develop a validated Arabic translated version of PEDI-EAT-10 and MCH-FS swallowing and feeding questionnaires, to be used as good screening tools to predict dysphagia and feeding difficulties in pediatric population. Another aim was to identify dysphagia in pediatric patients with recurrent or acute respiratory problems in terms of phases affected and severity of the swallowing breakdown in these patients. The last aim was to evaluate the effectiveness of management and swallowing rehabilitation among children with respiratory diseases.
This study was conducted on pediatric patients in 3 phases. Phase one included validation of the translated Arabic version of the two questionnaires, assessed on 202 patients with dysphagia and 202 healthy children for PEDI-EAT-10 with FEES scoring for the medical group. Another 160 patients referred to the clinic for feeding problems referred by two nutritionists diagnosing the patient with feeding disorder, another 160 parents of healthy children were asked to fill the MCH-FS questionnaire as control. Phase two was a cross sectional study conducted on pediatric patients with chest infection either acute or recurrent with suspect of dysphagia, attending dysphagia clinic Phoniatrics Unit in ORL department in Alexandria Main University Hospital.
Patients were assessed by PEDI-EAT-10Arabic, MCH-FS Arabic, water swallow test with pulse oximetry, FOIS as screening tools. Swallowing assessment was done then clinically by pre feeding assessment of oral motor structure and function, hydration status, weight, posture and position, cranial nerve assessment, oral pathological reflexes and drooling assessment. Instrumental assessment was then done by both FEES and VFSS. In phase three all patients received rehabilitation by according to the main etiology, swallowing breakdown severity, phases of swallowing affected. Five main lines of treatment were included: Medical treatment, surgical correction, BRAT (Positioning, thermal tactile stimulation of swallow reflex, modification of bolus variables, modification of the manner of feeding, oral sensory motor stimulation, use of adaptive utensils and swallowing manoeuvres), NMES of swallowing or shift to an alternative mode of feeding. After rehabilitation follow up was done 4-6 weeks post therapy which was equivalent to 20+/-2 sessions of rehabilitation by questionnaires, FEES and VFSS, FOIS. Some stopped the rehabilitation at this point and were on follow up schedule for a second and third time by FOIS, assessment of percentage of chest infection after management, only those with unsafe swallow in the last follow up and those on NGT were reassessed by instrumental swallowing evaluation or if they developed another attack of chest infection.
The study proved validity and reliability of both PEDI-EAT-10Arabic and MCH-FSArabic questionnaires with high predictive accuracy of PEDI-EAT-10Arabic of swallowing problems in pediatric population and high predictive accuracy of MCH-FSArabic in predicting feeding disorders in pediatric population. The cross-sectional study revealed 464 pediatric patients fitting the inclusion criteria, minimum age 10 days and maximum age 17 years and 9 months. Mean age of the studied group was 35.6+/-43.7 months and median age was 18 months, with bigger percentage of males. They studied group were further divided according to etiology into neurogenic disorders (41.2%) commonly CP, structural aerodigestive group (35.1%) commonest cause laryngomalacia, followed by GIT group (16.2%) and finally genetic disorders group (7.5%) commonest Down syndrome. Infant’s and adolescent’s main etiology was aerodigestive followed by neurogenic etiology, while toddlers and pre-schooler group and the school aged group commonest etiology was aerodigestive followed by neurogenic group. 42.2 % of the studied population had oral phase affection, 41.6% had premature spillage, 53.4% had delayed trigger of swallow reflex, 0.6% only had PAS score 1 with fluids and 22.4 % had this score with semisolids. Penetration with fluids percentage was 65.5% while with semisolids was 50.9%. Thirty three percent had aspiration with fluids while 26.3% had aspiration with semisolids. Only 22.4% did not have any residue while 59.3% had residue with only one consistency and 18.3% had residue with both consistencies.
Twenty three percent of total sample had chest infection once while 76.9% of the patients had recurrent chest infection. The once chest infection group was mainly had penetration or PAS score 1 while 6.5 % had aspiration. None of this group had oropharyngeal dysphagia.
FOIS had the highest predictive value of aspiration followed by the questionnaires and the least in accuracy in prediction of aspiration was the water the swallow test. Ninety two percent of the studied sample were on medical treatment. Surgical treatment percentage was 11.9%. All of the patients in our study were counselled about adequate positioning and postural techniques, 76.3% of the total sample had thermal tactile stimulation of swallow reflex. Total percentage receiving modification of bolus variables was 51.7% and same percentage received modification of the manner of feeding. Oral sensory motor stimulation was 57.5%. Only 18.1% used adaptive utensils. Six percent of the total sample were on swallowing manoeuvres. Fifty two percent of the sample were on neuromuscular electrical stimulation. Around 48% of the sample were put on alternative mode of feeding NGT or oro gastric tube feeding. There was a significant improvement before and after treatment both clinically by questionnaires and FOIS and instrumental assessment of fluids and semisolids.
Follow up across period of assessment was done at 1 month then 2 months then 3 months. All patients received rehabilitation and did follow up after 4-6 weeks. Only 16.3 % needed more sessions and instrumental assessment in the second follow up while 7.5 % needed 60 sessions and instrumental reassessment in the third follow up. Three-point seven percent had persistent aspiration after rehabilitation and needed more rehabilitation. The 14.4 % who had another attack of chest infection were asked to continue rehabilitation of swallowing to prevent further complications. There was a significant decrease in the percentage of chest infection after management from 100 percent to 14.4 %.
In conclusion, in the present study, the two translated questionnaires were found to be valid and reliable screening tools of pediatric dysphagia and feeding disorders. Pediatric dysphagia is an important factor to be included in the differential diagnosis of patients with chest infection especially if recurrent and if there are any of the symptoms or signs of dysphagia. Swallowing rehabilitation significantly improves patients with chest infections and signs of dysphagia both clinically and in instrumental assessment of swallowing.