Within the adult population, swallow studies are the gold standard in assessing how safe someone’s swallow is. But when it comes to children, they just aren’t. While swallow studies are a useful piece of the puzzle surrounding whether or not your child is able to swallow food and drink safely, they rarely provide us with an absolute, comprehensive picture of what’s going on during typical mealtimes. So, let’s take a look at how swallow studies are conducted, what kind of insight they provide, and how we ought to interpret their results.
Here we go!
Your child has been referred for a swallow study. They prepare you by suggesting that you bring a hungry child with her favorite cup or bottle, formula, milk, etc. Once you arrive, your child will be brought into a radiology room, placed in a chair, and encouraged to eat/drink. Right off the bat, I bet you can imagine one of the obstacles that’s common in getting a perfect swallow assessment: not only are you in a strange place with strange people and strange machines, but your child asked to perform a task that has not been a positive experience in the past. For many children, the atmosphere alone is overwhelming, not to mention the extra layer of pressure to “get a good picture” of her eating and swallowing. All of this to say, parents would do well to remember that whatever is seen during this process will give insight into that moment in time; it’s not necessarily indicative of what happens every time.
Still, though they have their limitations, swallow studies can be very powerful in determining whether a child is safe to eat and drink independently. They can detect aspiration, residue, and occasionally reflux. They can provide a real time examination of compensatory strategies to improve swallow safety, such as change in position, viscosity changes, and nipple flow levels. These studies can provide an exact suck:swallow:breathe count to determine efficiency and coordination with swallowing. However, although swallow studies help to define the nature of an individual’s dysphagia, they will not tell the whole picture of your child’s swallow, so parents and practitioners alike will benefit from reviewing the results of a swallow study within the context of parental reporting and clinical observations.
Here are a few examples to illustrate my point. The names of my patients have been changed to protect their privacy.
1. Joe was 15 months when he was referred to me for difficulties swallowing solid food, coughing/choking on sippy cups, and struggling to gain weight. I observed him drink diluted apple juice from a valved sippy cup, and immediately noticed signs of an unsafe swallow: a red mottled face, watery eyes, and coughing/sputtering after 3-4 sequential swallows. My clinical impression was that this little one was not safe to drink thin liquids from a sippy cup. So, we worked on finding a viscosity that didn’t cause him to sputter, and as the safety of the drink increased so did his intake: he started drinking more from the sippy cup and became more confident in swallowing solid foods.
A few weeks later he had a swallow study. His mom came into the clinic with a note from the study that said, “PASS! He is safe to drink thin liquids.” As a result, mom and dad stopped thickening his liquids, and (surprise!) he stopped drinking. Upon further investigation of the swallow study report, it was noted that Joe did not “cooperate well” during the study and only 3 single swallows were observed. Of those 3 single swallows, he did not aspirate, hence the recommendation of “safe on thin liquids.” What was not observed during the swallow study, but what I observed multiple times clinically, was that Joe has difficulty with coordinating sequences of swallows. With single sips, he did fine, but when he drank sequentially, the safety of his swallow disintegrates.
In this instance, the swallow study helped us to better understand what he could do with thin liquids (drink a single sip), but a comprehensive assessment of Joe’s swallow required us to look at the whole picture, one that included parental reports as well as clinical observations.
2. Jack was referred to me because he was volume limiting: in other words, he was unwilling to accept enough orally to sustain healthy growth. He was nearing 6 months of age and still only drinking 2-3 ounces per feed. As such, his weight plateaued, and we needed to dig in order to find out why he was taking such small bottles. We asked for a swallow study, and I was lucky enough to accompany Jack’s family to the appointment. What we saw at the study confirmed my suspicions.
Jack was given a 4-ounce bottle of barium, and his swallows looked fantastic for the first 1.5 ounces. The therapist performing the study was ready to stop the study, but I asked to let him keep going for the full feed to see what he did. At the 2-ounce mark, Jack became more uncoordinated in his swallow and a small trace of barium was observed in his airway, indicating microaspiration. This caused Jack to cry out and spit out the bottle. When his mom tried to feed him again, Jack refused.
This is just another illustration of how swallow studies show us a moment in time; they do not show us what happens every time. Had the clinician had stopped the study before Jack reached the 2 oz mark, we would still be left wondering why he was volume limiting. But taking a closer look, within the context of what we knew Jack was doing, we were able to get better direction as to how we could foster safer eating for this little one.
So, if your child is going to have a swallow study, take the results as a piece of their puzzle you are working out to get to the root of their feeding difficulty. Swallow studies are a wonderful tool: they give us insight into what’s happening. But when it comes to children, they do not necessarily provide an absolute answer. To get that, parents must rely on their – and their team’s – observations as well. So lean into your team. Discuss the results of your study, especially if something seems off or inconclusive. See if they match up to what is observed and what they have learned from your child’s feeding difficulty. Don’t hesitate to look at the whole story your child’s feeding experience is telling you. You might just get the answer you’re looking for!
Kathryn Steward, MS, CCC-SLP, Feeding Specialist