Telehealth voice assessment by speech language pathologists during a global pandemic using principles of a primary contact model: an observational cohort study protocol.

INTRODUCTION: SARS-CoV-2, a highly contagious severe acute respiratory syndrome, has spread to most countries in the world and resulted in a change to practice patterns for the assessment and diagnosis of people with voice disorders. Many services are transitioning to telehealth models to maintain physical distancing measures and conserve personal protective equipment used by healthcare workers during laryngoscopy examinations. The speech-language pathology primary contact (SLPPC) assessment for patients referred to ear, nose and throat (ENT) services in Australia has been shown to reduce waiting times for assessment while streamlining access to ENT assessment and allied health practitioner treatment pathways. METHODS AND ANALYSIS: A prospective observational cohort study will see patients in a newly developed telehealth model which uses the principles from a usual care SLPPC assessment protocol. Participants will be offered an initial telehealth assessment (speech-language pathology primary contact telehealth (SLPPC-T)) prior to being prioritised for a face-to-face laryngoscopy assessment to complete the diagnostic process. The telehealth assessment will collect sociodemographic information, personal and family medical history, key symptoms, onset and variability of symptoms, red-flag signs or symptoms for laryngeal malignancy, and clinical voice assessment data for auditory-perceptual and acoustic analysis. The study outcomes include (1) association of signs, symptoms and specific voice measures collected during SLPPC-T with voice disorder classification provided after laryngoscopy; (2) degree of concordance between voice disorder classification after SLPPC-T and after laryngoscopy; (3) health service and patient-related costs and health outcomes of the SLPPC-T; (4) patient and stakeholder views and beliefs about the SLPPC-T process. ETHICS AND DISSEMINATION: Ethical approval has been granted prior to commencement of the study enrolment by the Gold Coast Hospital and Health Service Human Research Ethics Committee (reference number HREC/2020/QGC/62832). Results will be shared through the publication of articles in peer-reviewed medical journals and presentation at national and international scientific meetings. TRIAL REGISTRATION NUMBER: ACTRN12621000427875.

Outcomes of a multidisciplinary Ear, Nose and Throat Allied Health Primary Contact outpatient assessment service.

BACKGROUND: Traditionally, patients are seen by an ear, nose and throat (ENT) surgeon prior to allied health referral for treatment of swallowing, voice, hearing and dizziness. Wait-times for ENT consultations often exceed those clinically recommended. We evaluated the service impact of five allied health primary contact clinics (AHPC-ENT) on wait-times and access to treatment. SETTING: A metropolitan Australian University Hospital Outpatient ENT Department. PARTICIPANTS: We created five AHPC-ENT pathways (dysphonia, dysphagia, vestibular, adult and paediatric audiology) for low-acuity patients referred to ENT with symptoms of dysphonia, dysphagia, dizziness and hearing loss. MAIN OUTCOME MEASURES: Using multiple regression analysis, we compared waiting times in the 24-month pre- and 12-month post-implementation of the AHPC-ENT service. In addition, we measured the number of patients requiring specialist ENT intervention after assessment in the AHPC-ENT, adverse events and evaluation of service delivery costs. RESULTS: Seven hundred and thirty-eight patients were seen in the AHPC-ENT over the first 12 months of implementation (dysphagia, 66; dysphonia, 153; vestibular, 151; retro-cochlear, 60; and paediatric glue ear, 308). All pathways significantly reduced the waiting times for patients by an average of 277 days, compared with usual care. The majority of patients were able to be discharged without ongoing ENT intervention (72% dysphagia; 81% dysphonia; 74% vestibular; 53% retro-cochlear; and 32% paediatric glue ear). No adverse events were recorded. CONCLUSIONS: The AHPC-ENT improved waiting times for assessment and access to treatment. Future research on cost-effectiveness and diagnostic agreement between AHPs and ENT clinicians would provide further confidence in the model.

Clinical feeding examination with cervical auscultation for detecting oropharyngeal aspiration: A systematic review of the evidence.

BACKGROUND: Cervical auscultation (i.e. listening to swallowing sounds) is the most commonly used technique in adjuvant to the clinical feeding examination by speech-language pathologists worldwide to assess for oropharyngeal aspiration risk in children. Despite its relative popularity in clinical practice, little is known on the clinical utility of cervical auscultation within a paediatric population. OBJECTIVE: To determine the diagnostic test accuracy of the clinical feeding examination with cervical auscultation in the detection of aspiration in children. TYPE OF REVIEW: Narrative review. Prospero Registration: CRD42017081467 Search strategy: Medline/Pub Med, Embase, CINAHL, AustHealth, Cochrane and UQ (Scopus) were searched up until October 2017. Specifically, the search terms used were: (((oropharyngeal OR respiratory) aspiration) AND (child* OR pediatr* OR paediatr*) and (cervical auscultation OR swallow sounds OR swallowing sounds OR accelerometry OR swallowing acoustics)). The search strategy also included scanning reference lists and citations of retrieved studies. EVALUATION METHOD: Extracted studies were reviewed by two independent reviewers. Methodological quality of studies was assessed using the QUADAS-2 tool. RESULTS: Only one study met inclusion criteria for this review, which had a bias for flow and timing. Use of cervical auscultation in conjunction with the clinical feeding examination to predict aspiration had a positive predictor value (PPV) of only 0.49 (0.31-0.66), indicating potential over-prediction of aspiration when cervical auscultation is used. In contrast a high NPV of 0.92 (0.78-0.98) was reported indicating that cervical auscultation is useful at ruling out aspiration in children. CONCLUSION: This review highlights the paucity of research studies assessing the accuracy of cervical auscultation as an adjuvant to the clinical feeding examination in aspiration detection within the paediatric population.

PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy.

OBJECTIVES: Cerebral palsy (CP) remains the world's most common childhood physical disability with total annual costs of care and lost well-being of $A3.87b. The PREDICT-CP (NHMRC 1077257 Partnership Project: Comprehensive surveillance to PREDICT outcomes for school age children with CP) study will investigate the influence of brain structure, body composition, dietary intake, oropharyngeal function, habitual physical activity, musculoskeletal development (hip status, bone health) and muscle performance on motor attainment, cognition, executive function, communication, participation, quality of life and related health resource use costs. The PREDICT-CP cohort provides further follow-up at 8-12 years of two overlapping preschool-age cohorts examined from 1.5 to 5 years (NHMRC 465128 motor and brain development; NHMRC 569605 growth, nutrition and physical activity). METHODS AND ANALYSES: This population-based cohort study undertakes state-wide surveillance of 245 children with CP born in Queensland (birth years 2006-2009). Children will be classified for Gross Motor Function Classification System; Manual Ability Classification System, Communication Function Classification System and Eating and Drinking Ability Classification System. Outcomes include gross motor function, musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function, communication difficulties, oropharyngeal dysphagia, dietary intake and body composition, participation, parent-reported and child-reported quality of life and medical and allied health resource use. These detailed phenotypical data will be compared with brain macrostructure and microstructure using 3 Tesla MRI (3T MRI). Relationships between brain lesion severity and outcomes will be analysed using multilevel mixed-effects models. ETHICS AND DISSEMINATION: The PREDICT-CP protocol is a prospectively registered and ethically accepted study protocol. The study combines data at 1.5-5 then 8-12 years of direct clinical assessment to enable prediction of outcomes and healthcare needs essential for tailoring interventions (eg, rehabilitation, orthopaedic surgery and nutritional supplements) and the projected healthcare utilisation. TRIAL REGISTRATION NUMBER: ACTRN: 12616001488493.

Relationship between brain lesion characteristics and communication in preschool children with cerebral palsy.

BACKGROUND: MRI shows promise as a prognostic tool for clinical findings such as gross motor function in children with cerebral palsy(CP), however the relationship with communication skills requires exploration. AIMS: To examine the relationship between the type and severity of brain lesion on MRI and communication skills in children with CP. METHODS AND PROCEDURES: 131 children with CP (73 males(56%)), mean corrected age(SD) 28(5) months, Gross Motor Functional Classification System distribution: I=57(44%), II=14(11%), III=19(14%), IV=17(13%), V=24(18%). Children were assessed on the Communication and Symbolic Behavioral Scales Developmental Profile (CSBS-DP) Infant-Toddler Checklist. Structural MRI was analysed with reference to type and semi-quantitative assessment of the severity of brain lesion. Children were classified for motor type, distribution and GMFCS. The relationships between type/severity of brain lesion and communication ability were analysed using multivariable tobit regression. OUTCOMES AND RESULTS: Children with periventricular white matter lesions had better speech than children with cortical/deep grey matter lesions (ß=-2.6, 95%CI=-5.0, -0.2, p=0.04). Brain lesion severity on the semi-quantitative scale was related to overall communication skills (ß=-0.9, 95%CI=-1.4, -0.5, p<0.001). Motor impairment better accounted for impairment in overall communication skills than brain lesion severity. IMPLICATIONS: Structural MRI has potential prognostic value for communication impairment in children with CP. WHAT THIS PAPER ADDS?: This is the first paper to explore important aspects of communication in relation to the type and severity of brain lesion on MRI in a representative cohort of preschool-aged children with CP. We found a relationship between the type of brain lesion and communication skills, children who had cortical and deep grey matter lesions had overall communication skills>1 SD below children with periventricular white matter lesions. Children with more severe brain lesions on MRI had poorer overall communication skills. Children with CP born at term had poorer communication than those born prematurely and were more likely to have cortical and deep grey matter lesions. Gross motor function better accounted for overall communication skills than the type of brain lesion or brain lesion severity.

Growth Restriction in Infants and Young Children with Congenital Heart Disease.

OBJECTIVE: The purpose of this study was to determine the prevalence of growth restriction in infants and young children with congenital heart disease (CHD) and investigate the relationship between poor growth, feeding difficulties, cardiac classification, and nutrition intervention on outcomes. DESIGN: This is a prospective observational cohort study of infants and young children with CHD aged 0-3 years admitted to hospital for cardiac surgery. Anthropometry, growth history, cardiac classification, cardiac diagnosis, feeding difficulty, and nutrition intervention data were collected for 78 participants. RESULTS: Many participants demonstrated growth restriction as evidenced by a z-score ≤ -2 for population growth parameters including weight/age z-score (n = 18, 23%), height/age z-score (n = 16, 21%), and weight/height z-score (n = 12, 18%). Increased hospital length of stay was associated with factors including faltering growth preadmission (P = .009), tube feeding required preadmission (P = .002), diagnosis of cyanotic CHD (P = .015), and presence of a feeding difficulty (P = .015). CONCLUSIONS: Growth restriction remains an ongoing problem in children with CHD. Faltering growth preadmission and lower growth parameters were associated with an increased hospital length of stay. Nutritional screening from diagnosis may detect growth faltering, improve access to early nutrition intervention, and improve patient outcomes.

Relationships between dietary intake and body composition according to gross motor functional ability in preschool-aged children with cerebral palsy.

BACKGROUND/AIMS: We aimed to determine the relationships between energy intake, macronutrient intake and body composition in preschool-aged children with cerebral palsy (CP) according to gross motor functional ability in comparison with typically developing children (TDC). METHODS: Seventy-three children with CP (70% male) of all functional abilities and 16 TDC (63% male) aged 2.8 ± 0.9 years participated in this study. Dietary intake was measured via a validated 3-day weighed food record. Body composition was determined via isotope dilution techniques. RESULTS: There was a significant relationship between energy intake and fat-free mass index, which was stronger in TDC compared to children with CP. There were no significant correlations between other dietary intake and body composition variables, despite differences in body composition as ambulatory status declined. Non-ambulant, tube-fed children had significantly lower protein intakes compared to orally fed children. No other differences in macronutrient intake between children with CP and TDC were apparent. CONCLUSIONS: Results suggest that relationships between dietary intake and body composition are not evident in this population, but develop over time. Physical activity levels may have a greater impact on body composition at this age. Longitudinal research is required to examine these factors.

Speech pathology services to children with cancer and nonmalignant hematological disorders.

Children with cancer and nonmalignant hematological disorders may require speech pathology (SP) support; however, limited evidence is available describing prevalence and severity of swallowing/feeding and communication impairments in this population. A retrospective chart review of 70 children referred to SP at the newly formed Queensland Children's Cancer Centre was conducted to describe the prevalence and severity of swallowing/feeding and communication dysfunction, and the association between impairment, oncology and hematology diagnosis, and service utilization (time and occasions of service). Swallowing/feeding disorders were the most commonly observed impairments at initial assessment (58.6%). Children with central nervous system tumors (P = .03) and nonmalignant hematological disorder (P = .03) had significantly higher rates of feeding impairment than other oncology and hematology diagnostic groups. Children with central nervous system tumors had the highest rates of oral phase (P = .01) and pharyngeal phase (P = .01) dysphagia (swallowing disorder). No significant difference was found between diagnostic groups for intensity of SP service delivery. Prospective research is required to examine prevalence and severity of disorders, and service utilization in a more established clinic, and to investigate interactions between cancer treatment and swallowing/feeding and communication dysfunction.

Radiation doses to children during modified barium swallow studies.

BACKGROUND: There are minimal data on radiation doses to infants and children undergoing a modified barium swallow (MBS) study. OBJECTIVE: To document screening times, dose area product (DAP) and effective doses to children undergoing MBS and to determine factors associated with increased screening times and effective dose. MATERIALS AND METHODS: Fluoroscopic data (screening time, DAP, kVp) for 90 consecutive MBS studies using pulse fluoroscopy were prospectively recorded; effective dose was calculated and data were analyzed for effects of behavior, number of swallow presentations, swallowing dysfunction and medical problems. RESULTS: Mean effective dose for the entire group was 0.0826 +/- 0.0544 mSv, screening time 2.48 +/- 0.81 min, and DAP 28.79 +/- 41.72 cGy cm2. Significant differences were found across three age groups (1.0-3.0 and >3.0 years) for effective dose (mean 0.1188, 0.0651 and 0.0529 mSv, respectively; P < 0.001), but not for screening time or DAP. Effective dose was correlated with screening time (P = 0.007), DAP (P < 0.001), number of swallow presentations (P = 0.007), lower age (P = 0.017), female gender (P = 0.004), and height (P < 0.001). Screening time was correlated with total number of swallow presentations (P < 0.001) and DAP (P < 0.001). CONCLUSION: Screening times, DAP, effective dose, and child and procedural factors associated with higher effective doses are presented for children undergoing MBS studies.