Development of the levels of feeding/swallowing impairment

An additional separate section was added to define levels of feeding/swallowing impairment. This was loosely based on the criteria used in the American Speech-Language-Hearing Association National Outcomes Measurement System (ASHA NOMS) [27], a multidimensional instrument assessing the supervision required for feeding and the type of diet. Our classification is much simpler and uses levels of impairment rather than abilities. This was simplified for general use both by reducing the number of levels, as some were not relevant for our age group and excluding activities that could only be collected by speech therapists or trained professionals, in order to be easily assessed in routine clinical practice. The functional levels assessed are scored separately from the checklist (Table 2).

Functional levels were classified as follows:

No impairment: the individual’s ability to eat is not limited by swallow function. Swallowing is reported as safe and efficient for all consistencies (when age appropriate), without choking episodes or other clinical signs such as retching or cough.

Mild impairment: swallowing is safe, but usually requires moderate cues to use compensatory strategies or more careful posturing or other intervention (thickening food or other edit in texture).

Moderate impairment: the individual is able to swallow some food consistencies safely by mouth but gets easily tired and/or is unable to complete a full meal and/or takes less than 50%of nutrition and hydration by mouth. These children may require need for oral supplements or tube feeding (NG tube or G-tube).

Severe impairment: individual is not able to swallow anything safely by mouth. All nutrition and hydration is received through non-oral means (e.g. nasogastric or G-tube).