Volume 12, Issue 5, March 2018 EBP - Pearson Assessments

2y ago
57 Views
2 Downloads
214.44 KB
13 Pages
Last View : Today
Last Download : 2m ago
Upload by : Dahlia Ryals
Transcription

Volume 12, Issue 5, March 2018EBPbriefsA scholarly forum for guiding evidence-basedpractices in speech-language pathologyUsing Thickened Liquids to ImproveSwallowing Physiology in Infants WithDysphagia: A Review of External EvidenceCaitlin A. Cummings, MA, CCC-SLPMelanie Stevens, MS, CCC-SLPNancy Batterson, OT/L, SCFESKathleen Cianca, MHS, OTR/LNationwide Children’s Hospital

EBP BriefsEditorMary Beth SchmittTexas Tech University Health Sciences CenterEditorial Review BoardKelly FarquharsonEmerson CollegeLisa BowersUniversity of ArkansasErin BushUniversity of WyomingSherine TambyrajaThe Ohio State UniversityAngela Van SickleTexas Tech University Health Sciences CenterManaging DirectorTina EichstadtPearson5601 Green Valley DriveBloomington, MN 55437Cite this document as:Cummings, C. A., Stevens, M., Batterson, N., & Cianca, K. (2018).Using thickened liquids to improve swallowing physiology ininfants with dysphagia: A review of external evidence. EBP Briefs,12(5), 1–10. Bloomington, MN: NCS Pearson, Inc.Copyright 2018 NCS Pearson, Inc. All rights reserved.Warning: No part of this publication may be reproduced or transmitted in any form or byany means, electronic or mechanical, including photocopy, recording, or any informationstorage and retrieval system, without the express written permission of the copyright owner.For inquiries or son, Always Learning, PSI Design, and PsychCorp are trademarks, in the US and/orother countries, of Pearson Education, Inc., or its affiliates.PsychCorp is an imprint of Pearson Clinical Assessment.NCS Pearson, Inc. 5601 Green Valley Drive Bloomington, MN 55437Produced in the United States of America.1.A

EBP Briefs Volume 12, Issue 5March 2018Using Thickened Liquids to Improve Swallowing Physiology inInfants With Dysphagia: A Review of External EvidenceAcknowledgmentsThe authors would like to acknowledge and thank all members of the interdisciplinary infant dysphagia clinical outcomegroup at Nationwide Children’s Hospital who assisted with formation of the clinical question, literature search and review,final summary of the evidence, and hospital-wide education regarding results and recommendations.Structured AbstractClinical Question: For infants with oropharyngeal dysphagia, does thickening liquidsdecrease laryngeal penetration and/or aspiration when compared to not thickening liquidsand continuing with thin liquids alone?Method: Literature ReviewStudy Sources: MEDLINE via Ovid, CINAHL, Google Scholar, ClinicalTrials.gov, and ScopusSearch Terms: The following terms were used individually and in several differentcombinations: infant, infant food, infant formula, infant nutrition disorders, deglutition,deglutition disorders, thickener, enterocolitis, necrotizing, thicken*, cereals, baby cereal,gastroesophageal reflux, rice cereal, thick it, simply thick, thicken up, xanthan gum, carobgum, swallowing, all infant (birth to 23 months), dysphagia, aspiration, videofluoroscopicstudy, videofluoroscopic swallow study, VSS, fiber optic endoscopic evaluation ofswallowing, FEES, nutritionNumber of Studies Included: 10Primary Results: There are a limited number of studies that examine the effect ofthin vs. thickened liquids on swallowing physiology in infants. Thickened liquids havebeen associated with slower bolus pharyngeal transit timing and improved swallowingphysiology when compared to thin liquids for certain groups. However, relevant studiespresent mixed results and include a range of medical diagnoses, sample sizes, researchmethodologies, dysphagia rating approaches, and clinical scenarios that make it difficult togeneralize to larger populations.Conclusions: There is limited and low-quality evidence to support the recommendation ofthickened liquids as an intervention that consistently improves swallowing physiology in theinfant population. More high-quality controlled studies with larger sample sizes are needed.Successful management of dysphagia in infants may require a variety of interventions thatinclude changes to liquid consistency as well as other compensatory strategies.iiiCopyright 2018 NCS Pearson, Inc. All rights reserved.

Using Thickened Liquids to Improve Swallowing Physiologyin Infants With Dysphagia: A Review of External EvidenceCaitlin A. Cummings, MA, CCC-SLPMelanie Stevens, MS, CCC-SLPNancy Batterson, OT/L, SCFESKathleen Cianca, MHS, OTR/LNationwide Children’s HospitalClinical Scenarioand the liquid is cleared from the larynx, but in 3 outof 10 swallows, silent aspiration is observed as well. Theinfant does not cough, choke, or demonstrate any otherovert reaction to this event (Arvedson, 2008). Molly andSamantha change the barium to nectar-thick and observeno laryngeal penetration or aspiration when they watch anadditional 20 swallows.Based on these observations, Molly initially wants torecommend changing the formula viscosity to nectar-thick.At her institution, the standard mixing equation for thisthickness is 1.5 teaspoons of pulverized infant rice cerealfor every ounce of liquid. The mother, however, is nervousabout mixing the formula and wants to know why it isnecessary if her daughter only aspirates a “little every nowand then.” Molly realizes that she is not as familiar with theevidence base behind this intervention when it involves theinfant population. Following department protocol, Mollyrecommends that since there was no evidence of oral orpharyngeal dysphagia with thicker formula, the parentsshould discuss with their pediatrician Molly’s instructions togive their daughter only formula thickened to nectar-thickfor now. Molly also schedules the patient for an outpatientfeeding evaluation follow-up appointment with her in1 month and advises the mother to call her if concernsarise before that time. Molly explains that in 1 month theycan reassess how well the patient is swallowing nectarthick liquids and decide if there are any next steps in thetreatment plan.After this VFSS, Molly and Samantha decide thatthickening liquids for infants with dysphagia would makea good topic for an interdisciplinary clinical outcomegroup (COG) involving various professionals across thehospital who work with this population and their families.Learning and coming to a consensus as an interdisciplinarygroup was designated as an important professional goalbecause “children [with feeding and swallowing disorders]Molly is a speech-language pathologist (SLP) andworks at a hospital evaluating and treating adults who havedysphagia, a disorder characterized by difficulties with theoral, pharyngeal, and/or esophageal phases of swallowing(ASHA, 2017a). She has extensive experience performingvideofluoroscopic swallow studies (VFSSs) and evaluating,in consultation with a radiologist, whether patients exhibitlaryngeal penetration and/or aspiration when swallowingliquids and solids. Thickening liquids is a commonintervention that Molly recommends to facilitate safer andmore efficient swallowing in adults (Steele et al., 2015)across a range of diagnoses including head and neck cancerand dementia (Alagiakrishnan, Bhanji, & Kurian, 2013;Barbon & Steele, 2015).Recently, Molly started a new job at a children’shospital. At her new institution, SLPs and occupationaltherapists (OTs) work collaboratively with children whohave feeding and swallowing disorders, and they performVFSSs together. One of Molly’s first patients is a 4-monthold female with a history of prematurity, wheezing, andvomiting. The patient’s parents have noticed recently thatshe coughs sometimes during bottle feeds with thin formula,her eyes water, and she has had recurrent upper respiratoryinfections. The patient’s physician recommended furtherevaluation of her swallowing via a VFSS. Molly and hercolleague Samantha, an OT, are scheduled to performthe VFSS together, along with a radiologist. During theevaluation, Samantha places the patient in a semi-reclinedposition and offers her thin barium via her normal bottleand standard-flow nipple. Molly observes on the fluoroscopymonitor that after a few normal swallows, sometimes thebarium enters the larynx and passes below the vocal folds.She records these observations as aspiration (passage ofmaterial below the level of the true vocal folds and into thetrachea; Arvedson, 2008). Sometimes the patient coughs1Copyright 2018 NCS Pearson, Inc. All rights reserved.

EBP Briefs Volume 12, Issue 5March 2018Using Thickened Liquids to Improve Swallowing Physiology inInfants With Dysphagia: A Review of External Evidenceand families are better served by an interdisciplinary teamthan by a single discipline in isolation” (Arvedson, 2008,p. 118). A group of interested colleagues consisting of sixSLPs, five OTs, one developmental pediatrician, and onedietician was formed. The goal of the group was to compileand review external evidence for the use of thickened liquidsas an intervention to improve swallowing safety in infantswith dysphagia.VSS, fiber optic endoscopic evaluation of swallowing, FEES,and nutrition. All articles had to be written in English,published after 2000, treatment studies, and peer-reviewedarticles. Additional parameters were set for the targetedage depending on what categories each database offered(e.g., 0 12 months, birth to 23 months, child).Searching databases was completed over four distinctrounds. MEDLINE was searched first; CINAHL, GoogleScholar, and ClinicalTrials.gov were searched second; Scopuswas searched third; a repeat search of Google Scholar wascompleted last. This repeat search was conducted after thereference librarian educated COG members on the “relatedarticle” search feature available on the Google Scholardatabase. After each search round, articles were dividedequally amongst the 13 COG members with instructionsto skim titles and abstracts and to record whether eacharticle appeared to address the PICO question and inclusioncriteria (see Table 1). Depending on the search round, eachCOG member skimmed anywhere from 5 to 20 titles/abstracts at one time.Searching five databases resulted in an initial yield of1,173 articles. The first review excluded 1,037 articles thatclearly were not relevant to the PICO question (i.e., theydid not address infants, thickening, or dysphagia; they werepublished outside of the year range; and/or they were nottreatment studies). The remaining 136 articles were givena “maybe” rating. Molly reviewed this list of articles andremoved 19 duplicates. The remaining 117 articles weredivided equally amongst COG member pairs who readthe full texts to determine if they met inclusion criteria.Group members were paired so that each article was readby two people from different disciplines; any disagreementregarding adherence to inclusion criteria was discussed infull group meetings and a decision to include or excludean article was made based on group consensus. The groupinitially rejected 100 articles and selected 17 articles forcritical appraisal. If an article was designated for criticalappraisal, the COG members that had initially read it wererequired to outline the participants, design, procedures, andoutcomes of the study in a literature review matrix housedwithin an online shared drive at their hospital. Once thegroup met again and gave detailed reports of each article, 6articles were deemed not to be treatment studies and 1 wasfound to not include thickening liquids in its procedures.These 7 articles were excluded, leaving 10 articles thatadhered to the PICO question and were included in thefinal analysis (see Figure 1).Clinical QuestionMolly first went to the American Speech-LanguageHearing Association (ASHA) website to review its evidencebased practice (EBP) resources. ASHA recommendswriting the clinical question within the PICO framework(population, intervention, comparison, outcome) as thefirst step in the EBP process to help guide a literature search(ASHA, 2017b; Bothe, 2010; Sackett, Straus, Richardson,Rosenberg, & Haynes, 2000; Straus, Richardson, Glasziou,& Haynes, 2005). Molly explained the PICO structure toher COG. In an effort to perform a literature review thatwas as targeted and organized as possible, the group decidedto narrow the age range to 0 12 months. Based on thePICO model, the COG finalized its clinical question as thefollowing: for infants ages 0 12 months with oropharyngealdysphagia (P), does thickening liquids (I) lead to decreasesin laryngeal penetration and/or aspiration risk (O) whencompared to not thickening liquids and continuing withthin liquids alone (C)?Search for the EvidenceMolly and Samantha met with their hospital’s researchlibrarian to develop a search plan. The following electronicdatabases were used to find appropriate research articlesthat addressed their clinical question: MEDLINE viaOvid, CINAHL, Google Scholar, ClinicalTrials.gov, andScopus. In order to try to capture all relevant literature,the following search terms were used individually andin a variety of combinations in the database searches:infant, infant food, infant formula, infant nutritiondisorders, deglutition, deglutition disorders, thickener,enterocolitis, necrotizing, thicken*, cereals, baby cereal,gastroesophageal reflux, rice cereal, thick it, simplythick, thicken up, xanthan gum, carob gum, swallowing,all infant (birth to 23 months), dysphagia, aspiration,videofluoroscopic study, videofluoroscopic swallow study,2Copyright 2018 NCS Pearson, Inc. All rights reserved.

EBP Briefs Volume 12, Issue 5March 2018Using Thickened Liquids to Improve Swallowing Physiology inInfants With Dysphagia: A Review of External EvidenceEvaluating the Evidencethickened liquids in adults, but there is inconsistent andlimited evidence in children, especially infants. The COGrated these studies as OCEBM Level 2 evidence becausethey were systematic reviews that addressed the effect ofthickening liquids on swallowing physiology in children, butthe papers’ parameters were not restricted specifically to theinfant (birth to 12 months) population.Four individual studies discussed thickened liquids asa treatment for dysphagia in infants who have anatomicdeficits and/or more critical medical diagnoses. A study byOngkasuwan et al. (2014) included four children under theage of 12 months with multiple congenital anomalies andtracheostomies. SLP raters noted improvement in laryngealpenetration and aspiration when given pureed solids vs.thin liquid with barium in three of the infants when using aspeaking valve and/or sham valve. Marques, Prado-Oliveira,Leirião, Jorge, & de Souza (2010) investigated swallowingin 11 children with isolated Robin sequence and airwayobstruction/respiratory difficulties. The majority of infants(7/11) demonstrated aspiration risk with thin liquids viafiberoptic endoscopic evaluation of swallowing (FEES), andthe authors reported that this risk decreased with thickenedmilk. In one case study, laryngeal penetration and silentaspiration of thin liquids were eliminated in an infantwith laryngeal cleft type I when given thicker milk (Rossi,Buhler, Ventura, Otoch, & Limongi, 2014.) In addition,a 5-month-old infant with history of acute ischemia in theoccipital cortex and aspiration pneumonia demonstratedincreased feed volumes, better oral coordination, andreduced overt signs of aspiration when given nectarthick vs. thin liquid (Peck & Rappaport, 2013). A VFSSsubsequently showed no aspiration or penetration of thinliquids as the subject was weaned from nectar, to half-nectar,to thin consistencies during feeding therapy.These four studies suggest there is some evidencethat thickened liquids improve swallowing physiologyand safety in the infant population. However, the overallquality of research methodology is low (i.e., case studies,observational methods), one study discusses purees and notthickened liquids specifically (Ongkasuwan et al., 2014),and thickening liquids is included sometimes along withother compensatory strategies/interventions that could haveaffected swallowing skill development (Peck & Rappaport,2013). In addition, the rigor of rating swallowing functionwas inconsistent across studies (Rossi et al., 2014;Marques et al., 2010), and aspiration risk was not alwaysquantitatively defined or eliminated when using thickenedIn pairs, the COG members rated the 10 selectedarticles. The Oxford Centre for Evidence-Based Medicine’s2011 Levels of Evidence table (OCEBM Levels of EvidenceWorking Group, 2011) was used to rate each article’streatment benefits (see Tables 2 and 3).Two systematic reviews closely approximated theCOG’s PICO question. Gosa, Schooling, & Coleman(2011) investigated the effect of thickened liquids onswallowing physiology in children. Of 22 studies thatmet the authors’ inclusion criteria, six involved a totalof 162 participants with some degree of dysphagia, andthe majority of subjects were younger than 1 year old.Two investigations reported elimination of laryngealand/or tracheal penetration in 71 100% of subjects whenthickened compared to thin liquids were used (Khoshoo,Ross, Kelly, Edell, & Brown, 2001; Mercado-Deane et al.,2001), but only 50% of the participants across five studiesshowed elimination of aspiration. In addition, one studyreported no increased incidence of aspiration across thinvs. thickened liquid trials. Authors concluded, though,that findings should be interpreted with caution. Most ofthe infants involved in the studies were relatively healthyand typically developing, and the majority of studies usedsmall sample sizes, nonexperimental research designs, andyielded mixed results. Gosa, Schooling, & Coleman (2011)highlighted that definitive conclusions about the efficacy ofthickening liquids in decreasing penetration/aspiration riskin infants are unable to be made without additional research.The second systematic review, by Steele et al. (2015),investigated the effect of thickening liquid consistency onswallowing function and identified 36 studies that met theirinclusion criteria. In total, articles suggested a reduction inthe risk of penetration/aspiration during swallowing as thinliquids progress to thicker consistencies. The value of theseconclusions was limited for Molly and her COG’s PICOquestion, however, because only one of the articles in Steeleet al. (2015) addressed the infant population (Goldfield,Smith, Buonomo, Perez, & Larson, 2013). Steele et al.(2015) also highlighted that because Goldfield et al. (2013)used a lower quality of research design with no controlgroup comparison, claims regarding the consistent efficacyof thickened liquids to facilitate safer swallowing conditionsshould be limited to the adult population at this time.Based on these systematic reviews, the COG decidedthat there appears to be a moderate quality of evidencesupporting a reduction in risk of aspiration/penetration with3Copyright 2018 NCS Pearson, Inc. All rights reserved.

EBP Briefs Volume 12, Issue 5March 2018Using Thickened Liquids to Improve Swallowing Physiology inInfants With Dysphagia: A Review of External Evidencethese mixed results and methodological weaknesses andsummarized the evidence as inconsistent and limited for thetypically developing infant population. The investigationswere rated as Level 4 evidence.In the final paper, Goldfield et al. (2013) studied 10premature infants with dysphagia by examining tonguemovement, soft palate movement, and bolus transit timeduring the swallowing of thin and nectar-thick liquidsduring VFSS. Average transit time of the bolus headthrough the pharynx was significantly longer for thethicker consistency. Swallowing nectar-thick liquid alsowas associated with more coordinated tongue and softpalate movements that created a “pump-like” action forswallowing. The COG rated this article as Level 5 evidence:mechanism-based reasoning. Each infant aspirated duringthin liquid trials, but the authors did not discuss whetherpenetration/aspiration resolved or continued with thickerliquids; the analysis was limited to bolus transit time, tonguemovement, and soft palate movement.feeds (Marques et al., 2010). Finally, the variety of subjectdiagnoses makes the results difficult to generalize to largergroups of infants. Molly and her colleagues determined thatthere was limited and mixed evidence that thickened liquidsimproved swallowing safety in infants who have anatomicor structural defects contributing to their dysphagia. Theydesignated these four studies as Level 4 evidence.Three studies investigated swallowing and suspecteddysphagia in infant groups who were otherwise previouslyhealthy. Khoshoo et al. (2001) completed a prospectiveinvestigation of 15 infants with RSV bronchiolitis anddysphagia and found that the majority of those whodemonstrated penetration and/or aspiration with thinliquids (8/9) demonstrated a “normal” swallow (i.e.,no penetration or aspiration) when given thickenedliquid. Mercado-Deane et al. (2001) studied swallowingfunction via upper gastrointestinal study and VFSSacross infants with and without an underlying diseasethat would predispose them to dysphagia. Of 93 infantswho demonstrated aspiration of thin liquids via VFSS,approximately 40% (37/93) improved when giventhickened liquids. Furthermore, 67% (22/33) of infantswho demonstrated laryngeal penetration of thin liquidsshowed normal swallowing when given thick liquids. Finally,Sheikh et al. (2001) completed a retrospective chart reviewof 13 typical infants with a new onset of choking/feedingconcerns. VFSS was performed around age 5 6 monthsand revealed that all infants aspirated thin liquids, withsix aspirating semi-thick and/or thick liquids as well. Thenine infants that aspirated thin and semi-thick liquids wereplaced on a thickened-feed diet. At a 9-month follow-up,“aspiration and swallowing dysfunction had finally resolved”(p. 1193) in all infants.Collectively, these studies suggest that thickeningliquids can be considered a safe, effective, and temporaryintervention for reducing aspiration. One study, however,presented limited information regarding how the SLPrated the swallowing event, and failed to present any raterreliability data (Khoshoo et al., 2001). Another describednormal swallowing only in very general terms as havingthe ability to swallow “satisfactorily” (Mercado-Deaneet al., 2001, p. 425). Direct comparisons of swallowingthin vs. thicker consistencies with each subject werenot always outlined (Sheikh et al., 2001). In addition,none of the studies reported a complete elimination ofpenetration/aspiration across their subjects when thickenedliquids were used. Molly and her colleagues notedThe Evidence-Based DecisionMolly, Samantha, and their COG concluded that theoverall empirical evidence for recommending thickenedliquids as a consistent and effective intervention for infantswho aspirate or penetrate thin liquids is limited and of lowquality. This characterization of the evidence was found inother articles encountered during the broad literature reviewas well (Miller, 2011). However, the COG noted that noneof the articles portrayed thickening liquids as unilaterallyharmful or stated that it should never be used for dysphagiamanagement. On the contrary, thickening liquids can beconsidered a “necessary and appropriate intervention” thatreduces aspiration risk in some cases (Gosa, Schooling,& Coleman, 2011, p. 348) if it is used judiciouslyand in combination with continuous monitoring as atransitional strategy toward establishing more normalizedswallowing function. Clinicians must carefully consider theheterogeneous nature of each subject case (Marques et al.,2010) and exhaust other adaptive strategies and techniquessuch as positioning changes, smaller bolus size, and pacingbefore pursuing thickened liquid recommendations(Peck & Rappaport, 2013). Thickening liquids also canbe temporary, as infants sometimes progress to normalswallowing function over time (Sheikh et al., 2001) or areweaned successfully from thick to thinner liquids (Peck &Rappaport, 2013; Rossi et al., 2014).4Copyright 2018 NCS Pearson, Inc. All rights reserved.

EBP Briefs Volume 12, Issue 5March 2018Using Thickened Liquids to Improve Swallowing Physiology inInfants With Dysphagia: A Review of External Evidencethey acknowledged that their appraisal of the literaturerelated to thickening liquids and infant dysphagia wouldhave to be ongoing and that future COGs may need tonarrow their clinical question and target more specificdiagnostic groups in order to identify more consistenttrends in recommendations and guidelines. McGrattan et al.(2017), for example, recently studied swallowing functionvia VFSS in infants with congenital heart disease. Althoughsignificantly fewer infants demonstrated aspiration withnectar-thick barium (8/30) compared to thin (18/30),the authors highlight that these results indicate mixedfindings. Thickening liquids may have positive effects forsome infants with dysphagia but may be limited in theirbenefit to others depending on the type and severity of theirswallowing impairment. Because this article was publishedafter completion of Molly and Samantha’s COG, it was notincluded in the formal systematic search and review process.Nevertheless, they designated its results as highly relevant totheir clinical practice and planned to include it in their nextround of article reviews when the COG meets in 2 years toupdate the final list of evidence.After the experience with their COG and literaturereview, Molly and Samantha both felt more confident withtheir knowledge of the evidence base for thickening liquidsas a treatment strategy for infants with dysphagia. Theywere more prepared to educate families and collaborate withcolleagues at all stages of the swallowing evaluation andtreatment process.Based on the limited evidence, the COG confirmedthat if penetration and/or aspiration is observed duringVFSS, alternative methods such as trialing differentfeeding positions and altering liquid flow rate should beexplored by the SLP and OT prior to thickening liquids.If these modifications are ineffective in reducing laryngealpenetration/aspiration, the most appropriate clinical courseof action is to increase liquid thickness in small incrementsuntil swallowing safety is demonstrated (Steele et al., 2015).The COG decided that patients should have an outpatientfeeding follow-up assessment within 1 3 months of a VFSS,depending on the case, in order to continue monitoringswallowing status, provide further parent education, anddecide if other evaluation and treatment measures arewarranted, such as progressively weaning to thin liquids orrepeating a VFSS in the future.Molly met with her patient and the mother duringtheir follow-up appointment and learned that she had beendoing well with nectar-thick formula via her standardflow nipple. The mother reported no observations ofdysphagia symptoms over the last month and no newrespiratory infections. Because of her patient’s success withthickened liquids, Molly recommended weekly feedingtherapy to trial weaning her incrementally back to athinner consistency of formula. With the patient’s referringdoctor’s approval, Molly explained that she could also usevarious modifications such as pacing (removing the nippleperiodically), changing positioning (using a more uprightor side-lying position), and reducing bolus size (using aslower flow nipple) to try to build safer swallowing skillsin a controlled manner (Peck & Rappaport, 2013; Rossiet al., 2014). If these modifications were not successful,thickened liquids could continue with ongoing monitoringby a feeding therapist and her doctor. Molly explained thatthis approach adheres to the available evidence base becauseit acknowledges that thickening liquids has been shown insome cases to improve swallowing safety in infants, but thatother intervention techniques and goals for resuming thinliquid feeds may be considered as well depending on thepatient. The mother voiced understanding and was excitedto start therapy in the next week.Molly and Samantha realized that no infant patientin the future would likely present with the exact sameoropharyngeal dysphagia case in the outpatient setting. Inaddition, they noted that the type of thickener, thickeningrecipes, and the benefits/drawbacks of different instrumentalevaluation techniques were variables that needed furtherconsideration in future appraisals of the evidence. Finally,Authors’ NoteCaitlin A. Cummings, MA, CCC-SLP, is a speechlanguage pathologist and EBP coordinator for the SpeechLanguage Pathology Department at Nationwide Children’sHospital. She helps lead EBP initiatives and providesfeeding evaluation and treatment primarily for childrenages birth through 3 years as a member of the cleft lip andpalate team. She is also a doctoral student at The Ohio StateUniversity specializing in speech disorders and bilingualdevelopment in children with cleft lip and palate andcraniofacial anomalies.Contact rgPhone: 614-722-3966Nationwide Children’s Hospital700 Children’s DriveColumbus, OH 432055Copyright 2018 NCS Pearson, Inc. All rights reserved.

EBP Briefs Volume 12, Issue 5March 2018Using Thickened Liquids to Improve Swallowing Physiology inInfants With Dysphagia: A Review of External EvidenceMelanie Stevens, MS/CCC-SLP, BCS-S, is a speechlanguage pathologist with board certification in swallowingand a clinical supervisor in the Speech-Language PathologyDepartment at Nationwide Children’s Hospital. Melanie has17 years of experience specializing in pediatric dysphagia,FEES, and communication and swallowing care forchildren with tracheostomies. She currently practices acrossinpatient, NICU, and pediatric aerodigestive team settingsand leads dysphagia EBP initiatives at the department andhospital level.Arvedson, J. C. (2008). Assessment of pediatric dysphagiaand feeding disorders: Clinical and instrumentalapproaches. Developmental Disabilities Research Reviews,14(2), 118–127. doi:10.

Pearson, Always Learning, PSI Design, and PsychCorp are trademarks, in the US and/or other countries, of Pearson Education, Inc., or its affiliates. PsychCorp is an imprint of Pearson Clinical Assessment. NCS Pearson, Inc. 5601 Green Valley Drive Bloomington, MN 55437 Produced in the U

Related Documents:

Find the volume of each cone. Round the answer to nearest tenth. ( use 3.14 ) M 10) A conical ask has a diameter of 20 feet and a height of 18 feet. Find the volume of air it can occupy. Volume 1) Volume 2) Volume 3) Volume 4) Volume 5) Volume 6) Volume 7) Volume 8) Volume 9) Volume 44 in 51 in 24 ft 43 ft 40 ft 37 ft 27 .

Printable Math Worksheets @ www.mathworksheets4kids.com Find the volume of each triangular prism. 1) Volume 36 cm 25 cm 49 cm 2) Volume 3) Volume 4) Volume 5) Volume 6) Volume 7) Volume 8) Volume 9) Volume 27 ft 35 ft t 34 in 21 in 27 in 34 ft 17 ft 30 ft 20 cm m 53 cm 21

Important Days in March March 1 -Zero Discrimination Day March 3 -World Wildlife Day; National Defence Day March 4 -National Security Day March 8 -International Women's Day March 13 -No Smoking Day (Second Wednesday in March) March 15 -World Disabled Day; World Consumer Rights Day March 18 -Ordnance Factories Day (India) March 21 -World Down Syndrome Day; World Forestry Day

Printable Math Worksheets @ www.mathworksheets4kids.com 1) Volume 2) Volume 3) Volume 4) Volume 5) Volume 6) Volume 7) Volume 8) 9) Volume Find the exact volume of each prism. 10 mm 10 mm 13 mm 7 in 14 in 2 in 5 ft 5

Insurance For The strong Summer /strong Road Trip. Introducing The "At-Home Version" Of Insurance Key Issues. Click here for PDF Archives. Back Issues: strong Volume 2 /strong - strong Issue /strong 20 - October 30, 2013. strong Volume 2 /strong - strong Issue /strong 21 - November 13, 2013: strong Volume 2 /strong - strong Issue /strong 22 - November 27, 2013: strong Volume 2 /strong - strong Issue /strong 23 -

Volume 3, Issue 2, March – April 2014 ISSN 2278-6856 Volume 3, Issue 2 March – April 2014 Page 44 2.1.1 6T SRAM cell Figure 2 Six-transistor CMOS SRAM cell [5]. The SRAM cell should be sized as small as possible to achieve high memory densities. A 6T SRAM is shown in Fig.2

4.3.klinger volume oscillator 8 4.4.volume keltner channels 9 4.5.volume udr 9 4.6.volume tickspeed 10 4.7.volume zone oscillator 11 4.8.volume rise fall 11 4.9.wyckoffwave 12 4.10.volumegraph 13 4.11.volume sentiment long 14 4.12.volume sentiment short 15 5. beschreibung der cond

March 14 - Bayshore March 15 - Bayport-Blue Point March 15 - Center Moriches March 17 - NYC March 21 - Hampton Bays March 22 - Glen Cove That is a pretty full schedule. As always we are looking to grow the band - anyone inter-ested please see Ed McGlade for details. The band will be running the uniform raffle again, please