2004;19:192–206. 1983;63(12):1992–7. in a chart note. we have offered more than one choice? Wheeler-Hegland KM, Rosenbek JC, Sapienza CM. 1999;14(5):486–96. This fosters real-world skills such as eating while performing other activities, such as having a conversation [9]. NPO. Enter your email address below and we will send you the reset instructions. The effects of lingual exercise in stroke patients with dysphagia. team (family, patient, doctor, etc.). On my SLP team, we share freely with each other the things we are learning and what The role of fiberoptic endoscopy in dysphagia rehabilitation. Higher level cognitive impairments involving organizational and sequencing skills may cause difficulty for patients undertaking appropriate strategies [8, 9, 40]. However, it was unclear whether these results were due to improvements at the ‘muscle level alone or neuroplastic modifications as well’ [93]. Clark H, Lazarus C, Arvedson J, Schooling T, Frymark T. Evidence-based systematic review: effects of neuromuscular electrical stimulation on swallowing and neural activation. Chest. Dysphagia. Factors affecting ability to resume oral nutrition in the oropharyngeal dysphagic individual. The social and psychological impacts of dysphagia can reduce patients’ quality of life [17]. Morgan A, Ward E, Murdoch B. they are really at end of life (or needing a tube feeding). Tracheotomised patients with TBI are likely to be dysphagic because of their neurological impairment, medications [5], intercurrent medical co-morbidities [37], or a combination of these factors. Some studies involving TBI subjects even include other subjects with head and neck cancers [21] and dysphagia due to other structural/anatomical issues [22]., The majority of research into neurogenic dysphagia has, however, focused on subjects with CVA [23••, 24–27]. 2002;17:197–201. Tumor Reducing food/fluid intake volume and speed can help prevent pharyngeal pooling and aspiration in patients with delayed or weak pharyngeal swallows [65]. 1989;3(1):19–26. Dysphagia Treatment is decided upon once a diagnosis is confirmed however many facets should be involved in that determination The clinician will choose a treatment program, based on the etiology, mental and physical capacity, and quality of life. Additionally, these postures are not effective in every patient [78–80] and there is a paucity of rigorous studies to demonstrate their efficacy, outcomes and limitations [78]. It’s hard not to judge in these situations Arend: In the acute hospital, I find good communication with the staff and explaining the An effortful breath hold with the super-supraglottic swallow aims to close the airway before and during the swallow [43]. Following further analyses, the authors concluded that RLA was the most important independent predictor of the time taken to achieve full oral feeding [29]. Classification of traumatic brain injury for targeted therapies. Folia Phoniatr Logop. Disorders of nutrition and swallowing: intervention strategies in the trauma centre. Hutchins BF. Treatment of dysphagia in adults : resources and protocols in English and Spanish Maria Provencio-Arambula, Dora Provencio, M.N. Ann Otol Rhinol Laryngol. Betts RH. 2010;136(8):784–9. Dysphagia: general. patient, and he’s so happy eating and drinking, and has fairly low risk parameters Arch Phys Med Rehabil. Sometimes, if they see the patient is really miserable, painful swallowing, lots of coughing, finding the not feel we have to rehab them—and we can focus on quality of life and involve the Videofluoroscopic swallow studies (VFSS) assesses the speed and coordination of movements during chewing and swallowing in the oral cavity, tongue base, pharynx, hyoid, larynx, and cricopharyngeal region [43]. Ultimately, you have to get someone in the facility to appreciate the complexities of all of the variables: patient rights, NPO stands for “non-per-oral,” which is another way to communicate “nothing by mouth.” Some people are placed on NPO status temporarily before surgeries or as part of some sort of treatment … Have a monthly meeting Krival: Does this milk issue appear to contribute to a problem? Dysphagia means difficulty swallowing. 2012;55:1232–46. 1998;13:69–81. Neurogastroenterol Motil. Swallowing disorders in severe brain injury: risk factors affecting return to oral intake. Surg Gynecol Obstet. The cognitive-communication/behavioral issues that influence the ability to safely eat and drink occur across multiple domains, creating challenges for patients attempting to swallow safely and influencing how dysphagia is assessed and managed [9, 40]. Instead, the severe illness necessitating the tracheostomy, whether neurological or not, and/or high dose medications [5] such as sedatives and neuromuscular blocking agents cause dysphagia, not the tracheostomy itself [37, 38, 58]. possibilities as our rehab patients. Or even more than two? Bulow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. going well, they can usually see for themselves, and then they ask what the options I absolutely would document the condition of the patient, and that you brought The supraglottic and super-supraglottic swallows are recommended in patients with reduced airway closure and/or a delayed pharyngeal swallow [43]. Dysphagia. 1985;66:372–5. Chest. Cherney LR, Halper AS. (nothing by mouth) patient with QOC (quality of care) and palliative plan of swallowing? Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. & Brown, L. Management of Dysphagia Following Traumatic Brain Injury. Epub 2010 Dec 30. Additionally, TBI-related frontal lobe damage [30, 31] can produce significant self-regulatory impairments [31]. 2013;92(6):486–95. Am J Speech Lang Pathol. 1990;5:147–51. However, the efficacy of these approaches is dependent on the patient having sufficient behavioral control and cognitive-communication skills to attend to, comprehend and recall and sequence commands consistently [8, 9, 40]. Arend: It will depend on how the patient does with milk-based products, just like with anything 2012;27:521–7. Oral health and swallowing problems. However, to be effective the patient must have sufficient behavioral control and cognitive-communication skills to attend to, comprehend and recall and sequence commands consistently [8, 9, 40]. Speech pathologists commonly recommend thickening fluids and/or softening or pureeing food [90]. 2001;20:124–30. Schooling T. Systematic review of oral-motor exercise. Thus, even when a patient with TBI is decannulated, they are highly likely to remain dysphagic and at risk of aspiration. The most frequent post-TBI oropharyngeal motor deficits are thought to be reduced range and/or control of tongue movements [11, 41, 42], in isolation or combined [32] with deficits such as delayed or absent pharyngeal swallow [6, 11, 32, 41–43]. Krival: Interacting with family and patients is a huge area of discussion in our field, isn’t Ludlow CL, Mullen R, Hasselkus A. Then if they still want to allow textures the patient will aspirate (and I’d have to really look at that on a case-by-case basis. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. These factors help identify patients at risk of dysphagia [12]. This handout is designed for Speech-Language Pathologist working with people who are on relatively long-term NPO status while recovering from other health impairments. In patients where oral feeding is contraindicated due to low responsiveness, sensory stimulation (tactile, olfactory, gustatory, auditory and visual) to has been suggested to improve patient responsivity [8, 9]. Nagoya J Med Sci. Lazarus C, Logemann JA. Lazzara G, Lazarus C, Logemann J. FEESST can also tests laryngopharyngeal sensory function [66]. To this end, small studies are emerging suggesting that strengthening exercises targeting the muscle level of the swallowing function are beginning to show some effect in some populations [76]. Current Dysphagia Therapy Techniques 1. Dysphagia. Am J Phys Med Rehabil. 2014;29(3):310–18. If the address matches an existing account you will receive an email with instructions to reset your password. Crit Care Med. regarding wishes, and they state they don’t know or can’t make a decision, are there So probably the starting place is before that particular issue arises with Doeltgen SH, Macrae P, Huckabee M-L. Pharyngeal pressure generation during tongue-hold swallows across age groups. Discussions must address psychosocial issues, such as the probable change in the patient’s role in the family and dependency issues following the TBI [115]. of example, I will sometimes point out that aspiration isn’t really bothering a given First, the pathophysiology of injury is dissimilar: CVA-related damage is usually focal whereas lesions in TBI represent a complex mixture of focal injury combined with diffuse axonal injury (DAI), with or without hypoxic injury. If the ability to swallow is compromised because of a cancer diagnosis or its treatment , it can get better after treatment is finished. Baguley IJ, Nott MT, Howle AA, Simpson GK, Browne S, King AC, et al. [42] reported four risk factors for dysphagia following severe TBI: lower admitting GCS (3–5), lower admitting RLA (levels I or II), tracheostomy and ventilation >2 weeks. Swallowing problems in adults with traumatic brain injury. Participant: I sometimes feel that I have more difficulty when educating other SLPs than MDs concerning Burkhead LM, Sapienza CM, Rosenbek JC. • Crary MA, Carnaby GD. This is particularly the case post- TBI, as attentional and memory impairments may affect their ability to recall and implement strategies. Patients with delayed initiation of the oral or pharyngeal phase of swallowing may benefit from strategies designed to increase sensory input before or during the swallow [65]. Speech Pathology Australia. Patient may require restraints to leave tube in place.” And really, I talk to the Treatment is patient-specific, with successful dysphagia ther apies implemented in one patient population not necessarily producing the same results in another population [64]. Terk AR, Leder SB, Burrell MI. In a recent online chat, John R. Ashford emphasized the importance of good oral hygiene to the overall health of dysphagia patients and infection control. Given the scarcity of evidence for many traditional forms of dysphagia management, regular monitoring and assessment of therapeutic strategies for individuals is recommended to maximize efficacy and avoid unwanted outcomes. Sharma OP, Oswanski MF, Singer DS, Buckley B, Courtright B, Raj SS, et al. Groher ME, Crary MA. Dysphagia is causally linked with an increased risk of aspiration pneumonia; [13–16] the incidence of which can be as high as 12 % following severe TBI [14]. If there are strategies to help, use them. 2012;93:1173–8. Arend: Assuming you mean in discussions related to swallowing, as we don’t manage the overall J Speech Lang Hear Res. The multifactorial nature of post-TBI dysphagia necessitates a comprehensive assessment of all the potential causal factors [23••]. 1998;13:208–12. Of those patients, 37% will develop pneumonia. Absent or decreased gag reflex 2. Arend: The American Geriatrics Society has references attached to their position statement Arch Phys Med Rehabil. De Vita M, Spierer-Rundback L, Eisen H, Rudy T. Effects of tracheostomy tube on swallowing function in patients following critical illness. Staff seems more comfortable when the doctor is saying, “feed them as we can.”. The Speech Pathology Association of Australia Limited; 2004. p. 9–11. (cough) are problematic for them, then it is okay to ask if they’ve now changed their The greater the severity of TBI, the greater the economic burden on healthcare providers [2, 3], particularly acute care and rehabilitation services. 2011 Jun;46(6):559-65. doi: 10.1002/ppul.21400. your session, what would that one key takeaway be? 1986;1:73–7. But now we see a decline in health or comfort. The effortful swallow increases oral pressure during swallowing, the amplitude of submental muscle activation [102], tongue base retraction, duration of pharyngeal pressure, among other changes [76]. Initially, we may have been guessing: you aspirate, you may or may not be able to Logemann JA. DYSPHAGIA GOALS was published by on 2015-08-16. Chest. 1993;8:160. A randomised study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. Sdravou K, Walshe M, Dagdilelis L. Effects of carbonated liquids on oropharyngeal swallowing measures in people with neurogenic dysphagia. Sour boluses have been shown to prompt faster initiation of bolus propulsion by the tongue and a faster pharyngeal phase of the swallow [87, 88]. Terre and Mearin [41] found that dysphagia improved along with better cognitive status on the RLA scale. Conversely, in dysphagia following CVA [47] the tongue control deficits were less severe and reduced pharyngeal peristalsis was more frequent [32]. Some do great even with the mucus issue. 2007;22(3):184–91. 2003;18:231–41. education. CAS  The epidemiology of traumatic brain injury: a review. Aspiration is very common, present in 38–63 % of patients [11, 32, 41, 42]. While performing these tasks, the patient watches real-time sEMG feedback of their muscle activity [103]. I think this translates J Speech Lang Hear Res. Find more similar flip PDFs like DYSPHAGIA GOALS. Dysphagia: clinical management in adults and children. it? Neuromuscular treatments for speech and swallowing: a tutorial. The variable nature of TBI increases the complexity of dysphagia in these patients: [10] depending on the severity, and neuroanatomical site/s of injury, the resulting dysphagia can range from mild to severe, often necessitating enteral feeding. Dane TEB, King EG. As attentional skills improve, distractors can be gradually re-introduced to the meal-time environment. It is also known as nil per os ( npo or NPO ), a Latin phrase that translates literally to English as "nothing through the mouth". The complications from dysphagia are varied, costly and potentially fatal. Determine area of weakness/deficits 3. Am J Speech Lang Pathol. palliation versus rehabilitation, particularly with the interdisciplinary team. If oral hygiene or dentition issues are observed at the bedside, referral to dental services is required, as excessive colonization of microorganisms in the oral cavity can contribute to respiratory infections [111]. Modification of the bolus temperature, taste or carbonation, applying downward pressure on the tongue when feeding with a spoon, allowing self-feeding (hand to mouth movement may provide additional sensory input), thermal/tactile stimulation (vertically rubbing the faucial arches with a cold laryngeal mirror to increase oral awareness prior to swallowing) and a presenting a bolus that requires chewing are all techniques that can be trialed to assist with bolus detection and improve swallow safety [62, 65]. © 2021 Springer Nature Switzerland AG. As appropriate, I help with some Stauffer J, Olson D, Pelta T. Complications and consequences for endotracheal intubation and tracheostomy: a prospective study of 150 critically ill adult patients. 2012;17(5):13, 15. I don’t mean to minimize Presence of a tracheotomy tube and aspiration status in early, postsurgical head and neck cancer patients. Law JH, Banhart K, Rowlett W, et al. Oral food trials may reveal whether they can accept being fed without becoming agitated [40]. 2004;19(3):226–40. However, in some patients with TBI, the cognitive-communication and behavioral impairments, rather than the physiological deficits, may be key to informing the effective management of dysphagia in this population. 1994;37:1041–9. Another study found that tracheostomy removal did not change subjects’ aspiration or dysphagic status [58]. with cervical osteophytes. Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. At Cleveland Clinic, we’ve assembled an entire team of all the specialists you need – including gastroenterologists, radiologists, pathologists, thoracic surgeons and swallowing therapists – to offer leading-edge Electrical stimulation and dysphagia: what we do and don’t know. Martens L, Cameron T, Simonsen M. Effects of a multidisciplinary management program on neurologically impaired patients with dysphagia. 2nd ed. Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ. so worried about being “correct” (a graduate school hangover?) else they want to eat or drink. In contrast, TBI is frequently sustained by healthy, young males [28]. Dysphagia & … Facial paralysis (cranial nervesVII, IX, X, XII) 4. Signs and Symptoms of Dysphagia Watch for and make note J Head Trauma Rehabil. Pulmonary aspiration in mechanically ventilated patients with tracheostomies. PubMed  1999;14:93–109. Dysphagia - low risk Upright for treatment – chin tuck position Moderate gag reflex – nitrous oxide Toothbrushing assistance – electric t/brush Rubber dam – composites Handscaling Care with impressions - overfill Positioning with training, support and appreciation for their efforts. If you are talking about patient who is truly at end of Recovery of oral nutrition after head injury in adults. conversation about goals of care. crossroads of tube-feeding versus palliative swallow. Arend: It helps to have family watch my session with the patient. Electrode placement can be difficult as the muscles are small and overlapping [105]. Participant: I was wondering two things: How do you suggest we introduce our “role” or skill set treatment plan. Brain Injury Rehabilitation Service, Westmead Hospital, University of Sydney, PO Box 533, Wentworthville, Sydney, NSW, 2145, Australia, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia, You can also search for this author in Brenda Arend: The main thing I’d want you to take away is the shift in focus from “rehab” to “palliative” Both techniques are effective tools for assessing dysphagia, detecting aspiration and trialing management strategies in patients with TBI [35]. Krival: I don’t think there is one perfect response, because the staff issue is so broad. 2004;67(1–2):17–23. As a Home Health SLP, I am often asked the same questions. And the second question, if a patient is truly NPO in acute care, my experience is they are really at end of life (or needing a tube feeding). Leder SB, Cohn SM, Moller BA. ideas on limited PO intake, focusing on comfort. This retrospective study examined the predictor variables for oropharyngeal dysphagia in 219 patients following severe traumatic brain injury. Arch Phys Med Rehabil. Dysphagia following TBI can be multifactorial, but mainly occurs because of neurological impairment to any or all of the three phases of swallowing (the oral preparatory, the oral and pharyngeal phases) and cognitive-communication and behavioral dysfunction [5–9]. with the now quick-turnover rate, how do you take that into account and help the NPO Effortful swallowing training combined with electrical stimulation in post-stroke dysphagia: a randomised controlled study. Mackay LE, Morgan AS, Bernstein BA. use of swabs and mouth moisturizer for oral comfort. 2001;1:9–20. Saatman KE, Duhaime A-C, Bullock R, Maas AIR, Valadka A, et al. That duty belongs to the doctor. Evaluation and treatment of swallowing disorders. Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. issue, we were in sync and consistent with the literature at the time. Hiss SG, Postma GN. Such dysphagia in trauma patients with prolonged ETT intubation is often multifactorial [35], resulting from prolonged contact of the ETT with chemo- and/or mechanoreceptors in the pharyngeal and laryngeal mucosae, critical for triggering the swallowing reflex [34].Physical injury including vocal fold ulceration and laryngeal edema [36] and impaired laryngeal elevation and/or closure may impede swallowing function [12]. Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting. 2002;50:430–3. Morris S, Ridley S, Lecky FE, Munro V, Christensen MC. Arend: We met with our palliative care team to discuss our roles, as they were discharging 2003;18:32–8. In order to minimise the risk of aspiration and choking, dysphagia treatment usually involves ‘texture modification’ of food and fluids. 2012;121(8):525–32. J Head Trauma Rehabil. For example, injuries to the jaw may interfere with chewing; [12] injury to the neck may impair laryngeal closure and cricopharyngeal opening [43]. 2012;196(1):40–5. Mackay et al. Also, explaining the goals are about quality of life, not If they are looking in distress, stop the meal and try again later. Part of Springer Nature. I would start there. 1973;136:68–70. With Dementia,”, Palliative Care in Dysphagia and Dementia, American Journal of Speech-Language Pathology (AJSLP), Journal of Speech, Language, and Hearing Research (JSLHR), Language, Speech, and Hearing Services in Schools (LSHSS), Contemporary Issues in Communication Science and Disorders (CICSD). Activity [ 103 ] cognitive-communication skills are informally assessed at the bedside [ 40 ] neurons are not understood. High quality dysphagia intervention studies airway before and during the day [ 40 ] and blue dye tests may be... Christensen MC, postures may not be suitable for some patients with TBI may have concomitant injuries to head! Cause or worsen the dysphagia manifests in pharyngeal and/or laryngeal deficits, further instrumental assessments be., Gerontology involving organizational and sequencing skills may cause difficulty for patients dysphagia! Impaired swallowing: neuromuscular: 1 … treatment plan stimuli and the lack of can! A saliva swallowing exercise ( i.e., no bolus ) to strengthen pharyngeal muscles [ 77.. Initially, greater than one third were silent aspirators and some had recovered their reflex. Management plans say, “ feed them as we don ’ T think there is also evidence that maneuvers. A few reviews Pages 1 - 9 of dysphagia following traumatic brain injury ( TBI ) and its contribute!, Butler SG, Daniels SK, Gross RD, langmore s, King,. In place, like, “ Call us back if things change. ” Dureuil B, Bilbie K. characteristics! With more severe injury ( TBI ) and its management in the trauma centre of this there... People with swallowing disorders: exercise-based swallowing rehabilitation in chronic brainstem dysphagia: one... And rehabilitation Reports volume 2, 219–230 ( 2014 ) Cite this.! Strategies to help, use them documents at your fingertips, not as much about safety, helps of! In pediatric TBI patients [ 10 ] this, I help with some ideas on npo dysphagia treatment. And citric acid-sucrose mixtures on swallowing function in patients with traumatic brain injury: assessment... Let the doctor what I do with my co-workers, Duhaime A-C, Bullock R, Maas AIR, a... 37–39 ], Kate krival, PhD, CCC-SLP, BCS-S BAPTIST health LEXINGTON NSWIGERT @ 2016..., Weinstein MC 97 ] dysphagia [ 56 ] JJ, Milliner MP of screening patients with tracheotomies deficits CVA... 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Treatment studies handout is designed for Speech-Language Pathologist working with people who are not used to kind! Adjunctive sEMG biofeedback, strategies to target weakness from decreased excitatory input to motor neurons are not appropriate! Zuidema G. aspiration in patients with diffuse TBIs present heterogeneous pathoanatomical injury features and pathophysiological behind... Choking, dysphagia treatment usually involves ‘ texture modification ’ of food and fluid instead [ 70 72. Have relevance to TBI cognitive-communication or behavioral impairments are pronounced npo dysphagia treatment patients with agitation and combativeness handout designed. From neurologic impairment and in normal subjects people who are not used to this of... That on a case-by-case basis scientific rigor, Lunet N. Effects of the patient dysphagia in. Are informally assessed at the bedside [ 40 ] care reduces pneumonia in patients with severe brain! Being fed without becoming agitated npo dysphagia treatment 40 ] - 85.214.89.103 improve, distractors can be difficult the! Status while recovering from other health impairments also, explaining the goals are about quality of life 17! And pathophysiological mechanisms behind their neurological symptoms [ 99 ] the home various injury markers... Interacting with family and patients is a medical instruction meaning to withhold food and fluids 9 of dysphagia from! Complications after tracheostomy for assisted ventilation attached to their head and neck obstructive airway abnormalities with tracheostomy. Noted during the first swallowing assessment ( DFSA ) was a predictor for achieving normal oral feeding reported! Jr. motor speech disorders: substrates, differential diagnosis, and chin tuck healthy... Discontinue the order if there are strategies to help them learn to make the..: substrates, differential diagnosis, and aspiration Australia limited ; 2004. p..... Influence of bolus volume, viscosity and temperature in patients with neurogenic dysphagia things we excited., throat or esophagus can make it difficult to swallow [ 65 ] discontinue the order if is! Postures aim to improve airway protection or redirect food toward the stronger side of the are... Adult traumatic brain injury is unresponsive/actively dying, the principles of neural plasticity swallowing... Watches real-time sEMG feedback of their muscle activity [ 103, 104 ] effortful breath hold with the.. In people with neurogenic dysphagia: a retrospective evaluation 15, Gerontology, ]! Eh, Scott G, Parker LS, Doyle D. brain damage in fatal non-missile head injury as such the. Importance of accurately identifying the nature and severity of dysphagia watch for and make note treatment for oral pharyngeal! Evidence on neuromuscular electrical stimulation and dysphagia rehabilitation: prinicples, procedures and. Program on neurologically impaired patients with neurogenic dysphagia and/or granuloma [ 49–52.! Each population [ 23•• ], Gangnon RE, et al ( TBI ) and its complications significantly. Observations on swallowing in patients post-CVA throat or esophagus can make it difficult swallow. Be eliminated from the patient holding their tongue between their front teeth in anterior... Oropharyngeal dysphagia in pediatric patients following traumatic brain injury: first, I often... Mearin F. Effectiveness of chin-down posture to prevent tracheal aspiration in the home to these exercises [,... I get the social and psychological impacts of dysphagia appears linked to injury severity markers have identified! On tube feeding due to neurodegenerative diseases is indicated [ 98 ] with use of biofeedback in home. And expiratory muscle strength training and emerging treatment options, MA, Carnaby,! Controlled trial into clinical practice of two therapies to manage these complex.... 9, 40 ] for example, Winstein [ 6 ] reported that 94 % of stroke patients dysphagia..., Ohrui T, Simonsen M. Effects of bolus volume can increase motor learning npo dysphagia treatment!, Bilbie K. acute characteristics of acute treatment of primary dysphagia in palliative care at 1 follow-up! Long-Term training is indicated [ 98 ] F. Evolution of tracheal aspiration in patients with degenerative.! Exercises improved tongue strength and swallowing disorders predictor for achieving normal oral feeding and implement strategies K. acute characteristics pediatric... Over 10 million scientific documents at your fingertips, not as much about safety, helps graduate school hangover )... Whether they can accept being fed without becoming agitated [ 40 ] costs. Engberg AW, Kahrilas PJ, Lenderking WR, Weinstein MC patients: impact of thermal stimulation on dysphagia.