Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephalopathy

Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephalopathy

YJPDN-02085; No of Pages 8 Journal of Pediatric Nursing xxx (xxxx) xxx Contents lists available at ScienceDirect Journal of Pediatric Nursing journa...

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YJPDN-02085; No of Pages 8 Journal of Pediatric Nursing xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Pediatric Nursing journal homepage: www.pediatricnursing.org

Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephalopathy Renan Alves Silva a,⁎, Viviane Martins da Silva a, Marcos Venícios Oliveira Lopes a, Nirla Gomes Guedes a, Ana Railka Oliveira-Kumakura b a b

Programa de Pós Graduação em Enfermagem da Universidade Federal do Ceará, Fortaleza, Ceará, Brazil Programa de Pós Graduação em Enfermagem da Universidade Estadual de Campinas, Campinas, Ceará, Brazil

a r t i c l e

i n f o

Article history: Received 21 August 2019 Revised 30 September 2019 Accepted 1 October 2019 Available online xxxx Keywords: Deglutition Cerebral palsy Child Nursing diagnosis Validation studies

a b s t r a c t The purpose of this study was to analyze the accuracy of the defining characteristics of the nursing diagnosis of impaired swallowing in children with encephalopathy. The measures of diagnostic accuracy for each indicator were verified through latent class analysis. The prevalence of swallowing impairment was 59.76% for a total of 82 children evaluated. The defining characteristics that had good measures of sensitivity (range: 79.59–99.99) and specificity (range: 72.72–99.99) were as follows: food falls from the mouth, tongue action ineffective in forming bolus, prolonged bolus formation, inability to clear the oral cavity, and food refusal. Eight characteristics can be used as warning signs for impaired swallowing because they have high sensitivity values. In addition, ten characteristics presented high specificity and can be used to confirm this diagnosis in children with encephalopathy. Considering the findings of the swallowing pattern assessments through the analysis of the accuracy measures, it is verified that the evidence presented here should guide the pediatrics nurses in the diagnosis decision making. Indicators of high sensitivity should be used as warning signs for swallowing impairment, and the high specificity indicators should be used as a confirmatory sign of this condition and requires immediate intervention. © 2018 Published by Elsevier Inc.

Introduction Nutrition is a need that is vital to human existence and involves numerous physical, chemical, behavioral, social, religious and spiritual processes. Some population groups are more vulnerable to having chewing, swallowing and feeding propulsion, such as children with neurological dysfunctions (Mishra, Sheppard, Kantarcigil, Gordon, & Malandraki, 2017). Studies point out that the transportation of the food bolus from the oral cavity to the stomach is a complex activity and is coordinated by the brainstem. The literature also highlights that this process can be divided into three phases: oral, pharyngeal and esophageal (Luz & Mezzomo, 2015; Menezes, Santos, & Alves, 2017; Mishra et al., 2017). When deglutition becomes impaired, serious long-term complications, such as respiratory aspiration, malnutrition, dehydration and growth retardation, result (Dahlseng et al., 2012; Farias, Maróstica, & Chakr, 2017). Studies have shown that children with neurological dysfunctions such as chronic nonprogressive encephalopathy have a high

⁎ Corresponding author at: Federal University of Ceara, Alexandre Baraúna Street, 1115. Rodolfo Teófilo, Fortress-Ce, Cep: 60430-160, Brazil. E-mail address: [email protected] (R.A. Silva).

risk of aspiration and repeated episodes of pneumonia due to swallowing impairment (Dahlseng et al., 2012). Impaired deglutition is a nursing diagnosis that represents a deleterious condition impacting the quality of life of children with neurological dysfunctions and their relatives. Impaired deglutition interferes negatively with the care provided by the entire multidisciplinary team, especially the nursing team (Silva, Oliveira-Kumakura, & Silva, 2017; Menezes et al., 2017). Therefore, identifying the nursing diagnosis impaired swallowing (00103) as early as possible becomes indispensable in diverse aspects and clinical contexts. This diagnosis is defined in the taxonomy of NANDA International, Inc. (NANDA-I) as the “abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal or esophageal structure or function” (Herdman & Kamitsuru, 2017, p. 173). In 1986, nursing diagnosis impaired swallowing was proposed as a human response to be modified by nursing intervention facing clinical conditions and care contexts. Subsequently, in 1998, defining characteristics and related factors were modified and still in 2017, the related factors classified in related factors, associated conditions and populations at risk were restructured (Herdman & Kamitsuru, 2017). This diagnosis belongs to nutrition domain 2, to class 1 of ingestion and has a large number of defining characteristics structured according

https://doi.org/10.1016/j.pedn.2019.10.006 0882-5963/© 2018 Published by Elsevier Inc.

Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006

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to losses in the oral, pharyngeal and esophageal phases (Herdman & Kamitsuru, 2017). It is essential to understand and identify which elements are relevant for diagnostic inference in the care of children with neurological dysfunctions. In this context, studies of diagnostic accuracy are paramount for adequate diagnostic inference because the knowledge of the defining characteristics that have a better predictive capacity for a given diagnosis allows the nurse a greater precision in the choice of interventions to be implemented. Therefore, this research design allows the identification of the defining characteristics that can predict the diagnosis, favoring the improvement of the diagnostic inference process (Chaves et al., 2016; Silva, Melo, Caetano et al., 2017; Silva, Melo, Santos et al., 2017, Silva, Oliveira-Kumakura, & Silva, 2017). Thus, when the rehabilitation nurse identifies these clinical indicators, interventions directly related to the maintenance of an effective swallowing and decisive for a better prognosis of the child with these neurological conditions can be implemented early. In addition, nutritional and respiratory complications from this health condition can be avoided by directly influencing the survival and recovery of these children. A search including CINAHL and Pubmed and Scopus, revealed there is a gap in scientific evidence available about defining characteristics of impaired swallowing in children with neurological dysfunctions. Furthermore, articles about this nursing diagnosis included cross-sectional studies that reported factors indirectly associated with swallowing, such as the risk of aspiration in patients with stroke (Oliveira et al., 2015) and oral mucositis in patients with cancer (Araújo et al., 2015). In view of the previous considerations, this study aimed to analyze the accuracy of the defining characteristics of the nursing diagnosis impaired swallowing (00103) in children with encephalopathy. Also, it was defined as a specific objective to calculate the precision measurements in the different swallowing phases. Methods Design A diagnostic accuracy study with cross-sectional design was developed in a nucleus of treatment and early stimulation located in northeastern Brazil. Diagnostic accuracy studies were useful to define sensitivity and specificity of clinical indicators for a nursing diagnosis. Population and sample Eighty-two children and adolescents (2 years b age b 12 years), primarily diagnosed with cerebral palsy or microcephaly associated with Zika virus infection and with clinical characteristics of chronic nonprogressive encephalopathy recorded in the medical records were included by naturalistic sampling, allowing the inclusion of subjects consecutively as they attended the institution for medical treatment. In this study, clinical characteristics of chronic nonprogressive encephalopathy included involuntary movements, hypotonia/hypertonia, absence of cervical control, and muscular contractures. Subjects were excluded if they had one of the following clinical conditions: nutrition acquisition through a nasogastric or nasoenteral catheter; history of gastrostomy, jejunostomy or ileostomy as a transient or permanent route of feeding; cleft lip or palate; or laryngomalacia. Study protocol To capture the variables of the study, the conceptual and operational definitions of the defining characteristics of impaired swallowing were constructed, considering the specificities of the study population, by two main authors of the study. Then, the conceptual and operational definitions of each indicator were evaluated by members of a study and research group on Nursing Care in Children's Health (CUIDENSC) from Federal University of Ceará/Brazil. The group consisted of two

PhD professors and students of master/doctorate programs, and undergraduate nursing. The group was comprised of two researchers (PhD), five PhD students, five MSc and two undergraduates who attended assiduously the meetings for the construction of the data collection instruments and the development of operational definitions for each clinical indicator. In this step, the principal investigator presented definitions of each indicator to start the discussion with the group. The judges' suggestions were recorded in order to improve the conceptual and operational definitions of the defining characteristics by directing the structure of the data collection instrument. Each conceptual and operational definition of the clinical indicators was evaluated to verify if the constructed definitions expressed single idea, were pertinent and corresponded to the clinical indicator, and if the attributes were different from each other. For these discussions, eight meetings were held with a mean duration of 45 min, and the conceptual and operational definitions of the clinical indicators were refined according to the consensus of the suggestions made by the participants. The main conceptual modifications were to change terms by synonyms and describe them in the context of neurological dysfunctions and their relationship to impaired swallowing. Operational definitions have also been modified including a detailed description of the stages of the evaluation of some indicators and the establishment of criteria to classify them as present or absent. Subsequently, a pretest was performed with 10% of the sample to be investigated to verify possible gaps. The application of the pretest did not generate any change in the instrument. Thus, considering that there was no change in the study protocol, for example, including children surveyed in the total sample to be investigated. The defining characteristics of the oral phase according to the NANDA-I Taxonomy are: abnormal oral phase of swallow study; choking prior to swallowing; coughing prior to swallowing; drooling; food falls from mouth; food pushed out of mouth; gagging prior to swallowing; inability to clear oral cavity; incomplete lip closure; inefficient nippling; inefficient suck; insufficient chewing, nasal reflux, piecemeal deglutition, pooling of bolus in lateral sulci; premature entrance of bolus; prolonged bolus formation; prolonged meal time with insufficient consumption and tongue action ineffective in forming bolus. Regarding the characteristics of the pharyngeal phase were: abnormal pharyngeal phase in swallow study; alteration in head position; regurgitation; choking; coughing; delayed swallowing; fevers of unknown etiology; food refusal; gagging sensation; gurgly voice quality; inadequate laryngeal elevation; nasal reflux; recurrent pulmonary infection and repetitive swallowing. Regarding the characteristics of the esophageal phase were: abnormal esophageal phase in swallow study; heartburn; hematemesis; acidic-smelling breath; bruxism; difficulty swallowing; epigastric pain; food refusal; repetitive swallowing; reports “something pinched”; unexplained irritability surrounding mealtimes; hyperextension of head; nighttime awakening; nighttime coughing; odynophagia; regurgitation; volume limitation; vomiting and vomit on the pillow. The defining characteristics investigated were: drooling; food falls from the mouth; food pushed out of the mouth; inability to clean the oral cavity; insufficient chewing; incomplete lip closure; nasal reflux, fragmented swallowing, bolus accumulation in the lateral sulci; prolonged bolus formation; prolonged meal time with insufficient consumption and ineffective tongue action in bolus formation; change in head position; cough; fever of unknown etiology; refusal to eat; inadequate laryngeal elevation; nasal reflux; recurrent pulmonary infection; repetitive swallowing; hematemesis; acid-smelling breath; bruxism; difficulty swallowing; refusal to eat; heartburn; repetitive swallowing; unexplained irritability around meals; hyperextension of the head; regurgitation; night waking up; night cough; vomiting and vomiting on the pillow. The defining characteristics unable to be collected in this study were: abnormal oral phase of swallow study; premature bolus entry; inefficient nipple; weak suction; choking before swallowing; coughing

Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006

R.A. Silva et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

before swallowing; suffocate before swallowing; abnormal pharyngeal phase in swallow study; late swallowing; gurgly voice quality; abnormal esophageal phase in swallow study; epigastric pain; heartburn; reports “something compressed”; odynophagia and volume limitation. It is noteworthy that the circumstances that led to the exclusion of these characteristics were due to the fact that were found from videofluoroscopy, an exam considered the gold standard to diagnose dysphagia not available in the service; Impairment of cognitive-motor domains, making it difficult to investigate them in this population, shows sufficient limit values of the gastric capacity of the target population of the study and due to the age group chosen for the study. Data collection Data collection took place from August to November 2016 using a form-based instrument based on the defining characteristics of NANDA-I impaired swallowing diagnosis. The form considered sociodemographic data for children and caregivers, clinical and dietary information, and general clinical evaluation. These data measured the defining characteristics of the studied diagnosis. The researchers contacted the institution's health professionals to determine which children met the criteria for inclusion in the study. The principal researcher has been involved with the development of research and continuing education projects at the institution where the study was conducted. She was responsible for prior contact and obtaining parental consent and proceeding to the later stages of data collection. Then, the researchers approached the caretakers responsible for the children and explained all the objectives of the research and the procedures involved in the research; as well as emphasized that this study was voluntary, confidential and that the possibility of leaving the study would not interfere with clinical care. Those responsible were informed as to the foreseeable risk of aspiration of food. However, the researchers were prepared to intervene immediately in the maneuvers if any signs suggestive of respiratory aspiration or discomfort were evident. In this way, data collection would be stopped. The invitation to participate in the study was made. Once an agreement was reached, following the routine of speech therapy service, the caretaker was requested to fast the child after 11 am on the day of the evaluation, with a minimum interval of two hours and a maximum of four hours, in order to avoid possible food refusals. Prior to the commencement of collection, researchers were trained to systematically standardize as defining features of conceptual and operational settings using data collection instrument and swallowing management techniques (consistency, fracturability, texture, flavors, temperature, viscosity). They were also instructed on how to proceed in cases of respiratory breathing through facilitating maneuvers such as supraglottic, supersuppraglotic, forced swallowing and Mendelsohn maneuver; postural changes or adjustments (posterior head displacement, lateral head displacement, axis displacement, head rotation and/or lateral decubitus). For data collection, instruments were used to perform the physical examination, such as the Class II Pediatric Littmann® stethoscope and Rossmax Medical® portable pulse oximeter in order to evaluate cardiovascular and pulmonary changes as well as a Sanny® goniometer to evaluate postural changes during swallowing. The principal investigator and two speech therapists from the institution's dysphagia outpatient clinic collected data. This evaluation was fundamental to identify the chewing capacity and progression of food of different consistencies in children with encephalopathy. Goniometry is an evaluation technique used as a functional diagnostic tool to objectively measure joint motion amplitudes. The goniometer is a durable, washable and inexpensive instrument that resembles a protractor with two long arms (one fixed and one mobile). An axis that must be aligned with the longitudinal axis of the segments adjacent to the joint, and the center should be positioned over the axis of the joint to be examined. In this study, the fixed part of the goniometer was

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aligned to the sternoclavicular joint. Thus, during the supply of food consistency, we tried to observe the presence of head tilt backwards. The cervical hyperextension was established by an angle N70° when associated with protrusion of the lips, mandible, tongue and bite during swallowing. The food was prepared following the guidelines contained in Resolution No. 216/04 of the National Surveillance Agency (Brazil, 2004). Menus were made with nutritional values recommended by the national dysphagia diet in the following consistencies: liquid, semiliquid, semisolid and solid. According to food preferences, the caregivers decided which foods to offer, taking into account the clinical evaluation of the orofacial structures. After choosing preferences for flavors and textures, the caregivers offered the food to the children. To perform this research step, the child was placed in a chair adapted with anthropometric adjustments in order to facilitate the observation of postural patterns and behaviors during swallowing. The chairs with anthropometric adjustments are built in the occupational therapy service itself in order to keep the child in an upright position through the use of rods according to their height and weight. It should be noted that the foods were offered starting with a lower-density and progressing to higher-density consistency, in the following order: liquid, semiliquid, semisolid and solid. Flavors progressed from savory to sweet, in order to avoid refusal or preference as to the type of consistency and flavor. Then, each participant in the study received a cup containing approximately 10 ml of each food consistency, which was offered gradually (2 ml, 3 ml, and 5 ml) by the responsible caregiver. Caregivers were not previously trained in how to manage food consistency. However, it was established that foods should always start from the most liquid consistencies to the solid ones; as well as from the salty to the sweetest with the intention of reducing the refusal of food. Solid foods were offered gradually (small, medium and large pieces) after assessing the child's ability to proceed with the sizes offered. Data analysis The data obtained during the evaluation were compiled in Excel software 2007, analyzed statistically with the support of the statistical package SPSS version 20.0 for Windows® and R software version 2.12.1, and the results were synthesized into tables. The descriptive analysis of the data included the calculation of absolute frequencies, percentages, measures of central tendency and dispersion. For the proportions of categorical variables, 95% confidence intervals were calculated. The Lilliefors test was applied to check for a normal distribution. The association between the defining characteristics and sociodemographic or clinical data was analyzed with a chisquare test for independence. To verify the sensitivity and specificity of each defining characteristic, the latent class analysis method was used (Collins & Lanza, 2010). This method is used when there is no perfect standard reference, as in the case of nursing diagnoses. Models based on two latent classes were adjusted for each swallowing phase to calculate measures of sensitivity and specificity with the 95% confidence intervals (Qu, Tan, & Kutner, 1996). A total of four latent class models for each swallowing phase were analyzed separately due to the large number of defining characteristics and the small sample size. In the present study, the nursing diagnosis of impaired swallowing was considered the latent variable, and the defining characteristics of each phase were considered the variables whose interrelationships were explained by the latent variable. Initially, a saturated model with all the defining characteristics of each phase of the swallowing process was adjusted. Then, characteristics that had 95% confidence intervals ranging from 0.5 (50%) for both sensitivity and specificity were sequentially excluded until a model in which all the components of the model had at least one diagnostic accuracy measurement N0.5.

Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006

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R.A. Silva et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

The likelihood ratio test (G2) and the entropy measure were calculated to verify the goodness of fit of the models. When the G2 test showed significance at the 5% level, indicating poor fit, the defining characteristics were sequentially excluded from the model, first considering those with the highest standard error until an adequate adjustment was obtained based on a nonsignificance of G2 test (p N 0.05) and an entropy measure ≥0.8. The entropy measure was used to verify whether the model was able to separate the two classes (with and without the nursing diagnosis). Values above 0.8 indicated good separation of the identified groups (the maximum value is 1.0). Random effects were applied to latent class models because of the conditional dependence between clinical signs and symptoms that present a strong physiological interrelationship, as is the case with the defining characteristics of impaired swallowing. It should be noted that the sensitivity value indicates the proportion of subjects with the nursing diagnosis for which the indicator was present representing defining characteristics initially present among subjects with the diagnosis. The specificity indicates the proportion of subjects without the diagnosis for whom the indicator was absent representing confirmatory defining characteristics for the nursing diagnosis (Lopes, Silva, & Araujo, 2012).

Most of the children had a medical diagnosis of cerebral palsy (n = 63; 76.8%) and only 23,2% (n = 19) of the children were diagnosed with microcephaly related to Zika virus infection. Regarding motor impairment and topographic location, the majority was classified with quadriplegia (n = 47; 74.60%), followed by diplegia. Regarding muscle tone impairment, there was a high prevalence of motor spasticity (n = 38; 60.32%). Regarding variables related to clinical conditions, the majority of caregivers did not exclusively breastfeed (n = 70; 85.4%). The minimum breastfeeding time was three days, and the maximum was three months. The participants underwent other types of breastfeeding, such as complementary or mixed. All the children used a baby bottle during the lactation/breastfeeding period, and 82.9% (n = 68) used pacifiers daily. From a total of 29 defining characteristics identified in the sample, eight were found in N70%. The frequency of all of the defining characteristics identified in children and adolescents with encephalopathy is presented in Table 2. The prevalence of the nursing diagnosis impaired swallowing in children with encephalopathy was 59.76%. The adjusted model showed a maximum entropy value with seven defining characteristics. Sensitive defining characteristics were as follows: tongue action ineffective in forming bolus (100%), prolonged bolus formation (100%), difficulty swallowing (87.71%), inability to clear the oral cavity (87.71%), and inefficient capturing of food bolus (81.65%). For defining characteristics with good specificity measures, there was an inability to clear the oral cavity (99.99%), prolonged bolus formation (99.99%), food refusal (99.99%), tongue action ineffective in forming bolus (99.99%), and insufficient chewing (99.99%). The defining characteristics that showed good measures of sensitivity and specificity were as follows: inability to clear the oral cavity, tongue action ineffective in forming bolus, and prolonged bolus formation. These defining characteristics are essential to predict the presence of impaired swallowing in children with neurological dysfunctions (Table 3). Then, to accomplish the objectives, specific adjusted models were constructed for each phase of swallowing. In the adjusted model for the deglutition phase, defined by the oral and oral anticipatory mechanisms, the defining characteristics that had good sensitivity measurements included tongue action ineffective in forming bolus (99.99%), prolonged bolus formation (99.99%), difficulty swallowing (87.75%), inability to clear the oral cavity (87.75%), inefficient capturing of food bolus (81.63%), food falls from the mouth (79.59%), and prolonged meal time with insufficient consumption (69.39%). The defining characteristics that had good specificity were as follows: tongue action

Ethical issues The consent of the research institution was granted by the Research Ethics Committee of the responsible institution (Code number: 53821416.2.0000.5054). Results To determine the accuracy measures of the defining characteristics of the nursing diagnosis of impaired swallowing contained in NANDAI, this study evaluated 82 children with neurological dysfunctions using a standardized data collection instrument in order to guarantee the fidelity of the findings. The majority of the children was male (62.2%), nonwhite (56.1%), had a family income below USD 235.00 (76.8%) and did not attend daycare (95.1%). The median age of the children was 3.45 years (IQR = 3.5) (Table 1). The sociodemographic variables of the caregivers of the children showed that the majority was female (n = 81; 98.8%), had a partner (n = 75; 91.5%) and did not work at the time of data collection (n = 82; 100%). Caregivers had a median age of 28.0 years (IQR = 12.0) and an average schooling of 6.94 years (±2.83).

Table 1 Demographic characteristics of the sample (n = 82). Variables

N

%

95% CI

Gender Male Female

51 31

62.2 37.8

51.38 28.08

71.92 48.62

Race White Non-white

36 46

43.9 56.1

33.67 45.32

54.68 66.33

Family income ≤USD 235.00 NUSD 235.00

63 19

76.8 23.2

66.62 15.37

84.63 33.38

Attend daycare Yes No

4 78

4.9 95.1

1.91 88.12

11.88 98.09

Age

Mean

SD

Median

IQR

p-valuea

3.46

2.02

3.45

3.50

b0.001

CI: confidence interval. a Lilliefors test for normality.

Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006

R.A. Silva et al. / Journal of Pediatric Nursing xxx (xxxx) xxx Table 2 Defining characteristics of impaired swallowing presented by the sample (n = 82). Defining characteristics

n

%

95% CI

1. Inadequate laryngeal elevation 2. Insufficient suck 3. Alteration in head position 4. Drooling 5. Incomplete lip closure 6. Pooling of bolus in lateral sulci 7. Unexplained irritability surrounding mealtimes 8. Prolonged meal time with insufficient consumption 9. Repetitive Swallowing 10. Recurrent pulmonary infection 11. Tongue ineffective in forming bolus 12. Prolonged bolus formation 13. Nighttime coughing 14. Food falls from mouth 15. Difficult swallowing 16. Inability to clear oral cavity 17. Regurgitation 18. Piece meal deglutition 19. Food pushed out of mouth 20. Insufficient chewing 21. Nighttime awakening 22. Bruxism 23. Food refusal 24. Hyperextension of head 25. Acidic-smelling breath 26. Nasal reflux 27. Vomitus on pillow 28. Vomiting 29. Fevers of unknown etiology

70 69 64 61 61 60 59 59 56 53 49 49 48 48 47 43 39 38 33 30 27 26 24 20 19 10 7 7 3

85.4 84.1 78.0 74.4 74.4 73.2 72.0 72.0 68.3 64.6 59.8 59.8 58.5 58.5 57.3 52.4 47.6 46.3 40.2 36.6 32.9 31.7 29.3 24.4 23.2 12.2 8.5 8.5 3.7

76.14 74.74 67.9 64.00 64.00 62.70 61.41 61.41 57.60 53.84 48.94 48.94 58.54 58.54 46.52 41.76 37.10 35.96 30.30 26.98 23.72 22.65 20.53 16.38 15.37 6.76 4.20 4.20 1.25

91.43 90.49 85.64 82.60 82.60 81.56 80.52 80.52 77.35 74.11 69.70 69.70 68.58 68.58 67.46 62.70 58.24 57.06 51.06 47.39 43.66 42.40 39.87 34.69 33.38 21.01 16.59 16.59 10.21

CI: confidence interval.

ineffective in forming bolus (99.99%), insufficient chewing (99.99%), prolonged bolus formation (99.99%), inability to clear the oral cavity (99.99%), and food falling from the mouth (72.72%). The characteristics that had good measures of sensitivity and specificity in the first phase of swallowing were as follows: tongue action ineffective in forming bolus, prolonged bolus formation, inability to clear the oral cavity, and food falls from the mouth (Table 4). In the esophageal phase of deglutition, six defining characteristics showed a good fit to the latent class model. Among the defining characteristics, only difficulty swallowing (99.99%) and food refusal (99.48%) were highlighted as indicators with high sensitivity. Regarding the specificity, good measures of the following defining characteristics were found: food refusal (99.99%), bruxism (74.15%), acidic smelling breath (74.10%), nighttime awakening (72.40%), and hyperextension of head (72.39%). It was also observed that this latent class model showed a good fit, since the entropy value

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was 0.97. These defining characteristics are confirmatory clinical indicators of impaired swallowing (Table 5). Discussion Regarding previous diagnostic accuracy studies of impaired swallowing, similar results are observed in this study, in which the prevalence was higher than 50%. (Otapowicz et al., 2010; Arvedson, 2013; Benfer et al., 2013; Erasmus, Van Hulst, Rotteveel, Willemsen, & Jongerius, 2012; Clancy & Hustad, 2011). It should be noted that in this study, it was understood that dysphagia is a phenomenon similar to impaired deglutition. Several indicators, including tongue action ineffective in forming bolus, prolonged bolus formation, inefficient capturing of food bolus, difficulty swallowing, inability to clear the oral cavity, food falls from the mouth, prolonged meal time with insufficient consumption, and food refusal, had valid sensitivity in at least one of the models of the latent class. Therefore, it is inferred that the indicators help in the identification of impaired swallowing, thus favoring clinical decision-making and the direction of the nursing interventions (Butcher, Bulechek, Dochterman, & Wagner, 2018). “Tongue action ineffective in forming bolus” refers to the absence of the propulsive thrust of the tongue into the anterior and lateral vestibules of the oral cavity to form the alimentary content. In children with neurological dysfunctions, the tongue's lack of action results from muscle hypotonia, which hinders its ability to flatten, sharpen, and make a concavity in the center. In this condition, the tongue is often thick and enlarged and lacks the lateral groove that assists in moving the bolus from front to back in swallowing (Kamide, Hashimoto, Miyamura, & Honda, 2015). Prolonged bolus formation may be defined as an increase in the preparation and oral transit time of the cohesive bolus for swallowing. Time is over one second for liquid consistency foods and over three seconds for semi-liquid/semi-solid foods (Lustre, Freire, & Silvério, 2013). Additionally, it is noted that the inability to clear the oral cavity includes the inability to form the food bolus and move it to the pharynx. This inability generates food retention in the mouth after the third deglutition with a time greater than three seconds for food of a semiliquid/semisolid consistency and four seconds for food of a solid consistency (Araújo, Silva, & Mendes, 2012; Kamide et al., 2015; Lustre et al., 2013). The inefficient capturing of the food bolus refers to the inability to bring the device to the mouth and/or capture all the food contained in the device. This measure identifies the child's ability and accuracy to collect food and move it toward the mouth. The defining characteristic of food falling from the mouth is defined as the occurrence of nutrient slip after lip capture (Queiroz, Andrade, Haguette, & Haguette, 2011).

Table 3 Latent class model adjusted for diagnosis Impaired Swallonwing from all defining characteristics (n = 82). Defining characteristics

Sensitivity

IC95%

Pooling of bolus in lateral sulci Food falls from the mouth Drooling Bruxism Inefficient capturing of food bolus Repetitive swallowing Nighttime awakening Difficulty swallowing Tongue action ineffective in forming bolus Insufficient chewing Incomplete lip closure Prolonged bolus formation Acidic-smelling breath Inability to clear the oral cavity Food refusal Prolonged meal time with insufficient consumption Prevalence

71.45 79.63 71.46 38.75 81.67 71.45 42.84 87.79 100.00 61.24 73.50 100.00 20.37 87.79 48.97 69.42 59.76%

55.1 66.0 55.4 25.4 64.5 56.3 29.1 74.1 100.00 46.5 59.9 100.00 11.3 49.5 34.2 54.7

83.6 88.5 82.2 53.7 90.4 81.4 57.1 94.1 100.00 73.8 84.7 100.00 37.9 97.5 63.9 80.8

Specificity

IC95%

24.2 72.68 21.2 78.7 12.1 36.4 81.7 87.8 100.00 100.00 24.20 100.00 72.60 100.00 100.00 24.20

12.9 51.20 10.00 58.5 5.1 21.7 61.3 32.1 100,00 100.00 12.50 100.00 52.50 100.00 100.00 11.90 Entropy: 100.00

0,429 0,848 43.6 88.8 28.9 56.00 92.1 98.6 100.00 100.00 44.60 100.00 84.90 100.00 100.00 45.50

CI: confidence interval.

Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006

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R.A. Silva et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

Table 4 Latent class model adjusted for diagnosis impaired swallowing from defining characteristics of the oral and oral anticipatory phase (n = 82). Defining characteristics Inefficient capturing of food bolus Pooling of bolus in lateral sulci Drooling Difficulty swallowing Tongue action ineffective in forming bolus Insufficient chewing Incomplete lip closure Prolonged bolus formation Inability to clear the oral cavity Food falls from the mouth Prolonged meal time with insufficient consumption Prevalence:

Sensitivity 81.63 71.43 71.43 87.75 99.99 61.22 73.47 99.99 87.75 79.55 69.39 59.76%

IC95% 68.30 57.30 57.00 72.90 99.90 46.99 59.20 99.90 73.90 63.10 54.8

89.60 82.00 82.10 94.00 100.00 73.40 83.50 100.00 94.60 88.10 79.7

Specificity 12.11 24.22 21.22 87.88 99.99 99.99 24.22 99.99 99.99 72.77 24.20 Entropy: 100.00

IC95% 2.60 12.20 9.50 40.80 99.90 99.90 12.30 99.90 99.90 54.20 13.00

51.10 44.00 45.20 97.90 100.00 100.00 44.90 100.00 100.00 85.10 45.10

CI: confidence interval.

This response is commonly reported by almost all children with neurological dysfunction. Difficulty swallowing is defined as the identification of clinical signs that suggest resistance to the progression of solid or liquid foods from the mouth to the lower larynx (Otapowicz et al., 2010). The main signs of difficulty swallowing are food stasis in the oral cavity, incomplete lip closure, mouth feeding, repetitive swallowing, a change in breathing rate, fast or difficult breathing, a change in heart rate, a 2% decrease in oxygen saturation during swallowing, perioral cyanosis, cough and choking (Benfer et al., 2013). In view of the sensitivity and specificity measures, changes in tone and mobility of the lips, cheeks and tongue contribute to increased oral transit time and, consequently, to a decrease in the formation of the bolus, favoring the pooling of the bolus in the lateral sulci of the oral cavity. The literature indicates that oral transit time is regulated by specific areas of the cerebral cortex responsible for voluntary movement. However, in children with neurological dysfunctions due to motor and cognitive disorders, oral transit time is increased (Goh, Choi, Kim, Park, & Park, 2018). It is verified that the diagnostic accuracy measurements present similar results to another study that compared the use of videofluoroscopy with clinical evaluation of swallowing in chronic non-progressive encephalopathy, in which clinical indicators: inability to empty the oral cavity, prolonged bolus formation, lingual in bolus formation, and insufficient fork mastication and specificity N80% (Santos et al., 2014). All the defining characteristics that have good measures of accuracy belong to the oral phase of deglutition. In this sense, it is essential to evaluate the structure of the stomatognathic system as well as the feeding dynamics of the child with neurological dysfunctions to determine the nursing diagnosis, to plan nursing interventions, to determine effectiveness of interventions and to evaluate the impact of an intervention on the reduction or minimization of possible clinical occurrences. There was no adjusted model identified for the defining characteristics of the second phase of swallowing. It was observed that some of Table 5 Latent class model adjusted for diagnosis Impaired swallowing from Esophageal phase defining characteristics (n = 82). Defining characteristics

Sensitivity IC95%

Bruxism Nighttime awakening Vomitus on pillow Hyperextension of head Food refusal Acidic –smelling breath Difficulty swallowing Prevalence:

43.00 46.00 3.00 19.00

25.00 29.00 0.00 2.00

65.00 66.00 100.0 75.00

75.00 75.00 88.00 72.00

59.00 59.00 72.00 54.00

75.00 16.00

0.00 3.00

99.00 60.00

100.00 72.00

100.00 10.000 54.00 84.00

100.00 38.82%

100.00 100.00 69.00 0.00 Entropy: 0,74

CI: confidence interval.

Specificity IC95% 86.00 87.00 94.00 84.00

99.00

defining characteristics of this phase are part of other phases of swallowing or the scope of other diagnoses such as risk of aspiration. The results in this study align with the practice of pediatric nurse who provides long-term care to children with complex health care needs, long-term conditions in rehabilitation and community-based settings. It is important to manage the ability of these children to ingest, chew, swallow and propel food satisfactorily (Vaughn et al., 2016). Therefore, the evidence presented here should guide rehabilitation nurses in the management of food consistencies, flavors and textures, favoring nutrition in a balanced way and optimizing the processing of foods in the oral cavity. There was a lower frequency of defining characteristics in the pharyngeal and esophageal phases, allowing us to confirm that swallowing changes can be managed (Silva, OliveiraKumakura, & Silva, 2017). Pediatric nurses have been discussing and improving methods that increase the effectiveness of their care. A previous integrative review emphasizes that the efficacy of the rehabilitation of patients with impaired swallowing can be demonstrated by the ability to feed orally, weight gain, and reduction in the occurrence of aspiration pneumonia (Silva, Oliveira-Kumakura, & Silva, 2017). Other studies point out that difficulties in swallowing may develop or worsen in adulthood and suggest changes in eating, swallowing, and the use of nasogastric or nasoenteral catheterization to support feeding. In particular, high digestive changes may trigger nutritional deficits, problems in the growth curve, more hospitalizations, and need for surgical interventions (Araújo et al., 2012; Vianna & Suzuki, 2011). Thus, pediatrics nurses should rely on evidence-based practices to optimize outcomes through the use of diagnostic information. Early actions based on an accurate diagnostic inference of impaired swallowing may reduce episodes of bronchoaspiration and pulmonary infections from the misuse of nasogastric catheters (Vaughn et al., 2016). This study favors the dissemination of the knowledge of a nursing problem that needs to be managed during the care process and directs aspects to health care for children with encephalopathy. The accurate identification of a nursing diagnosis is the starting point for the search for better health outcomes. In addition to the definition of nursing interventions, the pediatric nurse must define care goals, establishing the outcomes that will measure the quality of care provided. The Nursing Outcomes Classification (NOC) establishes five main outcomes for the nursing diagnosis impaired swallowing: Swallowing status, Swallowing status: oral phase, Swallowing status: esophageal phase, Swallowing status: pharyngeal phase, and Prevention of deglutition aspiration (Moorhead, Johnson, Maas, & Swanson, 2018). In this context, the establishment of outcomes allows the child to engage with the interprofessional team and other caregiver networks to identify expected outcomes, in addition to defining culturally sensitive expected outcomes, and use current evidence-based clinical experience and practice to identify health risks, benefits, costs and/or expected trajectory of the clinical condition (American Nurses Association, 2015).

Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006

R.A. Silva et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

In this study, it was observed that children with progressive chronic encephalopathy, affected by quadriplegia and hemiplegia/diplegia, had a severe clinical spectrum of the study diagnosis. Children with quadriplegic spasticity had a severe spectrum of impaired swallowing. It is essential to focus on the critical observations that the studies must be carried out with the purpose of analyzing the relationship between the degrees of clinical spectrum and an association with medical diagnoses to confirm such findings. Limitations The results obtained in this study should be viewed with caution, since the sample size may have influenced the construction of the latent class adjusted models because several low-frequency characteristics were excluded. The sample size may have influenced the presence of the defining characteristics and the high prevalence of the diagnosis in the sample evaluated. It takes into account that the cross-sectional design allows only timely assessment of clinical condition of children should be, and that the evaluation of two different medical conditions (cerebral palsy and infection zika virus), while presenting some similar clinical signs of encephalopathy, can clinically present different developments. The objectives of this study were limited to the clinical evaluation process of nursing diagnosis Deglutition impaired and, therefore, cannot be seen as a guarantee of establishing effective care. Implications for nursing practice Identifying the sensitive and specific defining characteristics of this diagnosis allows the nurse to intervene early, favoring the maintenance of effective swallowing. This early intervention reduces the nutritional and respiratory complications resulting from impaired swallowing and increases the survival of these patients. Considering the findings of the swallowing pattern assessments through the analysis of the accuracy measures, it is verified that the evidence presented here should guide the pediatrics nurses in the diagnosis decision making. Indicators of high sensitivity should be used as warning signs for swallowing impairment, and the high specificity indicators should be used as a confirmatory sign of this condition and requires immediate intervention. Conclusion This study made it possible to verify the diagnostic accuracy of impaired swallowing in children with neurological dysfunctions. We verified that eight defining characteristics had good sensitivity measurements and ten had good measures of specificity. This research will allow the improvement of the nursing diagnosis in question and will offer a better understanding of how this nursing diagnosis manifests in this clientele. This research also suggests the indicators that should alert the nurse to the diagnosis in question. Funding The authors declare that they have not received funding for the development of this study. Declaration of competing interest The authors declare no conflict of interest in the production and dissemination of this study in the journal. Acknowledgment Conselho Nacional de Pesquisa (CNPq) of the Federative Republic of Brazil.

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Please cite this article as: R.A. Silva, V.M. da Silva, M.V.O. Lopes, et al., Diagnostic accuracy of the defining characteristics of impaired swallowing in children with encephal..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.10.006