How is a video-fluoroscopic swallowing study (VFSS) performed in infants?

Video-Fluoroscopic Swallowing Study (VFSS) Procedure in Infants

A video-fluoroscopic swallowing study (VFSS) in infants should be performed by a multidisciplinary team including a radiologist and speech-language pathologist, with the infant positioned upright in a specialized seating device while being fed barium-mixed liquids of varying consistencies to evaluate swallowing function and detect aspiration. 1, 2

Indications for VFSS in Infants

VFSS is indicated for infants who present with:

• Cough or persistent oxygen desaturation during feeding
• Suspected or confirmed vocal cord paralysis or airway anomalies
• Failure to wean from oxygen therapy or ventilatory support
• Persistent or worsening pulmonary hypertension
• Failure to thrive
• Chronic pulmonary symptoms disproportionate to viral infections 1
• Persistent wheezing not relieved by bronchodilators or corticosteroids 1

Required Personnel and Equipment

• Core team members:

  • Radiologist for imaging guidance and interpretation
  • Speech-language pathologist for swallowing assessment
  • Occupational therapist for feeding positioning
  • Radiology technician for equipment operation 2

• Equipment:

  • Fluoroscopy machine with video recording capability
  • Specialized infant seating device that provides proper positioning
  • Barium contrast media specifically formulated for infant use
  • Various nipples and bottles that mimic the infant's typical feeding equipment 2, 3

Procedural Steps

1. Preparation:

   • Mix barium contrast with the infant's typical feeding substance (breast milk, formula)
   • Prepare different consistencies (thin liquid, nectar-thick, honey-thick) as needed
   • Position infant upright (45-90 degrees) in specialized seating device 4, 3

2. Imaging Sequence:

   • Begin with lateral view to visualize oral and pharyngeal phases
   • Observe anterior-posterior view to assess symmetry of swallowing
   • Record continuous video during active feeding 4, 3

3. Assessment Protocol:

   • Evaluate oral phase (sucking efficiency, bolus formation)
   • Assess pharyngeal triggering (timing of swallow reflex)
   • Examine pharyngeal phase (laryngeal elevation, epiglottic inversion)
   • Identify aspiration or penetration events (rated on 8-point Penetration-Aspiration Scale) 5, 3

4. Quantitative Measurements:

   • Total pharyngeal transit time
   • Suck-swallow ratio (infants with >3 sucks per swallow have higher aspiration risk)
   • Pharyngeal constriction ratio
   • Bolus clearance ratio 3

5. Therapeutic Trials:

   • Test modifications to feeding position
   • Evaluate different liquid consistencies
   • Try alternative nipple types or flow rates
   • Assess effectiveness of swallowing maneuvers 4

Interpretation and Management

• VFSS can detect:

  • Silent aspiration (occurs in approximately one-third of infants with normal clinical feeding evaluations)
  • Tracheal aspiration or laryngeal penetration
  • Swallowing dysfunction patterns 2, 5

• Intervention based on findings:

  • Thickened feeds (primary intervention, reduces aspiration risk by >90%)
  • Modified feeding techniques (positioning, pacing)
  • Alternative feeding routes for severe cases (nasojejunal, gastrostomy) 1, 2

Important Considerations and Pitfalls

• Radiation exposure: Keep fluoroscopy time to minimum necessary for diagnosis (typically 20-second video loops of mid-feed sucking) 3

• Silent aspiration: Present in up to 83% of infants with swallowing dysfunction, making clinical observation alone insufficient 5

• Follow-up: Most infants with swallowing dysfunction show resolution within 3-9 months with appropriate interventions 1

• Common pitfall: Relying solely on clinical feeding evaluations, which miss approximately one-third of cases with silent aspiration 2, 5

• Diagnostic limitations: A normal VFSS in the first year of life does not necessarily predict absence of subsequent respiratory infections 6

By following this structured approach to VFSS in infants, clinicians can accurately identify swallowing dysfunction and implement appropriate interventions to reduce aspiration risk and improve feeding outcomes.