VFSS vs FEES for Dysphagia Assessment in Infants with Down Syndrome
Videofluoroscopic swallow study (VFSS) should be the first-line instrumental assessment for infants with Down syndrome being evaluated for dysphagia. 1, 2
Rationale for VFSS as First-Line
VFSS remains the gold standard and preferred imaging modality for evaluating dysphagia in the pediatric population, including infants with Down syndrome. 1 The ACR Appropriateness Criteria specifically designate modified barium swallow (videofluoroscopic procedure) as the preferred method for oropharyngeal dysphagia assessment, performed in conjunction with a speech therapist to evaluate swallow function and examine rehabilitation strategies. 1
Key Advantages of VFSS in This Population
Comprehensive visualization: VFSS provides dynamic evaluation of the entire swallowing mechanism including oral cavity, pharynx, and cervical esophagus, assessing bolus manipulation, tongue motion, hyoid and laryngeal elevation, pharyngeal constrictor motion, epiglottic tilt, laryngeal penetration, and cricopharyngeus muscle function. 1
Critical for Down syndrome-specific pathology: Infants with Down syndrome demonstrate high rates of both oral phase dysphagia (89.8%) and pharyngeal phase dysphagia (72.4%), with abnormal sucking skills (63.7%), deficient bolus formation-control (62.2%), and abnormal swallow initiation (53.5%). 3 VFSS captures all these phases comprehensively.
Therapeutic guidance: VFSS allows testing with varying consistencies of barium and barium-impregnated foods to determine which consistencies can be swallowed safely and to establish compensatory strategies. 1, 2 This is particularly important as studies demonstrate dramatic reductions in aspiration with thickened liquids in infants. 2
Limitations of FEES in Young Infants
FEES has significantly lower diagnostic agreement with VFSS in young children compared to adults, making it less reliable as a first-line tool in this population. 4
Specific Performance Issues
Poor sensitivity for aspiration: FEES demonstrates only 50% sensitivity for detecting aspiration in young children (0.4-36 months), though specificity is higher at 82%. 4
Low diagnostic agreement: The agreement between FEES and VFSS in young children is low across all parameters (kappa = 0.061-0.302), unlike the near-parity seen in adults. 4
Risk of false negatives: A FEES negative for aspiration may miss significant aspiration risk, requiring interpretation in context of other risk factors. 4
Clinical Context for Down Syndrome Infants
Dysphagia is extremely common and clinically significant in infants with Down syndrome, warranting the most comprehensive initial assessment.
High prevalence: 57% of infants with Down syndrome ages 0-6 months have clinical concerns warranting VFSS referral, with 55% demonstrating confirmed dysphagia and 39% requiring feeding modifications or nonoral feeds. 5
Aspiration risk increases with age: Deep laryngeal penetration and/or aspiration occurs in 31.9% of infants <6 months and 51.3% of infants 6-12 months with Down syndrome. 6
Associated comorbidities: Laryngomalacia, pulmonary hypertension, pneumonia, and congenital cardiac disease are associated with dysphagia in this population. 6 Infants with desaturation during feeds have dramatically increased risk (OR = 15.8). 5
When FEES May Be Considered
FEES can serve as a supplemental or alternative assessment only in specific circumstances:
- When radiation exposure is absolutely contraindicated and must be avoided 7
- For bedside assessment when transport to radiology is not feasible 7
- As a follow-up tool after initial VFSS diagnosis to monitor therapeutic interventions 7
- When FEES findings are positive (high specificity means positive findings are likely significant) 4
Practical Implementation
All young infants with Down syndrome should be screened clinically for feeding and swallowing concerns, with VFSS referral for any identified concerns. 5
High-risk indicators requiring VFSS: Desaturation with feeds, functional airway/respiratory abnormalities, coughing during feeding, perceived swallowing problems, or fear of choking. 2, 5
Multidisciplinary approach: Assessment should involve speech-language pathologist collaboration during the VFSS to optimize therapeutic recommendations. 1, 2
Timing considerations: Swallow study findings are more likely to change in infants tested under 6 months of age (64.7% show changes on follow-up) compared to those tested at ≥6 months (20% show changes), suggesting need for serial assessments in younger infants. 6