Clinical Practice Guideline for the Management of Communication and Swallowing Disorders Following Paediatric Traumatic Brain Injury

Morgan, A., Mei, C., et al. (2017).

Melbourne (Australia): Murdoch Childrens Research Institute, 1-45.

This guideline provides recommendations for managing speech, language, and swallowing impairments in children up to 18 years of age within the first year of recovery after moderate or severe traumatic brain injury (TBI). The intended audience is "primarily ... hospital and community-based healthcare professionals who work with children with TBI in the early or rehabilitative phases of recovery" (p. 10).

Murdoch Children's Research Institute (Australia)

<div>"For speech and language disorders, treatment (i.e., cueing and educating families about interventions) can occur whilst the child is in post-traumatic amnesia (where appropriate). Formal treatment directed towards the child's impairment should commence after the patient has emerged from post-traumatic amnesia. The patient should receive regular therapy from local services post-rehab discharge (if available)" (Consensus-Based Recommendation; p. 40).</div>

<p>During formal or informal assessment of swallowing in children with traumatic brain injury, speech-language pathologists should assess:</p> <ul> <li>cognitive-behavioral factors such as alertness, fatigue, behavior, and insight;</li> <li>posture/positioning, tone;</li> <li>respiratory function;</li> <li>feeding and non-feeding bulbar and oral-motor assessment;</li> <li>oral phase (particularly effectiveness of oral transit);</li> <li>pharyngeal phase (particularly initiation of swallow and signs of aspiration); and</li> <li>a "need for non-oral feeding" (p. 31).</li> </ul> <p>"If clinically indicated (e.g., signs of aspiration)," instrumental assessment of swallowing should be used (Consensus-Based Recommendation; p. 34).</p>

<p>"Speech disorders should be managed by speech-language pathologists ... using the most efficacious evidence-based approach for the specific area of deficit" (p. 37). Treatment strategies may include:</p> <ul> <li>articulation or phonological therapy as needed;</li> <li>motor speech treatment "e.g., Lee Silverman Voice Treatment, Nuffield and compensatory strategies such as slow rate, over articulate, stress syllables" (p. 37);</li> <li>augmentative and alternative communication (AAC);</li> <li>activity and participation; and</li> <li>communication partner training and education (Consensus-Based Recommendation).</li> </ul>

<p>"Swallowing disorders should be managed by speech-language pathologists ... using the most efficacious evidence-based approach for the specific area of deficit" (p. 38). Treatment strategies may include:</p> <ul> <li>posture or position modification</li> <li>environmental support</li> <li>cognitive management (e.g., behavior, impulsivity, fatigue, awareness, pacing) with referral to other professionals if needed</li> <li>oral preparatory phase <ul> <li>"oral motor stimulation and exercises, systematic desensitization, jaw support, visual feedback for chewing" (p. 38)</li> <li>modified utensils&nbsp;</li> <li>modified textures or consistencies</li> </ul> </li> <li>oral phase <ul> <li>prompting for safe swallow strategies</li> <li>modified textures or consistencies</li> </ul> </li> <li>pharyngeal phase <ul> <li>modified textures or consistencies or nil per os (NPO)</li> <li>maneuvers or postures (e.g., chin tuck, supraglottic swallow, Mendelsohn maneuver)</li> <li>supplemental or alternate nutrition, as indicated by multidisciplinary team</li> </ul> </li> <li>parent/caregiver/staff education and training (Consensus-Based Recommendation)</li> </ul>

<div>"For swallowing disorders, treatment should occur post-extubation, when the patient is alert and able to manage their own secretions, and is responding appropriately to automatic movements. Treatment may commence with a tracheostomy in situ (if a child is chronically unable to manage their own secretions) with treatment focusing on tracheostomy management and education" (Consensus-Based Recommendation; p. 40).</div>

<p>For determining prognosis in speech/language or swallowing disorders in children with traumatic brain injury, there is limited evidence. However, the following variables may be taken into account:</p> <ul> <li>"extent and severity of brain damage (including size and site of lesion(s)) and other proxy measures e.g., Glasgow Coma Scale score, length of ventilation and intubation, loss of consciousness and length of post traumatic amnesia, brain surgery required post-injury, raised intracranial pressure;</li> <li>cause of [traumatic brain injury] TBI;&nbsp;</li> <li>cranial nerve involvement/palsy (speech and swallowing only);</li> <li>presence of seizures or other co-morbid medical conditions (e.g., loss of hearing or smell);</li> <li>extent of broader motor system involvement;</li> <li>additional physical/facial injuries (speech and swallowing only);</li> <li>trajectory of recovery post-injury (i.e., rapid vs. slow recovery in early phases);</li> <li>cognition (including visual and auditory system integrity, memory, attention, initiation, level of insight);</li> <li>compliance to recommendations;</li> <li>age/developmental stage at injury and pre-morbid functioning; [and]</li> <li>psychosocial support and pre-morbid family and social environment" (Consensus-Based Recommendation; p. 11).&nbsp;</li> </ul>

<p>When formally or informally assessing language in children with traumatic brain injury, speech-language pathologists should assess:</p> <ul> <li>pre-verbal communication skills, if age-appropriate;</li> <li>receptive and expressive spoken and written language, including discourse, narratives, attention, memory, executive functioning, impact on social skills and learning, and word-finding ability;</li> <li>functional communication such as conversational or social skills;</li> <li>augmentative and alternative communication (AAC), if applicable; and</li> <li>insight into impairment, as appropriate (e.g., "after approximately 4 years of age") (Consensus-Based Recommendation; p. 30)&nbsp;</li> </ul>

<p>"Language disorders should be managed by speech-language pathologists ... using the most efficacious evidence-based approach for the specific area of deficit" (p. 37). Treatment strategies may include:</p> <ul> <li>language stimulation and/or vocabulary intervention for pre-verbal/early communication</li> <li>expressive/receptive spoken and written language, including <ul> <li>scaffolding techniques including cueing, prompting, choices, and errorless teaching</li> <li>semantic, syntactic programs</li> <li>word finding, including confrontation naming</li> <li>literacy (reading, writing, narratives)</li> </ul> </li> <li>functional communication, including <ul> <li>social skills training</li> <li>functional tasks</li> <li>low-tech augmentative and alternative communication (AAC) such as gestures or picture boards</li> </ul> </li> <li>AAC as needed</li> <li>cognitive therapy as needed; should occur in consultation with psychologist if possible</li> <li>communication partner training and education (family, educational staff) (Consensus-Based Recommendation; p. 37)</li> </ul>

<div>"Speech-language pathologists should screen and monitor children with severe TBI for language deficits" (Evidence-Based Recommendation, Grade C Evidence; p. 24).</div>

<p>During formal or informal assessment for dysarthria in children with traumatic brain injury, speech-language pathologists should assess:</p> <ul> <li>articulation and phonological ability;</li> <li>voice;</li> <li>motor speech;</li> <li>intelligibility; and</li> <li>"insight and self-monitoring where appropriate (after approximately 4 years of age)" (Consensus-Based Recommendation; p. 31)</li> </ul> <p>Dysarthria assessment should include perceptual and, if appropriate and available, instrumental methods. Voice should be evaluated instrumentally, if clinically indicated (Consensus-Based Recommendation).</p>

<div>"Outcome measures (including Australian Therapy Outcome Measures (AusTOMS), Dysphagia Management Staging Scale, Oropharyngeal Swallow Efficiency, Goal Attainment Scales) should be used to document speech, language and swallowing outcomes pre- and post-therapy" (Consensus-Based Recommendation; p. 34).</div>

<p>After initial assessment, or as appropriate, speech-language pathologists should provide parents/caregivers and educators with education to support recovery of the child. Beneficial information may include:</p> <ul> <li>etiology and impact of speech, language, and swallowing deficits;</li> <li>definitions related to speech, language and swallowing as needed;</li> <li>expectations in the first year of recovery;</li> <li>"impact on social skills" (p. 41);</li> <li>intervention timing and factors that affect prognosis;</li> <li>"impact of monitoring and supporting" (p. 41) and techniques for support and advocacy; and</li> <li>return to school (Consensus-Based Recommendation).</li> </ul>

<div>It is suggested that speech-language pathologists conduct a brief initial assessment of "all areas of speech in all children moderate and severe [traumatic brain injury] TBI) (i.e., articulation, oral motor function, respiration, resonance, prosody, phonation, fluency)" (Evidence-Based Recommendation, Grade D Evidence; p. 31).</div>

<div>"Speech-language pathologists should commence treatment for speech, language and swallowing disorders in the acute stage once the patient is medically stable. In the early stages post-injury, priority may be given to swallowing and functional communication" (Consensus-Based Recommendation; p. 40).</div>

<div>It is suggested that SLPs conduct a brief initial assessment of "all areas of language in all children following moderate and severe [traumatic brain injury] TBI (i.e., semantics, syntax, morphology, phonology, and pragmatics) including narrative and word finding skills" (Evidence-Based Recommendation, Grade D Evidence; p. 30).</div>

<div>It is suggested that speech-language pathologists "assess core oral-pharyngeal phases of swallowing in all children following moderate and severe [traumatic brain injury] TBI (i.e., oral preparation, oral and pharyngeal)" (Evidence-Based Recommendation, Grade D Evidence; p. 31).</div>

<p>Recommendations for language assessment, with considerations for timing, are as follows:</p> <ul> <li>Within two days of admission, or when child is alert and medically stable, he/she should receive an informal language assessment by a speech-language pathologist. Following this, the child should be monitored "at least weekly for informal language performance" (p. 29), and when clinically indicated, assessed at key transition points (e.g., discharge from inpatient rehabilitation, hospital discharge).</li> <li>"Speech-language pathologists (SLP) should not administer a standardised language assessment earlier than 6 to 8 weeks post emergence from post-traumatic amnesia" (p. 29).</li> <li>Speech and language assessments may be required "at 3 to 6 months post-discharge, and then annually if deficits are ongoing" (p. 29).</li> <li>The child's language should be formally assessed before primary school and again before entering high school, or when concerns are present (Consensus-Based Recommendation).</li> </ul>

<div>It is suggested that "children with severe [traumatic brain injury] TBI and a ventilation period of greater than 1.5 days be screened by a speech-language pathologist for swallowing deficits" following extubation (Evidence-Based Recommendation, Grade D Evidence; p. 25).</div>

<div>"Speech-language pathologists and medical specialists and staff (e.g., doctors and nurses) are essential for the management of speech, language, and swallowing disorders, and should be referred during the acute stage. Children with a moderate or severe [traumatic brain injury] TBI should be referred ... to a speech-language pathologist during the acute phase (0 to 2 weeks)" (Consensus-Based Recommendation; p. 28). Regular monitoring should continue during inpatient and community rehabilitation.</div>

<p>Children should receive an initial swallowing assessment by a speech-language pathologist (SLP) within 2 days post-extubation, once he/she is alert and medically stable. If a swallowing disorder is identified, he/she should:</p> <ul> <li>be monitored at least weekly by SLP in acute and rehabilitation care; and</li> <li>assessed upon discharge and, if feeding difficulties persist, reviewed as needed by an SLP (Consensus-Based Recommendation).</li> </ul>

<p>Recommendations for assessment of speech, with considerations for timing, are as follows:</p> <ul> <li>Within two days of admission, or when the child with traumatic brain injury is alert and medically stable, he/she should receive a speech screening by a speech-language pathologist (SLP). The child should, when clinically indicated, be monitored by an SLP at transition points (e.g., from intensive care unit to inpatient rehabilitation, from inpatient to other rehabilitation setting) (Consensus-Based Recommendation; p. 29).&nbsp;</li> <li>Speech assessment may be required three to six months post-discharge, and annually if deficits continue (Consensus-Based Recommendation).</li> </ul>