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Pediatric Eating Assessment Tool-10 as an Indicator to Predict Aspiration in

Children With Esophageal Atresia

Article  in  Journal of Pediatric Surgery · March 2017

DOI: 10.1016/j.jpedsurg.2017.02.018

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 Journal of Pediatric Surgery 52 (2017) 1576–1579

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Pediatric Eating Assessment Tool-10 as an indicator to predict aspiration

in children with esophageal atresia☆
Tutku Soyer a,⁎, Sule Yalcin a, Selen Serel Arslan b, Numan Demir b, Feridun Cahit Tanyel a
a
Hacettepe University Faculty of Medicine, Department of Pediatric Surgery, Ankara, Turkey
b
Hacettepe University Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ankara, Turkey.

a r t i c l e i n f o a b s t r a c t

Article history: Aim: Airway aspiration is a common problem in children with esophageal atresia (EA). Pediatric Eating
Received 16 December 2016 Assessment Tool-10 (pEAT-10) is a self-administered questionnaire to evaluate dysphagia symptoms in children.
Received in revised form 20 January 2017 A prospective study was performed to evaluate the validity of pEAT-10 to predict aspiration in children with EA.
Accepted 20 February 2017 Methods: Patients with EA were evaluated for age, sex, type of atresia, presence of associated anomalies, type of
esophageal repair, time of definitive treatment, and the beginning of oral feeding. Penetration-aspiration score
Key words:
(PAS) was evaluated with videofluoroscopy (VFS) and parents were surveyed for pEAT-10, dysphagia score
Esophageal atresia
Pediatric Eating Assessment Tool-10
(DS) and functional oral intake scale (FOIS). PAS scores greater than 7 were considered as risk of aspiration.
Aspiration EAT-10 values greater than 3 were assessed as abnormal. Higher DS scores shows dysphagia whereas higher
Respiratory problems FOIS shows better feeding abilities.
Deglutition Results: Forty patients were included. Children with PAS greater than 7 were assessed as PAS+ group, and scores
less than 7 were constituted as PAS− group. Demographic features and results of surgical treatments showed no
difference between groups (p N 0.05). The median values of PAS, pEAT-10 and DS scores were significantly higher
in PAS+ group when compared to PAS- group (p b 0.05). The sensitivity and specificity of pEAT-10 to predict
aspiration were 88% and 77%, and the positive and negative predictive values were 22% and 11%, respectively.
Type-C cases had better pEAT-10 and FOIS scores with respect to type-A cases, and both scores were statistically
more reliable in primary repair than delayed repair (p b 0.05). Among the postoperative complications, only
leakage had impact on DS, pEAT-10, PAS and FOIS scores (p b 0.05).
Conclusions: The pEAT-10 is a valid, simple and reliable tool to predict aspiration in children. Patients with higher
pEAT-10 scores should undergo detailed evaluation of deglutitive functions and assessment of risks of aspiration
to improve safer feeding strategies.
Level of evidence: Level II (Development of diagnostic criteria in a consecutive series of patients and a universally
applied “gold standard”).
© 2017 Elsevier Inc. All rights reserved.

Respiratory problems are common in patients with repaired esoph-
ageal atresia (EA). Nearly half of the patients have respiratory complica-
tions [1]. In one study, it was reported that 19% of patients had recurrent
pneumonia, 10% had aspiration and 13% had chocking, gagging or cya-
nosis during feeding [1]. These complications are due to the gastro-
esophageal reflux disease (GERD) in 74% of cases, tracheomalacia in
13%, recurrent tracheoesophageal fistula (TEF) in 13%, and esophageal
stricture in 10% of the cases [1]. The incidence of airway aspiration
was 37% in patients with EA in videofleuroscopic (VFS) evaluation [2].
It is suggested that dyscoordination of upper esophageal sphincter re-
laxation and pharyngeal contraction may result in airway aspiration
☆ Cross-sectional study.
⁎ Corresponding author at: Hacettepe University Faculty of Medicine, Department of Pe-
diatric Surgery, Ankara, Turkey. Tel.: +90 532 6651960.
E-mail address: soyer.tutku@gmail.com (T. Soyer).
and most of the respiratory problems are related to aspiration. We pre-
viously reported that patients with oropharyngeal dysphagia had higher
incidence of airway aspiration and showed severe respiratory problems
[3]. Barium swallowing studies and VFS can be used to evaluate the as-
piration during deglutition. In addition, manometry and bronchoscopy
are commonly used to evaluate aspiration in children with respiratory
complications after the repair of EA [3]. However, there is no simple
method to assess the risk of aspiration in children with EA.
The Eating Assessment Tool-10 (EAT-10) is a validated, self-
administered, commonly used tool in clinical practice, which serves
for the assessment of symptom-specific outcomes [4]. Serial application
of the EAT-10 was shown to be effective in documenting the severity of
initial symptoms, monitoring of the treatment efficacy and in prediction
of aspiration and the risk of aspiration in patients with dysphagia. Pa-
tients with EAT-10 scores higher than 10 had 2.2 times more risk of as-
piration and the scores higher than 3 were predictive for airway
aspiration [4,5].

http://dx.doi.org/10.1016/j.jpedsurg.2017.02.018
0022-3468/© 2017 Elsevier Inc. All rights reserved.
 T. Soyer et al. / Journal of Pediatric Surgery 52 (2017) 1576–1579 1577

Therefore, in this study, we aimed to assess the validity of PEDI-EAT- Table 2

10 for the prediction of aspiration in children with EA. The Dysphagia Scoring System defined by Dakak et al. [6]. The total sum of DS was
obtained by multiplying the dysphagia frequency (presence of dysphagia, often = 1,
occasionally =1/2 and never = 0) with the row number. The patients with DS score of
1. Patients and methods 0 were considered as the group with no dysphagia, between 1 and 44 as the group with
mild dysphagia, and patients with DS scores greater than 44 were categorized as the group
Patients operated for EA were evaluated for age, sex, weight (per- with severe dysphagia.
centiles validated for Turkish children), type of atresia, presence of asso- Type of Nutrition Often Occasionally Never Total
ciated anomalies, type of esophageal repair, time to definitive treatment (1 points) (1/2 points) (0 points)
and the beginning of oral feeding. The study was carried out in collabo- 1. Water 1x
ration with Department of Pediatric Surgery and Center for Swallowing 2. Milk/soup 2x
Disorders of Hacettepe University. Patients who admitted to our center 3. Yogurt/Fruit puree 3x
for the last year were included. Children younger than one- year of age, 4. Jelly/jam 4x
5. Mashed potatoes or 5x
without oral feeding and with esophageal replacement were excluded scrambled eggs
from the study. Patients who had primary anastomosis before 1 6. Boiled vegetables or fish 6x
month of age were assessed as early repair, whereas patient operated 7. Bread 7x
after 1 month of age considered as delayed repair. Also, children were 8. Fresh fruits 8x
9. Meat 9x
grouped according to beginning of oral feeding as before 1 week, one
week to 1 month and 1 month after primary anastomosis.
Videofluoroscopy (VFS) is known to be the basic method for the in-
vestigation of the deglutitive functions and of aspiration. The oral, pha- parameter was also correlated with PAS positivity to define the risk of
ryngeal and esophageal phases of deglutition were evaluated with aspiration.
different consistencies of food in this procedure [3]. Liquid (1–3– This study was approved by the Local Ethical Committee (GO-16/
5–10–20 ml of barium), pudding (3–5–10 ml of barium with pudding) 410) and non-parametric tests were performed for statistical analysis
and solid (5–10 ml of barium with biscuit) barium tests were performed of our findings (SPSS 15.0). The sensitivity and specificity of PEDI-EAT-
with 5 ml volume of bolus. Pediatric and aspiration score (PAS) was also 10 to predict airway aspiration was evaluated. The results of groups
used for the full evaluation of VFS findings, and the score of 1–2 was de- were statically analyzed with non-parametric tests (Mann–Whitney
fined as ‘no penetration and aspiration’, of 3–6 as ‘penetration’, and of U) with SPSS 15.0. The correlation of demographic parameters with
7–8 as ‘aspiration’ (Table 1) [3]. Patients with PAS scores higher than 7 PAS scores was analyzed with Spearman correlation test and the sensi-
were assessed as the PAS + group and with scores less than 7 were tivity and specificity were determined by using 2 × 2 contingency ta-
assessed as the PAS- group. bles. The p values less than 0.05 were considered as significant.
Dysphagia score (DS) was evaluated by the scoring system intro-
duced by Dakkak et al. (Table 2) [6]. The total sum of DS was obtained
by multiplying the dysphagia frequency (presence of dysphagia, 2. Results
often = 1, occasionally = 1/2 and never = 0) with the row number
[6]. The patients with DS score of 0 were considered as the group with Forty patients were included in this study. Children with
no dysphagia, between 1 and 44 as the group with mild dysphagia, penetration-aspiration in VFS (PAS N 7) were assessed as the PAS +
and patients with DS scores greater than 44 were categorized as the group (n = 9), and patients with PAS b 7 were included in the PAS-
group with severe dysphagia. group (n = 31). Demographic features and results of surgical treatment
The pediatric version of the EAT-10 (PEDI-EAT-10) is a reliable and showed no difference between PAS + and PAS- groups (p N 0.05)
valid symptom specific outcome tool as a questionnaire including ten (Table 5). Fourteen patients had associated anomalies (33% of PAS +
questions and is validated for Turkish children [7,8] (Table 3). EAT-10 and 35% of PAS- patients). Ten patients had cardiac anomalies, three
scores higher than 3 were assessed as risk of aspiration [4]. of them had genitourinary anomalies, and one patient had VATER asso-
The pediatric functional oral intake scale (FOIS) adopted from an ciation. Gross A patients (n = 5) and three of Gross C patients
existing adult tool by Crary et al. [9]. It is a 7-point ordinal scale that doc- underwent delayed repair (after one months of age) for long gap atresia.
uments the functional intake of food and liquid in patients (Table 4). The rest of the Gross C patients underwent early (before one months of
Both scores were evaluated at the time of VFS for all patients and the age) repair. All of the patients underwent open surgical repair. The
results of scores were compared between PAS+ and PAS- patients. Each mean age of surgical repair was 1.93 days (1–4 days) in early repair
group. In delayed repair group; the mean age of operation was

Table 1
The Penetration and Aspiration Scale. Table 3
The Pediatric Version of Eating Assessment Tool (PEDI-EAT-10).
Score Definition VFS findings
PEDI-EAT-10 0 = no problem
1 No penetration No contrast material in the airway
4 = severe problem
2 and aspiration Contrast material passes to airway,
above the vocal cords, no contrast remnants 1. My child does not gain weight due to 0 1 2 3 4
3 Penetration Contrast material passes to airway, his/her swallowing problem.
above the vocal cords, visible contrast remnants 2. Swallowing problem of my child interferes 0 1 2 3 4
4 Contrast material passes to airway, with our ability to go out for meals.
at the level of vocal cords, no contrast remnants 3. Swallowing liquids takes extra effort for my child. 0 1 2 3 4
5 Contrast material passes to airway, at the level of 4. Swallowing solids takes extra effort for my child. 0 1 2 3 4
vocal cords, visible contrast remnants 5. My child gags during swallowing. 0 1 2 3 4
6 Contrast material passes to airway, 6. My child acts like he/she is in pain while swallowing. 0 1 2 3 4
below the vocal cords, no contrast remnants 7. My child does not want to eat. 0 1 2 3 4
7 Aspiration Contrast material passes to airway, below the vocal 8. Food sticks in my child's throat and my 0 1 2 3 4
cords, in addition to response to aspiration visible child chokes while eating.
contrast remnants 9. My child coughs while eating. 0 1 2 3 4
8 Contrast material passes to airway, below the vocal 10. Swallowing is stressful for my child. 0 1 2 3 4
cords, no response to aspiration Total score
1578 T. Soyer et al. / Journal of Pediatric Surgery 52 (2017) 1576–1579

Table 4 Table 6
The Functional Oral Intake Scale (FOIS). Comparison of scores [median (minimum-maximum)](Non parametric tests, Mann–
Whitney U was used for statistical analysis.) (Children with penetration-aspiration in
1 No oral intake VFS (PAS N 7) were assessed as the PAS+ group, and patients with PAS b 7 were included
2 Tube dependence with minimal/inconsistent oral intake in the PAS- group).
3 Tube supplements with consistent oral intake
4 Total intake of a single consistency Parameters PAS (+), n = 9 PAS (−), n = 31 P values
5 Total oral intake of multiple consistencies requiring special preparation
PAS 8 (7–8) 1 (0–5) 0.001*
6 Total oral intake with no special preparation, but must avoid specific food and
DS 27 (0–42) 3.5 (0–30) 0.012*
liquid items
pEAT-10 7 (0–14) 1 (0–13) 0.02*
7 Total oral intake with no restrictions
FOIS 5 (2–7) 7 (3–7) 0.04*

2.75 months (2–5 months) in PAS+, 2.25 months (2–3 months) in PAS- VFS is a dynamic diagnostic tool, which enables to define the relation
groups. between swallowing and respiratory problems. Penetration of bolus
Anastomotic stenosis was detected in 12 cases (22% in PAS+, 32% in food to hyolaringeal space and aspiration to airways can be seen in pa-
PAS- cases) by the help of upper GI studies. Esophageal dilatations were tients with oropharyngeal (OPD) dysphagia [3]. We previously reported
performed before VFS evaluations. Mean number of dilatations was 2 in that 28% of patients with EA had also OPD and all of these patients had
PAS + patients and 1.9 (min = 1- max: 3) in PAS- cases. The median higher PAS scores in VFS. Therefore, we suggested that OPD is a risk fac-
levels of PAS, PEDI-EAT-10 and DS were not higher in the PAS+ group tor for airway aspiration and should be considered as one of the causes
when compared to the PAS- group (p b 0.05) (Table 6). of respiratory complications [3].
The sensitivity and specificity of PEDI-EAT-10 to predict aspiration The EAT-10 is a validated, easily scorable symptom scoring system
were 88% and 77%, positive and negative predictive values were 22% that can be applicable over a broad range of swallowing problems
and 11%, respectively. [12]. Cheney et al. reported that there is a linear correlation between
When the demographic features and the results of surgical treat- EAT-10 and PAS scores [5]. Although, it is defined for adult patients,
ment were correlated with DS, FOIS and PEDI-EAT-10 scores, we pEAT-10 is validated for children. This 10-item questionnaire can be
found that Type-C cases had better PEDI-EAT-10 and FOIS scores than responded by parents and can be also used in very small children.
type-A cases, and both scores were statistically better in primary repair Therefore, we aimed to evaluate the validity of PEDI-EAT-10 to predict
than delayed repair (p b 0.05) (Table 7). The beginning of oral feeding respiratory problems in children with EA repair.
did not differ for each score (Table 7). Among the postoperative compli- Respiratory problems are not only seen in long gap EA patients but
cations, only leakage had an effect on DS, PEDI-EAT-10, PAS and FOIS also can be observed in type-C cases. Delius et al. reported the incidence
scores (p b 0.05). Patients with anastomosis leakage had higher DS, of respiratory complications in 46% of type-C cases [1]. In our series,
PEDI-EAT-10 and PAS scores and decreased FOIS scores (p b 0.05). most of the patients had distal fistula and the type of atresia did alter
the risk of aspiration. Besides, PAS+ and PAS− groups had similar de-
3. Discussion mographic features, including the time of esophageal repair and time
of oral feeding. Although the mean values of respiratory infection rates
In this study we found that pEAT-10 is validated and simple assess- were higher in the PAS− group, there was no statistical difference.
ment tool to predict airway aspiration in children with EA. It is also use- According to the VFS results, 22.5% of cases showed aspiration and 9
ful to define which patients need further investigations for respiratory of them were in the PAS+ group. When we evaluated the DS, PEDI-EAT-
problems. Respiratory problems after EA repair are very common and 10, FOIS scores, we found that PAS+ group had higher mean scores for
constitute 44% of all hospital admission rates for children [10]. Respira- DS and PEDI-EAT-10. On the contrary, FOIS scores were significantly
tory complications are related with GERD, aspiration, tracheomalacia, lower (Table 6). Our results suggest that PAS+ cases had both dyspha-
recurrent TEF and esophageal strictures [11]. Aspiration of airways is re- gia and aspiration and their functional oral intake was worse than that
ported in 37% of EA patients with respiratory problems [2]. Diagnostic of PAS- patients. Belafsky et al. reported that an EAT-10 score higher
and radiologic investigations are needed to evaluate the cause of respi- than 3 is predictive for aspiration [4]. In another study, it was shown
ratory problems after EA repair. that values of EAT-10 less than 16 did not rule out the possibility of as-
piration and scores higher than 15 increased the risk of aspiration 2.2
times in adults [5]. This report here is the first study that investigates
Table 5
Demographic features and results of treatments in groups (Non-parametric tests, Mann–
the applicability of PEDI-EAT-10 in patients with EA. We show here
Whitney U test was used for statistical analysis). that the sensitivity and specificity of PEDI-EAT-10 to predict aspiration
were 88% and 77% respectively, in patients with EA and/or TEF. The
Parameters PAS (+), n = 9 PAS (−), n = 31 p values
PEDI-EAT-10 can easily be applied and is responded well by parents or
Age (median) 30 (12–84) 48 (12–120) N0.05
Sex (male:female) 4:5 15:16 N0.05
Weight (median, percentile) 50 (3–75) 50 (25–75) N0.05 Table 7
Type of anomaly N0.05 Comparison of surgical parameters with DS, pEAT-10, PAS and FOIS scores. (Median levels
Gross A 2 (22.2%) 3(9.7%) and p values are listed. Non-parametric tests, Mann–Whitney U was used for statistical
Gross C 7 (77.8%) 29 (90.3%) analysis).
Associated anomalies (n,%) 3 (33%) 11 (35%) N0.05
Median Scores Gross A vs Primary vs Early (b1 week and 1
Definitive treatment N0.05
Gross C Delayed Repair week to 1 month) vs
Primary anastomosis 5 (55.5%) 27 (87%)
Delayed (N1 month)
Delayed repair 4 (45.5%) 4 (13%)
oral feeding
Postoperative complications N0.05
Anastomotic leakage 1 (11%) 1 (3.2%) PAS 2/1 1/4.5 1/1
Stenosis 2 (22%) 10 (32%) (p N 0.05) (p = 0.015)* (p N 0.05)
Recurrent fistula 1 (11%) 2 (6.4%) DS 27/4 3.75/27 4.25/4.50
Start of oral feeding after surgery N0.05 (p N 0.05) (p = 0.039)* (p N 0.05)
b 1 week 3 (33%) 18 (58%) FOIS 3/7 7/4 7/7
1 week- 1 month 4 (44%) 6 (19%) (p = 0.03)* (p = 0.005)* (p N 0.05)
N 1 month 1 (11%) 6 (19%) pEAT-10 8/1 1/7.5 1/1
Recurrent respiratory infection 4 (44.4%) 13 (41.9%) N0.05 (p = 0.015)* (p = 0.016)* (p N 0.05)
 T. Soyer et al. / Journal of Pediatric Surgery 52 (2017) 1576–1579
caregivers of EA patients. In addition, it can be self-administered by
older children or adult survivors. It would be useful for healthcare pro-
fessionals to suggest a possible aspiration as an underlying cause of re-
spiratory complications. The cut-off values for PEDI-EAT-10 for EA
have not been defined yet and this is one of the challenges we face for
future studies. In this study, the cut-off values could not be determined
due to the low number of patients in the PAS+ group (n = 9), There-
fore, the accumulating number of patients and data about PAS + pa-
tients will helpful in future studies.
In conclusion, aspiration is a common problem in patients with EA.
We found that PEDI-EAT-10 is validated tool with a high sensitivity
and specificity to predict airway aspiration in children. Children with
EA and higher PEDI-EAT-10 scores should undergo detailed evaluation
of deglutitive functions in order to predict the risk of aspiration and pro-
mote safer feeding strategies.
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