Purpose or Case Report: Videofluoroscopic swallowing studies (VFSS) are used to assess dysphagia in the pediatric population in conjunction with the Penetration-Aspiration Scale (PAS), which describes the degree of airway invasion during swallowing. However, guidelines regarding indications and follow-up are varied and vague, and often lead to over-referral, over and undertreatment, and follow-up that does not always benefit patients (i.e inadequate interventions in the interim to yield improvement). The aim of our work is to present clear guidelines for VFSS indications and follow-up to reduce unnecessary referrals, and promote clinically significant follow-up management.
Methods & Materials: Over the last eight years at our tertiary pediatric care centre, a multidisciplinary team has led a quality improvement program, involving observations of clinical practice and literature review, to identify shortcomings of the current indications and follow-up management surrounding VFSS.
Results: We developed a 10-point list of indications with specific clinical signs and conditions that warrant VFSS referral. This advances on guidelines proposed in the literature by including signs that are easily observed by parents and, in turn, better elucidated on history by physicians. These specific indications aim to decrease unwarranted referrals. We also propose a screening form handled by occupational therapists to preliminarily assess patients to ensure clinical benefit.

Furthermore, we discuss the importance of recording data complementary to the PAS such as positioning, vessel, and food textures. Although the PAS theoretically allows for objective scores to assess interval change, the literature suggests that these aforementioned factors influence penetration-aspiration, and thus we recommend consistency among these factors, when possible.

We propose a follow-up centered around functionality change as opposed to a time-based follow-up. Markers such as intake vessel changes (i.e child graduates from bottle to cup use) or clinical improvement or deterioration should be reasons for VFSS repeat. Compared to rigid time-based follow up, this increases efficiency by ensuring those in need of follow-up for functional changes can receive it, and minimises unnecessary follow-up and irradiation.
Conclusions: Our reformed guidelines aim to reduce unnecessary VFSS referral and optimize follow-up for patients to promote clinically significant impacts. These guidelines can improve VFSS referral and follow-up in the primary care setting.