DOI: https://doi.org/10.21203/rs.3.rs-2308479/v1
Purpose:The Pediatric Eating Assessment Tool (Pedi - EAT - 10) is a clinical screening tool that has been designed to assess pediatric patients at risk of penetration and/or aspiration symptoms of dysphagia, reported by parents or caregivers. The aim of this study was to translate and validate Pedi-EAT-10 in Greek language and to correlate its results with the Penetration and Aspiration scale (PAS) and pharyngeal residue.
Methods: This study included sample of 222 parents or caregivers who have children with and without feeding and/or swallowing disorders. The children were randomly selected from cypriot public school, cypriot special public school, and the Speech, Language, and Hearing clinic of the European University of Cyprus; the children’s parents filled out the Pedi-EAΤ-10 questionnaire. For test-retest reliability, all participants administered the Pedi-EAT-10 again once more 2 weeks after the initial administration.
Results: Validity was established by comparing the scores of children with and without feeding and/or swallowing disorders. Internal consistency of Pedi-EAT-10 was high (Cronbach's alpha 0.801). The split-half reliability technique demonstrated very good Pedi-EAT-10 internal consistency (split-half reliability coefficient = 0.789). A test-retest reliability measure showed strong correlation (r= 0.998). The cut-off point of Pedi-EAT-10 total score and PAS scale was 11.00. Finally, Pedi-EAT-10 total score in predicting pharyngeal residue observed a cut-off of 8.00.
Conclusion:In conclusion, the Greek version of Pedi-EAT-10 is shown to be a clinically valid and reliable screening tool for the assessment of the pediatric population with a risk of dysphagia.
• Clinical questionnaires for pediatric dysphagia play a valuable role in the screening procedure by providing a rapid determination of the possible presence of dysphagia.
• The Pediatric version of the Eating Assessment Tool (Pedi-EAT-10) is one of the clinical screening tools which has been designed to assess pediatric patients with risk of penetration and/or aspiration symptoms of dysphagia reported by parents or caregivers
What is New:
• This study provides the first validated version of Pedi- EAT – 10 in pediatric monolingual Greek-speaking populations in Cyprus, and the second validated and reliable Greek Pedi-EAT-10, in international literature.
• The clinical impact of this study is that the Greek version of Pedi – EAT – 10 will offer to clinicians in Greece and Cyprus another reliable tool that enhances the diagnosis of pediatric dysphagia and/ or feeding disorders.
Pediatric dysphagia is defined as a disorder of the swallowing sequence which results in difficulties compromising the safety, efficiency, or adequacy of nutritional intake in children [1–3]. Particularly, dysphagia is categorized according to the phases of the swallowing procedure that is influenced [2–5]. Oral dysphagia (phase I) mostly indicates immature or absent reflexes, uncoordinated chewing, poor lip closure, insufficient lingual motions, and, therefore, poor handling of the food bolus [6–7]. Pharyngeal dysphagia (phase 2) can be presented as laryngeal penetration (bolus enters the laryngeal vestibule), choking (food obstructs the airway), pharyngeal reflux; nasopharyngeal reflux and aspiration (the bolus enters the airway below the vocal folds) [5–6]. Aspiration symptom observed in phase 2 of the swallowing procedure is classified as the most severe symptom of paediatric dysphagia and frequently occurs when available glottic reflexes fail, compromising the integrity of the respiratory system [8].
Diagnosing the aforementioned symptoms of pediatric dysphagia requires clinical and instrumental evaluation by a Speech-Language Pathologist (SLP) with expertise in pediatric dysphagia, in collaboration with the parents and/or caregivers [4–5, 9]. Initially, a detailed clinical evaluation was performed for all children. Secondly, an instrumental evaluation of a child’s feeding and swallowing ability was selected [10]. The two most commonly instrumental assessments used internationally for the paediatric dysphagia population are the Videofluoroscopic Swallowing Study (VFSS) [11–13] and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) [4–5, 14]. To select the appropriate aforementioned instrumental evaluations, it is necessary to: collect medical and developmental history, complete clinical questionnaires by parents and/or caregivers, and perform a clinical bedside swallow evaluation by SLP [15].
According to the American Speech-Language-Hearing Association (ASHA) [16], clinical questionnaires play a valuable role in the screening by providing a rapid determination of the possible presence of dysphagia. These tools highlight the need for a referral swallowing assessment; the safety of oral feeding; and the need to refer the patient for nutritional support [16].
Clinical dysphagia questionnaires may vary depending on the target population (can be completed by health professionals, parents, and/or caregivers) and specifically are differentiated to adults and children [17–18]. Most self-reported questionnaires have been developed originally for use in the adult population and secondly for use in in pediatric populations [19]. Furthermore, parental reporting of difficulties during the feeding and swallowing procedure provide the opportunity to screen and assess more efficiently the appearance of penetration and aspiration symptoms of pediatric dysphagia [10, 20]. Some clinical screening tools that are universally utilized in the pediatric dysphagic population are: the “Montreal Children’s Hospital Feeding Scale (MCH-FS)” [21], the “Pediatric Assessment Scale for Severe Feeding Problems (PASSFP)” [22], the “Screening Tool of Feeding Problems in Children (STEP-CHILD)” [23] and the Pediatric Eating Assessment Tool (Pedi-EAT-10 ) [24], etc.
The Pediatric version of the Eating Assessment Tool (Pedi-EAT-10 ) is one of the clinical screening tools which has been designed to assess pediatric patients with risk of penetration and/or aspiration symptoms of dysphagia reported by parents or caregivers [24]. This tool can screen the severity of dysphagia by reporting on its Likert scale, ranging from 0 (no problem) up to 4 (severe problem), and answering 10 questions [10]. Internationally, the validity and reliability of the Pedi-EAT-10 have been proven in children with feeding and/or swallowing difficulties (dysphagia) [10, 25–26]. However, there are no validated screening questionnaires for dysphagia in the general pediatric population in the Greek language.
This study aims to validate the Greek version of the Pedi-EAT-10 questionnaire in Greek-Cypriot parents of children with feeding and/or swallowing disorders. Additionally, a cut-off point will be determined by receiver operating characteristic (ROC) analysis.
The methodology of the current study was conducted in two phases, as demonstrated in the flow chart (Fig. 1). These phases followed the World Health Organization (WHO) [27] guidelines and involved: the process of translation (phase I), cultural validation, and reliability testing of the Pedi-EAT-10 questionnaire (phase II) [27].
The translation process consists of the following steps: forward translation, a panel of experts, back translation, pretesting, and the creation of the final version [27]. Three Greek translators independently translated the questionnaire from English into the Greek language. The translators were SLPs and had a clear understanding of the questionnaire and the population in which it would be administrated. This increases the likelihood that the questionnaire is translated appropriately, and that the language used in the translated document closely matches the language of the target group. Subsequently, two bilingual experts with experience in the field of health and questionnaire development reviewed the translation by looking for any inconsistencies between the source language and the translated document [27]. The experts discussed and resolved errors related to the maintenance of the integrity of the source tool in terms of semantic, conceptual, and technical equivalence. During the back translation, another person blind to the original questionnaire back translated the new questionnaire into the source language (English) and compared it to the original document to check the correctness of the translation. The translated questionnaire was then pretested in a sample of 40 parents and/or caregivers who had children with (n = 20) and without (n = 20) feeding and/or swallowing disorders (pilot study) [28]. Eventually, the final Greek-translated version of the Pedi-EAT-10 questionnaire was created [27].
Five independent SLPs were asked to judge the relevance of each item of the questionnaire using a 4-point relevance scale with a score ranging from 1 not relevant to 4 highly relevant.
Two hundred and twenty-two n = 222 parents and/or caregivers who have children with and without feeding and/or swallowing disorders attended this research. The participants of this study were divided into two groups: one hundred parents and/or caregivers who have healthy children (PwHC group) (children without feeding and/or swallowing disorders) and one hundred and twenty-two parents and/or caregivers who have children with feeding and/or swallowing disorders (PwFSC group). The age range of the children was between 3–12 years old. Children of both groups were randomly selected from cypriot public school, cypriot special public school, and the Speech, Language, and Hearing Clinic of the European University of Cyprus.
All children that were having feeding and/or swallowing disorders undergone the following assessment procedure. An SLP of this study collected a medical and developmental history, gave the Pedi – EAT – 10, performed a clinical evaluation of dysphagia - bedside swallowing assessment, and evaluated instrumental assessments (FEES or VFSS) [1, 29–30]. During the instrumental assessment, the presence of residue and the penetration and aspiration score via the Penetration / Aspiration Scale (PAS Scale) were measured [24, 31–32]. After all, an interval period of 2 weeks was selected for the second administration of Pedi – EAT – 10.
Finally, when the assessment procedure was completed, the group with children who had feeding and/or swallowing disorders was categorised into four groups according to the main medical diagnosis: Acquired Disorders (e.g., Undiagnosed, Epileptic Encephalopathy, etc.), Cerebral palsy, Developmental Disorders (e.g., Autistic Spectrum Disorder, Psychomotor Retardation, etc.) and Syndromes (e.g., Down Syndrome, Fragile X Syndrome, etc.). In addition, due to the different and varied difficulties of feeding and/or swallowing disorders, subcategories were developed to characterize the sample more specifically: Oral sensory feeding disorder, Oral motor feeding disorder, and Oropharyngeal dysphagia.
This assessment procedure was carried out in order to describe the recruited sample more efficiently and to separate the two parents’ groups into those who had children with and/or without feeding/swallowing disorders. It is important to note that children without feeding and/or swallowing disorders followed only the collection of child case history form and the clinical evaluation assessment (an instrumental assessment was not performed).
The inclusion criteria of the sample were Greek – Cypriot parents with children with and without feeding and/or swallowing disorders aged 3 to 12 years. All parents and/or caregivers were monolingual Greek speakers. The group of children without feeding and/or swallowing disorders had a healthy history and typical feeding and swallowing development. On the other hand, the group of children that had feeding and/or swallowing disorders, their children should have had an official medical diagnosis and/or untypical feeding and swallowing development. The exclusion criteria were parents whose children were aged below 3 years old and above 12 years old and children who were not fed orally.
All parents and/or caregivers were asked to fill in the Greek version of the Pedi-EAT-10 questionnaire. It is important to note that approval to conduct this study was granted by the Cyprus National Bioethics Committee of Cyprus (EEBK/EΠ/2019/95).
The Kolmogorov-Smirnov and Shapiro-Wilk tests were performed for the distribution of the variables. All distributed variables were expressed through mean (M) and standard deviations (SD). An independent sample t-test was used to compare the two major groups (parents of children without feeding/swallowing disorders and parents of children with feeding/swallowing disorders).
The internal consistency of the Greek version of the Pedi-EAT-10 was measured using Cronbach’s alpha coefficient and the split-half reliability coefficient technique. A value greater than 0.8 is considered ‘‘good internal consistency,’’ and a value greater than 0.9 is considered ‘‘excellent internal consistency.’’ The test-retest reliability of Pedi-EAT-10 was assessed by estimating the Pearson r correlation. The Pearson r correlation was also used to correlate the Pedi-EAT-10 score with the PAS scale results. Moreover, for the determination of the content validity of the Pedi-EAT-10, the content validity index was computed between five SLPs specialized in pediatric dysphagia. The number of SLPs showed that the agreement for each item was divided by 5 (the total number of SLPs) to obtain the item content validity index (I-CVI). Items CVI were added and divided by 10 to obtain the total scale validity index (S-CVI). A range of 0,78 and above for I-CVIs and 0.8 for S-CVI/UA were recommended to consider the scale as having excellent content validity.
Finally, a Receiver Operating Characteristic (ROC) analysis was conducted between parents of children without feeding/swallowing disorders and parents of children with feeding/swallowing disorders to estimate the cut-off values of Pedi-EAT-10. Additionally, ROC analysis between parents of children with feeding/swallowing disorders was conducted to estimate the cut-off values of Pedi-EAT-10 according to the PAS scale.
All reported p-values were two-tailed, and the statistical significance was set at p < 0.05. The analysis was conducted using SPSS statistical software (version 21.0, Armonk, NY, USA).
The study’s groups were similar in their age and gender. The mean age of parents, PwFSC group was 6.82 ± 3.01 years versus a mean of 7.51 ± 2.54 years of the PwHC group. The underlying disease that caused feeding and/or swallowing problems for the PwFSC group included neurological disorders, congenital diseases, and neurodevelopmental and genetic disorders. All demographic data of the participants are presented in Table 1.
| PwFSC Group | PwHC Group | |
|---|---|---|
| Participants | 122 | 100 |
| M (SD) | M (SD) | |
| Children’s Years of Age | 6.82 (3.01) | 7.51 (2.54) |
| Gender, N (%) | ||
| Male Parent | 11 (9%) | 30 (30%) |
| Female Parent | 111 (91%) | 70 (70%) |
| Male Children | 81 (66.4%) | 57 (57%) |
| Female Children | 41 (33.6%) | 33 (33%) |
| Diagnosis, N (%) | ||
| Acquired Disorder | 14 (6.3%) | ---- |
| Cerebral palsy | 16 (7.2%) | ---- |
| Developmental Disorders | 57 (25.7%) | ---- |
| Syndromes | 35 (15.8%) | ---- |
| Clean Medical History | ---- | 100 (45%) |
| Feeding/Swallowing Disorder, N (%) | ||
| Oral Sensory Feeding Disorder | 42 (19.0%) | ---- |
| Oral Motor Feeding Disorder | 54 (24.3%) | ---- |
| Oropharyngeal Dysphagia | 26 (11.7%) | ---- |
| Typical Swallowing | ---- | 100 5%) |
Turning to the comparisons in the Pedi-EAT-10 an independent sample t-test analysis was computed. A statistically significant difference was observed in the total mean scores between the PwFSC (M = 10.76, SD = 7.77) and the PwHC group (M = 2.21, SD = 3.53) [t (220) = 9.886, p < .001] with the PwFSC group scoring significantly higher.
In terms of group effects according to medical diagnosis, the One-way ANOVA method was used, the analysis returned a main group effect in the Pedi-EAT-10 total scores. The analysis revealed a significant group effect F (4, 217) = 24.437, p < 0.001. Moving on to the main group effect results in accordance with the received diagnosis for feeding and/or swallowing disorders for Pedi-EAT-10 total scores, the One-way ANOVA analysis revealed a significant group effect showing that all the PwFSC subgroups scored significantly lower than the PwHC group [F (3, 218) = 41.152, p < 0.001] (Table 2).
| N | Pedi-EAT-10 | |||
|---|---|---|---|---|
| M (SD) | F (4, 217) | p | ||
| Acquired Disorder | 14 | 11.42 (7.51) | 24.437 | < 0.001 |
| Cerebral palsy | 16 | 16.81 (10.2) | ||
| Developmental Disorders | 57 | 8.77 (7.62) | ||
| Syndromes | 35 | 10.40 (5.22) | ||
| PwHC Group | 100 | 2.21 (3.53) | ||
| M (SD) | F (3, 218) | p | ||
| Oral Sensory Feeding Disorder | 42 | 8.52 (6.79) | 41.152 | < 0.001 |
| Oral Motor Feeding Disorder | 54 | 10.20 (7.36) | ||
| Oropharyngeal Dysphagia | 26 | 14.51 (8.41) | ||
| PwHC Group | 100 | 2.21 3.53) |
A Pearson r correlation coefficient was used to correlate Pedi-EAT-10 total score with pharyngeal dysphagia that was identified using the PAS scale score. The result returned significantly positive r = 0.479 and p < 0.001. A significant positive correlation was also between Pedi-EAT-10 total score and the residue score with r = 0.171 and p < 0.005.
The internal consistency of the Pedi-EAT-10 was estimated at Coefficient alpha = 0.801, which is excellent. The Reliability Measures, according to the Cronbach analysis of the Pedi-Eat-10, by item ranged from 0.767–0.843. Additionally, the split-half reliability technique also demonstrated very good Pedi-EAT-10 internal consistency (split-half reliability coefficient = 0.789). A test-retest reliability was also computed using Pearson r correlation. The analysis returned with strong correlation for the measures for the Pedi-EAT-10 total score (r = 0.998, p < 0.001) and for its 10-items (range: 0.927–0.998).
A ROC analysis was conducted to determine the cut-off points of Pedi-EAT-10 total and its construct validity. A statistically significant positive discrimination between the PwHC group and the PwFSC group was revealed (AUC 0.855, (95% CI: 0.802–0.908), p < 0.001). The cut-off point was equal to 4.00 with a sensitivity of 0.821 and a 1-specificity of 0.192 (Fig. 2). Additionally, a ROC analysis revealed that a statistically significant positive discrimination was observed between the: (a) the PwHC group and the group of parents having children with oral-pharyngeal dysphagia diagnosis [AUC 0.972 (95% CI: 0.936-1.000), p < 0.001] with the cut-off point being 5.00 (sensitivity: 0.875 and specificity 0.012); (b) the PwHC group and group of parents having children with oral-motor feeding disorder diagnosis [AUC 0.956 (95% CI: 0.920–0.991), p < 0.001] with the cut-off point being 4.00 (sensitivity: 0.852 and specificity 0.037); (c) the PwHC group and group of parents having children with oral sensory feeding disorder diagnosis [AUC 0.940 (95% CI: 0.908–0.980), p < 0.001] with the cut-off point being 4.00 (sensitivity: 0.745 and specificity 0.037).
The ROC analysis was also used to evaluate the predictive validity of the Pedi-EAT-10 total score for aspiration. The analysis showed an AUC of 0.869 (95% CI of 0.774 to 0.963), p < 0.001 with the cut-off point being 11.00 (sensitivity: 1.00 and specificity 0.371) for children with aspiration (PAS > 5) (Fig. 3).
Finally, regarding the accuracy of Pedi-EAT-10 total score in predicting pharyngeal residue, the ROC analysis returned an AUC of 0.735 (95% CI of 0.636 to 0.832), p < 0.001 with the cut-off point being 8.00 (sensitivity: 0.778 and specificity 0.338) (Figure. 4).
As for the content validity of the scale regarding the relevance of the questionnaire, five experts were asked their opinion. The S-CVI was equal to 0.96. The clearance of the questionnaire and the CVI for all items was 1 except for items 6 and 8, which was 0.80.
The Pedi-EAT-10 tool is a simple, caregiver - administered questionnaire in order to evaluate the high risk of dysphagia symptoms (penetration and aspiration) in the pediatric population [24, 26]. The original Pedi-EAT-10 was adapted from the adult version of Eating Assessment Tool 10 (Eat − 10) [33]. Even the adult version in Greek is already validated [34]; this is the first study that presents the translation in the Greek language of the pediatric version. According to the literature, the first standardised Pedi-EAT-10 questionnaire was developed in English [24], and it’s the first validation to another language was the Arabic [9]. Consequently, this study is the second in a row validation of Pedi-EAT-10 questionnaire and specifically in Greek language. At this point, it is important to note that there is no current valid in Greek language questionnaire for children with feeding and/or swallowing disorders in Cyprus, and this research was designed to provide the first one and that was the Pedi - EAT − 10.
The results of this study have proven that the translated tool is discriminative, valid, and reliable in a screening process for coping the occurrence of feeding and/or dysphagia symptoms in the Greek – Cypriot pediatric population. Specific hierarchical stages of translation and cultural adaptation were followed to demonstrate equivalence between the Greek, Arabic, and English versions of the Pedi-EAT-10 [9, 35]. Also, high internal consistency, consistent construct validity, and excellent test-retest reliability, which were observed in the results, indicated the accuracy and the equivalence between the Greek version and the existing two once questionnaires [9, 35].
In this study, the mean age for children with feeding and/or swallowing disorders was 6.82 ± 3.01 years, while the mean age for the other group of children without feeding and/or swallowing disorders was 7.51 ± 2.54 years, and 61.7% were males, in the whole sample. The mean age of children with feeding and/or swallowing disorders in Arabic and English studies was 2.48 ± 1.79 years, 52.8% were males [9], and 4.8 ± 1.4–9.7 years, 51% were males [35], respectively. In addition, the mean age for children without feeding and/or swallowing disorders in Arabic and English studies was 2.81 ± 1.79 years and 4.1 ± 1.6–7.8, respectively. Therefore, the present study included a more comprehensive age range and recruited elder children than the other two versions.
This study categorized the group of children with feeding and/or swallowing disorders into four groups, with respect to the medical diagnoses: Acquired Disorders (6.3%), Cerebral palsy (7.2%), Developmental Disorders (25.7%), and Syndromes (15.8%). The Arabic version of Pedi-EAT-10 similarly categorized its sample [9]. It included children with Cerebral palsy (46%), Gastrointestinal causes (25%), Airway problems (18%), Syndromes (6%), and others (5%) [9]. The original English version, Pedi - EAT − 10, focused only on children with Cerebral palsy [35]. In 2017, a study concentrated on the validation of Pedi-EAT-10 to predict aspiration in children with esophageal atresia [26]. Another study completed in 2022 aimed to assess oropharyngeal dysphagia in children with eosinophilic esophagitis using several clinical assessment methods, one of which was the Pedi - EAT – 10 [36].
The current study categorized the children with feeding and/or swallowing disorders into three major subcategories (1. Oral sensory feeding disorder, 2. Oral motor feeding disorder and 3. Oropharyngeal dysphagia). Compared to the above-mentioned studies, this research not only included a wide range of medical diagnoses but also categorized feeding and swallowing difficulties more specifically according to the existing literature [37, 38]. Τhis study is the only one that carried out these further categorizations in the sample and this has the effect of demonstrating greater value of the screening tool for subsequent evaluation.
Furthermore, the construct validity was demonstrated by the Greek version of Pedi-EAT-10, and the characteristics of pharyngeal dysphagia were identified using the PAS scale [26] and the pharyngeal residue score [39]. A significantly positive correlation between Pedi-EAT-10 total and PAS score indicated, with r = 0.45 and p < 0.005. These outcomes are in agreement with the following studies: Pedi - EAT − 10Arabic [9], original Pedi-EAT – 10English [35], Pedi-EAT-10English in children with neurological impairments [25], Pedi-EAT-10 English in children with esophageal atresia [26]. This fact proved that the Pedi-EAT-10 and PAS scale combined together have an excellent potentiality in identifying aspiration and penetration. Moreover, the only study that correlated the Pedi-EAT-10 and pharyngeal residue was from Adel et al [9] and it is in agreement with the results of this study. Also, Duncan et al [40] was noted a similar correlation measure with this study but using different tools. They correlated Pedi - EAT − 10, Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) and aspiration/penetration symptoms on VFSS and the correlated measures are in agreement with this study (Pedi-EAT-10 and (I-GERQ-R) r = 0.369 and aspiration/penetration r = 0.351) [40].
Also, a significant positive correlation was proved between Pedi-EAT-10 total score and the residue score with r = 0.171 and p < 0.005. This significant positive correlation of the current study was observed in another research between Pedi-EAT-10 and other feeding and/or swallowing scales or tools [25, 36, 41].
Additionally, the internal consistency of the Pedi-EAT-10 was slightly lower than the English version = 0.87 [35] and Arabic version = 0.986 [9], but still excellent (Coefficient alpha = 0.801).
In this study, the item-by-item analysis ranged from 0.767–0.843 for the Pedi - EAT − 10. Τhis result is approximately in agreement with the range that was reported for the Arabic version of Pedi-EAT-10 (0.546–0.94) [9], as well as, with Thoyre’s et al study [41] that indicated a significant moderate to strong correlations between the 10 items.
The test-retest reliability analysis for the Greek version of Pedi-EAT-10 total score (r = 0.998, p < 0.001) and for its 10-items (range: 0.927–0.998) was excellent. These results were also observed in Adel et al [9], Serel Arslan et al [35], and Thoyre et al study [41].
Furthermore, the Greek version of Pedi-EAT-10 demonstrated very good discriminant validity between the children with and without feeding and/or swallowing disorders. Specifically, the same statistically significant positive discrimination was observed with the Arabic version of the questionnaire [9].
The predictive validity for aspiration of the Greek Pedi-EAT-10 total score was calculated at 11.00 with the use of the ROC analysis. This type of analysis was used in other studies, and their results were in approximate agreement with the current study [25, 41]. On contrary, the aforementioned result is not in agreement with the Arabic version of Pedi - EAT − 10, and this probably is attributed to cultural variation [9]. It is also important to note that other studies, which used Pedi-EAT-10 and PAS scale, even they had underlined its predictive validity for aspiration they did not calculate the cut-off values for several reasons [26, 41] as in this study. Thus, the above are indicating that the Greek version of Pedi-EAT-10 indicated is of high sensitivity and specificity in identifying aspiration symptoms.
Regarding the accuracy of Pedi-EAT-10 total score in predicting pharyngeal residue, the ROC analysis demonstrated a cut-off point of 8.00 which is in good agreement with Adel’s [9] study.
Moreover, the total content validity index (CVI) of the Greek version of Pedi-EAT-10 was 0.96 and this result was similar to Pedi-EAT-10 Arabic [9] and almost the same to the English version CVI = 0.91 [35].
It must also not be omitted the fact that this study distinguishes itself from others because it performed more analyses than no other study calculated. Specifically, it used the split-half reliability technique to demonstrate the internal consistency and presented good internal consistency (split-half reliability coefficient = 0.789). Moreover the additional ROC analysis that was performed in this study revealed statistically significant positive discrimination between (a) the PwHC group and the group of parents having children with oral-pharyngeal dysphagia diagnosis, with the cut-off point being 5.00; (b) the PwHC group and group of parents having children with oral-motor feeding disorder diagnosis, with the cut-off point being 4.00 (sensitivity: 0.852 and specificity 0.037); (c) the PwHC group and group of parents having children with oral sensory feeding disorder diagnosis with the cut-off point being 4.00 (sensitivity: 0.745 and specificity 0.037).
The findings of this study have a number of limitations. Firstly, a larger sample of participants is required to generalize to the pediatric dysphagia population in Cyprus. Still, it is essential to note that the sample was clearly categorized according to the type of the medical condition as well as classified into feeding and/or swallowing disorders subgroups. Additional research is also necessary to evaluate the ability to monitor the progress of intervention.
The current study presents the Greek version of the Pedi-EAT-10 questionnaire, which proves to be a very useful utility for SLP clinicians in Cyprus and for Greek speaking populations in order to assess the risk of aspiration and penetration in children with feeding and/or swallowing disorders. It should be noted that this is the second validated and reliable Pedi-EAT-10 in international literature. Moreover, to our knowledge it is the first validated questionnaire in feeding and/or swallowing disorders that concerns the paediatric population for monolingual Greek speaking populations. Furthermore, this tool is proven to have excellent internal consistency, reliability, and validity. All the major statistical results are in agreement with other studies that used Pedi-EAT-10. Nevertheless, this questionnaire could only serve as screening tool in the clinical assessment of dysphagia, giving crucial information about the presence or absence of aspiration and penetration in instrumental assessment.
ASHA American Speech-Language-Hearing Association
Eat -10 Eating Assessment Tool 10
FEES Fiberoptic Endoscopic Evaluation of Swallowing
I-CVI Item content validity index
I-GERQ-R Infant Gastroesophageal Reflux Questionnaire Revised
M Mean
MCH-FS Montreal Children’s Hospital Feeding Scale
PAS Penetration and Aspiration scale
PASSFP Pediatric Assessment Scale for Severe Feeding Problems
Pedi - EAT – 10 Pediatric Eating Assessment Tool
PwFSC group Parents and/or caregivers who have children with feeding and/or swallowing disorders
PwHC group Parents and/or caregivers who have healthy children
ROC Receiver Operating Characteristic
S-CVI Total scale validity index
SD Standard deviations
SLP Speech-Language Pathologist
STEP- CHILD Screening Tool of Feeding Problems in Children
VFSS Videofluoroscopic Swallowing Study
WHO World Health Organization
Statements and Declarations: The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors declare that no funds, grants, or other supports were received during the preparation of this manuscript.
Competing Interests: The authors have no relevant financial or non-financial interests to disclose.
Author Contributions: All authors contributed to the study conception and design. Rafaella Georgiou, Andri Papaleontiou, Louiza Voniati and Dionysios Tafiadis carried out material preparation, data collection, and the data analyses were performed by Rafaella Georgiou and Dionysios Tafiadis and supervised by the rest authors. Rafaella Georgiou wrote the first draft of the manuscript and Dionysios Tafiadis, Louiza Voniati, Nafsika Ziavra and Vasiliki Siafaka commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Ethics approval: An ethical approval to conduct this study was granted by the Cyprus National Bioethics Committee of Cyprus (EEBK/EΠ/2019/95) and by the Committee on Ethics and Research, of the University of Ioannina, Greece with protocol number: 27828.
Consent to participate: A written informed consent was obtained from all participants included in the study after explaining the study’s objectives and confirming the liberty to refuse participating in the study without affecting the quality of care.