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American Journal of Speech-Language Pathology logoLink to American Journal of Speech-Language Pathology
. 2025 Oct 29;34(6):3454–3465. doi: 10.1044/2025_AJSLP-25-00203

Using the BaByVFSS Impairment Profile to Characterize the Impact of Thin and Mildly Thick Liquid Consistencies on Validated Physiological Components of Swallowing in Bottle-Fed Children

Maureen A Lefton-Greif a,b,c,✉, Kathryn A Carson d,e, Jeanne M Pinto a, Bonnie Martin-Harris f,g,h,i
PMCID: PMC12611409  PMID: 41161678

Abstract

Purpose:

Thickening liquids is a common intervention to minimize aspiration despite limited understanding of how two different consistencies impact swallow physiology in babies. This investigation used the BaByVFSS Impairment Profile (BaByVFSSImP) to examine the influence of different liquid consistencies on validated physiological components of swallowing during bottle feeding.

Method:

Participants were bottle-fed thin and nectar-thick barium liquid (Varibar) during clinically indicated videofluoroscopic swallowing studies (VFSSs) at two study sites. Swallowing impairments were scored using the BaByVFSSImP. Demographic and clinical data, maximum Penetration–Aspiration Scale (PASmax) scores, Feeding/Swallowing Impact Survey (FS-IS) scores, and pre- and post-VFSS levels of feeding were collected.

Results:

Two hundred twenty-five babies (median age = 2.9 months, interquartile range = 1.1–7.1 months) with heterogeneous conditions participated. On the BaByVFSSImP, mildly thick liquid was associated with lower (better) impairment scores than thin for Domain 2 (Palatal-Pharyngeal Approximation, p = .02), Domain 3 (Airway Invasion/Laryngeal Closure, p < .0001), and Domain 4 (Aspiration, p < .0001). Domain 1 (Lingual Motion/Pharyngeal Swallow Initiation) and Domain 5 (Pharyngeal Transport and Clearance) did not differ by consistency. However, impairment scores with thick liquid were higher (worse) for Component 2 and lower (better) for Component 5. With mildly thick liquid, Domain 3 (rs = .82, p < .001) and Domain 4 (rs = .74, p < .001) had strong positive correlations with PASmax, while Domain 2 (rs = .15, p = .02) and Domain 5 (rs = .20, p = .003) had weak positive correlations with PASmax. Correlations between post-VFSS feeding recommendations and mildly thick liquid impairment scores for Domain 3 (rs = .24, p < .001), Domain 4 (rs = .31, p < .001), and Domain 5 (rs = .13, p = .05) were significant. Domain scores did not significantly correlate with FS-IS subscales. Significantly greater volumes of thin liquid barium were administered compared to mildly thick barium at both study sites (p < .001).

Conclusions:

Our findings demonstrate improved swallow physiology and airway protection with mildly thick compared with thin liquids in bottle-fed children with diverse diagnostic conditions. Additional studies are needed to guide clinical decisions about thickening liquids for individual and well-defined populations of children that take into account their diagnostic conditions and physiological impairment profiles and move beyond the limitations associated with Penetration–Aspiration Scale findings alone.

The increasing prevalence of childhood dysphagia, coupled with initiatives to improve clinical outcomes for these children, has led to greater use of videofluoroscopic swallowing studies (VFSSs)/modified barium swallow studies (MBSs). These examinations are performed with babies who are bottle-fed to define pharyngeal physiology, detect the presence and characteristics of swallowing impairments, and identify interventions that optimize nutrition and airway protection (Benfer et al., 2017; Bhattacharyya, 2015; Borowitz & Borowitz, 2018; Horton et al., 2018; Lefton-Greif et al., 2011). Administration of thick liquid contrast is a common intervention introduced to slow and alter the direction of bolus flow when airway invasion is observed with thin liquid barium (Clave et al., 2006; Duncan et al., 2019; Goldfield et al., 2013; Inamoto et al., 2013; Logemann et al., 2008; McGrattan et al., 2017). When this strategy is considered advantageous on VFSS examinations, it informs clinical decision making and frequently leads to recommendations to provide thickened liquids for these babies (Basharat et al., 2019; Coon et al., 2016; Duncan et al., 2019; Mancopes et al., 2024).

Despite the frequent implementation of dietary recommendations for thickened liquids, questions have been raised about the safety and burdens associated with this practice (Cummings et al., 2018; Gosa et al., 2011; Lazenby-Paterson, 2020; Madhoun et al., 2015; Wallace et al., 2023). While some children experience improved airway protection with thick liquids (Basharat et al., 2019; Duncan et al., 2019; Goldfield et al., 2013), others exhibit swallowing patterns associated with an increased risk of aspiration (Fuller et al., 2022; Mancopes et al., 2024; McGrattan et al., 2017). The practice of thickening liquids is particularly concerning because aspiration on thickened liquids can negatively impact the lungs, especially early in life when maximizing lung function is crucial to long-term pulmonary health (Jordan & McEvoy, 2020; Matsumura et al., 2025; Nativ-Zeltzer et al., 2018, 2021; Taniguchi & Moyer, 1994). Additional concerns have been raised given insufficient evidence supporting the use of thickened liquids as an intervention, particularly in relation to some reported burdens and potential consequences associated with this practice. Reports include, but are not limited to, gastrointestinal and nutritional problems linked to certain thickening agents, variability in how thickened liquids are prepared, lack of concordance between thickened liquids used in radiology and those prepared outside the radiology suite, and the costs and logistical challenges associated with purchasing thickeners and preparing thickened liquids (Cichero et al., 2011; Cummings et al., 2018; Duncan et al., 2023; Lazenby-Paterson, 2020; Levy et al., 2019; Madhoun & Jadcherla, 2016; Ng et al., 2022; Stewart & Burr, 2021; Wallace et al., 2023; Wolter et al., 2018).

Recent advances in the development of standardized and validated digital video imaging protocols and analysis tools have enabled the objective detection of biomechanical and temporal swallow measures predictive of aspiration risk in children (Dharmarathna et al., 2021; Miles et al., 2022). In addition, the BaByVFSS Impairment Profile (BaByVFSSImP) has been validated as a tool that provides a standardized assessment of physiological swallowing impairments from VFSS images of bottle-fed babies ingesting thin liquids (Lefton-Greif et al., 2018; Martin-Harris et al., 2020). Despite these recent advances, our understanding of the physiological impact of different liquid consistencies remains limited. Clarifying these differences could inform decision making about consistency-based interventions. We undertook this current study to (a) improve our understanding of the impact of thin and mildly thick liquid consistencies on the validated physiological components of swallowing in bottle-fed children by using the BaByVFSSImP (Martin-Harris et al., 2020; Northern Speech Services, 2025) and (b) begin efforts to ascertain the clinical value of this tool either as an outcome measure itself or in clinical trials as has been demonstrated by the MBSImP, which served as the model for this tool (Martin-Harris et al., 2008; Northern Speech Services, 2017). We hypothesized that the BaByVFSSImP would capture differences and similarities in swallowing impairments in response to two consistencies commonly administered during VFSS examinations with children during bottle feeding.

Method

Participants and Data Collection

Caregivers provided written informed consent for in- and out-patient bottle-fed babies referred for clinically indicated VFSS at The Johns Hopkins University School of Medicine (JHH) and the Medical University of South Carolina (MUSC) between 2012 and 2016. This prospective parent investigation focused on the standardization and quantification of physiological swallowing impairments in 300 consecutively referred bottle-fed children and was approved by the institutional review boards (IRBs) at the study sites (JHH: NA_00041524, MUSC: ERMA: HR# 20343, Northwestern IRB: STU00205740 [internal] and SITE00000551 [external]; Martin-Harris et al., 2020). The current study draws from the subset of participants presented with both thin and mildly thick barium.

Radiologic imaging and protocols were standardized between the data collection sites. Commercially prepared, standardized thin and nectar-thick liquid barium contrasts (Varibar, Bracco Diagnostics Inc.), classified as “thin” and “mildly thick” on the IDDSI (Steele, 2017), were administered from baby bottles/nipples that were used in routine feeding. We use the term “mildly thick” to mean the same as “nectar thick.” Through collaboration between speech-language pathologists and pediatric radiologists at both sites, images were acquired using the lowest level of magnification (approximately 6.7 field of view) needed for visualization of space between the laryngeal surface of the epiglottis and arytenoids, with a continuous (30 pulses per second) fluoroscopy acquisition rate and digital video recordings at the standard resolution of 30 frames per second. In adherence with the principle of “as low as reasonably achievable” (ALARA; Lukoff & Olmos, 2017; Tolbert, 1996), randomly recorded video segments of swallowing sequences (“fluoro-on” time) were selected to capture swallowing dynamics deemed necessary for the diagnosis and management of individual children while limiting exposure to ionizing radiation (Arvedson & Lefton-Greif, 1998, 2017; Hiorns & Ryan, 2006; Newman et al., 2001). Examining speech-language pathologists proceeded with clinically indicated compensatory strategies (e.g., bolus or nipple modifications, or positional changes) to improve airway protection and bolus clearance that were outside the scope of this study and not evaluated in this investigation.

All clinician raters completed standardized training and demonstrated comparable competencies before using the BaByVFSSImP to score digital video images for the 21 components of swallow physiology across five functional domains (see Table 1; Lefton-Greif et al., 2018; Martin-Harris et al., 2020). Clinical information and identifiers were anonymized before the raters used frame-by-frame analysis to review all images of thin and mildly thick liquid swallowed during each study. Raters identified and scored the most impaired components for each consistency using the overall impression scoring method as previously reported (Martin-Harris et al., 2008).

Table 1.

Domains and components on the BaByVFSS Impairment Profile.

No. Domains Components
1 Lingual Motion/Pharyngeal Swallow Initiation

  • 1. Initiation of nutritive sucking (NS)

  • 2. Number of sucks to form bolus for swallowing

  • 3. Nutritive suck rhythmicity/organization

  • 4. Suck/swallow bolus control

  • 5. Bolus location at initiation of pharyngeal swallow

  • 6. Timing of initiation of pharyngeal swallow

2 Palatal-Pharyngeal Approximation

  • 7. Palatal-pharyngeal approximation/palatal integrity

  • 8. Location of bolus at time of palatal-pharyngeal approximation

3 Airway Invasion/Laryngeal Closure

  • 9. Early laryngeal vestibular closure

  • 10. Timing of airway entry

  • 11. Amount of penetration

  • 12. Frequency of penetration

4 Aspiration

  • 13. Late laryngeal vestibular closure

  • 14. Amount of aspiration

  • 15. Frequency of aspiration

5 Pharyngeal Transport and Clearance

  • 16. Epiglottic movement

  • 17. Tongue base (TB) retraction

  • 18. Pharyngeal stripping wave

  • 19. Valleculae residue

  • 20. Pyriform residue

  • 21. Pharyngoesophageal segment (upper esophageal sphincter)
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Additional data collected included (a) Penetration–Aspiration Scale (PAS) scores (Rosenbek et al., 1996; Weinstock et al., 2021; Wick et al., 2019); (b) levels of feeding pre- and post-VFSS status (see the Appendix; Lefton-Greif et al., 2014; Martin-Harris et al., 2020); and (c) caregiver responses to the Feeding/Swallowing Impact Survey (FS-IS), a validated instrument designed to measure the impact of children's feeding/swallowing problems on their caregivers (Lefton-Greif et al., 2014). As previously published, there were eight possible levels of feeding status pre- and post-VFSS, which were rank-ordered from 0 to 7, with 0 representing total oral feeding without any restrictions and 7 representing nothing by mouth (Lefton-Greif et al., 2014; Martin-Harris et al., 2020). See the Appendix.

Statistical Analysis

Characteristics of the 225 children who had VFSS scores for mildly thick liquids were summarized using counts and percentages or median and interquartile ranges (IQRs) and compared across study sites using Fisher's exact tests for categorical measures or Wilcoxon rank sum tests for continuous measures. Individual component scores were compared across liquid consistencies using Bowker's test of symmetry. Domain scores for each consistency were calculated by summing the individual component scores within the domain and compared across consistencies using the Wilcoxon signed-rank test. The frequencies and percentages of maximum PAS (PASmax) scores were calculated for both thin and mildly thick liquids and compared using Bowker's test of symmetry. Domain scores for thick liquids were correlated with PASmax, VFSS recommendations, and FS-IS using Spearman correlation after controlling for the thin liquid domain scores.

Statistical analysis was performed using SAS Version 9.4 (SAS Institute, Inc.). All p values are two-sided, and significance was set at p < .05.

Results

Of the 300 bottle-fed children in our database, 225 (75%) were presented with both thin and mildly thick liquid barium during their VFSS examinations (Martin-Harris et al., 2020). Table 2 summarizes the characteristics of the children overall and by study site. Overall, there were 86 females and 139 males with a median age of 2.9 months (IQR = 1.1–7.1) and with a range of underlying diagnostic conditions. One site had more children with gastrointestinal and pulmonary conditions, and the other site had a higher number of children with cardiac diagnoses. Significant differences were also found between the two sites for ethnicity, household income, and age at the time of visit. The volume of barium administered with thin liquid (range: 0–60 ml) was significantly greater than with mildly thick liquid (range: 0.1–60 ml)—thin: Mdn = 15 ml (IQR = 7–26), thick: Mdn = 5 ml (IQR = 3–10), difference: Mdn = 6 (IQR = 0–15); Wilcoxon signed-rank test p < .001.

Table 2.

Demographic and clinical characteristics of children presented with mildly thick liquids stratified by institution.

Characteristic All N = 225 JHH n = 87 MUSC n = 138 p
Sex, n (%) .48
 Male 139 (61.8) 51 (58.6) 88 (63.8)
 Female 86 (38.2) 36 (41.4) 50 (36.2)
Ethnicity, n (%) .01
 Hispanic 19 (8.4) 10 (11.5) 9 (6.5)
 Not Hispanic 191 (84.9) 76 (87.4) 115 (83.3)
 Unknown 15 (6.7) 1 (1.2) 14 (10.1)
Race, n (%) .40
 African American 65 (28.9) 22 (25.3) 43 (31.2)
 Asian 4 (1.8) 3 (3.4) 1 (0.7)
 Caucasian 127 (56.4) 52 (59.8) 75 (54.4)
 More than one race 27 (12.0) 10 (11.5) 17 (12.3)
 Unknown 2 (0.9) 0 (0) 2 (1.4)
Household income ($, by zip code), Mdn (IQR) 50,499 (38,600–62,408) 62,408 (50,404–85,246) 44,522 (35,642–54,355) < .001
Age at clinic visit (months), Mdn (IQR) 2.9 (1.1–7.1) 5.8 (2.0–9.2) 2.2 (1.0–5.4) < .001
Preterm (< 37 weeks), n (%) 89 (39.6) 35 (40.2) 54 (39.1) .89
Adjusted age for preterm birth (months), Mdn (IQR) 1 (0–6) 4 (0–8) 1 (0–4) < .001
Weight for age percentile, Mdn (IQR) 26.6 (3.4–64.1) 32.2 (4.4–66.6) 21.7 (2.8–55.2) .25
Height for age percentile, Mdn (IQR) 14.9 (0.5–52.4) 22.6 (2.4–68.7) 10.9 (0.2–46.8) .03
BMI for age percentile, Mdn (IQR) 51.8 (11.1–88.0) 52.7 (15.0–88.0) 45.4 (5.8–88.0) .97
Weight for height percentile, Mdn (IQR) 62.6 (11.6–93.6) 49.9 (14.7–92.9) 68.8 (9.4–94.3) .49
Weight for height percentile < 5%, n (%) 33 (16.8) 9 (11.0) 24 (20.9) .08
Ever had feeding tube, n (%) 159 (71.6) 60 (69.8) 99 (72.8) .65
Diagnostic conditions, n (%)
 GI/digestive/nutritional 128 (56.9) 58 (66.7) 70 (50.7) .02
 Developmental delays/behavioral 33 (14.7) 17 (19.5) 16 (11.6) .12
 Pulmonary 87 (38.7) 50 (57.5) 37 (26.8) < .001
 Nervous/neuromuscular 24 (10.7) 13 (14.9) 11 (8.0) .12
 Anatomic/structural 69 (30.7) 31 (35.6) 38 (27.5) .24
 Known genetic/syndromic/metabolic 36 (16.0) 14 (16.1) 22 (15.9) > .99
 Environmental exposures/social 22 (9.8) 14 (16.1) 8 (5.8) .02
 Cardiac 86 (38.2) 17 (19.5) 69 (50.0) < .001
 Allergy/immune/systemic processes 4 (1.8) 2 (2.3) 2 (1.4) .64
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Note. The total number of diagnostic conditions exceeds the number of subjects, as some subjects had multiple underlying diagnostic conditions. Missing data: feeding tube, 3; income, 7; height and weight measures, 28. The p values comparing JHH and MUSC are from Fisher's exact tests for categorical variables and Wilcoxon rank sum tests for continuous variables. JHH = The Johns Hopkins University School of Medicine; MUSC = Medical University of South Carolina; IQR = interquartile range.

As illustrated in Table 3, mildly thick liquid was associated with lower (better) impairment scores than thin on Domain 2 (Palatal-Pharyngeal Approximation, p = .02), Domain 3 (Airway Invasion/Laryngeal Closure, p < .0001), and Domain 4 (Aspiration, p < .0001). Although impairment scores on Domain 1 (Lingual Motion/Pharyngeal Swallow Initiation) and Domain 5 (Pharyngeal Transport and Clearance) did not differ by consistencies, with mildly thick liquid, they were higher (worse) for Component 2 (more sucks to form a bolus) and lower (better/earlier) for Component 5 (bolus location at the time of pharyngeal swallow initiation). Table 4 displays the lower (better) PASmax scores with mildly thick compared with thin liquid, on one or more swallows (p < .001). Approximately 79%–80% of the scores for both consistencies, on one or more swallows, were rated as ≤ 2 or 8, and comparatively fewer scores were distributed in the mid-range of the scale (i.e., 3 through 7).

Table 3.

Comparisons between thin and mildly thick liquids on BaByVFSS Impairment Profile domain and component scores.a

No. Domain Component Range of possible scores p valueb p valuec
1 Lingual Motion/Pharyngeal Swallow Initiation

  • 1. Initiation of nutritive sucks

 0–2 .80 .80

  • 2. Number of sucks to form bolus

 1–7 .07

  • 3. Nutritive suck rhythmicity/organization

 0–2 .55

  • 4. Suck/swallow bolus control

 0–2 .90

  • 5. Bolus location at initiation of pharyngeal swallow

 0–3 < .0001

  • 6. Timing of initiation of pharyngeal swallow

 0–2 .25
2 Palatal-Pharyngeal Approximation

  • 7. Palatal-pharyngeal approximation/palatal integrity

 0–3 .02 .02

  • 8. Location of bolus at time of palatal-pharyngeal approximation

 0–2 .03
3 Airway Invasion/Laryngeal Closure

  • 9. Early laryngeal vestibular closure

 0–3 < .0001 < .0001

  • 10. Late laryngeal vestibular closure

 0–3 < .0001

  • 11. Timing of airway entry

 0–4 < .0001

  • 12. Amount of penetration

 0–2 < .0001

  • 13. Frequency of penetration

 0–3 < .0001
4 Aspiration

  • 14. Late laryngeal vestibular closure

 0–3 < .0001 < .0001

  • 15. Amount of aspiration

 0–2 < .0001

  • 16. Frequency of aspiration

 0–3 < .0001
5 Pharyngeal Transport and Clearance

  • 17. Epiglottic movement

 0–2 .06 .51

  • 18. Tongue base retraction

 0–4 .86

  • 19. Pharyngeal stripping wave

 0–2 > .99

  • 20. Valleculae residue

 0–4 .93

  • 21. Pyriform residue

 0–4 .86

  • 22. Pharyngoesophageal segment (upper esophageal sphincter)

 0–3 .30
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a

Thin with higher (worse) impairment scores than mildly thick except for Component 3.

b

p value from Bowker's test of symmetry comparing thin to mildly thick liquid.

c

p value from Wilcoxon signed-rank test comparing thin to mildly thick liquid measures.

Table 4.

Maximum Penetration–Aspiration Scale (PASmax) scores: comparing thin to mildly thick liquids (N = 225).

PASmax scores Thin liquids
n (%)		 Mildly thick liquids n (%) p valuea
Score: < .001
 1 = Does not enter airway 34 (15.1) 83 (36.9)
 2 = Enters airway / above folds / ejected 47 (20.9) 46 (20.4)
 3 = Enters airway / above folds / not ejected 11 (4.9) 14 (6.2)
 4 = Enters airway / contacts folds / ejected 19 (8.4) 16 (7.1)
 5 = Enters airway / contacts folds / not ejected 11 (4.9) 11 (4.9)
 6 = Enters airway / below folds / ejected 4 (1.8) 3 (1.3)
 7 = Enters airway / below folds / not ejected 2 (0.9) 1 (0.4)
 8 = Enters airway / below folds / no effort 97 (43.1) 51 (22.7)
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a

p value from Bowker's test of symmetry comparing thin to mildly thick liquid.

Table 5 presents the Spearman correlation of the summative domain scores for mildly thick liquid with the FS-IS, VFSS feeding recommendations, and PASmax while controlling for thin liquid scores. Mildly thick liquid summative scores for Domain 3 (rs = .82, p < .001) and Domain 4 (rs = .74, p < .001) had strong positive correlations with PASmax, whereas Domain 2 (rs = .15, p = .02) and Domain 5 (rs = .20, p = .003) had weak positive correlations with PASmax. Correlations between post-VFSS feeding recommendations and mildly thick liquid impairment scores for Domain 3 (rs = .24, p < .001), Domain 4 (rs = .33, p < .001), and Domain 5 (rs = .13, p = .048) were significant. Domain scores did not significantly correlate with FS-IS subscales.

Table 5.

Correlation of domain summative scores, maximum Penetration–Aspiration Scale (PASmax), feeding recommendations (recs), and Feeding/Swallowing Impact Survey (FS-IS) for mildly thick liquids while controlling for thin liquid domain scores.

Domain 1
 2
 3
 4
 5
Measure Lingual Motion/Pharyngeal Swallow Initiation
 Palatal-Pharyngeal Approximation
 Airway Invasion/Laryngeal Closure
 Aspiration
 Pharyngeal Transport and Clearance
rs p rs p rs p rs p rs p
PASmax .05 .52 .16 .02 .82 < .001 .74 < .001 .20 .003
Feeding recs
 Post-VFSS −.13 .09 .12 .08 .24 < .001 .31 < .001 .13 .05
 Pre-VFSS −.10 .20 −.06 .38 .09 .19 .07 .28 .05 .44
 Change (Post – Pre) −.02 .80 −.21 .002 −.10 .16 −.19 .006 −.02 .72
FS-IS:
 Limits subscale .03 .67 .04 .52 −.02 .72 −.05 .43 −.00 .94
 Prevents subscale −.00 .99 .06 .38 −.04 .53 .01 .83 −.15 .03
 Worry subscale .02 .76 .12 .08 .05 .43 .13 .05 −.06 .37
 Feeding subscale .09 .25 .10 .15 −.00 > .99 −.05 .43 −.06 .41
 Worry breathing item .04 .58 .16 .02 .03 .71 .09 .19 −.09 .20
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Note. p value is from Spearman rank correlation. VFSS = videofluoroscopic swallow study; rs = Spearman rank correlation coefficient.

Discussion

We demonstrated that the BaByVFSSImP can identify and quantify the impact of two different liquid consistencies during VFSS exams and found that mildly thick liquids were associated with improved swallow physiology and decreased aspiration in a heterogeneous group of children during bottle feeding (Lefton-Greif et al., 2018; Martin-Harris et al., 2020). Our findings expand upon the literature in several important ways. First, we identified and quantified the influence of mildly thick liquids on swallowing physiology in comparison to that of thin liquids. Next, our findings move beyond some of the limitations associated with the prevailing practice in the use of the PAS in the absence of physiological data in bottle-fed children. Finally, to the best of our knowledge, this is the first report of a validated and standardized tool that can detect and quantify both the differences and similarities in how different bolus consistencies influence the swallowing mechanism in bottle-fed children. Such information is critical for the development of appropriate strategies, optimal clinical outcomes, and research metrics in bottle-fed children with dysphagia (Duncan et al., 2019; Goldfield et al., 2013; Mancopes et al., 2024; Martin-Harris et al., 2020; Slovarp et al., 2018).

Thin and Mildly Thick Consistencies: Similarities and Differences in Swallow Impairments

We found improved swallow physiology and airway protection with mildly thick compared with thin liquid contrasts in a cohort of bottle-fed children with diverse underlying conditions. Although our findings align with the existing literature, this alignment does not undermine the value of our results. Rather, this study expands upon our prior work that identified functional domains of swallowing physiology critical to airway protection and bolus flow with thin liquids in bottle-fed children (Martin-Harris et al., 2020). The current investigation showed mildly thick liquids were aspirated less often than thin and demonstrated lower (better) scores on multiple physiological components associated with airway protection; however, more sucks were needed to form a bolus (higher [worse] scores on Component 2), which may be reflective of reduced sucking efficiency. Components comprising airway invasion/laryngeal closure and aspiration domains had strong associations with PASmax scores, highlighting the presence and timing of multiple laryngeal closure mechanisms involved in airway protection. It is not surprising that these multiple components clustered together, as they were consistent with our findings with thin liquids and demonstrate the potential sensitivity of this tool for comparing consistency-related interventions.

Summative domain scores for Airway Invasion/Laryngeal Closure, Aspiration, and Pharyngeal Transport and Clearance demonstrated clinically robust associations between mildly thick liquids and the post-VFSS feeding recommendations, which were provided by examining clinicians who were unaware of the scoring outcomes. These findings parallel those previously reported for thin liquid contrast and provide further evidence that mechanisms of airway protection and pharyngeal clearance influence clinical decision making (Martin-Harris et al., 2020). Mirroring our previous work, no significant association was observed between summative domain scores and caregiver burden as assessed by the FS-IS (Lefton-Greif et al., 2014). This finding was not unexpected since health care outcomes that are conceptually closer to what is being measured (e.g., post-swallow feeding recommendations with swallowing dysfunction) are typically characterized by stronger correlations than outcomes tied to more distal relationships that are potentially influenced by multiple intervening variables (e.g., burdens or impact on caregivers and swallowing dysfunction) (Brenner et al., 1995; Wilson & Cleary, 1995). Importantly, these findings underscore the critical need for detailed, validated, and quantifiable analyses of VFSS images that provide metrics that improve our understanding of the interactions between swallowing physiology and both proximal and more distal health outcomes used in dysphagia care.

Prevailing Practice Patterns: Limitations and Moving Forward

Currently, the PAS is used across the life span as standardized system for describing the depth of airway entry, the patient's response, and whether contrast is cleared from the airway (Duncan et al., 2019; Miller et al., 2023; Rosenbek et al., 1996). Although PAS scores provide important information about airway protection, to our knowledge, the scale has not been validated in children despite its common use to define dysphagia severity, inform clinical decisions, and serve as a metric for clinical and research outcomes (Chou et al., 2023; Dharmarathna et al., 2021; Liao & Ulualp, 2022; Miles et al., 2022). In addition, the sensitivity of its predictive value for the detection of aspiration in children is unclear (Duncan et al., 2019; Miller et al., 2023).

Miller et al. (2023) reported that PAS scores without corresponding physiological and temporal data lacked the sensitivity to predict aspiration during a single encounter. These authors found that increased frequency and depth of penetration were associated with a greater likelihood of thin liquid aspiration in a heterogeneous population of children. In another study of children with diverse underlying etiologies, Duncan et al. (2019) reported that up to 26% of their subjects with penetration but no aspiration, during their initial evaluations, aspirated during repeat examinations despite the absence of any underlying neurological conditions or comorbidities that would explain their decline in swallowing function. Taken together, PAS scores alone provide only partial information for predicting aspiration events during a single study or on repeat examination. The pairing of multiple measures to improve the clinical utility of VFSS examinations has been the focus of recent investigations. Specifically, pairing temporal measures with biomechanical or physiological metrics can aid in predicting aspiration during a single VFSS examination (Dharmarathna et al., 2021; Miles et al., 2022; Miller et al., 2023). Our findings provide additional support for the need to use a combination of physiological and temporal metrics to overcome the sensitivity limitations associated with the use of PAS scores alone.

Our study also adds to the existing literature by contributing to questions about the general scaling properties of the PAS as well as specific considerations that may be unique to bottle-fed children (Steele & Grace-Martin, 2017). Our PAS scores were characterized by a bimodel distribution, consistent with data from pediatric VFSS examinations reported by Wick et al. (2019). Although, the reasons for the infrequent scoring of mid-scale PAS levels are not entirely clear, it is plausible that differences between nonextreme but adjacent PAS levels may not have been sufficiently distinguishable due to inconsistencies in the resolution of viewing screens or the incomplete calcification of the structures comprising a baby's aerodigestive tract (Lefton-Greif et al., 2018). Nevertheless, our findings of a bimodal distribution of scores may explain why some studies with bottle-fed children have grouped the eight levels of PAS scores into three levels of airway entry: (a) normal or no airway entry, (b) penetration or above the vocal folds, and (c) aspiration or below the vocal folds (Chou et al., 2023; Dharmarathna et al., 2021; Liao & Ulualp, 2022; Miles et al., 2022; Miranda et al., 2023). We suspect that collapsing the 8-point ordinal PAS levels into three broader levels obscures critical nuanced information about airway protection (e.g., including whether contrast is expelled from the airway following penetration or aspiration events) and hinders communication of meaningful findings. Further investigation into the relationship between grouped PAS scores, physiological data, and their influence on meaningful clinical outcomes is needed.

Next Steps

Advances in our understanding of predictors of penetration and aspiration using standardized protocols have provided the groundwork for future research aimed at identifying and addressing gaps in clinical care (Dharmarathna et al., 2021; Miles et al., 2022; Miller et al., 2023). Future investigations that compare composites of swallow impairment profiles could help clinicians identify optimal intervention targets to promote safe and efficient feeding for individual children and cohorts with shared underlying conditions and identify children at risk for aspiration during oral feeding, even when aspiration is not detected during their VFSS examinations. In addition, impairment profiles may guide clinical decision making about the use of thickened liquids for individuals and groups of patients by accounting for their specific diagnostic conditions and underlying physiological impairment profiles. Such information is needed to move beyond the limitations associated with the use of PAS alone and can limit the risks and potential adverse consequences associated with consistency-based or other interventions and improve outcomes for these children and their families.

Limitations

A primary limitation of this study is the use of data derived from clinically indicated VFSS examinations of bottle-fed children with heterogeneous underlying conditions. Hence, our investigation was consistent with adherence to the guideline principles of ALARA (Granata et al., 2025; Tolbert, 1996) and does not provide normative data, which would necessitate exposing healthy children to unnecessary radiation. Another limitation inherent to clinically indicated examinations is that clinicians made patient-specific decisions for the selection of nipples/bottles, positioning during exams, volume of liquid administered, and when to conclude the studies—all of which may have had an impact on our findings. It is not clear whether the larger volumes of thin compared to mildly thick liquid administered during VFSS examinations influenced our findings and potentially led to sampling biases. A comprehensive review of factors, other than consistencies of liquid, which may have influenced physiological features of swallowing, is beyond the scope of this discussion.

It should be noted that our study did not track changes in physiological features during the course of the study or include the follow-up needed for assessment of short- or long-term clinical outcomes. In addition, we are unable to determine whether our findings are generalizable to bottle-fed children with unified, specific underlying diagnoses or individual children (van den Engel-Hoek et al., 2014). However, the BaByVFSSImP holds promise for identifying and quantifying swallowing impairments in bottle-fed children with specific etiologies as it has been validated across a broad range of underlying conditions in the study sample.

Conclusions

This investigation demonstrates improved swallow physiology and airway protection with mildly thick compared with thin liquids during a single VFSS in bottle-fed children with diverse underlying diagnostic conditions. Additional studies are needed to guide decisions about thickening liquids for individual and well-defined populations of children, taking into account diagnostic conditions and physiological impairment profiles, to move beyond the limitations associated with PAS findings alone.

Data Availability Statement

The data analyzed in the current study are available upon reasonable request to the corresponding author.

Acknowledgments

The authors are grateful for the support of the Arricale Foundation. This work was supported by the National Institute on Deafness and Other Communication Disorders Grant 5R01DC011290-05 (awarded to M.A.L.-G. and B.M.-H.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Portions of this work were presented as a scientific paper at the 33rd Annual Meeting of the Dysphagia Research Society in Philadelphia, PA (March 2025). The authors wish to thank the families for partaking in this project.

Appendix

Levels of Feeding Status: Pre– and Post–Videofluoroscopic Swallow Study

0 Total oral feedings without any restrictions
1 Total oral feedings with caregiver use of specific feeding routines
2 Total oral feedings with specific liquid/food limitations or special preparations
3 Partial oral feeding with tube supplementation for liquids or nutrition and oral feedings without specific liquid/food limitations or special preparations
4 Partial oral feeding with tube supplementation for liquids or nutrition feedings with specific liquid/food limitations or special preparations
5 Tube dependent with consistent oral intake of specific liquids or foods
6 Tube dependent with minimal oral tastes
7 Nothing by mouth
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Funding Statement

The authors are grateful for the support of the Arricale Foundation. This work was supported by the National Institute on Deafness and Other Communication Disorders Grant 5R01DC011290-05 (awarded to M.A.L.-G. and B.M.-H.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Portions of this work were presented as a scientific paper at the 33rd Annual Meeting of the Dysphagia Research Society in Philadelphia, PA (March 2025).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data analyzed in the current study are available upon reasonable request to the corresponding author.

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