APPLICATIONS IN CONTRAST IMAGING 7 discrete, standardized stimuli and tasks that have been specifically developed to reveal impairments in swallowing physiology. Furthermore, if liquids/ foods representative of each IDDSI level were administered, the exam would be too lengthy, exposing the pa- tient to unnecessary radiation. Rather, exploring swallowing ability through the full range of foods/liquids as part of a non-radiological clinical examina- tion outside of the fluoroscopy suite is more appropriate. It is helpful to think of foods in terms of categories; it is unnecessary to test every item in a category. For example, if the MBSImP protocol is followed, the solid task (Lorna Doone cookie coated with pudding barium) is meant to assess the patient’s ability to break down the solid bolus (IDDSI Level 7). It may then be possible to infer from the cookie task how the pa- tient will perform with IDDSI Levels 5 and 6. If the patient presents with a score of “(1) slow and prolonged chewing and mashing, but complete recollection or formation of the bolus is achieved,” foods with an IDDSI Level 6 consistency (Soft & Bite-Sized) might be suitable. On the other hand, if the patient earns a score of “(2), disorga- nized chewing and mashing, with solid pieces left unchewed,” food with an IDDSI Level 5 (Minced & Moist) may be more suitable.The foods themselves do not have to be tested in the fluoro suite; rather, evidence has shown that the presence and nature of swallowing impairment are best identified with a standardized set of barium consisten- cies used in conjunction with the MB- SImP protocol. 9 Pediatric Considerations Regardless of the patient’s age, the purpose of the MBSS is to diagnose swallowing pathophysiology and to determine effective compensatory and treatment strategies.As in adults, a stan- dardized protocol permits collection of baseline data and comparison between repeat exams and among patients. However, the MBSImP has not been validated in infants or children. Work is underway to create and validate the BaByVFSSImP © Impairment Profile to quantify swallowing observations made from videofluoroscopic swal- lowing studies in bottle-fed patients. 31 Until the BaBYVFSS is made widely available, clinicians evaluating pediatric dysphagia are advised of the following: (1) a standard protocol should be at- tempted with all patients and, if there is non-compliance, the protocol can then be modified; (2) protocols must be de- velopmentally appropriate with regard to viscosity of materials presented, pre- sentation of barium material (bottle/ nipple, open cup, straw, etc.), and posi- tion (semi-upright, upright, etc.). 6,19,32,33 Additionally, it is well documented that infant swallowing function changes to a greater degree over time, so the MBSS protocol must allow for evaluation across multiple swallows throughout the first few minutes of swallowing. This may be accomplished by intermit- tently viewing the infant drinking from the bottle at discrete points where con- tinuous fluoroscopy can be applied to help the clinician and radiologist eval- uate for significant changes in swallow- ing function. 33,34 Varibar Thin Liquid (IDDSI Level 0) is representative of both breastmilk and standard infant formula in terms of thickness. 22,35-37 Therefore, it is the pre- ferred first consistency to administer during the MBSS in pediatric patients. Other liquid consistencies (e.g.,Varibar Nectar [IDDSI Level 2] and Varibar Thin Honey [IDDSI Level 3]) are adminis- tered only if performance indicates po- tential for improved swallowing safety with their administration. Importantly, many infants show improved safety of oropharyngeal swallowing function under MBSS with increased thickness to IDDSI Level 1 (Slightly Thick).There is currently no Varibar product that meets the clinical characteristics of IDDSI Level 1 (Slightly Thick). IDDSI Level 1 (Slightly Thick) can consistently and accurately be produced by mixing equal parts Varibar Thin Liquid with Varibar Nectar.This ratio has been con- firmed to be accurate with the IDDSI Flow Test across multiple trials. 38 Then, as for adults, the results of the MBSS should assist the clinician in deter- mining which IDDSI Level (0- Thin, 1- Slightly Thick, 2- Mildly Thick, or 3- Moderately Thick) is most appropriate for the safe and adequate oral intake of liquid/food for pediatric patients. In infants and young children, considerations for dietary recommen- dations need to account for the fact that significant nutrition is often con- sumed via breastmilk, formula, and/or baby food; therefore, it is important to understand how these items fit into the IDDSI framework. Studies show that the viscosity of expressed breastmilk is usually consistent with a thin liquid consistency (IDDSI Level 0). 35 Similarly, most standard cow’s milk formulas meet the clinical criteria of a thin liq- uid consistency (IDDSI Level 0). 22,36,37 A notable exception is Enfamil™ A.R. Ready to Feed infant formula (vs the powder version that has to be reconsti- Table 2. Varibar Mapped to IDDSI Levels 30 Varibar Product IDDSI Level # IDDSI Level Name Thin Liquid 40% 0 Thin Nectar 40% 2 Mildly thick Thin Honey 40% 3 Moderately thick Honey 40% ≥4* Extremely thick Pudding 40% ≥4* Pureed *Too thick to flow through the syringe on an IDDSI Flow Test – however, at Level 4, there is also a “stickiness” component; therefore, to confirm Level 4, the IDDSI Fork Drip Test and the IDDSI Spoon Tilt Test would also need to be performed.