Level
Baseline items
References
A
The breathing pattern classification should be split in three main and proper categories: Mouth breathing, nasal breathing or oronasal breathing
Felicio et al., 2010 ; Felicio & Ferreira, 2008 ; Fujimoto et al., 2009 ; Grandi et al., 2012 ; Marchesan et al., 2012 ; Valera et al., 2003 ; Basheer et al., 2014 ; Sano et al., 2018 ; Yamaguchi et al., 2015 ; Ikenaga et al., 2013 ; Mattos, 2018 ; Milanesi et al., 2018 ; Andrade et al., 2012
A
Watching a child breathing at rest in a spontaneous and stress-free context is relevant to determine the awake and habitual breathing pattern.
Felicio et al., 2010 ; Felicio & Ferreira, 2008 ; Fujimoto et al., 2009 ; Ieto, 2011 ; Andrade et al., 2012
Observing the child for 5 consecutive minutes at rest is enough to be relevant to determine the awake and habitual breathing pattern
Fujimoto et al., 2009 ; Nagaiwa et al., 2016; Ikenaga et al., 2013
B
Observing an open mouth posture at rest (in a spontaneous and stress-free context) is relevant to determine the awake and habitual breathing pattern
Basheer et al., 2014 ; Bueno et al., 2015 ; Cuccia et al., 2008 ; Harari et al., 2010 ; Junqueira et al., 2010 ; Lopes et al., 2014 ; Milanesi et al., 2018 ; Pacheco et al., 2015 ; Saitoh et al., 2018 ; Sano et al., 2018 ; Valera et al., 2003
B
Amplitude of mouth opening is relevant to determine the awake and habitual breathing pattern
Cattoni et al., 2007 ; Milanesi et al., 2018 ; Andrade et al., 2012
C
Observing fully closed lips will influence your decision
C
Observing the lips slightly open will influence your decision
C
Observing half-open lips will influence your decision
C
Observing wide open lips will influence your decision
C
Observing that sometimes the mouth is open, sometimes the mouth is closed will influence your decision.
B
Time spent with an open mouth posture is relevant to determine the awake and habitual breathing pattern
Fujimoto et al., 2009
C
Observing an open mouth posture (lips slightly, half or wide open) for the half of the observation time or more will influence your decision.
C
Observing the mouth closed for the half of the observation time or more will influence your decision.
C
Observing an open mouth posture for the entire observation time will influence your decision.
C
Observing the mouth closed for the entire observation time will influence your decision.
B
Hearing noisy breathing at rest is relevant to determine the awake and habitual breathing pattern
Felcar et al., 2010 ; Marchesan, 2000 ;Valera et al., 2003
C
Hearing nasal inspiration noises will influence your decision.
C
Hearing oral inspiration noises will influence your decision.
B
Watching the child’s behaviors/habits at rest is relevant to determine the awake and habitual breathing pattern
Abreu et al., 2008 ; Lopes et al., 2014 ; Saitoh et al., 2018 ; Trawitzki et al., 2005 ; Valera et al., 2003
C
Observing the child itching his/her nose will influence your decision.
C
Observing the child licking and/or playing with his/her lips, or sticking out the tongue will influence your decision.
C
Observing the child sucking his/her finger, lower lip or an object will influence your decision.
C
Observing not any behaviors/habits will influence your decision.
C
One occurrence of one of these behaviors during the entire observation is enough to be relevant to determine the awake and habitual breathing pattern
A
Watching a child just after swallowing is relevant to determine the awake and habitual breathing pattern
Bueno et al., 2015 ; Knösel et al., 2011 ; Saitoh et al., 2018 ; Valera et al., 2003
Observing at least 2 sips is enough and relevant to determine the awake and habitual breathing pattern
B
Observing the air intake just after swallowing is relevant to determine the awake and habitual breathing pattern.
C
Observing the child breathing through his/her mouth just after swallowing will influence your decision
C
Observing the child breathing through his/her nose just after swallowing will influence your decision
C
Observing a mouth opening just after swallowing will influence your decision.
C
Observing the mouth closed just after swallowing will influence your decision.
A
Watching the child while chewing is relevant to determine awake and habitual breathing pattern
Felicio et al., 2010 ; Felicio & Ferreira, 2008 ; Saitoh et al., 2018 ; Silva et al., 2007 ; Valera et al., 2003 ; Ikenaga et al., 2013 ; Nagaiwa et al., 2016 ; Sano et al., 2018 ; Bueno et al., 2015
Observing 2 bites is enough to be relevant to determine awake and habitual breathing pattern
B
Time spent with an open mouth posture while chewing is relevant to determine the awake and habitual breathing pattern
C
Observing an open mouth posture for the half of the chewing occurrences or more will influence your decision.
C
Observing the mouth closed for the half of the chewing occurrences or more will influence your decision.
C
Observing an open mouth posture for all the chewing occurrences will influence your decision.
C
Observing the mouth closed for all the chewing occurrences will influence your decision.
C
Observing the child chewing with his/her mouth open will influence your decision.
C
Observing the child chewing with his/her mouth closed will influence your decision.
A
Encouraging or forcing the child to breathe through the nose (forced nasal breathing) is relevant to determine awake and habitual breathing pattern
Bakke et al., 2007 ; Felicio et al., 2010 ; Felicio & Ferreira, 2008 ; Pacheco et al., 2015 ; Zaghi et al., 2020
Placing tape on the child’s lips for 3 minutes is enough and relevant to determine awake and habitual breathing pattern
Verbally ask the child to take 5 consecutive breaths through the nose is enough and relevant to determine awake and habitual breathing pattern
C
Observing signs of tiredness while the child is forced to breathe through the nose will influence your decision.
C
Observing signs of dyspnea while the child is forced to breathe through the nose will influence your decision.
C
Observing signs of efforts to maintain labial closure (wrinkles on the chin, contraction of face muscles, …) when the child is forced to breathe through the nose will influence your decision.
C
Observing none of the signs (tiredness, dyspnea, efforts) above will influence your decision.
C
Observing that the child fails to breathe through the nose during the entire exercise will influence your decision.
B
Observing the air intake just after the forced breathing will influence your decision
Baseline items
Items in the second questionnaire
Experts’ suggestions
Modified items according to experts’ suggestions
Observing the child for 5 consecutive minutes at rest is enough to be relevant to determine the awake and habitual breathing pattern
Observing the child for 3 consecutive minutes at rest in several different resting situations is relevant to determine the awake and habitual breathing pattern.
8/13 experts agreed with the proposal. The other mentioned essentiality and suggested modifications, such as increasing the number of observation opportunities rather than lengthen the observation time.They generally proposed between 2 and 4 different situations to observe: watching a film, stringing beads, drawing, playing, listening to a story. They also suggest observing the child at the beginning and end of the assessment.
Conditions of observation at rest: Observe the child for 3 consecutive minutes at rest in 3 different resting situations (watching a movie, drawing, playing quietly, threading beads) and at different moments of the assessment’s situation.
Observing at least 2 sips is enough and relevant to determine the awake and habitual breathing pattern
When observing the child’s air intake after swallowing, at least 3 sips of water are enough and relevant to determine the awake and habitual breathing pattern.
6/13 experts agreed with this proposal. The other mentioned essentiality and suggested modifications, such as increasing the number of sips. Most experts suggested up to 5 or 6 swallows, others suggested not to give a specific number but rather to offer a small glass of water.
Condition of observation of the child’s air intake after swallowing: Observe the child drinking a small glass of water (at least 3 sips) and watch the air intake after each swallow.
When observing the child’s air intake after swallowing, at least 3 swallows of solid bolus are enough and relevant to determine the awake and habitual breathing pattern.
6/13 experts agreed with this proposal. The other mentioned essentiality and suggested modifications in line with the previous item: about 5 swallows or a whole food (like a biscuit).
Condition of observation of the child’s air intake after swallowing: Observe the child eating 1 or 2 biscuits (at least 3 swallows) and watch the air intake after each swallow.
Observing 2 bites is enough to be relevant to determine awake and habitual breathing pattern
When observing the child’s breathing during chewing, at least 3 bites are enough to be relevant to determine the awake and habitual breathing pattern.
6/13 experts agreed with this proposal. The other mentioned essentiality and suggested modifications in line with the previous item: about 5 bites or a whole food (like a biscuit).
Condition of observation of the child’s breathing during chewing: Observe the child eating 1 or 2 biscuits (at least 3 bites).
FIRST ROUND
SECOND ROUND (modified items)
LEVEL
Items
N
CVR threshold
CVR
Items
N
CVR threshold
CVR
A
Watching a child breathing at rest in a spontaneous and stress-free context is relevant to determine the awake and habitual breathing pattern.
14
0.44
0.57
Validated in the first round
Observing the child for 5 consecutive minutes at rest is enough to be relevant to determine the awake and habitual breathing pattern
14
0.44
-0.86
Observing the child for 3 consecutive minutes at rest in several different resting situations is relevant to determine the awake and habitual breathing pattern
15
0.425
0.20
B
Observing an open mouth posture at rest (in a spontaneous and stress-free context) is relevant to determine the awake and habitual breathing pattern
14
0.44
0.00
Observing the mouth posture (lips and tongue) at rest is relevant to determine the awake and habitual breathing pattern
15
0.425
0.60
B
Amplitude of mouth opening is relevant to determine the awake and habitual breathing pattern
14
0.44
-0.29
Watching how open the lips are for more than half of the time at rest, is relevant to determine the awake and habitual breathing pattern
15
0.425
0.47
C
C
Observing fully closed lips will influence your decision
7
0.622
0.43
Observing fully closed lips for more than half of the time will influence your decision
11
0.496
0.82
C
Observing the lips slightly open will influence your decision
7
0.622
-0.43
Observing the lips slightly open for more than half of the time will influence your decision
11
0.496
0.64
C
Observing half-open lips will influence your decision
7
0.622
-0.14
Observing half-open lips for more than half of the time will influence your decision
11
0.496
1.00
Observing wide open lips will influence your decision
7
0.622
0.43
Observing wide open lips for more than half of the time will influence your decision
11
0.496
0.64
C
Observing that sometimes the mouth is open, sometimes the mouth is closed will influence your decision.
7
0.622
0.14
Not observing a main pattern (sometimes the lips are open. sometimes the lips are closed) will influence your decision.
11
0.496
0.64
B
Non-existent in first round
Observing the position occupied by the tongue for more than half of the time at rest is relevant to determine the awake and habitual breathing pattern
15
0.425
0.73
C
Observing an upper tongue position for more than half of the time will influence your decision
14
0.44
0.86
C
Observing a low tongue position for more than half of the time will influence your decision
14
0.44
0.71
C
Observing a low and forward tongue position for more than half of the time will influence your decision
14
0.44
0.86
C
Not observing the tongue position (because of closed lips) for more than half of the time will influence your decision
14
0.44
0.57
B
Time spent with an open mouth posture is relevant to determine the awake and habitual breathing pattern
14
0.44
0.71
Validated in the first round
C
Observing an open mouth posture (lips slightly, half or wide open) for the half of the observation time or more will influence your decision.
13
0.456
0.69
C
Observing the mouth closed for the half of the observation time or more will influence your decision.
13
0.456
0.69
C
Observing an open mouth posture for the entire observation time will influence your decision.
13
0.456
0.54
C
Observing the mouth closed for the entire observation time will influence your decision.
13
0.456
0.85
B
Hearing noisy breathing at rest is relevant to determine the awake and habitual breathing pattern
14
0.44
-0.29
Knowing that the child does not present any medical condition, hearing noisy breathing at rest is relevant to determine the awake and habitual breathing pattern
15
0.425
-0.20
C
Hearing nasal inspiration noises will influence your decision.
9
0.548
-0.11
Knowing that the child does not present any medical condition, hearing nasal inspiration noises on repeated breathing cycles will influence your decision.
11
0.496
0.27
C
Hearing oral inspiration noises will influence your decision.
9
0,548
-0.33
Knowing that the child does not present any medical condition, hearing oral inspiration noises on repeated breathing cycles will influence your decision.
11
0.496
0.27
B
Watching the child’s behaviors/habits at rest is relevant to determine the awake and habitual breathing pattern
14
0.44
0.71
Validated in the first round
One occurrence of one of these behaviors during the entire observation is enough to be relevant to determine the awake and habitual breathing pattern (ex. Observing the child sticking out his/her tongue just once is enough to be relevant to determine awake and habitual breathing pattern)
13
0.456
-0.85
In addition to other the signs, observing more than one occurrence of some habits/behaviors (finger sucking, nose itching, lips playing) during the entire observation is relevant to determine the awake and habitual breathing pattern
15
0.425
0.33
C
Observing the child itching his/her nose will influence your decision.
13
0.456
-0.69
In addition to the other signs, observing the child itching his/her nose on more than one occasion will influence your decision.
11
0.496
-0.09
C
Observing the child licking and/or playing with his/her lips, or sticking out the tongue will influence your decision.
13
0,456
-0.23
In addition to the other signs, observing the child licking and/or playing with his/her lips, or sticking out the tongue on more than one occasion will influence your decision.
11
0.496
0.82
C
Observing the child sucking his/her finger, lower lip or an object will influence your decision.
13
0.456
-0.38
In addition to the other signs, observing the child sucking his/her thumb, sucking his/her lower lip or sucking an object on more than one occasion will influence your decision.
11
0.496
0.82
C
Observing not any behaviors/habits will influence your decision.
13
0.456
-0.54
In addition to the other signs, not observing any behaviors/habits will influence your decision.
11
0.496
0.82
A
Watching a child just after swallowing is relevant to determine the awake and habitual breathing pattern
14
0.44
0.57
Validated in the first round
Observing at least 2 sips is enough and relevant to determine the awake and habitual breathing pattern
11
0.496
-0.09
When observing the child’s air intake after swallowing, at least 3 sips of water are enough and relevant to determine the awake and habitual breathing pattern
15
0.425
-0.07
Non-existent in first round
When observing the child’s air intake after swallowing, at least 3 swallows of solid bolus are enough and relevant to determine the awake and habitual breathing pattern
15
0.425
-0.07
B
Observing the air intake just after swallowing is relevant to determine the awake and habitual breathing pattern.
11
0.496
0.64
C
Observing the child breathing through his/her mouth just after swallowing will influence your decision
10
0.52
0.60
Validated in the first round
C
Observing the child breathing through his/her nose just after swallowing will influence your decision
10
0.52
0.80
C
Observing a mouth opening just after swallowing will influence your decision.
11
0.496
0.09
When watching the child’s air intake after swallowing, observing a mouth opening in most cases will influence your decision.
15
0.425
0.87
C
Observing the mouth closed just after swallowing will influence your decision.
11
0.496
0.64
A
Watching the child while chewing is relevant to determine the awake and habitual breathing pattern
14
0.44
0.57
Validated in the first round
Observing 2 bites is enough to be relevant to determine the awake and habitual breathing pattern
12
0.475
-0.50
When observing the child’s breathing during chewing. at least 3 bites are enough to be relevant to determine the awake and habitual breathing pattern
15
0.425
-0.33
C
Observing the child chewing with his/her mouth open will influence your decision.
12
0.475
0.83
Validated in the first round
C
Observing the child chewing with his/her mouth closed will influence your decision.
12
0.475
0.50
B
Time spent with an open mouth posture while chewing is relevant to determine the awake and habitual breathing pattern
12
0.475
0.83
C
Observing an open mouth posture for the half of the chewing occurrences or more will influence your decision.
11
0.496
0.82
C
Observing the mouth closed for the half of the chewing occurrences or more will influence your decision.
11
0.496
0.64
C
Observing an open mouth posture for all the chewing occurrences will influence your decision.
11
0.496
1.00
C
Observing the mouth closed for all the chewing occurrences will influence your decision.
11
0.496
0.64
A
Encouraging or forcing the child to breathe through the nose (forced nasal breathing) is relevant to determine the awake and habitual breathing pattern
14
0.44
0.14
In addition to the other contexts of observation, encouraging or forcing the child to breathe through the nose (forced nasal breathing) is relevant to determine the awake and habitual breathing pattern
15
0.425
0.33
Placing tape on the child’s lips for 3 minutes is enough and relevant to determine the awake and habitual breathing pattern
10
0.52
-0.60
In addition to the other signs or assessment situations, placing tape on the child’s lips for 3 minutes is enough and relevant to determine the awake and habitual breathing pattern
13
0.496
-0.69
Verbally ask the child to take 5 consecutive breaths through the nose is enough and relevant to determine the awake and habitual breathing pattern
10
0.52
-0.20
In addition to the other signs or assessment situations, verbally asking the child to take 7 consecutive breaths through the nose is enough and relevant to determine the awake and habitual breathing pattern
13
0.496
-0.23
C
Observing signs of tiredness while the child is forced to breathe through the nose will influence your decision.
10
0.52
0.60
Validated in the first round
C
Observing signs of dyspnea while the child is forced to breathe through the nose will influence your decision.
10
0.52
0.60
C
Observing signs of efforts to maintain labial closure (wrinkles on the chin. contraction of face muscles, …) when the child is forced to breathe through the nose will influence your decision.
10
0.52
0.80
C
Observing none of the signs (tiredness, dyspnea, efforts) above will influence your decision.
10
0.52
0.00
In addition to the other signs or assessment situations, not observing any sign of tiredness, dyspnea or effort when the child is forced to breathe through the nose will influence your decision.
13
0.496
0.38
C
Observing that the child fails to breathe through the nose during the entire exercise will influence your decision.
10
0.52
0.80
Validated in the first round
B
Observing the air intake just after the forced breathing will influence your decision
10
0.52
0.60
S-CVI average round 1= 0.63 S-CVI average round 2= 0.6 S-CVI total average = 0.77;
Bold items are CVR > threshold