Implementation, Indications, and Rationale for Modified Free Water Protocols in Paediatric Dysphagia: A UK Survey

BackgroundModified Free Water Protocols (MFWPs) are increasingly referenced in UK paediatric dysphagia practice despite no published paediatric evidence of safety or efficacy. AimsTo examine how, for whom, and why MFWPs are used or discussed by UK Speech and Language Therapists (SLTs), whether clinicians can reference any supporting evidence, and how outcomes are monitored. MethodsCross-sectional online survey of UK paediatric dysphagia SLTs with Likert-scale, yes/no, and open-ended items; data analysed descriptively and thematically. ResultsSixty-eight clinicians responded; 64 % (44/68) reported using an MFWP, yet only 12 % (8/68) had local written guidance. Most adaptations derived from adult FWPs, most often the Frazier protocol. No respondent cited paediatric evidence or justification for "cooled-boiled/sterile" water. MFWPs were applied to children with thin-fluid aspiration, refusal of thickeners, chronic respiratory disease, and severe neurological impairment; groups that would not meet adult FWP candidacy. Outcome monitoring centred on respiratory health but without details of how or when monitoring occurred; hydration and functional indices were rarely reported. ConclusionsUK clinicians are applying heterogeneous, unvalidated adaptations of adult FWPs to children. The use of "cooled-boiled/ "sterile" water is unsupported and distracts from evidence-based safeguards such as oral care and supervision. National guidance and paediatric outcome evidence are urgently required.