BrazJOtorhinolaryngol.2015;81(1):97---106
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
www.bjorl.org
REVIEW
ARTICLE
Quantitative
evaluation
of
taste
in
childhood
populations:
a
systematic
review
夽
,
夽夽
Raissa
Gomes
Fonseca
Moura
a,b,∗,
Daniele
Andrade
Cunha
c,d,
Ada
Salvetti
Cavalcanti
Caldas
e,f,
Hilton
Justino
da
Silva
c,daDepartmentofHumanCommunicationHealth,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil bDepartmentofPhonoaudiology,UniversidadeFederaldoRioGrandedoNorte(UFRN),Natal,RN,Brazil cDepartmentofNutrition,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil
dDepartmentofPhonoaudiology,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil eDepartmentofPathology,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil fInstitutodeMedicinaIntegralProfessorFernandoFigueira(IMIP),Recife,PE,Brazil
Received3January2014;accepted15April2014 Availableonline18October2014
KEYWORDS Taste; Child; Evaluation; Dysgeusia
Abstract
Introduction:Taste isof greatimportance for the feedingprocess. Seen inthis light, it is essentialtoinvestigatethissenseinchildren asdevelopinghumanbeings.However, despite littlevariationintheuseofteststhatmeasurethegustatorycapacity,therearestillquestions abouttheapplicabilityandeffectiveuseoftoolsforquantitativeassessmentinchildren.
Objective: Tosearchtheliteratureonquantitativeinstrumentsusedfortheevaluationoftaste usedinstudieswithchildren.
Methods:A searchwas conducted inthe PUBMED andWeb ofScience platforms, and sub-sequently, the identified articles were selected and reviewed. The descriptors and terms used were ‘‘taste,’’ ‘‘child,’’ ‘‘assessment,’’‘‘diagnosis,’’ and‘‘dysgeusia’’. Original arti-clesrelatedtothethemeinEnglish,restrictedtochildrenandwithnoyearlimitation,were selected.Studiesconductedinotherstagesofhumandevelopment,exclusivelyorconcurrently withthepediatricpopulation;animalstudies;literaturereviewarticles;dissertationsandbook chapters; andcase studiesand editorialswere excluded. Thedata analysiswas performed through acatalogingprotocolcreatedfor thisstudy,includingthefollowing points:author, researchdepartment,year,location,population/sample,age,purposeofthestudy,methods, andprimaryresults.
夽 Pleasecitethisarticleas:MouraRG,CunhaDA,CaldasAS,daSilvaHJ.Quantitativeevaluationoftasteinchildhoodpopulations:a
systemicreview.BrazJOtorhinolaryngol.2015;81:97---106.
夽夽
Institution:UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil.
∗Correspondingauthor.
E-mail:raissagfm@hotmail.com(R.G.F.Moura).
http://dx.doi.org/10.1016/j.bjorl.2014.04.002
98 MouraRGetal.
Results:5613itemswerefound.5307wereexcludedbasedontitle,248byabstractanalysis, and43byfulltextevaluation.Fifteenarticleswereselectedforanalysis;ofthese,sixwere repeatedarticles,andthusninearticleswereselectedforreview.
Conclusion:Thetestsaimingatevaluationoftastewerejudiciouslyused,ensuringreliability forfutureresearch,whichmayemploymethodssimilartopreviousstudies.
© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE Paladar;
Crianc¸a; Avaliac¸ão; Disgeusia
Avaliac¸ãoquantitativadopaladarnapopulac¸ãoinfantil:revisãosistemática
Resumo
Introduc¸ão:Opaladarédegrandeimportânciaparaoprocessodealimentac¸ão.Vistodessa forma,torna-sefundamentalaaveriguac¸ãodestesentidojuntoàscrianc¸as,quesãoseresem desenvolvimento.Porém,apesar dapoucavariac¸ãonautilizac¸ãodetestes quemensurama capacidadegustatória,aindaexistequestionamentoacercadaaplicabilidadeedousoeficaz dosinstrumentosdeavaliac¸ãoquantitativa,especificamentenapopulac¸ãoinfantil.
Objetivo:Levantar naliteratura osinstrumentos quantitativos para aavaliac¸ãodo paladar utilizadosemestudoscomcrianc¸as.
Método: BuscadosartigosrealizadanasplataformasPUBMEDeWebofScience,seguindoetapas deselec¸ãoeanálisecríticadosperiódicosencontrados.Osdescritoresetermosutilizadosforam taste,child,assessment,diagnosisedysgeusia.Foramselecionadosartigosoriginais relaciona-dosaotemanoidiomainglês,realizadossomentecomapopulac¸ãoinfantilesemrestric¸ãode ano.Foramexcluídosestudosrealizadosemoutrasfasesdodesenvolvimentohumano, exclu-sivamenteouconcomitantementecomapopulac¸ãoinfantil;estudoscomanimais;artigosde revisãodeliteratura,dissertac¸õesecapítulosdelivros,artigosdeestudodecasoeeditoriais. Aanálisedos dadosfoirealizada pormeiodeum fichamentoprotocolar criadopara este estudo, contemplando os seguintes pontos: autor, departamento de pesquisa, ano, local, populac¸ão/amostra,idade,objetivodoestudo,métodosutilizadoseresultadosprincipais.
Resultados: Foramencontrados5613artigos.Foramexcluídos5307artigospelotítulo,248pelo resumoe43pelotextolidonaíntegra.15manuscritosforamanalisados,dosquaisseiseram artigosrepetidos.Assim,9artigosforamselecionadosparaestarevisão.
Conclusão:Foiobservadaautilizac¸ãocriteriosadostestesdeavaliac¸ãodopaladar,garantindo confiabilidadeàspesquisasfuturasquevenhamautilizarmétodossemelhantesaosestudosjá realizados.
©2014Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Thereleaseofchemicalsduringthechewingprocessallows the taste buds in the oral cavity, pharynx, and larynx to transmitinformationfortherecognitionofthetasteofthe food.Tasteisacomplexsensorymechanismthatcanbe bro-kendownintofourbasicsensations(salty,sweet,sour,and bitter),but alwaysresultingfromtheinteractionof allof themandinfluencedbyolfactoryandtrigeminalnerve medi-atedfactors(texture,consistency,temperature,etc.).1
Changes in taste can be characterized as ageusia (absence of taste); hypogeusia (decreased perception of taste);dysgeusia(distortedtastecapacity);parageusia (dis-torted sense of taste in the presence of stimulus); and phantogeusia(distortion of taste perception, but without thepresenceofstimulus).2,3Thegustatorydisordersofsome individuals areaffected by changes in nasal---oral airflow4 during respiration that changes the influence of smell on
taste.Inotherindividuals,adecreaseofsalivafromchronic mouth breathing,5 which is common in childhood alters the perception of taste. Other causes of gustatory disor-dersincludepoorhygieneandimpairedoralcondition6and some specificepilepsymedications.7 Inchildren, aloss of sense of taste can cause a significant decrease in food intake possibly resulting in eating disorders, which can affectphysicalgrowthandoveralldevelopment,aswellas reducethepleasureandcomfortassociatedwithfoodand increasethedangeroffoodpoisoningorexcessiveexposure toharmful environmentalchemicals thatwould otherwise bedetectablebythesenseoftaste.8
Quantitativeevaluationoftasteinchildhoodpopulations 99
used toassess taste, but there arequestions about their applicabilityinchildrenandtheeffectivenessoftheiruse specificallyinthatpopulation.
Thus,thisreviewproposesasystematicevaluationofthe literature,insearchofthosequantitativetoolsusedforthe assessmentoftasteinchildren,documentingthefrequency of use, selection criteria, and howthese instruments are appliedinchildren.
Methods
Researchstrategy
Forthe formulation of this literature review, the authors sought to answer the following questions:‘‘What are the instrumentsusedforquantitativeassessmentoftastein chil-dren?Howaretheyselected?Whatisthefrequencyofuseof theseinstruments?Aretheyeffectiveanddotheyallowan adequatecharacterizationofthechildpopulationregarding changesintaste?’’
Fromthesequestions,aliteraturesearchwasperformed in PubMed and Web of Science, two international search platforms,asthesedatabasesenjoyaninternational recog-nition and reputationand address the topicinvestigated. ThedatasearchoccurredinJulyof2013.
For the conduction of this literature search in a more efficientand goal-focused configuration, descriptors were used(DeCSandMeSH),i.e.,keywordsforretrievingthemes fromthescientificliterature,andfreeterms(FTs),whichare termsnotfoundinDeCSandMeSH,butwereofrelevance to this research. From them, the following combinations weresearchedintheEnglishlanguage:Taste(DeCS/MeSH) ANDChild(DeCS/MeSH);Taste(DeCS/MeSH)ANDAssessment (FT);Taste(DeCS/MeSH)ANDDiagnosis(DeCS/MeSH); Dys-geusia(DeCS)ANDChild(DeCS/MeSH);Dysgeusia(DeCS)AND Diagnosis (DeCS/MeSH); Dysgeusia(DeCS) ANDAssessment (FT).
The search was conducted independently by two researchers,followingtheinclusionandexclusioncriteria; pointsofconflict wereresolvedata latertimebyathird reviewer.
Selectioncriteria
Thefollowinginclusioncriteriawererequired:original arti-cleswithquantitativemethodsfor theevaluationoftaste exclusivelyforachildpopulation(0to<12yearsold,based onthearticle2ofLawNo.8069ofJuly13,1990,that pro-videsfortheEstatutodaCrianc¸aedoAdolescentedoBrasil [BrazilianStatuteofChildrenandAdolescents]);10and arti-clespublishedintheEnglishlanguage.Nolimitsweresetfor theperiodofpublications,andinthePubMedplatform, fil-tersrelatedtospecies(humans)andage(6---12years;birth to18 years;birthtoonemonth;birthto23months,1---23 months,and2---5years)wereactivated.
Original articlesthat did not mentionthe subject dis-cussed in this review in their title, abstract,or text and studiesinotherphasesofhumandevelopment(exclusively, or in studies on children that also included adolescents, adults,and/or elderlysubjects)wereexcluded, aimingat analysis of assessment instruments used only in the child
population. Alsoexcluded were animal studies, literature review articles, dissertations, book chapters, case study articles,andeditorials,becausethisresearchwasaimedto searchforlargepopulation-basedstudiesalreadyvalidated forpublicationinscientificjournals.
Dataanalysis
Throughtheuse ofthedescriptorsandFTsdefinedabove, theauthorsidentifiedandselectedarticlestobeanalyzed intheselecteddatabaseplatforms.
Initially, the articles’ titles were read. Then, the abstractsof articlesselected duetothe relevanceof the titlewereread,andifthepredeterminedinclusioncriteria weremet,thearticleswerereviewedinfull, followingan establishedprotocol.
The articles finally selected were those which met all eligibilitycriteriaset forthabove,enabling toanswer the questionsofthisreview.
Datafromtheselectedarticlesofinterestforthepresent reviewwereanalyzedindetailthroughtheprotocolcreated for this study. Through this protocol, the following items were covered: author, research department, year, place, population/sample,age,purposeofthestudy,methods,and mainresults.
Datapresentationwasmadeutilizingtherelevantdata fromeach article throughtables and figures, in order to facilitateitsobservationandunderstandingduringthe pre-sentationanddiscussionofresults.
Results
5613studieswerefoundwiththeuseofthesearch descrip-torsandFTsabove.Ofthese,5307wereexcludedbytitle, 248byabstract,and43byfulltextreading.Thus,15articles wereselectedaccordingtoinclusionandexclusioncriteria, butsixwererepeatedarticles,leavingnineanalyzedinthis review(Fig.1).
Articles Found: 5613 Pubmed:2475 Web of science:3138
Excluded by title: 5307 Pubmed:2234 Web of science:3073
Excluded by text:43 Pubmed:28 Web of science:15
Selected articles:15
Repeated articles:6
Analyzed articles:9
Excluded by abstract: 248 Pubmed:201 Web of science:47
100
Moura
RG
et
al.
Table1 Resultsofselectedstudiesaccordingtothevariablesanalyzed.
Author Department Year Country Population/ sample
Age Objectives Methodsused Primaryresults
Laing,DG; Wilkes,FJ; Underwood, N;Tran,L11
Medicine 2011 Australia 432Aboriginal(166) andnon-Aboriginal (266)childrenfrom publicschools:186 boysand246girls
8---12years Todeterminethelevel ofexistingtaste disordersinAboriginal andnon-Aboriginal children,matchedfor ageandgenderand livinginthesamesocial andeducational environment
Fiveincreasingconcentrationsof sweet,salty,sourandbittertastes, andcorrespondingchemical substances(sucrose,sodium chloride,citricacidandquinine hydrochloride);fivesamplesof water;mouthrinsingwithwater providedateveryofferedtaste; 20---30sbetweentastes;
representativefigures;classification oftastedisorder(threeerrorsinfive solutionsofeachtaste)
41childrenwithdisordersof taste;higherprevalencein Aboriginalchildrenandin girls;greaterdifficultyin sweettaste,followedby bitter,sour,andsaltytastes
Shin,IH;Park, DC;Kwon,C; Yes,SG12
Medicine (Otorrhinolaryn-gology)
2011 SouthKorea 42children(24boys and18girls)with chronicotitismedia witheffusionand42 controlchildren matchedforgender andage
3---7years Toevaluatethechanges intastethresholdsin childrenwithchronic otitismediawith effusionandto correlatewithbody massindex
Electrogustometer;recordthe minimumvoltagewithgustatory detection.Chemicaltestofthe taste;applicationthroughoutthe oralcavity;fourconcentrationsfor taste(sweet-sucrose,sour-citric acid,salty-sodiumchloride,and bitter-quininehydrochloride); thresholdsetbytheminimum concentrationidentifiedbytaste
Averageoftastethresholdsin electrogustometry
significantlyhigherintheleft andrightsidesofthetongue insubjects.Chemicaltaste test,withmediumthresholds tosweetandsaltytastes significantlyhigherinthe studygroup;chronicotitis mediawitheffusioncancause changesintaste,andthismay berelatedtopediatric obesity
Knof,K;Lanfer, A;Bildstein, MO; Buchecker,K; Hilz,H17
FoodTechnology 2011 Germany 191children(54%boys and46%girls)from NorthofGermany
3---10years Topresentanewmodel forevaluationoftaste sensitivityand preferenceinchildren
Non-quantitativetestoftaste preferenceandsensitivitytest.Five concentrations,inascendingorder, ofsweet,sour,salty,andbitter tastespresentedinsmallcupswitha volumeof20ml;theindicationof presenceorabsenceofataste,and preferenceshouldberequested; durationof15min;distilledwater offeredbetweeneachtastetest; chemicalagentsused:sucrose, monosodiumglutamate,sodium chloride,andcaffeine
Quantitative
evaluation
of
taste
in
childhood
populations
101
Table1 (Continued)
Author Department Year Country Population/ sample
Age Objectives Methodsused Primaryresults
Furquim, TRD; Poli-Frederico, RC;Maciel, SM; Gonini-Júnior,A; Walter, LRF6
Odontology 2010 Brazil 181children fromrural andurban areasof Londrina(106 girlsand75 boys)
Children whohave completed 12years bytheend of2005
Toevaluateifthe sensitivitytobittertaste andtheperceptionof sweettastehavean influenceondental cariesinurbanandrural areas
Methodof‘‘wholemouth’’ describedbyNilssonand Holm(1983)forsweettaste; dripmethod(simplified) describedbyHarrisand Kalmus(1949)forbitter taste;inboth,increasing serialconcentrationsof sweet(sucrose)andbitter (phenylthiocarbamide) solutionsappliedrepeatedly; aninitialfamiliarizationwith solutions;mouthrinsingat everytastingprocedure;the firstconcentrationperceived oftheexposedtasteshould berecorded
Statisticallysignificanthigher valueinsensitivity,onlyfor bittertasteinstudentsfrom ruralareas,comparedto studentsfromurbanareas; femaleswithhigherscoresof gustatorysensation;
statisticallysignificant associationbetweenthe presenceofdentalcariesand thegreaterperceptionof sweettaste,bothinurban andruralareas;greater severityofdentalcaries amongchildrenwithless sensitivitytobittertaste, withastatisticallysignificant associationonlyinchildrenof theurbanarea
Baik,J;Lee, H14
Nutrition 2009 South Korea
407children (199boysand 208girls) recruited,but 91students fromfive elementary schools locatedina ruralareaof Kyeonggi Province, SouthKorea, wereincluded inthestudy analysis
6---9years Tocomparethephysical growth,tasteacuity, foodbehaviors,and preferencesamong groups,dividedbylevel ofpresenceofresidual plaque
Theacuityofsweet(sucrose) andsalty(sodiumchloride) tastespunctuatedbythe minimumdetectionthreshold ofsolutions;Previous guidancegivento participants.Six
concentrationsofeachtaste providedinascendingorder; exposuretothesolutionwith thetasteandtotwoother sampleswithwater,askingto identifythetastesolution
102
Moura
RG
et
al.
Table1 (Continued)
Author Department Year Country Population/ sample
Age Objectives Methodsused Primaryresults
Armstrong, JE; Hutchinson, I;Laing,DG etal.13
Medicine 2007 Australia 34children (13boysand 21girls) recruited fromalocal school
6---9years Todeterminewhether facialelectromyography canprovidereliable answersaboutdifferent smellandtastestimuli andwhether,through theuseof
electromyography,itis possibletodiscriminate olfactoryandgustatory stimuliaspleasantor unpleasant
Eightconcentrationsoftwo tastes(pleasant
---sweet/sucrose---and unpleasant---bitter/quinine hydrochloride);facialcontrol oftheactivityofzygomatic musclesandlevatorlabiiby EMG;mouthrinsingwith waterbetweeneachtaste test;inclusionoftwo distractortastes(citricacid ---sour,andsodiumchloride ---salty)
Over90%zygomaticmuscle responsetoeightoffered tastes;97.1%forbittertaste and100%forsweettaste.For levatorlabiimuscle,67.6%of responsestosweettasteand 90%tobittertaste.
Electromyographicactivityin bothmuscleschosenallowed theassessmentof
discriminationamong pleasantandunpleasant tastesandodors,indicating thatthechildrenperceived thehedonicqualitiesofthe stimuli,suggestingthatthe facialexpressionmeasuredby electromyographycanprovide objectivedata,adequateto theevaluationofsmelland tastesensesinchildren Rogers,SJ;
Hepburn,S; Wehner,E18
Psychiatry 2003 USA 102children dividedinto fourgroups: classicautism (n=26), fragileX syndrome (n=20), developmen-taldelayof unknown etiology (n=32),and childrenwith typical development (n=24)
1---4years Toassessthepresenceof sensorysymptomsin autisticchildren,related toparents’reports, intellectualability,age, severityofautism,and specificsymptomsand maladaptivebehaviors
ShortSensoryProfile
(questionnairewithscores,in whichparentsofchildren scoreonthesensoryprofile oftheirchildrenwithregard totactile,gustatoryand olfactory,visual,auditory, andmotionsensibility).Scale of0---4;thegreaterthe number,thegreaterthe involvement
Quantitative
evaluation
of
taste
in
childhood
populations
103
Table1 (Continued)
Author Department Year Country Population/ sample
Age Objectives Methodsused Primaryresults
Vissera,J; Kroezeb, JHA; Kampsa, WA; Bijleveld, CMA16
Psychology 2000 Netherlands 45children (25boysand 20girls)from primary schools
3---6years Todevelopan evaluationtestof tastetothechild population,by studyingthe perceptionof tasteinyoung children
Thirteenconcentrationsofsweettaste and13ofbittertastetestedinisolated roomswithachild’sstory
contextualizingthemoment.Detection thresholdsforsucroseandurea measuredduringtheincreasing presentationoftheconcentrations, andaversiontoureahedonistically evaluatedwiththeaidofdrawingsof facialexpressions.Threesolutions(two withdistilledwaterandtheotherwith thetastesolution)presented.Mouth rinsingwithwaterateverytasting
Allchildrenunderstoodthetask, performingitonthefirstand secondtimeswithstabilizing responses.Onlyonthethirdtime didthescoresrelatedtobitter tastetestdecrease,probably duetothedegreeofdistraction ofchildren,demonstratingthat itispossibletostudythe perceptionoftasteinveryyoung children,iftheageistakeninto accountinthedevelopmentof thetest.Validdatacanbe obtainediftheproceduresareof shortduration,easyto
understand,andintrinsically motivating
Buzina,R; Jusic,M; Sapunar, J; Milanovic, N15
Nutrition 1980 Yugoslavia 110children (78boysand 32girls)
9---12years Toinvestigate whetherthe nutritionalstatus ofzincis associatedwith functional disorders,suchas physical
development, anorexia,and hypogeusia
‘‘Tasteacuitykit,’’preparedforthe studyaccordingtoHenkin(1969, 1971).Recognitionanddetection thresholdmeasuredduringthe presentationandselectionofthefour tastes-sodiumchloride(salty), sucrose(sweet),urea(bitter),and hydrochloricacid(sour).Presentation ofsequencesofthreedropsof solutionsonthesurfaceofthetongue (twodropsofwater+onedropof solutedissolvedinwater).13different solutions.Foreverytaste,3
concentrations.Resultsobtainedby detectionandrecognitionthreshold (lowestconcentrationperceivedand discriminatedbythechild).
Hypogeusiaconsidered,withfailurein thedetectionorrecognitionofthree concentrationsofthesametaste
Theresultsshowedthatthe occurrenceofmoderateto severedegreehypogeusiawas statisticallysignificant,when associatedwithreducedzinc contentofhair.Childrenwith moderatetoseverehypogeusia belongedtothemost
104 MouraRGetal.
Analyzingtheselectedarticles(Table1),agreat diver-sityofstudieswerefound.Thisdidnotallowforstatistical analysis(meta-analysis),especiallybecausethesample,the age of the population, and the objectives of the studies werevaried.However,despitethesedifferences,important insightsandconclusionscanbedrawnfromthisreview.
Authors belonging tothe departmentsof medicine11---13 andnutrition14,15 areprimarilyresponsiblefor the produc-tion of taste-related studies conducted on children. It is possible that the interest in these areas stems from the need to identify and determine the influence of taste in thefoodprocess, consideringthe impactofthe gustatory discriminationand perceptiononfeedintake--- whichcan leadtoeatingdisorders,whichmayinturnaffectthe phys-icalgrowthandoverall developmentofthechild. Clearly, thereis alackof studiesperformed byphonoaudiologists, evenwiththeconsiderableimportanceofthissenseforthe developmentofthestomatognathicfunctions,e.g., masti-cation.In thiscontext,the needarises for anexploration ofthe subjectby amultidisciplinary team, enablingearly diagnosesandinterventionsinindividualswho,for various reasons,presenttastechanges.
Studiesrelatedtothequantificationoftastethatfocused exclusively on the pediatric population emerged in the 1980s,15 butabreakoccurredduringaperiodof10years. Fromtheyear2000onwards,16studiesonthissubjectbegan tobepublishedmorefrequently.6,11---14,17,18Despitethelarge timelagbetweenthemomentsofpublicationofthese stud-ies,fewchangeshaveoccurred.Theassessmentprocedures remainedsimilar,asstudiescontinuedtobeconductedwith asubjectiveapproach,showinglittletechnological advance-mentinthis lineof researchforthe pediatricpopulation. Only in 2007,13 electromyography started to be used as an adjunct tool for evaluation of the ability for percep-tionanddiscriminationoftastes,demonstratingefficacyfor suchpurpose. Andrecently,12 electrogustometry wasused toevaluatethegustatorydetection.Thefindingsshowthat thechemosensoryfunctionoftastehasbeguntogainground amongstudiesofthevariousareasofthehealthsciences. However, one should bear in mind the need for greater emphasisonthedevelopmentofassessmentmethodologies, aimingatvalidationandthecoherentuseofresources, espe-ciallyincountriessuchasBrazilthatexhibithighindicesof eatingproblemsinthepediatricpopulation.
Australia11,13 and South Korea12,14 lead those studies relatedtotasteinchildren.However,theauthorsalsonote astudy6 conductedin Londrina, Paraná,Brazil. Thus,the importancegiventothischemosensoryfunctionthatforso longwasneglectedinfavorofstudiesofotherhumansenses isnowevident.Weemphasizetheimportanceofthatstudy whichsought toestablish relationships betweenthe pres-enceofdentalcariesandtheperceptionofsweetandbitter tastesby childrenfrom differentregions ofthat Brazilian state.Perhaps thisserves asawarningthat care mustbe takenintheprovision offoodtochildren,andthe impor-tanceoforal health. According toFelicio,19 children with cariesandtoothlosscandecreasetheintakeand mastica-tionoffoodsthatrequirecuttingandgrindingmovements, thus influencing the activity of the orofacial muscles and alsoexposingtheindirectinfluenceoftasteinthe develop-mentofthestomatognathicsystemanditsvitalfunctions, suchaschewing,swallowing,andspeaking.Whenheshowed
thatquantitativetoolsexisttoassesstasteandtheircostfor preparation anduse is reasonable, Furquim etal.6 raised questionsaboutthelowlevelofconcerninBrazilfor con-ductingresearchaimedatchemosensoryfunctions.
Thevastmajorityofstudiesweanalyzed6,11,13---17reported onpopulationsofhealthychildren,possiblybecausethere arenoregulatorynormativestandardsthat allow compar-isons between populations with normal development and groupsofsickchildren.However,twostudies12,18soughtto compare groupsbased onthepresenceof ataste-limiting condition.ThestudybyShinetal.12highlightedthepossible influenceofchronicotitismediawitheffusion inchildren; andRogersetal.18 soughttoestablishcomparisonsamong childrenwithdifferenttypesofinvasivedevelopmental dis-orders. As to the sample size of the studies, a balance between>100and<100subjectsevaluatedwasfound,with aminimumof3413andamaximumof43211 children. Simi-larly,a balancebetweentheprevalence inthe numberof female6,11,13,14 and male12,15---17 children was noted in the studiesanalyzed.Onlyonestudydoesnotmentiongender.18 Theagerangeforthereviewedstudiesrangedfrom118 to126,11,15 years,comprisingalargepart oftheagegroup defined aschildren byart. 2of Law No.8069 of July 13, 1990,which providesfor theStatuteof Childrenand Ado-lescentsinBrazil10thatwasadoptedinthisreview.Possibly, thedifferenceinthisrespectwasduetotheneedfor evi-denceondifferentaspectsofchilddevelopment,suchasthe influenceofgustatoryresponsivenessintheprocessof nutri-tionandtheconsequentoveralldevelopmentofthechild, aswellastheproperestablishmentof oralhealth of chil-drenwithdisordereddietsandexposuretofoodswithhigh levelsofsugar.
Theauthorsnotedthatthediversityofthepopulations surveyed demonstrates the importance of studies on gus-tation, to consider the possible negative implication of this factor onthe qualityof life ofindividuals living with complete or partial loss of their ability of gustatory dis-crimination. This also brings about the need to perform adjustmentsinthemethodologyemployedfordifferent pop-ulationgroupsintermsofage,language,andcognitiveand attention level, so that the instruments used are effec-tive andefficientin determiningthe gustatory difficulties in children with widely varied clinical and developmen-talpresentations.Theseprecautionswillmandatethatthe researcheradherestotheneedsofthetargetaudience,and thus obtainconsistentresults inthedatapresented.Also, thiswillallowtheevaluationtechniquestobereproduced for the same conditions, or with minor changes by other researchersfordifferentsituationalcontexts.
Quantitativeevaluationoftasteinchildhoodpopulations 105
Thisfacilitatedtheestablishmentofstandardsfor quantita-tive assessment for use withchildren, but with attention giventothevariousmethodsofusingthesepatterns,asa possiblestrategyofadaptationofthepopulationassessed.
In most cases, the tests and instruments used in the selectedstudies followedthe sameevaluationcriteriafor taste. Six studies11,14---17 used exclusively psychophysical evaluation methods composed of a standardized physi-cal stimulus and a standardized psychological response; the children were exposed to various types of taste diluted in waterand, thus, based ontheir gustatory per-ception, responses were elicited. Some studies sought answers regarding the detection of taste,6,14---17 as to the pleasantness13,16 andpreference;17 otherssought informa-tion about gustatory discrimination.11,12,15 This reveals a possiblemethodtobedevelopedinpursuitofthe standard-izationofquantitativeinstrumentsfortasteassessmentin childrenagedfromzeroto12years.
However, three studies used different methodologies.12,13,18 The electrogustometer, a device that provides quantitative gustatory detection thresholds bymeans of theapplication ofan electric currentin four areas of the tongue (tip, base, and sides), registering the minimum voltage that allows the individual being evaluated toperceive a metallic or sour taste, was used withtheaimofevaluatingthechangesintastethresholds inchildrenwithchronicotitismediawitheffusion,relating these findings to body mass index.12 Electromyography, besidesrepresentingapsychophysicaltest,wasusedasan accessoryandasacomputerizedcontrolforthemovement ofspecificfacialmusclesofindividualsexposedtopleasant (sweet)andunpleasant(bitter)tastes.13 Finally,onestudy establishedscoresfromzeroto4pointsthroughasensory profile questionnaire of patients with autistic spectrum disorders,throughtheresponsesofthechildren’sparents.18 To facilitate standardization of the instruments used, exposure to water immediately after each taste sam-ple offered, a procedure known as rinsing was used in all the studies that adopted a psychophysical test methodology.6,11---17 In these same studies, the number of samples varied between 315 and 1316 for each evaluated taste. However,the numberof samplesincreased propor-tionallytothedecreaseintastesevaluated.Thus,therewas a trendfor the presentationof three,15 four,12 or five11,17 sampleswhenassessingthefourbasictastes(sweet,salty, sour, and bitter), and an increase in the number of sam-pleswhenonlytwodistincttastesweretested.13,14,16Some studies6,11,14,16,17reportedthatthesesampleswere increas-ingly concentrated, representing a method to establish a scoreforthetestthroughtheminimumthresholdof detec-tionofthesolution.
In addition, there wasan agreement onthe choice of the evaluated tastes, considering that the studies used two6,13,14,16ormore11,12,15,17psychophysicaltestsforthefour basic tastes,andsomestudies15,16 havechosen toprovide alternatives, such as solutions with water and a specific taste. One study17 reported that theapplication timefor theentire test wasapproximately15min;anotherstudy11 relatedthattheintervalbetweentheexposureofonetaste sampletothesubsequenttastewas20---30s.Themethodof applicationofthesolutionsrangedfromtheapplicationof
thesolutiononthe surfaceofthe tongue6 todrinkingthe foodsolution.17
In most of the studies we analyzed,6,11---16 the sco-ring process was based on the minimum threshold of detection6,12,14---16anddiscrimination13,15,16ofconcentration. Fora study11 that evaluated only the gustatory discrimi-nation, the authors considered the presence of a ‘‘taste disorder’’whenthreeerrorsoccurredafterthesubjectwas exposedtofiveconcentrationsofeachtasteinthe evalua-tion;andHorn,Jusic,Sapunar,andMilanovic(1980)15found hypogeusia(decreasedgustatoryacuity)whendetectionor discriminationerrorsoccurredinthreeconcentrationsofthe sametaste.
As forthe child population,some studiesadopted rep-resentative figures to aid in taste identification11 and pleasantness;16 other investigations adopted a children’s story tocontextualize the test conducted,16 a time prior to the test to familiarize with solutions,6 and guidelines priorto individualevaluation.14 These performed adapta-tionspossibly involvethe particularitiespresented by the child population, such as cognitive, linguistic, and emo-tionaldevelopment,and differentlevels ofattention and concentrationthatshouldbefactorsaddressedwhen design-ingevaluativeinstrumentsspecifictothisagegroup.Thus, somechangespossiblyoccurtoadapttheconditionsofan evaluativemethodologytotheageofthepopulation.
Inthedescriptionoftheevaluativemethodologiesused, itwasnotedthattherearealreadyseveralcommonpoints in the instruments used for taste evaluation, and a few pointswere referred asdisagreements or not clarified by research.Still,thevarioustechniquesmaygenerate ques-tionsabouttheireffectiveness,consideringtheexistenceof somediscrepancies.Butitmustbeconsideredthat,foreach populationgroup,someadjustmentsalwayswillneedtobe made.
106 MouraRGetal.
and feasible to conduct these tests in children, provided thattheyarerelevanttotheconditionsandneedsrequired by the specific age group. Therefore, the importance of earlyinvestigationofgustatoryconditionsthroughreliable means of diagnosis should be emphasized. The authors suggest conducting studies for validation of quantitative tasteassessmenttoolstouseinpediatricpopulationswith typicalandatypicaldevelopment.
Conclusion
Withtheadvancementofresearchandtheinterestofmany professionalsinvolvedinthefunctionoftaste(speech the-rapists, nutritionists, otorhinolaryngologists, neurologists, occupational therapists, and dentists), we are achieving goodresults---especiallyregardingstandardizationof quan-titativeteststhatareappropriateandage-specific.
This reviewshowedthat, althoughtherearestillsome differencesand little informationon some specific points (such as the duration of the test and the time between each sample) and some technological increments in the evaluationoftaste, thepsychophysical testsfor quantita-tiveevaluationofthisfunctionalreadyfollowthestandard criteriaofchoiceregardingthemethodologyapplied (pre-sentation and chosen gustatory stimuli, presentation and quantityofsamplesbytaste,useoftherinsingmethod)and thescoringmodalityadopted.
Therefore,thefindingsinthisstudyenablegreater reli-abilityforfutureresearch,employingsimilarmethodologies and based on published studies for assessment of gusta-toryfunction.Furthermore,thismethodologycanbeapplied with reliability in the phonoaudiological rehabilitation of childrenwithdisordersoftaste.
Funding
This study was supported by FACEPE 2012 (Fundac¸ão de AmparoàCiência eTecnologiadoEstadode Pernambuco) andCNPq(ConselhoNacionaldeDesenvolvimentoCientífico eTecnológico),Process:475641/2011-6.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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