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Maximum Phonation Time and Body Mass Index in Nondysphonic Eutrophic Children
ARTICLE IN PRESS
Maximum Phonation Time and Body Mass Index in Nondysphonic Eutrophic Children Leila Susana Finger, Carla Franco Hoffmann, and Carla Aparecida Cielo, Santa Maria, Brazil SUMMARY: Background. Literature presents controversial maximum phonation time values in children. Objective. Verify and correlate the maximum phonation time of vowels /a, i, u/ and the body mass index of children. Method. Evaluation of 484 children, eutrophic and without dysphonia, aged from 4:00 to 7:11 years. Sampling: questionnaire, audiometric screening, auditory-perceptual evaluation of voice, and assessment of the body mass index. Data collection: measurement of the maximum phonation time of /a, i, u/. Descriptive statistics, t test, and multiple regression at 5% significance. Results. /a:/ = 3.77 seconds at age 4:00 years, 5 seconds at 5:00, 5.85 seconds at 6:00, and 7.5 seconds at 7:00 for boys, and 3.89 seconds, 4.89 seconds, 5.61 seconds, and 6.61 seconds for girls, respectively; /i:/ = 3.49 seconds at age 4:00 years, 4.96 seconds at 5:00, 5.72 seconds at 6:00, and 6.88 seconds at 7:00 for boys, and 3.49 seconds, 4.73 seconds, 5.41 seconds, and 6.63 seconds for girls, respectively; /u:/ = 3.64 seconds at age 4:00 years, 4.85 seconds at 5:00, 5.76 seconds at 6:00, and 7.08 seconds at 7:00 for boys, and 3.54 seconds, 4.73 seconds, 5.64 seconds, and 6.47 seconds for girls, respectively. There were no significant differences between genders, except for /a:/ at age 7:00 years. The correlations were not significant. Conclusion. Maximum phonation time of /a, i, u/ increased with age and its value in seconds was approximately equal to the age in years. At the age 7:00 years, /a:/ from boys was longer. The body mass index did not show influence on the maximum phonation times. Key Words: Voice−Child−Preschool−Phonation−Speech−Language and hearing sciences.
INTRODUCTION Maximum Phonation Time (MPT) provides information about the individual’s neuromuscular and aerodynamic control of voice production1−3 and is used to evaluate glottic efficiency and vocal quality in adults and children. The MPT is influenced by the vital capacity, which varies according to age, gender, stature, weight, and body surface area.1−5 In another study with 82 children there was no influence of the body mass index (BMI) on the MPT; but there was influence of the abdominal circumference on the vital capacity, and as a consequence on the MPT.6 It is an easily obtained measurement which requires only the use of a chronometer.1−4 According to the PubMed database there were only 14 studies published in the last 5 years, including dysphonic children, with some syndrome, and undergone surgery. However, the MPT is related to the continuous emission of isolated phonemes, and it is not a simple task to measure it when evaluating children. One is required to provide the children means that favor the concrete processing of the verbal orientations, thus facilitating the evaluation of MPT in this population.7 The studies which evaluate MPTs present controversial results regarding phonation times2,4,7−10 and the differences between boys and girls,11−15 possibly because they evaluated Accepted for publication September 30, 2019. From the Universidade Federal de Santa Maria, Departamento de Fonoaudiologia, Santa Maria, Rio Grande do Sul, Brazil. Address correspondence and reprint requests to Leila Susana Finger, Universidade Federal de Santa Maria, Departamento de Fonoaudiologia, Av. Roraima, 1000, Camobi, Santa Maria, RS 97105-900, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.09.018
MPT within wide age ranges, and did not considered sex. It is difficult to compare these results with the results from our study. The influence of the BMI on the MPT from children6 and from adults16 lacks exploration, so more evidences are needed. In general, the expected MPT in seconds for the population of children is approximately the child’s number of years, increasing with age and also revealing the nervous and muscle maturation that occurs as the child physically grows.5,17 Therefore, our study’s objective is to verify and to correlate the MPTs of vowels /a, i, u/ and the BMI of nondysphonic children with ages from 4:00 to 7:11 years.
MATERIALS AND METHODS This is an analytical, quantitative, and contemporary crosssectional observational research that meets the recommendation of regulation 466/2012 of the Brazilian National Research Ethics Committee (CONEP/2012) and was approved by the Research Ethics Committee of the author’s institution under number 0306.0.243.000-10. We contacted the schools, and their directors were invited to read and sign the Institutional Authorization Term after receiving the clarifications about the research. The caregivers were also invited to read and sign the Free and Informed Consent Form (FICF). The children were also free to opt for participating or not in the study. All participants received written feedback regarding the performed assessments, as well as activities to promote human communication aimed at students and teachers, in the institutions that manifested interest.
ARTICLE IN PRESS 2 Sampling The target population was composed of children who went to schools within private, municipal, and state networks from two medium-sized cities. To obtain 5% significance this study’s sample would have to be composed by at least 385 children. Procedures for selecting schools and children To recruit the schools, we performed a survey of the institutions and listed them alphabetically. Then, we conducted a draw of the schools to contact. When the school did not accept to participate in the research, we invited the next one on the list. For the schools that opted to participate, we sent the FICFs to the 4:00 to 7:11 years old children’s caregivers. The children who were authorized by their caregivers and who manifested interest in participating in the study went through the inclusion and exclusion criteria to compose the sample. Inclusion and exclusion criteria to compose the sample The criteria for including children into the sample were: ages from 4:00 to 7:11 years, to avoid children with accumulation of adipose tissue observed in the prepubertal phase14; adhesion of the caregiver to the FICF and agreement of the child to participate; and BMI among the 5 to 85 percentiles, ie, eutrophic. The exclusion criteria were: report, by the caregiver of the child, of current speech therapy or otorhinolaryngological treatments for voice, of laryngeal surgery, of current laryngeal affections,2,3,18 of periodically practicing any singing style (at least once a week)17; not passing the hearing screening18; BMI indicative of overweight, obesity, or underweight; and speech therapy diagnosis of dysphonia through auditory-perceptual evaluation of the voice.2,3 The caregiver of the children answered a questionnaire for gathering personal data about the children (inclusion criteria) and ascertaining the data related to current speech therapy and/or otorhinolaryngological treatments for voice, to laryngeal surgery, to the presence of current laryngeal affections, and to the periodic practice of singing (exclusion criteria). We also submitted the children to audiometric screenings using the scanning of pure tones at the 0.5, 1, 2, and 4 kHz frequencies at 20 dB, only through air conduction, to evaluate the presence of hearing alterations and contemplate the exclusion criteria.19 We conducted the screenings in a quiet room20 assessed through the Icel-DL-4200 digital sound pressure measurer (Resolution 274/01 of the Brazilian Federal Council of Speech, Language, and Hearing Sciences). To exclude the obese, overweight, and underweight subjects and include only those eutrophics, we calculated the BMI, which was considered an instrument to apply the exclusion criteria as well as to collect study data. The children who presented alterations in some of the assessments
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described were excluded from the research and referred to more complete evaluations. We applied the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scale to investigate the occurrence of dysphonia (exclusion criteria). We included in the study the children who presented scores up to 33/100 (mildly deviant - MI). This criterium, including children mildly deviant according to CAPE-V, was adopted based on some studies stating that voices with mild levels of hoarseness, nasality, and/or breathiness are considered “expected voices” in infancy.3,21,22 Evaluation of the BMI To obtain the BMI, we evaluated the children measuring their weight and height. We measured the weight using a duly calibrated Toledo 150 digital scale, with a capacity of 125 g to 150 kg. We measured the height using a Caumaq Ltda stadiometer fixed on a flat wall without baseboard. The children were in orthostatic positions, barefoot, and wearing light clothes.23,24 We calculated the BMI values by dividing the weight in kilograms by the squared height in meters (BMI = kg/m2).23-25 The BMI normality values employed were those proposed by the World Health Organization. We considered as underweight children who were below the fifth percentile for their age and gender; as eutrophic children, those who were between the 5th and 85th percentiles; as overweight children, those with BMI values higher or equal to the 85th percentile; and as obese children, those above the 95th percentile. We only included eutrophic children in the study.24,25 Speech therapy evaluations for sampling The children in the sample had three MPT/a/ and MPT/i/ sustained emissions (for CAPE-V) timed in seconds and recorded in a quiet room, with a noise level below 50 dBSPL, as established by a digital Icel-DL-4200 sound pressure measurer.25−27 We performed the collections before recess and the physical education classes so to avoid the interference of intensive and/or abusive voice use.18 For data collection, in an orthostatic position, the child was instructed to emit the MPT, after a deep inspiration, in habitual pitch and loudness, until the end of the air expiration. Furthermore, we collected samples of spontaneous speech and CAPE-V phrases adapted to Portuguese27−29: “Erica tomou suco de pera e amora” (The blue spot is on the key again); “Agora e hora de acabar” (We eat eggs every Easter); “S^onia sabe sambar sozinha” (How hard did he hit him); “Minha m~ae namorou um anjo” (My mama makes lemon muffins); “Olha la o avi~ao azul” (We were away a year ago); and “Papai trouxe pipoca quente” (Peter will keep at the peak). We also asked the children to talk about recess, the physical education classes, and the activities they performed at school. When the spontaneous speech sample was small, we also asked them to talk about the people that lived in their
ARTICLE IN PRESS Leila Susana Finger, et al
MPT and BMI in Nondysphonic Eutrophic Children
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homes, their toys, and their pets. We then cut out a 30 second excerpt from the spontaneous speech to perform the auditory-perceptual evaluation of voice, based on CAPEV’s recommendation of using at least 20 seconds of spontaneous speech.2-4,28-30 For the recordings, we positioned the Behringer ECM8000 omnidirectional microphone with a 15 to 20 kHz frequencycapturing flat range, attached to a Zoom H4n professional digital recorder (96 kHz, 16 bits, and signal capturing regulated at 50%), in front of the child's mouth and at a 90° angle. We kept the microphone 4 cm from the mouth to collect the sustained vowel,31 and 10 cm to collect phrase repetition and spontaneous speech.3,30
voice); tension (excessive vocal effort); pitch (perceptive correlation of the fundamental frequency); and loudness (perceptive correlation of the sound pressure).27,31 Pitch and loudness were not employed in this work’s evaluations because the judges were blinded regarding the gender and age of the children. The degree of alteration was defined as the average of the percentages attributed by each of the three judges for each parameter and for each child. This was the result of the auditory-perceptual evaluation of the voice. Due to anatomic characteristics and to the body growth process, children with a mild global severity degree were considered nondysphonic.15
Auditory-perceptual evaluation of voice We used the auditory-perceptual evaluation of voice to exclude dysphonic children. Three speech therapists with experience in the area of voice and with their audiometric exams within normality performed judgments based on the MPT/a, i/ sample, the CAPE-V phrase repetition, and the spontaneous speech of each child.27,31 We edited the voice and speech samples on a Crystal Sound Fusion soundboard with its capturing characteristics preserved. We transferred the files from the WAV extension to the PCM audio format; 44,100 Hz, 16 bits, Mono. We edited the samples so to present the sustained emission of vowels /a, i/, the chained speech, and the CAPE-V phrases sequentially in a single audio file. This grouping aimed to reduce the difficulties in the auditory-perceptual evaluation inherent to children’s voices, considering the importance of the production of a single evaluation of the vocal deviation, regarding all types of samples produced by the individual.32 We recorded the files onto CDs and sent them to the judges for them to perform their judgments independently. The speech-therapist judges, who are not authors of this work, were blinded regarding the identification of the subjects and the evaluations of the other judges. They received a CD with recordings of the voices to be analyzed. The first six tracks were of children’s voices whose vocal quality was neutral to serve as an anchor during the evaluations. These voices could be heard freely to guide their judgment.32 The anchor voices were independently analyzed by four speech therapists uninvolved in the research and deemed normal. We oriented the judges not to perform the analyses at the end of the day or tired, and to hear the voices using earphones as many times as necessary. For the analysis, we employed the CAPE-V analog visual scale, which evaluates six predetermined parameters with the possibility of including two additional ones. The linear analog scale presented 100 mm of length (from 0 to 100 mm), in which each judge marked her classification regarding the degree of deviation observed in each parameter.27,31 The auditory-perceptual vocal parameters of the CAPEV protocol are the following: global severity degree (global impression of voice alteration); roughness (irregularity in the sound source); breathiness (escape of air audible in the
Data collection We sent 3,240 FICFs to the parents, and, after applying the inclusion and exclusion criteria, 484 children remained with ages from 4:00 to 7:11 years, thus composing this study’s sample. We stratified them in age ranges of 4:00, 5:00, 6:00, and 7:00 years, with each age range subdivided into boys and girls. We also obtained the MPT/u/ to compose the corpus of data, in the same occasion and conditions used for the MPT/a, i/ emissions described previously. We considered the longest emission time for each of the vowels and stratified the data by age range (4:00, 5:00, 6:00, or 7:00 years) and sex (boys or girls).
Statistical analysis We performed the statistical analysis using the SPSS v19 software, at a 5% significance level (P ≤ 0.05). We conducted descriptive statistical analysis and evaluated the difference between genders (in each age range) using the t test. We also performed multiple regression, seeking to relate the BMI variable in the prediction of the MPTs for the different age ranges and genders.
RESULTS Table 1 shows MPT of vowels /a, i, u/ from boys by age range. It was observed that within our study the observed MPT in seconds corresponds to the child’s age in years. Table 2 shows MPT of vowels /a, i, u/ from girls by age range. It was observed that within our study the observed MPT in seconds corresponds to the child’s age in years. Table 3 shows MPT from boys and girls by age range. There was significant difference between MPT /a/ from boys and girls 7:00 years old. Table 4 shows multiple regression between MPT and BMI from boys by age range. There is no significant correlation between the variables. Table 5 shows multiple regression between MPT and BMI from girls by age. There is no significant correlation between the variables.
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TABLE 1. Maximum Phonation Times of Vowels /a, i, u/ From Boys by Age Range Percentiles Measurement MPT/a/ (s)
MPT/i/ (s)
MPT/u/ (s)
Age (Years)
5
10
25
50
75
90
95
4 5 6 7 4 5 6 7 4 5 6 7
1.72 2.34 2.88 3.85 1.61 2.29 2.61 3.26 1.53 2.39 2.61 3.36
2.10 2.59 3.11 4.29 1.84 2.47 2.91 4.11 1.66 2.49 2.90 4.23
2.42 3.49 4.14 5.44 2.32 3.35 3.68 5.37 2.62 3.18 3.86 5.16
3.64 4.77 5.49 7.61 3.15 4.81 5.51 6.55 3.25 4.39 5.55 6.83
4.49 6.60 7.51 9.40 4.50 6.33 7.29 8.42 4.55 6.19 7.18 8.83
5.67 7.71 9.03 10.93 5.82 8.27 9.01 10.22 5.50 7.90 9.19 10.38
7.38 8.80 10.06 11.87 6.49 9.08 10.29 10.67 8.01 9.35 9.96 11.59
Abbreviations: MPT, maximum phonation time; s, seconds.
TABLE 2. Maximum Phonation Times of Vowels /a, i, u/ From Girls by Age Range Percentiles Measurement MPT/a/ (s)
MPT/i/ (s)
MPT/u/ (s)
Age (Years)
5
10
25
50
75
90
95
4 5 6 7 4 5 6 7 4 5 6 7
1.67 2.47 2.52 3.73 1.79 2.28 2.52 2.99 1.78 2.46 2.61 2.90
1.92 2.72 2.58 3.96 1.93 2.60 2.59 3.42 1.98 2.59 3.03 3.59
2.45 3.41 3.47 4.92 2.26 3.35 3.47 5.16 2.55 3.37 3.80 5.20
3.41 4.59 4.78 6.02 3.21 4.25 4.78 6.77 3.26 4.38 4.72 6.30
4.99 6.42 6.96 8.15 4.57 6.14 6.96 8.30 4.43 5.71 7.87 7.88
6.17 7.43 9.66 10.52 5.30 7.43 9.66 9.78 5.21 7.42 9.23 9.43
7.84 7.99 10.41 11.31 6.21 7.99 10.64 10.57 6.25 8.45 10.94 10.90
Abbreviations: MPT, maximum phonation time; s, seconds.
TABLE 3. Maximum Phonation Times From Boys and Girls by Age Range Age (Years) Measurement (Mean SD) MPT/a/ (s) MPT/i/ (s) MPT/u/ (s)
4 B (n = 42)
G (n = 50)
5 P Value
3.77§1.68 3.89§1.82 0.76 3.49§1.50 3.49 §1.36 0.99 3.64§1.64 3.54§1.39 0.76
B (n = 58)
G (n = 84)
6 P Value
5.00§1.9 4.89 §2.18 0.72 4.96§2.00 4.73 §1.80 0.50 4.85§2.05 4.73 §1.78 0.70
B (n = 70)
G (n = 57)
7 P Value
5.85§2.18 5.61§2.17 0.54 5.72§2.26 5.41§2.40 0.50 5.76§2.32 5.64§2.39 0.78
* Significant t test (P ≤ 0.05). Abbreviations: B, boy; G, girl; MPT, maximum phonation time; s, seconds; § standard deviation.
B (n = 60)
G (n = 63)
P Value
7.50§2.45 6.61§2.34 0.049* 6.88§2.26 6.63§2.20 0.53 7.08§2.39 6.47§2.20 0.14
Leila Susana Finger, et al
MPT and BMI in Nondysphonic Eutrophic Children
TABLE 4. Multiple Regression Between MPT and BMI from Boys by Age Range BMI Age (Years) MPT/a/ (s)
corr
MPT/i/ (s)
corr
MPT/u/ (s)
corr
4
5
0.05 0.73 0.09 0.58 0.06 0.71
0.20 0.13 0.24 0.074 0.13 0.35
6 0.07 0.54 0.06 0.603 0.10 0.40
7 0.25 0.055 0.22 0.095 0.07 0.61
There is no significant correlation between the variables. Multiple regression (P ≤ 0.05).
TABLE 5. Multiple Regression Between MPT and BMI From Girls by Age Range IMC Age (years)
4
MPT/a/ (s)
corr
MPT/i/ (s)
corr
MPT/u/ (s)
corr
0.17 0.23 0.25 0.089 0.165 0.26
5 0.08 0.45 0.016 0.89 0.063 0.57
6 0.07 0.63 0.03 0.84 0.10 0.48
7 0.05 0.69 0.08 0.53 0.24 0.052
There is no significant correlation between the variables. Multiple regression (P ≤ 0.05).
DISCUSSION Several authors consider that within the children population the expected MPT in seconds corresponds to the child’s age in years,3,4,33 which was corroborated by this study’s results (Tables 1 and 2) and by the study in reference32 which observed an MPT/a/ of 5.6 s for children with ages from 4:00 to 6:00 years, 8.2 seconds from 7:00 to 9:00 years, and 10.4 seconds from 10:00 to 12:00 years, as well as MPT/s/ of 4.7 seconds from 4:00 to 6:00 years, 7.3 seconds from 7:00 to 9:00 years, and 10.1 seconds from 10:00 to 12:00 years. For some authors,9 school-age children without voice alterations have MPTs around 10 seconds. Other researchers1 subdivide children into two groups: children and small children, considering average MPTs of 8.95 seconds and 7.5 seconds, respectively. It is important to consider the MPT results by age range, due to the neuromuscular development during the child’s growth; so one can establish reliable comparisons, applicable in the clinical practice.2,33 Other authors suggest7 that an increase in the MPT may be possible after several emissions performed with visual support and emphasize the importance of implementing verbal instructions for the children with the purpose of improving their performance in this activity that requires abstraction.
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A study7 that obtained the MPTs of 20 children with ages from 7:00 to 9:00 years using visual support concluded that MPTs obtained with the aid were longer than those without it. The average MPTs of vowels /a, e, i/ were of 9.72 seconds, 9.29 seconds, and 10.20 seconds on the first collection; 10.82 seconds, 11.03 seconds, and 12.17 seconds on the second; 12.42 seconds, 12.80 seconds, and 12.66 seconds on the third; and 10.56 seconds, 11.17 seconds, and 11.50 seconds on the fourth. The authors7 associate the MPT improvement to previous training and, especially, to the use of visual support to obtain them. The MPT/a/ obtained in the study in reference2 were of 5.77 seconds at age 4:00 years, 7.16 seconds at 5:00, and 10.32 seconds at 6:00 years old, ie, emissions longer than the respective chronological ages, which are results similar to those obtained in other studies.7,14 However, they disagree with the MPT/a/ found in the present research (Tables 1 and 2) and in other studies3,4 whose results show average MPTs in seconds which are numerically close to the age of the child in years. Some works that evaluated MPTs diverge when the phonation times2,3,5,11 and the gender differences5,11−15 are considered. When evaluating 200 children, average MPT/a/ of 14.2 seconds for boys and 13.1 seconds for girls with age 6:00 years were observed,9 which are longer than those found in this research (Table 3). Another study,10 in which the MPT/a/ for girls were of 8.86 seconds at age 4:00 years, 10.47 seconds at 5:00, and 13.81 seconds at 6:00, and for boys were respectively of 9.99 seconds, 10.2 seconds, and 14.2 seconds, also obtained longer MPTs than those found in the present investigation. A longer MPT/a/ in boys compared to girls was observed,9 which agrees with the present study when determining a longer MPT/a/ in boys at age 7:00 years than that found in other research.13,14 However, only the MPT/a/ in boys at age 7:00 years was significantly longer; for the other vowels and age ranges in this work and those of other studies, there were no significant differences between genders.11,12 When assessing 71 children with ages from 6:00 to 10:00 years, the obtained MPT/a,i,u/ were of respectively 10.44 seconds, 11.22 seconds, and 10.09 seconds for girls, and 9.90 seconds, 10.69 seconds, and 10.19 seconds for boys with ages 6:00, 7:00, and 8:00 years.11 A study,12 which also did not demonstrate differences between MPTs from boys and girls, evaluated children with ages from 4:00 to 10:00 years and showed that the MPT/a/ of boys varied from 4.88 seconds at 4:00 years to 10.04 seconds at 10:00 years; for girls, the values ranged from 5.39 seconds to 11.1 seconds. The work in reference13 evaluated 150 children with ages from 8:00 to 10:00 years and revealed that the averages for girls and boys were, respectively, of 12.35 seconds and 13.70 seconds for MPT/a/; 12.72 seconds and 13.67 seconds for MPT/i/; and 12.04 seconds and 11.64 seconds for MPT/u/. The authors considered the MPTs predominantly longer than those found in other studies.11,12 The results of the work above also showed there was no correlation among MPT, age, and height of the children, yet the occurrence of
ARTICLE IN PRESS 6 these correlations was not constant for all the MPT emissions nor all the groups. Children’s MPTs increase with age,1,2,7,14 which was also observed in the present work (Tables 1 and 2). In the investigation in reference,2 the MPTs were significantly longer at age 6:00 when compared to the emissions at age 4:00, results which are corroborated by our study (Tables 1 and 2) and several other studies,2,5,13,14 thus making evident the nervous and muscular maturation that occurs as the child physically grows.1-3 The study in reference2 found a significant positive correlation between the BMI and the MPT/s,z/. The authors related this result to the influence of the body dimensions on the acoustic measurements of children.25 Such findings seem to demonstrate the relationship between the expiratory and phonatory control and body measurements.1-3 In the present study, the BMI variable did not affect the MPT/a,i,u/ in the different age ranges (Tables 4 and 5). Such findings agree with those described in the study in reference14 which evaluated 150 children with ages from 8:00 to 10:11 years and found MPT/a/ longer in boys, whereas the MPT/i/ and MPT/u/ did not show significant differences. It is known that MPTs suffer influence from countless variables and these influences are not yet fully understood, especially during infancy, when significant changes occur in body growth, influencing size and shape of structures, as well as their functions and the interrelation among them.15 Thus, we suggest that future studies about the MPTs of children may also contemplate the evaluation of body posture and pulmonary function, besides exploring the influence of issues related to emotional maturity and cognition, abdominal circumference, neuromuscular and aerodynamic control during phonation, as well as the effect of using previous training and visual support in obtaining the MPT.
CONCLUSIONS Upon analyzing the MPT/a,i,u/ and the BMI of eutrophic nondysphonic children within the age range from 4:00 to 7:11 years, we concluded that the MPT in seconds is approximately the children’s age in years, and increased with age; that, at age 7:00 years, the MPT/a/ was longer in boys; and that the BMI did not show influence over the MPT.
ACKNOWLEDGMENTS C. A. Cielo acknowledges support from Brazilian agency CNPq (Grant 301326/2017-7). The authors thank Prof L S Dorneles (English revision).
REFERENCES 1. Colton RH, Casper JK. Understanding Voice Problems - A Physiological Perspective for Diagnosis and Treatment. Baltimore: Williams & Wilkins; 1990. 2. Cappellari VM, Cielo CA. Tempo maximo de fona¸c ~ao de crian¸c as preescolares. Rev Bras Otorrinolaringol. 2008;74:552–560.
Journal of Voice, Vol. &&, No. &&, 2019 3. Behlau M, Madazio G, Feij o D, et al. Avalia¸c ~ao de voz. In: Voz Behlau M, ed. O livro do especialista vol. I. Rio de Janeiro: Revinter; 2008:85–245. 4. Wilson DK. Voice Problems in Children. Baltimore: Williams & Wilkins; 1987. 5. Gramuglia ACJ, Tavares EL, Rodrigues SA, et al. Perceptual and acoustic parameters of vocal nodules in children. Int J Pediatr Otorhinolaryngol. 2014;78:312–316. 6. Pascotini FS, Haeffner LSB, Cielo CA. Forced vital capacity and maximum phonation time compared to waist circumference and nutritional status of children. Rev CEFAC. 2016;18:915–922. 7. Paes SM, Azevedo RR. Effect of visual support in the evaluation of maximum phonation time children. Disturb Com. 2010;22:127–132. 8. Finnegan DE. Maximum phonation time for children with normal voices. J Commun Disord. 1984;17:309–317. 9. Shigemori Y. Some tests related to the air usage during phonation. Clin Invest Otol. 1977;23:138–166. 10. Rockenbach SP, Feij o AV. Study of the maximum phonation time in children of six to ten years of age. Pro-Fono. 2000;12:81–85. 11. Spinelli ICP. Phonatory measures of children at a public school in the city of S~ao Paulo. S~ao Paulo: Universidade de S~ao Paulo (USP) Sa ude Materno Infantil; 2004. 12. Fabron EMG, Santos GR, Omote S, et al. Respiratory dynamics measurements in children with four to ten years of age. Pro-Fono. 2006;18:313–322. 13. Modolo DJ, Beradinelle R, Brasolotto AG. Rela¸c ~ao entre tempo maximo de fona¸c ~ao, estatura e idade em crian¸c as de oito a 10 anos. 17 Congresso Brasileiro de Fonoaudiologia; 2009. Salvador: Sociedade Brasileira de Fonoauidologia; 2009:1541. 14. Kneipp C, Habitzreuter F, Mezadri T, et al. Overweight and associated variables in schoolchildren in Itajaí in the State of Santa Catarina, Brazil. Ci^enc. Saude Coletiva. 2015;20:2411–2422. 15. Ramos LA, Souza BO, Gama AC. Vocal analysis in children: an integrative review. Dist Com. 2017;29:20–32. 16. Hamdaman AL, Tabri ABIR, Saade D, et al. Relationship between acoustic parameters and body mass analysis in young males. J Voice. 2012;26:143–147. 17. Lopes LW, Barbosa Lima IL, Alves Almeida LN, et al. Severity of voice disorders in children: correlations between perceptual and acoustic data. J Voice. 2012;26:819.e7–819.e12. 18. Behlau M, Azevedo R, Madazio G. Anatomia da laringe e fisiologia da produ¸c ~ao vocal. In: Behlau M Voz, ed. O livro do especialista vol I. Rio de Janeiro: Revinter; 2008:1–51. 19. Conselho Federal de Fonoaudiologia. Resolu¸c ~ao CFFa n.° 274/01 em 20 de abril de 2001: Disp~oe sobre a atua¸c ~ao frente a triagem auditiva escolar. Brasília: CFFa; 2001. Encontrado em: URL: http://www. fonoaudiologia.org.br. 20. Conselho Federal de Fonoaudiologia. Resolu¸c ~ao CFFa n. 364/09 em 30 de mar¸c o de 2009: Disp~oe sobre o nível de press~ao sonora das cabinas/salas de testes audiologicos e da outras provid^encias. Brasília: CFFa; 2009. Encontrado em: URL: http://www.fonoaudiologia.org.br. 21. Schott TCA, Sampaio TMM, Oliveira DSF. Frequ^encia fundamental de crian¸c as da cidade de Niter oi. Rev CEFAC. 2009;12: 290–295. 22. Yamasaki R. Correspond^encia entre escala anal ogicovisual e escala numerica na avalia¸c ~ao de vozes. 16 Congresso Brasileiro de Fonoaudiologia. Campos do Jord~ao: Sociedade Brasileira de Fonoaudiologia; 2009. p. 1080. 23. Diniz KS, Pacheco LF. A rela¸c ~ao entre exercício físico e o índice de massa corporal em crian¸c as obesas e n~ao obesas de uma escola p ublica. EFDeportes.com, Revista Digital. 2011;15. Encontrado em: URL: http://www.efdeportes.com/. 24. Cielo CA, Pascotini FS, Haeffner LSB, et al. Maximum phonation time of /e/ and voiceless /_e/ and their relationship with body mass index and gender in children. Rev CEFAC. 2016;18:491–497. 25. WHO (Word Health Organization). Child growth standards 2007. Encontrado em: URL: http://www.who.int/.
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MPT and BMI in Nondysphonic Eutrophic Children
26. Sim~ oes-Zenari M, Nemr K, Behlau M. Voice disorders in children and its relationship with auditory, acoustic and vocal behavior parameters. Int J Pediatr Otorhinolaryngol. 2012;76:896–900. 27. Behlau M. Consensus auditory: perceptual evaluation of voice (CAPEV), ASHA 2003. Refletindo sobre o novo/New reflexions. Rev Soc Bras Fonoaudiol. 2004;9:187–189. 28. Kelchner LN, Brehm SB, Weinrich B, et al. Perceptual evaluation of severe pediatric voice disorders: rater reliability using the consensus auditory perceptual evaluation of voice. J Voice. 2010;24:441–449. 29. Oliveira RC, Teixeira LC, Gama ACC, et al. Auditory-perceptive, acoustic and vocal self-perception analyses in children. J Soc Bras Fonoaudiol. 2011;23:158–163.
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30. Solomon NP, Helou LB, Stojadionovic A. Clinical versus laboratory ratings of voice using CAPE-V. J Voice. 2011;25:7–14. 31. Mu~ noz MB, Dassie-Leite AP, Behlau M, et al. Speech language pathology disorders in children with congenital hypothyroidism: critic review of literature. Rev CEFAC. 2014;16(6): 2006–2014. 32. Sales NJ, Gurgel RQ, Rebelo Gon¸c alves MI, et al. Voice performance evaluation of street children from Aracaju, Brazil using perceptualauditory and acoustic analyses. J Voice. 2013;5:589–594. 33. Labio RB, Tavares EL, Alvarado RC, Martins RH. Consequences of chronic nasal obstruction on the laryngeal mucosa and voice quality of 4 to 12 years old children. J Voice. 2012;26:488–492.
Maximum Phonation Time and Body Mass Index in Nondysphonic Eutrophic Children Leila Susana Finger, Carla Franco Hoffmann, and Carla Aparecida Cielo, Santa Maria, Brazil SUMMARY: Background. Literature presents controversial maximum phonation time values in children. Objective. Verify and correlate the maximum phonation time of vowels /a, i, u/ and the body mass index of children. Method. Evaluation of 484 children, eutrophic and without dysphonia, aged from 4:00 to 7:11 years. Sampling: questionnaire, audiometric screening, auditory-perceptual evaluation of voice, and assessment of the body mass index. Data collection: measurement of the maximum phonation time of /a, i, u/. Descriptive statistics, t test, and multiple regression at 5% significance. Results. /a:/ = 3.77 seconds at age 4:00 years, 5 seconds at 5:00, 5.85 seconds at 6:00, and 7.5 seconds at 7:00 for boys, and 3.89 seconds, 4.89 seconds, 5.61 seconds, and 6.61 seconds for girls, respectively; /i:/ = 3.49 seconds at age 4:00 years, 4.96 seconds at 5:00, 5.72 seconds at 6:00, and 6.88 seconds at 7:00 for boys, and 3.49 seconds, 4.73 seconds, 5.41 seconds, and 6.63 seconds for girls, respectively; /u:/ = 3.64 seconds at age 4:00 years, 4.85 seconds at 5:00, 5.76 seconds at 6:00, and 7.08 seconds at 7:00 for boys, and 3.54 seconds, 4.73 seconds, 5.64 seconds, and 6.47 seconds for girls, respectively. There were no significant differences between genders, except for /a:/ at age 7:00 years. The correlations were not significant. Conclusion. Maximum phonation time of /a, i, u/ increased with age and its value in seconds was approximately equal to the age in years. At the age 7:00 years, /a:/ from boys was longer. The body mass index did not show influence on the maximum phonation times. Key Words: Voice−Child−Preschool−Phonation−Speech−Language and hearing sciences.
INTRODUCTION Maximum Phonation Time (MPT) provides information about the individual’s neuromuscular and aerodynamic control of voice production1−3 and is used to evaluate glottic efficiency and vocal quality in adults and children. The MPT is influenced by the vital capacity, which varies according to age, gender, stature, weight, and body surface area.1−5 In another study with 82 children there was no influence of the body mass index (BMI) on the MPT; but there was influence of the abdominal circumference on the vital capacity, and as a consequence on the MPT.6 It is an easily obtained measurement which requires only the use of a chronometer.1−4 According to the PubMed database there were only 14 studies published in the last 5 years, including dysphonic children, with some syndrome, and undergone surgery. However, the MPT is related to the continuous emission of isolated phonemes, and it is not a simple task to measure it when evaluating children. One is required to provide the children means that favor the concrete processing of the verbal orientations, thus facilitating the evaluation of MPT in this population.7 The studies which evaluate MPTs present controversial results regarding phonation times2,4,7−10 and the differences between boys and girls,11−15 possibly because they evaluated Accepted for publication September 30, 2019. From the Universidade Federal de Santa Maria, Departamento de Fonoaudiologia, Santa Maria, Rio Grande do Sul, Brazil. Address correspondence and reprint requests to Leila Susana Finger, Universidade Federal de Santa Maria, Departamento de Fonoaudiologia, Av. Roraima, 1000, Camobi, Santa Maria, RS 97105-900, Brazil. E-mail: [email protected] Journal of Voice, Vol. &&, No. &&, pp. &&−&& 0892-1997 © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2019.09.018
MPT within wide age ranges, and did not considered sex. It is difficult to compare these results with the results from our study. The influence of the BMI on the MPT from children6 and from adults16 lacks exploration, so more evidences are needed. In general, the expected MPT in seconds for the population of children is approximately the child’s number of years, increasing with age and also revealing the nervous and muscle maturation that occurs as the child physically grows.5,17 Therefore, our study’s objective is to verify and to correlate the MPTs of vowels /a, i, u/ and the BMI of nondysphonic children with ages from 4:00 to 7:11 years.
MATERIALS AND METHODS This is an analytical, quantitative, and contemporary crosssectional observational research that meets the recommendation of regulation 466/2012 of the Brazilian National Research Ethics Committee (CONEP/2012) and was approved by the Research Ethics Committee of the author’s institution under number 0306.0.243.000-10. We contacted the schools, and their directors were invited to read and sign the Institutional Authorization Term after receiving the clarifications about the research. The caregivers were also invited to read and sign the Free and Informed Consent Form (FICF). The children were also free to opt for participating or not in the study. All participants received written feedback regarding the performed assessments, as well as activities to promote human communication aimed at students and teachers, in the institutions that manifested interest.
ARTICLE IN PRESS 2 Sampling The target population was composed of children who went to schools within private, municipal, and state networks from two medium-sized cities. To obtain 5% significance this study’s sample would have to be composed by at least 385 children. Procedures for selecting schools and children To recruit the schools, we performed a survey of the institutions and listed them alphabetically. Then, we conducted a draw of the schools to contact. When the school did not accept to participate in the research, we invited the next one on the list. For the schools that opted to participate, we sent the FICFs to the 4:00 to 7:11 years old children’s caregivers. The children who were authorized by their caregivers and who manifested interest in participating in the study went through the inclusion and exclusion criteria to compose the sample. Inclusion and exclusion criteria to compose the sample The criteria for including children into the sample were: ages from 4:00 to 7:11 years, to avoid children with accumulation of adipose tissue observed in the prepubertal phase14; adhesion of the caregiver to the FICF and agreement of the child to participate; and BMI among the 5 to 85 percentiles, ie, eutrophic. The exclusion criteria were: report, by the caregiver of the child, of current speech therapy or otorhinolaryngological treatments for voice, of laryngeal surgery, of current laryngeal affections,2,3,18 of periodically practicing any singing style (at least once a week)17; not passing the hearing screening18; BMI indicative of overweight, obesity, or underweight; and speech therapy diagnosis of dysphonia through auditory-perceptual evaluation of the voice.2,3 The caregiver of the children answered a questionnaire for gathering personal data about the children (inclusion criteria) and ascertaining the data related to current speech therapy and/or otorhinolaryngological treatments for voice, to laryngeal surgery, to the presence of current laryngeal affections, and to the periodic practice of singing (exclusion criteria). We also submitted the children to audiometric screenings using the scanning of pure tones at the 0.5, 1, 2, and 4 kHz frequencies at 20 dB, only through air conduction, to evaluate the presence of hearing alterations and contemplate the exclusion criteria.19 We conducted the screenings in a quiet room20 assessed through the Icel-DL-4200 digital sound pressure measurer (Resolution 274/01 of the Brazilian Federal Council of Speech, Language, and Hearing Sciences). To exclude the obese, overweight, and underweight subjects and include only those eutrophics, we calculated the BMI, which was considered an instrument to apply the exclusion criteria as well as to collect study data. The children who presented alterations in some of the assessments
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described were excluded from the research and referred to more complete evaluations. We applied the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scale to investigate the occurrence of dysphonia (exclusion criteria). We included in the study the children who presented scores up to 33/100 (mildly deviant - MI). This criterium, including children mildly deviant according to CAPE-V, was adopted based on some studies stating that voices with mild levels of hoarseness, nasality, and/or breathiness are considered “expected voices” in infancy.3,21,22 Evaluation of the BMI To obtain the BMI, we evaluated the children measuring their weight and height. We measured the weight using a duly calibrated Toledo 150 digital scale, with a capacity of 125 g to 150 kg. We measured the height using a Caumaq Ltda stadiometer fixed on a flat wall without baseboard. The children were in orthostatic positions, barefoot, and wearing light clothes.23,24 We calculated the BMI values by dividing the weight in kilograms by the squared height in meters (BMI = kg/m2).23-25 The BMI normality values employed were those proposed by the World Health Organization. We considered as underweight children who were below the fifth percentile for their age and gender; as eutrophic children, those who were between the 5th and 85th percentiles; as overweight children, those with BMI values higher or equal to the 85th percentile; and as obese children, those above the 95th percentile. We only included eutrophic children in the study.24,25 Speech therapy evaluations for sampling The children in the sample had three MPT/a/ and MPT/i/ sustained emissions (for CAPE-V) timed in seconds and recorded in a quiet room, with a noise level below 50 dBSPL, as established by a digital Icel-DL-4200 sound pressure measurer.25−27 We performed the collections before recess and the physical education classes so to avoid the interference of intensive and/or abusive voice use.18 For data collection, in an orthostatic position, the child was instructed to emit the MPT, after a deep inspiration, in habitual pitch and loudness, until the end of the air expiration. Furthermore, we collected samples of spontaneous speech and CAPE-V phrases adapted to Portuguese27−29: “Erica tomou suco de pera e amora” (The blue spot is on the key again); “Agora e hora de acabar” (We eat eggs every Easter); “S^onia sabe sambar sozinha” (How hard did he hit him); “Minha m~ae namorou um anjo” (My mama makes lemon muffins); “Olha la o avi~ao azul” (We were away a year ago); and “Papai trouxe pipoca quente” (Peter will keep at the peak). We also asked the children to talk about recess, the physical education classes, and the activities they performed at school. When the spontaneous speech sample was small, we also asked them to talk about the people that lived in their
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homes, their toys, and their pets. We then cut out a 30 second excerpt from the spontaneous speech to perform the auditory-perceptual evaluation of voice, based on CAPEV’s recommendation of using at least 20 seconds of spontaneous speech.2-4,28-30 For the recordings, we positioned the Behringer ECM8000 omnidirectional microphone with a 15 to 20 kHz frequencycapturing flat range, attached to a Zoom H4n professional digital recorder (96 kHz, 16 bits, and signal capturing regulated at 50%), in front of the child's mouth and at a 90° angle. We kept the microphone 4 cm from the mouth to collect the sustained vowel,31 and 10 cm to collect phrase repetition and spontaneous speech.3,30
voice); tension (excessive vocal effort); pitch (perceptive correlation of the fundamental frequency); and loudness (perceptive correlation of the sound pressure).27,31 Pitch and loudness were not employed in this work’s evaluations because the judges were blinded regarding the gender and age of the children. The degree of alteration was defined as the average of the percentages attributed by each of the three judges for each parameter and for each child. This was the result of the auditory-perceptual evaluation of the voice. Due to anatomic characteristics and to the body growth process, children with a mild global severity degree were considered nondysphonic.15
Auditory-perceptual evaluation of voice We used the auditory-perceptual evaluation of voice to exclude dysphonic children. Three speech therapists with experience in the area of voice and with their audiometric exams within normality performed judgments based on the MPT/a, i/ sample, the CAPE-V phrase repetition, and the spontaneous speech of each child.27,31 We edited the voice and speech samples on a Crystal Sound Fusion soundboard with its capturing characteristics preserved. We transferred the files from the WAV extension to the PCM audio format; 44,100 Hz, 16 bits, Mono. We edited the samples so to present the sustained emission of vowels /a, i/, the chained speech, and the CAPE-V phrases sequentially in a single audio file. This grouping aimed to reduce the difficulties in the auditory-perceptual evaluation inherent to children’s voices, considering the importance of the production of a single evaluation of the vocal deviation, regarding all types of samples produced by the individual.32 We recorded the files onto CDs and sent them to the judges for them to perform their judgments independently. The speech-therapist judges, who are not authors of this work, were blinded regarding the identification of the subjects and the evaluations of the other judges. They received a CD with recordings of the voices to be analyzed. The first six tracks were of children’s voices whose vocal quality was neutral to serve as an anchor during the evaluations. These voices could be heard freely to guide their judgment.32 The anchor voices were independently analyzed by four speech therapists uninvolved in the research and deemed normal. We oriented the judges not to perform the analyses at the end of the day or tired, and to hear the voices using earphones as many times as necessary. For the analysis, we employed the CAPE-V analog visual scale, which evaluates six predetermined parameters with the possibility of including two additional ones. The linear analog scale presented 100 mm of length (from 0 to 100 mm), in which each judge marked her classification regarding the degree of deviation observed in each parameter.27,31 The auditory-perceptual vocal parameters of the CAPEV protocol are the following: global severity degree (global impression of voice alteration); roughness (irregularity in the sound source); breathiness (escape of air audible in the
Data collection We sent 3,240 FICFs to the parents, and, after applying the inclusion and exclusion criteria, 484 children remained with ages from 4:00 to 7:11 years, thus composing this study’s sample. We stratified them in age ranges of 4:00, 5:00, 6:00, and 7:00 years, with each age range subdivided into boys and girls. We also obtained the MPT/u/ to compose the corpus of data, in the same occasion and conditions used for the MPT/a, i/ emissions described previously. We considered the longest emission time for each of the vowels and stratified the data by age range (4:00, 5:00, 6:00, or 7:00 years) and sex (boys or girls).
Statistical analysis We performed the statistical analysis using the SPSS v19 software, at a 5% significance level (P ≤ 0.05). We conducted descriptive statistical analysis and evaluated the difference between genders (in each age range) using the t test. We also performed multiple regression, seeking to relate the BMI variable in the prediction of the MPTs for the different age ranges and genders.
RESULTS Table 1 shows MPT of vowels /a, i, u/ from boys by age range. It was observed that within our study the observed MPT in seconds corresponds to the child’s age in years. Table 2 shows MPT of vowels /a, i, u/ from girls by age range. It was observed that within our study the observed MPT in seconds corresponds to the child’s age in years. Table 3 shows MPT from boys and girls by age range. There was significant difference between MPT /a/ from boys and girls 7:00 years old. Table 4 shows multiple regression between MPT and BMI from boys by age range. There is no significant correlation between the variables. Table 5 shows multiple regression between MPT and BMI from girls by age. There is no significant correlation between the variables.
ARTICLE IN PRESS 4
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TABLE 1. Maximum Phonation Times of Vowels /a, i, u/ From Boys by Age Range Percentiles Measurement MPT/a/ (s)
MPT/i/ (s)
MPT/u/ (s)
Age (Years)
5
10
25
50
75
90
95
4 5 6 7 4 5 6 7 4 5 6 7
1.72 2.34 2.88 3.85 1.61 2.29 2.61 3.26 1.53 2.39 2.61 3.36
2.10 2.59 3.11 4.29 1.84 2.47 2.91 4.11 1.66 2.49 2.90 4.23
2.42 3.49 4.14 5.44 2.32 3.35 3.68 5.37 2.62 3.18 3.86 5.16
3.64 4.77 5.49 7.61 3.15 4.81 5.51 6.55 3.25 4.39 5.55 6.83
4.49 6.60 7.51 9.40 4.50 6.33 7.29 8.42 4.55 6.19 7.18 8.83
5.67 7.71 9.03 10.93 5.82 8.27 9.01 10.22 5.50 7.90 9.19 10.38
7.38 8.80 10.06 11.87 6.49 9.08 10.29 10.67 8.01 9.35 9.96 11.59
Abbreviations: MPT, maximum phonation time; s, seconds.
TABLE 2. Maximum Phonation Times of Vowels /a, i, u/ From Girls by Age Range Percentiles Measurement MPT/a/ (s)
MPT/i/ (s)
MPT/u/ (s)
Age (Years)
5
10
25
50
75
90
95
4 5 6 7 4 5 6 7 4 5 6 7
1.67 2.47 2.52 3.73 1.79 2.28 2.52 2.99 1.78 2.46 2.61 2.90
1.92 2.72 2.58 3.96 1.93 2.60 2.59 3.42 1.98 2.59 3.03 3.59
2.45 3.41 3.47 4.92 2.26 3.35 3.47 5.16 2.55 3.37 3.80 5.20
3.41 4.59 4.78 6.02 3.21 4.25 4.78 6.77 3.26 4.38 4.72 6.30
4.99 6.42 6.96 8.15 4.57 6.14 6.96 8.30 4.43 5.71 7.87 7.88
6.17 7.43 9.66 10.52 5.30 7.43 9.66 9.78 5.21 7.42 9.23 9.43
7.84 7.99 10.41 11.31 6.21 7.99 10.64 10.57 6.25 8.45 10.94 10.90
Abbreviations: MPT, maximum phonation time; s, seconds.
TABLE 3. Maximum Phonation Times From Boys and Girls by Age Range Age (Years) Measurement (Mean SD) MPT/a/ (s) MPT/i/ (s) MPT/u/ (s)
4 B (n = 42)
G (n = 50)
5 P Value
3.77§1.68 3.89§1.82 0.76 3.49§1.50 3.49 §1.36 0.99 3.64§1.64 3.54§1.39 0.76
B (n = 58)
G (n = 84)
6 P Value
5.00§1.9 4.89 §2.18 0.72 4.96§2.00 4.73 §1.80 0.50 4.85§2.05 4.73 §1.78 0.70
B (n = 70)
G (n = 57)
7 P Value
5.85§2.18 5.61§2.17 0.54 5.72§2.26 5.41§2.40 0.50 5.76§2.32 5.64§2.39 0.78
* Significant t test (P ≤ 0.05). Abbreviations: B, boy; G, girl; MPT, maximum phonation time; s, seconds; § standard deviation.
B (n = 60)
G (n = 63)
P Value
7.50§2.45 6.61§2.34 0.049* 6.88§2.26 6.63§2.20 0.53 7.08§2.39 6.47§2.20 0.14
Leila Susana Finger, et al
MPT and BMI in Nondysphonic Eutrophic Children
TABLE 4. Multiple Regression Between MPT and BMI from Boys by Age Range BMI Age (Years) MPT/a/ (s)
corr
MPT/i/ (s)
corr
MPT/u/ (s)
corr
4
5
0.05 0.73 0.09 0.58 0.06 0.71
0.20 0.13 0.24 0.074 0.13 0.35
6 0.07 0.54 0.06 0.603 0.10 0.40
7 0.25 0.055 0.22 0.095 0.07 0.61
There is no significant correlation between the variables. Multiple regression (P ≤ 0.05).
TABLE 5. Multiple Regression Between MPT and BMI From Girls by Age Range IMC Age (years)
4
MPT/a/ (s)
corr
MPT/i/ (s)
corr
MPT/u/ (s)
corr
0.17 0.23 0.25 0.089 0.165 0.26
5 0.08 0.45 0.016 0.89 0.063 0.57
6 0.07 0.63 0.03 0.84 0.10 0.48
7 0.05 0.69 0.08 0.53 0.24 0.052
There is no significant correlation between the variables. Multiple regression (P ≤ 0.05).
DISCUSSION Several authors consider that within the children population the expected MPT in seconds corresponds to the child’s age in years,3,4,33 which was corroborated by this study’s results (Tables 1 and 2) and by the study in reference32 which observed an MPT/a/ of 5.6 s for children with ages from 4:00 to 6:00 years, 8.2 seconds from 7:00 to 9:00 years, and 10.4 seconds from 10:00 to 12:00 years, as well as MPT/s/ of 4.7 seconds from 4:00 to 6:00 years, 7.3 seconds from 7:00 to 9:00 years, and 10.1 seconds from 10:00 to 12:00 years. For some authors,9 school-age children without voice alterations have MPTs around 10 seconds. Other researchers1 subdivide children into two groups: children and small children, considering average MPTs of 8.95 seconds and 7.5 seconds, respectively. It is important to consider the MPT results by age range, due to the neuromuscular development during the child’s growth; so one can establish reliable comparisons, applicable in the clinical practice.2,33 Other authors suggest7 that an increase in the MPT may be possible after several emissions performed with visual support and emphasize the importance of implementing verbal instructions for the children with the purpose of improving their performance in this activity that requires abstraction.
5
A study7 that obtained the MPTs of 20 children with ages from 7:00 to 9:00 years using visual support concluded that MPTs obtained with the aid were longer than those without it. The average MPTs of vowels /a, e, i/ were of 9.72 seconds, 9.29 seconds, and 10.20 seconds on the first collection; 10.82 seconds, 11.03 seconds, and 12.17 seconds on the second; 12.42 seconds, 12.80 seconds, and 12.66 seconds on the third; and 10.56 seconds, 11.17 seconds, and 11.50 seconds on the fourth. The authors7 associate the MPT improvement to previous training and, especially, to the use of visual support to obtain them. The MPT/a/ obtained in the study in reference2 were of 5.77 seconds at age 4:00 years, 7.16 seconds at 5:00, and 10.32 seconds at 6:00 years old, ie, emissions longer than the respective chronological ages, which are results similar to those obtained in other studies.7,14 However, they disagree with the MPT/a/ found in the present research (Tables 1 and 2) and in other studies3,4 whose results show average MPTs in seconds which are numerically close to the age of the child in years. Some works that evaluated MPTs diverge when the phonation times2,3,5,11 and the gender differences5,11−15 are considered. When evaluating 200 children, average MPT/a/ of 14.2 seconds for boys and 13.1 seconds for girls with age 6:00 years were observed,9 which are longer than those found in this research (Table 3). Another study,10 in which the MPT/a/ for girls were of 8.86 seconds at age 4:00 years, 10.47 seconds at 5:00, and 13.81 seconds at 6:00, and for boys were respectively of 9.99 seconds, 10.2 seconds, and 14.2 seconds, also obtained longer MPTs than those found in the present investigation. A longer MPT/a/ in boys compared to girls was observed,9 which agrees with the present study when determining a longer MPT/a/ in boys at age 7:00 years than that found in other research.13,14 However, only the MPT/a/ in boys at age 7:00 years was significantly longer; for the other vowels and age ranges in this work and those of other studies, there were no significant differences between genders.11,12 When assessing 71 children with ages from 6:00 to 10:00 years, the obtained MPT/a,i,u/ were of respectively 10.44 seconds, 11.22 seconds, and 10.09 seconds for girls, and 9.90 seconds, 10.69 seconds, and 10.19 seconds for boys with ages 6:00, 7:00, and 8:00 years.11 A study,12 which also did not demonstrate differences between MPTs from boys and girls, evaluated children with ages from 4:00 to 10:00 years and showed that the MPT/a/ of boys varied from 4.88 seconds at 4:00 years to 10.04 seconds at 10:00 years; for girls, the values ranged from 5.39 seconds to 11.1 seconds. The work in reference13 evaluated 150 children with ages from 8:00 to 10:00 years and revealed that the averages for girls and boys were, respectively, of 12.35 seconds and 13.70 seconds for MPT/a/; 12.72 seconds and 13.67 seconds for MPT/i/; and 12.04 seconds and 11.64 seconds for MPT/u/. The authors considered the MPTs predominantly longer than those found in other studies.11,12 The results of the work above also showed there was no correlation among MPT, age, and height of the children, yet the occurrence of
ARTICLE IN PRESS 6 these correlations was not constant for all the MPT emissions nor all the groups. Children’s MPTs increase with age,1,2,7,14 which was also observed in the present work (Tables 1 and 2). In the investigation in reference,2 the MPTs were significantly longer at age 6:00 when compared to the emissions at age 4:00, results which are corroborated by our study (Tables 1 and 2) and several other studies,2,5,13,14 thus making evident the nervous and muscular maturation that occurs as the child physically grows.1-3 The study in reference2 found a significant positive correlation between the BMI and the MPT/s,z/. The authors related this result to the influence of the body dimensions on the acoustic measurements of children.25 Such findings seem to demonstrate the relationship between the expiratory and phonatory control and body measurements.1-3 In the present study, the BMI variable did not affect the MPT/a,i,u/ in the different age ranges (Tables 4 and 5). Such findings agree with those described in the study in reference14 which evaluated 150 children with ages from 8:00 to 10:11 years and found MPT/a/ longer in boys, whereas the MPT/i/ and MPT/u/ did not show significant differences. It is known that MPTs suffer influence from countless variables and these influences are not yet fully understood, especially during infancy, when significant changes occur in body growth, influencing size and shape of structures, as well as their functions and the interrelation among them.15 Thus, we suggest that future studies about the MPTs of children may also contemplate the evaluation of body posture and pulmonary function, besides exploring the influence of issues related to emotional maturity and cognition, abdominal circumference, neuromuscular and aerodynamic control during phonation, as well as the effect of using previous training and visual support in obtaining the MPT.
CONCLUSIONS Upon analyzing the MPT/a,i,u/ and the BMI of eutrophic nondysphonic children within the age range from 4:00 to 7:11 years, we concluded that the MPT in seconds is approximately the children’s age in years, and increased with age; that, at age 7:00 years, the MPT/a/ was longer in boys; and that the BMI did not show influence over the MPT.
ACKNOWLEDGMENTS C. A. Cielo acknowledges support from Brazilian agency CNPq (Grant 301326/2017-7). The authors thank Prof L S Dorneles (English revision).
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