Main pathological conditions causing swallowing disorders.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"8459",leadTitle:null,fullTitle:"Glomerulonephritis and Nephrotic Syndrome",title:"Glomerulonephritis and Nephrotic Syndrome",subtitle:null,reviewType:"peer-reviewed",abstract:"Chronic kidney disease is a worldwide disease affecting up to 4% of the population. In many cases, glomerulonephritis is the underlying disease leading to kidney failure. One hallmark of glomerulonephritis is proteinuria, which may in its most severe form lead to nephrotic syndrome. In seven chapters, this book puts light on different aspects related to the pathophysiology and clinical aspects of glomerulonephritis. In addition, chapters dealing with the importance of biomarkers in patients with glomerulonephritis will be beneficial for the open-minded reader. Nevertheless, new insights in renal rehabilitation in patients with chronic kidney disease will be provided.",isbn:"978-1-78984-314-9",printIsbn:"978-1-78984-313-2",pdfIsbn:"978-1-83962-383-7",doi:"10.5772/intechopen.78833",price:119,priceEur:129,priceUsd:155,slug:"glomerulonephritis-and-nephrotic-syndrome",numberOfPages:124,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"404561518d53b3dd68ce74d6225588c0",bookSignature:"Thomas Rath",publishedDate:"October 30th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/8459.jpg",numberOfDownloads:5532,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:1,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:1,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 10th 2018",dateEndSecondStepPublish:"January 14th 2019",dateEndThirdStepPublish:"March 15th 2019",dateEndFourthStepPublish:"May 20th 2019",dateEndFifthStepPublish:"July 19th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"67436",title:"Dr.",name:"Thomas",middleName:null,surname:"Rath",slug:"thomas-rath",fullName:"Thomas Rath",profilePictureURL:"https://mts.intechopen.com/storage/users/67436/images/system/67436.jpg",biography:"Thomas Rath is a doctor of medicine and specialist in internal medicine, nephrology, hypertension, and infectious diseases. He lives in Kaiserslautern, a city of 100,000 inhabitants in the southwest part of Germany. After completing his studies at the University of Mainz, he became a resident at the Westpfalz-Klinikum in Kaiserslautern, a tertiary care hospital with 1300 hospital beds. There, he is Head of the Department of Nephrology and Transplantation Medicine and also responsible for the outpatient clinic for patients with infectious diseases. He is an active member of many national and international societies. During his scientific career he has published more than 25 papers in peer-reviewed journals and more than 150 abstracts and posters at national and international congresses. He gives lectures at the Technical University of Kaiserslautern on “artificial organ support.”",institutionString:"Westpfalz Klinikum",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Westpfalz Klinikum",institutionURL:null,country:{name:"Germany"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1163",title:"Nephrology",slug:"nephrology"}],chapters:[{id:"68109",title:"Calculation of GFR via the Slope-Intercept Method in Nuclear Medicine",doi:"10.5772/intechopen.85739",slug:"calculation-of-gfr-via-the-slope-intercept-method-in-nuclear-medicine",totalDownloads:808,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"A determination of the glomerular filtration rate (GFR) with high accuracy is of great relevance especially in cases of insufficient kidney function. In nuclear medicine, the standard method is based on blood sample measurements with Cr-51 ethylenediaminetetraacetic acid (Cr-51-EDTA) or Tc-99m diethylene-triamine-pentaacetate (Tc-99m-DTPA), providing very high accuracy and reliability. In particular, the slope-intercept method turned out to be the most appropriate and is therefore routinely used in many hospitals worldwide. For this purpose, blood samples are drawn at certain time points starting 120 minutes after injection, which are then measured together with a standard probe in a gamma counter; based on the results, the GFR calculation is then usually performed automatically with an appropriate software. In this chapter, the mathematical background as well as a step-by-step description of the slope-intercept method is given. In our study, we found that at least three blood samples should be drawn in order to achieve highest quality and reliability. Furthermore, a sample size of at least three blood samples allows an error calculation which provides an estimation of the reliability of the preceding measurement.",signatures:"Barbara Katharina Geist",downloadPdfUrl:"/chapter/pdf-download/68109",previewPdfUrl:"/chapter/pdf-preview/68109",authors:[{id:"290848",title:"Dr.",name:"Barbara Katharina",surname:"Geist",slug:"barbara-katharina-geist",fullName:"Barbara Katharina Geist"}],corrections:null},{id:"67378",title:"Biomarkers in Renal Vasculitis",doi:"10.5772/intechopen.86489",slug:"biomarkers-in-renal-vasculitis",totalDownloads:783,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The use of biomarkers in glomerular diseases has been subject of investigation during the last decades, as it can provide worthwhile evidence in diagnosis, but also, it can guide treatment and give information about prognosis and response. Renal biopsy is still the compulsory technique to establish diagnosis, and also to offer information about the severity of renal damage. However, as an invasive method, it cannot be regularly performed during follow up, so the need to find and establish measurement of molecules, easily collected, which are associated with disease pathogenesis and predict renal function outcome seems very attractive to nephrologists. The renal complications of systemic vasculitis are very important for the outcome of the disease, and several substances and molecules, such as inflammatory cells, autoantibodies, cytokines, chemokines and growth factors are produced and may serve as biomarkers to provide useful information for diagnosis, follow up of the disease.",signatures:"Polyvios Arseniou, Stamatia Stai and Maria Stangou",downloadPdfUrl:"/chapter/pdf-download/67378",previewPdfUrl:"/chapter/pdf-preview/67378",authors:[{id:"231042",title:"Associate Prof.",name:"Maria",surname:"Stangou",slug:"maria-stangou",fullName:"Maria Stangou"},{id:"299733",title:"Dr.",name:"Polyvios",surname:"Arseniou",slug:"polyvios-arseniou",fullName:"Polyvios Arseniou"},{id:"299734",title:"Dr.",name:"Stamatina",surname:"Stai",slug:"stamatina-stai",fullName:"Stamatina Stai"}],corrections:null},{id:"66750",title:"Childhood Idiopathic Nephrotic Syndrome as a Podocytopathy",doi:"10.5772/intechopen.85994",slug:"childhood-idiopathic-nephrotic-syndrome-as-a-podocytopathy",totalDownloads:887,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Idiopathic nephrotic syndrome is the commonest manifestation of glomerular disease in children. The syndrome is characterized by massive proteinuria, hypoalbuminemia, generalized edema, and hyperlipidemia. Although genetic or congenital forms are now well recognized, nephrotic syndrome is largely acquired. The latter form can be idiopathic or primary (the causes are unknown) and secondary (the causes are known renal or non-renal diseases). Idiopathic nephrotic syndrome consists of the following glomerulonephritides: minimal change nephropathy (MCN), focal segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), mesangial proliferative glomerulonephritis (MesPGN), and membranous nephritis (MN). The etiopathogenesis of nephrotic syndrome has evolved through several hypotheses ranging from immune dysregulation theory and increased glomerular permeability theory to the current concept of podocytopathy. Podocyte injury is now thought to be the basic pathology in the syndrome. The book chapter aims to highlight the mechanisms underlying the pathogenesis of nephrotic syndrome as a podocytopathy.",signatures:"Samuel N. Uwaezuoke",downloadPdfUrl:"/chapter/pdf-download/66750",previewPdfUrl:"/chapter/pdf-preview/66750",authors:[{id:"229083",title:"Associate Prof.",name:"Samuel N.",surname:"Uwaezuoke",slug:"samuel-n.-uwaezuoke",fullName:"Samuel N. Uwaezuoke"}],corrections:null},{id:"67831",title:"Membranous Nephropathy",doi:"10.5772/intechopen.87051",slug:"membranous-nephropathy-1",totalDownloads:781,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Membranous nephropathy (MN) is a glomerular disease that is the leading cause of nephrotic syndrome in non-diabetic Caucasian adults. MN is most often primary (idiopathic) and the remaining is secondary to systemic disease or exposure to infection or drugs. The majority of patients with MN have circulating antibodies to the podocyte antigens phospholipase A2 receptor (PLA2R) (70%) and thrombospondin type-1 domain-containing 7A (THSD7A) (3–5%). Immunologic remission (depletion of PLA2R antibodies) often precedes and may predict clinical remission. Untreated, about one-third of patients undergo spontaneous remission, one-third have persistent proteinuria but maintain kidney function and the remaining one-third will develop end stage kidney failure. All patients with idiopathic MN should be treated with conservative care from the time of diagnosis to minimise proteinuria. Immunosuppressive therapy is traditionally reserved for patients who have persistent nephrotic-range proteinuria despite conservative care. Immunosuppressive agents for primary MN include combination of corticosteroids/alkylating agent or calcineurin inhibitors and rituximab. This chapter will review the epidemiology, diagnosis and treatment of MN, particularly focusing on idiopathic MN.",signatures:"Bhadran Bose, Sunil V. Badve, Vivekanand Jha, Chen Au Peh and David Johnson",downloadPdfUrl:"/chapter/pdf-download/67831",previewPdfUrl:"/chapter/pdf-preview/67831",authors:[{id:"50425",title:"Prof.",name:"David",surname:"Johnson",slug:"david-johnson",fullName:"David Johnson"},{id:"223457",title:"Dr.",name:"Bhadran",surname:"Bose",slug:"bhadran-bose",fullName:"Bhadran Bose"},{id:"294755",title:"Dr.",name:"Sunil V.",surname:"Badve",slug:"sunil-v.-badve",fullName:"Sunil V. Badve"},{id:"299784",title:"Dr.",name:"Chen",surname:"Au Peh",slug:"chen-au-peh",fullName:"Chen Au Peh"},{id:"299785",title:"Dr.",name:"Vivekanand",surname:"Jha",slug:"vivekanand-jha",fullName:"Vivekanand Jha"}],corrections:null},{id:"68114",title:"Primary Membranous Nephropathy as a Model of Autoimmune Disease",doi:"10.5772/intechopen.88003",slug:"primary-membranous-nephropathy-as-a-model-of-autoimmune-disease",totalDownloads:845,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Membranous nephropathy is the most common cause of adult nephrotic syndrome worldwide with a significant health care burden. There has been a leap in our understanding of the disease mechanism over the last decade with a remarkably strong genetic component to the development of the disease and its strong association with high affinity antibody—in the form of anti-PLA2R autoantibody in the majority of cases, with a smaller proportion associated with anti-THSD7A autoantibody. New evidence is now providing confirmation of specific elements in the development of the disease pathogenesis, such as involvement of loss of peripheral tolerance. There is a striking correlation between disease activity and anti-PLA2R antibody levels, along with response to treatment; evidence points strongly to these antibodies being pathogenic. The development of membranous nephropathy therefore follows the well appreciated multi-hit step-wise path to autoimmune clinical disease. Given its strong genetic basis and putative pathogenic antibody the disease provides an invaluable model for understanding of autoimmunity. This chapter focuses on the most up to date knowledge of autoimmune membranous nephropathy and provides a paradigm for understanding the underlying disease mechanisms in autoimmunity.",signatures:"Patrick Hamilton, Durga Kanigicherla and Paul Brenchley",downloadPdfUrl:"/chapter/pdf-download/68114",previewPdfUrl:"/chapter/pdf-preview/68114",authors:[{id:"251913",title:"Dr.",name:"Patrick",surname:"Hamilton",slug:"patrick-hamilton",fullName:"Patrick Hamilton"},{id:"291340",title:"Prof.",name:"Paul",surname:"Brenchley",slug:"paul-brenchley",fullName:"Paul Brenchley"},{id:"298314",title:"Dr.",name:"Durga",surname:"Kanigicherla",slug:"durga-kanigicherla",fullName:"Durga Kanigicherla"}],corrections:null},{id:"67754",title:"Treatment of Idiopathic Membranous Nephropathy (IMN)",doi:"10.5772/intechopen.86741",slug:"treatment-of-idiopathic-membranous-nephropathy-imn-",totalDownloads:662,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"We present a 59-year-old patient with type 2 diabetes mellitus and massive nephrotic syndrome (anasarca) and biochemical syndrome. The renal biopsy showed a membranous nephropathy (MN). In the blood analysis the patient presented antibodies against M-type phospholipase A2 receptor (anti-PLA2R) positive at a very high titer. Given the existence of idiopathic membranous nephropathy (IMN), treatment was started with a modified Ponticelli regimen, with no response, requiring periodic ultrafiltration sessions. Rituximab induces nephrotic syndrome (NS) remission in two-thirds of patients with IMN, even after other treatments have failed. We proposed treatment with rituximab based on published evidence. In IMN, the presence of M-type anti-receptor antibodies of A2 phospholipase is considered highly specific to idiopathic forms, but the presence of such antibodies has not been shown to be associated with a particular clinical profile. Assessing circulating anti-PLA2R autoantibodies and proteinuria may help in monitoring disease activity and guiding personalized rituximab therapy in nephrotic patients with IMN.",signatures:"María Carmen Prados Soler, María Dolores Del Pino y Pino, Álvaro Pérez Fernández, Llenalia Gordillo García, María José López Ruiz and César Luis Ramírez-Tortosa",downloadPdfUrl:"/chapter/pdf-download/67754",previewPdfUrl:"/chapter/pdf-preview/67754",authors:[{id:"291444",title:"Dr.",name:"María Carmen",surname:"Prados Soler",slug:"maria-carmen-prados-soler",fullName:"María Carmen Prados Soler"},{id:"301092",title:"Dr.",name:"María Dolores",surname:"Del Pino Y Pino",slug:"maria-dolores-del-pino-y-pino",fullName:"María Dolores Del Pino Y Pino"},{id:"301094",title:"Dr.",name:"Álvaro",surname:"Pérez Fernández",slug:"alvaro-perez-fernandez",fullName:"Álvaro Pérez Fernández"},{id:"301095",title:"Dr.",name:"Llenalia",surname:"Gordillo García",slug:"llenalia-gordillo-garcia",fullName:"Llenalia Gordillo García"},{id:"301096",title:"Dr.",name:"María José",surname:"López Ruiz",slug:"maria-jose-lopez-ruiz",fullName:"María José López Ruiz"},{id:"301097",title:"Dr.",name:"César Luis",surname:"Ramirez-Tortosa",slug:"cesar-luis-ramirez-tortosa",fullName:"César Luis Ramirez-Tortosa"}],corrections:null},{id:"67010",title:"Renal Rehabilitation: A Perspective From Human Body Movement",doi:"10.5772/intechopen.86156",slug:"renal-rehabilitation-a-perspective-from-human-body-movement",totalDownloads:766,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The prevalence and incidence of advanced chronic kidney disease has grown progressively in most countries of the world. Hemodialysis is the most common treatment that replaces the renal function, and although it allows to replace the function of the kidney, the patients who undergo it can present numerous alterations that lead to a loss of functional physical capacity and a decrease in the quality of life related to health. It is unknown to what extent low physical activity, uremia and anemia determine the decrease in functional capacity of these patients. The functional tests most frequently used in the published literature are characterized by their ease of application and their low cost, since they do not require large measuring instruments to quantify basic qualities in subjects with impaired or dysfunction of the renal system from the aerobic capacity, muscle performance and flexibility as axes within the kinetic wellbeing which is committed in the stay of the renal hemodialysis units.",signatures:"Jorge Enrique Moreno Collazos and Diana Carolina Zona Rubio",downloadPdfUrl:"/chapter/pdf-download/67010",previewPdfUrl:"/chapter/pdf-preview/67010",authors:[{id:"294671",title:"Dr.",name:"Jorge Enrique",surname:"Moreno Collazos",slug:"jorge-enrique-moreno-collazos",fullName:"Jorge Enrique Moreno Collazos"},{id:"295668",title:"Prof.",name:"Diana Carolina",surname:"Zona Rubio",slug:"diana-carolina-zona-rubio",fullName:"Diana Carolina Zona Rubio"}],corrections:null}],productType:{id:"1",title:"Edited 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Swallowing disorders in children is a topic of great interest, from the epidemiological, clinical, rehabilitative, and, not least, cultural perspective. If significant steps forward have been made in recent decades in all aspects of adult swallowing (under normal conditions and for different comorbidities), medical knowledge about aspects of swallowing in childhood (normal, abnormal, and deviant) has not improved at the same speed. This has created a major gap between the more practical aspects of patient care and people requiring specific interventions.
Before proceeding to the discussion of the most typical physiopathological and clinical aspects related with this disorder, a brief epidemiological and etiological framework of the problem is appropriate.
Data about the incidence (new cases) and prevalence (disorder in a given period of time) of swallowing disorders in childhood are not reported separately in the literature. This is mainly due to the heterogeneity of the population studied, in reference to the assumed consistency and the different ways of detection of the disorder. It is estimated that 25–45% of normally developing children can have eating disorders and swallowing problems, and in children with developmental disorders, the prevalence is estimated to be 30–80%. Feeding problems associated with serious sequelae (lack of growth and chronicity) were reported in 10.3% of children with physical disabilities (26–90%), medical conditions, and prematurity (10–49%). This is due to an improvement in survival rates of premature babies with low birth weight and with complex medical conditions [1–3]. Tables 1 and 2 summarize the main morbid conditions and possible interactions (comorbidities) that are associated with swallowing disorders in children.
Disease | |
---|---|
Neurological | Encephalopathies (cerebral palsy, perinatal anoxia), Traumatic Brain Injury, Neoplasms, Mental delay, Prematurity and developmental delays |
Anatomical and structural | Congenital (tracheoesophageal fistula, palatal cleft), Acquired |
Genetic | Chromosomal (Down S.), Syndromic (Pierre Robin, Treacher-Collins), Dysmetabolisms |
Systemic diseases | Respiratory (chronic lung disease, bronchopulmonary dysplasia), Gastrointestinal (GI dysmobility, constipation), Cardiac |
Psychosocial and behavioral | Oral deprivation |
Secondary reversible diseases | Iatrogenic |
Main pathological conditions causing swallowing disorders.
Coexisting diseases |
---|
Motor |
Sensory and psychic |
Perceptual |
Praxis |
Gnosis |
Cognitive |
Communicative behavioral |
Main pathological conditions associated with swallowing disorders.
From the etiological point of view, only a brief reference to the most common causes of dysphagia in children, including conditions associated with developmental abnormalities, that is, early onset conditions, requiring prolonged or chronic measures of medical, rehabilitation, and/or residential support, is necessary.
These conditions (Table 1) are mainly associated with neurological disorders (cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, and muscle weakness): factors affecting neuromuscular coordination (prematurity and low birth weight), complex diseases (heart disease, lung disease, gastroesophageal reflux disease, and delayed gastric emptying), structural anomalies (cleft lip and/or palate, laryngomalacia, tracheoesophageal fistula, esophageal atresia, cervical-facial abnormalities, and choanal atresia), and genetic syndromes (Pierre Robin, Prader-Willi, Treacher-Collins, and deletion of chromosome 22q11).
To these conditions, the iatrogenic conditions related to the use of drugs (reduced reactivity, hypotonus, and decreased appetite), surgery, or medical measures, which require alternative ways of feeding or assisted breathing, and any other conditions that induce sensory deprivation of orofacial and pharyngeal structures, including a limited availability of food, which may be associated with social, emotional, and environmental problems (e.g., difficulty of parent-child interaction) (Table 2) [4], must be added.
The cultural problem that has created such a gap between child and adult dysphagia is represented by the fact that the swallowing act evolves into a continuum that already starts during intrauterine development and continues throughout the lifespan. The passage between these two conditions, therefore, is slow, but the differences between child and adult swallowing and pathophysiological conditions of one and the other make the two realities very different to each other and not comparable. An adequate approach to childhood dysphagia implies, inevitably, a reminder of the pathophysiological aspects, with a short premise that a swallowing act has, in the child, a predominantly nourishing component and a protective action on the lower respiratory tract.
It all rests on the close relationship that exists, even in an evolutionary sense, between structure and function. If an organ evolves (morphologically and topographically), the functions it performs also have to adapt to this evolution. If the functions that the organs perform are vital functions (breathing and swallowing—aimed at nutrition), is it possible that the importance of such functions conditions the structure?
So what is the role of external events, for example, environmental, which are able to affect the relationship between shape and function? These considerations would lead us away from the topic of our chapter. Going back to the initial topic, it must surely be said that the swallowing act, as a complex and integrated neuromotor event, begins “in utero” [5, 6]. The possibility of developing swallowing acts precociously affects the close relationship that exists between the digestive, respiratory, and cardiocirculatory apparatus in the embryo and fetus. Very early on, these apparatus make connections with neural structures, which are themselves evolving and beginning their myelination. All such structures are immersed in a liquid environment, circumscribed by the wall of the uterus. The containment cavity and growing structures are affected by the relationships with the nervous structures: such relationships involve a delicate balance between growth and maturation, which takes place at the organ and apparatus level. So the central and peripheral integration among neural structures is perfected in parallel to the integration with the organs-apparatus integration and the functions they carry out (Table 3).
Organ-function integration between center and periphery.
NS: nervous system; RS: respiratory system, GI: gastrointestinal tract; CC: cardiocirculatory tract.
Pharyngeal swallowing appears between 10 and 12 weeks of gestation and a complete suckling appears in the 18–24th weeks: it is between the 34th and 36th weeks that the fetus produces efficient swallowing, able to contribute to volume adjustment of the amniotic fluid. This swallowing activity is also essential to the development of the gastrointestinal apparatus and of the fetus itself [6, 7]. However, after birth, maturation structures and functions do not guarantee an adequate oral feeding, suggesting that extrinsic factors, related to the learning of external inputs, have a significant role in this maturation [8]. This optimization of the organs acquires the connotations of their real development toward an efficient and safe swallowing. Such enabling requires a long time: a child develops motor patterns similar to adults, only during adolescence. This underlines the complexity of this function, which, throughout life, is enriched with more and more complex socializing and cultural meanings. The concept of feeding, as an element intimately connected with swallowing, is established very early on. This concept is linked to the set of functions that are linked to oral structures: first of all, neuromotor skills [2] and also communication and social functions, as previously mentioned. As strictly regards feeding, it provides an increasingly sophisticated enabling of the oral structures, which allows the management, in the oral cavity, of increasingly more diversified boluses, in terms of consistency, volume, temperature, viscosity, and elasticity. The feeding activities allow a perfect conformation of the oral cavity to the anatomical adaptations that involve the head and neck fully during growth [9]. These same anatomical adaptations also involve the pharynx, so the interaction between feeding and swallowing, and more properly the interaction between the oral and pharyngeal phase of swallowing, becomes more and more intimate and functional. This adaptation is aimed at creating a neuromotor act that has to be effective (protective of the lower respiratory tract), efficient (complete transport of volumes), and functional (supporting of hydration and nourishment), while maintaining its own individual character and social pleasure. Table 4 summarizes the oromotor abilities required by a small child (before 2 years) as a function of the consistencies managed [10]. In such a rapidly evolving system, the development of oral motor skills assumes great importance. These skills are being developed within a system that is changing quickly in both the structural and neuromotor sense: this occurs rapidly within the first 3 years of life [5, 10]. During this period, children are engaged in a great variety of oral experiences, sometimes oriented to satisfying their basic nutritional need: this need is associated with the exploration of the surrounding environment, which should always be comfortable and rewarding. From a clinical point of view, a problem exists when a child is “locked” into a specific feeding schedule, when it is anchored to a feeding scheme beyond which they cannot progress. As the oral motor skills represent a sequential progression of increasingly complex skills, any interruption in this progression can limit their development and cause the loss of previously acquired skills [11].
Months | Progression of foods and fluids | Oromotor abilities | Gross motor abilities |
---|---|---|---|
0–4 | Liquid | Sucking the nipple | Head control |
4–6 | Purèe | Sucking from spoon | Sitting position, hands forward |
6–9 | Purèe, soft solid | Drink from glass, vertical mastication (reduced lateral movements) | Hands to the mouth, pincer hands, begins to hold the spoon, and begins to eat with hands |
9–12 | Ground, coarse purèe | Drink from glass independently | Refined pincer hands and eating with hands |
12–18 | All consistencies | Tongue lateral movements, drinking from a straw | Greater autonomy at meals, discovering foods and bringing to the mouth |
18–24 | Research of chewable foods | Lateral chewing | |
>24 | Harder solids | more mature chewing | Autonomous, manages utensils and glasses without spilling |
Neuromotor skills and oral management of the bolus within 2 years of age.
At birth, a child needs to be able to breathe on its own and to feed safely. This implies, as already mentioned, a perfect cooperation of the swallowing effectors, which reflects a state of optimal health (relating to the development of the respiratory, gastrointestinal, and cardiovascular apparatus), optimal nervous integration, and optimal mother-child relationship.
From the anatomo-functional perspective and aimed at sucking activity, it should be remembered that the child, toothless at birth, has a high larynx (at the height of the first two cervical vertebrae), and a high respiratory rate (70–80/min, with minimal thoracic movements) but mostly a large tongue inside a relatively small mouth. Swallowing of milk occurs with a suckling neuromotor pattern, characterized by in-out tongue movements, facilitated by an opening-closing movement of the mandible, miming a squeezing act. During this activity, the face musculature, mainly the lip muscles, is kept hypotonic and the iolaryngeal axis is high and immobile. Swallowing triggers from the valleculae, and the pharyngeal passage is realized with a suction/swallowing ratio equal to 1. Table 5 summarizes these events in the light of an overall maturation of the child [12–14]. It should be remembered that, at this time, swallowing is purely reflex, relegated to the activity of the bulbar swallowing center. At weaning, anatomical changes allow the realization of new swallowing patterns. The tongue tends to flatten out and acquires the ability to perform up/down movements between the mandible and the hard palate. Lips acquire tone to achieve a greater attachment to the nipple. The laryngeal lowering allows the volumetric increase of the pharynx and the realization of a negative pressure inside the mouth. The child is now able to move a greater volume of liquids, reaching a sucking/swallowing ratio superior to 1. These events become possible due to a progressive disappearance of oral reflexes. Swallowing triggers from the valleculae, as above, but the increased flow and the lower position of the larynx can facilitate episodes of penetration. Table 6 summarizes these events [12]. The myelination of subcortical and subsequently cortical structures, as previously mentioned, interfere with the bulbar centers (neuromotor control): now swallowing becomes an automatic act, submitted to the sensorial afferents coming from the periphery, mainly from the oral cavity. The growth of orofacial structures allows for more and more precise and refined neuromotor patterns enabling the development of oral skills and the ability to manage boluses of different volume and consistency [15]. Table 7 summarizes these anatomical variations in young children up to 2 years old and older than 6 years. Between 2 and 6 years of age, swallowing mainly reaches the optimization of the oral activities and the stabilization of the pharyngeal phase. Even the anticipatory phase of swallowing tends to stabilize in this age group. As regards chewing, this activity is enriched by movements of laterality and circularity of the tongue and mandible, with transport of the bolus in the molar region and the beginning of trituration of harder and harder consistencies. The duration and number of masticatory cycles, as well as their efficiency in terms of strength, precision, and coordination, develop progressively. From 6 to 12 years, chewing is further perfected. A reduction in the number and duration of the chewing cycles occurs with a strengthening of the propulsive phase, due to the strengthening of the masticatory muscles. In the meantime, the tone of mentalis and orbicularis muscles decreases. Also in this phase the exposure to different consistencies and volumes is a powerful stimulus to the optimal use of swallowing effectors, all activities that, in the nervous system, are supported by mechanisms of neuronal sprouting (brain plasticity). The correct knowledge of these events and of the time frames mentioned earlier underlies the correct assessment of children with swallowing disorders. The failure to achieve abilities, chronologically expected in an age band, will surely negatively compromise the achievement of further abilities.
Months | Motor activity | Feeding activities | Jaw | Tongue | Lips |
---|---|---|---|---|---|
0–1 | Reflex movements of limbs Raises the head | Sucking of finger (if approached to the mouth) | Phasic bite | Tongue = jaw | Mimic muscles silent |
1–2 | Circular movements of limbs Raises the head | Hands to the mouth (if lying down) | Phasic bite | Tongue at rest Tongue besides gums | Lip synchronous with other facial muscles |
3–5 | Trunk control Head control Sitting position | Head-trunk control Objects to the mouth | Phasic bite Stable jaw (head control) | Movements of tip-body-base Gag from mid-third of the tongue Inhibition lingual movements | Development of facial muscles lips control separate lips movements Lips-cheek activities |
Neuromotor patterns and effectors: sucking.
Months | Motor activity | Feeding activities | Jaw | Tongue | Lips |
---|---|---|---|---|---|
6–9 | Sits and turns Objects from hand to hand Manipulates objects Explores with indexes He/she gets up briefly | Sucking of finger (if approached to the mouth) Independent movements of tongue/jaw (trunk control) He/she holds bottle | Phasic bite abolished Stabilized mandible Lateral movements | Up-down movements Gag reduced Perceived consistency (bolus crush) Lateralizes the bolus | Lower lip stabilizer active Use of perioral muscles Bolus between molars: use of the lips and cheeks |
10–12 | Crawling Gets up Upright position | Fine motor skills development | Controlled pressure of soft foods Opening/closing controlled Circular-rotary movements | Use of all intrinsic tongue muscles (various shapes) All moving angles Combination of movements | Active lips/cheeks used to manage soft foods Contracts lower lip: clearing from teeth and gums Occasional packeting/drooling Rare drooling |
13–24 | Fast walking Jumps with 2 feet Walking on tiptoe Draws closed forms Makes puzzles | Head-trunk control Objects to the mouth | Circular-rotary movements No turning of head to bite (most mandibular control) | Consistence modifies lingual movements Tongue on right and left Tongue clears the mouth Tongue/mandible: independent movements (12–24) Lips licking (18–20) | Maintaining lip prehension during lingual and mandibular movements |
Neuromotor pattern and effectors: weaning.
Younger child | Older child | |
---|---|---|
Oral cavity | Tongue fills the mouth | Tongue lies on the floor of mouth |
Edentulia | Primary teeth | |
Tongue at rest between the lips and against the palate | Tongue behind your teeth and not against the palate | |
Cheeks rich in fat | Chewing using buccinator muscles | |
Small jaw | Relationship between jaws almost normal | |
Sulci important during sucking | Sulci less important during sucking | |
Pharynx | Oropharynx not well defined | Lengthening of the pharynx with oropharynx defined |
Skull base with obtuse angle to the nasopharynx | Skull base with right angle | |
Larynx | 1/3 of the adult | |
1/2 glottis cartilaginous | 1/3 glottis cartilaginous | |
Epiglottis vertical and narrow | Epiglottis wider and flattened |
Growth of structures in the younger and older child.
It has previously been said that the alterations of the oromotor development, in one or more associations summarized in Table 3, result in an arrest in the development of the child’s feeding skills, with the possibility of losing skills already acquired. Dysphagia, which is not properly diagnosed, can result in multiple clinical signs, in various combinations.
First, it can determine weight loss and a failure to thrive so as to require a parenteral or enteral nutritional support. Dehydration, respiratory complications or aspiration pneumonia, food adversion, and rumination (i.e., involuntary regurgitation of undigested food that can be chewed and re-swallowed) are other possible signs of dysphagia.
From these assumptions, the major requests for phoniatric-logopedic evaluation of children with swallowing disorders are derived. Most commonly, children refuse some consistencies or have a difficult approach to meals, with little interest in eating. All these conditions may reflect alterations in the physiology of swallowing such as a slow gastric motility or constipation. A child who refuses new consistencies may suffer from gastroesophageal reflux and other gastrointestinal disorders. A gastroesophageal reflux can cause pain during or after the meal, which children associate with feeding.
This can impede feeding and cause severe behavioral problems that make it difficult, if not impossible, for the parents to feed the baby adequately. As mentioned earlier, a limited taste experience related to oral intake may affect inadequacies in the oral sensorimotor development. Parents can also signal that the child does not show a sense of hunger but rather shows a sense of aversion or avoidance to sensory stimulation, making meal times a real struggle. Every child is different and these conditions may be present in various combinations [16]. Table 8 summarizes some of the main conditions which lead to a request of consultation. The table shows conditions referring to a variety of swallowing disorders, some mentioned in the section on etiology. It is obvious that if the baby is born with a craniofacial malformation, the oral and/or pharyngeal phase of swallowing will consequently result as compromised.
Incoordination between sucking and swallowing (shockable rhythm) |
Weak feeding |
Alterations in breathing or apnea during the meal |
Gagging excessive or frequent coughing during the meal |
Occurrence of difficulties in supply |
Diagnoses associated with dysphagia, malnutrition, or craniofacial anomalies |
Shutdown/reduction in body weight gain from 2 to 3 months (malnutrition) |
Marked irritability during the meal |
History of respiratory diseases and feeding difficulties |
Lethargy during the meal |
Feeding time more than 30–40 min |
Unexplained refusal of food and malnutrition (failure to thrive) |
Drooling that persists beyond 5 years |
Nasal regurgitation during the meal |
Delay in the maturation and development of food habits |
Sending criteria to phoniatric-logopedic assessment.
The clinical approach to children with swallowing disorders does not differ substantially from the approach to other pathological conditions. In children, as in adults, it has to be borne in mind that dysphagia is a symptom, underlying one or more morbid or comorbid conditions. The approach to children is complicated by the inability of the young patients to directly express their discomfort and this is often mediated by caregivers.
To summarize, possible goals of the non-instrumental clinical evaluation are as follows: to identify the possible etiology of dysphagia, to formulate hypotheses about its nature and severity, to estimate functions and their integration (sensory-motor skills and breathing), to induce therapeutic modifications, to investigate safe food options for the child and to raise awareness among family members, to indicate the best instrumental evaluation, and to identify the possibilities of and the patient’s ability to cooperate in medical examinations.
Therefore, the clinical approach to children with swallowing disorders is influenced by the age of the child, the main pathology, and the comorbidities. The importance of age has already been emphasized: depending on their age, the children should have specific oromotor skills and there is the gradual disappearance of reflex activities. Table 9 summarizes the main steps of the non-instrumental clinical evaluation.
Clinical history
|
| ||
General observation:
| Anatomy
| Reflexes
| Behaviour
|
Observation during the meal |
| ||
Swallowing osbervation:
| NPO child
| PO child
|
Steps of non-instrumental clinical evaluation (bedside evaluation).
In clinical practice, the absence of standardized assessment protocols is a serious concern: the literature offers us different protocols (Table 10) [17–22] but their application is not always standardized and verified by an instrumental gold standard. This lack of tools interferes with the collection of information and the comparison of the skills of the young patients.
Neonatal oral motor assessment Scale (NOMAS) (Palmer et al [17]) (Breast feeding/Bottle feeding) |
Systematic assessment of the infant at the breast (SAIB) (Association of Women’s Health, Obstetric and Neonatal nurses, 1990) |
Preterm infant breast-feeding behavior scale (PIBBS) (Nyqvist et al. [19]) |
Breast feeding evaluation (Tobin [20]) (term infants) |
Feeding flow sheet (Vandenberg [21]) (bottle feeding) |
Infant feeding evaluation (Swigert [22]) |
Main bedside protocols of evaluation.
The non-instrumental clinical evaluation has to provide the proposal of foods in different volumes and consistencies, depending on the age of the child. It will occur with specific modalities depending on whether the child is fed (Table 11) or not fed orally [nill per os (NPO)] (Table 12).
|
Bedside evaluation and test with bolus in orally fed child (PO).
|
Bedside evaluation and test with bolus in non-orally fed child (NPO).
In children with tracheotomy, non-instrumental evaluation will be conducted in the same way as in children with an intact airway considering that, in children, few data are available about the impact of tracheotomy on swallowing abilities. When possible, the tests with bolus are performed verifying the presence of bolus traces or blue-dyed water in the airway. The use of speaking valves has to be encouraged, allowing phonation, increasing laryngeal reflexivity with a better lower airway protection, and clearing secretions. The use of speaking valves reduces mechanical ventilation dependence time and stay in NICU, and accelerates decannulation and recovery of oral feeding.
At the end of the non-instrumental clinical evaluation, with respect to what has been previously reported, it is necessary to identify those children for whom a referral for an instrumental clinical evaluation is worthwhile. Table 13 summarizes the assessment process up to this point.
Evaluation process: synthesis.
The two main instrumental tools for assessing swallowing in children, as in adults, are represented by the dynamic radiological and the dynamic endoscopic evaluations, respectively, known with the Anglo-Saxon acronyms of VFSS (videofluoroscopic swallowing study) [23] and FEES (fiberoptic endoscopic evaluation of swallowing) [24]. These procedures evaluate the behavior of swallowing effectors during the passage of the bolus, which implies that the child, who is a candidate for such procedures, can be fed orally [25]. During the procedure, the clinician can rely on monitoring the heart activity, breathing, and O2 saturation, in order to obtain additional information about physical or behavioral changes associated with the swallowing disorder. Similarly, the colorimetric variations of the skin (pallor or cyanosis), nasal regurgitation, and alterations of sucking-swallowing/breathing rhythm may be considered.
Broadly, the instrumental evaluation, compared to the bedside evaluation, has the advantages shown in Table 14. It is worth remembering that with regard to the information they provide, FEES and VFSS are not equivalent but complementary. The clinician chooses the procedure most appropriate in relation to the characteristics of the young patient or to the information being sought, in the awareness that the two procedures have both advantages and disadvantages [26] (Table 15).
|
Advantages of the instrumental clinical evaluation compared to the clinical non-instrumental evaluation.
Advantages | Disadvantages | |
---|---|---|
FEES | Less invasive Easy to perform Well tolerated Possible for a long time (fatigue viewing) Portable (acute and sub-acute patients) Routine Economic Therapeutic feedback Decision making of oral feeding Natural foods Direct visualization of structures Motor and sensory activities Three-dimensional similar view Optimal pooling evaluation Pooling management viewing | Pharyngeal phase only White-out Indirect consideration about
Fear and discomfort Poor vision in repeated swallowing acts Not possible if changes in upper airway |
VFSS | Whole deglutition evaluation Time parameterization | Invasive (radiological exposure) Uncomfortable execution Environment and suitable personnel Expensive Bi-dimensional view (under estimation of pooling matter) Motor activity only (reaction to aspiration, if documented) Fatigue evaluation missing |
Advantage and disadvantage comparison between VFSS and FEES.
It is a procedure that uses ionizing radiation and should be used sparingly, especially in very young children. When indicated, the tool verifies the actual usefulness in improving the safety and efficacy of the swallowing act, under different examination conditions: varying the consistency or the viscosity of the bolus, verifying the clearing of the mouth, pharynx, or esophagus; varying the position of the child, implementing postures or maneuvers (when possible); varying the speed of feeding, child position, and changing pacifier or spoon characteristics [27, 28].
When performing an endoscopy, the possibility of achieving the maximum collaboration of the child is crucial. Any device useful for making the child and its parents less anxious and for increasing compliance has to be adopted. The family is asked to bring pacifiers, bottles, or utensils commonly used during meals and also to bring the dishes commonly eaten by the child: either the most liked or those that create the greatest difficulties. The choice of endoscope size is based on the age of the child: obviously, the smaller the endoscope, the lower the imagine definition. With a child of over 3 years of age, it is possible to use standard size endoscopes (2.4 mm in diameter), with a younger age group smaller devices are advisable (1.5 mm diameter). To optimize cooperation and minimize discomfort, anesthetic spray puffs or a small amount of cotton, soaked in a 1:1 mixture of 4% lidocaine and oxymetazoline, can be introduced into the nasal cavity [29]. A viable alternative is to lubricate the tip of the endoscope with a 2% lidocaine gel. This is always desirable in patients with airway lability (very young children or of low weight) in compromised general conditions or with tracheotomy. For the endoscopic evaluation, the baby may be supine in a cot or a pram but for the dynamic study of swallowing he/she should preferably have the chest lifted: the baby can be held in the mother’s arms or on her knees.
Older children can be seated in a high chair without any help. If the child tends to assume specific postures during the meal (due to a physical impairment, as in cerebral palsy) they will be maintained after the introduction of the endoscope and verified during the test. Similarly, the efficiency of therapeutic postures or maneuvers will be checked. The procedure substantially does not differ from that used for adults [30]: the static, anatomical, dynamic, and non-swallowing assessments are performed with the tip of the endoscope in the naso-nasopharyngeal, high, and low position. The tests with bolus are performed with the tip of the endoscope in the high position.
In the
In the
In the
The delicate touch of the aryepiglottic folds with the tip of the endoscope activates the adduction reflex, mediated by the superior laryngeal nerve: the reflex is essential for an adequate protection of the lower airways during swallowing. For the same purpose, pulsed air can be used, supplied with variations of pulsing or of intensity [flexible endoscopic evaluation of swallowing with sensory testing (FEESST)] [33, 34]. In children who are noncooperative, who have cognitive disorders, or are very young, only the adduction reflex can be appreciated [34].
After the anato-functional assessment and in relation to age, foods of different consistencies and volume will be proposed to the child. The foods preferably have a natural color or are dyed. The child is fed by its parents. It is always advisable to start with pleasing food, in order to increase the compliance to the test, then subsequently, as for adults, to use food which is more difficult to manage in the oral cavity [30, 35]. During the test with bolus, different parameters have to be considered.
The first parameter to evaluate is the
The progression of the bolus into the laryngeal vestibule is called
Aspiration is the progression of secretions or bolus below the true vocal cords. In FEES, this event can occur before or after swallowing: they are events well evaluated in endoscopy [36]. Pre-swallowing aspiration can be due to a delayed triggering or a late laryngeal valve activation. Post-swallowing aspiration can be due to an overflowing from the pharyngeal containment cavities. At the highest point of swallowing, the white-out prevents the direct visualization of aspiration (intra-swallowing aspiration). In this case, aspiration can be inferred after swallowing, by evaluating residue of food in the larynx or cervical trachea or evaluating the expulsion of streaked secretions by coughing [28, 30, 35].
The evaluation of swallowing abilities with bolus can be quantified by the same test as is available in FEES. The progression of bolus through the upper airway can be quantified using the penetration-aspiration scale [37], and the presence of residue can be quantified with the pooling score (
The clinical non-instrumental and instrumental evaluations should enable the clinician and the rehabilitator to set up an ideal treatment plan for the child (Table 13).
In general, a treatment plan should (1) guarantee the child an adequate nutritional and water intake, (2) be protective of the respiratory tract, (3) support the child in eating and drinking, (4) guarantee the optimal oral sensory stimulation, (5) improve the QoL of the child and family, and (6) help the family in conceiving new therapeutic strategies [38–40].
All of these respecting the actual clinical condition (morbidity and comorbidities) inside the evolutive temporal windows are linked to age of the child. The treatment plan should also consider all the possible settings of a child’s life: home, kindergarten, school, and leisure environments. The treatment plan must consider all the indications aimed at achieving the objectives mentioned earlier, by means of medical, surgical, and nutritional strategies. For example, if the child suffers a major reflux, he/she will be treated pharmacologically or surgically, to prevent the negative feedback that the reflux has on swallowing and feeding. Other general considerations, previously underlined, are the importance of ensuring the child the best sensory oral-pharyngeal stimulation and the best oromotor stimulation. Only in this way will the swallowing abilities of the baby progress through all the steps of a satisfactory development.
In planning treatment, the clinician has to consider if the children can be safely fed orally or not, and the general performance of the child during mealtimes. In practice, useful therapeutic strategies are represented by dietary modifications, such as the food being thickened, diluted, chopped, blended, mixed, and viscosity varied, depending on the functional age and disease of the baby. These changes must guarantee a nutritional and water intake able to ensure the growth of the child. Within the first year of life, the use of commercial thickeners should be limited. Sometimes, it could be advantageous to vary the bolus presentation with a break during the feed. With older children, the same effect is produced by varying consistencies. The same strategies should also be considered in tube-fed children (NGT or PEG/JPEG) when the possibility of assuming per os even a single consistency is verified.
The time windows in the physiological growth of the effectors, previously mentioned, should be considered and respected, as far as possible. The use of devices or adapted utensils has the purpose of fractioning the presentation of the bolus, in terms of volume and speed: with younger children, pacifiers in different shapes and with different holes can be used, while with older ones, utensils with modified handles are more appropriate [41, 42]. The use of maneuvers (forced swallowing, Mendelsohn, supraglottic, super-supraglottic, and Masako) changes the timing and strength of the swallowing act: their implementation requires that the child can learn them and be motivated for their execution. Relatively simpler is the use of postures, which can also be implemented passively, very small children can be held in the arms, or older children can be placed in adjustable seating [43]. The use of oromotor exercises [44] provides active or passive activities of the effectors, always without the use of foods. These exercises are aimed at optimizing the efficiency of the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles. Sensory stimulations act on the swallowing reflex. These gustatory, thermal, or tactile stimulations can be applied on different effectors: cheeks, lips, and tongue. They are indicated for children with reduced responses or reduced opportunities for stimulation. At other times, it is possible to intervene on children who have an excessive response or aversion to stimulations: in this case, the treatment is expected to reduce the reflexivity of the child.
With the increasing integration and interaction of the financial markets, the number of financial crises has considerably increased especially since 1990s. With the contagion effect, on the other hand, the impacts and consequences of the financial crises go beyond the national level by causing significant international costs. In this context, an important part of those crisis is stem from the problems experienced in the banking sector, which is one of the leading sectors that have significant impact on the world economy.
As the importance of the banking sector on economies increases, the risk factors that has to managed by the sector has also increased considerably. Laeven and Valencia [1] emphasized that there were 151 banking crises worldwide between 1970 and 2017 where the duration of these crises is different with respect to the income levels of the countries. Accordingly, while the banking crises in high-income countries are considerably consistent and continue for 5 years or more, in low- and middle-income countries, banking crises continue for 4 years or less. In term of its outcomes, on the other hand, banking crises have devastating effects such as persistent output losses, economic activity, welfare, asset prices, unemployment, government debt, tax revenue [1, 2, 3, 4].
As one of the fastest growing sectors of the global financial industry, participation banking sector accelerated its development especially as of the 1990s and become an important part of the banking sector for significant number of countries worldwide. Furthermore, the financial crisis experienced in 2008 shed doubts on the conventional banking system and draw attention to participation banking. The financial crisis of 2008 is considered to be the second most serious breakdown since the 1930s. The crisis, started in the USA, spread to many other countries in a short time and turned to a global crisis. As a consequence, the banking sector in those countries has adversely affected. In this regard, the interest in participation banks has increased, as they were more resistant to the financial crisis compared to conventional banks in terms of profitability, liquidity and asset quality [5, 6].
The breakdown of 2008 also triggered the efforts to investigate the impact of banking crisis on participation banks. However, most of these efforts aim to compare the impact of the crisis on participation banks and conventional banks, or investigate the performance of participation banks before/during/after the global financial crisis [7, 8, 9, 10]. Despite those attempts, there is no prior study investigates the early warning indicators of banking fragilities of participation banks. Early warning indicators are crucial since they provide opportunity to detect the fragilities of the banking system and take precautions against a forthcoming banking crisis. In this regard, although there are number of studies in the literature on the significant indicators of banking crisis in Turkey, there have been no attempts to examine the indicators of banking fragilities of the participation banks. For instance, Tosuner [11] developed an early warning system to investigate the banking crisis in Turkey. The author reveals that domestic credit, M2, international reserves, real exchange rate and international trade are leading indicators of banking crisis of Turkey. To identify the causes of bank crises and determine the crisis indicators, Tunay [12] develop an early warning model for Turkey. The results show that exchange rate position, terms of trade, capital adequacy, interest rate risk and market risk are important factors of the banking crisis in Turkey. In addition, Cergibozan and Arı [13] develops a model specific to Turkey to examine the determinants of banking crisis over the time period 1990 and 2013. According to the results, increasing inflation and interest rate, depreciation rate, excessive fiscal deficit, increasing bank loans and bank short positions, liquidity mismatch and decreasing bank reserves are important determinants of banking crisis of Turkey. Furthermore, research on the subject on the participation banks and crisis has been mostly restricted to analyzing the financial performance of participation banks or limited comparisons of the financial performance of conventional banks and participation banks [14, 15, 16].
Motivated by the literature, this study constructs a model specific to participation banks in Turkey to identify the leading indicators fragility towards banking crisis. In addition, apart from the existing literature, this study considers banking level explanatory variables over a recent time period 2008 and 2018. This paper has been divided into five sections. The first part of this study gives the introduction. The second section presents an overview of the Islamic financial system and development of participation banks in Turkey. The third part highlights the key concepts of banking sector fragility. The fourth section is concerned with the data and methodology employed for this study. The fifth section presents the results of the study and the last section concludes the study.
The Islamic financial system is constructed on the basis of Shari’ah principles (Islamic Law). In other words, Islamic financial system can be defined as a system in which all financial activities and transactions are carried out within the framework of Islamic rules. The main motive behind the emergence of Islamic financial system is the demand for a system that are based on Islamic principles. In other words, Islamic financial system has primarily arisen to stimulate the unused funds of Muslims with high religious sensitivity to evaluate their investments and further enabling the capital movements between countries. The fundamental resources of Islamic Law are the Holly Qur’an and Sunnah. One of the most important features of Islamic finance is the control of commercial activities and financial transactions with certain standards, moral principles and prohibitions in order to avoid injustice and unjust enrichment. The main prohibitions of Islamic finance can be given as follows:
Prohibition of Riba (Interest)
Prohibition of Gharar (Uncertainty)
Prohibition of Maysir (Gambling)
One of the key principles of Islamic religion is the prohibition of riba. According to majority of Muslim jurist, all forms of interest is forbidden by Islam [17]. According to Islamic terminology, riba arises in two forms as riba on loans (Riba al-nasiah) and Riba al-fadl (riba on sales). In this regard, riba al nasiah addresses to “riba in money to money exchanges, where the exchange is delayed or deferred and gives rise to an additional charge” that also called as Riba al-Jahiliyyah [18]. According to Qur’an, riba al nasiah is strictly forbidden. According to Özsoy [19], riba al-Fadl, on the other hand, is involved in a transaction through the combination of the followings:
An exchange of goods and money in cash.
Exchange between two goods or money of the same kind.
The goods are among the interest classes mentioned in the hadith or belonging to these classes although they are not included in the hadith.
Excess of one of the goods compared to the other.
Most of the Muslim scholars argue that there is not a specific definition of riba in Qur’an. They support the idea that there is only a certain type of riba, Riba al-Jahiliyyah, in the period when the Qur’an was revealed. The riba, which is forbidden in a very harsh manner in the Quran, is based on an exorbitant increase in nature, and the jahiliyya riba, in which the principal is folded many times. Moreover, the supporters of this view argue that, it is not riba if an addition is made to the original amount in return for maturity from the very beginning of lending. Therefore, it is supported that the prohibited riba, riba-Jahiliyah, is different from the loan with interest transactions that stipulates the increase from the very beginning [19]. In this context, Rahman [20] explains that riba is the increase in capital, which raises the principle amount several folds by continuing redoubling. As stated, it is initially a situation that a part of wealth is loaned on interest for a certain period of time. If this loan cannot be paid on the expiration date then the extension of maturity leads to high increase in the principle amount where big sums involved. This situation ends up with the debtor pays the interest alone in installment but they cannot pay the usury interest nor the principle amount [21]. From this point of view, they differentiate the interest in current economic transactions with the interest prohibited by the Qur’an. They claimed that what is meant in the verse of the Qur’an is exorbitant interest, thus, the current interest practices are legitimate since these transactions are different from the interest prohibited in the verses and hadiths. They argue that the interest given by banks is not unlawful and should be excluded from the scope of riba. Accordingly, they claim riba, which is forbidden in the Quran, is the usury rather than interest. For instance, Metwally [22] states that riba is closely related with usury. The author explains usury is interpreted as riba and it can be defined as the excess or addition over the principal capital lent. In other words, among some scholars and jurists, riba and usury is used for different terms where usury does not refer to interest [23]. Moreover, Ahmad and Hassan [24] argue that riba is involved in loan transactions that is used for consumption purposes. However, it is not prohibited by Islamic law if it is used for production purposes or the empowerment of micro and small enterprises [20]. Nevertheless, the majority of Islamic scholars state that there are no differences in the meaning and the scope of riba and any transaction that involves a predetermined return is riba and strictly prohibited by Islamic law [19].
Maysir means gamble or game of chance in Arabic. It can be explained as taking risk for increasing wealth by chance. Furthermore, maysir is also seen as speculation and price manipulation [25]. According to Mihajat [26], the activities are considered as gambling if the following three elements are in question:
The existence of betting subject matter/asset from both sides of the gambler.
The existence of the game that use to determine who is the winner and who is loser.
The winner will take the property that being bet, while the loser will lose his bet property.
In games of chance, the win is one-sided. Namely, the gain of one party depends on the loss of the others. Maysir includes all gambling, speculative and chance contracts and it also contains the obligations and benefits that were not fully disclosed by either party at the time the contract was concluded [27]. If the risk involved in a game is not controllable and none of the players can affect the probability of the money paid back, such a game is a game of chance. In maysir, all deviations in actual earnings versus expected earnings are a result of the luck element and is prohibited by Islam [28]. In Islamic finance, maysir means “any transaction conducted by the two parties to posses the ownership of a particular asset or service which obtain benefit to one party and harm to others by linking a particular transaction with an act or event.” [26]. According to Kamali [29], maysir is prohibited since it causes an unclean and immoral inducement with a hope of making profit by the loss of the others.
The second fundamental principle of Islamic finance is the prohibition of gharar in mutual contracts. Iqbal and Molyneux [30] states that gharar is one of the most challenging issue in the Islamic law. The types of gharar is divided into excessive, medium and minor gharar by The Accounting and Auditing Organization for Islamic Financial Institutions [30, 31]. In this regard, excessive gharar is existed in a transaction if:
it is involved in an exchange-based contract or any contract of that nature.
If it is excessive in degree.
If it relates to the primary subject matter of the contract.
If it is not justified by a Shari’ah-recognizable necessity.
The principles of gharar as can be categorized as follows [32]:
Gharar in the terms and essence of the contract includes:
Two sales in one.
Downpayment (‘Arbun) sale.
“pebble”, “touch” and “toss” sales.
Suspended (Mu‘allaq) sale.
Future sale.
Gharar in the object of the contract includes:
Ignorance about the genus.
Ignorance about the species.
Ignorance about attributes.
Ignorance about the quantity of the object.
Ignorance about the specific identity of the object.
Ignorance about the time of payment in deferred sales.
Explicit or probable inability to deliver the object.
Contracting on a nonexistent object.
Not seeing the object.
When the historical development of Islamic finance is examined, it is seen that although the first practices of interest-free banking dates back to antient times, the foundations of modern Islamic banking began to emerge in the mid-1940s with the establishment of the Patni Cooperative Credit Society and the Muslim Fund Tanda Bavli in India. However, it was only at the end of the 1960s that interest-free banks emerged in a comprehensive manner by establishment of Mit Ghamr Savings Bank in Egypt. Following this, Nasser Social Bank, established in Egypt in 1971, is the first interest-free commercial bank based on Islamic laws. With the 1970s, there has been an increase in the number of institutions providing banking services that have adopted Islamic rules in many countries. For instance, in 1975 Dubai Islamic Bank is established in United Arab Emirates. In the same year, Islamic Development Bank (IsDB) is established in order to support the economic and social development of member countries and Muslim minorities within the framework of Islamic rules. In addition, the first academic meeting in the field of Islamic economics, the International Conference on Islamic Economics, was held in Mecca in 1976. In 1977, Kuwait Finance House, The Faisal Islamic Bank of Egypt, Establishment of The Faisal Islamic Bank of Sudan are established. In addition, to promote the coordination between Islamic banks, International Association of Islamic Banks is established in the same year. In 1978, the first attempt towards establishment an Islamic bank in Europe is occurred with the Islamic Finance House established in Luxembourg. These developments have also triggered the spread of Islamic banking in other countries and between 1975 and 1990, Islamic finance gained rapid global momentum and spread to many countries such as UK, US and Switzerland. As a result of the increasing volume and growth of the Islamic finance industry, it has brought with it the need to establish and regulate standards in the field of Islamic finance. For this reason, Accounting and Auditing Organization for Islamic Financial Institutions (AAOIFI) is established in 1990. In 2000s, Islamic finance continue its growth globally and spread to countries such as Thailand, Singapore, Kazakhstan, Umman and Germany.
As of 2019, the global Islamic finance assets reach US$2.88 trillion by 14% increase with respect to 2018 [33]. Figure 1 represents the segmental composition of the Islamic finance industry. According to the figure, the Islamic finance industry is comprised of Islamic banking, Sukuk, Islamic funds and Tekaful.
Islamic finance industry, 2019 [
According to the figure, the Islamic banking is accounted for 72.4% of the industry and has the largest component of the Islamic finance industry. The total Islamic banking assets in 2019 reach US$ 2 trillion and there exist 526 Islamic banks globally [33]. According to IFSI [34], in 2019 the global Islamic banking assets increase by 13% compared to 2018. According to the report, the main reason of the increase in the Islamic banking assets in the GCC region with the considerable mergers of the Islamic banks. Sukuk,1 on the other hand, account for 22% of the global Islamic finance industry and is the second largest component of the sector. In 2019, the total sukuk outstanding value reach to US$538 billion with a 15% increase compared to 2018. In 2019, there are 308 murabaha, 293 ijara, 235 mudaraba, 229 other sukuk, 225 hybrid sukuk and 156 salam is issued globally. The value of total Islamic funds outstanding is US$140 billion in 2019. It is comprised of mutual funds (US$1555), pension funds (US$86), insurance funds (US$76) and exchange traded funds (US$29). Global Tekaful assets2 increase by 10% and account for US$51 billion. In 2019, Turkey is the fastest growing market in tekaful assets [33].
In line with the global developments, for the purposes of merging the idle funds into the economy and providing funds to the country, participation banks3 have begun to established in Turkey by considering the needs of those who oppose the conventional banking system that operate based on interest. The financial liberalization process experienced in the 1980s has a significant role in terms of improving the efficiency of the Turkish banking system and encouraging the competition in the sector. With this process, the legal, structural and institutional arrangements made significant contributions to the development of the Turkish banking sector. In this respect, interest rates and exchange rates were liberalized, new entrances to the banking system were allowed and various arrangements were made for foreign banks to come to Turkey or open branches. Foreign banks were allowed to operate and open branches in Turkey. Table 1 presents the historical development of the participation banks in Turkey. In this regard, the first attempt towards establishing a participation banking is made with by introduction of the Special Finance Houses (SFHs) in 1983. The operations of SFHs started in 1985 by providing financial products and services within the framework of Islamic principles and prohibitions. Following those arrangements, Albaraka Turk Special Finance House and Faisal Finance Special Finance House Were established in 1984 and 1985 respectively. Additionally, Kuveyt Turk Special Finance House in 1989, Anadolu Special Finance House in 1991, İhlas Special Finance House in 1995, Asya Finance Inc. in 1996 were established and stated their operations in the sector. By the Law no. 5411 article 3, SFHs was replaced with “Participation Banks” in 2005. In 2015, the government was attempted to participate in participation banking with the establishment of Ziraat Participation Bank, Vakıf Participation Bank and Emlak Participation Bank were introduced into industry between 2015 and 2019. As of 2021, Turkey is hosting a dual banking system, where both Islamic and conventional banks operate in the banking sector, with six participation banks as Kuveyt Turk Participation Bank Inc., Albaraka Turk Participation Bank Inc., Turkiye Finance Participation Bank Inc., Turkey’s Ziraat Participation Bank Inc., Vakıf Participation Bank Inc. and Emlak Participation Bank (Table 1).4
1983 | Establishment of Special Finance Houses (SFHs) |
1984 | Establishment of Albaraka Turk Special Finance House |
1985 | Establishment of Faisal Finance Special Finance House |
1989 | Establishment of Kuveyt Turk Special Finance House |
1991 | Establishment of Anadolu Special Finance House |
1995 | Establishment of İhlas Special Finance House |
1996 | Establishment of Asya Finance Inc. |
2005 | Establishment of Turkiye Finance Participation Bank |
2015 | Establishment of Ziraat Participation Bank |
2016 | Establishment of Vakıf Participation Bank |
2019 | Establishment of Emlak Participation Bank |
The historical development of the participation banks in Turkey.
Table 2 presents the share of total assets of participation banking in total banking assets. According to the table, while the share of participation banking in total banking system is 6.3% in 2019, it reached to 7.1 in 2020. Furthermore, the annual compound growth rate (CAGR) of the participation banking sector assets are 24.0% between 2015 and 2019.
Share of total assets of participation banking in total banking assets.
The main indicators of the participation banks that operate in Turkey is presented in Table 3. According to the table, the funds collected in the participation banking sector in 2020 is increased by 49% compared to previous year. Furthermore, the total assets grew by 54% compared to 2019 and reached to TL 437 billion in 2020. The net profit of participation banks increased by 52.4% from TL 2.4 billion in 2019 to TL 3.7 billion in 2020. Total shareholders’ equity, on the other hand, increased by 26.8% to TL 27.6 billion.
2019 | 2020 | Change, % | |
---|---|---|---|
Funds Collected | 215.983 | 322.017 | 49.1 |
Funds Collected TL | 91.145 | 102.620 | 12.6 |
Funds Collected FC | 106.533 | 149.513 | 40.3 |
Precious Metals FC | 18.305 | 69.884 | 281.8 |
Funds Allocated | 149.475 | 240.133 | 60.7 |
Total Assets | 284.45 | 437.092 | 53.7 |
Shareholder’s Equity | 21.762 | 27.603 | 26.8 |
Net Profit | 2.433 | 3.716 | 52.4 |
Main indicators of the participation banks, TL million [30].
According to TKBB report, Kuveyt Turk Participation Bank has the highest net profit among participation banks in 2020, with TL 1400.3 million [30, 35]. In this context, Kuveyt Türk Participation Bank was followed by Türkiye Finance Participation Bank with 675.7 million TL, Vakıf Participation Bank with 666.9 million TL, Ziraat Participation with 638.6 million TL, Albaraka Turk Participation Bank with 255 million TL and Emlak Participation Bank with 80 million TL [30] (Table 4).
Year | Total number of branches | Total number of employees |
---|---|---|
2011 | 685 | 13.851 |
2012 | 828 | 15.356 |
2013 | 966 | 16.763 |
2014 | 990 | 16.270 |
2015 | 1.080 | 16.554 |
2016 | 959 | 14.467 |
2017 | 1.032 | 15.029 |
2018 | 1.122 | 15.645 |
2019 | 1.179 | 16.040 |
2020 | 1.255 | 16.849 |
Total number of branches and employees of the participation banks in Turkey [36].
In 2020, the total number of domestic and international branches of 6 participation banks operating in Turkey is 1.255 which constitutes more than 10% of the total branch network of the banking sector. The total number of branches of participation banks increased by 83% in 2020 and reached to 1.255 compared to 2011. Accordingly, while the total number of employees in the participation banks in Turkey is 13.851 in 2011, it increased to 16.849 in 2020 with an increase of 22%.
The banks are one of the leading financial institutions in Turkey. Therefore, the problems that may arise in the banking system have the potential to cause destructive social, economic, political and cultural outcomes. For this reason, the attempts towards revealing the vulnerabilities in the financial system to prevent to the costs of those crises or overcoming with the minimum cost where the crisis is inevitable, has gain considerable attention. Accordingly, banking sector fragility index (BSFI) is developed to detect the fragilities and vulnerabilities in the banking system, which is firstly introduced by Kibritçioğlu [37]. According to Kibritçioğlu [37], although banks are exposed to various risk factors, massive bank runs and withdrawals, huge amount of lending booms and increasing unhedged foreign liabilities of banks are the main banking crisis indicators. Accordingly, to monitor the fragilities of the banking sector, the author constructs a BSFI based on liquidity risk, credit risk and exchange rate risk. In this index, bank deposits (DEP), foreign liabilities of banks and credits the domestic private sector are considered as a measure of liquidity, exchange rate and credit risks respectively. The BSFI can be given as follows:
In Eq. (1), the BSFI is the average of standardized values of CPS, FL and DEP, where μ and σ are the mean and standard deviation of the variables. Regarding the BSFI, the fragility episodes of the countries are divided into three as tranquil, medium and high fragility episodes. In this respect, the banking system is in tranquil episode if the index approaches the sample period average. The banking sector of the country is in medium fragility episode where BSFI is between 0 and − 0.5. A high fragility episode is experiencing by the countries if BSFI is equal or lower than −0.5. In addition to this index, to investigate whether bank runs play a crucial role in triggering the banking crisis, Kibritçioğlu [37] also constructs an alternative index by excluding the liquidity risk factor:
According to the results, both indices reveal the similar results. This implies bank runs do not have a prominent role in explaining the banking crises in majority of the sample countries. Furthermore, to investigate the fragilities of Indian banks, Singh [38] developed a monthly BSFI following Kibritçioğlu [37]. The index is the weighted average of annual growth in real time deposits, real non-food credits, real investments in approved and non-SLR securities, real foreign currency assets and liabilities and the real net reserves of commercial banks. The author also constructs an alternative index, by excluding the bank deposits from the index, to show bank runs do not play a significant role for the fragility episodes of Indian banks.
By using the BSFI, Ahmad and Mazlan [39] aimed to monitor the trend and determinants of fragilities of locally and foreign-based commercial banks operating in Malaysia. Although the scholars consider BSFI of Kibritçioğlu [37], different proxies are employed to measure the liquidity, credit and exchange rate risks. The BSFI can be given as follows:
As seen from the above equation, the credit risk factor is measure by using non-performing loans (NPL) and exchange rate/market risk is proxied by time-interest-earned ratio (tier). According to the results, bank specific variables and macroeconomic variables do not have any effect on the fragility of the foreign-based banks. Furthermore, asset quality, management quality and size of the bank asset are significant indicators for the bank fragility of local-based banks in Malaysia.
In addition to those efforts to investigate the fragilities of conventional banks, the BSFI index is also applied to Islamic banking to determine the banking fragilities as well. For instance, Kusuma and Asif [40] use the BSFI of Kibritçioğlu [37] to identify the fragility episodes of Indonesian Islamic banks by considering bank deposits and domestic credit proxies. The authors use the only macroeconomic variables such as ratio of M2 to reserve growth, credit growth, inflation rate and real effective exchange rate as explanatory variables of their model.
Wiranatakusuma and Duasa [41] constructs a monthly Islamic banking resilience index (IBRI) to examine the signaling macroeconomic indicators towards the resilience of Indonesian Islamic banks. The IBRI is constructed based on liquidity risk and credit risk factors. To measure liquidity risk, the authors use bank deposits. Furthermore, the credit risk factor is proxied by financing variable which is the various kinds of financings of Islamic banks. In the study, four macroeconomic variables, the ratio of M2 to international reserves, inflation rate, real effective exchange rate and credit growth, are investigated. The results of the study suggest that all of those macroeconomic variables are capable of explaining the vulnerabilities of Indonesian Islamic banks against the adverse external shocks.
By year 2021, six participation banks are operating in Turkey. These banks are Kuveyt Turk Participation Bank, Albaraka Turk Participation Bank, Türkiye Finance Participation Bank, Turkey’s Ziraat Participation Bank, Vakıf Participation Bank and Emlak Participation Bank. As explained in Section 1.2, Ziraat Participation Bank Inc., Vakıf Participation Bank Inc. and Emlak Participation Bank are established in 2015, 2016 and 2019 respectively. For this reason, regarding data availability and reliability, the analysis is conducted by considering the banks that are established before 2008. Therefore, Kuveyt Turk Participation Bank, Albaraka Turk Participation Bank, Turkiye Finance Participation Bank are included into the regression which represent 70% of the participation banking system in Turkey. Considering the fact that the origin of each banking crisis is stem from different reasons and vulnerabilities, there is lack of a standard number or list of explanatory variables in the literature. Nevertheless, there is some variables that are frequently used and found as statistically significant in the literature. Therefore, in this study, the banking level indicators are determined regarding the leading indicators of banking crisis literature.5 Accordingly, the indicators of the fragility of participation banks towards a banking crisis are investigated by considering banking level variables:
Capital Adequacy: capital adequacy ratio, shareholders’ equity to asset ratio.
Asset Quality: growth of total assets, the ratio of fixed assets to total assets.
Earning: Return on assets, return on equity.
Management: Cost to income ratio, total operating expenses.
Liquidity: Financing to total deposits ratio (FDR).
Sensitivity: the ratio of net open position in foreign currency assets to total regulatory capital, the ratio of total securities to total assets.
Namely, in this study it is investigated if capital adequacy, asset quality, management quality, earning ability, liquidity and sensibility to market risk variables are significant to explain the banking sector fragility of participation banks in Turkey.6 The final data set covers the period between 2008 and 2018. The banking sector data is extracted from Bankscope, Fitchconnect and Datastream databases.
In this study, probit model is employed to investigate the significant indicators of fragilities of participation banks in Turkey. Probit model, as a binomial choice model, is seen one of the most powerful method regarding the early warning system literature [47, 48, 49]. In probit model, the dependent variable is a binary choice model and takes the values 0 and 1 with respect the occurrence of the certain event. Accordingly, in this study, the dependent variable, Y_(i,t), refers to the fragility episode (FE) of the participation banks in Turkey. In this study, the medium and high fragility episodes are considered as fragility episode. In this respect, FE take the value 1 if the participation banks are medium or high fragile to banking crisis. It takes the value 0 referring that the banks are experiencing a tranquil episode.
The
Where X(i,t) is the set of explanatory variables,
Following Kibritçioğlu [37], the BSFI is constructed for identifying the indicators of fragilities of participation banks in Turkey. The index is comprised of credit risk, liquidity risk and exchange rate risk. In this regard, non-performing financing (NPF), bank deposits (DEP) and times interest earned ratio (tier) are used to measure credit risk, liquidity risk and exchange rate risk respectively. The BSFI can be given as:
The BSFI is transformed into a binary variable FE, defining the fragility episode. The participation banks in Turkey experiences three stages as high fragility, medium fragility and tranquil episodes with respect to the level of BSFI. Accordingly, banking system is experiencing a high fragility period if BSFI is less than −0.5. This states that Islamic banks at time t are highly fragile to banking crises. The system is in medium fragility episode if BSFI is between −0.5 and 0. On the other hand, an episode is classified as tranquil period if the BSFI exceeds 0.
As can be seen from Eq. (6), the alternative BSFI is designed by excluding bank deposits variable from the BSFI1. In this regard, defining and detecting the fragile and tranquil episodes towards banking crisis by observing the index value is crucial as the index reveals detailed information on the business cycles within the banking system.
To examine the significant banking level indicators of fragility of participation banks in Turkey, first the BSFI is constructed. In this regard, the fragile and tranquil episodes are determined based on the index. Table 5 presents the fragility and tranquil episodes in Turkey between 2008 and 2018. According to the table, the participation banks in Turkey experiences 20 fragility periods and 16 tranquil periods between 2008 and 2018.7 It is observed that, majority of participation banks in Turkey experienced fragility episode in 2007, the year before the financial crisis. Furthermore, although it is argued that the participation banks are more resistant and perform better during the financial crisis in terms of profitability compared to conventional banks [15], the participation banks are in fragility episode in 2009 and 2010, in the following two years of the financial crisis. As the effects of the financial crisis spread rapidly to other developed and developing countries and took over the banking sectors in those countries, it is seen that participation banks in Turkey also be affected by the outcomes of the crisis. In this regard, according to Hasan and Dridi [7], while the business models of the participation banks prevent the destructive outcomes of the 2008 crisis, the participation banks suffer from greater decline in profitability after 2009 because of their weak risk management practices. As the impact of the global financial crisis on the world economy continued in 2012, most of the countries such as USA and developed economies in the eurozone, have not been able to fully recover and overcome the negative outcomes of the crisis. With the deepened eurozone recession, debt ratios and unemployment increased in those countries. The slowdown in the global economy also affected Turkey. The GDP growth of Turkey slowed down. Furthermore, the external balance of the Turkish economy has deteriorated and the ratio of current account deficit to GDP reached 10%. In line with the global slowdown and deterioration of the Turkish economy, it is seen that the participation banking sector is adversely affected and majority of the banks in the sector experiences a fragile period in 2012. In 2014, developments such as the rapid decline in oil and natural gas prices, the inability of the European economy to recover from the recession, the slowdown in the Chinese economy and the uncertainties in the Middle East caused slowdown in the global economy. Parallel to these global developments and its continuing current account deficit problem, the Turkish economy also grow lower than expected. Accordingly, participation banking sector in Turkey experiences fragility episode in 2014. The political developments (i.e., Brexit, US Presidential elections) and concerns in the global economy (i.e., fluctuations inf energy prices, uncertainty in global interest rate, exchange rate depreciations) affect the financial markets worldwide in 2016. In this regard, the growth of the Islamic finance assets has also deceased. In this regard, the main reason of the slowndown is shown as the depreciation of exchange rate in Turkey, Indonesia, Malaysia and Iran [50]. Accordingly, the table show that in 2016, the participation banks in Turkey has experienced fragility episode in line with those global and domestic developments. In this regard, when the return on assets of the participation banks in Turkey are examined, it is seen that its value decreased by 11% on average in 2016 compared to 2015. Furthermore, since the global uncertainties and the impact of the foreign exchange risks become effectual in the global scale, the improvement of the Islamic finance sector slowed down in 2018 compared to 2017. As in 2016, the return on assets ratio of participation banks in Turkey decrease on average by 15% compared to previous year.
Fragile and tranquil episodes of the participation banks.
Table 6 present the BSFI1 and BSFI2 for the participation banks in Turkey. Accordingly, when the movement paths of the BSFI1 and BSF2 are compared in Table 6, it is observed that both indices follow a similar path. In this respect, bank deposits do not play a significant role in explaining the fragility episodes in Turkish participation banks as in conventional banks [37]. As Laeven and Valencia [4] suggest, the impact of bank runs on banking crises has decreased with the savings deposit insurance.8
Banking sector fragility indices.
To investigate the significant indicators of fragilities of participation banks in Turkey, probit model is employed over the time period of 2008 and 2018. To remedy a possible endogeneity, the explanatory variables of the regression of the fragility of Turkish participation banks are lagged one year. The final explanatory variable set for the analysis of the significant indicators of fragility of Turkish participation banks towards banking crisis is determined by following several steps. Firstly, to indicate the significances of the variables, each independent variable is analyzed separately. Secondly, those significant variables are divided into the categories with respect to CAMELS classification. Thirdly, probit model is conducted with respect to those groups. Finally, the explanatory variables that are significant in each step constitute the final explanatory variable set. Accordingly, the final explanatory variable set is comprised of capital adequacy ratio, return on assets, net interest margin, cost to income ratio and FDR. The dependent variable is the binary fragility variable that is regressed on the lagged variables by employing panel regression.
Table 7 presents the estimation results of the probit regression. According to the table, among capital adequacy indicators, the capital adequacy ratio has significantly and negatively correlated with the probability of the fragility of participation banks in Turkey. The capital adequacy ratio, which is the ratio of the total regulatory capital to risk weighted assets, is considered as one of the most crucial indicators for the safe and stable banking system by indicating the financial strength [50]. In other words, the ratio shows whether the bank’s capital is sufficient against the calculated risks that the bank may be exposed to during its operations. The ratio is related to banking crisis since it mirrors the risky assets and indicates financial health and stability of the banks. To prevent possible banking crises and ensure the healthy functioning banking system, various restrictions have been imposed on the risks taken by banks. In this context, the capital adequacy ratio constitutes an important part of the Basel Criteria. According to the Basel criteria, the minimum capital adequacy ratio must be higher than 8%. In addition to the standard level of 8%, the minimum ratio of 12% is set for the Turkish banks in 2006. It has been seen as one of the most effective measures to prevent Turkish banks from experiencing capital shortages during the financial crisis [38]. According to the TKBB [36], while the capital adequacy ratio of the participation banks in Turkey is 16% in 2018, the level increases to 18% in 2019 and 2020 based on the low non-performing financings ratio and high asset quality of the banks. In line with the related literature,9 the results of the probit regression show that capital adequacy ratio is a significant indicator of the fragility of the Turkish participation banks to banking crisis.
Variables | Coefficient | Std. error | Z-stat. | Prob. |
---|---|---|---|---|
Capital adequacy ratio | −0.041 | 0.10 | −3.03 | 0.002** |
Asset growth | −0.021 | 0.008 | −2.66 | 0.008** |
Cost to income ratio | 0.023 | 0.006 | 3.63 | 0.000*** |
FDR | −0.023 | 0.007 | −3.31 | 0.001** |
Return on assets | −0.035 | 0.007 | −3.51 | 0.001*** |
Results of the probit regression.
*p < 0.1
**p < 0.05
***p < 0.01
Return on assets is a profitability ratio which is an important indicator for the financial performance of banks. The ratio shows the bank’s ability to generate profit from its assets. In line with the related literature, the results of the analysis show that return on assets is significant indicator of the fragility of the participation banks [53]. Put differently, increasing return on assets reflects the strength and efficiency of participation banks and decreases the likelihood of experiencing a fragility towards banking crisis. Since the conventional banks operate based on interest, they have a fixed rate of return. However, as interest is prohibited by the Islamic law, the investments are based on mark-up and equity in participation banks. Furthermore, the pre-agreed return on deposits do not allowed, there is higher risks and uncertainties of return on investments [54]. For this reason, return on assets is crucial for the participation banks in Turkey.
According to the estimation results, cost to income ratio, which is measured as the operating expense as a percent of operating income, has significant impact on the fragility of the participation banks. The indicator is frequently used in the literature to measure management efficiency [55]. Furthermore, low cost efficiency is an essential factor of low profitability of banks [56, 57]. In line with the literature, the estimation results suggest that lower values of cost to income ratio, increases the likelihood of participation banks to experience banking crisis. The cost to income ratio is crucial especially for participation banks since they are found as less cost efficient than conventional banks in the countries where both banks operates in the same banking sector [58].10
Asset growth is found as statistically significant indicator and decreasing value of this variable increases the fragility of the participation banks. As Al-Kayed et al. [59] investigate, optimal asset growth has a positive impact on the performance of the participation banks. In this regard, since the asset growth is originated from TPF, those funds should be allocated to public to obtain optimal margin income and revenue sharing [60].
As conventional banks and participation banks are different in terms of financing, the loan to deposit ratio in Shari’ah banking calculated as financing to deposit ratio (FDR) [61, 62, 63]. FDR indicates the ability of participation banks to repay funds withdrawn by customers, based on financing as a source of liquidity [64]. In other words, it is the ratio of financings outstanding to third party funds (TPF) [65]. According to the results, FDR is found as negatively correlated with the fragility of participation banks in Turkey. As Kinanti [66] states, FDR has a positive impact on the profitability of participation banks. Furthermore, increasing FDR ratio increases the bank’s ability to channel financing, therefore, makes participation banks less prone to banking crisis. In addition, according to Widiwati and Rusli [67], since FDR demonstrates that the bank is able to adjust the amount of funds received and the murabaha financing distributed it has also positively related with the murabahah financing. Furthermore, TPF has also has a positive impact on murabahah financing as banks accept high amount of funds, the distribution of murabahah financing increases.
The estimation results reveal that, among banking level indicators, return on assets, FDR, capital adequacy ratio, asset growth and cost to income ratio are the leading indicators of banking sector fragility of participation banks in Turkey. In this respect, return on assets, FDR, capital adequacy ratio and asset growth are found as negatively related with the fragility of participation banks. Accordingly, increasing return on assets, FDR, capital adequacy ratio and asset growth make participation banks less prone to experiencing a banking crisis. Cost to income ratio, on the other hand is also found as statically significant and positively related with the banking sector fragility of the participation banks. Therefore, increasing cost to income ratio increases the likelihood of the participation banks in Turkey to experience banking crisis.
Turkish banking sector hosts dual banking system where both conventional banking and Islamic banking operate in the same banking sector. Furthermore, the banks that operates based on Islamic banking practices are called as “participation banks”. Although the literature on the banking sector fragility indicators of conventional banks is vast, there are limited number of studies that focus on participation banks. For this reason, in this study, the significant banking level indicators of participation banks towards banking crisis is investigated. The estimation is employed by conducting probit model over the time period 2008 and 2018. According to the estimation results, asset growth, capital adequacy ratio, FDR, return on asset and cost to income ratio are significant banking level indicators of the banking fragility of participation banks in Turkey. Accordingly, increasing return on assets, FDR, capital adequacy ratio and asset growth decreases the likelihood of experiencing banking crisis. On the other hand, the results suggest that increasing cost to income ratio increases the probability of banking sector fragility of participation banks.
Following Kibritçioğlu [37], the BSFIs are constructed in order to investigate whether bank deposits are essential role in determining the banking sector fragility of the participation banks in Turkey. It is important to examine the role of bank runs in Turkish participation banking sector since they play a crucial role in majority of the banking crisis as Asian crisis and Argentina crisis in 1989 [4, 67]. However, it is found that both of the indices follow the same pattern, revealing that bank deposit are not crucial in determining the fragility of the participation banks. In line with the existing literature, with the adoption of deposit insurance, the role of bank runs in banking crisis become less effective [4, 68]. Although conventional banks and participation banks share similar objectives, they perform their functions in different manners which make their risk exposure idiosyncratic in terms of their funding methods, principles and prohibitions. As one of the fastest growing sectors of financial industry, participation banking has developed rapidly on a global scale. In addition to its rapid growth and its share in the banking sector, it attracted special attention with the financial crisis experienced in 2008. Although the participation banks are considered as they performed better compared to conventional banks during the financial crisis of 2008, a considerable amount of literature has been published after the crisis reveal that they have also experienced negative outcomes of the crisis, therefore, they are not completely safe against banking crisis [69, 70]. Furthermore, according to the results of this study, although the participation banking sector in Turkey experiencing a tranquil episode in 2008, the sector was in fragility episode in 2009, 2010 and also majority of the banks in 2007. Accordingly, by revealing the leading indicators of the banking sector fragility for participation banks, the results of this study are crucial and beneficial since policymakers may prevent potential future banking crises and take early precautions to minimize the losses by utilizing the results of this study.
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