Pediatric dysphagiaJune 13, 2014

Anatomy and physiology

Stability is provided positionally (structures are very close and large amounts of fat)

Tongue fills entire oral cavity – touching cheeks, hard, and soft palate

Tongue tip sticks out past the alveolar ridge and touches the lower lip

Fat pads in the cheeks help support oral and pharyngeal function

Soft palate is large, uvula close to the tip of epiglottisFaucial pillars touch the epiglottis Hyoid and larynx very close together, near the

mandible and much higher in the neck

Anatomy and physiology

Base of tongue and larynx◦Descend during the first 4 years of life◦By 4 years the base of tongue has descended far

enough that it forms the anterior wall of the oropharynx

◦Changes continue during childhood and accelerate during puberty

Sucking pads disappear between 4 to 6 months of life Infants tongue fills its mouth and sits more anteriorly

than an adults Mandible is smaller, makes the tongue look oversized Tongue, soft palate, pharynx and larynx are higher in

the neck ◦Facilitates to coordinate nasal breathing during the

swallow

Coordination between sucking, swallowing and breathing

Obligatory nose breathers because of their anatomy

Swallow coincides with cessation of breathing (1 sec)

Most infants begin with a suck(le) – swallow – breathe pattern (1:1:1 ratio)

May change to 2:1:1 ratio towards the end of a feed

Establish and maintain a rhythmic pattern

Four phases of swallow

Oral prep phase◦When sucking occurs in infants◦Longer in children who are eating solid foods that

have to be chewed ◦Manipulates food or liquid in the mouth to form a

bolus◦Lips close around the nipple or cup so no liquid is lost ◦Liquid is moved around the mouth to form a bolus◦Bolus is held between the tongue and hard palate◦Soft palate is pulled forward against the base of the

tongue to keep the bolus from falling into the pharynx

◦The airway is open and nose breathing continues

Four phases of swallow

Oral voluntary phase◦Begins as soon as the child moves the bolus

posteriorly ◦Ends when the bolus leaves the oral cavity◦Less than one second for an infant with normal

development◦Tongue is elevated toward the soft palate◦Tongue presses against roof of the mouth in a

peristaltic motion to squeeze food or liquid backward

◦The bolus leaves the mouth

Four phases of swallow

Pharyngeal phase◦Begins with the initiation of the pharyngeal swallow◦True vocal folds close - arytenoids come together◦The false vocal folds close◦The hyoid and the larynx are pulled up and forward◦Epiglottis is pushed down to deflect the bolus to either

side and to move it posteriorly away from the airway◦Bolus propelled through the pharynx by pressure

created by base of tongue, movement of the upper esophageal sphincter (caused by lifting the larynx)

◦ In the pharynx the bolus divides, half moves through the pyriform sinus on each side of the pharynx

◦Rejoins right above the level of the upper esophageal sphincter

Four phases of swallow

Esophageal phase – persistent peristaltic wave moves bolus through the esophagus into the stomach

Wave associated with each pharyngeal swallow

May be delayed or observed after 4 or more swallows

Suckling/sucking

Infants start with a suckle Sometime between 6-9 months it changes to a suck Engage in nutritive and non-nutritive suckle Nutritive suckle

◦ Continuous burst which changes to intermittent bursts ◦ Bursts become shorter with longer pauses as feeding

proceeds◦ One suck per second◦ Swallow 1:1 ratio◦ Suck more often than swallowing towards end of the

feeding (2:1 ratio)Non-nutritive suckle

◦ More repetitive ◦ On a pacifier—more repetitive bc. nothing to swallow ◦ 6 sucks per second, 6-8 sucks per swallow

Suckling/suck

In a suckle◦ Lips close around a nipple and turn outwards (inner part

of the lips touch the nipple)◦ Both positive and negative pressure used to expel milk◦ Positive pressure occurs when fluid is compressed,

squeezed or pushed out of the nipple (squeezing toothpaste out of the tube)

◦ Negative pressure similar to suction action (using a syringe to draw out liquid)

◦ Tongue, lower lip, mandible and hyoid move together ◦ Move down and forward and then up and back◦ Downward movement causes negative pressure◦ Up and back movement causes positive pressure◦ Occurs 2 times per second

Suckling/suck

In a suck:◦The front of the tongue pushes against the

nipple and causes positive pressure◦Back of the tongue lowers which increases the

volume of the oral cavity ◦Causes negative pressure and suction ◦Negative pressure more important especially

during breast feeding

Response to stimuli

Reflexes and responses to protect the airwayReflexes are triggered from receptors in the

nose, nasopharynx, upper airway and lungsTriggered by chemical receptors (responds to

chemicals such as water, milk or secretions, acid, etc) or mechanical receptors (touch and pressure)

Any time the infant has a pause in respiration because of these receptors it is called apnea

Protective to shut the airway and close larynxIf it continues causes hypoxia and

bradycardia

Primitive reflexes

rooting suckling sucking swallowing tongue thrusting biting gagging palmomental

Feeding and swallowing impairments

Infant who fails to suckle feed or who suckles or swallows poorly demonstrates problems of feeding readiness, illness or injury

More concerned about the infant who continues to have feeding failure

Causes lie in developmental history of the mouth, pharynx and representation of these areas in the brain

Abnormalities of mouth and pharynx and/or of the brain

Sharing of function between mouth/pharynx and the brain

Feeding and swallowing impairmentsSensory input from the mouth and the

pharynx stimulate the development of various areas in the brain which further refine the oral and pharyngeal movements

Hypoplasia of the tongue may achieve a suckle with compensatory functions of the pharyngeal constrictor wall, palatine folds

Children with cleft palate may compensate by use of the tongue, and constrictors

Premature infantsGestational period is less than 36 weeks Negatively affect their growth and

developmentNot capable of oral feeding due to

◦poorly organized sucking bursts◦Disorganized jaw and tongue movements◦Immature lungs◦Intolerant of apneic periods during swallowing◦Other circulatory or neurological immaturity

Premature infants

Maternal anxiety because infants are ◦Less interactive◦Less responsive◦Fussier with less positive affect◦Fewer vocalizations during feeding and play◦Chronic illnesses and significantly higher level of

care giving Ultrasound show swallowing amniotic fluid as

early as 13 weeksSuck, swallow and breath coordination

develops after 34 weeks gestationOral prematurity – lack of sucking pads

(fattieness of cheeks)

Premature infants

Birth weight◦An extremely low birth weight (ELBW) infant is

defined as one with a birth weight of less than 1000g (2lb, 3oz)

◦Most extremely low birth weight infants are also the youngest of premature newborns, usually born at 27 weeks' gestational age or younger

◦Infants born at less than 1500g are defined as having very low birth weight (VLBW)

Premature infants

Birth weight◦Low birth weight infants are < 2500g◦Infants whose weight is appropriate for their

gestational ages are termed appropriate for gestational age (AGA).

◦Infants who are heavier than expected are large for gestational age (LGA)

◦Those smaller than expected are considered small for gestational age (SGA) and are also usually found to be intrauterine growth restricted (IUGR) prior to birth.

Premature infants

Intercranial hemorrhage ◦½ to 1/3 infants weighing less than 1500 gms◦Results in visual deficits, gross motor disorders, speech

delays and swallowing disorders◦Location and extent of hemorrhage

Necrotizing enterocolitis ◦Excessive gas ◦Mucosal injury in the esophagus◦Perforated bowel◦Short gut syndrome due to surgery◦Feeding intolerance abdominal distention, gastric retention

of feedings◦Total NPO, bowel rest, antibiotics and surgery

Premature infants

Infant respiratory distress syndrome◦ Insufficient amounts of surfactant◦ 70% of infants younger than 28 weeks develop IRDS

Bronchopulmonary dysplasia◦ Seen in infants with positive pressure ventilation◦ Increased respiratory rates◦ Decreased pulmonary compliance◦ Impaired gas exchange and respiratory fatigue◦ Infants under 1000 grams develop BPD (50-85%)◦ Treated with oxygen, steroids, and diuretics◦ Feeding difficulties due to inability to regulate breathing

and swallowing, decreased endurance and orally defensive◦ Pace the infant, frequent breaks, burp frequently and

increase the amount of oxygen

Prematurity

Congenital heart disease◦Deficits in cardiovascular system◦Results in abnormal blow flow◦ Increased heart rates and blood pressure◦Compensate for inability to pump enough blood◦ Increased oxygen demands during feeding◦Use more external support ◦Provide frequent breaks ◦Higher caloric formula◦High flow nipple ◦Proceed with caution not to overwhelm with too much

formula

Tetralogy of Falot

Ventricular septal defect (hole between the right and left ventricles)

Narrowing of the pulmonary outflow tract (the valve and artery that connect the heart with the lungs)

Overriding aorta (the artery that carries oxygen-rich blood to the body) that is shifted over the right ventricle and ventricular septal defect, instead of coming out only from the left ventricle

A thickened muscular wall of the right ventricle (right ventricular hypertrophy)

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Gastroesophageal reflux disease

Contents of the stomach (acid) returning to the esophagus

Lower esophageal sphincter does not work properlyIncrease in intra-abdominal pressure above the

pressure of the LESDuring normal activities of crying, coughing, moving

and defecatingGastrostomy tubes develop significant GERD within

6-12 months Symptoms include:

◦ Projectile vomiting◦ Cough, choke, or gag◦ Abnormal posturing (arching back) ◦ Exhibit irritability

GERD

Respiratory complicationsEsophageal/gastroenterologic complicationsFailure to thriveDiagnosis

◦Barium swallow◦PH Probe◦Upper endoscopy◦Scintigraphy

Nuclear medicine Positron emission tomography

GERD Management

◦ Behavioral Position at 30 degree upright or on an incline Thickened feedings Smaller more frequent feedings Fasting before bed

◦ Medical Inhibits nocturnal acid secretions

◦Tagamet◦Zantac ◦Pepcid ◦Axid

Increases amplitude of peristaltic contractions ◦Reglan

Surgical ◦Nissen fundoplication- sphincter sewn tightly shut so

that it’s a one way valve downward—they would never be able to vomit

Short bowel syndrome

Inability to absorb nutrients Occurs after resection of the small intestineCaused by

◦Multiple intestinal atresias◦Intestinal malrotation◦Necrotizing enterocolitis◦Abdominal wall defects

Nutrition via central lineAnti-motility drugs (Imodine or Lomotil)

Cerebral palsy

Cerebral palsy◦ Occurring prior to or at birth or soon after◦ Spastic cerebral palsy – excessive muscle tension, abnormal

postures and movements, exaggerated gag reflex◦ Infant unable to hold the nipple because of increased

muscle tone and an arched posture◦ Once the nipple is in place, the infant may gag and

unrhythmical◦ Delayed swallow – at risk for aspiration ◦ GERD makes ingestion of food painful ◦ 25% of older children have dysphagia◦ Bite reflexes, drooling, poor trunk control, coughing or

choking during meals

Head injury

With dysphagia stay in hospitals twice as long

Nutritional needs during coma◦Decorticate or decerebrate posturing need 20%

higher basal energy ◦1½ times greater caloric intake for the healing

process◦Dysphagia similar to those of adults however,

differences include physiological differences, cognitive and behavioral issues, social impact on the family

◦Start feeding at Rancho level III

Head injury

◦Impulsive, taking large bites, failing to chew and swallow before taking another bite

◦GERD ◦Treatment suggestions

Upright posturing Reduce oral hypersensitivity Absent swallow reflex Bite reflex Used a rubber coated spoon

Autism spectrum disorder

Pervasive developmental disorder and autism◦Social withdrawal, communication deficits, and

repetitive stereotypic behaviors◦Hypersensitivity to light, sound, pain, smell & touch◦Social withdrawal affects oral phase◦ Impaired body posture and tone interferes with

positioning for feeding◦Hypersensitivity to smell cause infants to recoil from

food◦Hypersensitivity to touch and taste may interfere with

the oral phase◦Lick, smell or attempt to eat nonfoods (pica)

Spina bifida

Spina bifida◦Spinal column malformation◦Lack of closure of the neural tube◦Vertebrae do not completely fuse ◦Limited sensation and motor control difficulties◦May experience difficulty in all phases due to

limited sensation◦Pharyngeal and esophageal stages of swallow

affected by the cranial nerve damage ◦Suck and intake of food disturbed due to

sensory impairment and dyspraxia (difficulty coordinating movements)

Fetal alcohol syndrome

Fetal alcohol syndromeAirway feeding problems

◦Choanal stenosis – atresia◦CHARGE – coloboma, heart disease, atresia of the

choanae, retarded growth and development◦Genital hypoplasia and ear anomalies ◦Pierre Robin sequelae

Glossoptosis Inward palatal arches Lateral pharyngeal wall hypotonia

◦Tracheo-esophageal fistulae or atresia Repair may cause tracheomalacia

◦Laryngeal anomalies◦Pyloric stenosis

Moebius syndrome

Moebius syndrome◦Damage to the cranial nerves ◦Weakness of the face, mandible, lips, and

tongue◦Difficulty closing lips ◦Food and liquid dribbles out of the mouth

Pediatric dysphagia

Cognitive impairment and developmental delay◦Motor coordination and delay interfere with

self-feeding and oral phase of swallowing◦Communication disorders cause difficulty in

expressing preferences◦Down syndrome and Prader-Willi syndrome

HIV/AIDS

HIV/AIDS◦White blood cells, the brain, and other parts of

the body are affected◦Transmitted in utero and/or through breast milk◦45% have serious feeding problems◦Static encephalopathy – developmental delay,

microcephaly, seizure, non-progressive◦Progressive encephalopathy – neurological

deterioration due to direct brain infection ◦Oral herpes, cognitive, language, and attention

deficit disorders◦Odynophagia – pain while swallowing due to

damage of the esophagus, crying after a couple of swallows

HIV/AIDS

◦Malnutrition – affects other systems in the body and puts them at risk for aspiration, increased fatigue during eating, slow feeders with poor sucking, chewing and bolus formation and food aversion to textures

◦Effects of AIDS drugs caused nausea, vomiting, increased reflux and decreased appetite

◦Treatment Analgesic 20 minutes before a meal Increase flow of oxygen Medicine in pudding or other flavorful foods Smooth cold foods Avoid strong flavor and acid foods

Failure to thrive

Failure to thrive◦Consistently below the third percentile for age or is less

than 80% of the ideal weight for age◦Organic, non-organic and mixed etiology◦Organic factors include

Endocrine deficiencies Chronic diseases Enzymatic defects Genetic anomalies Oral motor dysfunctions

◦Non-organic factors include Poor mother infant interaction Psycho social issues Environmental deprivation Child abuse Poor feeding practices

Craniofacial anomalies

Cleft palateCleft lipSubmucous cleft Surgical repairPositioning Nipple burping Type of bottle Frequency of feeding

Normal development of feeding

bottle/breast cup drinking

straw drinking

birth – 6 months

7 – 12 months (about 1 month after spoonfeeding begins)

36 months

Normal development of feeding

Spoon feeding

Munching/chewing

Controlled, sustained biting

Rotary chewing

4-6 months

6-7 months

12 + months

12-15+ months

Normal development of feeding

Normal development of feeding

Evaluation for dysphagia

Screening to determine if an individual is at riskSilent aspiration (lack of cough when food or liquid

enters the airway)Complete assessment as part of a teamDetermine appropriate interventionFailure to thrive Monitor for weight gain and developmentNon-instrumental Clinical Evaluation (NICE)

◦ Breathing and physical coordination◦ Ability to form a seal and suck using nutritive and non-nutritive

sucking ◦ Caregivers counseled and further evaluation scheduled if

necessary

Dysphagia evaluation

Refer when ◦ Difficulties observed relating to feeding and ingestion of

food or liquid◦ At risk for aspirating food or liquid ◦ Does not receive adequate nourishment

Case historyClinical assessment

◦ Caregiver and environmental factors◦ Cognitive and communicative functioning◦ Head and body posture◦ Oral-motor mechanism◦ Laryngeal function ◦ Swallowing mechanism

Case history

Current status◦ Medical diagnosis◦ Present concerns◦ Reason for referral

Social history◦ Family, parent/caregiver relationship, Siblings◦ Home and feeding environment

Medical history◦ Neonatal/birth history◦ Pregnancy and delivery history ◦ Apgar scores◦ Perinatal complications◦ Anesthesia during birth◦ Respiratory, ventilatory support◦ Current medications◦ Past surgeries

Case history

Medical history contd.◦Genetic and neurological evaluation◦Lab reports◦Ear infections◦Sleep patterns◦Current interventions◦Allergies◦Motor and speech and language development◦Personality

Feeding and swallow history◦Feeding develop◦Tube feeding history◦Weight gain history◦Reflux/emesis during and after meals◦Aversive behaviors

Evaluation

behavior/state/sensory integration◦Stage 1: deep sleep◦Stage 2: light sleep◦Stage 3: drowsy semi dozing◦Stage 4: quiet alert◦Stage 5: active alert◦Stage 6: alert agitated◦Stage 7: crying

Evaluation

◦Tolerance for feeding State-related: staring, panicked or hyperalert,

silent crying, dozing, and startle Motor-related: facial grimacing, twitching,

hyperextension of the trunk, arms, hands or legs Autonomic mild: gasp, sigh, sneeze, sweating,

hiccup, tremor, startle, and strain Autonomic severe: coughing, gagging, reflux, skin

color change, respiratory pausing, irregular respiration

Evaluation

General postural control/tone◦ Assess muscle tone/posture/movement abnormalities◦ Evaluate head/neck/trunk alignment◦ Disassociation of head/neck from shoulder girdle (head

support)◦ Note abnormal compensatory behaviors

Respiratory function/endurance◦ Respiratory patterns at rest and during activity◦ Respiratory patterns

Belly breathers Gulp breathers Ribcage flaring Sternum depression Reverse breathing Irregular shallow

◦ apnea

Evaluation

Oral motor/cranial nerve evaluation◦Oral primitive reflexes◦Oral structure and function

Lips◦Observe lips at rest and note symmetry◦Observe bilabial closure◦Maintain lip closure for 5 seconds◦Upper and lower lip for strength increased, decreased or

normal◦Anatomical deviations◦Symmetry and range of motion

Lip opening and closing independent from the jaw Lip rounding Lip spreading Lip resistance Abnormal movement patterns, retractions,

Evaluation

Jaw ◦ Size of jaw◦ Position of jaw (protrusion, retraction, clenched)◦ Symmetry and degree of jaw opening◦ Side to side movement, in and out movement◦ Strength ◦ Abnormal movements (jaw thrusting)◦ Malocclusions

Neutrocclusion: class I molars properly aligned Distocclusion: class II mandibular molars are too far posterior in relation to

maxillary molars Mesiocclusion: class III mandibular molars are too far anterior in relation to

maxillary molars◦ Dental bite

Open bite: upper and lower incisors and possibly canines do not meet Overbite: the upper incisors overlap the lower incisors with significant gap

between them Overjet: the upper incisors project in front of the lower incisors creating a

space Cross bite: maxillary and mandibular teeth are not vertically aligned

Evaluation

Oral motor structures and function◦Tongue

Size micro or macroglossia Movement abnormalities

◦Fasciculations ◦Tremors◦Protruded or retracted◦Contour – flat, thick, or bunched ◦ Increased or decreased tone◦Lingual deviances – scarring, short frenulum, bifid tip◦Observe protrusion, retraction and lateralization independent of

the jaw◦Tongue tip and back elevation◦Tongue cupping◦Lingual strength by pressing against cheeks on either side◦Abnormal movement

Evaluation

Swallow and feeding evaluation◦ Assess the oral/preparatory phase ◦ Make inferences about the pharyngeal stage◦ Suspect problems with later refer for videoflouroscopy◦ Bottle feeding

Evaluate nutritive vs. non nutritive swallow Type of bottle, type of fluid, flow or nipple Note position Suckle initiation Strength of tongue seal (0-6 months) Strength of lip seal (6 months up) Suckle vs. sucking Mandibular excursion Suckle/swallow ratio at beginning vs. end of feeding Length of burst cycle Length of feeding (endurance)

Evaluation

Cup drinking◦Lip/cheek movements◦Tongue movements◦Jaw stability◦Biting cup◦Loss of material

Straw drinking◦Lip/tongue/cheek movements◦Vary viscosity of liquids (control volume)

Evaluation

Spoon feeding◦Anticipatory open mouth◦ Jaw gradation◦Lip/tongue/cheek movement◦Clean spoon? How?

Biting/chewing soft solid foods◦Anterior munching patterns

Straight up and down jaw movement Diagonal munch food moves side to side

◦Mature rotary chewing pattern (later) Bite/grind Open mouth or lip closure Lip/tongue/cheek/jaw movements

Evaluation

Biting/chewing hard solids◦Tongue lateralization

Midline to side Side to midline to side Side to side

Cervical auscultation◦Pediatric stethoscope is placed near the larynx and the

sounds of swallowing/respiration are observed Start listening to normal respiration before introducing food Listen to cycles of sucking/swallowing/breathing Listen for timing of the swallow response Observe change in respiratory sound after the swallow

Evaluation for dysphagia

Instrumentation ◦ Modified barium swallow study

Videoflouroscopy Food coated with barium is ingested Head and body in different positions Views recorded for later analysis Real-time visualization of the swallow process Determine whether the individual should feed orally or not

◦ Fiber-optic endoscopic evaluation of swallowing Following topical anesthetic insert a flexible fiber-optic laryngoscope

through the patient’s nose and down into the pharynx Cough, hold his breath, swallow different textures of food (dyed for

visualization) Oral and esophageal phase not visible

Evaluation

Videoflouroscopic swallow study◦ Responsibilities of the feeding specialist

Positioning of the infant/child Assembling the feeding equipment Instructing the parents who act as feeders during the study Assuming the role of the feeder Working with radiologist to obtain an optimum view Helping infant/child to maintain midline head position Evaluating stages of swallow Making suggestions for intervention and compensatory strategies

◦ Responsibilities of the radiologist Reviewing the films Diagnosing anatomical abnormalities Assessing adequacy of airway protection and swallowing parameters in

conjunction with feeding specialist Screening esophageal phase Reviewing video tape with feeding specialist to discuss objective

findings◦ Time 2-3 mins because of hazardous radiation

Evaluation

Videoflouroscopic swallow study◦Getting started

Be sure the child is hungry Make feeding as familiar and natural as possible (familiar

utensils) Parent/primary caregiver should feed the child Use simultaneous audio and video recordings to

document techniques/flow rates Universal precautions

◦Positioning Premature infants use small seat (Tumbleform with

appropriate support for head/neck/trunk at a 45 degrees) For full term infants use larger seats or special seats such

as a MAMA chair (multiple application, multiple articulation)

Evaluation

◦Materials Several nipples and bottles Poor feeders need to increase the flow rate Slow rate – 3.6ml/minute Fast rate – 16.2 ml/minute Have glucose, formula or breast milk that is not mixed

with barium to continue with feeding between evaluations

Hardest to the easiest consistencies of food Various cups Straw Spoons (one shallow bowl) Syringe Pacifier

Evaluation

Evaluation

Videoflouroscopic swallow study◦Procedure

Presentations◦For infants start with NNS◦ Introduce nipple feedings using regular or preemie nipple

with regular flow rate◦Older children liquids may be presented via a spoon (2 ml) ◦ Increase quantity and texture and vary the utensils◦For infants with NPO

Start with easiest consistencies Establish NNS Introduce familiar bottle feeding and compare NS and NNS With older children begin with spoon feedings Instruct the parents/caregivers to feed the infant the same

way as they do at home

Evaluation

◦Interpretations/recommendations Infants trigger at the vallecula by tongue pressing the posterior pharyngeal wall

Tongue back/down movement is more posterior than in older children

Some infants may experience ventricular penetration during the initial suckle burst

This penetration will clear after the first few swallows if normal

Evaluation

Videoflouroscopic swallow study◦Oral phase

Suckling from a nipple◦Latching on to nipple with a tight lip or tongue seal

◦Initiates suckling◦Rhythmical suckling 1-2 sucks per swallow/breath

◦Stripping the nipple◦Nipple compression◦Posterior nipple placement

Evaluation

Removing food from a spoon◦Mouth opening◦Closure around spoon◦Lip assistance to remove food◦Masticating (or munching) or mashing between gums or tongue and hard palate

◦Manipulate the food from side to side to form a bolus

◦Holding the food in midline on the dorsum of the tongue in preparation for the swallow

◦Utensil use – spoon, fork, cup etc.

Evaluation

Videoflouroscopic swallow study◦Oral stage

Posterior transit of the bolus Oral transit time from the first posterior

movement until the bolus reaches the head of the ramus of the mandible

Lingual peristalsis with hard and soft palate Soft palate simultaneously with the triggering of

the swallow response

Evaluation

◦Pharyngeal stage Begins with elicitation of swallow response and

ends with bolus passing the CP segment Laryngeal elevation and anterior movement Epiglottic excursion Pharyngeal contraction, no residue CP dilation

◦Esophageal phase Primary peristalsis Secondary peristalsis

Dysphagia treatment

Feeding environment◦Minimize auditory and visual distractions◦Light not too bright or too dark◦Noise reduced, music encouraged◦Caregiver should be relaxed and unhurried◦Respond to client signals regarding feeding speed, food

choices, and quantity◦Communication strategies developed◦Utensils for feeding must be appropriate

Slow-flow nipple Teflon coated spoon Shallow bowled spoon Cutout cups

Dysphagia treatment

Body positioning ◦Body posture and stability ◦Upright 90 degree hip angle, symmetrical

position with postural support to provide stability

◦Head and neck secure to prevent extraneous movements

◦Chin tuck ◦Head rotation

Dysphagia treatment

Modification of foods and beverages

Dysphagia treatment

Oral motor exercises and swallowing techniques◦Range of motion of the tongue exercises◦Lip strengthening exercises◦Cheek strengthening exercises◦Jaw exercises

Bubble blowing Straw sucking

Dysphagia treatment

Vital stimulation Different pediatric placements