sem15 3 handouts

8/12/2019 SEM15 3 Handouts

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IMPROVING EATING BEHAVIORSIN CHILDREN WITH

FEEDING AVERSION

Presented by

Merry M. Meek, M.S., CCC-SLP

NDT Advanced Speech Instructor


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NORMAL ORAL-MOTOR

DEVELOPMENT


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NORMAL ORAL - MOTOR DEVELOPMENT

Traditionally oral-motor development has been viewed in terms of oral reflexes, the structural

aspects of the mouth and jaw, the motor activity of the tongue and mouth and the muscle tone ofthe cheeks and face. The sensory aspects of oral-motor function have not been stressed and

therefore their contribution is poorly understood.

I. Sensory Aspects

1. Vision:The importance of functional vision is rarely considered in the feeding process, but

should be, particularly if the child has any neuromotor involvement such as cerebral palsy.In some cases where children push back into extension or have exaggerated mouth opening

as the spoon approaches the mouth, functional visionmust be considered. The child may

not be able to maintain binocular fusion of the approaching spoon and therefore may see adouble image. In some instances bringing the spoon up from under the chin will diminish

this response and if so, is an indication of a possible functional vision problem. In addition,

the appearance of food has a great impact on how that food will be received. Children who

have not had much experience with food will often be unwilling to experience foods theyare notfamiliar with and often have aversive reactions to the color and size of food, as well

as the smell.2. Smell: Children who have had lengthy hospitalization, those fed primarily by tubes or

those with limited food variety acceptance, have a different developmental experience with

food. In many cases this includes the lack of experience of smell. Some children who have

had lengthy hospitalization become familiar with hospital smells and actually prefer them.This aspect of developmental experience with smell must be considered in treatment.

Therapy should include an active program of olfactory stimulation of various foods to

attempt to normalize this aspect of feeding.3. Taste:Taste is also an experience that may be lacking. Various tastes must be introduced

gradually and tolerance developed. Honoring the child's choices is extremely important. Awell organized feeding program will present a sequential and graded introduction of taste,

with consideration to texture.4. Tactile:Textures of foods have a great deal of importance. Some children do not like soft

foods that slide around the mouth. Other textures feel offensive and children withoutfeeding experience do not have the ability to move the bolus around or to deal with mixed

textures.

5. Auditory/Vibration: The auditory vibration experience of food adds an element ofexperience and this must be developed gradually. First with small bites and crunches of

small foods like pretzel sticks and softer foods with consistency like watermelon and apple.

II. Postural Aspects

1. Chin Tuck:Chin tuck allows good closure of the lips and the proper muscle activity of the

face and mouth for speech and feeding. Neck elongation is critical to the ability of the headto achieve capital flexion. As the neck elongates, the jaw moves forward and down into achin tuck. This provides the stability required for the oral musculature to developed graded

control.

2. Neck Elongation: The young infant does not have much of a neck. Over the first few monthsthe neck begins to elongate. This elongation allows a change in alignment of the structure of

the mouth and jaw. Neck elongation provides more mobility of the head and assists in

developing proximal stability of the shoulders.


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THE MUSCULATURE OF THE FACE


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THE MUSCULATURE OF THE TONGUE


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THE INFLUENCE OF RESPIRATION

ON FEEDING AND SPEECH


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ORAL-MOTOR ASSESSMENT


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ORAL MOTOR SPEECH EVALUATION

Merry M. Meek

PRIMARY AND SECONDARY MEDICAL DIAGNOSES:

1. General Postural Tone and Alignment

2. Changes in Facial Expression

3. 0ral-Facial Tone

4. Response to Finger Stimulation Outside Mouth/ Inside Mouth

5. Dental Development

6. Oral Reflexes (presence/absence)

Rooting reflex

Suck/Swallow reflex

Bite reflex

Gag reflex

7. Jaw Control

At rest

In activity

8. Tongue Control

At rest

In activity9. Lips andCheeks Control

At rest

In activity

10. Respiration Pattern (at rest and in activity)

Abdominal

Immature abdominal-thoracic

Mature abdominal-thoracic

Asynchronous

11. Feeding Behavior

Co-ordination of suck, swallow, respiration, rhythm

Lip closure during swallow

Normal bite

Munching-vertical chewing


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Vertical-rotary chewing

Jaw grading

12. Abnormal and compensatory patterns

Abnormal bite (tonic)

Jaw thrust

Jaw extension

Tongue thrust

Tongue protrusion

Drooling

13. Upper Gastrointestinal Results (UGI)

Oral, pharyngeal, esophageal phase of swallow

Presence of reflux

14. Reflux Evaluation

UGI Study

pH Monitor Study

Radioisotope Study

15. Respiration/Phonation

16. Articulation


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POTENTIAL RISK FOR ASPIRATION

1. Frequent coughing, choking, and/or gagging during meals.

2. Poor or no weight gain.3. Eating new food textures.

4. Rigid feeding behaviors.

5. Poor control of oral secretions.6. Wet/gurgly sounds before, during, and/or after eating and drinking activities.

7. Frequent irritability.

8. Poor sleep habits (e.g., difficulty going to sleep, frequent waking, restless sleeper).9. Frequent upper respiratory infections, and/or pneumonia.

10. Motor involvement which affects respiratory coordination, sensory-motor activity, muscle

tone, oral-motor function, and/or postural control against gravity.11. Functional problems of the oral and/or pharyngeal mechanisms which might result in

aspiration.

CRITERIA FOR REPEAT OPM STUDIES

Repeat oral-pharyngeal motility studies are indicated prior to implementing a significant changein an infant or child's oral-motor/feeding treatment plan, feeding equipment, or dietary texturesif:

1. there is a recurrence of symptoms previously thought to have been resolved,2. aspiration occurred without immediate, effective clearing of aspirated materials during the

previous study,

3. the initial study was terminated prior to completion,4. the initial study could not be analyzed, or

5. there is a significant medical change (e.g., surgery, medication change) which may affectoral-motor function.

Not to be duplicated without permission of author.

a:meek96-97\risk.asp


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TREATMENT GUIDELINES


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TREATMENT GUIDELINES

The management approach should include the following goals:

1. Identifying factors interfering with oral feeding.

2. Establishing adequate caloric intake.

3. Facilitating more normal postural tone and alignment and oral-facial tone.

4. Improving respiratory control.

5. Playing with foods in a variety of ways; using games, books, play foods, tea parties, "real Mr.Potato Heads".

6. Normalizing response to sensory stimulation.

A. Introducing a good oral hygiene program.

B. Normalizing the olfactory response to the "smell of food".

C. Encouraging hand-to-mouth and toy-to-mouth exploration if appropriate for his

chronological age.

D. Facilitating hand play with foods.

E. Introducing flavors on the child's fingers if he can reach his mouth and gradually thicken

the flavor (changes texture).

F. Using Nuk brush to facilitate vertical chewing helps to organize oral rhythm whilefacilitating for jaw stability, tongue lateralization, lip closure and controlled movements.

Graham cracker crumbs, Parmesan cheese, sugar sprinkles (dark- light brown sugar,colored sugar for cookies) can be effective because they melt.

G. Encouraging swallowing of small, thin 1/2 pieces noodles, cheese, cooked vegetableswith broth or drinking other liquid.

H. Developing oral sound play where indicated to facilitate coordinated oral movements.


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FOOD PARAMETERS


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Food Parameter

Visualize Feel Smell Taste

pictures/books develop names and interest

games - Lotto Lingo matching match to fake smells

spice bags fill strong

real foods or liquids

water all feel wet weak to strong liquids mix easy with sa

Capri Sun

clear pop

formula

variety of sugars rough sweet sugars melt with saliva

Parmesan cheese acidic cheese melts with saliva

pizza/spaghetti sauce

candy sticky sweet mix with saliva stays fil

noodles smooth bland

Cheetos, chips, thin pretzels rough salty strong

meat, vegetables rough strong

fruits hard strong


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Food Parameters

Visualize Feel Smell Taste


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SIZE IS EXTREMELY IMPORTANT

Finely grated or shredded Cheese, vegetables, or fruits

Granules White/brown sugar, decorative

sugars

Pinch Parmesan cheese, real bacon

bits

Tiny crumbs Pretzel thins, Cheetos, candy

strips, shoe string potato chips

Dip it in Any food they like - sweet/sour

sauce, pizza sauce, ranch

dressing

Small pieces no more than " Noodles, Cheerios pieces or

Rice Krispies

One drop others Clear liquids 1stunless like

already

Use children's dishes/tea party and baby dolls to feed if no peers are

included in session


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PHYSICAL HANDLING TECHNIQUES

FOR ORAL PREPARATION


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PREPARATION FOR THE TONGUE


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Management of Drooling

Assess: oral facial tone cervical alignment

Mouth closureTongue posture

Kinesthetic cues

Situations where drooling is occurring as part of

overflow

Treatment

I. Improve kinesthetic awareness. Improve oral

motor control. Improve swallowing

sequence.

II. Surgery to reroute salivary ducts

III. Scopolamine patches- antihistamine

IV. Other medications (see report formAACPDM)


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SPECIAL SYNDROMES


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Nager- Miller Syndrome Postaxial Acrofacial Dysostosis

1. Downward slanting palpebral fissures (eye lids)

2. Absence or underdeveloped cheek bones

3. Severely underdeveloped lower jaw

4. Malformed outer and middle ears

5. Cleft of hard or soft palate

6. Absence of lower eye lashes

7. Scalp hair extending on to cheek

8. Incompletely developed ulnar and radius bones

9. Underdeveloped or missing thumbs

10. Webbed finger and toes

11. Occasional absence of the radial limb

12. Shortened or bowed forearms

13. Limitation of elbow extension

14. Legs and toes may also be affected such as abnormal growth of

tibia and fibula bones

15. Stomach or kidney reflux


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DIAGNOSTIC CRITERIA OF RETT SYNDROME

ESSENTIAL CRITERIA

Normal prenatal and perinatal period

Normal birth head circumference

Apparently normal early development

Deceleration of head growth starting by 4 months CA

Loss of acquired hand skills

Loss of communication skills (words and interpersonal)

Stereotypic hand wringing or hand washing

SUPPORTIVE CRITERIA

Awake breathing dysfunction: apnea, hyperventilation, forced air or saliva

expulsion, air swallowing

Growth retardation

Bruxism

Seizures and electroencephalogram profile

Scoliosis

Vasomotor instability

Gait dyspraxia

Unprovoked laughing or screaming

Reduced or altered pain response

Eye pointing


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BIBLIOGRAPHY FOR ORAL MOTOR MANAGEMENT

Alexander, R., Boehme, R. & Cupps, B. (1993). Normal development of functional motor

skills. Tucson, AZ.: Therapy Skill Builders.

Bly, L. (1994). The components of normal movement in the first year of life andabnormal movement. Tucson, AZ. Therapy Skill Builders.

Glass, R. P. & Lucas, B. (1990). Making the transition from tube feeding to oral feeding.Nutrition Focus for Children with Special Health Care Needs, Vol. 5(6).

Langley, B. & Lombardino, L. (Spring, 1991). Neuro developmental strategies formanaging communication disorders in children with severe motor dysfunction, Pro-Ed.

Morris, S.E. (1989). Development of oral-motor skills in the neurologically impairmentchild receiving non-oral feedings. Dysphasia, 3, 134-154.

Morris, S.E. (1982). The normal acquisition of oral feeding skills: Implications for assessment

and treatment. Central Islip, NY: Therapeutic Media, Inc.

Morris, S.E. & Klein, M.D. (1988). Pre-feeding skills. Tucson, AZ: Therapy SkillBuilders, A Division of Communication Skill Builders.

Mueller, H. (1972). Facilitating feeding and pre-speech. In P. Pearson & C. Williams(Ed.), Physical therapy services in the developmental disabilities. Springfield, IL: C.C. Thomas.

Nelson, C., Meek, M., Moore, J.C. (1994). Head-neck treatment issues as a base for oral-motor function. Clinician's View. Albuquerque, NM.

Satter, E. (1987). How to get your kid to eat, but not too much. Palo Alto, CA." BullPublishing Co.

Schemer, A. L. & Tscharnuter, I. (1990). Early diagnosis and therapy in cerebral palsy.

New York: Mercel Dekker, Inc.

Wolf, L. F. & Glass, R.P. (1992). Feeding and swallowing disorders in infancy:

Assessment and management. Tucson, AZ. Therapy Skill Builders.

Young, E. H. (1964). Motor-kinesthetic speech training. Stanford University Press.

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