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SPHS 543 JANUARY 29, 2010 Failure to Thrive (FTT) Poor weight gain/growth failure Below 3 rd 5 th percentile No gain for three consecutive months Often causes overlap Illness, disorder, feeding difficulty, parent/child interaction May impact cognitive development Slide 2 GASTROESOPHAGEAL REFLUX The return of gastric contents, either food alone or mixed with stomach acid, into the esophagus. Reflux is normal! Slide 3 Slide 4 BARRIERS TO REFLUX LES contains gastric contents; pressure differentials Growth longer esophagus, more upright, solid foods Saliva Acid neutralization Clears refluxed materials Polypeptide hormone Respiratory protective systems Cough/airway clearance (6 mos +) Slide 5 GER Delayed gastric emptying Strictures Esophageal spasm leads to odynophagia Respiratory impact Increased WOB Lack of energy = slower digestion Asthma subgroup Pressure sensitive constipation Slide 6 GER OR GERD? Weight loss or inadequate weight gain (FTT) Persistent irritability Food refusal/selectivity Posture -arching Coughing/choking Pain Apnea Sleep disturbance Recurrent pneumonia Slide 7 CAUSES OF GERD Food allergies/intolerance Immature digestive system Structural Immature neurological system Low tone Slide 8 TREATMENT Non-medical Thickening Positioning Feeding frequency Slide 9 TREATMENT Medication Improves gastric motility Metoclopramide Erythromycin Lowers gastric acid production Ranitidine hydrochloride Proton pump inhibitor Omeprazole, lansoprazole Slide 10 TREATMENT Surgical Fundoplication Percutaneous endoscopic gastrostomy (PEG) Jejunostomy feedings Slide 11 TREATMENT Child/Family Food as power Slide 12 NORMAL DEVELOPMENT AND FEEDING SKILLS Everything is connected Gradual disassociation of movements Tactile senses give way to visual and auditory Drive toward independence Slide 13 STABILITY Stability Need a stable base from which to develop movement (mobility) and functional skills Central to distal External (positional) stability Supporting one body part against another Against an external source Achieve muscle balance on both sides of a joint Slide 14 STABILITY Internal (postural) stability No reliance on external aid or support Balance of contraction between agonist and antagonist muscles Movement through space Slide 15 STABILITY Achieves external stability by lying supine Initial success with a controlled reach Slide 16 STABILITY Balance of co-contraction of shoulder begins to develop internal control Positional stability of elbow on floor Weight shifts Slide 17 MOBILITY Mobility develops from a proximal base of stability Affects refined development of distal oral-motor skills Dependent on neck/shoulder girdle stability Dependent on trunk/pelvic stability Slide 18 PROXIMAL AND DISTAL Relative terms Head/neck distal to body Jaw is proximal to distal lips, cheeks, tongue Slide 19 SEPARATION OF MOVEMENT From gross motor to fine motor Slide 20 GROSS-TO-FINE PROGRESSION Present in all skill areas Gradually develop isolation of a skill Slide 21 REFINED ORAL SKILLS Slide 22 STRAIGHT PLANES OF MOVEMENT TO ROTATION Straight planes first Random, undirected Alternate pulls from extensor or flexor muscles Then lateral/diagonal planes and rotary skills Gain stability by balancing extensor/flexor systems Graded function Lateral righting reactions Slide 23 Tendency toward active movement of extensor muscles of neck and back Gradual control of counterbalancing flexor muscles Stability in head control Slide 24 Rolling and weight shifting Diagonal and rotary movements Slide 25 ORAL-MOTOR SKILLS Parallel feeding and speech development Develop from straight planes to lateral then rotary Jaw opens and closes for munching Lateral movement as food moves side to side Circular rotational movement to grind food Slide 26 MIDLINE DEVELOPMENT Four midlines in the body Vertical Horizontal Two diagonals Develop our sense of midlines through weight shifts over proximal joints Experience plays a major role Slide 27 MIDLINE AWARENESS OF MOUTH Home base resting place for the tongue Newborn tongue fills oral cavity Grooved tongue = vertical midline Tongue tip elevation = horizontal midline Lateral movement = diagonal/rotational midline Center of mouth = defined sense of horizontal, vertical, diagonal oral midlines Slide 28 REVERSION TO EARLIER PATTERNS As children acquire a new skill, some of the previously learned control and stability may be lost temporarily Often seen in the development of oral-motor skills Softer foods munching with some tongue lateralization Move to harder foods, may revert to forward- backward tongue pattern before using more controlled tongue lateralization Slide 29 REVERT TO EARLIER PATTERNS May revert to suckle-swallow with introduction of spoon before using lips May cough/choke with cup when previously handled bottle well Slide 30 ECONOMY/EFFICIENCY OF MOVEMENT When two or more possibilities exist, the choice will be the one requiring the least effort Rhythmicity and smoothness Body rhythms Timing Coordination Slide 31 Slide 32 Slide 33 Slide 34 Slide 35 Slide 36 Slide 37 Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Slide 48 Slide 49 Slide 50