SPHSC 543MARCH 5 & 12, 2010

Questions?

TREATMENT

Assessment will have identified if there is a problem and what the problem is.

Any treatment plan must meet three criteria:

should be safe

should strive to maintain optimal nutrition

should be farsighted

TREATMENT

What the child needs to bring to the treatment process:

… Functioning GI system

… Stable pulmonary system

… Developmentally appropriate oral sensorimotor and feeding skills

Look at relationships between oral and respiratory systems, and child’s learning and communication strategies.

TREATMENT

What influences tone/movement patterns?

Look at limiting movement patterns and look for automatic reflexes that can be elicited to promote normal patterns of movement.

Family dynamics

… Important in evaluation and treatment planning

BASIC PRINCIPLES

Facilitate normal patterns of movement and normalize ability to accept/integrate input – visual, auditory, vestibular, taste and temperature

Include treatment into typical ADLs of childhood

… Mealtime

… Toothbrushing

… Bathing

… Dressing

… Play

Remember: The ultimate goal may not be achieving full oral feeding

… Success may include whole or part nutrition by non-oral means

TREATMENT

Can be direct

… Oral “exercises”

… Non-nutritive oral stimulation (NNOS)

… Therapeutic tastes

Can be indirect

… Alterations in

Environment

Positioning

Seating

Communication signals

Food consistency

TERMINIOLOGY

Feeding Therapy

Implies primary goal is oral feeding

Oral Sensorimotor Treatment

… Primary goal is coordinated movements of the mouth, respiratory and phonatory systems for communication and oral feeding

… Focus is on the ‘total’ child

TREATMENT VS MANAGEMENT

Treatment

… Goal is to improve a problem or condition underlying feeding dysfunction

Management

… Underlying cause of problem cannot be modified by treatment techniques at this time

… Address symptomatology to maintain health and nutrition

… “Buy time” until the underlying problem changes through maturation or medical improvement

OPTIONS FOR TREATMENT/MANAGEMENT

Medical techniques

… Medications, O2, NGT

Surgical techniques

… Repair of anatomical anomalies

… G Tube placement

Modification of feeding situation

… State

… Posture and position

… Swallowing

… Oral-motor control

… Coordination of SSB

… Tactile responses

GETTING READY

Prepare the infant

… State, tone and movement, tactile responses

Prepare the environment

… Visual stimuli

… Noise

… Temperature

Prepare the feeder

STATE

Feeding possible in drowsy/semi-dozing, quiet alert and active alert states

Hypersensitive, easily disorganized –drowsy versus active/alert state

Sleepy –very alert

Look at patterns of states, transitions between states, and stability of state

May need to modify environment during feeding

STATE

Tactile

… Alerting effect

… Often combined with movement

Temperatures

… Cooler

… Change clothes/diaper

… Unbundle

… Cool washcloth

AROUSAL

From sleepy/semi-drowsy to calm, alert

… Variable, not predictable, not rhythmic

Movement

… Can have a strong alerting effect

… Picking up baby, being in an upright position

… Rocking from side-to-side

Auditory

… pitch, tone, rhythm, quiet to louder, lively music

CALMING

Irritable, crying, hyperstimulated, disorganized, easily startled

Containment and rhythmicity are key

Tactile

… Firm, deep pressure and containment

Swaddling

… Physical containment

… Tonic, disorganized

… Frequent, firm proprioceptive and deep pressure contact

CALMING

Swaddling continued

… Arms together in midline, hips flexed, head covered

… Use well-flexed, vertical position

… Use body – posture and firmness of holding

… Infant massage

Movement

… Rhythmic, constant, predictable

… Try different rhythms

… Bouncing, rocking when swaddled

CALMING

Auditory

… Decreasing auditory input

… White noise, rhythmic, repetitive music

… Minimal speech

Tone, posture, position

… Balance between flexor and extensor

… Movements should be smooth and well modulated

… Alignment of head, neck and trunk are crucial

OPTIMAL FEEDING POSITION

Overall flexion

Orientation of head and extremities about the midline

Shoulders symmetric and forward

Arms flexed and toward body midline

Hips flexed from 45-90 degrees

SEATING/POSITIONING

Look at shoulder girdle, trunk, hips/pelvis, sitting base, stability of feet, eye contact/control, head control and spinal mobility

… Soft chair (bean bag) or foam/towel between shoulders – retraction

… Vest attached to chair, foam/towels on table – protraction

… Hold shoulders down

… May need trunk supports/pads

… Rolled towels under knees – posterior pelvic tilt

… Lumbar spine – anterior pelvic tilt

… Seat depth, width, angle

SEATING/POSITIONING

… Sitting base – wider (pommel) more stable; hip adductor to bring knees together

… Foot rest, towels, blankets, books

… Eye control/contact – supine – no demands for head control.

… Feeder should be at eye level

… Head/spine – must look at hips, pelvis, trunks and shoulder girdle first. Slight recline, head rest, chin tuck

… Abdomen – build muscle tone and control. Improve breathing and postural adjustments during mealtimes

SEATING/POSITIONING

Freedom of movement – spinal movement and changes movement around body axis

FEEDING POSITIONS

En face

… Maximal head control is possible, harder to provide trunk support

Supine in lap

… Hard to control side-to-side head movement

… Hands free tube feeders, pacifier for NNS

… Can be inclined

Sidelying on lap

… Trunk straight and well supported

… Helps retracted tongue come forward

FEEDING POSITIONS

Head in greater flexion

… Facilitate sucking and lip seal

… Compensate for poor laryngeal elevation

Head in slight extension

… Assists breathing

SWALLOWING

Depends on where the problem is:

… Poor organization of bolus in oral phase

… Delayed swallow reflex initiation

… Abnormal pharyngeal phase

… Incoordination of pharyngeal/esophageal peristalsis

IMPROVE BOLUS FORMATION

Problem with tongue control

… Provide single bolus then pause to allow organization

… Small boluses (0.1-0.5 cc, 1 Tbsp to 2 oz)

… Allows establishment of suck

… Thicken liquid

Moves slower, easier for tongue to maintain bolus

DELAYED SWALLOW REFLEX INITIATION

Thermal stimulation

… Triggers faster swallow reflex in adults

… Refrigerator-chilled liquids or semisolids

… May diminish over subsequent swallows

If non-orally fed – may suck on frozen pacifier

Thicken liquid/pureed foods

Improving laryngeal closure

… Forward head flexion/chin tuck

… Angled bottle, cut out cup, straw

ASPIRATION DURING SWALLOW

Usually caused by reduced or insufficient laryngeal elevation/closure and part of the bolus seeps under epiglottis into airway

Treatment techniques aimed at improving laryngeal elevation and changing viscosity of bolus to minimize seep

Strong forward head flexion or chin tuck – changes relative position of larynx so needs less elevation

Use cut out cup or straw to assist in maintaining neck flexion; use angled bottle

Thickening feedings – moves slower so more time to elevate

ASPIRATION AFTER THE SWALLOW

Usually secondary to residue

… Decreased pharyngeal peristalsis

… Dysfunction of the CP muscle

… Inadequate pressure gradients

Noisy, wet-sounding breathing that is worse following feeding

Modify food texture

Encourage “dry” swallows

Palatal trainer

DECISION-MAKING AND ASPIRATION

Degree of swallowing dysfunction

Amount of aspiration

Response to treatment

Underlying pulmonary status

Tracheostomy

Therapeutic feeds

Full PO with modifications

GER

Non-oral restriction decreases GER but may still have….

… Ascending aspiration

… Need to increase/maintain oral skills

… Provide therapeutic feeds

ORAL-MOTOR CONTROL

Hypotonia – poor stability and abnormal control

Need to ‘wake up’ or ‘alert’ CNS

… Tapping

… Vibration

… Quick stretch

Masseter and buccinator muscles

Lips/tongue

ORAL-MOTOR CONTROL

Hypertonia – abnormal movement and may lead to abnormal alignment

Neurological insult or abnormality, stress

… Preparatory movements

Handling

Body alignment

… Firm pressure

… Shaking/vibrating

… Tongue retraction

… Environmental management

TONGUE

Neck extension – functionally pulls tongue into retracted position

May be hypertonic or passively retracted

May be actively seeking point of stability (micrognathia)

Postural support – improve head/neck alignment

Handling – normalize tone, neck/shoulders

Modify tone in tongue

… Finger in midline

… Shaking, jiggling, tapping, stroking, vibrating

Longer nipple

TONGUE

Bunched, humped, retracted, hypotonic

Lacks central groove

Get tongue forward

Downward pressure to midline

Stroking forward with downward pressure

Firm straight nipple with cross-cut

TONGUE

Tongue-tip elevation – pressed against hard palate, distal to alveolar ridge

Common in preemies – may be a means of stabilization

Postural support

Preparatory handling

Quick swiping or vibration

Downward pressure

Assist with mouth opening

… Stimulation to lips

… Downward pressure on jaw

TONGUE

Protrusion – sits on lower lip below nipple and interferes with lip seal

Hypotonia/weakness/increased tone

Neck extension

Postural support – neutral or slightly flexed

Preparatory handling to reduce tone

Sensory input – firm tapping

Firm, downward pressure to midline

Firm straight nipple

Facilitate lip activity

POOR MOUTH OPENING

Poor arousal

Neurologic insult

Prepare state

Elicit rooting reflex

Assist mouth opening – gentle downward pressure

Inhibit jaw clenching – vibration, very small-range, low amplitude side-to-side movement

Touch/pressure to gums

WEAK SUCK

Ineffective feeding

Overall weakness, medical/nutritional compromise, immaturity, myopathies, respiratory/endurance

Provide oral stability – optimal positioning, firm cheek/jaw support, traction on nipple

Increasing flow rate (with caution)

JAW MOVEMENT

Excessive – no stable base for tongue, lip seal may be compromised

Develop stable base for jaw, slightly tucked chin position, develop neck flexor musculature

Preemies – often have jaw instability. Poor developed tone/bulk in oral-facial mm, minimal active neck flexion, neck hyperextension common

Neurologically-based hypertonicity – poorly balanced control between opening and closing mm. May lead to strong downward thrust of jaw

Neck hyperextension – could be immature development of neck flexion, abmormal mm tone or stress

ABNORMAL TONGUE MOVEMENT

Attempts to use marked jaw depression to create negative pressure suction

Postural support – neck/head alignment key. Don’t allow neck hyperextension. Head in neutral or slight flexion will provide additional positional stability to jaw.

External support – firm pressure under jaw. Keep pressure distal and under mandible, proximally will be under base of tongue could interfere with sucking.

ABNORMAL TONGUE

Increased neck flexion – if doesn’t respond well to external support, bring head into strong neck flexion. Help grade jaw movement. Continually monitor respiratory status.

Handling techniques to reduce overall mm tone

May need to target tongue

LIP SEAL

Negative pressure reduced or broken intermittently

Smacking/kissing, excessive fluid loss

Low tone, weakness – preemies or conditions

Excessive jaw movements

ABNORMAL TONGUE MOVEMENTS

Strong protrusion – treat tongue

Treat underlying problems first– facial weakness/hypotonia, excessive jaw movement

External support – cheeks/lips and jaw support, too.

CHEEKS

Hypotonia/weakness, diminished fat pads

Poor stability leads to poor lip seal. Excessive jaw excursion may result

Increase facial tone

Cheek/jaw support

POOR INITIATION OF SUCKING

Crying, fussing, ‘tuning out’ – baby hungry and will become increasingly frustrated

May root excessively and unable to inhibit – turns head wildly from side-to-side

Extreme mouth opening and unable to close

Tongue protrusion/lapping pattern may be attempt as sucking

Hypersensitive response or poorly developed sucking patttern

Poor state/organizational abilities – overly hungry

POOR INITIATION

Treat underlying problems – if poor state/organization treat those underlying conditions

Preparatory handling

Stabilize front of head with jaw control as needed

Place nipple firmly at midline, cheek support as needed –for central reference point

Assist with mouth closure – firm jaw control to assist with closure, grading of mouth open, vibration to relax tension and assist with closure

Facilitate appropriate tongue movement

COORDINATION OF SSB

Prolonged sucking – feeding induced apnea

Having difficulty ‘pacing’ SS and B

Strong, rapid sucking with difficulty initiating breathing even when nipple removed

More common in preemies

External pacing

Be sure baby can initiate breathing

May have better regulation later in feeding

Decrease rate of flow – thicker liquid, slower flow – to allow time to organize

COORDINATION OF SSB

Short sucking bursts

1-3 sucks in a burst before pausing for multiple breaths

Pauses too frequent/long compared to sucking bursts

May be adaptive response

VFSS

Look at respiratory status

Endurance

COORDINATION OF SSB

Uneven pattern with duration of bursts/pauses varying considerably

May be uneven pattern of breathing and swallowing within the sucking burst.

Frequent choking/coughing noted

General neurological disorganization, respiratory problem, nipple flow problem

Assist with external organization

Understand respiratory status

Pace, reduce flow rate, bolus size

ORAL-TACTILE HYPERSENSITIVITY

Responses are exaggerated out of proportion to stimulus (e.g., placing bottle or toy in mouth)

At the extreme end of hypersensitive responses

Easily elicited, stronger, more negative and often include a behavioral response

May cry, grimace, wiggle, arch away, keep mouth closed. If feeder persists may begin to gag and may vomit.

MULTIFACTORIAL CAUSE

Immaturity and illness – immature CNS, at the mercy of physiologic status, poor regulatory filtering mechanisms, becomes a pattern

Delayed introduction of oral feeding – critical period for acquisition of oral feeding skills may be missed (Illingworth & Lister)

Unpleasant oral-tactile experiences – negative or traumatic oral-facial experiences during the course of medical treatment

TREATMENT

Adaptive, well-modulated responses is the goal.

Reduce aversive stimuli – look at care routines

Grade oral/tactile stimuli – start in a range where the child is comfortable and slowly build up to a point where it is not tolerated and then step back slightly. “Dance” on the edge of the infant’s tolerance.

… May need to start distal and move proximal

… May need to move from smooth to soft to unusual to prickly, firm to light pressure, etc.

VIBRATION

Vibratory afferents are carried along different neural pathways than light touch and touch/pressure.

More integrating and less likely to stimulate an aversive response.

Can be effective even with preemies

Hold vibrator against finger, nipple, pacifier. Use an electric toothbrush.

ORAL EXPLORATION

Mouthing toys and hands is a crucial component in helping them tolerate increasing complexity and variety of oral sensations.

Variety – don’t let child get ‘stuck’ on only one thing.

Feeding specialist needs to reintroduce this stage of normal development in a way the baby can tolerate.

ENDURANCE AND RESPIRATORY COMPROMISE

Need to increase ventilation and cardiac output to match ‘work’ of feeding

Reduced intake, poor weight gain

Generally has normal OM control and SSB

Initially feeds well but stops early in feeding

Regulate liquid flow – faster at beginning to get more in, softer nipple, slightly larger hole. Monitor carefully!!

Manipulate feeding schedule – limit feeding time, time between feedings, demand schedule

Nutritional supplements, caloric density

ENDURANCE AND RESPIRATORY COMPROMISE

Structural abnormalities or respiratory disease = increase WOB

Much of available energy is used in cardiorespiratory system with little reserve for additional activity (i.e., feeding)

Increase WOB may lead to GER

Treatment for endurance should be considered

Reduce expectations for feeding

Small volume feedings; pacing

Stopping or postponing oral feeding

Supplemental O2, nebulizers

VENTILATION VERSUS PERFUSION

Ventilation – amount of air in and out of lungs and alveoli

Perfusion – ability of alveoli to exchange gas

Supplemental O2 is not helpful in all respiratory problems – if perfusion is poor, increasing O2 amount will not improve saturation in blood

May still be helpful with feeding since ventilation-perfusion ratio may change with increased work

Need oximetry

INCREASED NUTRITIONAL REQUIREMENTS: ADDITIONAL CALORIES

Skill in balancing medical and nutritional needs with parents’ skills and expectations

Frequently an issue with respiratory/endurance problems

OM skills generally intact so leads to optimism and enthusiastic pursuit of oral feeding

Perception of failure on the part of the infant or parent if goals not readily achieved

INCREASED NUTRITIONAL REQUIREMENTS: ADDITIONAL CALORIES

May need to change the way in which progress is measured

… Primary goal should be infant’s overall growth

… Oral feeding often comes at a high price

… Supplemental nutrition should be viewed as support rather than last resort or failure

… Provides a built-in nutritional system during setbacks

… Focus on quality of oral control and parent-child interaction rather than calories

… Small volume/partial oral to build motoric and sensory foundations, hunger/satiation

NON-ORAL FEEDING

Full non-oral feeding –

… Motor deficit

… Extreme tactile hypersensitivity/aversion

… State or arousal problems

… Medical conditions that preclude oral feeding

… Any combination of these

Existing OM skills should be maintained for future oral feeding and speech

Prevent oral aversion and hypersensitivity due to lack of oral input

Facilitate oral hygiene

NON-ORAL WITH TX ORAL FEEDS

Primarily non-oral

Feeding-related functions show adequate competence to allow small amount of safe oral feeding

To improve OM skills and move toward larger volumes as able.

Safe for oral but cannot take full oral

Allowed to feed as much as possible within certain parameters (length, frequency) with balance non-oral

NON-ORAL PLUS ORAL

Limited nippling at each feeding using good techniques and within physiologic parameters.

Amount not finished is given though tube

Use only with indwelling NGT or GT

Often used with preemies

Alternate nipple and tube feedings

Should be close to taking full volume

Good for those with limited endurance

NON-ORAL PLUS ORAL

Daytime oral and nighttime tube

TRANSITION FROM TUBE TO ORAL

Begin the process of transitioning to oral feeding at the point when non-oral feeding begins

Comprehensive and aggressive oral therapy program

… Normal OM skills

… Expected short-term use (6-12 months)

Primary objectives

… Minimize negative or aversive oral stimulation

… Promote pleasurable experiences and oral exploration

… Maintain/build OM skills and interest

… Associate oral activity with satisfaction of hunger

… Maintain whatever degree of oral intake that is safe

… When possible, expand rather than introduce

TRANSITION

Consistency, whatever program is established, is essential

Assess child and parents’ readiness

Often lengthy and difficult; it’s a process

… “He will eat when he’s hungry” does not apply

… Set goals that reflect steps rather than final outcome

Establishing level and quality of OM skills

Determine swallowing ability

What’s the original medical condition?

What’s the current status?

LETTING GO

Degree of OM impairment

Lack of change/improvement in medical status

Move away from oral goal in a way that supports the child and family

Quality of life

… ‘Recreational’ oral feeding

… Tolerates oral stimulation for ongoing hygiene to face, mouth, teeth, gums

DESENSITIZATION HIERARCHY

From 18 months and older

No obvious OM deficits

May have oral sensory problems due to sensory deprivation

Tolerating –

… Be in same room

… Looking at food

Interacting –

… Uses utensils in play, preparation

DESENSITIZATION HIERARCHY

Smelling

… Tolerates odor of food

Touching

… Tolerates on fingers, hand, upper body, chin/cheek, nose, lips, teeth and tongue

Tasting

… Licks lips or tongue

… Bites and spits out

… Bites and holds in mouth before spitting out

… Chews and partially swallows

… Chews/swallows with drink

… Chews/swallows independently

DESENSITIZATION HIERARCHY

Eating

Gradual changes that lead the child to functional eating without any specific intervention by others except expected monitoring for age

Individual variation as needed

… Collaboration with MD, RD, daycare, school or other therapists, with caregivers and child as primary team members!

… Consistent approach and encouragement/feedback

MEALTIME ENVIRONMENTS

Home, daycare, school, restaurant

… Modify environment as best you can

… Placemats, utensils, cups, bowls

… Proud plates, brag books

Adaptive seating

… Lightweight, washable, easy to use

… Fits under table to allow child to be included in mealtime

ORAL CONTROL – FROM SIDE OR BEHIND

First do positioning for best posture

Middle finger

… Behind chin on belly of tongue

… Inhibits jaw opening, helps closing, indirectly inhibits tongue protrusion

Index finger

… Between lower lip and chin

… Facilitates graded jaw opening, helps control head

Thumb

… Under chin, provides jaw stability only

ORAL CONTROL – FROM FRONT

Helps maintain eye contact

Requires more control from the child

Index or middle finger

… Under chin

… Provides jaw stabilization

Thumb

… On chin

… Facilitates graded jaw opening

TOLERATING FACE WASHING

Preparation for mealtime/snack activity and at end of meal/snack

Provide postural support and stability

Provide oral control as needed

Use firm, deep pats moving distal to proximal

… Cheek bones to lips, one side then the other, upper lip stretching downward, chin moving upward

Use different textured cloths

Use rhythm/singsong

SPOON FEEDING

Wash your hands and help child wash theirs

Provide postural support and stability

Begin with jaw closed

Spoon approaches from low to midline

Graded jaw opening – support as needed

Put spoon straight in – about half way

Press down and flat on tongue, hold to allow tongue to quiet and lips to close.

Take spoon straight out

Let upper lip learn to be active so don’t scrape against the lip

SPOON FEEDING

Clamping – provide extra flexion and wait for child to relax

Sensitivity – face washing and tooth brushing

Lip retraction – positioning toward midline

Tongue thrust before swallow – better head/neck control and oral control

No swallow – chin tuck/neck elongation, reload spoon and come towards them

CHEWING

Wash your hands and help child wash theirs

Provide postural support and stability

Provide oral control

Begin with jaw closed

Food approaches from midline and low or level with mouth. Use food that is easy to handle

Graded jaw opening while maintaining flexion

Place food on chewing surface of teeth at side

Facilitate graded jaw closure

Maintain oral control; watch head and trunk

Don’t facilitate chewing motion – wait with continuous oral control

CHEWING

Tone in cheeks – use finger to stretch and release cheeks before starting

Poor lip closure – face wipe to stretch upper lip down, lower lip up. Push jaw up.

Exaggerated jaw movement – use oral control to grade jaw

CUP DRINKING

In typically developing children, spoon feeding builds to cup drinking

Wash your hands and help child wash theirs

Provide postural support and stability

Provide oral control

Thicker liquids are easier to control in the beginning

Begin with jaw/lip closure

Approach at midline or slightly below level of the mouth

Place cup between lips – not between teeth

CUP DRINKING

Rest rim on but do not push down on lower lip

Tilt cup until it touches upper lip and wait

Goal is active downward motion of upper lip to draw in liquid

Don’t remove cup unless child pulls away – watch child’s signals

Maintain oral control

CUP DRINKING

Bite reflex – move out so it doesn’t happen

Gulping – prevent with slight chin tuck/neck elongation so the kid is looking down in the cup

Use thicker liquids, cut out cup, clear cup, let child help “hold” the cup

STRAW

Prerequisites: nasal breathing, lip seal with active lip function, light jaw closure, cheek and tongue movement to build up negative pressure

Wash, provide posture support and stability, provide oral control

Dip straw into liquid and place finger over hole on top

Place straw between lips, let a drop of liquid out and wait for active suck

Gradually require more suction by keeping finger over hole

Short, wide and small diameter straws

Use juice box

BOTTLE FEEDING

Need NNS to serve as a link that will facilitate transition to NS

Wash hands, provide posture support and stability

Provide oral control from the front – tongue control with middle finger, thumb and index finger on cheek to provide movement forward to facilitate sucking

Bottle approach from midline or below

Facilitate graded jaw opening

Pressure on tongue with nipple to stimulate suck

Rock or shake nipple may help if has intermittent suck

SELF-FEEDING

Wash, provide posture support and stability

Provide oral control if it has not been discontinued prior to this stage

Begin with finger foods to eliminate use of utensils

Hand-over-hand or child holding on to your fingers as you hold the food or spoon

Food or spoon at midline on table. Gather food on spoon.

Jaw is closed.

Food or spoon at midline.

SELF FEEDING

Spoon straight in, maybe pressing down on tongue for stability/organization

Spoon straight out, maybe pausing to let lips and jaw close

May need slight chin tuck/neck elongation to prevent biting on spoon

Spoon back to plate/bowl

Finger foods follow the same pattern but are presented laterally to facilitate chewing

QUALITIES OF UTENSILS

Spoons –

… size of bowl

… depth of bowl

… Size and weight of handle

Cups –

… size

… height/width

… cut out cup – see liquid, to prevent hyperextension

… Cup lip

… Flexibility

… Handles or no handles

QUALITIES OF UTENSILS

Finger foods

… Shape

… Texture

… Way to make it graspable

TREATMENT IDEAS

You set the stage – playful, fun, positive and calm

Activities with no food

… Touch/pressure to hands/feet (weight bearing, holding, deep pressure)

… Massage and vibration – Begin distal and move proximal

… Play with cups, utensils, dolls, tooth brushes, etc.

… Rhythm, bouncing, patting, stroking

… Sensory – lentils, corn meal, rice, play doh, damp sand, damp sponge, finger paints

TREATMENT IDEAS

Food activities – play – explore, measure, pour, art, put food on toy, put toy in mouth, drive food in cars, peanut butter play doh, etc.

Help prepare food – buy it, stir, grind, pass it, feed you, join the family at meal times, wash dishes

Many short work periods better than one long one

Once a week with family follow through

Carryover to home

TOOTHBRUSHING

Goals:

… To improve oral hygiene

… Reduce limiting movement patterns

… Normalize response to sensory stimulation

Procedure (may vary per child)

… Introduce activities with fingers or toys – touch, taste, movement in mouth that is enjoyable

… Explore and play with toothbrush, NUK

… Provide sensory input with fingers – proceed slowly and systematically within child’s tolerance level

TOOTHBRUSHING

Procedure

… Use small sponge, washcloth, NUK

… Brush all parts of the mouth – tongue, lips, cheeks, gums. Brush sides of tongue to encourage lateralization

… Introduce taste on finger, cloths, toothbrushes

… When able to tolerate oral stimulation, brushing movements and taste in mouth, introduce small amounts of toothpaste

… Use a basting syringe to squirt water in mouth and have child lean forward to let water fall from mouth

JAW THRUST

Sitting posture

Reduce sensory input that might overload the child

Position prone on your lap or over a bolster with arms forward. Shoulders should be higher than hips. Let gravity help the tongue and jaw to drop into a more forward position.

Reduce hypersensitivity caused by teeth contacting spoon, toy, finger. Carefully graded pressure to face, gums and teeth

Jaw control and closure

Toothbrushing to normalize sensory stimulation

JAW CLENCHING/TOOTH GRINDING

Postural control to eliminate instability

Position prone on lap/bolster with shoulders higher than hips. Gravity will pull jaw into more open position

Build postural control to develop proximal stability.

Reduce hypersensitivity – pressure to face, gums, teeth

Toothbrushing

Help child explore mouth movements and sensations so they don’t get ‘stuck’ with clenching

What is child communicating by clenching/grinding?

JAW RETRACTION

Better sitting posture

Reduce sensory input that might overload child

Position prone on lap/bolster and use gravity

JAW INSTABILITY

Build postural tone in trunk to build proximal stability

Play games that allow tapping, stroking and other tactile input to TMJ

Support jaw with hands

Have child hold on to the edge of a cup with the teeth while drinking. Utilizes normal developmental strategy

TONIC BITE REFLEX

Posture

Sensory overload

Graded pressure to face, gums, teeth

Toothbrushing

Reduce frequency of elicitation – use a clear rhythm when feeding so mouth is more open, place cup on lower lip so cannot bite to stabilize, use a coated spoon

TONGUE RETRACTION

Use physical handling to build tone in trunk, shoulders and neck to provide proximal stability

Prone on lap/bolster

With child prone, stimulate lips, move into mouth, stroke tongue

Keep head in chin-tucked position with neck elongated. Tap upward on chin at base of tongue

EXAGGERATED TONGUE PROTRUSION AND TONGUE THRUST

Exaggerated tongue protrusion – maintains easy flow of movement seen in normal suckle pattern but protrusive movement is exaggerated and moves beyond the border of the gums/lips

Tongue thrust – forceful protrusion of the tongue from the mouth. Stronger than tongue protrusion and can break a previously sustained rhythm

Physical handling to build tone in trunk and proximal stability

Sitting posture

Change food consistency so tongue protrusion is not needed to move it backward (e.g., no up-down movement for sucking or chewing, no lateralization)

EXAGGERATED TONGUE PROTRUSION AND TONGUE THRUST

Place hand on jaw to keep tongue in mouth

Initiation of suckling or suck pattern from the lips rather than the tongue – use thickened liquids, pureed foods, cup with wide mouth, jaw support

Place spoon in child’s mouth and press down on the middle of the tongue. Remove the spoon and encourage lip closure

LIP RETRACTION AND PURSING

Better sitting posture

Reduce sensory input

Look at sensory properties of food

Create a relaxed environment so child can use more mature feeding patterns without effort

Reduce hypertonicity in neck and shoulder girdle – scissor-fashion on cheek

Place fingers on side of child’s nose and vibrate downward to bottom of upper lip

Face wiping

LOW TONE IN CHEEKS/LIMITED UPPER LIP MOVEMENT

Physical handling to build tone in trunk and proximal stability

Patting, tapping, stroking, etc. on cheeks and lips

Increase sensory input to lips/cheeks through play, food selection (spicy, tart, sour, ice)

Teach straw drinking while helping child to close lips

HYPERREACTION

Consult medical personnel to rule out/discus neurological dysfunction

Better posture

Reduce sensory information overload

Use firm pressure with finger, toy, spoon while slowly moving back in mouth to the point of gag

Jaw control techniques to limit exaggerated movement

HYPOREACTION

Consult medical personnel to rule out/discus neurological dysfunction

Build posture tone in trunk and proximal stability

Select type, intensity and frequency of sensory stimulation

SENSORY DEFENSIVENESS

Child has stronger reactions to a specific sensation than would be expected

Introduce slow vestibular stimulation to help child integrate multiple sensory information

Use music to organize and integrate sensory reactions

Use appropriate touch especially to mouth

Verbally prepare child (“Here it comes!”)

toothbrushin

SENSORY OVERLOAD

Modify space – reduce clutter, dim lights, quiet, soft music

Explore graded touch

Use music to help organize and integrate sensory reactions

SUCKING/SUCKLING

Better feeding position

Reduce sensory input that overloads child

Prone on lap or bolster using angled bottle

Help with jaw support

Music with regular rhythm and 60 bpm

Use binky trainer to control liquid flow

TRANSITION FROM SUCKLE TO SUCK

Develop activity in cheeks and upper lip – easier to teach using a spoon blenderized foods

Use a cup with thick liquid. Provide jaw/cheek support resting cup on lower lip. When given jaw/cheek support, a more mature up-down suck pattern often will emerge. Sucking pattern should be initiated from the lips rather than from the tongue.

DROOLING

Inadequate head/trunk control to support efficient swallow

Decreased saliva control with motor demands

Teething

Poor jaw stability

Nasal congestion

Reduced sensory cues to face

Attention or power

Cranial nerve dysfunction

Side-effect of medication or allergic reaction

Sweet foods

DROOLING

Improve head and neck control

Improve sensory awareness in face and within mouth. Increase awareness of wetness and dryness

Improve jaw, lip and cheek control

Emphasize and value dryness

Teach straw drinking to improve cheek/lip control

TANTRUMS

Serve foods that are appropriate to sensory characteristics and motor requirements of the child

Explore child’s communication patterns

Explore your reactions to child’s tantrum and eliminate power contest

Remain neutral and limit feeding time, depending on abilities

Serve appropriate portion sizes

Say nothing and walk out of the room, or remove child from room

Offer food only at regularly scheduled meals/snacks

DIAGNOSTIC TESTS/PROCEDURES

Basic understanding of common tests regardless of professional practice setting.

Strengths/limitations

Implications of results

Integrate data into clinical feeding observation

Is additional information needed?

Most developed for adults; lack of normative data with children (manometry, FEES, scintigraphy)

PHYSIOLOGICAL MONITORING

Heart rate, respiratory rate, oxygen saturation

Cardiorespiratory monitor

… Numerical and visual display of heartbeat and respiration

… Averaged over a given period of time (e.g., 10 secs

… Strengths – quick approximation of infant’s status.

… Movement artifact /not always accurate

PHYSIOLOGICAL MONITORING

Oximetry –

… Oxygen saturation of capillary blood flow through an external sensor.

… Expressed as a percentage of 100.

Normal infant -- sats above 95%

Below 90% generally indicate some degree of hypoxia.

… Baseline, changes in response to work/handling, effectiveness of O2 treatment

PHYSIOLOGICAL MONITORING

Strengths –

… Easy to transport, non-invasive

… Ongoing, instantaneous info

… More reliable index than observation

Limitations –

… Very sensitive to movement

… Natural pigment of baby

… Ambient light/infrared heating sources

PHYSIOLOGICAL MONITORING

Pneumogram –

… Two-channel study based on chest wall excursion and heart rate

… Computerized –multichannel recording of parameters such as heart rate, RR, O2 sats, nasal airflow, esophageal pressures

… Gives exact values rather than averaged values so subtle changes in parameters are identified.

PHYSIOLOGICAL MONITORS

Polysomnogram – “Sleep study”

… Multichannel recording of respiration, airflow, chest and diaphragm movement, oxygen and carbon dioxide levels, heart rate and esophageal pressures

… EEG recordings for length of two complete sleep cycles

… Measures the greatest number of variables

… Differentiates between central and obstructive apnea, apnea secondary to seizures, obstructive apnea due to GER or airway collapse

… Limitations – specialized sleep lab, expertise

GASTROINTESTINAL

Technetium scan (AKA GE scintigraphy or a milk scan)

… Small amount of radionuclide isotope is added to the feeding

… Images are made every 30 seconds over a one hour period after the feeding looking for material in the esophagus.

… Number/height of reflux episodes calculated and compared with standards

… Gastric emptying computed by measuring the percentage of food remaining within the stomach after on hour.

GASTROINTESTINAL

Strength

… Info on several important parameters of GER:

Acidity/alkaline reflux

… Unlikely to miss reflux events

… Height of reflux in esophagus

… Contribution of delayed gastric emptying

… Radioactive tracer not absorbed and total radiation exposure is low

Criticized

… Overly sensitive to reflux

… High false positive rate

GASTROESOPHAGEAL

Barium swallow (AKA esophogram or upper GI)

… Evaluates structure and function of esophagus and stomach

… Ba delivered either orally or NG tube

… Fluoroscopy – real-time events observed

… Still photos taken for later review

… Esophageal motility can be evaluated

… Presence of spontaneous reflux or attempt to elicit by giving pressure to abdomen

… Rad exposure is proportional to time of exposure, but generally brief

… Not sensitive enough to GER, may detect aspiration

UGI

From Wolf & Glass, 1992

GASTROINTESTINAL

pH probe –GER

… Sensor inserted through nose to an area just above LES to continuously measure acidity of esophagus

… At least a 24 hour hospital stay

… Record kept at beside of baby’s activities for later correlation with changes in pH.

Data is recorded on the total number of episodes of pH <4.0, total time with pH<4.0, number of episodes greater than 5 mins, and longest episode of pH<4.0. Typically, episodes of pH<4.0 must last longer than 10 secs to be recorded.

GASTROINTESTINAL

pH probe –GER

… Sensor inserted through nose to an area just above LES to continuously measure acidity of esophagus

… At least a 24 hour hospital stay

… Record kept at beside of baby’s activities for later correlation with changes in pH.

Data is recorded on the total number of episodes of pH <4.0, total time with pH<4.0, number of episodes greater than 5 mins, and longest episode of pH<4.0. Typically, episodes of pH<4.0 must last longer than 10 secs to be recorded

GASTROESOPHAGEAL

Data generates a reflux score

‘Gold standard’ for evaluation of GER

AIRWAY/GASTROINTESTINAL

Pediatric Endoscopy

… Esophagoscopy/esophageal manometry, laryngoscopy, bronchoscopy

Rigid or flexible tube

Directly observes structures within the body

Obtain tissue via biosy or aspiration

Treatment

Advances in fiberoptics permitted flexible endoscopes that can be used with even extremely small infants

VIDEOFLUOROSCOPIC SWALLOWING STUDY (VFSS)

VFSS aka MBS

… Specifically designed to assess the pharyngeal swallow

… Normal feeding situation is simulated but may need to use ‘tricks’

… Purpose –document aspiration, reason for aspiration and the point at which it occurs

… Assess possible therapeutic interventions

… Positioning can be customized

VFSS

From Wolf & Glass, 1992

CFE LIMITATIONS

Info not readily obtained at bedside:

… VP function

… Laryngeal elevation and closure

… Pharyngeal motility, transit time

… Pooling of secretions and contrast in valleculae and pyriform

… Number of swallows to clear material

… Presence and timing of aspiration in relation to the swallow.

… Bolus movement through UES and esophagus

VFSS

SLP/MD

… Observations relating to timing of swallow

… Coordination in oral/pharyngeal phase

… Phary peristalsis

… Pooled material prior to swallow or residue after

… Esophageal transit time

… Aspiration before, during, after swallow

VFSS

Seating/postioning –

… Support of trunk, neck and head

… Semireclining angle of approx 45 degrees.

… Tumbleform chair

… Child’s own seating system

… Most wheelchairs don’t fit; some have removable parts

… Height of seat in relation to floor

VFSS

Need careful guidelines for appropriate

… Radiologic risks to infant versus the yield of info from the test

… How will information be used?

Personnel involved varies –

… OT, SLP, MD, tech

… Regardless, should have expertise in infant and skill in interpreting images

Parent participation

VFSS

Emergency back up equip and personnel as needed

Flexible enough protocol to address each baby’s needs

Endurance

VFSS -- FEEDING TECHNIQUE

Multiple variables

… Nipple, syringe, nipple alternating with pacifier to look at NNS and NS, spoon, cup, straw, liquid thickness, solids

Bolus type, amount, texture, temperature, timing can be varied

Risk of aspiration kept at minimum

Caregivers provide samples of food

… Regularly given

… Causing trouble

… Introduction

Lateral view -- most important and most information

VFSS

AP view—

… Documenting asymmetry/pooling

… Head positions

Therapeutic changes

Flexed, extended, turned, etc.

Neurologically impaired

… Better at handling homogeneous consistency

VFSS

Alternate feeding methods with plans for oral-motor stimulation

Repeat studies:

… Significant change in medical or neurological status

… Recurrence of previous symptoms

… Previous documentation of silent aspiration

… Tx program changes are indicated for diet textures or compensation techniques

Improved oral-motor function in profoundly neurologically impaired children have not shown to be directly correlated with improved pharyngeal transit time.

VFSS -- LIMITATIONS

Lack of standardization –

… Positioning

… Amount and order of presentation

… Therapeutic modifications

… Overly sensitive

VFSS VS CLINICAL FEEDING EVALUATION (CFE)

Benefits of CFE first –

… Establish baseline behaviors to compare with feeding during VFSS.

… Feeding during VFSS is often not representative

Paradoxical performance

Has significant feeding d/o but swallows Ba without difficulty

Pre-determine types/textures of foods, order of presentation, optimal positioning, equipment needed

Able to formulate and test treatment strategies

VFSS

Confirms need for VFSS

… Radiation exposure

Signs during CFE

… Coughing/choking

… Noisy, wet respirations

… Subtle signs –unexplained respiratory infection or illness, difficulty managing oral secretions.

Aspiration can be silent

… Logemann reports 40% of adult patients who asp during VFSS not identified during bedside

VFSS

Pay particular attention to medical history, parent descript of feeding, subtle indicators of potential swallow dysfunction

Generalizability of feeding sample has been questioned

… Relatively brief sampling

… Ba may alter baby’s swallowing response

Not intended to identify GER as objective, but can be seen