The Basics of Feeding:A Workshop in Pediatric Dysphagia

Part III

Stacy Antoniadis, MA, MPH, CCC/SLP

Lisa McCarty, MS, CCC/SLP

Julie McCollum Daly,BS, OTR/L

Cindy Straub, BS

Medical Problems Associated With Feeding - By Symptoms

• Fatigue

• Food refusal

• Apnea during feeding

• Difficult transitions

• Spillage and drooling

• Head tilting

• Poor weight gain

Symptom with Etiologies: Fatigue

• Cardiac• BPD• Chronic diseases

– leukemia– cystic fibrosis

• Neuromuscular disease– muscle weakness, cerebral palsy– spinal cord injury, spina bifida

Symptom with Etiologies: Food Refusal

• Chronic– Gastro-Esophageal (GE) Reflux

– Allergies• milk and food intolerances

– Hypersensitivity

– Pain

Symptom with Etiologies: Food Refusal

• Acute– Oral lesions

– Otitis media

– Pharyngitis

– Medications

Symptom with Etiologies: Apnea During Feeding

• Prematurity

• Aspiration/penetration

• Cardiac/respiratory insufficiency

Symptom with Etiologies: Difficult Transitions

• Developmental delay

• Hypersensitivity/sensory integration disorder

• Autism

• Dysphagia

Symptom with Etiologies: Spillage and Drooling

• Hypotonia

• Hypertonia

• Oral motor apraxia

• Cleft lip/palate

• Micrognathia

• Developmental delay

• Abnormal swallow

Symptom with Etiologies: Head Tilting

• Back tilt– poor oral motor control– abnormal swallow– impaired visual field or eye control

• Forward tilt– poor head control– abnormal swallow

• To one side tilt– asymetric neurologic problem

• facial palsy, torticolis

Symptom with Etiologies: Poor Weight Gain

• Inadequate diet, diluted formulas

• Poor appetite• Slow feeding• Spilled food• Hidden infections• Cystic Fibrosis

• Cardiac insufficiency• Renal insufficiency• Malabsorption• Genetic• Hormonal deficits• Psychological/

relationship problems

Gastroesophageal Reflux (GER)

• Symptoms– food refusal, posturing, vomiting, regurgitation, pain,

irritability during feeding• Diagnostic tests for GER

– pH probe– endoscopy– barium swallow (cookie swallow, modified barium

swallow)– - milk scan– - esophageal manometry

Observing GE Reflux

• Note the timing of the swallowing bursts.

• Note what happens when facilitation is offered.

• Note how the reflux is triggered.

Gastroesophageal Reflux (GER)

• Treatment– Medical

• drugs• positioning• feeding therapy

– Surgical• fundoplication• pyloroplasty• tube insertion (NG, J, gastrostomy)

Nutrition and the Child With Developmental Disabilities

• Big concern is MALNUTRITION

– Three types:• marasmus• kwashiorkor• marasmic kwashiorkor

Nutrition Research on Children with Developmental

Disabilities

• Cincinatti University Affiliated Program study (n=83 children with DD)– most were under/over weight and had

feeding disorder– some had nutrient deficiency– other problems: unusual food habits,

metabolic disorders

Nutrition Research on Children with Developmental

Disabilities

• Norwegian study– growth stunting in children with

feeding problems, lack of appetite, food aversions

Components to Nutritional Assessment

• Anthropometry

• Biochemical indices

• Clinical indices

• Drug/Nutrient interactions

• Dietary indices

Factors Influencing Caloric Intake

• Activity level

• Body composition

• Monitoring

Pathogenesis of Malnutrition

• Reduced nutrient intake

• Increased nutrient requirements

• Impaired nutrient absorption

Suggested Criteria for Referral

• Height or weight below the 10th or greater than 90th percentile

• Cross over >2 growth channels

• Mechanical feeding difficulties

• Unusual food habits

• Inherited metabolic disorders

The goal of a nutrition program is to establish

adequate intake for growth and energy.

Next Steps After Identification

• Involve team and family

• Consider ethnic dietary practices

• Consider income level of family

• Review of child’s illnesses/medications

• ADA’s guidelines for disability areas

• Adjust nutrition plan to meet family needs

Feeding Safety Practices

Texture

• Definition

• Oral motor patterns

• Problems and options

Consistency

• Definition

• Safety issues

Temperature

• Serving/holding temperature

• Sensitivity to hot and cold food

• Safety issues

Positioning for Feeding

• Check for position

• Head at midline

• Position of person presenting food

• Continue to recheck body and head position

• Alternate positioning during meals

Mealtime

• Position and head alignment

• Presentation of food

• Meal time problems– hyperextension, tongue thrust, vocalization

• When to offer food

• Checklist for food refusal

• Dangerous practices

Fluids

• Offering fluids– every 3-4 bites– do not hold to the end of meal

• Thickening liquids– rice cereal, Thick-It, etc

• Dangerous practices

• Handouts for parents