training for feeding
DESCRIPTION
TRANSCRIPT
Training for Feeding
Presented by: Dr.Shilpa Prajapati
CONTENTS• DEFINITION
• ANATOMY OF ORAL STRUCTURE
• PHYSIOLOGY OF ORAL STRUCTURE
• WHAT IS ORAL DYSFUNCTION?
• CAUSES OF ORAL DYSFUNCTION
• SYMPTOMS OF ORAL DYSFUNCTION
• EVALUATION
• TREATMENT
• TRAINING FOR FEEDING IN PREMATURE INFANTS
• REFERENCES
FEEDING: DEFINITION
• Feeding can be defined as placement of food in the mouth, manipulation of food in oral cavity prior to initiation of swallow, including mastication and oral stage of swallow when the bolus is propelled backward by the tongue.
ANATOMY OF ORAL STRUCTURE
Oral Phase of Swallowing
Food is held within the mouth A bolus is formed in the central portion of the tongue
At same time, the base of the tongue and the soft palate close the oral cavity to prevent food spilling into the open larynx and trachea.
Tongue pushes bolus posteriorly toward the pharynx with an anterior-to-posterior tongue elevation.
As the bolus enters the pharynx the actual swallow or pharyngeal reflex is triggered.
B
Oral Preparatory phase Oral phase
Pharyngeal Phase
This phase is a reflex action. The bolus passes through the pharynx quickly and then enters the esophagus.This takes place in less than a second.
The initiation of this process starts when the bolus passes the anterior faucial arch and reaches the posterior pharyngeal wall. Elevation of the soft palate prevents material from entering the nasal cavity.
This stage is followed by the pharyngeal constrictor muscles pushing the bolus further into the pharynx, toward the cricopharyngeal sphincter. The larynx prevents material from entering the trachea by respectively closing the true vocal cords. Contraction of the lower pharyngeal constrictor is followed by relaxation of the cricopharyngeal muscle, allowing the bolus to pass into the esophagus.
Esophageal Phase
WHAT IS ORAL DYSFUNCTION?• Children with hypersensitive oral dysfunction may be very
picky eaters and may possibly one eat one type of food.
• Many children with oral dysfunction may resist eating solid foods and may gag when trying to eat foods with a lot of texture.
• They may also prefer bland food and dislike using toothpaste.
• In addition, they may also have a fear of choking.
• Those with hyposensitive oral dysfunction may put all kinds of food and nonfood items in their mouths. In addition, they may chew on their clothing or fingers. They may also prefer flavorful food.
CAUSES OF ORAL DYSFUNCTION• Some of the conditions:
o Cerebrovascular accident(CVA),
o Head injury ,
o Brain tumor,
o Anoxia,
o Guillain-Barre syndrome,
o Parkinson disease,
o Quadriplegia.
SYMPTOMS OF ORAL
DYSFUNCTION• Symptoms reported by patient (check all that apply):
o Drooling
o Coughing
o Choking
o Difficulty swallowing:• Solids• Liquids
o Pain on swallowing
o Weight loss
o History of aspiration or pneumonia
EVALUATION
• Mental status:o Alert or oriented o Direction following
• Physical status(symmetry, control, tone):o Head controlo Trunk controlo Endurance o Respiratory
o Suctioning required o Tracheostomy
EVALUATION • Outer oral status:
o Facial expression o Jaw movement o Lip movement o Sensationo Abnormal reflexes
• Inner oral status(symmetry, control ,tone) :o Dentition o Tongue
• Appearance • Tone• Movement
o Protrusion o Lateralizationo “ ng”-”ga”
EVALUATION
• Soft palate/Gag reflex
• Cough (reflexive / voluntary)
• Swallowo Spontaneouso Voluntaryo Laryngeal movement• Tongue• Elevation
EVALUATION
• Food managemento Pureeo Mechanical softo Chopped/groundo Regular dieto Liquids• Thick • Semi thick• Thin
TREATMENT: GOALS
1. To improve motor control at each stage of swallow through normalization of tone and the facilitation of quality movement
2. To maintain an adequate nutritional intake
3. To prevent aspiration
4. To re-establish oral eating to the safest , optimum level.
5. To facilitate appropriate positioning during eating
PRINCIPLES OF FEEDING
1. Patient is looking at and reaching for foodo Visual field o Normal hand to mouth movement patterns o As much control of the situation-adjustmento Patient’s intake is monitored –avoid too much food in
to the mouth.o To monitor for sign of aspirationo Assesse voice quality upon completion of the swallow
2. After completing the feeding process, the patient should remain in an upright position for 15-30 min to reduce the risk of reflexing
DURING ORAL FEEDING
• Patient must:
1) Be alert,
2) Be able to maintain adequate maintain trunk and head positioning with assistance,
3) Have a beginning tongue control,
4) Manage secretion with a minimal drooling and
5) Have a reflexive cough
DIET SELECTION
• Food chosen should
1) Be uniform in consistency and texture,
2) Provide sufficient density and volume,
3) Remain cohesive,
4) Provide pleasant test and temperature and
5) Be easily removed and suctioning when necessary
DIET PROGRESSION• Stage – I food level( pureed form):
1) best for a patients with little or no jaw control, moderate or delayed swallow.
2) Pureed food move more slowly, allowing time for the swallow response to trigger.
3) It helps to increase the oral intake and patient should be advanced to the next level as soon as possible.
• Stage – II food level( mechanical soft / cohesive):1) Best for a patients with a beginning rotatory chew, enough tongue
control with assistance to propel food back toward the pharynx, and a minimal delayed swallow.
2) Reduce the risk of aspiration and start of the swallow response as the back of the tongue elevates toward the hard palate,
3) Patient improve tongue control.
DIET PROGRESSION
• Stage – III food level(chopped / ground food):
1) This stage require chewing, controlled bolus formation, and a fair swallow.
2) This food group offers a wider variety of consistencies
3) Patient should progress to a regular diet
• When a patient is ready to progress to next diet level the therapist can adjust the meal by requesting one or two item from the higher group, enabling assessment at new level
Treatment - Oral preparatory stageStructure
Symptoms Problem Pre-feeding technique
Feeding technique
Trunk
Leaning to one side
Hips sliding forward out of chair
↓trunk tone, Ataxia ,↑trunk tone, Poor body awareness
↑tone in hip extensors
Facilitate trunk strength Exercises : patient clasp hands, lean down, touch food Arm raise to 90’ shoulder flection moves arm turning side 2 side
Provide firm sitting surface
Assist patient to hold correct position as a head control, provide perceptual boundary ,lateral trunk support
Adjust positioning so that patient lean slightly forward
Head Inability to hold head in mid line
Inability to move head
↓toneWeakness
↑tone ,Poor ROM
Facilitate strength through neck & head flexion ,extension lat.flex
Tone reduction of head shoulder and trunk
Assist with head control
As above
Treatment: Oral preparatory
stageStru.
Sympt. Problem Pre-feeding technique Feeding technique
UE Spillage of food from utensil
Inability to self-feed
↓tone Apraxia↓ co-ordination
↑toneAbnormal movt. pattern
Facilitate tone through weight bearing , taping muscle belly
Reduce proximal tone from scapula mobilization weight bearing
Guide correct movement pattern : consider adoptive equipment
See above
Face
Drooling , food spillage from mouth
↓lip control , poor sensation, apraxia
↓sensation
Place weight blade between patient’s lipsAsk patient to hold trunk blade while therapist tries to pull it out.Vibrate lips with electric tooth brush Lip exercises 2-3 times daily ,Blow bubble in to glass of liquid
Use side hand grip for head control , the therapist assist lip close & jaw closerUse straw when drinking liquid Place food to unimpaired side.Use cold food / liquid
Special Straw- Drinking Techniques
Treatment: Oral preparatory
stageStruct.
Symptoms Problem Pre-feeding technique
Feeding technique
Tongue
Pocketing of food in cheeks.Poor bolus formation
Retracted tongue
↓sensation Poor tongue control
Increased tone,Retracted jaw
Tongue exercise
Tongue ROM , wrap tip of tongue , gently pull tongue forward, side to side and up downVibrate tongue back & side ways to decrease tone & facilitate protrusion Normalize neck tone & jaw tone
Avoid crumbly foods Stroke patient outside cheek where pocketing occur with index finger back and up towards patient’s ear.
Reduce tone as needed during meal
Treatment: oral stageStruct.
Symptoms Problem Pre-feeding technique
Feeding technique
Tongue
slow oral transit,Inability to make a “ng-ga” sound
Tongue retraction
Slow oral transit timeInability to channel food back toward pharynx
Poor anterior to posterior movements. :↓tone,Poor sensation, ↑tone
Inability to form central groove in tongue,Apraxia
Practice “ng-ga” soundsAs above
Grasping tongue wrapped in gauze, pull forward to front teeth; stock firmly down middle of edge of tongue blade
Tuck chin toward chest.Avoid crumbly food.Use warm vs. hot/cold food.
As above
Treatment: oral stageStruct.
Symptoms Problem
Pre-feeding technique
Feeding technique
Tongue
Repetitive movt. Of tongue; food is pushed out front of mouth
Food falls off tongue into cheeks or food remain on tongue without patient awareness.
Tongue thrust
Poor sensation
Facilitate tongue retraction to bring tongue back into normal position; vibrate on either side of the frenulum, with a finger.Increase jaw control; teach isolated tongue movement.
Ice tongue; ice in gauze to prevent from slipping into the pharynx; brush tongue with a tooth brush to stimulate receptors.
Correct positioning.Place food away from midline of tongue toward back of mouth.Provide pressure to back of tongue with a spoon after food placement
Use food with a high density.Alternate presentation of foods- cold, hot during meal.
Treatment: oral stageStruct.
Symptoms
Problem Pre-feeding technique Feeding technique
Tongue
Slaw oral transmit time; food remains on hard palate; coughing before swallow
Slow oral transit time.Food remain on back of tongue
Poor tongue elevation; decrease tone
Decrease tone,↑ tone,↓ LOAWeakness
Ask patient to practice k,g,n,d,t sounds.Lightly touch tongue blade or soft tooth-brush to roof of mouth at back of tongue, instruct patient to press tongue, resist movt with brush. Vibrate tongue at below chin; provide quick stretch by pushing down on base of tongue.
Tone reduction: vibrate base of tongue, wrapped tongue by wet gauze pull tongue forward.
Give correct position with finger under chin with base of tongue, move finger upward and forward to facilitate elevation.
Adjust correct position to ↓ tone.Reduce tone by giving rest during exercise.
Treatment: oral stage
Structure
Symptoms Problem Pre-feeding technique
Feeding technique
Tongue Coughing before swallow; retracted tongue.
↓ sensation Grasping base of tongue under chin between two fingers move it back and forth to ↓ tone.
With finger under chin at a base of tongue, move finger.
Treatment: pharyngeal stageStructure
Symptoms Problem
Pre-feeding technique Feeding technique
Soft palate
Tight voice; nasal regurgitationAir felt through nose.↓ tone, nasal speech
Delayed swallow
Inadequate soft palate movt; ↓ tone, rigidity, ↑ tone
↓ triggering of response
Facilitate normal head and neck positionHave patient tuck chin into therapist cupped hand and applies resistance afterwards patient says “ah”Speed and height of uvula, elevation should ↑ followed by thermal application.
Thermal application repeat up to ten times a day
Facilitate normal positioning Patient have tuck chin slightly to ↓ rate of food entering into pharynx
Alternate presentation start with cold substances followed by hot.
Treatment: pharyngeal stage
Struct.
Symptoms Problem Pre-feeding tech
Feeding technique
Hyoid Delayed elevation of hyoid bone,Poor tongue elevation,Tongue retraction
Delayed swallowIncomplete swallowAbnormal tongue tone; poor ROM
↑ tongue humping as elevation of tongue and hyoid stimulates triggering of responseTone reduction
Place index finger under chin and facilitate tongue elevation
Pharynx
Coughing after swallow
Coting of pharynx seen on videofluroscopy,Gurgly(hoarse) voice
↓ pharyngeal movement,Penetration into laryngeal vestibule
Unilateral pharyngeal movements.
None Alternate presentation of stage II & stage III foods. Tilt head to stronger side.If patient with law tone, patient use compensatory technique: patient turn head toward affected side during swallow to prevent pooling in affected pyriform sinuses.
Treatment: pharyngeal stage
Structure
Symptoms
Problem Pre-feeding technique
Feeding technique
Larynx
Coughing, chocking after swallow
Noisy swallow
↓ laryngeal elevation;↓ tone,Weakness
↑ tone,Rigidity,Uncoordinated swallow
Quick ice up sides of larynx; ask patient to swallow.Vibrate laryngeal musculature from under chin
ROM—side to side, back and forth.Using ice chipped or pack in wash cloth and place around larynx for 5 minutes
Teach to clear throat immediately after swallow.Use effortful swallow.
Placing finger and thumb along both side of larynx, assist with upward elevation before swallow.
Treatment: pharyngeal stage
Structure
Symptoms
Problem Pre-feeding technique
Feeding technique
Trachea
Continuous coughing during, before and after
Aspiration – if before: poor tongue control, if during delayed swallow, if after : ↓ pharyngeal movement.
Blocked airway
Teach to produce voluntary cough :ask to take deep breath followed by cough, therapist uses palm of hand to push downward on the sternum.
none
Encourage patient to keep coughing; facilitate reflexive cough.Push downward on sternum when patient breath out.Suction patient if problem increase.
Push into patient sternal notch to assist with cough.Seek medical assistance
Due to insufficient closure of the larynx in delayed swallow
Oral cavity doesn’t close well in
preparatory phase due to poor tongue
control
When larynx opens,
↓ pharyngeal movt,
bolus enters into trachea
Esophageal Phase
Peristaltic muscle action pushes food through esophagus to stomach OR
aspiration occurs
Treatment : Esophageal stage
Structure
Symptoms Problem Pre-feeding technique
Feeding technique
Esophagus
Frequent regurgitation of food or liquid and coughing or choking after swallow;Material collecting in a side pocket in a esophagus.
Inability to pass through the pharynx or esophagus
Esophageal diverticulum
Partial or total obstruction of the pharynx or esophagus
Requires a medical diagnosis; problem can be seen through traditional barium x-ray study.Surgical correction is needed
Report symptoms to medical staff.(therapist cannot treat)
TRAINING FOR FEEDING IN
PREMATURE INFANTS
• Therapeutic positioning and handling are used to enhance development of normal oral-motor skills.
• Placing the infant in an upright position with the neck elongated is encourage.
• Hyper-flexion of the neck must be avoided because occlusion of the airway must be result.
• The infant’s respiration, heart rate and color should be monitored constantly, when first attempting oral feeding.
Positions for Facilitating Suck
Facilitating Suck• The position in which a baby is held during feeding, can
influence a baby’s ability to suck.
• Holding babies in the proper position not only helps them relax and better control their shoulders, trunks, and hips, but also helps them control their jaws, cheeks, lips, tongue movements, & overall smoothness of swallowing.
• Proper positioning can affect the baby’s strength, organization, and energy for sucking, increasing the time of efficiently sucks on the nipple
• In the chin tuck sets up the neck & jaw muscles for the strongest sucking
Shoulders & Trunk
Shoulders & Trunk• Ideally, the baby’s arms should be forward, with hands
resting on or near the bottle. The position in which the baby’s shoulders are drawn back in a tight or retracted position can lead to tension in the shoulders, neck, jaw, and throat. Swallowing is more difficult, and the baby has to work harder. The harder the baby has to work, the less formula or breast milk will be consumed.
• When trying to improve baby’s shoulder and arm position, remember that some babies cannot handle both arms forward at first. They may need to start with one arm and over time progress to both arms. Gradually, your baby may comfortably rest both hands on the bottle or may hold your hands while you are holding the bottle
Hips
Tongue Lateralization• Tongue lateralization is necessary for placing food over the teeth and
keeping it there during the whole chewing process. Without good sideways tongue movement, food falls off the teeth and isn’t well-chewed.
• You can use the NUK brush with the child, or let the child use it while you supervise. But a child should NEVER be left alone with the brush because choking can occur.
• Infa-Dent Finger Toothbrush
Choosing a nipple and Cup
• Developmental Skills• Size• Shape & Design• Safety• Lid Cover• Handles• Weight• Training System
References Pediatric physical therapy, 3rd edition, by:
Jan Stephen Tecklin
Occupational therapy, 4th edition, by: Lorraine Williams Pedretti
Starting again, by: Patricia M. Davies
•THANK YOU