ws 7, pediatric swallowing and feeding - complex decision-making, arvedson

Pediatric Swallowing and Feeding:

Complex Decision Making

CSHA, Monterey

2010

WS7 – April 16, Friday, 8:30-11:30/2:00-5:00

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S

Children’s Hospital of Wisconsin

Medical College of Wisconsin

[email protected] & [email protected]

Joan C. Arvedson, Ph.D. 3/25/2010

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Pediatric Dysphagiawith Health Issues & Complications

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, [email protected] & [email protected]

Dysphagia: Health Considerations

Nutrition/hydration & undernutrition

Neurologic & neurodevelopmental issues

Pulmonary/airway issues

Gastroesophageal reflux disease (GERD)

Medication effects

Diagnoses Seen in Feeding, Swallowing, & Nutrition Center (FSNC)

Angelman Sy ndromeSev ere atopyAutism spectrum disordersBreastf eeding dif ficultyCanav an sy ndromeCat ey e sy ndromeChromosomal etiologiesPrematurity & complicationsOrof acial malf ormationsAirway malf ormationsCockay ne syndromeCongenital diaphragmatic

herniaCongenital heart diseaseCornelia DeLange

Common Nutrition Risk Indicators

Failure to grow over 2-3 months

Weight/height below 5th %ile

Chronic diarrhea/constipation

Long term use of drugs

Excessive drooling

Common Nutrition Risk Indicators

Frequent reflux/emesis

Oral sensorimotor feeding difficulties

Metabolic disorders

Abnormal CBC/urine screens

Suspected caregiver neglect

Undernutrition and Growth

Acute: decreased weight-for-height (wasting)

Chronic: decreased height-for-age (stunting)

Effect on linear growth may lag weight effects by 4 months

Children who survive malnutrition - generally stunted

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C ostello syndromeC raniosynostosisC ri-du-chatDandy Walker SyndromeDiabetesDown syndromeEos inophilic GI diseaseEscobar syndromeHirschsprung syndromeHemolytic uremic

syndromeIUGRKlinefelter syndromeM itochondrial diseaseNoonan syndromePanhypopituitarismC erebral palsySeizure disorders

P ierre Robin sequenceEagle-Barrett syndromeRobinow syndromeShort gutSpina BifidaStickler syndromeTEFSolid organ transplantationTurner syndromeV ATERV elocardiofacial syndrome

Formula intoleranceC hoking phobia“Sleeper eaters”A bsent hunger drive


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Undernutrition: Severity of Effects

Correlated with onset & duration

Most profound damage when period of deprivation occurs during first 2 years

Pulmonary Disease with Neurologic Impairment

Respiratory complications of dysphagiaDisordered timing/incoordinationAspiration

Airway obstruction

High risk infants (apnea & hypoxia)

Older children: disorders of respiration

Signs & symptoms of aspiration vary

Aspiration Generalizations

Usually silent with neurologic deficits

High index of suspicion for signs of pharyngeal dysmotility

Congestion during feeds

Multiple swallows per bolusDelayed initiation of pharyngeal swallow

Respiratory distress (e.g., cough, wheeze)

Congenital Laryngomalacia

Redundant supraglottic mucosaCommon mechanisms

Cuneiforms drawn inward during inspirationExaggerated omega shaped epiglottis curls on itselfArytenoids collapse inward

Stridor in Severe CLM

Inspiratory

High pitched

Loudest when upset

More evident in supine

CLM: SLP Role for Feeding

Determine most efficient oral feeding: position, liquid flow, pacing

Monitor inspiratory stridor & effect on PO

Effects of GER & nipple feeding?

Reassurance to parents regarding positive prognosis in coming months

Spoon feeding & cup drinking may be focus earlier than in typical infants

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Pierre-Robin Sequence

Mandibular Hypoplasia (Micrognathia)

Glossoptosis (retroplaced tongue)

Airway obstruction

U-shaped cleft palate (not primary characteristic, seen in about 80%)

Pathophysiology: Chronic Aspiration

May be more insidious than acute aspiration (direct & indirect)

Most prone: Swallowing dysfunction & neuromuscular disease

Clinical indicators may be scarce

Laryngeal penetration (deep)

Endangerment to airway from aspiration

Life threatening physiologic alterations

Timing of Aspiration with Swallow

Before: Delay in onset of pharyngeal swallow or abnormal tongue movements

During: Ineffective laryngeal closure or timing incoordination

After: Results in residue from multiple factors (e.g., decreased tongue base retraction, reduced sensation, incoordination of pharyngeal constrictors)

Protection from Aspiration

Normal swallow

Cough

Not reliable predictor even in infants with normal swallows

By 1 mo., 90% of infants have cough reflex

Other protectors of lung (e.g., mucociliary clearance, phagocytosis by alveolar macrophages, lymphatic drainage, gag)

Swallowing Problems & GI Disease

Esophageal structural abnormalities (TEF)

Motility disorders

Inflammatory diseases

Constipation aggravates in neuro disorders

74% of CP

Multiple causes (e.g., PO with fluid)

GER Prevalence & Epidemiology

Highest < 2 years of age

Preterm infants: 63%CP: 92% with GI symptoms & signs

Healthy infants pH probe: esophageal acidification common

21% of all ped pts to GI clinic present with signs/symptoms suggestive of GER

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GER Prevalence & Epidemiology

Typical symptoms of GER in < 50% in children with upper airway manifestations

25-30% of all children with GER have EER & upper aerodigestive tract symptoms/signs

Reflexes Involved in Development of Upper & Lower Airway Disease

Esophago-laryngeal reflex

Acid is introduced into distal esophagus

Laryngospasm results

Laryngeal chemoreflex

Direct acid stimulation to larynx

Apnea, bradycardia, & hypotension result

More active in infants & gradually disappear

GER Medications for Apnea in Premature Infants

Theophylline or caffeine: neither drug consistently eliminates apnea in all patients

Note: caffeine exacerbates GER in adults & older children!

Antireflux medications do NOT reduce frequency of apnea in premature infants

(Kimball et al., 2001)

Manifestations of GER are due to

effects of gastric acid, BUT

abnormalities of motility &

sphincter function cause GER

Multiple Causes of GER

Impaired LES function

Increased intraabdominal pressure

Delayed gastric emptying

Impaired esophageal acid clearance

Functional GER - “Happy Spitter”

Infants, onset usually < 2-3 months

Effortless regurgitation (spitting up)

Frequency decreases after 6 months

If infant grows well, no major work-up needed

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Risk Factors (Atypical Manifestations)

Lower airway diseases

Upper airway

Upper digestive

chronic halitosis otalgia/chronic OM

loss of taste Sandifer’s syndromefood refusal chronic pharyngitis

dental caries drooling

Eosinophilic Esophagitis (EE)Entity emerged since 1997 – previously confused with reflux esophagitis

Inflammation due to allergic factors may also include upper airway disease

Not correlate with ? GER

Endoscopy

Denser infiltrates of eosinophils relate to nonacid-related cause of esophagitis

Furrows or rings often notedSteiner et al (2004)

Treatment of EE in PediatricsLack randomized controlled trialsCase series suggest

Elemental dietOral steroids Topical steroids

Lack of control group: impossible to evaluate effect of interventions

Kukuruzovic et al. 2004, Cochrane Database Syst Rev

GER Evaluation

Clinical evaluation

Radiographic study

Scintigraphy

Esophageal pH testing (most sensitive)

Endoscopy & biopsy

Treatment of GERD:Infants & Children

Positioning

Dietary treatments (e.g., thickening feeds)

Feeding schedule changes

Pharmacologic therapy

Surgery (fundoplication)

Types of Medications & Dysphagia

Sedatives

Benzodiazepines

Dopamine antagonists

Anticholinergics

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Clinical Assessment of Feeding & Swallowing: Infants & Children

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S

[email protected] & [email protected]

Presentations of Feeding Disorders

4 Key Questions to Ask ParentsHow long does it take to feed your child?

Longer than 30 minutes, tip-off for problem

Are meal times stressful to child &/or parent?Neurologic based skill & safety issues?

Behavior and/or sensory issues?

Is your child gaining weight OK?If no weight gain for 2-3 months, sign of problem

Are there signs of respiratory problems?e.g., congestion ? during feeding; gurgly voice

Global Feeding Evaluation Goal

To determine safest & most efficient consistencies for a child to eat orally (to whatever extent possible) while maintaining adequate nutrition & hydration

Development in Typical ChildLiquid by nipple first 4-6 months

Breast milk

Formula

Strained smooth food by spoon (6 months)

Sitting with minimal support

Lumpy foods by 10-11 months

Difficult if delayed until 14-16 months

Cup drinking before 12 months

Age of Introduction to Solids

Age (months) Type of Solid

4-6 Smooth puree (SP)

6-9 SP; Textured puree; Easily dissolvable solids

9-12 Soft, mashed, & diced solids

12-18 Toddler diet of chopped table food

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Inadequate growth due to inadequate intakeProlonged time for feedings (but with adequate calories for growth)Delayed progression of oral feeding skills (textures, variety, etc)Recurrent respiratory disease (question of aspiration from above or below)Complicating factors: behavior, sensory, relationship, social


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Feeding/Swallow EvaluationHistory

Physical examination

Observation of typical feeding or mealtime

Referral for additional examinations

Instrumental swallow study

Medical/surgical specialists

Nutrition

Psychology/Social Work

OT/PT

Common Criteria for Referral Feeding periods longer than 30 to 40 minutes

Unexplained food refusal & undernutrition

Weight loss or lack of weight gain for 2-3 mths

Excessive gagging or recurrent cough with feeds

Infants on nipple feeds Sucking , swallowing, breathing incoordinationWeak suck

Breathing disruptions during feeding

Common Criteria for Referral

Airway related concernsHistory of recurrent pneumonia & feeding difficulty

Concern for possible aspiration during feeds

Diagnosis of disorders associated with dysphagia

Irritability or behavior problems during feeds

New onset of feeding difficulty

Lethargy or decreased arousal during feeds

Common Criteria for ReferralDrooling persisting beyond age 5 years

Nasopharyngeal backflow/reflux during feeding

Delay in feeding developmental milestonesNot spoon feeding by 9 months (dev. age)

Not chewing table food or self-feeding finger food by 18 months

Not drinking from a cup by 24 months

Craniofacial anomalies

Steps in Clinical Evaluation

Consultation received Initial Assessment

Possible next step depends on airway status

If respiration normal, clinical feeding evaluation

If respiration abnormal, airway evaluation (hold feeds until airway is clear)

Clinical Evaluation: Airway Concerns?

If none: Develop plan in context of global needsOral sensorimotor interventionNutrition guidelines

Behavioral therapyMonitor status & alter plan as needed

If yes: Instrumental examination or further medical workup

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Feeding History FactorsPositions/posture/seating (gross/fine motor)

Duration of meal times (average & range)

Intervals between meal times

Types of food (preferred, non-preferred)

Assistance/independence of feeding

Tube feeding (e.g., type, timing)

Food record: 2-3 days

Feeding History FactorsRespiratory status

Signs of stress & distress

Test results & medications

Sleep patterns (waking, snoring, mouth breathing)

Cognition & communication

Behavior during meals; apart from meals

Therapeutic intervention (developmental/feeding)

Nervous System Exam

Muscle tone

Reflexes

Cognition & language

Visual tracking

Gross & fine motor skills

Sensory function

Infant Evaluation

State & overall posture/positioning

Respiratory status (rate, patterns, voice)

Resting heart rate

Exam of oral peripheral mechanism

Non-nutritive sucking

Nutritive suck/swallow/breathe

Clinic Airway Evaluation

Respiratory rate: at rest & feeding

Respiratory effort:

Stridor

Stertor

Retractions: suprasternal, substernal

Clinic Airway Evaluation

Voice quality variables

Strong, clear phonation, appropriate pitch

Weak, breathy, husky to hoarse

Gurgly, wet

Velopharyngeal function inferences (e.g., hypernasality, hyponasality)

Pharyngonasal penetration/backflow/reflux

Frequent burping (not clear implications)

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Airway Stability for PO Feeding

Airway stability is prerequisite for successful PO

If airway concerns are noted during physical exam, possible next steps:

Otolaryngology airway exam (FFL, DLB)

Bedside/clinical oral feeding evaluation

Combined FFL & FEES with ORL & SLP

Videofluoroscopic swallow study (VFSS)

Monitor status for a few days

Evaluation of Transition Feeder & Older Child

General observations

Posture, alertness, direction following

Oral sensorimotor function

Bolus formation & oral phase of swallow

Pharyngeal phase inferences

Therapeutic trials

Postural Control Evaluation

Muscle tone (hypotonia or hypertonia)

Central alignment relates directly to oral sensorimotor system

Presence of primitive reflexes

Level of physical activity

Self oral stimulation

Use of eye contact, head turning, & touch

Optimal Sitting Posture

Neutral head position

Neck elongation (No chin tuck for infants)

Symmetrical shoulder girdle stability & depression

Pelvis stability, hips symmetrical in neutral

Hips, knees, & ankles at 90 degrees

Feet in neutral with slight dorsiflexion (never plantar flexed), supported by firm surface

Cranial Nerve Evaluationfor Feeding/Swallowing

Lack of chewing: CN V

Facial asymmetry & lack of lip movement: CN VII

Delayed swallow & pharyngonasal penetration/backflow/reflux: CN IX & X

Tongue thrust or atrophy: CN XII

Gag ReflexIndependent of swallow

Sensory: CN IX

Motor output: CN X, XII, & V

Elicited by touching posterior pharyngeal mucosa (standard testing)

Difficult to assess importance of changes in absence of other findings

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Tonic Bite ReflexJaw moves up into clenched position on presentation of spoon or other object

Response to contact to biting surfaces of side gums (molar tables)

Persistence with neurologic deficit –should disappear by 9-12 months

Cranial Nerve V

Oral Sensory vs Motor Disorders

Nipple confusion

Not differentiate tastes in bottle even with intact suck

Manages liquids better than solid foods

Sorts food in mixed texture

Inefficient suck breast & bottle

Differentiates tastes in bottle

Oral-motor inefficiency or incoordination for all textures

Swallows food whole when given mixed textures


Holds food under tongue or in cheek and avoids swallowing

Vomiting only certain textures

Gags when food approaches or touches lip

Hypersensitive gag with solids, normal liquid swallow

Unable to hold & manipulate bolus on tongue, food falls out

Vomiting not texture specific

Gags after food moves through oral cavity

Gags after swallow is triggered with liquid & solid


Tolerates own fingers in mouth, but not accept others

Does not mouth toys

Refuses tooth brushing

from Palmer & Heyman, 1993

Tolerates others’ fingers in mouth

Accepts teething toys, but not to bite or maintain in mouth

Accepts tooth brushing

Immature vs Abnormal Patterns

Patterns are likely to be distinguishable insuck-swallow-breathe sequencingjaw control or stability

tongue mobilitylip closure

dissociation of tongue, jaw, & cheek movements while drinking & chewing

Next Steps?Nutrition AnalysisMedical Workup (Genetics, GI, ENT, etc)Behavioral PsychologyOccupational Therapy/Physical TherapyInstrumental Swallowing Study

Need to define oral, pharyngeal, & upper esophageal components for management

Oral Sensorimotor Intervention

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Criteria for Instrumental Evaluation

Risk for aspiration by history or observationPrior aspiration pneumoniaSuspicion of pharyngeal/laryngeal problem on basis of etiologyGurgly voice qualityNeed to define oral, pharyngeal, & upper esophageal components for management

Patient Considerations

Diagnostic & management needsNature of swallow impairmentPatient’s ability to feed safelyDevelopment of management plan

Ability or readiness to participateMedical stabilityAbility/willingness to cooperateAge, cognitive, & developmental status

Procedural Considerations

Components of swallow process evaluated

Phase(s) of deglutition

Ability to detect aspiration or risks

Capacity to define nature of deficit

Estimate of agreement: specific procedure and usual patterns of feeding

Flexible Endoscopic Evaluation of Swallowing (FEES)

No radiation

Bedside exam possible

Defines some aspects of pharyngeal physiology

Can evaluate handling of secretions

Sensory testing can be done

Videofluoroscopic Swallow Study(VFSS)

Defines oral & pharyngeal phasesDefines esophageal transit time, basic motilityDelineates aspiration related factors

Before, during, or after swallowsTexture specificityEstimate of risk

What VFSS is NOT

To rule out aspiration or determine if child aspirates with oral feeding (important finding but not reason for exam)

Simulation of a real meal

Evaluation of oral skills for bolus formation

Chewing evaluation

Esophageal function (only upper esophagus)

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Important Considerations in High Risk Pediatric Patients

Radiologist must be presentFluoroscopy time minimumWell formulated Q & ACaregivers includedFindings shown to caregiversFindings interpreted & used as part of total team approach: maximize safety

VFSS Procedural Considerations

Purpose & questions formulated clearly

Positioning/seating: typical & optimal

Cooperative patient imperative for interpretation

Shortest fluoroscopy time possible

Review in slow motion, frame-by-frame

Feeding Supplies & Recipes

Readily available when caregivers are asked to bring food samplesTextures & barium recipes need to be standardizedData lacking, especially in childrenPoor relationship between viscosity of dysphagia diet foods & swallow barium test feeds of different viscosities (Strowd et al., 2008)

Preparation of PO FeedersHungry, but not starving

Schedule close to feeding time if possible

Normalize the situation as much as possibleChild’s own utensils

Video/music as needed

GT + PO: same guidelines as for total PO, unless child gets slow, continuous tube feeds

Preparation of Tube Feeder: NPO

Child should demonstrate some level of oral intake, at least for therapeutic “taste trials”

NG tube – remove in some instances

Amount per bolus: 2 to 3 ccTotal of 10-15 cc preferred for validity & reliability

Medication schedules maintained, or in some cases, adjustments needed

Child’s “State”

Typical feeding status appropriate

Increased risks for aspiration

LethargyAgitation (fussing & crying)

Cooperative child: interpretation possible in reliable & valid ways

Always remember: Just a brief window in time, not a typical meal

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Procedural Decisions

No fixed order for presentations in pediatrics

Preferable to start with thinnest liquidControlled bolus size to start, e.g., spoon before going to bottle or cup drinking

Work toward thicker as needed

Not want residue in pharynx that may complicate interpretation with thinner later

Exceptions: Parents tell us that child will not accept any thing else if he gets liquid first

Lateral ViewEncompassing

Lips anterior

Soft palate superior

Posterior pharyngeal wall posterior

Fifth to seventh cervical vertebrae inferior, varying with age of child

Simultaneous view of oral, pharyngeal & upper esophagus before food is presented

Antero-Posterior View

When asymmetry is known or suspected

Unilateral vocal fold paralysis or paresis

Tonsil related questions

Other possibilities?

Keep in mind radiation exposure time

Importance of findings for management

Oral Phase Swallow Problems

Lips (poor closing, drooling, leakage)

Hesitation/pooling

Tongue action deficits

Gagging

Poor posterior tongue thrust

Passive leakage over tongue base

Delayed oral transit

Initiation of Pharyngeal Swallow

Delayed swallow onset/trigger

Material in valleculaeMaterial in pyriform sinuses

Failure to initiate/trigger swallow

Pharyngeal Swallow Problems

Pharyngonasal (nasopharyngeal) reflux or regurgitation or backflowPenetration

To underside of epiglottis (superior)To laryngeal vestibule/vocal folds

AspirationResponse to aspirationClearance of airway

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Pharyngeal Swallow ProblemsPharyngeal contraction reduced

Pharyngeal motility reduced

Tongue base retraction reduced

Post-swallow residue, e.g.,

Valleculae

Pyriform sinuses

Posterior pharyngeal wall

Clearance of residue?

Esophageal Swallow Findings

Upper esophageal sphincter

Opening, e.g., reduced, incoordinated (usually pharyngeal phase problem)Prominence

Bolus passage

Slow, interrupted

Retrograde movement of contrast (better term than reflux in this instance)

Aspiration Before Swallow: Causes?

Limited tongue action

Limited mandibular movement

Reduced tongue & soft palate approximation

Delayed initiation/onset of pharyngeal swallow

Premature spillage

Material in valleculae & pyriform sinuses

Pharyngeal dysmotility

Aspiration During Swallow: Causes?

Vocal fold paralysis/paresis

Reduced laryngeal excursion

Pharyngeal incoordination

Pharyngonasal (nasopharyngeal) penetration, backflow, or reflux

Aspiration During Swallow

Neural control

Initiation under voluntary control

Involuntary control for completion

Airway

Closes upon initiation of pharyngeal swallow

Multiple levels of airway protection common

Aspiration After Swallow

Reduced tongue base retraction

Residue in valleculae

Penetration into laryngeal vestibule

Reduced pharyngeal contraction/motility

Residue in pyriform sinuses

Reduced hyolaryngeal excursion

Cricopharyngeal dysfunction

Pharyngonasal penetration/backflow may occur

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Aspiration After Swallow

Neural Control

Involuntary for esophageal phase

Airway

Open

Precipitating factors with open airway

Pharyngeal residue spills over

Gravity brings material in nasopharynx lower into airway

Esophageal Dysphagia Diagnosis

Dysphagia for solids > liquids, structural cause likely

Dysphagia for solids & liquids similar, dysmotility likely cause

Interpretation of VFSS Findings

SLP reviews with caregivers & therapists or others involved in care

Findings by phase of swallowTiming of penetration/aspiration related to physiologic processes

If review reveals a finding not anticipated or noted during exam, SLP contacts PA or radiologist to discuss or review togetherImportant that reports are not discrepant

Recommendations After VFSSChanges in route of nutrition/hydration

Nutrition guidelines

Position & posture changes

Alterations of food textures, temperatures

Utensil changes

Changes in feeding schedule & pacing

Oral sensorimotor program with food

Nonnutritive oral sensorimotor program

Management: Prognosis & Priority

Oral feeding prognosis tied closely to

Underlying etiology & diagnosis

Neurologic findings

Cardiopulmonary status

Feeding priorities established on basis of

Severity

Combination of deficits

Principles for Repeat VFSS

Same as for initial VFSS

Information needed for

Definition of etiology or diagnosis

Guide for management decisions

NOT some arbitrary time interval

Child should be at baseline

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Infants in Need of Intervention

Prolonged stay in NICU Extensive exposure to negative oral stimulation, e.g., endotracheal tubes, suction, sticky tapeBefore oral feeding introduction, time is needed

Break oral & perioral aversion Offer exposure to sucking via nonnutritive oral sensorimotor therapy (e.g., pacifier)

Nonnutritive Stimulation

Enhances oral sensorimotor skill development

Builds on in utero experiences of sucking & swallowing

Helps when size & shape of pacifier match infant’s mouth

NNS Cochrane Review

21 studies (15 randomized controlled trials, all infants born < 37 weeks gestation)Main Outcome

NNS significantly decreased length of stay (LOS) in preterm infants No consistent NNS benefit revealed with respect to other major clinical variables

Positive clinical outcomes: Transition from tube to nipple & better bottle feeding performance

Pinelli & Symington, 2005

Oral Stimulation for Preterm Infants

Exp. Group: oral stimulation of oral structures 15 min. once per day for 10 daysControl group: sham oral stimulationStarted 48 hr after d/c of nasal CPAPExp. Group reached independent oral feeding faster (X=11 days, control = 18 days). No difference in length of stay.

Fucile, Gisel, & Lau, 2002

Nipple Feeding Principles

Non-stressful for infant & feederMost efficient suck:swallow ratio is 1:1Burst of rhythmic suck/swallows followed by cessation of sucking and a breathTotal feeding completed in about 20 min.No increased work of breathing, fatigue, or signs of respiratory stress

Interventions

PositioningLimit feeding duration (poor endurance)

Nonnutritive oral sensorimotor therapy

Jaw/cheek support

External pacing

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Tools for Oral FeedingBottles & nipples

IndividualizeGive infant time to adapt/learn

Thickeners – Be cautious!!!May assist bolus formation, slow flowMay slow gastric emptyingMay increase coughingMay interfere with digestion

Evidence-Based Guideline: Introduce Oral Feeding (McCain 2003)

Requirements for oral feeding (PO)Sustain awake behaviorCoordinate sucking-swallowing-breathingMaintain cardiorespiratory stability for time to ingest a caloric volume adequate for growth

Neurologically immature preterm infant <32 wk post conceptual age (PCA) cannot meet the above requirements

Behavioral Organization

< 32 weeks: typically not express hard crying or deep sleep with regular respirations

By 32 weeks, infant expresses full range of behavioral states – important milestone for PO as need to sustain organized, awake behavior

From 32 wks PCA to term age, maturation of brain structure is associated with improvement in behavioral sate expression & motor organization

Self-Regulation ReadinessAt 32 to 35 weeks PCA

Feeding based on awake or restless behavior

PO progressing & concluding based on infant’s ability to tolerate without fatigue or distress

Successful feedings: Increase in quiet sleep time & shorter feeding times

Adequate weight gain compared to infants fed prescribed volumes

More opportunities to practice nipple feeding

Demand FeedingBy 35 wks PCAFunctional suck-swallow-breathe pattern allowing for safe PO is not present until 32-34 wks PCA (Volpe, 2000)Infants 32-36 wks PCA

Suck-to-swallow ratio 3:1 & 4:1 with occasional disruption in regular breathingOccasionally exhibit tongue twitching or tremors

Principles of Management

Whole child approachTotal oral feeding cannot be the goal for all chidlren

Nutrition & respiratory status critical

GER managed optimallyChanges in management needed

with gains or regression

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Food RulesScheduling

Meal times < 30 min + planned snacksNothing between meals, except water

EnvironmentNeutral atmosphere - no forced feedingNo game playing; no reward with food

ProceduresSolids first; self-feeding encouragedMeal over if food is thrown in angerClean up only at end of meal

Intervention Based on Developmental Skill Levels

Oral stimulation for infantsSpoon feeding & chewing readiness

Cup drinking

Texture changes

Spoon Feeding LearningUse foods that stick to spoonAvoid foods

Too much liquid (e.g., soups)

Slippery (e.g., sliced peaches)

Roll off spoon (e.g., peas)Use spoon with flat bowl

Plastic coated non-breakable

Cup Drinking

About 1-2 months after spoon feeding is well establishedOpen cup with thickened liquid (milkshake or fruit “slush”)Cup: wider at top, clear so feeder can control amount per sip wellChild can “help” with handsIndependent: Lip helps reduce spills

Chewing Practice

1-2 months after spoon startedGradual changes from smooth puree

One change at a time (e.g., taste, texture)

Thin strip placed on molar table/surface

Alternate sides to promote later tongue action

Finger Foods

Readiness

Pick up objects with thumb & fingers

Bring fingers or objects to mouth

Bite, chew, & swallow variety of textures

Guidelines

Food in small strips

Place food in front of child (2-3 pieces)

Guide hand to mouth as needed

Fade help as appropriate

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Common Problem TexturesThin liquidsDry or lumpy foods

Pureed food between bites of dry foodMulti-textures foods (e.g., vegetable soup)

Foods that do not dissolve with saliva

Raw fruits & vegetables

Modifying TexturesModifier should match flavor of food

Fine cracker crumbs in soup

Apple juice with applesauce

Milk with yogurt or puddingWhen offering a new texture

Few spoons of familiar texture first

Then new texture (e.g., blended carrots, fork mashed)

Oral Sensorimotor Treatment for Anatomic Problems - Jaw

Thrust: tone

Retraction: tone

Clenching: tone

Instability: tone

Tonic bite reflex: not related to tone

Mouth play: fingers, toys Assisted toothbrushingProne position; Forward pull under jawMouth play for gradual openingActivities for jaw closurePressure at TMJ; sensory stimulation; coated spoon

Oral Sensorimotor Treatment for Anatomic Problems - Lips

– Retraction: tone

Limited upper lip movement: & tone

Cheeks: tone

Reduced sensory awareness

Finger tapping, vibration

Varied textures, temps Tapping & stroking

Stroke & tap, esp. TMJ

Varied textures, temps; drop of liquid in corner of lips

Oral Sensorimotor Treatment for Anatomic Problems - Tongue

Thrust: or tone, or respiratory stress

Jaw stabilization, thickened liquid at lip, food placed on sides, exercises for lateral tongue movement, spoon at midtongue with downward pressure

Oral Sensorimotor Treatment for Anatomic Problems - Tongue

Retraction: or tone

Hypotonia: tone

Prone position, tongue stroking back to front, chin tuck for older child, upward tapping under chin

Vary textures & tastes to sensory input; Food or liquid added gradually

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Oral Sensorimotor Treatment for Anatomic Problems - TongueDeviation

Limited movement

Head at midline; stimulation of less active side with finger, toys, toothbrushVary textures, temps, tastes; Vibration

Oral Sensorimotor Treatment for Anatomic Problems – Soft PalateNasopharyngeal reflux

Upright or prone position; Angled bottle for prone position; Cheek & tongue function activities; Thickened liquids (if swallow is normal)

Feeding with Gastrostomy TubeUpright positionPump or gravity delivery, air removed

Formula at room temperature

Feeding time minimum or > 20 min

Oral stimulation during feeding (or prior)

Tubing flushed after feedings or meds

Mealtime Behavior ProblemsRefusal of new foods

Introduce one at a timeAvoid power struggles

Refusal of groups of foods

Respect preferencesDo not beg, punish, or bribeSet a good examplePrepare foods in a variety of waysSelect other foods with same nutrients

Mealtime Behavior ProblemsWanting a particular food every day

Probably change with boredom over timeDo not call attention to behaviorParent controls what food is served

Consider food “jag” at snackInclude other foods typically liked

Acting outIgnore undesirable behaviorAttend to & respond to desirable behaviorModel good eating behaviors

Treatment Summary

Airway & nutrition highest prioritiesOral sensorimotor practice can NOT jeopardize nutrition & pulmonary statusForced feeding or prolonged feeding times: never appropriateGI tract (e.g., GER)

major inhibitor of appetiteaspiration risk

Whole infant/child approach is critical

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ws 7, pediatric swallowing and feeding - complex decision-making, arvedson

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