Feeding and swallowingin infants

and children

Types Swallowing of problems

“Dysphagia”(dis'fahjuh)

Dysphagia fall into three categories based on the

phase: Oral dysphagia – Problems occur due to issues with lips, tongue, cheek muscles, and/or jaw movement. Children may hold food in mouth, have difficulty chewing, drool or spill liquids and have difficulty moving food to /from chewing surface and back of mouth.

Pharyngeal dysphagia — These swallowing problems happen before food reaches the esophagus and may result from neuromuscular disease, obstructions or surgery. Patients experience difficulty starting a swallow; food goes down the wrong pipe; or there is choking and coughing. This may result in poor nutrition or dehydration, aspiration (which can lead to pneumonia and chronic lung disease). Conditions that may cause pharyngeal dysphagia include Lou Gehrig's disease, brain injury, cerebral palsy, multiple sclerosis, muscular dystrophy, spinal cord injury, stroke, cervical osteophytes or other obstructions. Neurologic causes often result in Oropharyngeal Dysphagia.

Esophageal dysphagia — These swallowing problems originate in the esophagus. Food or liquids "stick" in the chest or throat and sometimes come back up. Causes in children include eosinophilic esophagitis, gastroesphageal reflux disease (GERD) and esophageal-motility disorders, as well as later stages of some of the neurological diseases mentioned above.

Physical Factors There are 4 primary areas that impact feeding & swallowing:

• Respiratory system - airway restrictions: lg. tonsils/ adenoids, choanal stenosis, laryngomalacia, jaw &/or tongue retraction

• GI system - GER and possible laryngeal closure and the sensory feedback that result may ‘train’ them to eat less or less often.

• Pharyngeal function-motility decreased strength or coordination and sensory (hyper/hypo)impairments

• Oral function – Structure, muscle strength, coordination and sensation impact feeding and are obviously the most easily seen and reported

Physical Symptoms

Respiratory: destating, nasal flaring , change of color, coughing, gagging, needing to ‘catch breath’, mouth breathing, frequent open mouth posture, snoring/ noisy breathing, Hx of Frequent URI, recurrent PNA, ‘asthma’, gets sleepy during meals.

GI: symptoms of GERD, ‘breath caught’, wet sound in throat, coughing/gaging between feedings/meals.

Pharyngeal: avoiding solids, gagging on solids, oral defensiveness, and “behavioral issues” around eating

Oral: prolonged eating at any stage, open mouth chewing, drooling food preferences for smooth consistencies and crunchy food

Oral-Motor Tone and Feeding

Poor Muscle Tone Poor Feeders

Oral motor function is the very fine motor function of the oral mechanism (i.e., jaw, tongue, lips, cheeks) for purposes of eating drinking, speaking, and vegetative activities.

Oral motor function requires the feedback of sensory processing to achieve the dissociation, grading, direction, timing, and coordination of mouth movement for eating, drinking, speaking, and other vegetative activities.

Children with specific oral motor deficits will exhibit avoidance/ refusal of food texture types and may not adapt to different nipples/cups.

Correlations & Complications:

• Premature birth• Cerebral Palsy • Down Syndrome & other facial

syn.• Cleft palate • GERD • Prolonged tube feeding• Sensory Integration DeficitsAll may lead to Failure to thrive

Feeding Milestones Oral Motor Development:

• Nipple feeding - 36wks gestational age• Spoon feeding - introduced approx.

@4 to 6 mos.• Cup drinking - introduced by 8 - 9mos.• Biting and chewing – development

window 4 -8 mos. Is best time to introduce

• Straw drinking – about 18 mos.* Assuming normal gross & fine motor

milestones met.

Gastroesphageal Reflux

Feeding difficulties due to GER

Reflux vs. Spit up Lower esophageal

sphincter (LES) is less developed in infants.

Relaxed or weak lower esophageal sphincter muscle can allow acidic contents of the stomach to reflux to the esophagus, oral and pharynx and oral cavity.

Diagnosis of GERD is clinically inferred based on • Interview of Caregiver• Association of signs and

symptoms of reflux events

• Frequent or prolonged duration of reflux events

• Absence of alternative diagnoses

Common amongst infants

• Mild vomiting or regurgitation of milk, food and saliva; does not contain large amounts of foods and fluids

• Not forceful• About 40% of infants

spit up on regular basis• Usually occurs after

feeding or burping Typically no further or

acute distress occurs after “spitting up”

Infant remains satiated until next feeding time

GER Signs/ Symptoms may include:

• Heartburn• Nausea• Arching or stiffening of the body in response to swallowing• Facial grimacing during swallow• Pain, irritability, constant/sudden crying after eating• Frequent coughs, hiccups; “wet burp”• Frequent vomiting after eating; vomiting more than 1 hour

after eating; recurrent regurgitation that persist after 1 year of age

• Poor weight gain/loss• Constant eating or drinking• Inability to tolerate certain foods; decreased acceptance

or consumption of foods despite hunger• Coughing, gagging, choking• Frequent sore throats• Respiratory issues (pneumonia, bronchitis, wheezing)• Bad Breath• Drooling

• Feeding therapy, planned programs, oral-motor techniques, and positioning changes will not be successful until GI symptoms/ issues are resolved

Food allergiesAlmost as bad as GER

Food Allergies Foods that most commonly cause allergies

Cow’s milk Fish. ShellfishWheat Nuts, peanutsSoy

3 most common reactions• Intestinal• Respiratory• Skin Reactions

Can occur immediately or up to 48 hours after eating• Typical allergic reaction manifests within 2 hours

Food allergy or reaction caused by• Food poisoning• Enzyme deficiencies (e.g. lactose intolerance)• Flavonoids and preservatives, toxins, naturally occurring

pharmacological substances

Feeding/ Dietary Approaches

If allergies or intolerance is suspected• Food diary

• Record of type, amount, timing and description of any symptoms that occur (consider keeping for a 2-4 week period)

• Elimination diet• Exclusion of suspected foods or restrictive diet• May not be nutritionally complete, should be done

in conjunction with or planned with assistance of a registered dietician

• Slowly reintroduce foods thereafter Nutritional replacements for milk i.e., protein, calcium,

riboflavin, Vitamin A• Leafy greens• Orange fruits• Vegetables• Meat• Meat alternatives (tofu, soy, legumes, poultry)

A look into Resistant and Picky Eaters

Challenges Can permanently impair their long-term

growth Often have a low percentile for weight and

height Can interfere with a child’s ability to learn

properly and progress academically Can lead to hospitalizations Affect the child’s socialization and self-

esteem (Ernsperger & Stegen-Hansen, 2004)

Some Statistics Nearly 80% of children with severe mental

retardation have feeding difficulties and inadequate diets (William, Coe, & Synder, 1998)

75% of children diagnosed with Autism Spectrum Disorders experience atypical feeding patterns & have limited food preferences (Mayes and Calhoun, 1999)

45% of typically developing children experience some level of eating problems during childhood (Bentovim, 1970)

Picky Eaters vs. Resistant Eaters

Picky eaters may have certain limitations or aversions to foods but they eventually eat enough of a variety of foods to maintain a balanced and healthy diet

Resistant eaters are on the extreme end of the continuum and have serious food aversions and/or medical impairments that prevent them from eating a balanced diet

(Ernsperger & Stegen-Hansen, 2004)

Characteristics of a Resistant Eater

Limited food selection. Total of 10-15 foods or less.

Limited food groups. Refuses one or more food group.

Anxiety and/or tantrums when presented with new foods. Gag or become ill when presented with new foods.

Experiencing food jags. Require one or more foods be present at every meal prepared in the same manner.

May be diagnosed with a developmental delay or MR.

(Ernsperger & Stegen-Hansen, 2004)

Food Neopobia Scale (FNS)

Simple 10-item questionnaire developed by Pliner and Hobden (1992) that can be administered to determine if the child is a resistant eater.

A score greater that 35 is considered high; and that child may benefit from a comprehensive tx program

Typically developing two-to-four-year-olds experience food neophobia for short periods of time. By age five most children have decreased their fear of new foods and are willing to try new and novel foods.

SEE HANDOUT!

Resistant eaters and Developmental Disabilities

There is a high correlation between problem eating and children with disabilities.

Specific characteristics include:- Sensory Integration dysfunction- Immature respiration- Delayed oral-motor development - Limited communication skills- Rigid behaviors/routines

Sensory Integration Dysfunction Proprioceptive difficulties include positioning and

movement of the limbs and head, and motor planning. (ex: jaw opening, holding utensils, positioning in a chair, spilling cups etc…)

Vestibular difficulties include balance and movement from the eyes, neck, and head. (ex: focusing on how they are moving, body position, fear of falling)

Tactile Sensory difficulties can include hyposensitive or hypersensitive (ex: little or no reaction to pain, difficulty holding and using utensils, rub or bite their skin vs. prefer food to be the same temperature, avoid lumpy or mixed textured foods, dislike messy activities)

(Ernsperger & Stegen-Hansen, 2004)

Sensory Integration Dysfunction (con’t)

Taste Sensory difficulties include how the taste buds of the tongue receive and interpret information (ex: difficulty transitioning from water to juice or accept milder dilute tastes)

Olfactory Sensory difficulties include smell perception (ex: children with chronic congestion or open mouth posture may not interpret flavors effectively)

Visual Sensory difficulties include when the brain is unable to link visual info with auditory, touch, and movement sensations or it inadequately processes the sensory messages (ex: cover one eye or squints, have difficulty shifting eye gaze from one object to the other etc..)

Auditory Sensory difficulties include localizing the direction of sound and figure/ground discrimination , i.e. between a wide variety of environmental and speech sounds (ex: Overly stressed and anxious by loud noises, unable to follow multi-step verbal instructions, trouble attending to verbal instructions etc…)

(Ernsperger & Stegen-Hansen, 2004)

Treatments

We work with: Inconsistent or poorer oromotor skills with regard

delayed &/or atypical development, i.e. fewer readiness behaviors spoon feeding/ solids/cup drinking/ ineffective chewing/ open mouth postures

Any client who displays oral-motor difficulties as compared to their typically developing peers for feeding and speech:

• Reduced mobility • Reduced agility • Reduced precision • Reduced endurance

Aims of treatment To increase the Somatosensory awareness of the

oral mechanism To normalize oral tactile sensitivity To improve feeding skills and nutritional intake To increase differentiation of oral movements thru

Dissociation: The separation of movement, based on stability and adequate strength, in one or more muscle groups.

Grading: The controlled segmentation of movement through the mid range of any particular ROM.

And by decreasing “Fixing”: An abnormal posture used to compensate for reduced stability which inhibits mobility.

To improve the precision of volitional movements of oral structures for speech production

Who to refer? Low birth wts. with slow gain. – children below 10th

percentile. Babies/kids not gaining well and taking more than 30

minutes to complete an age appropriate feeding. Resistant/ picky eaters. Clumsy, poorly ‘coordinated kids, especially with: Any droolers, open mouth posture kids (if not mouth

breathing b/c of huge tonsils) Children not babbling by 9 mos. and 15mo. olds with

no true words. Children whose parents do not understand most of

what they say in context. Children who ‘undertsand’everything said to them,

but have no or few true words.

References: Ernspereger, L., & Stegen-Hanson, T. (2004). Just Take a Bite. Easy, Effective

Answers to Food Aversions and Eating Challenges. Mayes & Calhoun, (1999). Symptoms of Autism in Young Children and

Correspondence with the DSM. Infants and Young Children., v. 12. Pliner and Hobden (1992). Development of a Scale to Measure the Trait of

Food Neophobia in Humans, Appetite, v. 19. Williams, K., Coe, D., & Snyder, A. (1998). Use of Texture fading in the

Treatment of Food Selectivity. Journal of Applied Behavior Analysis, v. 31 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint

Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

Journal of Pediatric Gastroenterology and Nutrition 49:498-547 2009 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepalogy, and Nutrition