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

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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

1

Pediatric Dysphagiawith Health Issues & Complications

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

Dysphagia: Health Considerations

Nutrition/hydration & undernutritionNeurologic & neurodevelopmental issuesPulmonary/airway issuesGastroesophageal reflux disease (GERD)Medication effects

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

AngelmanSy ndromeSevere atopyAutism spectrum disordersBreastf eeding diff icultyCanavan syndromeCat eye syndromeChromosomal etiologiesPrematurity & complicationsOrofacialmalf ormationsAirway malformationsCockayne syndromeCongenital diaphragmatic

herniaCongenital heart diseaseCornelia DeLange

Common Nutrition Risk Indicators

Failure to grow over 2-3 monthsWeight/height below 5th %ileChronic diarrhea/constipationLong term use of drugsExcessive drooling

Common Nutrition Risk Indicators

Frequent reflux/emesisOral sensorimotor feeding difficulties

Metabolic disordersAbnormal CBC/urine screensSuspected caregiver neglect

Undernutrition and Growth

Acute: decreased weight-for-height (wasting)Chronic: decreased height-for-age (stunting)

Effect on linear growth may lag weighteffects by 4 monthsChildren who survive malnutrition - generallystunted

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Co stello syndromeCran iosynostosisCri- du-chatDandy Wal ker SyndromeDiabetesDown syndromeEosinophilic GI diseaseEs cobar syndromeHirs chsprung syndromeHemol ytic uremic

syndromeI U G RKlinefelter syndromeMito chondrial diseaseNoo nan syndromePa nhypopituitarismCe rebral palsySeizure disorders

Pie rre Robin sequenceEagle -Barrett syndromeRobinowsyndromeShort gutSpina BifidaStickler syndromeTE FSolid organ transplantationTurner syndromeVATERVe locardiofacialsyndrome

Formula intoleranceCho king phobia

“Sleeper eaters” Abs ent hunger drive




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Undernutrition: Severity of Effects

Correlated with onset & duration

Most profound damage when period ofdeprivation occurs during first 2 years

Pulmonary Disease withNeurologic Impairment

Respiratory complications of dysphagiaDisordered timing/incoordinationAspirationAirway obstruction

High risk infants (apnea & hypoxia)Older children: disorders of respirationSigns & symptoms of aspiration vary

Aspiration GeneralizationsUsually silent with neurologic deficitsHigh index of suspicion for signs ofpharyngeal dysmotility

Congestion during feedsMultiple swallows per bolusDelayed initiation of pharyngeal swallowRespiratory distress (e.g., cough, wheeze)

Congenital Laryngomalacia

Redundant supraglottic mucosaCommon mechanisms

Cuneiforms drawn inward duringinspirationExaggerated omega shaped epiglottiscurls on itselfArytenoids collapse inward

Stridor in Severe CLM

InspiratoryHigh pitched

Loudest when upsetMore evident in supine

CLM: SLP Role for FeedingDetermine most efficient oral feeding:position, liquid flow, pacingMonitor inspiratory stridor & effect on PO

Effects of GER & nipple feeding?Reassurance to parents regarding positiveprognosis in coming monthsSpoon feeding & cup drinking may be focusearlier than in typical infants

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3

Pierre-Robin SequenceMandibular Hypoplasia(Micrognathia)Glossoptosis (retroplaced tongue)Airway obstruction

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

Pathophysiology: Chronic AspirationMay be more insidious than acute aspiration(direct & indirect)Most prone: Swallowing dysfunction &neuromuscular disease

Clinical indicators may be scarceLaryngeal penetration (deep)Endangerment to airway from aspirationLife threatening physiologic alterations

Timing of Aspiration with SwallowBefore: Delay in onset of pharyngeal swallowor abnormal tongue movementsDuring: Ineffective laryngeal closure or timingincoordinationAfter: Results in residue from multiple factors(e.g., decreased tongue base retraction,reduced sensation, incoordination ofpharyngeal constrictors)

Protection from AspirationNormal swallowCough

Not reliable predictor even in infants withnormal swallowsBy 1 mo., 90% of infants have cough reflex

Other protectors of lung (e.g., mucociliaryclearance, phagocytosis by alveolarmacrophages, lymphatic drainage, gag)

Swallowing Problems & GI Disease

Esophageal structural abnormalities (TEF)Motility disordersInflammatory diseasesConstipation aggravates in neuro disorders

74% of CPMultiple causes (e.g., PO with fluid)

GER Prevalence & EpidemiologyHighest < 2 years of age

Preterm infants: 63%CP: 92% with GI symptoms & signsHealthy infants pH probe: esophagealacidification common

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

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4

GER Prevalence & Epidemiology

Typical symptoms of GER in < 50% inchildren 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 DiseaseEsophago-laryngeal reflexAcid is introduced into distal esophagusLaryngospasm results

Laryngeal chemoreflexDirect acid stimulation to larynxApnea, bradycardia, & hypotension result

More active in infants & gradually disappear

GER Medications for Apneain Premature Infants

Theophylline or caffeine: neither drugconsistently eliminates apnea in all patientsNote: caffeine exacerbates GER in adults &older children!Antireflux medications do NOT reducefrequency 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 functionIncreased intraabdominal pressureDelayed gastric emptyingImpaired esophageal acid clearance

Functional GER - “Happy Spitter”

Infants, onset usually < 2-3 monthsEffortless regurgitation (spitting up)

Frequency decreases after 6 monthsIf infant grows well, no major work-upneeded

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Risk Factors (Atypical Manifestations)

Lower airway diseasesUpper airwayUpper digestive

chronic halitosis otalgia/chronic OMloss of taste Sandifer’s syndromefood refusal chronic pharyngitisdental caries drooling

Eosinophilic Esophagitis (EE)Entity emerged since 1997 – previouslyconfused with reflux esophagitisInflammation due to allergic factors mayalso include upper airway diseaseNot correlate with ? GEREndoscopy

Denser infiltrates of eosinophils relate tononacid-related cause of esophagitisFurrows or rings often noted

Steiner et al (2004)

Treatment of EE in PediatricsLack randomized controlled trialsCase series suggest

Elemental dietOral steroidsTopical steroids

Lack of control group: impossibleto evaluate effect of interventions

Kukuruzovic et al. 2004, Cochrane Database Syst Rev

GER Evaluation

Clinical evaluationRadiographic studyScintigraphyEsophageal pH testing (most sensitive)Endoscopy & biopsy

Treatment of GERD:Infants & Children

PositioningDietary treatments (e.g., thickening feeds)Feeding schedule changesPharmacologic therapySurgery (fundoplication)

Types of Medications & Dysphagia

SedativesBenzodiazepinesDopamine antagonistsAnticholinergics

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6

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 efficientconsistencies for a child to eat orally(to whatever extent possible) whilemaintaining adequate nutrition &hydration

Development in Typical ChildLiquid by nipple first 4-6 months

Breast milkFormula

Strained smooth food by spoon (6 months)Sitting with minimal support

Lumpy foods by 10-11 monthsDifficult 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 adequatecalories 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 EvaluationHistoryPhysical examinationObservation of typical feeding or mealtimeReferral for additional examinations

Instrumental swallow studyMedical/surgical specialistsNutritionPsychology/Social WorkOT/PT

Common Criteria for Referral

Feeding periods longer than 30 to 40 minutesUnexplained food refusal & undernutritionWeight loss or lack of weight gain for 2-3 mthsExcessive gagging or recurrent cough with feedsInfants on nipple feeds

Sucking , swallowing, breathing incoordinationWeak suckBreathing disruptions during feeding

Common Criteria for ReferralAirway related concerns

History of recurrent pneumonia & feeding difficultyConcern for possible aspiration during feedsDiagnosis of disorders associated with dysphagia

Irritability or behavior problems during feedsNew onset of feeding difficultyLethargy or decreased arousal during feeds

Common Criteria for ReferralDrooling persisting beyond age 5 yearsNasopharyngeal backflow/reflux during feedingDelay in feeding developmental milestones

Not spoon feeding by 9 months (dev. age)Not chewing table food or self-feeding fingerfood by 18 monthsNot drinking from a cup by 24 months

Craniofacial anomalies

Steps in Clinical EvaluationConsultation received Initial AssessmentPossible next step depends on airway status

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

Clinical Evaluation: Airway Concerns?If none: Develop plan in context of global needs

Oral sensorimotor interventionNutrition guidelines

Behavioral therapyMonitor status & alter plan as needed

If yes: Instrumental examination or furthermedical workup

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Feeding History FactorsPositions/posture/seating (gross/fine motor)Duration of meal times (average & range)Intervals between meal timesTypes of food (preferred, non-preferred)Assistance/independence of feedingTube feeding (e.g., type, timing)Food record: 2-3 days

Feeding History FactorsRespiratory statusSigns of stress & distressTest results & medicationsSleep patterns (waking, snoring, mouth breathing)Cognition & communicationBehavior during meals; apart from mealsTherapeutic intervention (developmental/feeding)

Nervous System ExamMuscle toneReflexesCognition & languageVisual trackingGross & fine motor skillsSensory function

Infant Evaluation

State & overall posture/positioningRespiratory status (rate, patterns, voice)Resting heart rateExam of oral peripheral mechanismNon-nutritive suckingNutritive suck/swallow/breathe

Clinic Airway Evaluation

Respiratory rate: at rest & feedingRespiratory effort:

StridorStertorRetractions: suprasternal, substernal

Clinic Airway EvaluationVoice quality variables

Strong, clear phonation, appropriate pitchWeak, breathy, husky to hoarse

Gurgly, wetVelopharyngeal function inferences(e.g., hypernasality, hyponasality)

Pharyngonasal penetration/backflow/refluxFrequent burping (not clear implications)

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Airway Stability for PO Feeding

Airway stability is prerequisite for successful POIf airway concerns are noted during physicalexam, possible next steps:

Otolaryngology airway exam (FFL, DLB)Bedside/clinical oral feeding evaluationCombined FFL & FEES with ORL & SLPVideofluoroscopic swallow study (VFSS)Monitor status for a few days

Evaluation of Transition Feeder& Older Child

General observationsPosture, alertness, direction followingOral sensorimotor functionBolus formation & oral phase of swallowPharyngeal phase inferencesTherapeutic trials

Postural Control EvaluationMuscle tone (hypotonia or hypertonia)Central alignment relates directly to oralsensorimotor system

Presence of primitive reflexesLevel of physical activitySelf oral stimulation

Use of eye contact, head turning, & touch

Optimal Sitting PostureNeutral head positionNeck elongation (No chin tuck for infants)Symmetrical shoulder girdle stability &depressionPelvis stability, hips symmetrical in neutralHips, knees, & ankles at 90 degreesFeet in neutral with slight dorsiflexion (neverplantar flexed), supported by firm surface

Cranial Nerve Evaluationfor Feeding/Swallowing

Lack of chewing: CN VFacial asymmetry & lack of lip movement:

CN VIIDelayed swallow & pharyngonasalpenetration/backflow/reflux: CN IX & XTongue thrust or atrophy: CN XII

Gag ReflexIndependent of swallowSensory: CN IXMotor output: CN X, XII, & VElicited by touching posterior pharyngealmucosa (standard testing)Difficult to assess importance of changesin absence of other findings

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Tonic Bite Reflex

Jaw moves up into clenched positionon presentation of spoon or other objectResponse to contact to biting surfacesof side gums (molar tables)Persistence with neurologic deficit – should disappear by 9-12 monthsCranial Nerve V

Oral Sensory vs Motor Disorders

Nipple confusion

Not differentiate tastes inbottle even with intact suck

Manages liquids better thansolid foods

Sorts food in mixed texture

Inefficient suck breast & bottle

Differentiates tastesin bottle

Oral-motor inefficiency orincoordinationfor a ll textures

Swallows food whole whengiven mixed textures


Holds food under tongue or incheek and avoids swallowing

Vomiting only certain textures

Gags when food approachesor touches lip

Hypersensitive gag withsolids, normal liquid swallow

Unable to hold & manipulatebolus on tongue, food falls out

Vomiting not texture specific

Gags after food movesthrough oral cavity

Gags afte r swallow istriggered with liquid & solid


Tolerates own fingers inmouth, but not accept others

Does not mouth toys

Refuses tooth brushing

from Palmer & Heyman, 1993

Tolerates others’ fingers inmouth

Accepts teething toys, but notto bite or maintain in mouth

Accepts tooth brushing

Immature vs Abnormal Patterns

Patterns are likely to be distinguishable insuck-swallow-breathe sequencing

jaw control or stabilitytongue mobilitylip closuredissociation of tongue, jaw, & cheek movementswhile drinking & chewing

Next Steps?Nutrition AnalysisMedical Workup (Genetics, GI, ENT, etc)Behavioral Psychology

Occupational Therapy/Physical TherapyInstrumental Swallowing Study

Need to define oral, pharyngeal, & upperesophageal 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 problemon basis of etiologyGurgly voice qualityNeed to define oral, pharyngeal, & upperesophageal 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 evaluatedPhase(s) of deglutitionAbility to detect aspiration or risksCapacity to define nature of deficitEstimate of agreement: specificprocedure and usual patterns of feeding

Flexible Endoscopic Evaluationof Swallowing (FEES)

No radiationBedside exam possibleDefines some aspects of pharyngealphysiologyCan evaluate handling of secretionsSensory testing can be done

VideofluoroscopicSwallow Study(VFSS)

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

Before, during, or after swallowsTexture specificityEstimate of risk

What VFSS is NOTTo rule out aspiration or determine if childaspirates with oral feeding (important findingbut not reason for exam)

Simulation of a real mealEvaluation of oral skills for bolus formationChewing evaluationEsophageal function (only upper esophagus)

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Important Considerationsin High Risk Pediatric Patients

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

VFSS Procedural Considerations

Purpose & questions formulated clearlyPositioning/seating: typical & optimalCooperative patient imperative forinterpretationShortest fluoroscopy time possibleReview in slow motion, frame-by-frame

Feeding Supplies & RecipesReadily available when caregivers areasked to bring food samplesTextures & barium recipes need to bestandardizedData lacking, especially in childrenPoor relationship between viscosity ofdysphagia diet foods & swallow bariumtest feeds of different viscosities(Strowd et al., 2008)

Preparation of PO FeedersHungry, but not starvingSchedule close to feeding time if possibleNormalize the situation as much as possible

Child’s own utensilsVideo/music as needed

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

Preparation of Tube Feeder: NPOChild should demonstrate some level of oralintake, 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 insome cases, adjustments needed

Child’s “State”Typical feeding status appropriateIncreased risks for aspiration

Lethargy

Agitation (fussing & crying)Cooperative child: interpretation possiblein reliable & valid waysAlways remember: Just a brief windowin time, not a typical meal

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Procedural Decisions

No fixed order for presentations in pediatricsPreferable to start with thinnest liquid

Controlled bolus size to start, e.g., spoon beforegoing to bottle or cup drinking

Work toward thicker as neededNot want residue in pharynx that maycomplicate interpretation with thinner later

Exceptions: Parents tell us that child will notaccept any thing else if he gets liquid first

Lateral ViewEncompassing

Lips anteriorSoft palate superiorPosterior pharyngeal wall posteriorFifth to seventh cervical vertebrae inferior,varying with age of child

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

Antero-Posterior ViewWhen asymmetry is known or suspectedUnilateral vocal fold paralysis or paresisTonsil related questionsOther possibilities?

Keep in mind radiation exposure timeImportance of findings for management

Oral Phase Swallow ProblemsLips (poor closing, drooling, leakage)Hesitation/poolingTongue action deficitsGaggingPoor posterior tongue thrustPassive leakage over tongue baseDelayed oral transit

Initiation of Pharyngeal Swallow

Delayed swallow onset/triggerMaterial in valleculae

Material in pyriform sinusesFailure to initiate/trigger swallow

Pharyngeal Swallow ProblemsPharyngonasal (nasopharyngeal)reflux or regurgitation or backflowPenetration

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

Response to aspirationClearance of airway

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Pharyngeal Swallow ProblemsPharyngeal contraction reducedPharyngeal motility reducedTongue base retraction reducedPost-swallow residue, e.g.,

ValleculaePyriform sinusesPosterior pharyngeal wall

Clearance of residue?

Esophageal Swallow Findings

Upper esophageal sphincterOpening, e.g., reduced, incoordinated(usually pharyngeal phase problem)Prominence

Bolus passageSlow, interrupted

Retrograde movement of contrast (betterterm than reflux in this instance)

Aspiration Before Swallow: Causes?

Limited tongue actionLimited mandibular movementReduced tongue & soft palate approximationDelayed initiation/onset of pharyngeal swallow

Premature spillageMaterial in valleculae & pyriform sinuses

Pharyngeal dysmotility

Aspiration During Swallow: Causes?

Vocal fold paralysis/paresisReduced laryngeal excursionPharyngeal incoordinationPharyngonasal (nasopharyngeal)penetration, backflow, or reflux

Aspiration During Swallow

Neural controlInitiation under voluntary controlInvoluntary control for completion

AirwayCloses upon initiation of pharyngeal swallowMultiple levels of airway protection common

Aspiration After SwallowReduced tongue base retraction

Residue in valleculaePenetration into laryngeal vestibule

Reduced pharyngeal contraction/motilityResidue in pyriform sinuses

Reduced hyolaryngeal excursionCricopharyngeal dysfunctionPharyngonasal penetration/backflow may occur

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15

Aspiration After SwallowNeural Control

Involuntary for esophageal phaseAirway

OpenPrecipitating factors with open airway

Pharyngeal residue spills overGravity brings material in nasopharynxlower into airway

Esophageal Dysphagia Diagnosis

Dysphagia for solids > liquids,structural cause likely

Dysphagia for solids & liquids similar,dysmotility likely cause

Interpretation of VFSS FindingsSLP reviews with caregivers & therapists orothers involved in care

Findings by phase of swallowTiming of penetration/aspiration related tophysiologic processes

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

Recommendations After VFSSChanges in route of nutrition/hydrationNutrition guidelinesPosition & posture changesAlterations of food textures, temperaturesUtensil changesChanges in feeding schedule & pacingOral sensorimotor program with foodNonnutritive oral sensorimotor program

Management: Prognosis & PriorityOral feeding prognosis tied closely to

Underlying etiology & diagnosisNeurologic findingsCardiopulmonary status

Feeding priorities established on basis ofSeverityCombination of deficits

Principles for Repeat VFSS

Same as for initial VFSSInformation needed for

Definition of etiology or diagnosisGuide for management decisions

NOT some arbitrary time intervalChild should be at baseline

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Infants in Need of Intervention

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

Break oral & perioral aversionOffer exposure to sucking via nonnutritive oralsensorimotor therapy (e.g., pacifier)

Nonnutritive StimulationEnhances oral sensorimotor skilldevelopmentBuilds on in utero experiences of sucking& swallowing

Helps when size & shape of pacifiermatch infant’s mouth

NNS Cochrane Review21 studies (15 randomized controlled trials, allinfants born < 37 weeks gestation)Main Outcome

NNS significantly decreased length of stay (LOS)in preterm infantsNo consistent NNS benefit revealed with respectto other major clinical variables

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

Pinelli & Symington, 2005

Oral Stimulation for Preterm InfantsExp. 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 lengthof stay.

Fucile, Gisel, & Lau, 2002

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

InterventionsPositioningLimit feeding duration (poor endurance)Nonnutritive oral sensorimotor therapy

Jaw/cheek supportExternal pacing

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17

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 toingest a caloric volume adequate for growth

Neurologically immature preterm infant <32 wkpost conceptual age (PCA) cannot meet theabove requirements

Behavioral Organization

< 32 weeks: typically not express hard crying ordeep sleep with regular respirationsBy 32 weeks, infant expresses full range ofbehavioral states – important milestone for PO asneed to sustain organized, awake behaviorFrom 32 wks PCA to term age, maturation ofbrain structure is associated with improvement inbehavioral sate expression & motor organization

Self-Regulation ReadinessAt 32 to 35 weeks PCAFeeding based on awake or restless behaviorPO progressing & concluding based on infant’sability to tolerate without fatigue or distressSuccessful feedings: Increase in quiet sleep time& shorter feeding timesAdequate weight gain compared to infants fedprescribed volumes

More opportunities to practice nipple feeding

Demand FeedingBy 35 wks PCAFunctional suck-swallow-breathe pattern allowingfor 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 occasionaldisruption in regular breathingOccasionally exhibit tongue twitching ortremors

Principles of ManagementWhole child approachTotal oral feeding cannot be the goal for allchidlrenNutrition & respiratory status criticalGER managed optimallyChanges in management neededwith 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 onDevelopmental Skill Levels

Oral stimulation for infantsSpoon feeding & chewing readinessCup drinkingTexture 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 wellestablishedOpen cup with thickened liquid (milkshake or fruit“slush”)Cup: wider at top, clear so feeder can control amountper sip wellChild can “help” with handsIndependent: Lip helps reduce spil ls

Chewing Practice

1-2 months after spoon startedGradual changes from smooth pureeOne change at a time (e.g., taste, texture)

Thin strip placed on molar table/surfaceAlternate sides to promote later tongue action

Finger FoodsReadiness

Pick up objects with thumb & fingersBring fingers or objects to mouthBite, chew, & swallow variety of textures

GuidelinesFood in small stripsPlace food in front of child (2-3 pieces)Guide hand to mouth as neededFade help as appropriate

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Common Problem Textures

Thin 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 Textures

Modifier should match flavor of foodFine cracker crumbs in soupApple juice with applesauceMilk with yogurt or pudding

When offering a new texture

Few spoons of familiar texture firstThen new texture (e.g., blendedcarrots, fork mashed)

Oral Sensorimotor Treatmentfor Anatomic Problems - Jaw

Thrust: toneRetraction: toneClenching: toneInstability: toneTonic bite reflex: notrelated to tone

Mouth play: fingers, toysAssisted toothbrushingProne position; Forwardpull under jawMouth play for gradualopeningActivities for jaw closurePressure at TMJ;sensory stimulation;

coated spoon

Oral Sensorimotor Treatmentfor Anatomic Problems - Lips

– Retraction:tone

Limited upper lipmovement: & toneCheeks: toneReduced sensoryawareness

Finger tapping, vibrationVaried textures, tempsTapping & strokingStroke & tap, esp. TMJVaried textures, temps;drop of liquid in cornerof lips

Oral Sensorimotor Treatmentfor Anatomic Problems - Tongue

Thrust: ortone, or respiratory

stress

Jaw stabilization,thickened liquid at

lip, food placed onsides, exercises forlateral tonguemovement, spoonat midtongue withdownward pressure

Oral Sensorimotor Treatmentfor Anatomic Problems - Tongue

Retraction: ortone

Hypotonia: tone

Prone position, tonguestroking back to front,chin tuck for olderchild, upward tappingunder chinVary textures & tastesto sensory input;Food or liquid addedgradually

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Oral Sensorimotor Treatmentfor Anatomic Problems - TongueDeviation

Limited movement

Head at midline;stimulation of lessactive side withfinger, toys,toothbrushVary textures,temps, tastes;Vibration

Oral Sensorimotor Treatment forAnatomic Problems – Soft PalateNasopharyngealreflux

Upright or proneposition; Angledbottle for proneposition; Cheek &tongue functionactivities; Thickenedliquids (if swallow isnormal)

Feeding with Gastrostomy TubeUpright positionPump or gravity delivery, air removedFormula at room temperatureFeeding time minimum or > 20 minOral 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 foodsRespect 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 SummaryAirway & nutrition highest prioritiesOral sensorimotor practice can NOT jeopardizenutrition & 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 making, arvedson

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