2.5 - Feeding Flashcards
What are the 10 guidelines for Infant Feeding
Bottling is efficient (<20-30minutes)
Consistent bubbling in bottle
Coordinated suck/swallow/breathe
Adequate intake with minimal effort (dependent on size)
Consistent feeding times
Limited oral leakage/loss
/swallow/breathe
No cough/choke/gag with bottling
Minimal emesis
Parental comfort and ease
Consistent weight gain
How is the goal for a coordinated suck–swallow–breathe pattern modified for infants with cleft?
Coordinated compression–swallow–breathe
When is a Pre-Natal Pharyngeal Swallow first seen?
10-12 weeks gestation
When is the Palate complete (in utero)?
By 12th week gestation
When is True Suckling noted prenatally?
18-24 weeks gestation
When is Pre-Natal Coordinated Suck–Swallow–Respiration sequence?
34-37 weeks gestation
What Feeding Reflexes should be seen in an Infant at 0-1 Months?
(5)
Suckle on nipple (anterior—posterior motion of tongue)
Obligate nasal breather
Rooting reflex present
Hands should be flexed across chest d/feed
Nipple is not readily released
What Feeding Reflexes should be seen in an Infant at 2-3 Months?
(2)
Mouth open to anticipate food
Active lip movement = suckling
What Feeding Reflexes should be seen in an Infant at 4 Months?
(5)
Dissociating lip/tongue
Able to purse the lips
Blowing raspberries
Incorporation of sound production
Voluntary control of mouth
What Feeding Reflexes should be seen in an Infant at 4-6 Months?
(6)
Tongues shows up/down movement
Wide range of tongue/jaw movements
Teething
Rooting reflex and bite reflex gone
Start of spoon feeds
Pushing foods out with tongue (thrusting)
What Feeding Reflexes should be seen in an Infant at 7-9 Months?
(6)
Mouth used to explore environment
Coordination of lip, tongue and jaw movements
Upper lip cleans food off spoon
Tongue moves laterally to move solids
May start cup drinking
Lower lip stabilizes for cup
What Feeding Reflexes should be seen in an Infant at 10-12 Months?
(5)
Finger feeding begins
Weaning from nipple to cup
Closes lips around spoon
Controlled bite on cracker/ early chewable
Vertical/diagonal chew
What Feeding Reflexes should be seen in an Infant at 13-18 Months?
(5)
Finger feeding continued
Scoops food to mouth
Coordination of phonation, swallowing, breathing
Lateral tongue movment with chewing
Straw use
What types of textures are best for an infant between 0-6 months?
Liquid by nipple
What types of textures are best for an infant at 6 months?
Strained baby foods
What types of textures are best for an infant between 10-11 months?
(2)
Lumpy foods
Early finger foods
What happens if presentation of lumpy/chewable foods is delayed beyond 14 months?
It will be hard for children to accept these textures
What feeding issues may be seen in infants with Cleft Lip ?
What issues are usually not seen?
Difficulty latching on initially
Problems with breast or bottle feeding
What strategies are often used for feeding Infants with Cleft Lip?
(4)
Typically successful with standard bottles
Occasional nipple modifications may be needed
Can be breastfed with minimal positional adjustments
Feeding not as successful with bilateral complete cleft lip
What is the KEY for feeding Infants with Cleft Lip?
Adequate seal around nipple to produce consistent intra-oral pressure for sucking action
In regards to a cleft palate, what are the problems a result of?
Poor oral suction
What is mostly due to nasal reflux?
6
- Selection of most appropriate bottle and nipple
- Positioning of nipple
- Positioning of infant (feed baby upright)
- Follow feeding schedule
- Frequent burping due to excessive air intake
- Nasal saline post-feeds (recommended a lot)
How is the safety of the swallow in children with cleft palate?
Usually good with occasional exceptions
What is the structural difference with infants with cleft palate (CP) or cleft lip and palate (CLP)
limited build up of intraoral pressure for sucking
What does high effort and high fatigue equal?
low intake and high caloric expenditure (prob. w/ weight gain)
What is the safety like when swallowing for infants with cleft lip/palate?
Typically good with occasional exceptions
Summarize the feeding differences for infants with cleft lip as compared to infants with cleft palates?
(3)
- Rarely have problems w/ breast/bottle feeding
- May have difficulty latching on at first
- Tell parents to put bottle nipple inside of the cleft
Summarize the feeding differences for infants with cleft palate as compared to infants with cleft lips?
(2)
- problems as result of: stress, positioning, malnutrition, weight loss
- Mostly due to nasal reflux
a. bottle/nipple selection
b. Positioning: nipple, infant
c. Follow feeding schedule
d. Frequent burping
e. Nasal saline
What is the vicious cycle of feeding issues in cleft palate?
(6)
- Weak suck and low oral intake
- Increased feeding time
- Poor weight gain
- Nasal reflux
- Fatigue
- Parental stress
What is the typical oral phase of swallowing in infants?
5
- Rooting reflex: lip seal around nipple
- Sucking reflex: tongue squeezes nipple against alveolar ridge/hard palate
- Positive pressure with nipple - fluid release
- Tongue moves posteriorly, jaw drops, oral cavity increases in size
- Negative pressure results in liquid from nipple
What are difficulties associated with cleft lip +/- palate or craniofacial anomalies?
Need to find this answer
What is the Vicious Cycle of Feeding Issues in Cleft Palate?
7
Weak Suck + Reduced Oral Intake
Increased Feeding Time
Poor Weight Gain
Nasal Reflux
Fatigue
Parental Stress
Weak Suck + Reduced Oral Intake
What are the clinical signs/symptoms of structural deficits?
- Inefficient or ineffective suck
- Excessive intake of air
- Nasopharyngeal reflux
- Lengthy feed times
- Fatigue.
L
What is the problem area for airway involvement?
- upper airway obstruction
- Congestion
- Suck/swallow/breath sequence coordination
What are the clinical signs/symptoms of airway involvement?
7
- Inspiratory stridor
- Difficulty maintain 02 saturations
- Nasal flaring
- Micrognathia or Glossoptosis
- Gulping
- Liquid loss
- Choking/coughing
What are the clinical signs/symptoms of neurological impact?
- Incoordination of suck/swallow/respiratory sequence
- Hypotonicity or hypertonicity
- Lack of sucking effort
- State control and organization difficulties
- Lacks basic oral attempt or interest
When doing a pediatric feeding initial evaluation, what structures/functions are you looking at?
- symmetry and tone at rest
- hard/soft palate
- Facial structures
- Lip/tongue
- Ulcers/ thrust
When doing a pediatric feeding initial evaluation, what reflexes and functions are you looking at?
- Gag
- Rooting
- Suck/Swallow
- suck rhythm
- suck rate
- Suck strength
- Tongue action
- Suck/swallow ratio
When doing a pediatric feeding initial evaluation, what other things are you looking at?
- resting heart (affects reading) and respiratory rates
- Current level of function (diet, volumes, etc.)
- Parent/caregiver understanding, comfort, stress level
- Watch out for typical signs of swallow dysfunction
When doing a pediatric feeding initial evaluation, what are medical red flags for feeding difficulties?
- Excessive vomitting (reflux)
- Mucus in stool (milk protein intolerance?)
- Constipation
- Eczema/rashes
- Chronic nasal congestion
- Excessive bloating after feeds/gas
When assessing quality of feeding, what do you look at for rate/rhythm?
- Suck-swallow-breath-coordination
- Ability to self-pace
- Number of breathing breaks
- Anterior loss
When assessing quality of feeding, what do you look at for respiratory/cardiac status?
- Respiratory rate
- Heart rate
- Color change
- Oxygen saturation
- Desturation may indicate aspiration
When assessing quality of feeding, what do you look at for increased effort?
- Jaw excursions
- Nasal flaring
- Retractions
- Stridor
- Refusal behaviors
- Feeding aversions
- Volume limiting/grazing
- Poor weight gain
What are possible recommendations following feeding assessment?
- increase calorie formula (24 Kal)
- Modifications in positioning
- Chin/cheek supports
- Compression on nipple of MSNF
- Ongoing assessment of ability to tolerate increased flow rate
- Monitor airway (i.e. coughing, gagging, facial color changes, watery/runny eyes)
- Frequent weight checks
Close monitor of Ins/outs - Reflux contribution?? (can cause feeding aversion)
What is included in pediatric feeding therapy?
- Encourage breastfeeding as appropriate
- Limit feeds to <30 minutes
- Follow baby’s lead
- Keep feeding diary
- Weekly weight checks
- Counseling parents through process
- Intervene as necessary
What is more specific information about encouraging breastfeeding as appropriate?
- Value - bonding, breastmilk
2. Consider brief periods of nursing during non-feeding times
What is more specific information about following baby’s lead?
infant guided feeding (Catherine Shaker)
What is more specific information about intervening as necessary?
- Bottle/nipple selction
2. Strategies to improve feeding efficiency
In regards to intervention, what do we need to know about pacing?
- Can help progress patients relying on NG/G tube feeds to all oral intake
- Do not fully break seal! (might stop eating altogether)
What is external pacing?
Pacing baby while bottle feeding in order to control bolus size, give baby time to breath/catch breath when not properly coordinating suck-swallow-breath triad
In regards to intervention, what do we need to know about boundaries?
- Check/jaw support for external boundaries
2. Can use at first to aid latch and provide as necessary
In regards to intervention, what do we need to know about positioning?
Sidelying/semi-upright
In regards to intervention, what do we need to know about considerations?
- Medical factors
2. Oral-motor delays
In regards to specialty bottling considerations, what are the four basic parameters?
- Pliability of the nipple
- Shape
- Size
- Hole type and size
In regards to specialty bottling considerations, what do you need to consider?
- type and extent of cleft
2. oral-motor feeding abilities
What do we know about the specialty bottle system known as Haberman?
- Two chambers separated by disc that only allows one-way flow
- Adjustable flow nipple with one-way valve
- Rotating collar changes rate of flow
- Good for those w/ weak suck
What do we know about the specialty bottle system known as Pigeon?
- Occludes space of cleft
- Fast flow nipple w/ one-way valve
- Firm side/soft side
- Firm side occludes cleft, tongue compresses soft side
- Relies on baby’s ability to suck/extract liquid independently
- No squeezing
What do we know about the specialty bottle system known as Mead-Johnson Nurser?
- Nipple = longer, softer, cross-cut
- Fits standard bottle
- Allows chewing/munching action to extract
- Can be used for thickened liquids
- Parent controls flow rate by squeezing bottle
- OUR JOB: Teach parents to squeeze in sync w/ baby’s swallow
What do we know about the specialty bottle system known as Dr. Brown’s speciality bottle system?
- New, similar to pigeon
2. “infant-paced feeding valve
What is a major disadvantage of all these different types of specialty bottle systems?
Cost - parents often try several options before finding one that works
What is additional information about the Mead Johnson Nurser?
- Baby chews on cross-cut nipple
- Parent controls feeding by squeezing in sync with the baby sucking
- Longer nipple than others (may actually pass area of cleft)
- Leakage around collor is sometimes a problem
What is the Mead Johnson Nurser good for?
Good for weak suck and nipple can be used on any bottle
What are some alternative feeding options?
- Pigeon valve placed in standard nipples
- Cross-cut nipples
- Squeezing “drop-ins” to assist with extraction
What do we need to know about oral hygiene?
- Frequent cleaning of bottles and area of cleft required
- Use Washcloth/gauze
- Water and/or hydrogen peroxide
- No syringe or cotton swab
What are the steps of the feeding progression?
- Children with clefts should transition to solids at the same age as typical toddlers (4-6 months)
- It is safe to offer purees and age appropriate solids before cleft is repaired
- Some children with clefts have difficulty transitioning to solids due to nasal regurgitation
- Post-surgically (9-12 months for palate) they will have some restrictions right after surgery to avoid fistula
What causes feeding issues in Cleft Palate?
3
Poor negative pressure
Poor intramural pressure (due to structural differences)
Reduced/limited efficiency
Fatigue
Excessive air intake
Nasal reflux
What can assist feeding issues created by cleft palate?
6
Selection of most appropriate bottle and nipple
Positioning of nipple
Positioning of infant (feed baby upright)
Follow feeding schedule
Frequent burping due to excessive air intake
Nasal saline post-feeds
How is the safety of the swallow in children with cleft palate?
Usually good with occasional exceptions
Do Infants with Cleft Lip have problems with breast/bottle feeding?
Rarely
Do Infants with Cleft Lip have difficulty latching on at first?
Sometimes
Do professions tell parents of Infants with Cleft Lip to put bottle nipple inside of the cleft or under the cleft?
Inside
Can parent and/or infant Stress cause problems in infants with cleft palate?
Yes
Can Feeding Positioning cause problems in infants with cleft palate?
Yes
Can Malnutrition cause problems in infants with cleft palate?
Yes
Can Weight Loss cause problems in infants with cleft palate?
Yes
Can Nasal Reflux cause problems in infants with cleft palate?
Yes
What is the Vicious Cycle of Feeding Issues in Cleft Palate?
7
Weak Suck + Reduced Oral Intake
Increased Feeding Time
Poor Weight Gain
Nasal Reflux
Fatigue
Parental Stress
Weak Suck + Reduced Oral Intake
