Chapter 1 Flashcards
Malocclusion
Misalignment of upper and lower teeth, irregular bite, cross bite, cam affect speech and eating
Meta analysis
Quantitative stat analysis of several separate but similar studies to test pooled data for stat significance.
Necrotizing enterocolitis (NEC)
2nd to 3rd week in preterm formula fed infant leads to damage of intestinal system with increased mortality. 50%
Peer support
Lactation support by individual with same life experience
Sudden infant death syndrome (SIDS)
Sudden and unexplained death in infancy may be explained or not
Systemic review
Detailed and strategic search involving summarizing results of quantitative studies - high level of evidence on the effectiveness of healthcare interventions
Technology mediated support
Technology used by LC to deliver education, care and support via social media, mobile apps, videoconferencing and telehealth
Lactation support provider
Trained, certified or licensed BF education, care, and support according to specific scope.
Exclusive breastfeeding
No other food or drink for 6 months. Oral rehydration solutions, and medicines or vitamins in liquid form are not considered food or drink.
Benefits breastfeeding for infants and children
Protect respiratory illness, reduced risk of asthma, protective against GI infections and diarrhea (may be dose related), reduces risk of otitis media, lowers risk of cavities, lowers risk of malocclusion, lowers risk of NEC in preterm infants, lowers risk for SIDS (strongest with exclusive), lowers risk of childhood leukemia, may lower risk of obesity, may reduce risk of diabetes , may be associated with higher performance on intelligence tests
Benefits for lactating parents
Lowers risk of breast cancer and ovarian cancer, associated with lactational amenorrhea (if 6 months or longer), may decrease risk for Type 2 diabetes, may lower risk of cardiovascular disease
Global impact
Economic benefits in reduction of illness, in black population in US worse with increased NEC and other illness including GI, >1500 maternal deaths could be averted by optimal breastfeeding
Evidence based practice (EBP)
Integration of best available clinical evidence, clinician and provider expertise and patient needs and preferences into comprehensive plan of care and support
Has become expectation and evidence based medicine are now expected in health care
John’s Hopkins EBP - identify clinical practice problem or question, find and evaluate the research, translate research into clinical practice
Highest level of evidence is RCT
*** Finding and evaluating evidence **
Evidence informed practice (EIP)
Process by which a clinician uses knowledge and expertise to evaluate all forms of clinical evidence patient needs and preferences and the specific clinical presentation and circumstances to create an individualized plan of care and support
Need to elevate clinical expertise over pure RCTs, clinical intuition is important
Patients have complex needs, need to value their experiences and values
Consider all forms of research - fit the method to the problem
Consider the community values and culture
Balance all 3 pillars: Clinical expertise, patient needs and patient values
Knowledge translation, Knowledge to Action (KTA)
The syntheses, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health
Can take a long time to implement new findings
Knowledge to Action (KTA) - identify problem, modify and review knowledge, adapt knowledge to local situation, assess barriers, select and tailor interventions, monitor knowledge of use. This process is cyclical
Qualitative research
Scientific inquiry that seeks to interpret the meaning of life experiences, cultures and social processes from personal perspective, predominately through interviews and observations
Quantitative research
Scientific inquiry that uses precise objective measurement and statistical analysis to describe, compare or determine causation of interventions and effects
Systemic review
A process of evaluating multiple studies of one focus area or intervention and synthesizing the results to determined the best or most evidence supported course of action for patient care
RCTs as part of EBP
Overemphasis is problematic
Costly, complicated
Randomization to no treatment group can be unethical
Interventions not tested in RCT are considered not evidence based
May be undervaluing clinical expertise and patient needs
Statistical findings may not be clinically relevant
PICOT Method
P = patient, problem, population I= intervention, prognostic factor, exposure C= comparison (what is alternative) O=Outcome of interest T = time involved to demonstrate outcome
Good research databases
CINAHI
PubMed
PsycINFO
Cochran Collaboration: systematic reviews
BF Peer reviewed journals
Journal of human lactation
Breastfeeding medicine
Clinical lactation
International Breastfeeding Journal
Type 1 error
Study concludes there is a significant effect when there is not (pvalue gives that amount accepting by test)
Type 2 error
Study concludes there is a difference when there is not
Power
How likely you are to find a real difference if one exists (best if at least 80%)
Statistical vs clinical significance
Large sample get stat sig but not clinically relevant
Stat terms Inferential stats Dependent and independent Null hypothesis and alternative Pvalue Type 1 error Type 2 error
Just review
Power of a study
Stat sig vs clinical sig
Know it
Relative risk
Risk or odds of disease for groups that exposed or unexposed
Compares prob of getting the disease or condition in exposed vs unexposed
Tests t-test, paired t-test, ANOVA, chi-square, correlation, multiple regression, logistic regression
Know this
Odds ratio
Odds of getting a disease in exposed vs unexposed. More complex than RR and doesn’t translate like RR hard to interpret if not rare events
NNT, RD, Attributable Risk, Population Attributable Risk
Number needed to treat = 1/ RD
Qualitative Methods Evaluation
Multiple constructed realities, subject-object interaction, simultaneous mutual shaping, , value bound inquiry
Have philosophies that govern
Usually natural settings, purposive sampling, inductive analysis,
Qualitative design phases
Identify the problem Conduct literature review Address ethical issues Gaining entry Focused exploration, confirmation and closure , dissemination
Sampling in qualitative
Purposive, convenience, max variation sampling, snowball sampling (people refer each other), theoretical (select participants to ensure accuracy of emerging groups)
Ankyloglossia
Condition involving an atypically short, thic, or tight frenulum that tethers the bottom of the tongue to the floor of the mouth, restricting the range of motion
Cleft lip
Anormal fissure or opening sesulting from failure of fusion during embyonic development (cleft lip or palate) In uppper lip and can extend into nose Congenital midline defect 2nd most common birth defect Can still nurse
Dysphagia
Swallowing disorder characterized by difficulties swallowing foods or liquids
Dysrhythmic
Haing an irregular rhythm
Frenectomy
Resectin of the lingual frenulum to improve tongue movement
Frenulum
A small fold of tissue that helps secure or restrict the movement of a semimobile body part. Freula can be found throughht the body but in the oral cavity are under tongue and between upper lip and gums
Hypertonia
Condition of muscle rigidity or too much (increased) muscle tone
Hypotonia
A condition of muscle flaccidity or dereased muscle tone
Macroglossia
Abnormally large tongue
Micrognathia
Smaller than normal tongue
Pierre Robin Sequence
Sequence of abnormalities beginning in utero, romarily consisting of a small lower jaw (micrognathia), a retracted or displaced tongue (glossoptosis) and airway obstruction. Usually als cleft palate
Peristaltic
Wavelike motion of tongue which assists in removving milk from the nipple and facilitates swallowing
Retrognathia
Having a recession of one or both of the jaws (mandible and maxilla) but more common in lower (mandible)
Oral Assessment
- Observation of infant’s oraofacial anatomy
- Identification of deviations in oral anatomy and how may contribute to dysfunctional or poor feeding behavors
- Observation of the infant’s feeding reflexes and indentification of abnormal presentations
- Observation of the effectiveneess of feeding - suck-swallow-breathe coordination
- Observation of the fit between infant’s mouth and nipple
Lips
Lips assist tongue in drawing in the nipple and stablilizing in mouth
Lips in neutral position while nursing
If hypotonia can’t maintain seal - more work and fatigue
Hypertonic lips may be compensatory due to weakenss in cheeks, jaws or tone
Tethered maxillary frenulum (upper lip or superior labial frenulum) - may lead to poor suck and later gap in teeth, monor congenital defect, can lead to lip curling, poor transfeer and pain in nipples
Assessing Lip
Look for blanching of frenulum when lift lip (too tight)
Observe entire feed, breaks in seal? Lip retraction?, tremors?, leaking milk
Sucking blisters can mean tight lip or tongue tie or hypertonia
How to imporve when problem with lip
Firm pressue (tapping) on lips prior to feeding
Put finger in mouth and pull back so infant grabs - resistance training
If distressed stop doing
Show parent how to flip back
Provide referrral for tight labial frenulum
May need to pump or hand express to keep up supply
Refer to OT or Speech language pathologist who specializes in infant feeding
Deal with Cleft lip
Use finger or shape breast to seal cleft
Prefers one breast - teach slide over to other
Work with team, safe and effective to breastfeed after surgery
Buccal pads, subcutaneous fat in checks - structural support or oral activity
Low birth wt or prematurity can have low facial tone or pooly developed pads
Hypotonia and thin cheeks - hard to maintain pressure - get exhausted
Asses with gloved finger inside and push with thumb - should not be able to almost touch
Deep creases under eyes - mean thin cheeks
Look for collapsing - dimples when feeds
Use Dancer HOLD - team to parents
Provide supplementary food (breast best) until develop
Jaw - provides stability for movement of tingue lips and cheeks
How evaluate?
Premature can have jaw instability due to underdeveloped muscles
To assess: observe for asymmetry, micrognathia or retrognathis, while feeding look for jaw grading, clenching or tremors
Glowed pinkie finger - in corner count reflexive bites, is it weak
Micrognathia and Retrognathia
Micro - abnormally small lower jaw, if severe can push tongue back and obstruct airway
Retrognathia - abnormally receding lower job - both can be familial, can lead to nipple pain, can try tipping head back to bring jaw to correct position
Wide jaw
Can cause breaks in seal, loss of suction, and increased work
Jaw clenching
Can be to manage rapid flow OR hyppertonia or weakness in another area
HOw to help when jaw weak or injured
Hold finger under bony part of jaw
Make sure body is positioned correctly
Exercise jaw by eliciting bites - don’t stress - several times a day
Refer for PT or chiropractic body work or speech therapist or OT if swallowing issue
Tongue - helps draw with lips the nipple into mouth
Shapes structure of palate
Must elevate and put pressure on nipple to work
If can;t move properly will tire and ineffective transfer
Anterior tongue ties - heart shape - easy to diagnose
Posterior tongue ties - harder to diagnosis
Tongue tie incidence, treatment
Incidence - 0.02 to 10.7, more common in males
Fenotomy (release) or frenectomy (resectin)
Bunched or retracted tongue
Traumatic birth process, torticollis, ankyloglossia, hypertonia, or early bottle
Tongue protrusion
Abnormal tongue development (macroglossia) or hypotony (Downs)
Tongue tip elevation
Adaptive compensatry behaviour make hard to latch, preemies, traumatic birth, hypotonia ankyloglossia or resporatory problems
Tongue problems assessment
Poor head position can neg influence tongue position
Pull breast away and should see tongue cupping
Clicking, smacking, milk dripping
Press down should get resistance back
While crying does tongue elevate
Tap on lip or end of tongue - does it stick out beyond gums
How to assist with problem tongue
Exercises Short frequent feeds Postition with head in extension so lower jaw close to breast Refer to specialist Supplement if needed
Hard palate evaluate
Should be intact, moderate slope and smooth, arc of tongue
Epstein pearls may be observed no big deal
Soft palate function
Elevates during swallowing
Should have intact uvula
Clefts of hard and soft palates
Unilateral or bilatera, partial or incomplete or complete
Any type can make breastfeeding difficult or impossible
Submucosal clefts are hard to diagnosis
Weak or dysfunctional soft palate feeding challenges
Generalized hypotonia from prematurity, structural differnces n eurologic involvement or a syndromic condition
Velopharyngeal dysfunction
Cant close nasal cavity from oral cavity impact swallowing
Assess hard and soft palate
Family history of cleft
Visual assessment of palate - including intact uvula
Gloved finger feel hard palate for ridges etc
See whole feeding and make sure no nasal regurgitation
How help when cleft palate
Usually not fixed until 10 months
Palatial obturator - prosthetic but not routinely used in West
Sit baby upright, demonstrate chin support , teach rhythmic compressions
Keep track of weight gain, use weighted feeds
Supplement with donor milk if needed
Protect milk supply - pumping
Try alternative feeding methods - make sure don’t develop aversion
GI tube may be neccessary
Abnormal nasal passages also how assess
Are nose breathers but can’t be mouth
Deviated septum can impact breathing while feeding
Choanal atresia - one or both nasal passages blocked (rare)
To assess: visually assess if breathing is congested or infant struggles when feedng, were any instruments used in delivery
Can use baby strength saline drops, bulb syringes can make swelling worse, refer to primary care
Adaptive reflexes
Rooting reflex - touch lips or cheek, head turns and gape response (begins at 32 weks), integrates at 4-6 months
Sucking reflex light touch of nipple or finger to lips or tongue. At 15-18 weeks, integrates at 6-12 months
Nutritive sucking: sucing burses and pauses in response to liquid, Slower, and only when there is liquid
Non nutritive: fast shallow suck 6-8 per swallow, stimulates MER, helps self-soothe, increases peristalsis of GI tract, manage pain (wait to use pacifiers until BF established)
Absent or Weak suck what does it mean
Absent - CNS immaturity, trisomy, premature, drugs during labor or congenital issues
Weak - CNS issues, abnormalities of muscles, sick, doesnt provide adequate stimulation leading to reduction in milk supply
Disorganized suck
Immature pattern of 3-5 sucks with pause, dysrhythmic and uncoordinated
Swallow reflux
Elicit by bolus of fluid touching soft palate tongue and back of mouth
9-14 weeks gestational, continues to adulthood
Tongue thrust reflex
Tongue moves down and foward to drawn in and grasp breast
Appears at 28 weeks gestation
Integrates by 6 months
Gag reflex
Elicit by touching mid to posteriour tongue - first line of defense to choking
18 weeks gestation and have as adults
Can by hyperactive (immaturity) - stimulate too often and can develop food aversion
Cough reflex
No evidence of lung damage by aspiration of breast mik
Normal at begin of feeds when milk comes fast
- Stepping reflex
- Palmar grasp
- Moro response
- Crawl to breast
2, Integrated by 5-6 months - Startle reflext - integrate by 3-6 months
Also predictable hand movements to stimulate, move and shape breast
Suckling cycle
- Downward movement of posterio tongue leads to increased negative intraoral pressure (increases vacuum)
- Persistalic movement of tongue
- Draws nipple in mouth by vaccuum, nipple in ideal place
- Lips and cheeks make seal - negative pressure, jaw provides stable base for rest to move
- Tongue drawn down and with milk ejection brings milk to oral cavity
- Various movement moves bolus of milk back and then swallow reflex, soft palate elevates and prevents milk flowing to nose
Coordination of Suck Swallow Breathe
Often not coordinated at first at birth
Very variable as adapt to milk flow
Anatomy different in babies - structures close which allow to develop suck-swallow-breath
Matures in infants so pattern changes so decreased number of swallows during prolonged respiratory pauses
See nonnutritive at beginning at end of feeds
Suck Phase
Number varies based on flow - milk ejection vs slowing down
Swallowing - 3 Phases
- ORal - remove milk and bolus goes to back
- Pharyngeal - complex and protective mechanisms, anatomy very different from adults believe to help learn to coordinate. Breathing ceases for 0.5 seconds while bolus goes toward esophagus away from airway
- Esophageal - goes down to stomach
Drooling at less than 3 months
Weak swallow control
Observations for Poor Feeding quality
- Respiratry noises - stridor (raspy) - narrowing or floppy obstructed airway
Wheezing - high pitched noise during exalation - some constriction
Apnea: prolonged periodic breath holding while trying to manage swallowing
Fatigue: fall asleep due to stress or other causes
Poor intake: follow by weighted feeds
Poor growth: weight loss of 10% by the fifth day and failure to properly recover our markers for some optimal infant feeding (careful about fluids during labor)
Feeding aversions; can result from aspiration respiratory compromise choking or other sensory-based factors or medical procedures
Chapters 4-7
