Exam 2 Flashcards
1
Q
Viscosity and Swallowing
A
Problem:
- Thin liquids are often challenging for patients with reduced laryngeal closure
- Thick liquids are challenging for patients with reduced paryngeal contraction
Viscosity:
- Water: 1.00 centiPoise (cP) at room temp
- Blackstrap Molasses: 5,000-10,000 cP
- Ketchup: 50,000-70,000 cP
- Peanut Butter: 150,000-250,000 cP
As viscosity increases, more force is required
Higher temperature reduces viscosity
1
Q
Mechanisms of Pediatric Feeding & Swallowing Disorders
Gastroesophageal reflux disorder
A
- GERD complications: structures, changes to esophageal motility, under-nutrition
- Sensory or experientially based feeding issues ensue
- Apiration risk with GERD
- Signs/symptoms of GERD in children:
- Frequent vomiting
- Frequent burping
- Abdominal pain
- Failure to thrive
- Food refusal (often due to pain with oral feeding)
- Voice changes, cough, frequent URI
2
Q
Lingual Resistance Exercises (Therapeutic Procedures)
A
- Lingual resistance exercises involve pressing specific portions of tongue against hard palate
- Lingual, labial, buccal strength
- Some tools provide visual feedback
- IOPI - Iowa Oral Pressure Instrument
- Evidence
- Robbins et al. (2007). The effects of lingual exercise in stroke patients with dysphagia
- Yeates et al. (2008). Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports.
- Evidence
3
Q
Peripheral Nerves Level
A
- Motor: lower motoneuron, drive movement
- Sensory: sensory conduit
3
Q
Laryngeal Cancer
A
- Similar TNM classification system
- For disease staging, larynx divided into 3 sections:
- supraglottic
- glottic
- subglottic
- Glottic region cancers most common (prognosis is pretty good)
- Subglottic cancers rare
- Supraglottic region cancers more likely to spread to lymph nodes (worse of 3 cancers)
4
Q
Problems with speech and swallowing for ventilated patients
A
- Difficulty coordinating speech or swallowing with breathing cycle for ventilator
- Difficulty with short exhalation cycle of ventilator for timing of speech and swallowing
- Cuff is usually inflated
- Assessment Procedures:
- Best to focus on speech before swallowing
- Present food at beginning of exhalation
5
Q
Anatomical Differences
A
- In infants verses adults:
- Significantly higher laryngeal position
- Velum and tongue fill more of oral cavity
- Tongue
- Very large relative to oral cavity
- Velum:
- Large, fills space between epiglottis and tongue
- Makes contact with top of epiglottis
- Anatomic protection of airway during repetitive suck burst that precedes each swallow
- Infants breathe nasally
- Velum lowered to allow nasal breathing
6
Q
Cortical Level
A
- Motor: Intent, initiation, programming, execution
- Sensory: recognition, awareness, motor tuning
6
Q
Surgical Treatment for Laryngeal Cancer
A
- Small tumors may be treated with radiation/chemo, or laser surgery only
- Partial laryngectomy - may include removal of just one vocal fold
- Hemilaryngectomy (AKA vertical) - one half (r or l) of larynx removed
- Supraglottic laryngectomy - structures above the glottis removed
- Total laryngectomy - complete removal of larynx, epiglottis and hyoid; stoma created for new airway; airway and swallowing tract are physically separated
7
Q
Cerebral regions important for swallowing
A
- Primary sensory and motor regions
- Parietal/association cortex
- Insula and basal ganglia regions
7
Q
Mechanisms of Pediatric Feeding & Swallowing Disorders
Early aversive feeding experiences
A
- Intubation/extubation, feeding tubes
8
Q
Role of SLP (Pediatric Swallowing)
A
- Specialized knowledge or oral, pharyngeal & laryngeal anatomy and physiology
- Including knowledge of development
- Part of multidisciplinary hospital team
- Consultative services in NICU, direct services to inpatients and outpatients
- Prevalance rates have significantly increased due to increased infant survival rates
- earlier premies surviving but often with complex medical problems
- growing need for SLP services in this area
- Counseling services associated with treatment
9
Q
LMN Disease and Muscle Disease - Myasthenia gravis
A
- Neurotransmitter between motor nerves and muscles is excessively depleted with use
- Repeated movements for swallowing show fatigue and weakness
9
Q
Chemotherapy
A
- Drugs that kill cancer cells
- Delivered orally or intravenously
9
Q
Range of Motion Exercises
(Therapeutic Procedures)
A
Improve extent of movement of lips, jaw, tongue, pharynx, larynx and vocal folds
- Lips
- ROM
- Jaw
- Therabite or Dynasplint
- Tongue
- ROM
- Pharynx
- Tongue hold maneuver
- Larynx
- Shaker head lifts
- Vocal folds
- Exercises to encourage vocal fold closure
11
Q
Hiatal hernia
A
Protrusion (hernia) of upper stomach into thorax due to tear/weakness in diaphragm
11
Q
Postural Techniques (compensatory procedure)
A
(Can be used regardless of cognitive level of pt)
Changes in body posture
Potentially change dimensions of pharynx and direction of the food flow without increasing patient’s work or effort during swallowing
Postural techniques can:
- eliminate or reduce aspiration
- improve oral and pharyngeal transit times
- improve bolus clearance
11
Q
Mechanisms of Pediatric Feeding & Swallowing Disorders
Prematurity
A
- Respiratory system often under-developed
- At risk for other medical complications
- Infections, intra-cranial bleeds
- Poor development of lungs, GI system
- Babies less than 30-32 weeks fed via TPN, then tube feeding
- For oral feeding, must have:
- coordination of SSB
- GI system capable of tolerating breast milk/formula
- sufficient sucking skills
- Often require supplemental tube feeding even after introducing PO trials
12
Q
Diet Decisions in Dysphagia Treatment
A
- Solid Texture?
- Level 1: pureed
- Level 2: moist, soft-textured foods
- Level 3: regular with exclusion of hard, sticky or crunchy foods
- Regular
- Liquids?
- Thin
- Nectar-like
- Honey-like
- Spoon-thick*
- Level of supervision
- Presentation considerations (mostly for liquids. for solids, more compensation tools - suction cup bowl e.g.)
- Teaspoon-sized, straw, cup-drinking, nosey cup, etc.
- Use of compensatory postures, swallowing manuevers, et.
13
Q
Disordered Feeding and Swallowing Skills
A
Incidence of feeding disorders (Arvedson, 2010)
- In normally developing children, 25-45%
- In children with developmental disorders or chronic disease, 33-80%
- Estimates as high as 80% in children with cognitive deficits
Pediatric swallowing disorders incidence increasing
- Increased survival of preterm infants plus other factors
14
Q
Brainstem Level
A
- Motor: Junction box: Upper motorneuron/lower motorneuron, motor/sensory.
- Centers: swallow, respiration, heart
- Sensory: reflexes, sensory condui
14
Q
Shaker Head Lift Exercise
Resistnace Exercises
(Therapeutic Procedures)
A
- Improves magnitude of upper esophageal sphincter opening
- Increases anterior excursion of larynx - likely due to increased contraction of specific suprahyoid muscles
- Hyolaryngeal excursion assists with CP opening
- Lie supine and raise the head to look at toes
- Both isometric and isokinetic exercise
- Number of repetitions specified
- Duration of hold is specified
- Lie down in supine position
- Raise head and look at toes without raising shoulders off the ground
- Isometric: 1-minute sustained head raising with a 1-minute rest between each trial, x3 reps (work up to this)
- Isokinetic: 30 consecutive head raisings, at constant speed, for strengthening (work up to this)
15
Q
Dysphagia-Mechanical Altered (Level 2)
A
- Description: moist, soft-textured and easily formed into a bolus. Meats are no larger than 1/4th inch. Meat requires additional moisture additive
- No dried fruits, no pineapple
- Examples:
- pancakes soaked in syrup
- Souffles
- Soft bananas
- Rationale: Transitional diet from pureed to more solid texture. Must be able to form a bolus and have some chewing ability
- Mild-moderate oral/pharyngeal dysphagia
- Mixed textures allowed
15
Q
Developmental Milestones: 3-6 months
A
- Head control increases
- Muscles around face/cheeks develop
- Sucking pads are absorbed/disappear by 6 months
- Structures elongate
- Neck gets longer
- Laryngeal position begins to lower but descent continues to age 2 years
- Airway protection begins to be due more to muscular action than anatomic configuration
- Improved timing/coordination of suck-swallow-breathe
- Rooting and suck reflexes fade
- Some volitional component to sucking emerges
- Bilabial closure and tongue tip elevation appear
- Less loss of material from mouth
- At 4-6 months
- Lower jaw moves downward
- Space in mouth increases
- More up and down tongue movements possible by 6 months
16
Transitioning from Enteral to Oral Diet
* Introduce oral foods/fluids sequentially, and one meal at a time
* Concurrent reduction in enteral nutritional support (so they develop a hunger response)
* Often calorie count/liquid intake monitoring is needed during transition
* Progress from oral snacks/therapeutic feeds to one meal a day
* Then build up to 3 meals a day
* Prior to enteral support being removed, track stability of patient's weight and oral nutritional intake
17
Signs and Symptoms of Pediatric Dysphagia
* Apnea or bradycardia during feedings
* Decreased O2 saturation level
* Coughing, choking, spluttering, gagging
* Frequent vomiting
* Color changes
* Bluish around lips, grey/dusky
* Change in phonatory or respiratory sounds
* Prolonged feedings and early fatigue with feedings
* Poor weight gain/failure to thrive
* Pseumonia, repeated URIs
18
Mechanisms of Pediatric Feeding & Swallowing Disorders
Motor-Based Problems
* Primary problems with postural tone and movement patterns
* Need positioning strategies during mealtime
* Tone: normal, hypertonicity, hypotonicity, mixed
* Reduced oral-motor control
* Reduced safety with PO feeds
19
Cerebrovascular Accident (CVA/stroke) affect on swallowing
* Depends on
* location of damage,
* extent of damage,
* functional connections that are disrupted due to damage
* Damage to sensory regions
* may affect sensation of residue, penetration & aspiration
* Damage to volitional motor control regions
* may affect swallow initiation, coordination
* muscle weakness or paralysis from UMN damage may result in bolus transport problems
* Swallowing deficits: -
* reduced ability to initiate saliva swallow
* delayed trigger of pharyngeal swallow
* incoordination of oral movements in swallow
* incoordination of pharyngeal events in swallow
* increased pharyngeal transit time
* reduced pharyngeal contraction and clearing
* penetration and aspirationcricopharyngeal muscle dysfunction
19
Non-nutritive Versus Nutritive Sucking
Non-nutritive Suck
* Non-nutritive suck (NNS)
* Reflex governed
* Rate ~2/sec
* Not always followed by swallow
* Pacifier, finger, thumb
* Rhythmic, strong NNS is a prerequistite for feeding
* Benefits
* Calming, self-regulation/sensory regulation, exploration, fills desire for sucking
* Improves initiation & duration of nutritive suck
* Improves O2 sats, lowers heart rate
* May enhance growth & improve GI function in tube feeding
20
Hydration and Thickened Liquids
Problem:
* When liquids are thickened - does the body recognize the liquid as a semi-solid or a liquid? How is hydration maintained?
* Modified cornstarches - main ingredient in commercial thickeners
* When mixed with a liquid, the fluid is absorbed by the starch and is thickened
* During the digestive process (from mouth to small intestine):
* acids and enzymes break down starches
* reverses thickenign action and releases water
21
Sensory Stimulation
| (Therapeutic Procedures)
**Thermal-tactile application**
* Using temperate and tactile sensation to prime oropharynx
* Cold touch application is applied to anterior faucial pillars
* Then followed by volitional swallow by patient
* Goal: increasing sensory input to brainstem (via CN IX, X, etc.) may help trigger swallow resposne
* May shorten pharyngeal swallow response by stimulating the glossopharyngeal nerve
22
Liquid Foods
* Four frequenly used terms were chosen to label levels of liquid viscosity (i.e., thickness or resistance-to-flow) in the NDD
* Viscosity: defined as the material's resistance to flow
* Proposed terms for liquids and correlating viscosity ranges:
* Thin: 1-50 centiPoise (cP)
* Nectar-like: 51-350 cP
* Honey-like: 351-1750 cP
* Spoon-thick: \>1,750 cP
24
LMN Disease and Muscle Disease - Polyneuropathy
* Can occur with disease or after radiotherapy
* Multiple peripheral nerves (e.g., CN V, VII, IX, X) affected and can produce weakness in swallowing musculature
25
Treatment Begins During Evaluation
Diagnostic work-up unveils:
* Diagnosis
* Physiologic swallowing function
* Response to trial treatment procedures
* General aspects of patient status
Treatment should address physiological causes of dysphagia
26
Chin Tuck (postural technique-compensatory procedure)
Head in flexion (chin goes down to the chest)
* maintains bolus in anterior oral cavity
* positions tongue base toward posterior pharyngeal wall
* may improve airway protection
* may narrow laryngeal airway entrance and improve bolus drive (Welch et al, 1993)
* may widen vallecular space in some patients
Contraindications (don't use if patient has):
* poor lip closure
* poor oral transfer of bolus
* cervical spinal problems, neck contractures, etc.
27
LMN Disease and Muscle Disease - Amyotrophic Lateral Scleriosis (ALS)
* Progressive disease
* 25% show initial corticobulbar deficits
* Ultimately affects both LMNs and UMNs
* Weakness of musculature affecting oral control and transport of bolus, VP closure, pharyngeal contraction, and airway protection
29
Cricopharyngeal (C-P) Bar
Muscle/sphincter can protrude prominantly and cause narrowing of upper esophagus
29
Muscles/sensory receptors Level
* Motor: effect movement
* Sensory: sensation receptors
29
Physiologic Swallowing Function
Symptoms:
* subjective evidence of disease or problem
* coughing, throat clearing
* complaint of food sticking in throat or chest
Signs:
* objective evidence of disease or problem
* nasal regurgitation
* laryngeal penetration, aspiration
* residue in the valleculae/pyrifrom sinuses
Physiological deficit:
* disordered muscular/mechanical function that underlies symptoms or signs
30
Traumatic Brain Injury (TBI) and Dysphagia
* Diffuse neurologic deficits, often impacting multiple areas of behavioral control
* Up to 60% of TBI patients may present with dysphagia after initial injury
* Many patients will show improved swallowing function in first 6 months after injury
* In addition to oral and pharyngeal phase deficits, behavioral deficits that impact swallowing include:
* Impulsivity (large, unsafe bite size)
* Reduced safety awareness
* Reduced appetite control and nutrition awareness
32
Radiation Therapy
* Uses high-dose radiation to kill CA cells & shrink tumor
* Attempt to use smallest effective delivery range to limit healthy tissue death
34
Parkinson's Disease and Dysphagia
* Basal ganglia influence quality of movement
* resting tone, steadiness of movement, initiation of movement
* In PD, execution of voluntary movement most affected
* Swallowing deficits depend on stage and extent of disease progression and effects of medication
* Deficits predominantly affect oral and pharyngeal phases
* Oral phase:
* lingual tremor,
* velar tremor
* repetitive tongue pumping
* piecemeal deglutition
* pocketing in lateral sulci
* Pharyngeal phase:
* residue in vallecula and pyriform sinuses
* decreased laryngeal elevation
* penetration and aspiration
* PES dysfunction
35
Caution
* Inverse correlation between fluid consumption and thickness of liquids
* thicker the fluid level, less fluid consumption by patient
* Inverse correlation between food intake and degree of diet modification
* greater the degree of diet alteration, less patient eats
36
Modified Diets: Encouraging Intake
* Aroma
* Seasoning
* Visual
* Layering/swirling
* Molding
* Garnishing
* Modify texture of foods naturally
* Serve at appropriate temperature
37
Barriers to an effective treatment program
Patient barriers:
* depression and apathy
* fatigue
* expectations
* poor oral hygiene
Clinician barriers: -
* adequate tools
* adequate knowledge
Clinicians must practice EBP
Patients may be harmed when the clinician does not have adequate tools and knowledge
38
Diet Modification (Compensatory Procedures)
Must use judiciously
* -Downgraded diet significantly affects patient's desire to eat, quality of life, potentially hydration/nutrition levels
SOLID TEXTURES
* Level 1 - Dysphagia-Pureed
* Level 2 - Dysphagia-Mechanically Altered
* Level 3 - Dysphagia Advanced Regular
LIQUIDS - greater viscosity --\> moves slower
* Thin
* Nectar-like
* Honey-like
* Spoon-thick
39
Brainstem (control of swallowing)
* Critical area for programmed, involuntary aspects of swallowing
* Sensory input and motor output coordinated through brainstem nuclei and "swallowing center"
* housed primarily in upper medulla
* coordinates and initiates programmed pharyngeal and esophageal components
40
Evidence for Water Protocols
Garon, Engle & Ormiston (1997), A randomized control study... J Neuro Rehab
* **20 post-stroke pts**, known aspirators, were randomized to no water and +water groups
* Limited pts to those in rehab unit, one CVA only, no nnuerodegenerative or multiple medical Dxs
* Followed strict oral hygiene program
* Followed for 1 year, no pts developed pnuemonia, dehydration or other complications
* pt satisfaction much higher in +water group
\*sample is very narrow -- not very representative
41
Mechanisms of Pediatric Feeding & Swallowing Disorders
Autism Spectrum
* Increased sensitivity to taste, smell, texture, sight of foods
* Often normal O-M skills but very restricted food items that they will tolerate
42
Subcortical (Basal ganglia) Level
Motor: initiation, refinement, inhibition Sensory: Motor tuning, awareness, sensory conduit
43
Textured Foods
NDD Levels
* NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability)
* NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing)
* NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability)
* Regular (all foods allowed)
44
Normal Development of Feeding & Swallowing Skills
Depends on multiple factors
* CNS maturation & overall development
* anatomical changes associated with growth
* meidcal stability/medical health
* postural stability and control
* strength
* timing of food introduction and method of delivery
* child's early experiences with feeding
Breathing and swallowing: basic functions for infant survival
* complex, highly coordinated sequencing of respiration and swallowing
* many elements can go wrong
45
Super-Supraglottic/Supraglottic Swallow
(Swallow Maneuvers; Therapeutic Procedures)
\*\*Closure before the trigger of the swallow\*\*
* Hold breath while bearing down (pushing down on arms of chair), take sip, swallow, cough and clear the airway
* Protects airway before/during the swallow and clears the laryngeal vestibule of penetrated material after the swallow
* Effects:
* Close airway entrance (vestibule) before/during swallow by attempting to narrow airway opening
* Close airway at true vocal folds before/during swallow
* Utilizes increased effort in breath hold
* May increase anterior laryngeal motino and tongue base movement
* May assist in upper esophageal sphincter opening
45
Infant Versus Adult Swallowing
* Larynx height
* Adult: lower
* Infant: higher
* Function: natural anatomic protection
* Tongue size
* Adult: relatively smaller
* Infant: relatively larger
* Function: less pressure and muscular load needed for swallow
* Velum and Epiglottis location
* Adult: very far apart
* Infant: touch
* Function: natural block of food before swallow
47
Improving Sensory Awareness (Compensatory procedures)
Provide a preliminary sensory stimulus prior to patient's swallow attempt
* Can prime the oropharynx before a swallow
May alert the CNS
May increase sensory awareness
* increased input through CN VII, IX and X -
* increased integration at brainstem level
Can result in improved oral and pharyngeal transit times
May create long-term changes over time (can be therapeutic)
Bolus characteristics which may improve timing and coordination of oral and pharyngeal swallow phases -
* sour, cold, carbonated, bolus requiring chewing, large volume bolus
* Increased downward pressure of spoon against the tongue when presenting food in the mouth
Self-feeding
47
Infant Swallowing
* Anatomy and swallowing function vastly different for infants versus adults
* In neonates/infants:
* Limited muscular control to protect airway
* Like adults, shared pathways between swallowing/feeding and respiratory systems
* High accuracy of timing between breathing and swallowing is essential
* Swallowing is governed by reflexes in young infants
* Rooting reflex
* Orienting toward direction of anything touching infant's mouth
* Sucking reflex
* Pattern varies from gestation to neonate to infant
48
Water Protocol Rules
* Water is only given after thorough oral cleaning
* Oral water is only given between meals, after mouth is thoroughly cleaned
* **Mechanical Cleansing** with an oral antiseptic helps to kill and remove biofilms
* **Oral Debridement** helps lift and remove inactive biofilms that are left behind
* Prescribed level of thickener is used for fluid intake during meals
* When water is given, all recommended therapy techniques should be used
* Water is _not_ used to deliver medications
* Ice chips can also serve as form of free water
* Water intake is monitored
49
Mendelsohn Maneuver
(Swallow Maneuvers; Therapeutic Procedures)
* Swallow and hold the swallow at the hight of laryngeal elevation
* May increase extent and duration of laryngeal evelation to increase duration and extent of UES opening
Instructions:
* Swallow normally and feel your voice box or adam's apple lift during the swallow
* On the next swallow, use your neck muscles (or hands at first) to hold the voice box up for several seconds during the swallow
* When you feel your voice box go up, hold it up with your neck muscles and do not let it down
* Hold it for several seconds and then breathe and relax
50
Developmental Milestones: 0-3 Months
* Chin low, in contact with rib cage
* Neck muscles, head stability, trunk stability not yet developed
* Body overall in flexion versus extension
* Jaw, tongue, cheeks, and lips working as a unit
* Tonuge is large & completely fills small oral cavity
* Sucking pads: fatty tissue pads inside inactive masseter muscles
* Develop within last 2 weeks *in utero*
* Narrows the oral cavity - contols/directs liquid flow
* Provide stability/support in cheeks to help tongue compress nipple
* Suck, swallow, breathe pattern
* Coordinated sequence at rate of ~1/sec
* Bursts followed by brief breathing recovery period
* Reflexes: rooting, gag, suck-swallow, phasic bite
* _Suckling pattern_ (tongue driven) versus sucking pattern predominates in infants ~0-6 mos
* Backwards-forwards movement of tonuge
* Draws liquid into mouth with extension-retraction tongue movements
* Some up and down jaw movement
* Rhythmic, strong, sustained, readily initiated
* Lips only loosely approximated
* Some loss of liquid from corner of mouth
52
Swallowing Treatment for Oropharyngeal Cancer
* Swallowing treatment for larger resections (e.g., \>/= 50% of tongue resected, adjacent regions resected):
* Start treatment early in post-operative period
* Includes intensive exercises to increase ROM and strength
* Lingual, buccal, BOT musculature
* Always pair O-M exs with act of swallowing
* May need volitional strategies to improve airway closure
* May need intraoral prosthesis
* Can address velopharyngeal deficit, posterior oral cavity deficit, hard palate deficit
* Examples: intraoral maxillary reshaping prosthesis, Palatal obturator
53
Zenker's Diverticulum
* Pouch develops in hypopharynx due to high pressure pushing mucosa through muscle layers
* Traps food/liquid
53
Biofeedback
| (Therapeutic Procedures)
* Videofluoroscopy
* Teaching patients about their individual swallowing function
* Review study to explain physiology and physiologic deficits
* EMG biofeedback
* Provides information regarding effort, duration, and timing of events
* Ultrasound
* Provides feedback regarding tongue mvmnt
* Videoendoscopy
* Provides information regarding timing and extent of vocal fold closure
* For FEES, can show information on residue and changes to residue with treatment techniques
53
Evidence for Water Protocols
Karagiannis, Chivers, Karagiannis (2011). Effects of oral intake of water... BMC Geriatrics
* 91 pts, known aspirators, were randomized to no water and +water groups
* pts from acute \* sub-acute units, included multiple medical Dxs and neurodegenerative Dsx, included immobile pts
* Followed strict oral hygiene program
* 6 pts (14.3%) in water+ group, no pts in no water group developed aspiration pneumonia
* pts who developed aspiration pneumonia: 5 had degenerative diseases, 3 were immobile and 3 had low mobility
* pts in +water group showed \> daily fluid intake and greater pt satisfaction
\*don't use water protocols with degenerative dieseases or with ambulatory issues
54
Reconstructive Surgery
* If small resection, primary closure
* Larger resection: tissue flap or tissue graft
* TISSUE FLAP
* piece of tissue elevated or raised from normal location
* one attachment to original location for blood supply
* other attachment to new, resected region
* TISSUE GRAFT
* taking tissue from one region, moving it to another
* often include a nerve in the graft that supplied previous region, allow it to supply new region
55
Goal of Dysphagia Management Program
Re-establish oral feeding while constantly maintaining adequate hydration, nutrition, safety
Eating should be enjoyable, efficient, safe
57
Tongue Hold Maneuver
Resistance Exercise
(Therapeutic Procedures)
* Used to improve tongue base to pharyngeal wall contact and improve pharyngeal clearance of bolus
* Tongue is protruded and held in forward position during swallow (saliva swallow)
* causes tongue base to be positioned anteriorly
* encourages an increase in pharyngeal wall contraction and bulging to achieve contact with anteriorly displaced tongue base
* Evidence: Lazarus et al. (2002). Effects of voluntary maneuvers on tongue base function fro swallowing.
* Protude the tongue maximally but comfortably and hold tongue between the central incisors
* Hold it and do not let go
* Swallow while holding tongue between incisors
58
Dysphagia-Pureed (Level 1)
* Description: hogeonous cohesive foods. Foods appear "pudding-like"
* No raw fruits or veggies, seeds or nuts
* All foods that require bolus formation, mastiction or "controlled" manipulation are excluded
* Examples:
* Mashed potatoes
* mashed bananas
* baby food (but don't give patient this example)
* Rationale- Moderate-Severe dysphagia
* Poor oral abilities
* Reduced airway protection
* Delayed pharyngeal swallow
60
Head Turn (postural technique-compensatory procedure)
Rotated/turn to impaired side
* May narrow pharyngeal recesses on weak side (can also close side of paralyzed VF) -
* Redirects bolus to stronger side -
* May be used in combination with chin tuck
Contraindications: -
* cervical vertebral problems which prohibit patient from turning head
61
Types of Ventilators
* Non-invasive
* Face mask/nasal mask
* Invasive
* Endotracheal or tracheostomy tube
* Positive pressure ventilators
* Deliver positive air pressure (room air +O2) to tracheostomy or endotracheal tubing to force air into lungs
* Expiration often passive
* Flow and volume adjusted to patient's needs
* Many different types of ventilators and modes
* Modes are adjusted as a patient is weaned to allow independence in breathing
63
Swallowing Deficits after Radiotherapy to Oropharynx
* Side effects of oropharyngeal radiation
* Reduced saliva flow (xerostomia)
* Reduced speed of tongue movement, longer oral transit time
* Delay in trigger of pharyngeal swallow
* Reduced frequency of swallowing
* Sores in mouth (mucositis), edema
* Can damage thyroid gland
* Fibrosis - muscle fibers convert to fibrous, connective tissue
* Secondary to damage of small blood vessels in radiated area
* Effects extend years after initial radiation
* Reduced blood supply to radiated region
* Pronounced tooth decay - impacted by decreased salivation
* Reduced sense of taste (usually comes back after treatment is over)
* If pharynx is in radiation field:
* Reduced pharyngeal contraction
* Reduced BOT mvmnt
* Reduced laryngeal elevation
* all lead to increase residue and often aspiration after swallow
64
Risk for Pneumonia
Influenced by:
* Mobility - less healthy lungs
* Nutritional status - compromise immune system
* Host immune response
* Oral hygiene
* Patient's other medical conditions
* Pulmonary status
* Histroy of previous pneumonias
65
Consequences of Feeding and Swallowing Disorders
* Reduced nutrition and hydration intake, failure to thrive
* Critical period for growth and maturation of nervous system/body
* 3rd trimester to first 2 years of life
* Malnutrition during critical period carries long-term consequences
* Inadequate growth, developmental delays
* Recurrent respiratory disease
* Additional medical complications
* Feeding disorders create significant stress for parents/caregivers
* earliest form of communication with caregivers is feeding
* breakdown in early communication
* parents often feel ineffective
* Prolonged time for feedings
* Delayed progression of oral feeding skills
* Problems with advancing in textures, variety of food, etc.
--\> Aggressive management therefore needed
66
Pediatric Populations at Risk for Feeding and Swallowing Disorders
* Premature infants
* Extended stay in NICU
* Birth trauma including reduced oxygen
* Congenital anomalies
* Cleft lip/palate, craniofacial syndromes
* Nuerological disorders
* Acute or chronic CNS disease, SMA, polyneuropathies
* Neuromuscular disorders
* Muscular dystrophy, cerebral palsy, spina bifida
* Other medical disorders: cardiac, respiratory, GI
* Toxicity/drug exposure
* Acquired brain injury
* TBI from shaken baby syndrome, MVA
* Tumor
* Seizure disorder
* Stroke
* Additional complicating factors and etiologies:
* Behavioral issues, sensory-based issues, interaction dynamic, etc.
67
Larger tongue resection Effects on Swallowing
* If \>50% of tongue resected, swallowing deficits more severe
* Lingual propulsion and ability to gather bolus severely reduced
* Tongue cannot contact palate to control bolus movement
* Liquid or thin paste feasible (tilt head back to allow gravity to propel bolus into pharynx)
67
Surgical effects on Swallowing - Hemilaryngectomy (unilateral laryngeal tumor)
* Vertical hemilaryngectomy includes one false VF, one ventricle, and one true VF, plus 1/2 thyroid cartilage
* Some tissue on operated side is reconstructed
* Allows intact VF to obtain near-closure for voice and swallowing
* Patients may show temporary aspiration during swallow
* To assist laryngeal closure during swallow: chin down, head rotation to operated side Laryngeal elevation usually minimally impacted
* Hyoid bone is left intact
68
Cerebellum Level
Motor: refinement, inhibition Sensory: Refinement
69
Head Back (postural technique-compensatory procedure)
Head in extension
* Uses gravity to assist with bolus transfer
* May improve oral transit
* \*But can reduce laryngeal closure\*
Contraindications (don't use if patient has):
* Poor laryngeal excursion
* Reduced laryngeal closure/airway protection
* Cervical spinal issues or other neck problems
70
Lower esophageal ring (Schatzki's ring)
Mucosal ring-type narrowing in lower esophagus
71
Bolus Control Maneuvers (Compensatory Procedures)
Multiple Swallows
* Break bolus into smaller portions
* Bolus swallow followed by dry swallow
* Can reduce residue post-swallow
Alternate solids w/ liquids
* Provides "liquid wash"
* Can help clear residue
Small bites/sips
* Can help control bolus flow
* Can reduce residue post-swallow
Periodic throat clears
* Can eject penetrated material
72
Oropharyngeal cancer Effects on Swallowing
* Affects:
* tongue base
* pharyngeal wall
* Difficulty propelling bolus through oropharynx
* velopharyngeal closure
* salivary flow (reduced)
* decreased bolus control (oral & pharyngeal)
* airway protection
* alterations to BOT and Phar. wall will impact bolus control and therefore airway protection
* extent of tissue resected directly impacts extent of swallowing and speech impairment
72
Enteral Support
* Enteral feeding may _not_ be in best interests of patient
* Enteral feeding, especially NG tubes, not not always prevent pneumonia (Gomes, et al., 2003)
* NG tubes associated with colonization of bacteria and aspiration of pharyngeal secretions and gastric conents
* Aspiration led to high incidennce pneumonia
* PEG tube more highly associated with pneumonia than J-tube
* Outcomes in dementia are not favorably improved after PEG (Dharmarajan et al., 2001)
* Entereal feeding can induce gastric problems
* GER
* LES or UES spontaneous relaxation, dysfunction
* Enteral feeding is sometimes needed (judicious use is best)
* May improve nutritional intake and ability to improve medically
* Should be used cautiously
* Should always try to upgrade patient to oral diet as tolerated
* Shorter vs. longer periods of time most appropriate, when possible
* Does not favorably impact quality of life
74
National Dysphagia Diet
Problem
* Breakdown in communication between care providers as patients transition within the continuum of care, i.e., acute care --\> skilled nursing or rehabilitation --\> home
* Lack of standard terminology
* lack of standard dietary textures
* Lack of viscosity standards for liquids
The National Dysphagia Diet (NDD) was published in 2002 by the American Dietic Association
The NDD aims to establish standard terminology and practice applications of dietary texture modificiation in dysphagia management
The NDD was developed through consensus by a panel of dieticians, SLPs, and food scientist
It proposes:
* Classification of foods according to eight textural properties, and anchor foods to represent points along continua for each property
* Classification of liquids according to 4 viscosity levels
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General Treatment Considerations
* Swallowing is the bst retraining for the swallow
* More than one treatment is usually neede to optimize the swallow
* Critical to involve the patient and the care providers in treatment planning
* Appropirate treatment will be impacted by physical barriers, cognitive status, level of independence and other factors
76
Coordination of Suck-Swallow-Breathe
* Ability to coordinate suck-swallow-breathe pattern is necessary for oral feeding
* Prior to 34 weeks, preterm infants generally not ready for full nutrition via oral feeding
77
Water Protocols: _Rationale_
Dehydration
* creates high medical costs
* very common in elderly
* often produces other system compromise/problems
Patients do not like thickened liquids
* Results in decreased liquid intake
* Reduces quality of life
Aspiration is most likely to result in pneumonia when:
* Material is pathogenic to lungs (e.g., foreign material, or contains bacteria)
* Patient's resistance is compromised
* Patient's mobility is compromised
Water, if aspirated, is less likely to cause pneumonia:
* Body is 60% water (not a foreign substance)
* Tap water has neutral pH so campatible with other body fluids
* Can be absorbed by lunch mucosal tissue if aspirated
* Does not obstruct airway if aspirated
* Will increase overall hydration level (thus potentaill improve health)
* Water allows swallowing for NPO patients
* Best way to improve swallowing is to swallow
79
Therapeutic Techniques
* Designed to change or improve swallowing physiology (permanently)
* Specificity
* Exercise program should target the physiologic components utilized during swallowing
80
Central Control of Swallowing
* Sensory representation and motor control for swallowing is bilateral
* If one hemisphere is damaged, other can compensate to some extent
* Bilateral strokes associated with more severe dysphagia
* Unilateral stroke in one area may produce transitory dysphagia, but often improves
80
Swallow Maneuvers
| (Therapeutic Procedures)
* Designed to alter physiology of swallowing to improve safety or efficiency
* Creates immediate effect on physiology
* Can lead to long-lasting changes over time in maneuver is performed regularly by re-trainging motor response patterns
81
Surgical effects on Swallowing - Supraglottic laryngectomy
* Hyoid bone, superior epiglottic, aryepiglottic folds, false folds removed
* Much airway protection lost
* No ep. cover or laryngeal sphincter closure except true VFs
* Decreased laryngeal elevation
* Hyoid bone lost, laryngeal suspension and elevation decreased
* If one SLN sacrificed, decreased sensation
* Decreased cough protection after penetration, increased aspiration
* If BOT affected, pharyngeal residue may increase
* Residue likely to fall into airway 2 degrees to lack of valleculae and smaller pyriform sinuses
* Surgery may include procedure to elevate and tuck remaining larynx under base of tongue
* Helps airway protection
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Dysphagia-Advanced (Level 3)
* Description: Regular diet with the exclusion of "very hard, sticky or crunchy foods". Food continues to have moisture added. Meats are ground or thinly sliced
* No nuts, seeds or dried fruits
* No crusty breads
* No grapes
* Examples:
* Eggs prepared any way
* Shredded lettuce
* Cassaroles with small chunks
* Well moistened fish
* Rationale: Transition diet from Level 2 to Regular. Includes more "mixed" consistencies
* Must have adequate dentition and a rotary chew
* Mild-moderate oral/pharyngeal dysphagia
83
Swallowing Disorder - Dysphagia (definition)
* Problems affecting any phase of the swallow: oral preparatory, oral transit, pharyngeal, esophageal
* May include aspiration
84
Evidence for Water Protocols
Carlow et al. (2012). Outcomes of a pilot water protocol... Dysphagia
* 16 pts, known aspirators, all on thickened liquids, received no water and +water Tx phase each
* Pts from inpatient units, included CVA, TBI, spinal cord injury, exclueded if acute or medically unstable, poor oral hygiene/infection, current pneumonia.
* Followed strict oral hygiene program
* Mean 54 days of studying/monitoring
* No pts in either tx phase developed pneumonia or other adverse events
* During +water phase, pts showed \> daily fluid intake and higher quality of life
86
Medical Options
| (Therapeutic Procedures)
* Few studies have examined the therapeutic benefit of medications on oropharyngeal swallowing function
* Treat the underlying disease
* L-dopa - Parkinson's disease; basal ganglia disorders
* Anticholinesterase agents and immunosuppressive drugs - Myasthenia gravis
* Reflux medication - GERD
* Trans dermal scopolamine - drooling
* Pilocarpine (SalagenTM) and Cevimeline (EvocacTM) - xerostomia or dry mouth
87
Use of the Speaking Valve
* CUFF MUST BE DEFLATED!
* Air cannot exit through stoma with valve in place
* Must deflate cuff or patient will not be able to expel air
* May be used as part of weaning process
* Can use to help create closed pressure systems (assists with swallowing)
* Respiratory therapist typically present when initiating use of speaking valve
* conjoint work w/SLP
* Can only use as tolerated by patient
* O2 saturation levels must be continuously monitored w/valve in place
* If O2 saturation drops, discontinue use and try later
89
Intraoral Prosthetic (Compensatory Procedures)
Augment the configuration of the palate to improve oral transit
Palatal Obturator
* Closes off a surgical or anatomical deficit
Palatal Lift
* Lifts the soft palate into an elevated or closed position to facilitate velopharyngeal closure
Palatal Reshaping Device
* Recontours the hard palate to interact with the remaining tongue
90
SLP's Management Process
* Multidisciplinary approach: OT, nutritionist, developmental pediatrician, PT
* Define the feeding and/or swallowing problem
* Identify the etiology of the problem
* Determine and conduct appropriate diagnostic tests
* Describe the physiological deficits associate with the problem
* Educate the family/caregiver and jointly design a treatment approach
* Implement Tx and monitor progress
* Evaluate progress
91
Developmental Milestones: 12-18 mos
* Refining of movements
* Quieter cup drinking, often sequencing several suck-swallow sips
* Actively uses lips to clean spoon
* More control with biting
* Rotary chew begins to develop, jaw motions more refined and complex
* Increased tongue control
* can lick lower lip
* can achieve full tongue tip elevation
* lateral tongue movements develop
93
Modification of Diet Level
* Many residents in skilled nursing facilities are on mechanically aletered diet
* Among residents on altered diets: (Groher et al, 1995)
* 91% were at dietary levels below that which they could tolerate safely (more restrictive than needed)
* 4% were at dietary levels higher than they could tolerate
* 5% were considered to be at the appropriate diet
* Patients should be on highest diet level that they can safely tolerate
* Diet level should be regularly reassessed and advanced when possible
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Surgical Treatment for Oropharyngeal Tumors
* SMALL TUMORS
* smaller tissue resection
* LARGE TUMORS
* removal of parts of more than one structure
* TONGUE TUMORS
* partial or total glossectomy
* TONGUE + ADJACENT TISSUE
* often require resection of tongue plus portions of alveolar ridge, mandible and floor of mouth
* LYMPH NODE INVOLVEMENT
* requires radical neck dissection -
* affects nodal areas of neck, SCM & omohyoid muscles, often CN XI
* TUMOR IN TONSIL OR BOT
* classified in oropharyngeal region; will require removal of tonsillar area, portions of BOT and lateral mandible, & radical neck dissection
* TUMOR IN FAUCIAL ARCHES, SOFT PALATE
* Classified in oropharyngeal region;
* will often require removal of part/all of soft palate, portion of pharyngeal wall
95
Mechanisms of Pediatric Feeding & Swallowing Disorders
Combination feeding problems
* Structural or medical may be primary, experiential piece adds to problem
97
What happens when we chew and swallow
* Compression: food deforms due to force applied, e.g., tongue presses on marshmallow against the palate
* Adheisiveness: food sticks to another surface, e.g., peanut butter sticking to palate
* Tensile: food extends due to force applied, e.g., elongation of food or liquid as it passes through pharynx
* Shear: food is cut into pieces by forces that are not necessesarily opposing e.g., grinding of food during chewing
* Fracture: food is broken by two directly opposing forces, e.g., incisors biting through a cracker
98
Domains of Service for Managing Pediatric Feeding & Swallowing
* NICU
* Hospital inpatient setting
* Hospital outpatient setting
* Outpatient medical clinics
* Private practice
* Early intervention
* Schools
99
Mechanisms of Pediatric Feeding & Swallowing Disorders
Structurally-based Problems
* Craniofacial anomalies/syndromes
* If lip/palate involved, lower seal, suction
* Structures that support PO feedings are altered
* Reduced swallow safety
* Need for feeding modifications, sometimes supplemental tube feedings
100
Partial tongue resection Effects on Swallowing
* If
* Short-term problems triggering pharyngeal swallow
* Decreased precision/strength/control of tongue in oral phases
102
Esophageal achalasia
Poor LES relaxation with reduced esophageal peristalsis
103
Oral cancer Sites
Most frequent locations: anterior floor of mouth or alveolar ridge in anterior mouth floor, tongue (ant or lat), lateral floor of mouth or lateral alveolar ridge
104
Human Papilloma Virus and Head and Neck Caner
* Virus that can infect skin and mucosal lining of areas (mouth, throat, genital areas)
* Many HPV subtypes - low and high risk
* Often no symptoms, often dealth with by immune system
* A minority of cases may lead to cancer (cervical CA, H & N CA in men and women)
* For H & N CA due to HPV:
* Most are spread through oral sexual contact, often takes years to emerge
* Usually affects base of tongue and tonsils
* Prognosis with oncology Tx much better
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# This is a prompt I guess
Treatment of Dysphagia
* NPO (nothing by mouth)
* Orogastric (OG)
* Nasogastric (NG)
* Percutaneous Endoscopic (PEG)
* Gastrostomy (G-tube)
* Jejunostomy (J-tube)
* Total Perenteral Nutrition (TPN)
106
Water Protocols: Benefits and Risks
* Several clinicians and researchers encourage intake of regular (un-thickened) water in dyshagic patients
* These protocols suggest providing water under controlled situations to patients who are on a recommended thickened liquid diet
* Frazier Free Water Protocol
* GF Strong Water Protocol
* Problem: potential increased risk of aspiration and developing aspiration pneumonia
107
Oral Cancer Effects on swallowing
* Reduced salivary flow
* Mucositis (as related to treatment)
* Oral prep/oral transit swallowing deficits
* Extent of tissue resected directly impacts extent of swallowing and speech impairment
108
Brainstem CVA
* UMNs synapse with LMNs at brainstem level
* Contains critical swallowing center
* Swallowing deficits:
* reduced or absent pharyngeal swallow response
* reduced hyolaryngeal elevation
* reduced oropharyngeal contraction
* reduced pharyngeal contraction
* reduced laryngeal closure
* reduced PES/UES opening
* generalized incoordination of swallow components (including respiration)
109
Xerostomia
* Feeling of a dry mouth; reduced salivation
* Causes:
* Medication
* Autoimune disorders
* Radiation
* Diagnosis:
* Sialometry - measures gland secretion
* Treatment
* Artificial saliva
* Stimulation of salivary secretions by mechanical or systemic therapy (if glands are still functional)
* Gustatory
* Treatment with citric acid foodstuff or sour lozenges
* Masticatory
* Treatment with gum chewing or sugarless candies
110
Dementia and Dysphagia
* Multi-infarct dementia, Alzheimer's Disease, alcoholic dementia
* Swallowing deficits occur in advanced stages
* Oral phase - predominantly under volitional control from cerebral cortex regions
* Cognitive deficits often affect volitional control, predominantly oral preparatory and oral transit phases
* But muscle weakness ultimately also affects pharyngeal phase
* Oral and Pharyngeal Phases
* lack of initiation of mastication or A--\>P transit
* holding food in oral cavity
* incoordinated oral control/oral movements
* delayed pharyngeal response
* reduced airway protection, aspiration
* Feeding deficits
* increased need for feeding cues (food preparation, utensil use)
* direct assistance needed with getting food into mouth, food preparation (hand-over-hand cues)
* assistance needed with initiating meal
111
Suck-Swallow-Breathe Synchrony
* Swallow emerges ~15 weeks gestation, consistent swallowing by 22-24 weeks
* Amniotic fluid swallowed daily
* Gestastional (
* Multiple sucks, not consistently linked to swallow
* Pause prior to re-initiating sequence
* Pattern and timing all reflexive
* No volitional component to swallowing in gestational development and neonate stages
* Coordination of S-S-B synchrony **begins** to evolve at 32-34 weeks
* Stabilizes at ~37 weeks
113
Head Tilted to Stronger Side (postural technique-compensatory procedure)
* Uses gravity to direct bolus to stronger side
* Used when both unilateral oral and unilateral pharyngeal weakness is present on same side
Contraindications: -
* Bilateral weakness or opposite oral and pharyngeal side weakness
114
Neuromuscular Electrical Stimulation
| (Therapeutic Procedures)
* Electrical Stimulation
* Surface muscle stimulation, e.g., VitalStim
* Stimulates skin and underlying muscle
* Intramuscular stimulation
* Elicits muscle contraction by stimulating nerve and nerve endings
* Augmentation of hyolaryngeal movement
116
Developmental Milestones: 24 mos
* Tongue becomes primary cleaner inside and outside of mouth
* refined intrinsic and extrinsic tongue muscle control
* Easy lip closure with no loss of liquid from cup
* Controlled, sustained bit
* better grading of jaw opening allows biting varying thickness of foods
* Complex chewing now in place
* Non-stereotypic vertical movements and rotary movements of jaw
* Long drinking sequences can occur when thirsty
117
Cervical Osteophytes
* Bony outgrowths of the cervical vertebrae
* Can protrude into pharynx and cause pharyngeal stasis
118
Developmental Milestones: 9-12
* Variety of foods included in diet by 9 mos
* different textures, shapes, tastes and temperatures of food
* foods for biting and chewing introduced
* soft diced solids
* Cup drinking ~9-10 mos
* tongue under cup surrounded by lower lip
* will pull back from cup after 1-3 sucks to reduced flow
* Lips are more active during eating
* Gag and bite reflexes fade
* Mouth is primary means of sensory exploration
* New objects often mouthed first
119
Management Procedures
Compensatory Treatment Procedures
* Redirect of improve flow of food through oropharynx
* Do not usually change underlying physiologic deficits of patient's swallow
Therapeutic Treatment Procedures
* Designed to change patient's swallowing physiology
Indirect vs Direct Therapy
* Indirect: involves exercises using no food or liquid
* Direct: incorporates small amounts of food or liquid while implementing swallowing techniques
120
Augmentative Devices (Compensatory Procedures)
* Syringe
* Syringe with extension
* Nosey Cup
* Straw
121
Supraglottic Laryngectomy: Swallowing Therapy
* BOT exercises
* Lingual ROM and bolus control exercises
* Volitional swallowing maneuvers
* Increase airway protection
* Increase pharyngeal bolus transit
* Diet modifications
* Compensatory strategies
122
Effortful Swallow
(Swallow Maneuvers; Therapeutic Procedures)
* Hard or forceful swallow
* Increase posterior tongue base motion during swallow to increase lingual driving force
* Can improve base of tongue to pharyngeal wall contact
* Can increase lingual driving force
* Can increase pharyngeal construction
* Can increase laryngeal elevation
* Helps reduce residue and protect airway
Instructions:
* Swallow normally but squeeze very hard with your throat and neck muscles throughout the swallow
* Use all of the muscles in your throat to swallow
123
Non-nutritive Versus Nutritive Sucking
Nutritive Suck
* Nutritive suck (NS)
* Rate ~1/sec
* Bottle or breast
* Nourishment purpose
* Infants
* Typical feeding 15-20 minutes,
* Occur at ~2-3 hour intervals
125
Feeding Disorder (definition)
* Problems in broad range of eating activities that may include:
* food refusal, disruptive mealtime behavior, rigid food preferences
* non-optimal growth, delayed self-feeding skills (or delayed feeding development in general)
* May or may not be accompanied by dysphagia
126
Mechanisms of Pediatric Feeding & Swallowing Disorders
Experientially-based problems
* Behavioral choice made by child to feel safe, comfortable
* Power struggle/interaction dynamic
* Swallowing anatomy/function typically normal
* Pharyngeal skills often normal
* May have restricted food repertoire
* Can begin/be associated with medical condition(s)
* Tx may focus on changing feeding dynamic and empowering child with feeding decisions
127
Developmental Milestones: 6-9 months
* Transition to strong, active _sucking pattern_
* strong activity of intrinsic tongue muscles
* up/down, raising/lowering of tongue
* decreased vertical excursion of jaw
* Shoulders and neck more stable
* Head moves independently of trunk
* Facial expressions are more pronounced
* By ~6 mos, infant can generate greater oral pressures
* experiment with raspberry sounds, etc
* more firm approximation of lips
* necessary for taking food from spoon
* liquid loss from mouth now rarely occurs
* spout cup often introduced at 6-9 mos
* Smooth pureed by spoon ~4-6 mos
* Sensitive period for textures and tastes ~4-10 mos
* important to introduce different tastes and textures during this period
* opportunities for chewing skills to develop
* may see coughing or gagging on new foods
* Single and combination pureed foods introduced by 5-7 mos
* Begin taking textured foods between 6-9 months
* dissolvable solids
* soft items with lumps
* Teeth erupt ~6-9 mos
* Biting action with central incisors
* helps for introducing more solids
* Vertical jaw movements (munching) predominate at 6-9 mos
* Mouthing for sensory exploration
128
Mechanisms of Pediatric Feeding & Swallowing Disorders
Sensory-based problems
* Oral-tactile hypersensitivity
* arching, gagging, turning head
* Oral-tactile hyposensitivity
* increased level of tolerance, decreased awareness of stimulus
* Aversion
* crying, jaw clenching, even w/oral stimulation
