Feeding Flashcards
Eating
Food in mouth and swallowing
Keeping food and fluids in the mouth, manipulating, and swallowing
Feeding process
Setting up (in adults)
Arranging, positioning, prepping
Bring food to mouth
Dysphagia
Difficulty at any stage of the swallow- oral to esophageal
How is mealtime is more than just about eating?
Opportunity to practice manipulations skills
- Finger feeding
- Using utensils
- Cutting meat
- Dipping food
Experience sensations
- Pudding, crackers, broccoli
Experience with communication and bonding.
- Bonding with mom
- Expressing desires (crying for bottle, please pass the pepper)
- Family table
- Lunchroom
Problems with feeding
10-25% of typically developing kids have issues
40-70% of preemies
Up to 80% of children with developmental disabilities and CP
Feeding is the corner stone of it all
- You have to grow a brain
Causes of feeding problems
Medical conditions: Cleft palate, GERD, Malformation
Food allergies and/or food avoidance
Oral motor function: delay, abnormal, inefficient
Sensory issues
Behavioral issues
When is an evaluation or consult needed for feeding?
Known diagnosis
- Cleft palate
- Premature
Idea there may be problems
- Are mealtimes taking more than 30 minutes?
- Are meals stressful?
- Does the child show signs of respiratory distress?
- Has the child not gained weight?
Contextual factors in eating
First 6 months fed in arms
7-24 months begin feeding independent
Adults - posture
Who is present at feedings
Culture
- When to allow self feeding – 6 months to 2 years
- Breast feeding
- Types of food and how you eat them
Socioeconomic status
What does eating require?
Motor ability - CNS, pulmonary, gastro
- Posture - muscle tone
- Hand control
Oral motor function
- Lip closure
- Jaw movement
- Tongue control
- Swallowing
Sensory perception
- Hot/cold
- Full/empty
- Liquid/solid
Social and cognitive
- Not eating with mouth open
- Knowing not to eat the garnish
Prerequisites to feeding
Oral integrity
- Remember the infant throat changes at about 9-12 months
- For children and adults consider teeth
* Ulcers
* Arthritis
Intact cranial nerves
Reflexes
- Swallow: regulates amniotic fluid
- Pharyngeal swallow: 10-12 weeks gestation
Secondary
- Bonding and parent and child issue
- Desire in older children and adults
Oral structures involved in feeding
Oral cavity
Pharynx
Larynx
Trachea
Esophagus
Oral cavity
Hard and soft palate, tongue, fat pads of cheeks, upper and lower jaws, teeth, lips
Contain food, chewing or mastication, and bolus formation
- Soup and things that fall apart are harder to swallow. Things that stick together like mac and cheese and mashed potatoes are easier to swallow when sicks.
Pharynx
Base of tongue, oropharynx, tendons, hyoid bone
Funnels food to esophagus
Air and food share this space
Larynx
Epiglottis and vocal cords
Valve to trachea that closes during swallow
Trachea
Tube below larynx
Cartilage rings
- Lacking these rings = chondromalacia
Airway to lungs
Esophagus
Thin and full of smooth muscles (involuntarily controlled)
Carries food from pharynx through the diaphragm and into the stomach
Swallowing process
Pre oral
Oral prep
Oral (oral transit)
Pharyngeal
Esophageal
What parts of the swallowing process are voluntary?
Pre oral, oral prep, and oral transit
Basic oral skills
Suckling
Sucking
Drinking from a cup
Munching
Chewing
Biting
Coordination of suck-swallow-breathe
Suckling
The back-and-forth motion of the tongue
At 32-34 weeks gestation, a normal child can usually sustain life
Present at birth
- Primary method of feeding until 8-10 months
- Nonnutritive (soothing)- rhythmic; not indicative of the ability to feed
- Nutritive- rhythmic with bursts and pauses
* Time to swallow
Sucking
Negative pressure, jaw movement, tongue can move up and down
True suck 4-6 months (negative pressure)
Tongue now moves up and down-can easily suck baby food
Cup may be introduced
Jaw stability is fair
6 months-as they move to a cup may have episodes of choking
9 months-strong suck from cup or bottle, minimal jaw excursion, stability is fair (physically able to move to chew soft foods, mashed foods)
12 months- jaw stability con’t to increase
Suck stops
May stabilize by biting cup
24 months-jaw stable, can drink from a cup
Drinking from a cup
In order to be effective, you must have jaw stability.
Have enough of this by a year old
Munching
Jaw just going up and down, no rotary
Chewing
Rotary and tongue lateralization
Biting
To tear and hold onto something
Coordination of suck-swallow-breathe
Happens from birth to 4-12 months because they haven’t gained that sitting posture yet
1 month
- 1 suck, 1 swallow then
- 2-3 sucks to swallow and breathe the whole time
- Cough-lost this coordination
- Breathing slows, within or between sucks
3-4 months
- 20 sucks then swallow
9 months
- Stop to swallow or breath
12months-should not be coughing
- Suck followed by swallow and breathing
Aspiration
Aspiration is uncommon before 4 months of age, rapid change between 4 and 12 months
The entrance of food into the larynx below the vocal cords
Laryngeal Penetration
- Entrance of food into the larynx above the vocal cords
Auditory
- Coughing or choking
Silent
- No swallow response
- Pooling or wet sounds on auscultation
- Change in voice
- Change in patient color, vitals, or decreased O2 level
Rooting reflex
Combined with grasp
Comes in around 32 weeks gestation
When you stroke side of cheek, turn head toward that sensation
Normal feeding for a baby
This is the most taxing and difficulty activity a baby undertakes, so problems often pop up
20-30 min
Rooting and suck reflex decrease as child is full
“When can I stop with bottle or breast”?
- Biologically and physiologically 6 months can eat anything mashed
- Varies from doc to doc
- Culture and society driven
- Mother’s preference
Development of feeding
Birth-1year: suckling
3 months: suck develops
5-6 months: suck is stronger, primitive bite reflex to “munch”, lip and tongue control improving
9 months: munching is voluntary, starting to move food around, lips are active
12 months: move to a cup, may lose liquids
- rotary chew starts
18 months: jaw is stable, can drink from a cup
- chews with lips closed
24 months: adult like patterns for suck and chew, swallows with lips closed, good tongue control
- all table food
Biting and chewing development
3-5 months
- Reflexive munching
- Can handle purred foods (suck it off spoon)
6 months
- Some tongue lateralization
- Control of the tongue
7-8 months
- Diagonal patterns begin
- Bite to hold only
9 months
- Munching continues
- Adds diagonal patterns
- Voluntarily bites on objects
- Lips are active rakers
12 months
- Rotary chewing begins
- Jaw stability
- Controlled mobility
- Coordination of tongue- moves food easily in mouth
- Easily chews food, including meat
18 months
- Meat and raw veggies
- Bite to cut
- Tongue can move food
- Packing
- No food loss
24 months
- All food
- Graded bite
- Mature, circular bite
- Good tongue movement
- Good lip closure
Development of self-feeding
6-8 months try to hold bottle
- Radial digital (thumb and pointer) grasp on cookie
9-13 months
- Develop posture that allows for self feeding
- Good finger feeders
- Older children may refuse to be fed (like doing it themselves)
15-18 months
- Good with a spoon - pronated grasp, good with sticky food
- May poke at spoon feeding at 12 months
24 months
- Spoon with out spillage
- Spoon feeding requires:
- Posture
- Midline head support
- Hand to mouth skills
- Disassociation of lip and tongue
30-36 months
- Uses a fork
Straws
- 2 years
- Sippy cups - spillage initially
- Straws - require lip closure and strong suck
- Also, cognitive skills
- No spillage
- By 2 there should be no backwash
Role of taste and smell
In children
- “Children have no sense of taste” LIE
- Develops in utero - varying amniotic fluid
- Breast babies are less likely to be picky eaters, why?
- Whatever mom eats, baby will taste
What about adults?
Evaluating feeding
Connection to performance components
Medical and developmental history
Feeding observation
Medical and developmental history
Instrumental Evaluations - use technology
Electromyography: surface electrodes to determine if swallowing is occurring
Barium swallow or Scintigraphy: pictured; barium is placed in bottle or cup, x-ray is taken and shows if there is any aspiration
Videoflouroscopic study: moving x-ray
Fiberoptic laryngoscope: camera is introduced
Diagnostic ultrasound: anterior throat
Manometry: catheter is introduced to the esophagus to measure force, timing, and sequence of swallow
Possible reasons for feeding problems
Disorders of appetite
Anatomic disorders
- Oropharynx
- Esophagus
- Trachea
Disorders affecting suck, swallow, breath
- Usually CNS, ABI, CVA, CP
- Have trouble with automatic and volitional aspects of feeding
Coordination disorders
- CP
Infections/Inflammation
Behavior/Experience/Many others
Dysphagia
Difficulty with any stage of swallowing
Not sensory related
Not developmental
Typically the result of:
- Neuro insult
- Structure
Causes of dysphagia in adults
Nondegenerative
- CVA (most common reason), Head Injury,
Degenerative
- Alzheimer’s, dementia, general aging
Remediation is often not an option
Others:
- Medication induced
- Context - money, place, depression
Symptoms of dysphagia in adults
Drooling
Decreased mastication (chewing)
Clearing throat
Choking
Nasal regurgitation
Residual food in oral cavity
Weight loss, dehydration, respiratory problems
Consider and evaluate sensory issues (usually hypersensative)
Medical care
Non use
Neurological
May see
- Tongue thrust
- Bite reflex
- Gag reflex
- Poor jaw grading
- Tongue retraction
- Inadequate suck
- Inadequate chew
- Drooling
Common motor impairments
Spasticity
Hypotonic
May not show up until solid food
Problems
- Head and neck control
- Jaw excursion
- Over or under active tongue
- Postural instability
- Hypotonic cheeks
- Elevation of shoulder
- Hypertonic bite
* Tonic bite
* Tongue thrust
* Lip retraction, pursing
Hypotonic
Poor head, neck and trunk stability
- Fall over
- Elevation of shoulders
- Hyperextension of neck
Open mouth-drooling
Wide excursion
Difficulty grading
- Open or closed
Difficulty in mid ranges
- Not hard enough or wears self out
Loss of food
Tongue may be inactive
- Or extreme in range
Lips may not seal or be active
- Spoon drag
Cheeks
- Packing
Types of dysphagia
- Paralytic
- Lower motor neuron
- Weakness or paralysis of oral structures
- Swallowing reflex may be absent
- Common in: CVA, TBI and Developmental disorders (MR) - Pseudobulbar
- Upper motor neuron
- Hyper or hypotonic oral structures
- Common in: CVA, CP, TBI - Mechanical
- Loss of structure or weakness due to trauma or surgery
Common in: cancer, car accident
Assessment - first
Pt history, diagnosis, surgeries etc.
- Allergies!!!!!!!!!!!!!!!!!!!!
- Who usually feeds and how
- Where do they eat, what do they eat
Current Nutritional source
- NG tube
- G tube (PEG)
- Special diet
Length of time a pt has been NPO
Respiration Status
Make sure you have ok for by mouth
- Videofluorscopy, electromygraphy, endoscope, manometry, scinctigraphy, ultrasonography
Assessment - second
Assess cognitive, perceptual and physical abilities (as appropriate)
Level of arousal, ability to follow directions
Ability to position self, move tongue, open mouth
Ability to localize and recognize temp
Desire to feed
Assessment - third
Remember safety and exposure (you and client)
Check ROM< strength of tongue lips and jaws
Head control
Vision
Look at any reflexes, appropriate or not
Last assess
Do a feeding trial
- Do you have clearance
- Try easy foods first and work up
* Start where they’re at and take a step back
- Make sure the client likes it
- Watch, feel and listen
To feel for swallow (both sides)
- Index finger under chin
- Middle finger at base of tongue
- Ring finger over thyroid cartilage
- Small finger above jugular notch
Intervention
Remedial (rehabilitation) or compensatory
Where and what can we impact?
- Posture
- Altering Food
* Levels 1-3 to normal
OT/SLP Treatment
- Oral prep
- Oral
- Pharyngeal
- Esophogeal-nope!
Texture progression
Pureed-baby food
Mashed-potatoes, peas (what you can do with a fork)
Chopped- broccoli, meats, carrots
Full
Pre oral stage of swallowing
smell, sight, salivation
Oral prep stage of swallowing
Chew
Form bolus
Oral (oral transit) stage of swallowing
Bolus pushed toward back of throat
Pharyngeal stage of swallowing
Soft palate elevates to close the nasopharynx
Breathing stops
Esophageal stage of swallowing
Things return to normal
Food passes to stomach
Nonoral feeding
- Types: NasoGastric (NG): short periods of time, for those that are immobile; or Gastrostomy (GT) or PEG (pericutaneous entergastric): fed through gut tube, surgical
>With PEG you have continuous and bolus feeding.
>Continuous – a drip all day everyday; they never get hungry
>Bolus: 3-4 meals a day
