Feeding Flashcards
What can cause dysphagia?
Medical Conditions: Cleft palate, GERD, Malformation- Pain
Food Allergies-food avoidance
Oral Motor Function-delay, abnormal, inefficient
Sensory Issues
Behavioral issues
What is dysphagia?
Difficulty at any stage of the swallow- oral to esophageal
When is a feeding eval needed?
If there is a known dx like cleft palate or prematurity.
If meal times take more than 30 minutes
If meals are stressful
If the child shows signs of respiratory distress
If the child has not gained weight
Eating requires…
Motor ability: CNS, pulmonary, gastro
- Posture/muscle tone
- Hand control
Oral motor function
- Lip closure
- Jaw movement
- Tongue controlswallowing
Sensory perception
- Hot/cold
- Full/empty
- Liquid/solid
Social and cognitive
- Not eating with mouth open
What are the prerequisites to feeding?
Oral integrity
- teeth
- ulcers
- arthritis
Intact cranial nerves
Reflexes
- swallow
Secondary
- bonding with parent
- desire
What is the oral cavity?
Hard and soft palate, tongue, fat pads of cheeks, upper and lower jaws, teeth, lips
Contain food, chewing or mastication, bolus formation
What is the pharynx?
Base of tongue, oropharynx, tendons, hyoid bone
Funnels food to esophagus, air and food share this space
What is the larynx?
Epiglottis and vocal cords
Valve to trachea that closes during swallow
What is the trachea?
Tube below larynx
Cartilage rings (chondromalcia)
Airway to lungs
What is the esophagus?
Thin and full of smooth muscles
Carries food from pharynx through the diaphragm and into the stomach
What are the steps of the swallowing process?
- Pre oral
- Oral prep
- Oral (oral transit)
- Pharyngeal
- Esophageal
Describe each step of the swallowing process.
Pre Oral: voluntary (OT)
- Smell sight, salivation
Oral Prep: voluntary (OT)
- Chew (rotary in adults)
- Form bolus
Oral (Oral Transit): voluntary (OT)
- Bolus is pushed against hard pallet, moved to back of throat
Pharyngeal: nonvoluntary (OT)
- Soft palate elevates to close the nasopharynx
- Breathing stops
Esophageal: nonvoluntary (not OT)
- Things return to normal
- Food passes to stomach
What must you have to drink from a cup?
Jaw stability, which usually presents at 24m
What are possible reasons for disorders with eating (not ED like in general)?
Disorders of appetite
- Anorexia
Anatomic disorders
- Oropharynx
- Esophagus
- Trachea
Disorders affecting suck, swallow, breath
- Usually, CNS
Coordination disorders
- CP
Infections/Inflammation
Behavior/Experience
What constitutes dysphagia?
neurological issue
What constitutes a feeding issue?
strong food/texture preference
hypersensitive olfactory
eating disorder (anorexia, bulimia)
positioning (head control, general strength, fatigue)
What is the toughest liquid to swallow?
water
Dysphagia symptoms in adults
They tell you!
Drooling
Decreased mastication (chewing)
Clearing throat
Choking
Nasal regurgitation
Residual food in oral cavity
Weight loss, dehydration, respiratory problems
What is aspiration?
The entrance of food into the larynx below the vocal cords
What is auditory aspiration?
coughing or choking
What is silent aspiration?
No swallow response
Pooling or wet sounds on auscultation
Change in voice
Change in patient color, vitals or decrease O2 level
What might you see in children who have oral hypersensitivity ?
Medical care:
- cavities
- OA in jaw
Tongue thrust
Bite reflex
Gag reflex
Poor jaw grading
Tongue retraction
Inadequate suck
Inadequate chew
Drooling
Motor impairments commonly seen with eating
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 (for neck support)
- Hypertonic bite
* Tonic bite
* Tongue thrust
* Lip retraction, pursing
Hypotonic feeding issues
Poor head, neck and trunk stability
- Fall over
- Elevation of shoulders
- Hyperext 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
What is paralytic dysphagia?
Lower motor neuron
Weakness or paralysis of oral structures
Swallowing reflex may be absent
Common in:
- CVA, TBI and Developmental disorders (MR)
What is pseudobulbar dysphagia?
Upper motor neuron
Hyper or hypotonic oral structures
More common in pediatric population
Common in:
- CVA, CP, TBI
What is mechanical dysphagia?
Loss of structure or weakness due to trauma or surgery
Common in:
- Cancer, MVA
Types of feeds with PEG or NG tubes
Bolus feeding
- pts develop hunger
- feed at meal time
Drip/continuous
There is no better or worse way. ICU and inpatient are typically on the continuous drip. If the family is going to take care of it after, they will typically use bolus feeding.
Family/pt preference
Feeding assessments used
Electromyography: surface electrodes
Barium swallow test
Videofluoroscopic: Moving x ray
Fiberoptic laryngoscope: Camera is introduced
Ultrasound: anterior throat
Manometry: catheter is introduced to the esophagus to measure force, timing, and sequence to swallow
What should we assess with feeding?
- Pt hx, dx, sx; nutritional source (NG, PEG, oral); NPO; respiration status
- Cognitive, perceptual, and physical abilities
- level of arousal, desire to feed, ability to position self, ability to follow directions - Oral abilities
- ROM and strength or tongue, lips, and jaw; head control; vision; reflexes - Do a feeding trial
- start with easy foods like yogurt
How do you feel for a swallow?
Index finger under chin
Middle finger at base of tongue
Ring finger over thyroid cartilage
Small finger above jugular notch
Compare remedial vs compensatory approaches.
Remedial - rehabilitation, strengthening
- LMN (paralytic) dysphagia
- modifying to increase strength
Compensatory - relearn, start over, education
- UMN (pseudobulbar) dysphagia
Put these in the order of which you would introduce them to a patient:
protein shake
water
diet coke
coffee with cream
black coffee
Protein shake
Coffee with cream
Diet coke
Black coffee
Water
Texture progression for typical kids
Pureed - baby food
Mashed - potatoes, peas
Chopped
Full
Dysphagia diet for adults or kids
- thick puree - pudding or apple sauce
- soft chewables - soft fruit (banana), cooked veggie
- drier chewable - bread, cookie
- foods that require biting - meat
- mixed textures - oatmeal with raisins
Fluid progression
- None
- spoon thick (commercial thicken)
- texture of honey
- nectar (pulp orange juice)
- thin flavored fluids (coffee with cream, coke)
- water
Dysphagia level I diet
Pureed
Difficulty protecting airway
- Crush injury, trachs
Little or no jaw or tongue control
Delayed swallow
Homogenous food, no bumps or lumps, same consistency
Moves slower to allow the swallow reflex to kick in
Goal is for oral feeding, stepping stone, may not be enough for caloric intake alone
Dysphagia level II diet
Soft food
Beginning rotary chew
Some tongue control
Minimally delayed swallow
Mild to moderate problems
Stick together
Good bolus, not fall apart
Provide good proprioceptive feedback
Dysphagia level III diet
Advanced diet
Able to chew
Able to form a bolus from different textures
Minimal jaw or tongue issues
Swallow can be mildly delayed but intact bilaterally
Think things a kid can eat without supervision
- rice, cooked veggies
- no skins, tough or dry course food
Dysphagia level IV diet
regular diet
What’s a half nelson?
CP feeding position we learned in peds
Used to support the jaw, lips, and for head control
Handling techniques before feeding
Oral support
- Stability
- Control
Tapping/stretching, vibration - to increase tone
Rhythmic/firm/deep touch pressure, NUK -to decrease tone
Good alignment
Pressure to mid to front=retracted tongue will relax
- mid to back = extended tongue will relaxed
Rhythmic downward pressure to tongue (palm) may facilitate a suck
Lateral movement can be inhibitory
Handling techniques during feeding
Oral support –not force
- Under and around the lower jaw
Downward pressure of spoon or nipple=suck
Down and in=up and down tongue movt
- Inhibit tongue thrust
To increase tongue movt lateral- move spoon to side
Food on the teeth promotes chewing
Stay away from the posterior aspect of tongue
- Gag
Head position for feeding
Chin tuck is best
Upright to slight flexion is ok
- Flexion reduces aspiration
* Can effect breathing
* Some kids like ext because they can breath better, puts them at risk for aspiration
How to initiate a swallow in pt with slow or delayed swallow
Frozen pacifier
Popsicle
Formula
How to improve transit with feeding
Handling of head and jaw
Outside support
Thickened liquids
- Proprioception
- Easier control
Positioning
How to increase strength or tone with feeding
Tongue exercises, jaw exercises-increase ROM and strength
Peanut butter, gum, tapping, vibration
Chin tuck and turning toward affected side
How to work with hypersensitivity with feeding
manual input, introduction of textures
How to effect poor tongue control with feeding
exercises
quick stretch
Compensatory strategies for weakness with feeding
Manipulate food
Inspect after meals
Place food on strong side
Break meals up
Compensatory strategies for abnormal reflexes with feeding
Avoid provoking them
Positioning
Exaggerate opening and closing of mouth
Compensatory strategies for hyposensitivity with feeding
Temperature, flavors
Compensatory strategy for delayed swallow
chin tuck
How to impact feeding with reduced laryngeal elevation
shaker exercise
nod head yes repeatedly
Ways to increase swallow
Chin tuck
Effortful swallow
Mendelsohn maneuver
- Tongue pushes to roof of mouth-point adams apple up
Neck rotation-usually toward affected side
Supraglottic swallow-hold breath then swallow
Estim to stimulate suprahyoid and thyrohyoid muscles
Surgery
Types of nonoral feeding
nasogastric
oralgastric
gastronomy
Feeding with a tracheostomy
May need to occlude during feeding
- talk to medical
Chin tuck method
Structural problems that effect feeding
Cleft palate or cleft lip
Micrognathia (small lower jaw)
Downs Syndrome
Adaptive equipment used for feeding
Scoop dishes
Adaptive nipples
Adaptive spoons
Adaptive cups
Sporks
Straws, sippy cups
- one way straw
Positioning equipment
Electric or weighted feeders
Modify the task
- Drink soup through a straw
- Eat with a spork
- Change up the food or texture
