Feeding Flashcards
Fiber endoscopic evaluation
An evaluation used to assess swallowing in which a flexible instrument is placed through the nostrils to view the pharynx, larynx, and trachea
Modified barium swallow
An evaluation using digital imaging to assess oral, pharyngeal, and upper esophageal function while ingesting various textures of food and liquids
Mendelsohn maneuver
Technique used to prolong the opening of the upper esophageal sphincter during a swallow, involves pushing the tongue into the upper palate while manually maintaining the Adam’s apple in an elevated position
Supraglottic swallow
Compensatory swallowing technique used to close the vocal cords before and during swallow
Steps:
- Take deep breath
- Hold breath while swallowing
- Cough to lear saliva or food
Pre-oral phase
Smell and visual appreciation of food
Stimulation of saliva
Mouth and UE motor movements to initiate the process of eating
Oral preparatory phase
Voluntary intake of food into mouth
Bolus formation with saliva
Chewing with molars and activation of buccal muscles to prevent pocketing
Bolus movement to the center of the tongue
Oral phase
Use of cheek and tongue muscles to retain bolus centrally
Posterior migration of bolus
Chin tuck
Compensatory swallowing maneuver that involves moving the chin towards the chest while swallowing, protects the airway and reduces the risk of aspiration
Advanced dysphagia diet
Dietary food texture modification described as soft consistency for safer swallowing that requires more advanced chewing ability
Examples:
- baked potato with skin
- moist pancackes
- thin sliced meat
Mechanically altered dysphagia diet
Dietary food texture modification described as moist, semi-solid consistency for safer swallowing that requires some chewing ability
Examples:
- cottage cheese
- ripe banana
- moist meat loaf
- scrambled eggs
Puree dysphagia diet
Dietary food texture modification described as smooth, uniform consistency for safer swallowing that requires very little chewing ability
Examples:
- pudding and plain yogurt
- smooth apple sauce
- whipped potatoes
Moderately thick dysphagia diet
Thickened liquid consistency so that it drips from a spoon for safer swallowing, progression from mildly thick that may be prepared with thickening gel or powder
Mildly thick dysphagia diet
Thickened liquid consistency for safer swallowing that is a progression from thin liquid
Examples:
- tomato juice
- fruit nectars
- egg nog
Thin dysphagia diet
Liquid consistency that requires an intact swallow
Examples:
- water
- ice chips
- broth
- coffee
- gelatin
Dysphagia diet levels
- Pureed foods
- Mechanical altered
- Dysphagia-advanced
Esophageal phase
Return of upper esophageal sphincter to tonic state
Passage of food through the esophagus to the stomach
Pharyngeal phase
Soft palate elevation
Larynx and hyoid elevation and protraction
Cessation of airflow to prevent aspiration
Vocal cord closure when whole bolus is moved through the pharynx
Dysphagia
Difficulty at any stage of the swallow- oral to esophageal
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`
Paralytic dysphagia
Lower motor neuron
Weakness or paralysis of oral structures
Swallowing reflex may be absent
Common in:
- CVA, TBI and Developmental disorders (MR)
Pseudobulbar dysphagia
Upper motor neuron
Hyper or hypotonic oral structures
More common in pediatric population
Common in:
- CVA, CP, TBI
Mechanical dysphagia
Loss of structure or weakness due to trauma or surgery
Common in:
- Cancer, MVA
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
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 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
Dysphagia
Difficulty at any stage of the swallow- oral to esophageal
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
Munching
Jaw just going up and down, no rotary
Chewing
Rotary and tongue lateralization
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
Signs of silent aspiration
- No swallow response
- Pooling or wet sounds on auscultation
- Change in voice
- Change in patient color, vitals, or decreased O2 level
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
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
