final exam Flashcards
what is a feeding disorder
- persistent failure to eat adequately which results in a significant loss of weight or failure to gain and growth delay
- onset usually in first year of life but can go to 6
unsafe or inefficient swallowing
3.lack of tolerance to food textures and taste - poor appetite regulation
- rigid eating patterns
what is a swallowing disorder
type of feeding disorder with unsafe or inefficient swallowing
increases the risk for aspiration
what is inefficiency
unable to meet caloric needs because swallow is not effective
what is overselectivity
restrictive in taste, type, texture or volume of foods eten
what is refusal in a feeding disorder
complete refusal to feed due to medical issues, GI distress, or traumatic experiences
what is a feeding delay
delayed development of feeding milestones
What is AFRID
Avoidant REstrictive Food Intake
lack of interest in eating
avoidance based on sensory characteristics of food
concern about aversive consequences of eating
causes significant weight loss, nutritional deficiency, dependence on feeding tube or supplements
interference with psychosocial function
what are risk factors for feeding disorders
- low birth weight
- developmental disabilities (Downs, autism, Cerebral palsy) that result in motor or muscle weakness or sensory defensiveness
- prematurity
- prenatal drug exposure
- diet restrictions ( diabetes, PKU) that cause feeding challenges
- craniofacial abnormalities
- neurologic issues
- cardiac and respiratory conditions
- nutritional and GI issues
what are some behavioral causes of feeding disorders
- negative parent behaviors: over and understimulatng, rigid, chaotic, overly anxious
- undesirable child behavors during mealtimes
- eating too slow
- eating too fast
what are factors in an infant for postitive feeding
infant must be: positive alert calm show readable cues for hunger and fullness willingness to try tastes and textures
what are factors in toddlers for positive feeding
toddlers must exhibit interest in eating indicate hunger and fullness follow a predictable meal schedule show positive behaviors
what affects a child’s eating abilities
environment nutritional status developmental status learning style/capacity senses muscles organs environment
what is prenatal swallowing
1.fetus swallows anmiotic fluid to mature digestive tract
2.pharyngeal swallow is developed by 15 weeks
consistent swallowing by 22-24 weeks
3. oral motor movements and suckling around 10-14 weeks
4. true suckling around 18-24 weeks (backwards/forwards movement)
5. suckling is the only pattern used by neonates because the tongue fills the oral cavity and does not extend beyond labial border
6. by 34 weeks gestation, healthy preterm infants suckle and swallow well enough for full oral feedings
7. decreased rates of fetal sucking are associated with digestive tract obstruction or neurologic damage
what is required for oral feeding
- coordination of suckling, swallowing, and breathing
- sequential timing of tongue, larynx and laryngeal muscles
- infant must be able to maintain heart rate, respiration before they can swallow
what are adaptive responses
babies compensate when they are not comfortable
they may stop feeding if something is wrong
they try to send cues
what motor development is important for feeding
head and trunk control to achieve jaw stability
pincer grasp to finger feed
must be able to reach across midline before you will see tongue lateralization
what is the developmental food continuum
breast/bottle: birth to 12 month
thin cereal: 5-6 month
thicker cereal 5.5-6.6 months
baby food puree: stage 1 food 6-7 months
thicker cereals and smooth puree stage 2 7-8 months
soft masked table food 8-9
hard munchables 8-9
meltables: 9 months
soft cubes (avocado, kiwi, vegtable soup) 10 months
soft mechanical single texture (muffins, small pasta) 11 months
mixed texture: stage 3: 12 months
soft table foods 13-14
hard mechanicals (cheerios, cookies) 15-18 months
what is protocol for infant feeding eval
chart review for birth/medical history, parent/staff interview
oral mech
what are clinical signs of ORAL difficulty in infant
- inefficient extraction
- disorganized suck swallow
- anterior spillage
- decreased ability to latch on to nipple
- disorganized tongue/jaw function
what are clinical signs of PHARYNGEAL difficulty in infants
coughing/throat clearing
spitting/gagging
physiological changes: drop in O2 saturations, increase in HR
changes in upper airways sounds via cervical auscultation
weak, hoarse or wet sounding cry
what should be in an infant chart review
feeding readiness medications pulmonary issues GI issues previous intubation or ventilator failure to thrive neurological involvement imaging is done bottle or breast current nutrition source feeding schedule craniofacial abnormalities GERD alertness syndromes
what are components of beside swallow for child
involves joint OT if sensory issues
uses childs cups/ utensils and introduced foods
chart review
oral mech
what are signs of ORAL difficulties >1 year
inefficient extraction poor labial seal on spoon or cut decreased mastication anterior spillage decreased bolus control disorganized tongue/jaw movement
what are signs of PHARYNGEAL difficulties >1 year
coughing/throat clearing gagging or emesis physiologic changes changes in upper airway sounds wet, gurgly vocal quality
What are critical decision options for pediatric (recommendations)
- cleared for PO diet no restrictions
- modified temporary diet
- remain NPO
- begin treatment
- allow time to improve
- change meds
- wean O2
- FVSS
- temporary NGT or G tube
- results impacted by presence of NGT
what are major reasons for outpatient evals
- picky eater
- not transitioning from baby foods
- choking/gagging
- not gaining weight
- dysphagia
- NPO children who families need guidance on oral stimulation, are ready to try oral feeds, or need dysphagia treatment
what is included in an outpatient pediatric eval
history of problem: when, traumatic events, differences in different settings
medications
medical history
weight/height
allergies
bowel habits
previous diagnosis: child on altered textures
home environment for meals: do they graze all day?
what is child routine
how does child tolerate different sensory input
why are stools important
lead you to cause of problem
food allergies
constipation will make reflux worse or make child feel full
what is a pediatric eating assessment tool PediEAT
questionnaire of observable symptoms of problem feeding in children 6 months to 7 years
completed by caregiver
what do you assess in an oral motor exam
jaw stability lip closure tongue protrusion/retraction tongue lateralization hard/soft palate number of teeth
what are typical diagnosis in outpatient rehab
sensory based feeding disorder oral motor dysfunction pharyngeal dysphagia picky eater GI issues parental issues
what is the difference between a picky and problem eater
- picky eater will eat >30 foods, problem <20
- foods lost are reacquired in picky eater not in problem
- tolerates new foods
- eats >1 food from most groups Problem refuses entire category
- picky adds new foods in 15-25 steps, problem >25
- eats with family vs. alone
- referred to as picky eater at well child checks vs across multiple checks
what are typical recommendations for picky eater
direct feeding therapy
refer to GI for reflux, constipation, or futher assess
consider allergy test
refer to nutritionist
home programs for problem eaters
establish feeding schedule seating adjustments change in feeding utensils/cups change in textures of foods oral stimulation
what are some interventions for infant feeding
modified side lying external pacing specialty nipple cheek support frequent burping chin support
what are goals of intervention for infants
improve quality experience by reducing stress
engaging families to assume an active role
teaching parents to read and respond to infants cues
what are oral motor treatments
proper seating with support jaw stability lip closure tongue lateralization chewing alterning presentation beckman's massage
what are sensory/behavior based treatments
- decrease anxiety around food
- encourage messy play
- pair foods with same color together in therapy
- food chaining: change only one characteristic of a food at a time
- engage in food play during session
- use nuk brushes vibration, spicy foods
- encourage child to help prepare foods
- use behavioral strategies such as checklists, special placemats, special utensils
what is auscultation and how do you use it
using a stethoscope to assess breathing and swallowing sounds
listen to breath prior to bolus to get a baseline
after bolus does it change?
What is NMES
neuromuscular electrical stimulation
electric current stimulates nerve to aid muscle strengthening for hyolaryngeal excursion
what are NMES precautions
dementia reflux pacemaker deep brain stimulator implantable ardioverter defibrillator seizures
when is NMES contraindicted
over carotid sinus
over active cancer
over active infection
what are the goals of compensation
airway protection
maintain nutrition and hydration
maintain general health
how are swallowing disorders managed
oral hygiene teaching feeding strategies restricting viscosities therapeutic and postural intervention ongoing education and counseling
what are non-oral feeding methods
NG tube: short term thru nose
J tube: into intestines: predigested food
PEG tube: directly into the stomach surgically
what is a PEG tube
percutaneous endoscopid gastrostomy
what is a j tube
jejunostomy tube
what are some compensatory strategies
- chin tuck: swallow initiation, airway protection
- head back: oral stage deficits
- small sips and bites
- repeat swallows
- thickening
- head tilt to strong
- head rotation to weak
- supra glottic maneuver
what principles of motor learning are used with rehab
- task specificity
- intensity
- feedback: both biofeedback and clinician driven
- need to know physiology to apply exercises
- key aspect is plasticity of skeletal muscles
- drill is essential
- efforts to increase strength should follow rules for strength training
what are different types of neural plasticity
perilesional: around the lesion
ipsilateral: same hemisphere different area
contralateral: different hemisphere same area
what is plasticity
the ability to change over time because of practice
what 3 elements interact for movement to be learned
- learner needs to understand task and be motivated
- the task needs to be appropriate with correct intensity and specific
- the enviornment: specific to the bolus and time of day
what exercises target oral prep and transfer
Iowa Tongue Pressure Inventory: isotonic and isometric
therabite: maximized jaw opening
what is trismus
lock jaw
what exercises target delayed initiation of swallow
thermal-tactile stimulation
what is FEESST
Fiberoptic endoscopic evaluation of swallowing with sensory testing
goes thru arytenoids with another device which sends air pulses
response to stimulation is the laryngeal adductor reflex
detects silent aspiration
what is HRM
high resolution manometry
assesses pharyngeal pressure changes
what exercises target BOT retraction
Masako
Effortful Swallow
Tongue pull-back maneuver
what exercises target hyolaryngeal excursion
mendelsohn maneuver
shaker exercise
chin tuck against resistance CTAR
what exercise targets impaired airway protection
supraglottic swallow
EMST expiratory muscle strength training (cough)
what are isometric exercises
done in static position
what is the free water protocol
improves QoL by allowing water to patients who aspirate thin liquids
candidacy: good oral hygiene, cognitive status
water permitted between meals not during or until 30 minutes after
no thin liquids with meds
how is masako performed
tip of tongue between teeth
patient dry swallows
10 reps
how is effortful swallow performed
imagine ping pong ball in mouth to swallow
10 reps
how is supraglottic swallow performed
hold breath swallow hard cough swallow again 10-12 times without breathing between do not use with stroke patients because of valsalva
how is mendelsohn maneuver performed
at peak of swallow patient squeezes and holds
document length of time
10 reps
how is the shaker exercise performed
patient lies flat
isometric: lifts head and looks at toes hold for 20 sec
isokinetic: repeatedly look at toes 20-30 times
may cause pain in cancer patients
what is onstage vs offstage
timing related to meds and parkinsons patients
what are other rehab options
- pitch gliding: improves airway protection
- myofascial release: massage that strengthens pharyngeal musculature
- expiratory muscle strength training: strengthens expiratory muscles
- free water protocol: improves subglottal pressure and vestibular squeeze
what are behavioral interventions for pediatric feeding disorders
- shaping,
- prompting,
- modeling,
- stimulus fading,
- alternate behavior,
- basic mealtime principles (schedules),
- food chaining
what are pediatric postural techniques
chin tuck chin up head rotation upright position (45 degree angle at hips and knees head stabilization reclining position side lying position for infants
what are adaptive techniques for pediatric dysphagia
postural equipment/utensils biofeedbac if active participant oral motor stimulation (increases sensation) sensory stimulation prosthetics
