Guest: Pediatric feeding swallowing disorders Flashcards
prenatal development
- Taste buds 6-7wk
- Swallowing 11-14wk
- Non-nutritive (NNS) sucking 18-24wk
- Nutritive sucking (NS) 33-36wk
- Functional taste sensation 14-18wk
- Functional olfaction ~24wk
- Coordinated sucking and breathing 38-40wk
postnatal development
Swallowing
* dependent on digestive, respiratory and sensory functions
* Not only anatomical overlap
* Reflexes involved in swallowing are used in both digestive and respiratory functions: Chemoreceptors, Mechanoreceptors, Thermoreceptors, Nocioreceptors
Sucking
* a brainstem reflex that persists for first 1-3 months and then matures
* NS starts with bursts of sucking then bursts of breathing
* Matures to bursts of 20-30 sucks-swallows with breaths (1:1:1; 2:1:1)
* Matures with increased volume per suck
* Not just dependent on gestational age
What are some clues to feeding ability?
- alertness (should not be falling asleep)
- breathing (should be consistent chest rise)
Infany feeding skills
- suction (oral)
- expression (oral): Jaw, lips, tongue (elevates to cause vacuum seal)
- Movement of fluid bolus: Tongue
- Pharyngeal: Pharynx constricts, palate elevates, epiglottis closes, vocal cords close UES relaxes then contracts
- Esophageal
Clues to diagnosis in infant feeding skills
- Oral phase poor suck, pocketing, spillage and drooling; sensory responses like gag and vomiting on early presentation
- Pharyngeal phase cough, gag, nasopharyngeal regurgitation, aspiration… & speech delay
- Esophageal phase as above (discordant upper esophageal relaxation) and regurgitation/vomiting
risk factors for feeding skills
Functional
* Prematurity
* Neurological or neuromuscular disease
* Cardio-respiratory disease
Structural
* Oro-facial-laryngeal
* Tracheoesophageal fistula (TEF)
Environmental
* negative/depriving experiences (especially oral)
* lack of love
Advantages and challenges of breastfeeding
Advantages
* NNS / oral stimulation - 27 weeks GA
* learning NS - 33-33 weeks (often start 29 weeks)
* Requires less sucks per burst (bottle fed babies have to continuously suck as continuous flow of milk)
* Helps feeding maturation & cognitive development
Challenges
* Flow of milk depends on skill; esp suction pressure
* Feeding studies in preterm focus on bottle feeding
Feeding as a learned behaviour
first 6 months are critical time for learning
* Dependent on maturation and stimulation
* Animal science ‘imprinting’ (eg. maternal deprivation during suckling period in many speicies can cause feeding difficulties)
* Delayed introduction of solids can lead to food refusal, vomiting, failure to chew
* Esophageal atresia without sham feeds may never establish oral feeding
What is PFD?
Pediatric feeding disorder
* Defined as impaired oral intake lasting at least 2 weeks that is not age appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction (in the absence of body image disturbances)
* Acute: 2 weeks to 3 months
* Chronic: 3 months or more
What is PFD associated with?
- medical dysfunction
- nutritional dysfunction
- feeding skill dysfunction
- psychosocial dysfunction
What is ARFID?
Avoidant Restrictive Food Intake Disorder - feeding disturbance
* psychiatric diagnosis in DSM 5
* associated with weight loss/ malnutrition and often dependance on tube feeding and oral nutritional support
What is most common cause of PFD?
neurological disorders
* others could be: autism, cardiorespiratory disorders, structural disorders (GI tract, ENT)
Aspiration
most feared end outcome typically associated with dysphagia where there is passage of material below vocal cords or penetration passage of material into larynx but above vocal cards
* thick solids is particularly bad if cannot clear
* cystic fibrosis and cerebral palsy are heightened risk
* 25% is silent; need instrumental diagnosis (VFSS, FEES)
Normalcy of aspiration
not all aspiration is bad depends (pharyngeal clearance is key):
* general health, mobility, oral & pulmonary health
* frequency, material & depth/clearance
Symptoms of dysphagia and aspiration
- Fussy with feeds
- Noisy breathing after feeds
- Turning head away or refusing feeds
- Vomiting
- Arching during feeds
- Coughing, choking, gagging during and after feeds
- Does better with thickened feeds
What can dysphagia be misdiagnosed with?
GERD
Most common causes of aspiration
- CNS disorder or lesion (aspiration is often seen as end stage for cerebral palsy)
- Vocal cord palsy
- Laryngeal cleft
- Neonatal Swallowing Dysfunction (usually improves over 6 months)
Clinical assessment of PFD
- History
- Examination
- Feeding assessment
Clinical assessment of PFD
* history
- Prenatal and birth history
- Respiratory
- GI
- Growth & Development
- Feeding history (history of refusal; solids worse than liquids consider structural issue)
- Family history & circumstances around feeding (time involved, who feeds and where, stress)
Clinical assessment of PFD
* examination
- Orofacial (chromosomal problems)
- Dentition
- Voice
- Respiratory
- Neurodevelopmental (difficult to assess in first 6 months)
- Nutrition
- Sensitivity to touch (or smell or texture)
Clinical assessment of PFD
* feeding assessment
Before - during - after feed
* RR/HR/Sats
* Arousal state
* Motor tone and oromotor function
* Caregiver interactions
Instrumental assessment of PFD
VFSS → Assess laryngeal and pharyngeal phase
* Limited assessment of oral phase (clinical exam)
* Limited assessment upper esophageal transit
* Delineates ‘risk’ of aspiration & timing relative to swallow (before-oral, during-phar or after-phar clearance)
* ‘safe’ textures can be determined
* Does not rule out aspiration
* Is not a real meal but artificial situation
* Is not a pass/fail exam
* Detailed but limited in time and real meal
* Normative data for infants insufficient
* Dynamic study but radiation dose limiting
* Challenging behavior limiting (32%)
Contraindication to VFSS
Feeding aversions
VFSS indications
- Risk for aspiration on history or clinical exam
- Prior aspiration pneumonia (but only 10-20% of those that aspirate & difficult to diagnose)
- Pharyngeal/Laryngeal problem
- Gurgly voice quality/stertor
- In order to manage swallowing problems
How to manage pediatric swallowing disorders
- GI role (medical domain)
- Feeding tubes
Manageing swallowing disorders through GI
- Identify the multidisciplinary team members (OT/speech, Psychology/Psychiatry, Dentistry)
- Assess nutrition - dietitian
- Assess need for endoscopy
- Assess need for a G tube (Safety, Nutrition)
Treatment for aspiration (and GERD)
Thickeners best option
Role of feeding tubes
- Impossible, unsafe or inadequate CHRONIC oral intake for nutrition and growth e.g. neurological disorders, craniofacial abnormalities, recurrent aspiration, etc. (Including to improve quality of life in PFD)
- To prevent wasting/malnutrition in high-risk scenarios e.g. CRF, CF, metabolic problems, CHD, SBS, IBD, etc.
- Support unpalatable diet or adherence to critical medications
- Rarely for gastric drainage and decompression
Can greatly improve QoL especially for parents who struggle to feed
Use of nasogastric tubes
Short term enteral nutrition support hospital and at home
* May have lower rates of emergency visits compared to G tubes at home (NICU grads)
* Trial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth
Risks of Ng tubes
- Safety concerns over nasal tube placement: Trachea and lungs, Brain, Esophagus
- Sleep disturbance for care giver
- Tube dislodgement (child pulls tube out or vomits up)
- Tube entanglement
- Tube blockages/kinking
- ncreased GERD
- Sinusitis
- Interference with normal swallow
- Oral aversion
