Infant Feeding and Evaluation Flashcards
What body systems does feeding rely on?
- Sensorimotor
- Neurologic maturation
- Cognition
- Emotion
- Human interaction
What are major feeding considerations for pediatrics?
- Physical structures are smaller - offers innate protection
- Initiated by reflexes, but is a learned behavior
- Under the age of 1, liquids make up all the calories in a child’ diet
- Bottling and breast feeding requires more frequent swallowing in a specific pattern
- Infants are less likely to show outward signs of swallow dysfunction compared to toddlers and adults
- At about 11-12 weeks in-utero the reflexes start to develop
What structures in the mouth offer protection?
- Epiglottis and soft palate offer innate protection and are touching at rest
- At 4 months the structure begins to change
- About 48 muscles are involved in swallowing
What is the timeline for the development of reflexes in typically developing newborns?
- Suck-swallow: suck documented from 11-15 weeks gestation. Sucking reflex is present at 29-30 weeks
- Rooting: begins at 28-30 weeks gestation and integrates at 4 months
- Gag: survival response, protects the airway. Often not present until 32 weeks gestation
- Suck, swallow, and breathing often do not combine until 34 weeks
Reflexes become volitional as motor learning and sensory experiences occur right after birth
What is the typical suck, swallow, breathe pattern?
- 2-8 sucks > swallow > breathe
When do the majority of NICUs begin oral feeding?
34 weeks
What is the postural control of a newborn?
- Physiological flexion helps provide stability for the oral movements and creates a tight chest wall
- Cervical and thoracic spinal areas are underdeveloped: head appears to rest on the thorax
- Upper chest is flat and narrow with no expansion during breathing (belly breathing) - not using chest muscles
- Ribs are horizontally aligned with no intercostal spacing - only able to use abdomen to breathe - respiratory rate will jump up/down quickly since they do not have accessory muscles developed
- Respiratory rate increases with increased activity
- Normal respiratory rate: 38-40 beats/min
- Influences of upright gravity and motor development should change the ribcage so that ribs dangle downward
- Motor development occurs in the trunk - mainly the abdominals
- The most important to develop are the obliques because they insert on the lower ribs to the iliac crest and pull ribcage down so that intercostals can activate
- Swaddling is used to promote postural stability
What happens as a baby’s postural control increases?
- Activation of intercostals - tummy time helps newborns learn how to use their intercostals to breathe
- Achievement of full head control
- Stabilization of hyoid
- Advanced respiratory pattern
- Sound production
What is the etiology of feeding difficulties in infants and children?
- Congenital defect in anatomy
- Neurologic concerns
- Neuromuscular conditions: SMA, Muscular Dystrophy
- Gastrological conditions
- Sensory differences
- Trauma: surgery or intubation may result in vocal cord paralysis
- Cardiac conditions
- Prematurity
What are common congenital anatomical defects?
- Tongue and lip ties
- Cleft lip or palate
- Laryngomalacia
- Tracheomalacia
- Micrognathia
- Vascular ring
- Tracheoesophageal Fistula
- Pyloric stenosis
- Laryngeal cleft
What is a tongue tie?
- A condition that restricts the tongue’s ROM due to a usually short, thick or tight band of tissue (lingual frenulum) that tethers the bottom of the tongue’s tip to the floor of the mouth
- There are different levels
- Makes it difficult to breast feed
What is a cleft palate?
- An opening or split in the roof of the mouth that occurs when the tissue doesn’t fuse together during development in the womb
- Impacts feeding
- It is like trying to drink from a straw with a hole in it (unable to build up enough positive pressure)
- Usually fixed at one year of age
What is laryngomalacia?
- Softening of tissues in larynx/voice box above vocal cords
- Most common cause of noisy breathing in infancy
- Floppiness
- Baby may sound like a dog chew toy
- It is like trying to drink a Wendy’s shake and when the baby sucks stronger it makes the straw collapse. By the baby having to exert a lot of pressure he/she may experience respiratory distress due to collapsed airway
What is micrognathia?
- A condition where the jaw is undersized
- Bottom lip has trouble completing the seal during feedings
What is pyloric stenosis?
- The pylorus/lower portion of stomach that connects to the small intestine has a problem
- Causes projectile vomiting that can cause dehydration
What are examples of neurological disorders that can cause problems with feeding?
- Seizures: require heavy drugs that sedate child
- Chiari Malformation Type II/Spina Bifida: CNS is affected and higher rates of silent aspiration
- CP/stroke in utero: postural stability can be an issue and may have problems with autonomic stability
What are examples of gastrological conditions that can affect feeding?
- Infant reflux (kids will either overeat or not eat enough)
- Gastroesophageal reflux disease (rashes, bloody diapers)
- Poor motility
- Short gut
- Constipation
What are examples of cardiac conditions that can affect feeding?
- Vocal cord paralysis (L pharyngeal nerve branches behind aortic arch, putting the nerve at risk of damage. Results more commonly in L vocal cord paralysis)
- Poor perfusion to GI tract
- Often do not have early opportunities for eating
- Poor endurance
- Higher rates of aspiration/penetration
Comorbidities:
- Down’s Syndrome
- Digeorge
- Midline defects
What is common in prematurity?
- Lack of physiological flexor tone
- Depending on PMA their reflexes may not have emerged yet
- Weaker muscle tone around mouth and less tongue strength
- Retracted/tip elevated tongue
- Negative experience to oral cavity
What does a clinical evaluation look like for a baby that is premature?
- Chart review
- Parent interview
- Developmental assessment
- Oral motor exam
- Food trial
- Recommendations
What are common feeding goals for a premature baby?
- Is their swallow safe?
- Can they meet nutritional and hydration goals?
- Are their skills functional?
- Is it a solid foundation for advancing skills?
What should be addressed when asking caregivers about the child’s medical history?
- Medical comorbidities
- Growth
- Tube feeding (nasogastric or g-tube), gravity vs pump; bolus vs drip; time length of each bolus; volume; tube feeding schedule (day vs night)
- Respiratory status: color changes (dusky or cyanotic); retractions; tachypnea; nasal flaring; diaphoresis/perspiration; stridor; chronic congestion
- Oral structure
- Allergies or restrictions due to medical comorbidities
What should be addressed when asking caregivers about the child’s environment?
- Posture and positioning
- Family meal time behaviors
- Cultural considerations
- Behaviors
- Familial support
- Parent child relationship
- Diet, length of meals, and frequency of meals (most kids drink their bottles within 20 min)
What should the development assessment for feeding entail?
- Head control
- Head positioning
- Trunk control
- Fine and gross motor coordination
- What happens in one part of the body impacts the rest
- Generally, kids who have difficulty with fine motor control are going to have a hard time with feeding
What is prolonged sucking? Is prolonged sucking good?
- Prolonged sucking is not good. It could indicate immaturity of brainstem function regulating the integration of SSB rhythms. It could also be an early indicator of neurological dysfunction
- Lengthy sucking burst without appropriate breaths
- Usually at the beginning of feeding, when most hungry
- Infant not able to pace respirations with swallow
- Pauses with rapid, panting respirations
- Leads to cyanotic and/or bradycardia, especially in preemies
What are short sucking bursts? Are short sucking bursts good?
- Appropriate suck/swallow/breathe ratio but pauses too frequent and long
- Efficiency and intake compromised
- Usually related to swallowing or respiratory difficulties
- Delayed, not complete, or poorly triggered
- May be poor oral-motor control effecting bolus formation and speed of swallowing reflex
- Respiratory distress with high rate more 75-80 minutes
- Works excessively hard to breathe during feeding (retractions in sternal clavicular region)
What are obvious signs of having problems with swallowing?
- Coughing
- Choking
- Desaturation during feeding
- Gagging - self-protective response
- Increased work of breathing
What are the “soft signs” of having problems with swallowing?
- Frequent respiratory illnesses
- Poor weight gain
- Refusal to eat or very picky eating - caused by negative feedings
- Wet sounding voice
- A baby quickly loses calories by aspirating since the body has to do extra work to try and break down things that shouldn’t be in lungs
What are considerations for Video Fluoroscopic Swallow Study (VFSS)?
- Completed in lateral view in pediatrics
- Requires two staff members
- Try to limit exposure to radiation
- Has the child had other VFSS?
- Does the child have any upcoming surgeries or consults that would impact VFSS?
- Breast milk and breast feeding implications
What two terms are used during VFSS?
Penetration: food goes into trachea but pulls back out
Aspiration: goes into trachea past vocal cords and into lungs
Gel based products cannot be used with children under one year of age
What are consideration for FEES?
- Not tolerated well in children with scope at the same time
- Structures are smaller so it can be difficult to assess
- Unable to see below level of vocal cords
What feeding difficulties are encountered in pediatrics?
- Environmental and postural changes
- Bottle or flow rate changes
- Positioning
- Facilitation techniques
- External pacing
- Thickened liquids
- Tummy time
- Non-nutritive feeding techniques
How can OT treatment change the environment during feedings?
- Decrease distractions
- Allow adequate time but keep feeding to 30 minutes maximum
- Ensure all caregivers are providing full attention to infant
- Don’t make multiple changes within on day
- Feed infant when fully alert and cueing (IDF - 1/5 scale looks at feeding readiness and feeding quality)
How can OT treatment address posture for successful feedings?
- Swaddling to promote physiological flexion
- Providing appropriate trunk and had control
- Outside of feedings work on activities that promote head and trunk control
- Baby is still working on swallowing while in tummy time position
What are signs that the flow rate of a bottle is too fast?
- Watery eyes
- Milk leaking out the mouth
What is a sign that the flow rate of a bottle is too slow?
- The baby is collapsing the nipple
What are two types of positioning for feedings?
1) Semi-reclined: the neck is supported by the hand as opposed to the crook of the arm
2) Elevated side-lying: helps prevent babies from having huge swings in vital signs. Keep ears, shoulder, and hips stacked and nose pointing towards wall
- If a child has vocal cord paralysis then feed baby with functioning cord pointing towards the ground. Gravity will pull milk down
What are examples of facilitation techniques during feedings?
- Oral stimulation
- Tongue support (caregiver places support at the area of the “double chin”)
- Chin support is good for babies that have a smaller lower jaw. Caregiver applies pressure behind jaw bone and pulls jaw forward
- Unilateral cheek support is good in the elevated sidelying position
- Bilateral cheek support is no longer used because it increases pressure in the oral cavity and can cause difficulties with swallowing
What is external pacing?
- Helps baby with the suck-swallow-breathe rhythm because the baby has difficulty managing flow with coordination of suck-swallow-breathe
- Allow baby to suck 3-5 times and then tilt bottle downward or remove bottle if baby has not paused to breathe
When are thickened liquids used for babies?
- Typically only used for VFSS
- A thickened liquid diet impacts diet
- It is extremely difficult to thicken breast milk and most therapists do not like putting babies on thickened liquids
What are OT feeding treatment goals?
- The goal of all these treatments is to eventually eliminate them
- Positive and consistent feeding experiences promote strong neural pathways and motor learning
- Since consistency is so important - paretnal involvement and education is key
- Use teach back and return demonstration with parents
What are possible reasons for a lack of progress after OT feeding treatment?
- Are caregivers being consistent? How can we help them be more consistent?
- Are the expectations realistic?
- Do we understand the underlying cause of feeding difficulties
- Is the underlying cause actually being addressed?
- Are there comorbidities?
