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Medically Based Pediatrics > Infant Feeding and Evaluation > Flashcards

Infant Feeding and Evaluation Flashcards

1
Q

What body systems does feeding rely on?

A
  • Sensorimotor
  • Neurologic maturation
  • Cognition
  • Emotion
  • Human interaction
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2
Q

What are major feeding considerations for pediatrics?

A
  • 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
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3
Q

What structures in the mouth offer protection?

A
  • 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
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4
Q

What is the timeline for the development of reflexes in typically developing newborns?

A
  • 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

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5
Q

What is the typical suck, swallow, breathe pattern?

A
  • 2-8 sucks > swallow > breathe
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6
Q

When do the majority of NICUs begin oral feeding?

A

34 weeks

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7
Q

What is the postural control of a newborn?

A
  • 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
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8
Q

What happens as a baby’s postural control increases?

A
  • 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
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9
Q

What is the etiology of feeding difficulties in infants and children?

A
  • 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
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10
Q

What are common congenital anatomical defects?

A
  • Tongue and lip ties
  • Cleft lip or palate
  • Laryngomalacia
  • Tracheomalacia
  • Micrognathia
  • Vascular ring
  • Tracheoesophageal Fistula
  • Pyloric stenosis
  • Laryngeal cleft
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11
Q

What is a tongue tie?

A
  • 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
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12
Q

What is a cleft palate?

A
  • 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
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13
Q

What is laryngomalacia?

A
  • 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
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14
Q

What is micrognathia?

A
  • A condition where the jaw is undersized

- Bottom lip has trouble completing the seal during feedings

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15
Q

What is pyloric stenosis?

A
  • The pylorus/lower portion of stomach that connects to the small intestine has a problem
  • Causes projectile vomiting that can cause dehydration
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16
Q

What are examples of neurological disorders that can cause problems with feeding?

A
  • 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
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17
Q

What are examples of gastrological conditions that can affect feeding?

A
  • Infant reflux (kids will either overeat or not eat enough)
  • Gastroesophageal reflux disease (rashes, bloody diapers)
  • Poor motility
  • Short gut
  • Constipation
18
Q

What are examples of cardiac conditions that can affect feeding?

A
  • 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
19
Q

What is common in prematurity?

A
  • 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
20
Q

What does a clinical evaluation look like for a baby that is premature?

A
  • Chart review
  • Parent interview
  • Developmental assessment
  • Oral motor exam
  • Food trial
  • Recommendations
21
Q

What are common feeding goals for a premature baby?

A
  • Is their swallow safe?
  • Can they meet nutritional and hydration goals?
  • Are their skills functional?
  • Is it a solid foundation for advancing skills?
22
Q

What should be addressed when asking caregivers about the child’s medical history?

A
  • 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
23
Q

What should be addressed when asking caregivers about the child’s environment?

A
  • 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)
24
Q

What should the development assessment for feeding entail?

A
  • 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
25
Q

What is prolonged sucking? Is prolonged sucking good?

A
  • 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
26
Q

What are short sucking bursts? Are short sucking bursts good?

A
  • 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)
27
Q

What are obvious signs of having problems with swallowing?

A
  • Coughing
  • Choking
  • Desaturation during feeding
  • Gagging - self-protective response
  • Increased work of breathing
28
Q

What are the “soft signs” of having problems with swallowing?

A
  • 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
29
Q

What are considerations for Video Fluoroscopic Swallow Study (VFSS)?

A
  • 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
30
Q

What two terms are used during VFSS?

A

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

31
Q

What are consideration for FEES?

A
  • 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
32
Q

What feeding difficulties are encountered in pediatrics?

A
  • Environmental and postural changes
  • Bottle or flow rate changes
  • Positioning
  • Facilitation techniques
  • External pacing
  • Thickened liquids
  • Tummy time
  • Non-nutritive feeding techniques
33
Q

How can OT treatment change the environment during feedings?

A
  • 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)
34
Q

How can OT treatment address posture for successful feedings?

A
  • 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
35
Q

What are signs that the flow rate of a bottle is too fast?

A
  • Watery eyes

- Milk leaking out the mouth

36
Q

What is a sign that the flow rate of a bottle is too slow?

A
  • The baby is collapsing the nipple
37
Q

What are two types of positioning for feedings?

A

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
38
Q

What are examples of facilitation techniques during feedings?

A
  • 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
39
Q

What is external pacing?

A
  • 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
40
Q

When are thickened liquids used for babies?

A
  • 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
41
Q

What are OT feeding treatment goals?

A
  • 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
42
Q

What are possible reasons for a lack of progress after OT feeding treatment?

A
  • 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?

Medically Based Pediatrics (12 decks)

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