Medically Based Peds (Feeding) Flashcards
Test
Feeding: Childs physical structures are
Smaller (these smaller structures offer innate protection)
Feeding skills are initiated by______ but is a ______ ______
Reflexes (start to develop at 11-12 wks) Learned Behavior (volitional, as motor learning and sensory experiences occur right after birth
At what age do liquids make up all the calories in a childs diet?
Under the age of 1
Bottle and breast feeding requires_________
More frequent swallowing in a specific suck-swallow pattern
Infants are less likely to show ________ signs of suck swallow dysfunction
outward
Structures of the newborn vs adult Tongue is \_\_\_\_\_\_\_\_ Pharynx is \_\_\_\_\_\_\_\_ Epiglottis is \_\_\_\_\_\_\_ Larynx is \_\_\_\_\_\_\_\_ Narrowest at \_\_\_\_\_\_\_ Trachea is \_\_\_\_\_\_\_\_\_
Tongue is bigger Pharynx is smaller Larynx is more anterior and superior Epiglottis is bigger and floppier Narrowest at cricoid Trachea is more narrow and less rigid
Epiglottis and soft palate offer innate protection and are touching at rest to protect from aspiration, this changes around
4 months of age
How many Mm involved with swallowing
48
Reflexes: Suck documented at ________
11-15 weeks gestation
Suck reflex is present at _________
29-30 weeks gestation
Rooting begins at __________ and integrates at ______
28-30 weeks gestation
4 mos
Gag, survival response, protects airway is present at ____
32 weeks gestation
Suck, swallow, breathing often does not combine until ______
34 weeks gestation
typical infant breathing pattern during feeding is _____
suck 2-8 times between breathing
Do not try to orally feed if _________
preemie, before 34 weeks
posture that helps provide stability for oral movements with infant feeding
physiological flexion
need good proximal stability to feed b/c it is so complex
use swaddling to provide postural stability
Infant postural control: physiological flexion causes\_\_\_\_\_\_\_\_ cervical and thoracic spinal area are \_\_\_\_\_\_\_\_\_\_\_ upper chest is\_\_\_\_\_\_\_\_\_ ribs are \_\_\_\_\_\_\_\_\_\_\_\_ respiratory rate \_\_\_\_\_\_\_\_\_ with activity normal respiratory rate \_\_\_\_\_\_\_\_\_\_\_
a tight chest wall
underdeveloped (head appears to rest on thorax)
flat and narrow with no expansion during breathing (belly breathing)
horizontally aligned with no intercostal spacing
increases
38-60 breaths per minute
what physiological change advances the breathing pattern and allows for complete head flexion?
Obliques insert lower ribs to iliac crest, activating these pull the ribcage down and allows the intercostals to activate which advances the breathing pattern and allows for complete head flexion
why is tummy time good
it teaches children to use accessory Mm for breathing rather than just belly breathing and this allows better suck-swallow patterns
Name one disease that can cause higher rates of silent aspiration
Chiari Malformation (Spina Bifida)
stroke in utero can cause problems with
autonomic stability
list some congenital anatomical defects
tongue and lip ties
cleft lip or palate
laryngomalacia = floppiness or low tone inside larynx
tracheomalacia = cartilage that keeps trachea open is flaccid, trachea partly collapses
micrognathia = smaller jaw, can’t use bottom lip to seal
vascular ring
tracheoesophageal fistula
pyloric stenosis
laryngeal cleft
neurological defects
seizure
strokes
Chiari malformation
low tone
list some gastrological conditions
infant reflux
gastroesophageal reflux disease (GERD) = becomes disease process when kids are suffering from it, can be caused by poor motility, sometimes kids will not eat or over eat.
short gut
constipation
list some cardiac conditions
vocal cord paralysis = during cardiac procedure, left pharyngeal nerve is put at risk b/c surgical tools press down on arch, these children have problems with silent aspiration
poor perfusion to GI tract
often do not have early opportunities for eating
poor endurance
higher rates of aspiration /penetration
prematurity conditions that affect feeding
lack of physiological flexor tone
depending on PMA, their reflexes may not have emerged
weaker muscle tone around mouth and less tongue strength
retracted/tip elevated tongue
negative experience to oral cavity
Prolonged Sucking
lengthy sucking bursts without appropriate amount of breaths (10-15 sucks in a row)
infant not able to pace respirations with swallow
pauses with rapid, panting respirations
leads to cyanotic and/or bradycardic especially in preemies
usually at beginning of feeding when most hungry
more in preterm especially in 34-38 wk gestation
Short Sucking Bursts (SSB)
appropriate suck swallow breath ratio but pauses too frequently and long (could be a sign of swallow delay)
efficiency and intake compromised
usually related to swallowing or respiratory difficulties
maybe poor oral motor control affecting bolus formation and speed of swallow reflex
respiratory distress
observe retractions in sternal and clavicular
signs of swallowing defect
OBVIOUS: coughing, choking, desaturation during feeding, gagging and increased work of breathing
SOFT SIGNS: frequent respiratory illnesses, poor weight gain, refusal to eat or very picky eater and wet sounding voice which gets worse as they eat or after eating
Video Fluoroscopic Swallow Study (VFSS)
Sometimes called Barium swallow study
Completed in lateral view
Requires two staff members
Radiation
Fiberoptic Endoscopic Evaluation of Swallow (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
Penetration
Goes into trachea but pulls back out
Aspiration
Goes into trachea and does not come back out
Environmental feeding treatments
decrease distractions
allow adequate time but keep feedings to 30mins
don’t make multiple changes within one day
feed infant when fully alert and cueing
(IDF) infant driving feeding
Postural feeding treatments
Swaddling to promote physiological flexion
Provide appropriate trunk and head control
tummy time to promote head and trunk control
Feeding treatment positions
Semi-elevated
Elevated side lying = keeps babies from having huge vital sign swings, if child has vocal cord paralysis, put vocal cord that is working toward the ground. Babies were able to stay on thin liquids longer in this position
Feeding treatment facilitation techniques
Oral stimulation
Tongue support
Chin support
Unilateral cheek support
Feeding treatment for external pacing
For infants who have difficulty managing the flow
poor suck-swallow breathe coordination
Feeding treatments thickened liquids
Typically only used if indicated on VFSS
Feeding treatment goals
Positive and consistent feeding experiences promote strong neural pathways and motor learning
Use teach back and return demonstration for parents
Feeding
The process of setting up, arranging, and bringing food or fluid from the plate or cup to the mouth, sometimes referred to as “self-feeding”
Eating
The ability to keep and manipulate food/fluid in the mouth and swallow it; eating and swallowing are often used interchangeably
Swallowing
A complicated process in which food, liquid, medication, and saliva pass through the mouth, pharynx and the esophagus into the stomach
Feeding disorder
A medical diagnosis in which an infant or child is not able to achieve adequate nutrition
What can feeding disorders result from
Varied etiologies
poor oral motor skills
oral sensorimotor impairments
maladaptive behaviors during eating
Failure to thrive
A medical diagnosis in which the infant child is not meeting his or her nutritional needs
Pocketing food in mouth
possible oral motor deficit
Gagging, retching, and vomiting associated with eating and drinking
Poor pyloric sphincter (lower esophageal sphincter) closing (GERD)
Gastroesophageal Reflux Disease
Feeding disorder criteria
1) Lack of adequate eating with significant weight loss or failure to gain weight, lasting one month or longer
2) Behavior is not attributable to a gastrointestinal or other medical condition
3) Behavior is not better explained by lack of available food or another mental disorder
4) Onset is before age 6
Gastrostomy tube (G-tube)
Helps to increase caloric intake
less visible
could be for a child who needs a more permanent option
there is not an uncomfortable feeling in nose or throat
Naso-Gastrostomy tube (NG-tube)
Helps to increase caloric intake
more visible
lots of area for infection (nose)
more temporary solution that does not require surgery
does not feel good down nose and throat
easy to pull out
may not be able to actively participate in childhood occupations
Sensory Processing Evaluations
Caregiver Sensory Profile-2 (Dunn model oral motor)
Infant Toddler Sensory Profile-2 (Dunn model oral motor)
Sensory Processing Measure or SMP-preschool (Ares model of sensory integration)
Oral tactile sensory processing reminders
eating is not just the inside of our mouth
allergies
proprioceptive is almost always calming
behaviors to assess during feeding evaluation
general temperament ability to self-sooth or calm attachment coping skills interaction with caregiver (very important) interaction with therapist eye contact ability to follow commands avoidant behaviors (what is parent doing when child is displaying the "no moments"
Oral motor skill evaluation
Lips: ROM and strength
symmetry
Cheeks: ROM and strength
symmetry
Jaw: Strength
Chewing pattern with food and non food items
Resting posture
Tongue: Lateralization to molars
protrusion and retraction
elevation
Palate: Shape/Vault
AbnormalitiesFeeding intervention strategies
Sensory-based
Oral motor (FOR = biomechanics and NDT)
Behavioral
Oral Motor Treatment Strategies
ROM/strength Beckman stretches Rona Alexander Facial wrapping Clearing spoon with lips Overland tongue bowling exercise
Sensory-Based feeding intervention
Expose child to new sensory experiences in a non-threatening play based manner first before presenting them in a feeding session
Allow child to have some choice
measured by assistance level or aversion level
pretend play for self feeding = have child feed a doll or stuffed animal
scooping food or non food items
sensory treatment with hypo-sensitive child
(under responsive) increase oral awareness with Nuk brush, vibration, chewy tubes use foods that will give input hot/cold salty/bold spicy crunchy
sensory treatment with hyper-sensitive child
(over responsive)
activities that will decrease the childs sensitivity
nuk brush, vibrations, chewy tubes, calming environment
Sensory based progression for the non-oral eater
dry spoon wet spoon spoon with water spoon with flavored water spoon with thickened water puree
sensory based feeding treatment
increase variety around the bowl (Marcia Dunn, get permission approach) increase texture (crumbs, dippers)
Steps to eating
stair step progression: tolerates interacts with smells touch taste eating Must always work at their level, never ask a client who is at tolerates to put food in mouth
Behavioral Modification Approach to Feeding
Behavioral Modification = Psychological approach that attempts to change or alter an individuals reactions to stimuli through reinforcement of adaptive behavior or extinction of a maladaptive behavior through punishment.
If decreased intrinsic motivation to eat, a behavioral modification FOR may be appropriate
weigh food before and after meal (scientific)
let child play with toy 1-2 minutes initially
set a time limit for meal (20-30mins)
consistency is crucial
Positive Reinforcement
Addition of something positive to increase the likelihood that a behavior will occur in the future. (2-3mins)
Negative Reinforcement
Taking away something to increase the likelihood that a behavior will occur in the future
(rarely used in feeding strategies)
Punishment
Addition or removal of something to decrease the likelihood that a behavior will occur in the future
Compliance training
System of reinforcement where verbal, gestural, and physical cues are given and positive reinforcement is given when child complies
Planned/active ignoral
positive reinforcement is consistently withheld for non-dangerous, non-destructive problem behaviors
Behavioral Modification Approach Protocol (Feeding)
Keep neutral voice and facial expression when offering bites
Actively ignore negative behavioral reactions
begin with 1 to 1 ratio of bites to opportunities to play
increase ratio reinforcement system when child is consistently taking bites
begin building volume, then increase variety (VERY IMPORTANT)
Deglutition
the normal consumption of solids and liquids
Birth to 6mos oral motor behaviors
Suckling and Sucking
Sucking is a more nutritive process
Sucking patterns: 1 suck/per second = nutritive suck
2 sucks/per second = non-nutritive
6-30 months oral motor behavior
Munching = flattening and spreading of tongue, combines with up and down jaw movements (primitive motion)
Chewing = spreading and rolling movements of the tongue, tongue lateralization and rotary movements
Tongue lateralization = movement of the tongue to the sides of the mouth to propel food between the teeth for chewing
Rotary Jaw Movements = smooth interaction and integration of vertical, lateral, diagonal and eventually circular movements of jaw used in chewing
Controlled sustained bite = easy, gradual closure of teeth on the food, with an easy release of the food for chewing
Food Texture Development
1 yr = pureed, blended, strained foods
1 1/2 yr = ground, lumpy foods
1 1/2 - 2 yr = cut up chunky diced foods
2 1/2 - 3 yr = all textures of table foods
Self feeding development (Finger feeding)
2 mos = brings fisted hand to mouth (supine and prone)
3 mos = hand to mouth with object
3 1/2 mos = recognizes bottle
5-6 mos = mouths and gums meltable crunches (baby crackers or puffs)
6-7 mos = feeds self a cracker
9 mos = independent finger feeding
Spoon and fork skills
9 mos = will bang a cup
9 1/2 mos = will stir spoon in imitation
12-14 mos = will bring filled spoon to mouth (but turns it over in route, more pronated grasp
15 - 18 mos = scoops food and will bring spoon and fork to mouth, spilling some
24 mos = brings food to mouth with utensil (palm facing up)
4 1/2 - 5 yrs = uses knife to butter bread or cut soft food
Cup drinking skills
Birth to 4 mos = accepts liquid from breast or bottle
4-6 mos = able to drink by cup held by a caregiver, poor lip seal, most of the liquid will spill
9 mos = able to hold and drink from bottle independently, able to drink from a cup, may spill, independent with sippy cup with valve
18 mos = can skillfully drink from a cup with lid using two hands
24 mos = can drink from an open cup with minimal spilling or liquid loss, by 30 mos should be able to skillfully drink by open cup with one hand
4-4/12 yrs = can pour liquid from carton or pitcher
Growth expectations
6 mos = weight doubles
12 mos = weight triples and length increases from 5-10 in
Second year = weight gain 4-6 lbs, length gain 4-5 in
Third year = 3.5-5.5 lbs, length 2-2.5in
What are the major principles of the Get Permission approach to feeding?
1) Adult sets goals
2) Child sets pace
What are “yes” behaviors or moments a child demonstrates during feeding?
1) Reaching forward
2) Leaning forward
3) Opening mouth
What are the “no” behaviors or moments a child demonstrates during feeding?
1) Pausing
2) Closed mouth
3) Turned head
4) Pushing food away
Describe a positive tilt during feeding
Parent leans toward child (physically or emotionally), child leans forward openly
Describe a negative tilt during feeding
Child pulling away from the meal
Pre-oral phase
Moves food or liquid to mouth
Oral preparatory phase
The oral structures form the bolus by tasting, chewing, manipulating and containing (Create Bolus)
Oral phase
Begins when the bolus is in the mouth and ends when the bolus enters the pharynx
Pharyngeal phase
Begins when the bolus enters the pharynx and ends when the bolus enters the esophagus
Esophageal phase
Begins when the bolus enters the esophagus and ends when the bolus enters the stomach
The order to address feeding importance
1) safety
2) nutrition/growth
3) feeding skill development
