oral phase dysphagia: motor-based feeding disorders

Question 1

types of disorders (4)

Answer 1

1) poor bolus lateralization
2) poor bolus mastication
3) poor labial seal
4) weak suck

Question 2

poor bolus lateralization

Answer 2

inability or difficulty moving the bolus from anterior area laterally to molar area (includes medializing)
-also affects ability to retrieve bolus laterally from buccal cavity and clear oral stasis (residue in mouth)

Question 3

presentation of poor bolus lat

Answer 3

• does not transfer bolus to molar area
• may fall into anterior sulcus
• typically stays on medial tongue; tongue may “pump” to move bolus back

Question 4

complications w/ poor bolus lat

Answer 4

• gag response
• loss of bolus over post. tongue
• large solid matter in phar. cavity- possible aspiration or airway blockage
• unable to eat solid matter

Question 5

conditions assoc. w/ poor bolus lateralization

Answer 5

• hyper/hypotonia
• any dx or condition assoc. w/ abnormal muscle function
• poor sensory awareness
• partial paresis

Question 6

tx strategies for poor bolus lateralization

Answer 6

• lateral lingual stroking, tapping, or tactile stimulation (vibration, textured teethers, flavored/textured gloves)
• increase sensory input (via taste, temperature, & texture)

Question 7

poor bolus mastication

Answer 7

inability/difficulty chewing solids or semi-solids

Question 8

presentation of poor bolus mastication

Answer 8

decreased force- does not exert adequate force during each chew
decreased endurance- does not demonstrate adequate chewing repetitions

Question 9

complications w/ poor bolus mastication

Answer 9

• gag response
• swallow of large bolus- at risk for aspiration or airway blockage
• downgrade solid diet (less firm or softer solids) or unable to eat solid diet

Question 10

assoc conditions w/ poor bolus mastication

Answer 10

• hypo/hypertonia
• any dx or condition assoc. w/ abnormal m. function
• sensory processing difficulties
• aversion to textures

Question 11

tx strategies for poor bolus mastication

Answer 11

• lateral biting stimulation: no teeth: use gloved finger; molar –> tool
• lateral placement of food
• pre-chewing foods- dissolvable crunchy sollids, feeding net- don’t require mastication; safer alternative
• gradual increase of texture - more sensory –> more motor

** never reach across mouth when finger inside; hold finger/tool perpendicular to molars to prevent putting finger in too far; cheek = barrier

Question 12

possible tools of bolus mastication tx:

Answer 12

gloved finger, Nuk, chewy toy, z-vibe, lil crunchies

Question 13

poor labial seal

Answer 13

inadequate ant. oral seal during oral and/or pharyngeal phase of swallow

Question 14

presentation of poor labial seal

Answer 14

• open lips during drinking, shewing, or swallow
• open mouth posture
• Ant bolus loss
• drooling
• jaw weakness and/or instability

Question 15

complications of poor labial seal

Answer 15

• unfavorable social feedings
• inefficient feedings secondary to bolus loss
• laryngeal penetration or aspiration secondary to poor oral seal
• complications assoc. w/ excessive drooling (social, personal, hygiene)

Question 16

assoc. conditions w/ poor labial seal

Answer 16

hypo/hypertonia

• any dx or condition assoc. w/ abnormal muscle function/fatigue or decreased endurance
• decreased respiratory status
• cleft lip
• poor sensory awareness, sensory defensiveness, or feeding aversion

Question 17

tx strategies for poor labial seal

Answer 17

labial tapping (passive)- tap lips in circular motion & follow w/ functional active task
labial stretches (passive)- stretch muscle in direction of muscle fibers; look for opposing m. pull/contraction
labial holding (active)- increases sensory and proprioceptive awareness- have them holding position, like holding pencil above lips
straw drinking (active)- make modifications- viscosity, cut straw, size of straw
spoon presentation
improve jaw stability & posture

Question 18

spoon presentation for poor labial seal

Answer 18

Those w/o good tone = need flat spoon so they don’t have to do as much

• *Maroon spoons- have a lot of surface area; only contact middle part of lips; the more nerves you contact, the more nerves you stimulate;
• *Lateral/horiz presentation of spoon helps; go up & contact upper lip, as you pull off, activates a bit and helps child pull off food; make it easier to get child to activate to get reward (food)

Question 19

4 things to do to achieve lip closure for tx

Answer 19

Flatbowl spoon, horz. Placement, contact upper/lower lips simult. & Downward pressure on tongue to get jaw to close more

Question 20

weak suck

Answer 20

inadequate sucking strength to functionally and efficiently remove liquid from breast/bottle
-most common prob in infants

Question 21

presentation of weak suck

Answer 21

• high suck/swallow ratio- bc of oral weakness, it takes infant 3-4 sucks to remove enough liquid to form normal-size bolus to swallow
• shortened sucking bursts (<10 sucks/burst)- weak sucking results in decreased ability to demonstrate normal-level sucking bursts
• general oral weakness- results in poor latch to nipple and limited effort exerted for each suck
• anterior loss of liquid

Question 22

complications w/ weak suck

Answer 22

lengthy feedings (>30 min)- inefficient

• incomplete feedings (doesnt finish full feeding secondary to fatigue)
• poor weight gain
• aspiration secondary to high suck/swallow ratio

Question 23

assoc. conditions to weak suck

Answer 23

• hypotonia
• any dx/condition assoc. w/ abnormal m. function, neurological dysfunction, fatigue or decreased endurance
• decreased respiratory status
• low birth weight or decreased sucking pads
• cleft palate (sometimes lip)

Question 24

tx strategies for weak suck

Answer 24

• higher flow nipple (bottle)- to match level of weakness so they don’t have to suck as hard
• cheek support (during feeding)- to decrease size of oral cavity
• resistive sucking on pacifier (active) - good for nasal regurge to clear nasal passages & helps w/ weak suck
• gentle resistance w/ bottle (active)- hand on chest & gently pull on bottle while they pull back
• side-lying position- always increases strength & swallow safety
• monitor/modify behavioral state- swaddle & borders!

Question 25

Things to remember:

Answer 25

• always wear gloves; use finger when possible
• use firm pressure to access muscle
• for low tone: vibration/tapping
• for high tone: stroking & firm, smooth movements to calm
• give client something to do during week, when you do not see him (homework?)