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Dysphagia > Pediatric Dysphagia > Flashcards

Pediatric Dysphagia Flashcards

1
Q

What is a feeding disorder?

A

“persistent failure to eat adequately” which results in significant loss of weight or failure to gain weight

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2
Q

When does a feeding disorder occur?

A

Prior to six years, but onset is usually in first year of life.

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3
Q

What are some symptoms demonstrated by peds with a feeding disorder?

A

Unsafe or inefficient swallowing

Growth delay

Lack of tolerances to food textures and tastes

poor appetite regulation

rigid eating patterns

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4
Q

What is a swallowing disorder?

A

Specific type of feeding disorder in which child exhibits unsafe or inefficient swallowing pattern that undermines feeding process.

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5
Q

What is ‘inefficiency’ refer to?

A

Inefficiency: unable to meet caloric and nutritional needs because process of feeding and swallowing is not productive

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6
Q

What does ‘overselectivity’ refer to?

A

Overselectivity: restrictive in taste, type, texture, and/or volume of foods eaten

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7
Q

What does ‘refusal’ refer to?

A

Refusal: complete refusal to feed, due to ongoing medical issues, gastro-intestinal distress, or traumatic experiences

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8
Q

What does ‘feeding delay’ refer to?

A

Feeding Delay: delayed development of feeding skill milestones

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9
Q

What new diagnosis did Amanda share about?

A

Avoidant Restrictive Food Intake Disorder

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10
Q

What is Avoidant Restrictive Food Intake Disorder (ARFID)?

A

Definition: An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with on (or more) of the following:

Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)

Significant nutritional deficiency

Dependence on enteral feeding (feeding tube) or oral nutritional supplements

Marked interference with psychosocial functioning

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11
Q

List the 5 primary causes/risk factors for pediatric dysphagia discussed in class.

A 
Low birth weight
Developmental disabilities
Prematurity
Prenatal drug exposure
Diet restrictions
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12
Q

What are some more cause/risk factor associated with pediatric dysphagia?

A 
Craniofacial abnormalities
Neurologic Issues
Cardiac problems
Respiratory conditions
Nutritional and Gastrointestinal Issues
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13
Q

Other than medical issues, what could be an explanation for pediatric dysphagia?

A

Negative parent behaviors: over-stimulating, under-stimulating, rigid and demanding, chaotic and frenzied, overly concerned or anxious

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14
Q

For a positive feeding time infants must exhibit what characteristics?

A

positive
alert
calm
show readable cues for hunger and fullness and willingness to try to tastes and textures

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15
Q

For a positive feeding time toddlers must exhibit what characteristics?

A

interested in eating, indicate hunger and fullness, follow a predictable meal schedule, positive behaviors

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16
Q

Why is in utero swallowing important?

A

it is important for the regulation of amniotic fluid volume and the maturation of the fetal digestive tract.

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17
Q

When does pharyngeal swallowing develop?

A

most fetuses develop the pharyngeal swallow around 15 weeks and are consistently swallowing by 22 to 24 weeks.

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18
Q

When do oral motor movements and suckling typically begin?

A

10-14 weeks

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19
Q

When does true suckling begin? What characterizes it?

A

True suckling begins around the 18th to 24th week and is characterized by distinct backwards/forwards movements of the tongue.

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20
Q

T/F

Frequency of suckling motions can be altered by taste.

A

True. If a mom eats something spicy or sweet, the baby may react differently!

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21
Q

Describe an infant’s ability to suckle outside the womb at 34 weeks gestation.

A

Some HEALTHY preterm infants suckle and swallow well enough to sustain full oral feedings.

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22
Q

Decreased rates of fetal suckling are often associated with what?

A

Digestive tract obstruction or neurological damage.

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23
Q

How many primary stages of sucking are listed in the Infant-Driven Feeding Scale in preterm infants?

A

5
Ranging from:

1a: no sucking; arrhythmic expression

to

5: Rhythmic, well-defined suction and expression; increasing suction amplitude; sucking pattern similar to term infant.

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24
Q

Oral feeding requires the sequential timing of what structures?

A

Tongue, larynx and laryngeal muscles.

26 Muscles and 6 Cranial Nerves!

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25
Q

What are some of the things that successful feeding experiences in infancy fosters?

A

Efficient nipple control
reaching
smiling and social play
Feeding gradually becomes a social event!

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26
Q

Successful emergence of communication = ???

A

successful feeding and swallowing

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27
Q

Describe the Synactive Model of Behavioral Organization.

A

This is a pyramid diagram where the bottom represents the most important thing an infant needs before anything else: Physiological Stability. They need to be able to breathe before they are wiggling their legs. From there the next tier is Motor Organization (moving around), then Behavioral State Organization, then Attention/Interaction, finally is Self-Regulation (self-soothing.)

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28
Q

Control in what two areas is needed prior to achieving jaw stability?

A

Head and trunk control are needed prior to achieving jaw stability.

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29
Q

Why is pincer grasp important?

A

Pincer grasp is not only helpful for picking up small toys but also for finger feeding small pieces of food.

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30
Q

Why is the ability to reach across the mid line important?

A

This demonstrates ability to cross the mid line, which is needed for tongue lateralization needed for mastication and bolus control.

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31
Q

During what ages should a baby be breast/bottle fed?

A

Birth - 12 months

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32
Q

Around what ages should thin baby food cereals be introduced?

A

5-6 months if they have the trunk support.

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33
Q

Around what age should slightly thicker baby food cereals be introduced? Liquid Puree?

A

5.5-6.5 months

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34
Q

When should stage 1 foods, thin baby food purees, be introduced?

A

6-7 months

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35
Q

When should stage 2, thicker baby food cereals and smooth puree, be introduced?

A

Around 7-8 months

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36
Q

Why don’t we just go to stage 3 baby foods right away?

A

Stage 3 are mixed consistency
(puree + chunks)
They need to have a chewing motion.

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37
Q

When should soft mashed table foods smooth purees be introduced?

A

8-9 months

38
Q

When should hard munchables be introduced? (e.g. raw carrot sticks, bell pepper strips, frozen pancakes)

A

8-9 months

Baby should not be left unsupervised with hard munchables as they may be a choking hazard.

39
Q

When should meltable hard solids be introduced? (biter biscuits, Ritz crackers, cheese puffs, etc)

A

around 9-9.5 months

40
Q

When should soft cubes (avocados, overcooked squash, kiwi, vegetable soup ingredients) be introduced?

A

10 months, even if they can’t chew it all or mash it with their tongue, they will still be safe.

41
Q

When should soft mechanical single texture (muffins, soft small pastas, thin deli meats, etc) be introduced?

A

Around 11 months.

42
Q

When should stage 3 foods (mixed textures) be introduced?

A

at 12 months

43
Q

By age 13-14 months, what foods should be introduced?

A

Soft Table Foods (fruit breads, muffins, cubed lunch meats, etc.)

44
Q

By 15-18 months, what foods can be introduced?

A

Hard mechanicals: cheerios, hard cookies, chips, raw fruits and veggies.

45
Q

What occurs during the 18-24 month stage?

A

Refinement of skills: mastication, tongue strength, speed of chewing, etc.

46
Q

Who can also be a part of a swallowing team with you?

A 
MD/NP/PA 
RDN
ENT
GI
RN
Parents
OT/PT
Pulmonologist 
Radiologist
RT
47
Q

What ages is the Infant Feeding Evaluation designed for?

A

Birth - 1 yo

48
Q

Who is invovled with an infant feeding evaluation?

A

SLP and OT

49
Q

What is an infant feeding eval?

A

A clinical (not objective) evaluation of the infant swallowing (bottle or breastfeeding)

50
Q

Do you want to assess both non-nutritive and nutritive assessments?

A

Yes, if possible. A non-nutritive assessment is kind of like an Oral Mech to get an idea of the structures and abilities.

51
Q

List some clinical signs and symptoms of oral difficulty in infant feeding.

A

Inefficient extraction

Disorganized suck swallow breathe pattern

Anterior spillage

Decreased ability to latch on to the nipple

Disorganized tongue/jaw function

52
Q

List some clinical signs and symptoms of pharyngeal difficulty in infant feeding.

A

Coughing/throat clearing

Spitting, gagging, emesis (vomiting)

Physiological changes such as drop in O2 saturations, increase in HR or RR

Changes in upper airway sounds via cervical auscultation (stethoscope to listen)

Weak, hoarse or wet sounding cry

53
Q

T/F Infants are often silent aspirators.

A

True.

54
Q

After 1 year-old, what evaluation is conducted to assess swallowing?

A

The Bedside Swallow Evaluation

55
Q

Who conducts the bedside swallow eval of a 1+ year old?

A

An SLP unless there are any tactile/sensory issues, in which case an OT should consult with the SLP.

56
Q

What are some factors to look for in a chart review?

A 
Gaining Weight?		Recurrent illness
H/o Pneumonia		Medications			
Pulmonary issues		 Current nutrition source 
GI issues			Craniofacial abnormalities
Intubation, ventilator and O2 		
GERD
Failure to Thrive 		Alertness
Neurological involvement		Syndromes
57
Q

What are some clinical signs and symptoms of oral difficulty in pediatric dysphagia?

A 
Inefficient extraction from bottle/sippy cup
Poor labial seal on spoon/cup/straw
Decreased mastication
Anterior spillage
Decreased bolus control
Disorganized tongue/jaw function
58
Q

What are some clinical signs and symptoms of pharyngeal difficulty in pediatric dysphagia?

A

Immediate or delayed coughing/throat clearing
Gagging or emesis
Physiological changes such as drop in O2 saturations, increase in HR or RR
Changes in upper airway sounds via cervical auscultation
Wet, gurgly vocal quality

59
Q

What should the blood oxygenation level be at?

A

Between 90-100%

60
Q

What are some of the possible outcomes of a bedside swallow exam of a pediatric dysphagia patient?

A 
Cleared for a PO diet without restrictions
Put on a modified diet temporarily
Keep NPO 
Begin treatment 
Allow time to improve
Change medications
Wean O2
Proceed with a Video Swallow Study
Need a temporary NGT/NDT or a G-tube
Results impacted by presence of NGT/NDT
61
Q

What are some of the major reasons for referrals for outpatient evaluations?

A

Picky eater (i.e. will not eat any fruits/vegetables)

Not transitioning from baby foods to table foods

Choking/gagging on foods

Not gaining weight

Dysphagia (oral or pharyngeal)

Children who are NPO and families either need guidance on oral stimulation, are ready to try oral feeds again or need dysphagia treatment (NMES)

62
Q

What is included in a pediatric outpatient dysphagia evaluation?

A

History of feeding problem – when did it start? What are the parents’ concerns? Were there any traumatic events surrounding feeding? Are there differences between eating at home vs. school?

Medications

Medical History/surgeries – neurological impairments?

Weight/height

Allergies

Bowel habits

63
Q

What is constipation?

A

Constipation means that you’re not moving your bowels often enough, and your bowel movements are harder and drier than normal.

64
Q

How often should the pediatric patients have bowl movements?

A

every 1-2 days they should have a bowl movement

65
Q

Why are stools so important?

A

Because it may tell us WHY a child is not eating.

66
Q

What kind of information can we get from stool?

A

Food Allergies – stools will be inconsistent and the child may be constipated or loose

Think of the GI tract as one long tube. If the child is constipated, then that may cause the reflux to worsen. Or it may make the child feel full and refuse to eat at meal time.

Does the child have CP and that is causing constipation?

67
Q

What is a PediEAT?

A

A caregiver questionnaire that assesses observable symptoms of problematic feeding in children ages 6 moths to 7 years.
Doesn’t provide a diagnosis, but provides an objective assessment of the child’s eating to facilitate a diagnosis and treatment decisions.

68
Q

What additional factors are important to note when conducting a pediatric dysphagia assessment?

A

Previously diagnosed Dysphagia?

Home Environment

Child’s Current Routine

Sensory Differences (not just food, but other ADLs)

Oral Motor Exam

Snack/Meal Observation

69
Q

What does a snack/meal observation consist of?

A

We ask families to bring food from home for the evaluation so that it is prepared just like it would be for a meal at home. We ask that they bring something the child likes and eats well and something they used to eat or refuse to eat.

70
Q

What are some typical diagnoses in outpatient rehab?

A

Sensory based feeding disorders

Oral motor dysfunction (Oral dysphagia) including tongue/lip ties

Pharyngeal dysphagia (based on VFSS)

Picky eating habits

GI issues

Parental issues

71
Q

Describe a “picky eater”

A

Decreased range or variety of foods but will eat >/= 30 foods

Foods lost due to “burn out” usually re-gained after ~2 weeks

Tolerates new foods on plate and usually can touch or taste

Eats >/= 1 food from most all food texture groups or nutrition groups

Adds new foods to repertoire in 15-25 steps

Typically eats with family, but frequently eats different foods than family

Sometimes reported as “picky eater” at well child checks

72
Q

Describe “problem feeders.”

A

Restricted range or variety of foods, usually <20

Foods lost are NOT re-acquired – food jags

Cries/falls apart with new foods

Refuses entire categories of food textures or nutrition

Adds new foods in >25 steps

Usually eats different foods than family and often eats alone

Persistently reported as “picky eater” across multiple well child checks
group

73
Q

List some typical recommendations after a pediatric swallow eval.

A

Direct feeding therapy by OT or ST

VFSS

Refer back to GI or pediatrician for management of reflux, constipation or for further assessment

Consider Allergy Testing

Refer to nutritionist if there is not one already involved

74
Q

What may be included in a Home Program?

A

Establish a feeding schedule

Seating/positioning adjustments

Change in feeding utensils/cups

Change in textures of foods offered

Oral stimulation of some kind

75
Q

Discuss some alternative and supplemental feeding methods.

A

Enteral or tube feeding – liquid nutrition is delivered through a tube (can be sole avenue for nutrition or supplemental to oral intake)

Short-term treatment: nasogastric tube, TPN

Longer-term treatment: gastronomy tube or jejunostomy tube

76
Q

List some interventions for the dyphagic infant.

A

Change the position of the baby while feeding

Change the bottle/nipple

Changing the formula or rice cereal

77
Q

What are some goals for infant feeding and swallowing?

A

Promotion of quality feeding experiences by reducing infant and feeder stress.

Engaging families to assume an active role in helping their infant be successful.

Teaching parents to read and respond to their infant’s cues.

78
Q

Describe Neuromuscular Electrical Stimulation (NMES) aka Vital Stim or Guardian.

A

Neuromuscular Electrical Stimulation or NMES uses a device that sends electrical impulses to nerves. This input causes muscles to contract. This may result in increased strength of those muscles and increased range of motion.

79
Q

Describe acute versus chronic dysphagia.

A

Acute may be related to intubation, trauma, medication

Chronic may be related to neurogenic cause, pulmonary conditions, feeding difficulty as an infant or oral aversion

80
Q

What should you consider in creating goals for treatment?

A

Goals obviously depend on the cause of the feeding problem/dysphagia

They can be created for intake of a specific volume of food, a specific number of repetitions for an exercise or to increase the variety of foods a child will accept.

81
Q

In the Functional Oral Intake Scale, what does 1 represent?

A

No oral intake

82
Q

In the Functional Oral Intake Scale, what does 2 represent?

A

Tube dependent with minimal/inconsistent oral intake.

83
Q

In the Functional Oral Intake Scale, what does 3 represent?

A

Tube supplements with consistent oral intake.

84
Q

In the Functional Oral Intake Scale, what does 4 represent?

A

Total oral intake of a single consistency (this is the line of Total oral intake)

85
Q

In the Functional Oral Intake Scale, what does 5 represent?

A

Total oral intake of multiple consistencies requiring special prep.

86
Q

In the Functional Oral Intake Scale, what does 6 represent?

A

Total oral intake with no special preparation, but must avoid specific foods/liquids

87
Q

In the Functional Oral Intake Scale, what does 7 represent?

A

Total oral intake with no restrictions

88
Q

How many stages are there in the Functional Oral Intake Scales?

A

7

89
Q

How can we treat children with pharyngeal dysphagia/NPO?

A

Oral stimulation is HUGE!!

Are they a candidate for neuromuscular electrical stimulation (NMES)?

Is there a plan for the child to become an oral feeder?

90
Q

What aspects do we treat with respect to oral motor treatments?

A 
Proper seating with support
Jaw Stability
Lip Closure
Tongue Lateralization
Chewing
Alternating how we present foods (e.g. textures/utensils.)
DO NOT scrape infant/child’s face with spoon as this can be confusing. If you must, use a cloth to wipe the face.
Beckman's Massage
91
Q

What are some approaches to treatment for children with sensory/behavior based treatment?

A

Wilbarger Deep Pressure and Proprioceptive Technique as well as encouraging other proprioceptive input
Encourage messy play
Pair foods with the same color together in therapy
Food chaining: Start with foods that the child will eat and only change one characteristic at a time (e.g. if child eats white string cheese, try white sliced cheese, then try cheese toast, then maybe cheese on pizza dough)
Engage the child in food play during therapy sessions with the idea that the child is going to move further along with each food.
For example, if a child will only touch a food with utensils, we will encourage the child to touch the food with just a single finger.
Use of nuk brushes, vibration, spicy foods vs. bland
Encourage the child to help prepare foods at home and in therapy
Use traditional behavioral strategies such as checklists, special placemats, special utensils

92
Q

What is the goal of treatment with a child who has sensory/behavior based dysphagia?

A

To decrease anxiety around foods and to make any interaction with food enjoyable.

Dysphagia (17 decks)

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