Pediatric Swallowing & Oral Motor/Feeding Disorders

Question 1

What are some statistics re: children/prematurity?

Answer 1

In 2009, 4.9 million children were born in the U.S.

1/10 children (40,000) were born premature.

“Prematurity” is any child born before 37 weeks gestation.

Highest rate for premature births was in 2006 (20%)… hitting kindergarten soon!!!

Question 2

T/F

Infants are miniature adults

Answer 2

False

Question 3

What is most of what an infant or child does during swallowing/feeding related to?

Answer 3

is related to airway maintenance and/or airway protection

Question 4

What is especially essential for swallowing?

Answer 4

Highly accurate timing of breathing w/ swallowing is essential

Question 5

What shared pathways exist for infants?

Answer 5

Shared pathways exist between the swallow/feeding & respiratory systems

Question 6

Even a subtle disruption in what can impact swallowing/feeding?

Answer 6

Even a subtle disruption in sensory-motor control can impact swallowing/feeding

Question 7

What may swallowing/feeding problems reflect?

Answer 7

may reflect problems elsewhere in the body

Question 8

KNOW THIS! ON EXAM!

Describe the suck-swallow-breathe synchrony

Answer 8

Structures present by 3.5 weeks gestation.

Swallow first occurs at 14-17 weeks gestation (15 oz of amniotic fluid a day).

Emerging S-S-B coordination at 31-33 weeks

S-S-B not functionally mature until 37-38 weeks or longer.

Anatomical link between the S-S-B structures is the hyoid bone.

Can’t learn; it’s a reflex

Question 9

Describe the non-nutritive Suck

Answer 9

Non-nutritive suck (NNS) rate is ≈2 sucks/second

NNS indicates an early sign of CNS integrity

Benefits of establishing a non-nutritive sucking pattern prior to the introduction of feeding include improved gastric motility, improved physiological states, and an ability for the baby to self-comfort and manage stress.

27-28 weeks: Weak single suck with long variable pauses emerge

30-33 weeks: short sucking bursts with long irregular pauses. May have periods of apnea (hold breath for 3 sucks before taking next breath)

Question 10

What is the nutritive suck rate?

Answer 10

approximately 1 suck/second

Question 11

What are the components to a nutritive suck?

Answer 11

expression (compression of the nipple)

suction (negative intra-oral pressure)

Cheeks and lips are not active but do help with stability

Tongue and Palate “seal” drives the swallow

Question 12

ON EXAM

At what age does the coordination of the S-S-B begin to evolve?

Answer 12

31-33 weeks

Question 13

T/F

Esophageal motility is coordinated and anti-reflux mechanisms of the LES are fully developed by 32 weeks gestation

Answer 13

FALSE

Question 14

What happens between 34-38 weeks?

Answer 14

longer sucking burst

more regular pauses

“immature” NS pattern of 1-5 sucks/burst often observed

respiration challenged by effort

Question 15

At what age is 12-18 sucks/burst common

Answer 15

38 weeks?

Question 16

What is a fully mature pattern of sucks/burst?

Answer 16

20-30 sucks/burst

Question 17

When is a fully mature pattern of 20-30 sucks/burst established?

Answer 17

44 weeks gestation (4-6 weeks past “full-term”)

Question 18

What are some developmental milestones from 0-3 months?

Answer 18

chin in contact with the rib cage

jaw, tongue, cheeks, and lips working as a unit

tongue is large & completely fills small oral cavity

Reflexes: gag, rooting, phasic bite, suck-swallow

sucking pads

Question 19

ON EXAM**

When do sucking pads develop and what are sucking pads?

Answer 19

develop the last 2 weeks in utero

fatty tissue pads surrounded by inactive cheek muscles

provide stability/support to help tongue compress nipple and to control/direct liquid flow

Question 20

ON EXAM

What are some developmental milestones from 3-6 months?

Answer 20

head control increasing

muscles around face/cheeks develop

sucking pads are gone by 6 months*

Everything elongates… neck gets longer, larynx is lower in the throat

airway is no longer protected by anatomical relationships but rather active muscle control

better coordination

munching pattern begins**

Rooting and Suck reflexes fade–therefore they have more choice *

Decreased loss of liquid at corner of the mouth

Bilabial closure and tongue tip elevation appear

Begins to have “a choice” with foods vs. an automatic response

spoon feeding often introduced (4-6 months)

Question 21

What are some developmental milestones from 6-9 months?

Answer 21

Shoulders and neck more stable

head moves independently of trunk

facial expressions are more pronounced

tongue sensitive enough to know it can’t mash all foods

learn about pressure (raspberries)

strong active suck–not reflexive it’s ACTIVE!

biting using central incisors

graded jaw movement

munching/early chewing patterns now more common

may see coughing or gagging on new foods

variety of foods in diet by 9 months

cup drinking.. gulping, tongue under cup surrounded by lower lip (9 months)

bite and gage reflexes fade

by this point, kids should be putting everything in their mouths (actually very important!)

Question 22

What are some developmental milestones from12-18 months?

Answer 22

refining movements

quieter cup drinking w/ 4-5 sips continuously

active lips clean spoon

more controlled biting

rotary chewing begins (18 months)

spits food

licks lower lip with tongue

Question 23

What are some developmental milestones at 24 months?

Answer 23

tongue becomes major cleaner inside & outside of mouth

easy lip closure w/ no liquid loss from cup

controlled, sustained bite, better grading of jaw opening to bite varying thickness of foods

Question 24

What happens between 4-5 years?

Answer 24

oral motor feeding skills and coordination are fully established between 4-5 years of age.

Question 25

What was the factor most associated w/ food refusal & dysphagia?

Answer 25

GERD

Question 26

GERD most correlates with what?

Answer 26

severe feeding problems

Question 27

When is GERD especially a problem for infants?

Answer 27

when it affects eating, growing, and sleeping

Question 28

What percentage of low birth weight infants have GER?

Answer 28

85%

Question 29

What percentage of infants with neuromuscular problems have GER?

Answer 29

75% | higher incidence in those with chronic lung disease

Question 30

What percentage of infants with GER show outward signs (e.g., spitting up?)

Answer 30

25%

Question 31

In normal children who had GER what percentage of babies are free of symptoms by 18 months?

Answer 31

60-80%

Question 32

What chromosome was recently discovered to be a genetic marker for GERD?

Answer 32

13q14

Question 33

ON EXAM*** What are GER signs?

Answer 33

coughing/choking during feeding chronic hoarseness or cough re-swallows/dry swallows seen during/after meals frequent spitting up or emesis; sour breath arches back into hyperextension during/after meals frequent irritable, cranky, moody, sleep problems frequent respiratory illness, disruptive breathing increased sensitivity to sensory input eats small amounts; self limits eats frequently frequent web burps Turns head to left during/after feeding (Sandifer signs) Limited movement patterns weight gain is suboptimal recurrent aspiration pneumonia teeth enamel problems or erosion of teeth frequent ear infections

Question 34

Before diagnosing GERD,what needs to be ruled out?

Answer 34

other medical problems or GI issues must be ruled out (milk allergies, esophageal web, hepatitis)

Question 35

What is essential in during a GERD diagnostic evaluation?

Answer 35

history is essential same types of evaluation techniques are used to evaluate GERD in infants as adults

Question 36

What are some important factors for GERD management & treatment with infants?

Answer 36

parental counseling formula changes (thickening or hypoallergenic formula may be tried) positioning changes smaller more frequent meals H2 blocker may be tried (Zantac is most preferred) Never use antacids w/ infants due to aluminum toxicity

Question 37

What are some positioning changes you can use with managing/treating GERD in infants?

Answer 37

prone position is the only consistently proven position to help prevent GERD. This is contrary to "back to sleep" recommendations for SIDS Sideline positions are helpful HOB raised--no studies support benefit despite common practice

Question 38

What are some conclusions you can get from doing a bedside swallow eval with pediatrics?

Answer 38

etiology? (is it an aversion, a dysphagia, an esophageal dysphagia w/ reflux that has caused an aversion?) successful strategies (thickening liquids? changing positions?) need for therapy? need for future referrals? what are your goals?

Question 39

Who are pediatric candidates for an MBS?

Answer 39

kids with frequent or recurrent low grade fevers kids with increased congestion during feeding; noisy breaths any signs of fore-mentioned pharyngeal "red flags" frequent upper respiratory infections neuro-motor involvement affecting S-S-B Any structural problems which may cause aspiration

Question 40

What is the criteria for someone to be allowed to get the MBS?

Answer 40

exhibit an ability to swallow alertness ability to consume sufficient intake in a reasonable time medically stable not showing significant aversion & will actually eat

Question 41

How can the family/staff prep their child for an MBS?

Answer 41

child shouldn't eat 3-4 hours prior to the study child should take meds at regular times assure/inform parents about "the x-ray" bring child's favorite utensils bring a typical meal

Question 42

What should we try before doing an MBS?

Answer 42

try re-positioning first try texture changes try flavor changes try presentation changes (pacing, bottle positioning) try adaptive equipment

Question 43

What should we expect when we are doing an MBS with an infant/child?

Answer 43

normal to have liquids enter the valleculae prior to swallow being initiated due to higher position of the larynx & valleculae and the placement of more tongue in the oral cavity once a swallow response is triggered, the pharyngeal phase occurs more frequently & w/ greater speed small amounts of residue in valleculae is normal less laryngeal elevation required for airway protection due to anatomy difficult to see hyoid/laryngeal motion due to reduced calcification of the hyoid & smaller pharyngeal space The newborn esophagus is immature which affects esophageal peristalsis. Therefore, there may be a hesitation of material at the level of the cervical esophagus upon screening

Question 44

What is different with doing FEES for a child than an adult?

Answer 44

need a pediatric scope, otherwise same pros and cons as adult populations

Question 45

What are some statistics of children/infants with feeding/swallowing problems?

Answer 45

25% of all children (1 out of 4) experience "feeding problems" up to 80% of children with developmental disabilities experience "feeding problems" with 3-10% of those being severe (CP, DS) up to 65% of children with sensory processing difficulties experience "feeding problems" (autism, PDD, drug/alcohol exposure) 26-90% of children with physical disabilities experience "feeding problems" 31% of all NICU graduates experience feeding problems 80% of premature infants born 28 weeks gestation or less experience "feeding problems"

Question 46

In terms of refusal, what are some questions we should have?

Answer 46

is it "normal" developmental behavior? is it a learned behavior? (e.g., physiological or psycho-social)

Question 47

What does a learned physiological behavior mean regarding refusal of food for pediatrics? (not sure if I worded this well)

Answer 47

response to GI issues** (#1 reason) food allergies inability to manage the flow of milk secondary to breathing problems etc..

Question 48

What does a learned psycho-social behavior mean regarding refusal of food for pediatrics? (not sure if I worded this well)

Answer 48

rare for feeding problems to solely be related to parenting but may contribute to an already difficult feeding relationship

Question 49

What is extremely important for a child to develop a positive relationship with?

Answer 49

with food/feeding during the first few months of life

Question 50

What fraction of typically developing children are thought to have some sort of aversion?

Answer 50

1 out 4

Question 51

What can aversions be to?

Answer 51

to touch, taste, temperature, textures, smell, or sight

Question 52

What can oral aversion/food hypersensitivity be the response to?

Answer 52

response of a more global sensory problem OR be localized only to the face and mouth

Question 53

In 2000, a study showed that infants who experienced difficulties during their first feeding attempts continued to show difficulty at what age?

Answer 53

6-12 months

Question 54

What are the biggest issues with aversion & selectivity?

Answer 54

transitioning to solid foods and enjoying mealtimes

Question 55

What may hypersensitivity be caused by?

Answer 55

general sensory overload traumatic oral & facial experiences oral sensory-motor deprivation GI issues

Question 56

ON EXAM: What are some RESPONSES that an infant may demonstrate when they have aversion or selectivity?

Answer 56

cry grimace wiggle arch away shutting down or "sleeping" keep his/her mouth closed gag vomit tongue glued to roof of mouth

Question 57

What are some signs of aversion/selectivity?

Answer 57

obvious preference or desire for one consistency over another any kind of adverse reaction to environmental factors (taste, smell, texture, sight) weight loss or failure to thrive (patterns/feeding battles) decreased interest in eating

Question 58

Describe oral motor problems for pediatrics

Answer 58

oral musculature and structures along with oral motor movements may affect age appropriate development and function of feeding skills (e.g., cleft palate, down syndrome, CP) adaptive diet and feeding equipment is often needed

Question 59

What do swallowing difficulties affect?

Answer 59

feeding function and safety

Question 60

What issues can impact swallowing safety?

Answer 60

neurological, respiratory, and cardiac

Question 61

ON EXAM What children are "at risk" for dysphagia?

Answer 61

neurological impairment (TBI & CP) genetic disorders (pierre robin syndrome, down syndrome) drug/alcohol exposure GI issues (reflux, eosinophilic esophagitis, fistulas, poor stomach emptying) food allergies broncho-pulmonary disorders (Poor SSB coordination, fatigue) cardiac disorders (rapid fatigue) negative oral stimulation (intubation, suctioning, infants learning to eat who are pushed past their skill level) vocal fold paralysis/paresis poor caregiver bond/understanding of infant's feeding/behavioral signs

Question 62

What are some common red flags that warrant a dysphagia referral?

Answer 62

feeding periods >30-40 minutes unexplained food refusal & under nutrition weight loss or lack of weight gain excessive gagging or recurrent cough with feeds infants on nipple feeds who have difficulty with sucking, swallowing, breathing incoordination; weak suck; breathing disruptions during feeding

Question 63

What can any feeding problems result in?

Answer 63

nutrition & growth deficiencies (FTT) developmental feeding delays social "differences" (food centered society) increased family pressures/difficulties

Question 64

When doing a pediatric assessment & plan of care, what information should we gather?

Answer 64

medical history gestational age milestones previous evaluations (PT/OT, MD, Radiology, Developmental specialist) history & description of the swallow problem feeding history/current diet and schedule parent/family goal (MUST have parental involvement/commitment)

Question 65

What should we observe during parent feeding observation time?

Answer 65

observe parent's interaction with their child techniques used attention to feeding ability to follow suggestions

Question 66

When a therapist is feeding, what should they observe/assess?

Answer 66

hold an infant during feeding (time for oral screening, feel for strength/tone/resistance/comfort, improvement with changes in feeding techniques noted?) Interact with a toddler/older child (trial play, behavioral, motivational techniques)

Question 67

What should we try/do during a pediatric assessment/plan of care?

Answer 67

position (upright, sideline, containment) texture/flavor (observe reaction to preferences, avoidances, interest in different foods, interaction with food) adaptive equipment (nipple changes, mesh bag, straw cups) Work with timing of feedings/meals (child should be hungry/schedule eval at feeding time**)

Question 68

What should we watch for during a pediatric assessment?

Answer 68

is the child considered an "at risk" child state of alertness? (deep sleep, light sleep, drowsy or semi-dozing, quiet alert, active alert, crying) any medical "red flags"? (heart rate, respiratory rate, oxygen saturation changes) any aversion/oral motor problems? any pharyngeal "red flags"? any signs of GERD? any stress cues?

Question 69

What are behavioral stress cues that an infant may display if they are having feeding/swallowing issues?

Answer 69

"shut down"/going to sleep (often briefly) decreased interest/distraction with eating (fussing with feeds or socializing rather than eating) "stop sign" hand display/fingers splayed turning away from intake pushing bottle away tongue on roof of mouth lips puckered closed

Question 70

What are pharyngeal red flags?

Answer 70

coughing/choking at meals wet cry or wet voice quality facial grimacing excessive nasal regurgitation failure to thrive weight loss drop in 02 saturation levels increase in respiration rate

Question 71

What should we conclude after a pediatric assessment?

Answer 71

etiology? successful strategies? what worked in the past? need for therapy? need for further referrals? what are your goals? what information/techniques can be given to the parents/caregivers now?

Question 72

What are some non-oral/tube feeding options?

Answer 72

orogastric (OG) Nasogastric (NG) Percutaneous Endoscopic Gastrostomy (PEG) Gastrostomy (G-Tube) Jejunostomy (J-Tube)

Question 73

If a child has an oral diet, what are some textures/consistencies that we can feed?

Answer 73

thin liquids thickened liquids strained/pureed foods (puddings, baby foods) thickened pureed foods (cream of wheat, soft mashed potatoes) lumpy foods (rice, noodles, cottage cheese) mashed table foods dry crunchy (cookies, veggie sticks) Chopped solid foods (banana chunks, breads) Whole solid/table foods/mixed textures

Question 74

What is the typical development progression of oral feedings?

Answer 74

liquid only by nipple for the first 4-6 months (breast milk, formula) strained smooth food by spoon (4-6 months) --sitting with minimal support lumpy foods by 10-11 months cup drinking between 6-12 months

Question 75

What are the ages of introduction of solids?

Answer 75

4-6 months: smooth puree 6-9 months: smooth puree; textured puree, easily dissolvable solids 9-12 months: soft, mashed, and diced solids 12-18 months: toddler diet of chopped table food

Question 76

What are some treatment techniques/therapy techniques to consider with someone with oral aversions?

Answer 76

work from developmental age of current oral skills, establish food patterns and branch out one attribute at a time (flavor, texture, temperature, color, etc..) try facial/oral food play, have fun with food, educate family on how to make meals a social time engage/involve parents in therapy--provide 1-2 goals each week that the family is accountable for upon return each week

Question 77

What should we implement regarding swallowing safety?

Answer 77

implement diet changes and establish compensatory measures to assist with safety and function (tenure, position, behavioral education related to risk factors) NMES consideration Educate/provide strategies to assist family with feeding safety, help family utilize medical and nutritional interactions with other caregivers (pediatrician/GI/respiratory/other MD, dietitians, OT/PT, educators)

Question 78

In terms of oral motor/sensory issues what should we establish?

Answer 78

establish functional oral motor tasks to improve strength and function (e.g., mesh bag for chewing/sensory desensitization, oral play via textural food progression such as Veggie sticks for biting/chewing, straw-squeeze bottle for labial/lingual strengthening and improved suction), tooth brushing via vibrating tooth brush to desensitize tongue/oral cavity

Question 79

How much has the preterm birthrate gone up since 1990?

Answer 79

gone up by 20%

Question 80

ON EXAM**** What is the average age of suck-swallow breaking acquisition?

Answer 80

34-37 weeks gestation

Question 81

What is the average age of full oral feeds?

Answer 81

38. 4-39.6 weeks for infants born less than 28 weeks gestation 37. 4 weeks was the mean of those born 28-32.6 weeks gestation 36. 2 weeks was the mean for those born 33-36.6 weeks gestation

Question 82

What are the goals of successful infant feeding?

Answer 82

SAFETY is the FIRST goal of feeding feedings should be NURTURING AND ENJOYABLE Feedings need to be FUNCTIONAL/NUTRITIONALLY ADEQUATE FOR GROWTH feedings should be INDIVIDUALLY and DEVELOPMENTALLY APPROPRIATE

Question 83

What are some factors for feeding READINESS in the preterm infant?

Answer 83

chronological age versus post conceptional age severity of illnesses/complications already experienced by the infant (chronicity) Respiratory/cardiovascular stability (02, apnea) motor stability (tone, posture, quality of movements) oral stability (S-S-B coordination) available energy & ability to manage the environment & activity ability to maintain alertness hunger & demonstration of hunger cues enteral tolerance of feedings

Question 84

Don't know how to word this.. don't think we need to know it, but here it is....

Answer 84

physiological stability: heart rate: Preemies-140+, term newborns 120_ respiratory rate: preemies-40-60 b/m; term newborns 20-40 b/m 02 saturation: 90-100%=goal for all ages (but there are exceptions--e.g., COPD)

Question 85

What are the three nipple types?

Answer 85

slow flow, standard flow, fast flow

Question 86

When would you use a slow flow nipple?

Answer 86

"learning" how to eat S-S-B incoordination/immaturity

Question 87

When would you use a "standard flow" nipple?

Answer 87

10-12 sucks per burst average maintains alertness throughout the feeding no signs of "work" of feeding

Question 88

When would you use a fast flow nipple?

Answer 88

fast flow is rarely needed for any age may be used with thickened formula

Question 89

What are the specialty nipples/bottle types?

Answer 89

bionic controlled flow feeder pigeon nipple and bottle system haberman feeder Dr. Brown

Question 90

Describe the Bionix Controlled Flow Feeder

Answer 90

various flow levels one of the slowest nipple flows available

Question 91

Describe the Pigeon Nipple and Bottle System

Answer 91

cleft lip and palate one-way valve squeeze bottle

Question 92

Describe the Haberman Feeder

Answer 92

oral facial problems various flow

Question 93

Why do we thicken formula?

Answer 93

thickening formula may be necessary if an infant has reached full term and is having ongoing SSB coordination issues the result in aspiration and/or aversive behaviors helps by reducing the formula flow improves the baby's sensory awareness/feedback of the presence of formula some believe cereal reduces reflux

Question 94

Why do we use rice cereal instead of thickener?

Answer 94

b/c thickener breaks down due to enzymes in breast milk so it doesn't stay thick

Question 95

What are the first signs/symptoms of stress in a baby with feeding/swallowing difficulties?

Answer 95

facial changes (eyes, eyebrows) changes in tone pulling away/"stop sign" fatigue changes in respiratory rate

Question 96

What are moderate stress cues in a baby with feeding/swallowing difficulties?

Answer 96

sighing yawning sneezing sweating tremoring startling grasping straining

Question 97

What are some major stress cues in a baby with feeding/swallowing difficulties?

Answer 97

coughing spitting up gagging/choking color change respiratory pauses irregular respirations

Question 98

What are some caregiver techniques to teach?

Answer 98

external pacing modified side lying chin and cheek supports oral stimulation/oral experiences

Question 99

Describe external pacing

Answer 99

....