Pediatric Swallowing & Oral Motor/Feeding Disorders Flashcards
What are some statistics re: children/prematurity?
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!!!
T/F
Infants are miniature adults
False
What is most of what an infant or child does during swallowing/feeding related to?
is related to airway maintenance and/or airway protection
What is especially essential for swallowing?
Highly accurate timing of breathing w/ swallowing is essential
What shared pathways exist for infants?
Shared pathways exist between the swallow/feeding & respiratory systems
Even a subtle disruption in what can impact swallowing/feeding?
Even a subtle disruption in sensory-motor control can impact swallowing/feeding
What may swallowing/feeding problems reflect?
may reflect problems elsewhere in the body
KNOW THIS! ON EXAM!
Describe the suck-swallow-breathe synchrony
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
Describe the non-nutritive Suck
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)
What is the nutritive suck rate?
approximately 1 suck/second
What are the components to a nutritive suck?
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
ON EXAM
At what age does the coordination of the S-S-B begin to evolve?
31-33 weeks
T/F
Esophageal motility is coordinated and anti-reflux mechanisms of the LES are fully developed by 32 weeks gestation
FALSE
What happens between 34-38 weeks?
longer sucking burst
more regular pauses
“immature” NS pattern of 1-5 sucks/burst often observed
respiration challenged by effort
At what age is 12-18 sucks/burst common
38 weeks?
What is a fully mature pattern of sucks/burst?
20-30 sucks/burst
When is a fully mature pattern of 20-30 sucks/burst established?
44 weeks gestation (4-6 weeks past “full-term”)
What are some developmental milestones from 0-3 months?
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
ON EXAM**
When do sucking pads develop and what are sucking pads?
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
ON EXAM
What are some developmental milestones from 3-6 months?
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)
What are some developmental milestones from 6-9 months?
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!)
What are some developmental milestones from12-18 months?
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
What are some developmental milestones at 24 months?
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
What happens between 4-5 years?
oral motor feeding skills and coordination are fully established between 4-5 years of age.
What was the factor most associated w/ food refusal & dysphagia?
GERD
GERD most correlates with what?
severe feeding problems
When is GERD especially a problem for infants?
when it affects eating, growing, and sleeping
What percentage of low birth weight infants have GER?
85%
What percentage of infants with neuromuscular problems have GER?
75%
higher incidence in those with chronic lung disease
What percentage of infants with GER show outward signs (e.g., spitting up?)
25%
In normal children who had GER what percentage of babies are free of symptoms by 18 months?
60-80%
What chromosome was recently discovered to be a genetic marker for GERD?
13q14
ON EXAM***
What are GER signs?
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
Before diagnosing GERD,what needs to be ruled out?
other medical problems or GI issues must be ruled out (milk allergies, esophageal web, hepatitis)
What is essential in during a GERD diagnostic evaluation?
history is essential
same types of evaluation techniques are used to evaluate GERD in infants as adults
What are some important factors for GERD management & treatment with infants?
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
What are some positioning changes you can use with managing/treating GERD in infants?
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
What are some conclusions you can get from doing a bedside swallow eval with pediatrics?
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?
Who are pediatric candidates for an MBS?
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
What is the criteria for someone to be allowed to get the MBS?
exhibit an ability to swallow
alertness
ability to consume sufficient intake in a reasonable time
medically stable
not showing significant aversion & will actually eat
How can the family/staff prep their child for an MBS?
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
What should we try before doing an MBS?
try re-positioning first
try texture changes
try flavor changes
try presentation changes (pacing, bottle positioning)
try adaptive equipment
What should we expect when we are doing an MBS with an infant/child?
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
What is different with doing FEES for a child than an adult?
need a pediatric scope, otherwise same pros and cons as adult populations
What are some statistics of children/infants with feeding/swallowing problems?
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”
In terms of refusal, what are some questions we should have?
is it “normal” developmental behavior?
is it a learned behavior? (e.g., physiological or psycho-social)
What does a learned physiological behavior mean regarding refusal of food for pediatrics? (not sure if I worded this well)
response to GI issues** (#1 reason)
food allergies
inability to manage the flow of milk secondary to breathing problems
etc..
What does a learned psycho-social behavior mean regarding refusal of food for pediatrics? (not sure if I worded this well)
rare for feeding problems to solely be related to parenting but may contribute to an already difficult feeding relationship
What is extremely important for a child to develop a positive relationship with?
with food/feeding during the first few months of life
What fraction of typically developing children are thought to have some sort of aversion?
1 out 4
What can aversions be to?
to touch, taste, temperature, textures, smell, or sight
What can oral aversion/food hypersensitivity be the response to?
response of a more global sensory problem OR be localized only to the face and mouth
In 2000, a study showed that infants who experienced difficulties during their first feeding attempts continued to show difficulty at what age?
6-12 months
What are the biggest issues with aversion & selectivity?
transitioning to solid foods and enjoying mealtimes
What may hypersensitivity be caused by?
general sensory overload
traumatic oral & facial experiences
oral sensory-motor deprivation
GI issues
ON EXAM:
What are some RESPONSES that an infant may demonstrate when they have aversion or selectivity?
cry
grimace
wiggle
arch away
shutting down or “sleeping”
keep his/her mouth closed
gag
vomit
tongue glued to roof of mouth
What are some signs of aversion/selectivity?
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
Describe oral motor problems for pediatrics
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
What do swallowing difficulties affect?
feeding function and safety
What issues can impact swallowing safety?
neurological, respiratory, and cardiac
ON EXAM
What children are “at risk” for dysphagia?
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
What are some common red flags that warrant a dysphagia referral?
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
What can any feeding problems result in?
nutrition & growth deficiencies (FTT)
developmental feeding delays
social “differences” (food centered society)
increased family pressures/difficulties
When doing a pediatric assessment & plan of care, what information should we gather?
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)
What should we observe during parent feeding observation time?
observe parent’s interaction with their child
techniques used
attention to feeding
ability to follow suggestions
When a therapist is feeding, what should they observe/assess?
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)
What should we try/do during a pediatric assessment/plan of care?
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**)
What should we watch for during a pediatric assessment?
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?
What are behavioral stress cues that an infant may display if they are having feeding/swallowing issues?
“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
What are pharyngeal red flags?
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
What should we conclude after a pediatric assessment?
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?
What are some non-oral/tube feeding options?
orogastric (OG)
Nasogastric (NG)
Percutaneous Endoscopic Gastrostomy (PEG)
Gastrostomy (G-Tube)
Jejunostomy (J-Tube)
If a child has an oral diet, what are some textures/consistencies that we can feed?
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
What is the typical development progression of oral feedings?
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
What are the ages of introduction of solids?
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
What are some treatment techniques/therapy techniques to consider with someone with oral aversions?
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
What should we implement regarding swallowing safety?
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)
In terms of oral motor/sensory issues what should we establish?
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
How much has the preterm birthrate gone up since 1990?
gone up by 20%
ON EXAM**
What is the average age of suck-swallow breaking acquisition?
34-37 weeks gestation
What is the average age of full oral feeds?
- 4-39.6 weeks for infants born less than 28 weeks gestation
- 4 weeks was the mean of those born 28-32.6 weeks gestation
- 2 weeks was the mean for those born 33-36.6 weeks gestation
What are the goals of successful infant feeding?
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
What are some factors for feeding READINESS in the preterm infant?
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
Don’t know how to word this.. don’t think we need to know it, but here it is….
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)
What are the three nipple types?
slow flow, standard flow, fast flow
When would you use a slow flow nipple?
“learning” how to eat
S-S-B incoordination/immaturity
When would you use a “standard flow” nipple?
10-12 sucks per burst average
maintains alertness throughout the feeding
no signs of “work” of feeding
When would you use a fast flow nipple?
fast flow is rarely needed for any age
may be used with thickened formula
What are the specialty nipples/bottle types?
bionic controlled flow feeder
pigeon nipple and bottle system
haberman feeder
Dr. Brown
Describe the Bionix Controlled Flow Feeder
various flow levels
one of the slowest nipple flows available
Describe the Pigeon Nipple and Bottle System
cleft lip and palate
one-way valve
squeeze bottle
Describe the Haberman Feeder
oral facial problems
various flow
Why do we thicken formula?
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
Why do we use rice cereal instead of thickener?
b/c thickener breaks down due to enzymes in breast milk so it doesn’t stay thick
What are the first signs/symptoms of stress in a baby with feeding/swallowing difficulties?
facial changes (eyes, eyebrows)
changes in tone
pulling away/”stop sign”
fatigue
changes in respiratory rate
What are moderate stress cues in a baby with feeding/swallowing difficulties?
sighing
yawning
sneezing
sweating
tremoring
startling
grasping
straining
What are some major stress cues in a baby with feeding/swallowing difficulties?
coughing
spitting up
gagging/choking
color change
respiratory pauses
irregular respirations
What are some caregiver techniques to teach?
external pacing
modified side lying
chin and cheek supports
oral stimulation/oral experiences
Describe external pacing
….
