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Fall '15-227 (Exam 2) > Pediatric Swallowing & Oral Motor/Feeding Disorders > Flashcards

Pediatric Swallowing & Oral Motor/Feeding Disorders Flashcards

1
Q

What are some statistics re: children/prematurity?

A

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!!!

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2
Q

T/F

Infants are miniature adults

A

False

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3
Q

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

A

is related to airway maintenance and/or airway protection

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4
Q

What is especially essential for swallowing?

A

Highly accurate timing of breathing w/ swallowing is essential

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5
Q

What shared pathways exist for infants?

A

Shared pathways exist between the swallow/feeding & respiratory systems

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6
Q

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

A

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

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7
Q

What may swallowing/feeding problems reflect?

A

may reflect problems elsewhere in the body

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8
Q

KNOW THIS! ON EXAM!

Describe the suck-swallow-breathe synchrony

A

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

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9
Q

Describe the non-nutritive Suck

A

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)

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10
Q

What is the nutritive suck rate?

A

approximately 1 suck/second

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11
Q

What are the components to a nutritive suck?

A

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

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12
Q

ON EXAM

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

A

31-33 weeks

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13
Q

T/F

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

A

FALSE

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14
Q

What happens between 34-38 weeks?

A

longer sucking burst

more regular pauses

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

respiration challenged by effort

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15
Q

At what age is 12-18 sucks/burst common

A

38 weeks?

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16
Q

What is a fully mature pattern of sucks/burst?

A

20-30 sucks/burst

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17
Q

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

A

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

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18
Q

What are some developmental milestones from 0-3 months?

A

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

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19
Q

ON EXAM**

When do sucking pads develop and what are sucking pads?

A

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

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20
Q

ON EXAM

What are some developmental milestones from 3-6 months?

A

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)

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21
Q

What are some developmental milestones from 6-9 months?

A

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!)

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22
Q

What are some developmental milestones from12-18 months?

A

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

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23
Q

What are some developmental milestones at 24 months?

A

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

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24
Q

What happens between 4-5 years?

A

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

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25
Q

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

A

GERD

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26
Q

GERD most correlates with what?

A

severe feeding problems

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27
Q

When is GERD especially a problem for infants?

A

when it affects eating, growing, and sleeping

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28
Q

What percentage of low birth weight infants have GER?

A

85%

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29
Q

What percentage of infants with neuromuscular problems have GER?

A

75%

higher incidence in those with chronic lung disease

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30
Q

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

A

25%

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31
Q

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

A

60-80%

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32
Q

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

A

13q14

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33
Q

ON EXAM***

What are GER signs?

A

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

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34
Q

Before diagnosing GERD,what needs to be ruled out?

A

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

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35
Q

What is essential in during a GERD diagnostic evaluation?

A

history is essential

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

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36
Q

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

A

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

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37
Q

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

A

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

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38
Q

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

A

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?

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39
Q

Who are pediatric candidates for an MBS?

A

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

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40
Q

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

A

exhibit an ability to swallow

alertness

ability to consume sufficient intake in a reasonable time

medically stable

not showing significant aversion & will actually eat

41
Q

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

A

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

42
Q

What should we try before doing an MBS?

A

try re-positioning first

try texture changes

try flavor changes

try presentation changes (pacing, bottle positioning)

try adaptive equipment

43
Q

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

A

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

44
Q

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

A

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

45
Q

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

A

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”

46
Q

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

A

is it “normal” developmental behavior?

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

47
Q

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

A

response to GI issues** (#1 reason)

food allergies

inability to manage the flow of milk secondary to breathing problems

etc..

48
Q

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

A

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

49
Q

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

A

with food/feeding during the first few months of life

50
Q

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

A

1 out 4

51
Q

What can aversions be to?

A

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

52
Q

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

A

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

53
Q

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

A

6-12 months

54
Q

What are the biggest issues with aversion & selectivity?

A

transitioning to solid foods and enjoying mealtimes

55
Q

What may hypersensitivity be caused by?

A

general sensory overload

traumatic oral & facial experiences

oral sensory-motor deprivation

GI issues

56
Q

ON EXAM:

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

A

cry

grimace

wiggle

arch away

shutting down or “sleeping”

keep his/her mouth closed

gag

vomit

tongue glued to roof of mouth

57
Q

What are some signs of aversion/selectivity?

A

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

58
Q

Describe oral motor problems for pediatrics

A

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

59
Q

What do swallowing difficulties affect?

A

feeding function and safety

60
Q

What issues can impact swallowing safety?

A

neurological, respiratory, and cardiac

61
Q

ON EXAM

What children are “at risk” for dysphagia?

A

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

62
Q

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

A

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

63
Q

What can any feeding problems result in?

A

nutrition & growth deficiencies (FTT)

developmental feeding delays

social “differences” (food centered society)

increased family pressures/difficulties

64
Q

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

A

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)

65
Q

What should we observe during parent feeding observation time?

A

observe parent’s interaction with their child

techniques used

attention to feeding

ability to follow suggestions

66
Q

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

A

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)

67
Q

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

A

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**)

68
Q

What should we watch for during a pediatric assessment?

A

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?

69
Q

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

A

“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

70
Q

What are pharyngeal red flags?

A

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

71
Q

What should we conclude after a pediatric assessment?

A

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?

72
Q

What are some non-oral/tube feeding options?

A

orogastric (OG)

Nasogastric (NG)

Percutaneous Endoscopic Gastrostomy (PEG)

Gastrostomy (G-Tube)

Jejunostomy (J-Tube)

73
Q

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

A

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

74
Q

What is the typical development progression of oral feedings?

A

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

75
Q

What are the ages of introduction of solids?

A

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

76
Q

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

A

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

77
Q

What should we implement regarding swallowing safety?

A

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)

78
Q

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

A

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

79
Q

How much has the preterm birthrate gone up since 1990?

A

gone up by 20%

80
Q

ON EXAM**

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

A

34-37 weeks gestation

81
Q

What is the average age of full oral feeds?

A
  1. 4-39.6 weeks for infants born less than 28 weeks gestation
  2. 4 weeks was the mean of those born 28-32.6 weeks gestation
  3. 2 weeks was the mean for those born 33-36.6 weeks gestation
82
Q

What are the goals of successful infant feeding?

A

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

83
Q

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

A

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

84
Q

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

A

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)

85
Q

What are the three nipple types?

A

slow flow, standard flow, fast flow

86
Q

When would you use a slow flow nipple?

A

“learning” how to eat

S-S-B incoordination/immaturity

87
Q

When would you use a “standard flow” nipple?

A

10-12 sucks per burst average

maintains alertness throughout the feeding

no signs of “work” of feeding

88
Q

When would you use a fast flow nipple?

A

fast flow is rarely needed for any age

may be used with thickened formula

89
Q

What are the specialty nipples/bottle types?

A

bionic controlled flow feeder

pigeon nipple and bottle system

haberman feeder

Dr. Brown

90
Q

Describe the Bionix Controlled Flow Feeder

A

various flow levels

one of the slowest nipple flows available

91
Q

Describe the Pigeon Nipple and Bottle System

A

cleft lip and palate

one-way valve

squeeze bottle

92
Q

Describe the Haberman Feeder

A

oral facial problems

various flow

93
Q

Why do we thicken formula?

A

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

94
Q

Why do we use rice cereal instead of thickener?

A

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

95
Q

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

A

facial changes (eyes, eyebrows)

changes in tone

pulling away/”stop sign”

fatigue

changes in respiratory rate

96
Q

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

A

sighing

yawning

sneezing

sweating

tremoring

startling

grasping

straining

97
Q

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

A

coughing

spitting up

gagging/choking

color change

respiratory pauses

irregular respirations

98
Q

What are some caregiver techniques to teach?

A

external pacing

modified side lying

chin and cheek supports

oral stimulation/oral experiences

99
Q

Describe external pacing

A

….

Fall '15-227 (Exam 2) (6 decks)

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