Third Section Class notes Flashcards
1
Q
Common Feeding Issues
A
- Oral-motor
- Swallowing disorders
- GERD (reflux)
- Sensory DIfferences
- Transition to oral feeding (from tube feeding)
- Feeding aversion
2
Q
What to asses?
Child-level
A
- Safety
- Structural
- Nutritional and Growth
- Oral Motor
- Sensory
- Behavioural/Motivational
3
Q
What to asses?
Safety
A
- What is the main safety concern in this feeding?
- How will you screen for it in the community or school?
- What will you do if you suspect a problem?
4
Q
Parts of the swallowing process
A
- Oral Phase
- Oral Propulsive Phase
- Pharyngeal phase
- Esophageal Phase
5
Q
Aspiration
A
The drawing of a foreign substance into the respiratory tract during inhalation
6
Q
Swallowing
A
- Develops early = in fetus (12-14 weeks gestation)
- ->Baby near 40 weeks swallows 1/2 of amniotic fluid per day
- At rest, mouth and throat structures favour respiration
- Valves
- ->lips, soft palate and tongue, epiglottis, UES
- Phases of swallowing: oral phase, pharyngeal phase, esophageal phase
7
Q
Respiration
A
- Pharynx serves dual role
- ->air goes through to the lungs
- food goes through to the stomach
- The body must have airway protection mechanisms
Airway related to head position
–>babies with respiratory compromise may have extended head position to maximize airway stability
8
Q
Label the mouth
A
right side
- Tongue
- Epiglottis
- Larynx
- Cricoid cartilage
- Trachea
Left side
- Nasopharynx
- Oropharynx
- Laryngopharynx
- Esophagus
9
Q
Clinical Indicators of Aspiration
A
Medical/feeding history and clinical evaluation
- history of aspiration pneumonia
- Coughing with oral feeds
- History of recurrent chest infections
- History of increased upper airways sounds/congestion during or after oral feeding
- History of wheezing and chest sounds with oral feeds
- Finding of chest x-ray suggestive of aspiration
- Sudden drop in heart rate with oral feeds
- Change in voice quality with oral feeds (wet voice)
10
Q
Observing swallowing
A
- forces that impact pressure gradients
- Bolus propulsion
- Initiation of swallowing reflex
11
Q
Swallowing Dysfunction
A
-Airway protection during swallowing
- Swallowing phases
- ->Aspiration before swallow
- ->Aspiration during the swallow
- ->Aspiration after the swallow
12
Q
Videofluoroscopy
A
-A videofluoroscopic swallowing study (VFSS) usesa. form of real-time x-ray called fluoroscopy to evaluate a patient’s ability to swallow safely and effectively. It is typically well tolerated, noninvasive, and can help identify the consistencies of food that a patient can most safely eat
- AKA Modified Barium Swallow
- Cervical Auscultation
- Decision tree for videofluoroscopic feeding study
13
Q
Gastroesophageal Reflux (GER)
A
- GER: spontaneous return of gastric contents into esophagus
- Aspiration from below
- Impact on feeding:
- ->volume
- ->frequency
- ->Gag reflex
- ->aversion
- Management:
- ->Important to work closely with MD and RD
- ->Medication
- ->Positioning
- ->Dietary
14
Q
Nutrition and Growth
A
- How can nutrition or growth be a particular challenge for kids with disabilities?
- How will you screen for it in the community or school?
- What will you do if you suspect a problem?
15
Q
Oral Motor Ability
A
- what is their current level of ability telling you about:
- What consistencies of food and drink that they can manage easily?
- What consistencies of food and drink they could achieve with some carefully graded experience?
16
Q
Normal Development-oral Motor
Newborn
A
- Strong rooting reflex
- Strong gag reflex
- Reflective suck
17
Q
Normal Development-oral Motor
One month
A
- Rooting and gag reflexes persist
- Suck-swallow-breath pattern may be poorly coordinated
18
Q
Normal Development-oral Motor
Two months
A
-Begins mouthing hands
19
Q
Normal Development-oral Motor
Three months
A
- Rooting beginning to disappear
- Start to see more non-reflexive up-down tongue movements
- Longer sequence of sucking before swallow/breathe
20
Q
Normal Development-oral Motor
Four months
A
- Rooting reflex should be integrated
- Increased oral exploration of objects/toys
- Mature sucking pattern begins
- More active lip closure (less drooling and liquid loss)
21
Q
Normal Development-oral Motor
Five Months
A
- Refinement of mature sucking pattern (cupped tongue, activation of lip/cheek muscles)
- Well coordinated pattern of suck-swallow-breathe (SSB)
- “Suckles” from spoon (tongue pushing forward)
22
Q
Normal Development-oral Motor
Six months
A
- Mature sucking pattern and coordinated SSB
- Open mouth in anticipation of spoon
23
Q
Normal Development-oral Motor
Seven Months
A
-Starts to clear food from spoon with active upper lip
24
Q
Normal Development-oral Motor
Eight months
A
Actively clears food from spoon
-On a dry solid (e.g. cookie) will see suck, suckle or phasic bite-release
25
Normal Development-oral Motor
| Nine to 10 months
Can transfer food from centre to side of mouth
- Munches on solids
- Holds dry solid between gums to break off a piece
26
Normal Development-oral Motor
| Eleven to twelve months
- Begins to chew
| - Able to suck liquid from a cup with well-coordinated SSB
27
Oral Motor Dysfunction
| Problems:
- Organization of burst-pause rhythm (often called "coordination of SSB")
- Strength of suck
- Structural problems
- ->cleft lip and palate
- Abnormal motor patterns
28
Sensory functioning
- Textures
- Colours
- Smells
- Appearance
29
Sensory Differences
| Clinical Presentation
- Sensory defensiveness
- Not mouthing toys and fingers
- Gagging
- Stuffing
- Strong tasting foods
- Preference for self-feeding
30
Behavioural/Psychological Difficulties
-Is the problem specific to feeding?
When are the other times that the child and feeder interact and the child has control?
-What does the child need out of their eating time and other psychological interactions that they are not getting
31
Occupational level
- Self-Feeding
- Positioning
- Food Preferences and Range
- Speed and Self Regulation of Eating
32
Normal Development of Self-feeding Skills
- Depends on environment factors including: exposure/learning opportunities, family culture
- In addition to child's physical (motor, cognitive, emotional/behavioural) factors
- And elements of the occupation - eg foods, and tools
33
Approaches to feeding
- breastfeeding support
- Positioning
- Handling
- Pacing
- Tools
- Food consistencies
- Feeding schedules
- Importance of early feeding experiences
- The "Get Permission" Approach to mealtime and Oral Motor Treatment
- Food Chaining
- Other sensory approaches
- Baby-led weaning
34
Get Permission Approach
- Positive tilt
- External cues
- Stabilization
35
Environmental Level
| Primary Feeder/Caregiver
- Energy and fatigue
- Family Obligations
- Attitudes/Wishes
- Access to Feeding and positioning Equipment
36
Doing Feeding
- Obtaining supplies
- Technical competence
Subtheme
- Impact of environment on feeds
- Parental competency and efficacy on feeding
37
Feeling Feeding
-General feeling
Parent overall perceptions
Subtheme
- Parental satisfaction with diet (content of feed)
- Adapting/accepting to child's feeding abilities or progress
38
Feeding as Family
- G-tube and sleep
- Participation of feeding and eating as family
Subtheme
- Impact on family
- Outings and travel (mobility)
39
Child's Perspective
- Child engagement
- Child's overall perceptions
Subtheme
-Child's behaviours
40
Feeding as participation
-School/Daycare/Recreational caregivers
Subtheme
-Participation in feeding at school
41
Health Supports
- HCP Interactions/Frustration with professionals
| - Caregiver support for feeding
42
Treatment models
- Consultative Tertiary Care
- Consultative School Health
- Direct Therapy
43
Therapy Approaches
| Remedial approaches:
- Improving oral motor development
| - Sensory attenuation through exposure
44
Therapy Approaches
| Compensatory Approaches
- Match food and drink to oral motor and swallowing ability
| - No expectation for change or growth
45
Therapy Approaches
| Behavioural - medically uncomplicated vs complicated
- Traditional behavioural approaches can benefit from a person-environment-occupation less
- Consider what else is happening
46
What head position makes the trachea vulnerable to penetration
-neck in extension
47
Explain which structures are in which position when this happens
the seal epigolous is not fully closing the airway
| -those structures are not protected and they are exposed to food (apiration_
48
If a child holds their head in this vulnerable position, which of the following cups would you consider trying first? Explain how you think the cup might address the problem
- most correct - the cut out cup (the middle cup)
- the nasal cut out
- you don't further have to put you head back to get the bottom of the cup
- You can tilt the cup all the way
- particular good when using to feed to someone
Cup 1 - if the child is a self feeder
49
You will ask the parents to screen for aspiration from food and drink taken by mouth and explain why you asked them
-look at the aspiration flow chart
most common one:
- does the child have a chest history, frequent bronchitis or pneumonia
- Do they cough or sputter when they drink fluids by the mouth (some kids that apirate don't have that reflexive to cough-that's why chest history is important)
- Their level of comfort when they are being feed- do they tend to act strongly to different types of food? Do they widen their eyes or express verbalization express discontent when water or fluids are on their way. Or do they appear like they are in pain with chest movement. The turning away of the head, might be scared or uncomfortable?
- Do they sound very wet after they eat? Listen to sounds when they are not eating. DO you hear a really strong swallow and they get rid of it. Thats good or does it stay there without them trying to swallow?
50
What can you do to make water safer to take by the mouth in this case
- we give them a substance that is thickener
- really clear instructions to thicken water
- have time to respond to it
- creates more pressure on those sinuses (more like a bolus feeling)
- thicker less vulnerable to spill over that unresponsive epiglottis
- same thickener to thicken food
51
If a child has a thickened liquids and managing swallow food into the esophagus but still is having chest infections, is there some other ways that they could be aspirating? if so how?
- we know that we take food in by mouth
- gerd or reflux can cause food to come and not vomit but enter the trachea.
- are they aspirating from the top or aspirating from the bottom
52
Write 3 questions you will ask parents if you suspect they are aspirating in this way
- a history of gerd or clinical signs of Gerd that they observed
- are they taking any medications for digestion (low sec - reducing acid production or proton pump inhibitor-reduce acid production in the stomach or a drug to tighten the sphincter)
- pain after eating how long it goes on
- vomiting after eating (15, 20 min , 30 )
- Are they getting chest pain
53
If a child's gag reflex is weak (meaning this might be a sign that they have poor sensory ability in the throat during swallowing), how might you change the texture of fluid, (not the consistency) to make the throat more responsive?
-could be a sign of aspiration
-like not having the coughing or sputtering
-texture (how rough it is)
-consistency (how thick it is)
-Water and juice (smooth texture
-carbonated beverage (rough texture)
-Could give carbonated water
grading activity - stronger response
54
As a school health therapist, what will you do if you think a child you assessed might be aspirating?
- they will engage other members of the team (their pediatrician, specialist or family doctor)
- start the ball rolling on looking for an objective test like a barium swallow to look at if the child is apriating or not
- clear plan
- What information is needed to make the referral
- clinical observation and parents history.
55
You conduct a feeding assessment for a 7-year-old child and find they should not eat hard solids, or drink thin liquids. Create a meal plan, balancing high and low effort within meals. Never repeat the same foods twice. The winning meal planners get a free coffee vouch
fill in while studying
56
Bent handle utensil
Who you think it could help? What problem would it solve? What kind of ‘person’ impairment or ‘occupation’ issue could this device address?
Built up handle - easier to grasp
Weight the handle -makes motor control easier, tremors
Use if you don’t have radial deviation (limited wrist movement)
Child with CP
May be too bug for a child
Hard to find smaller ones
57
Build Up Spoon handle
Who you think it could help? What problem would it solve? What kind of ‘person’ impairment or ‘occupation’ issue could this device address?
If kids don’t have the ability to do the pincer grasp for long periods of time use the built up spoon handle
Allows them to use a palmar grasp
58
Dycem
Who you think it could help? What problem would it solve? What kind of ‘person’ impairment or ‘occupation’ issue could this device address?
Gives stability to objects
Used like a placemat
Put on kids chairs so they don’t slide forward (kids with low trunk control)
Put on jar lids to give stability (allows for better grip)
Used for endurance kids may get tired and not use all components to complete the task
Used with kids with spasticity, amputees, kids with one arm that works better than other
You can wash it, but it loses its stick over a period of time
59
Plate-guard or Lipped Plate
Who you think it could help? What problem would it solve? What kind of ‘person’ impairment or ‘occupation’ issue could this device address?
Kids that would push food off their plate
Eliminates the bilateral task of using the knife to push food on the fork
Often use dycem and a lipped plate together
60
Haberman-Feeder
Who you think it could help? What problem would it solve? What kind of ‘person’ impairment or ‘occupation’ issue could this device address?
Cleft pallet
Used in the NICU often
Can control the flow with different types fo nipples with different openings
Infants with low suck don’t have to use as much EN to suck if the opening is larger
61
Hierarchy of evidence: Part 1
- Editorials, expert opinion
- Mechanistic studies
- Case reports, case studies
- Cross-sectional studies, surveys
- Case-control studies
- Cohort studies
- randomized control trials
- Systematic reviews and meta-analysis of RCTS
As you go up the period increase in quality of evidence and decrease fo risk of bias
62
Hierarchy of evidence: Part II
- Case series/reports
- case control studies
- cohort studies
- randomized control trials
- Systematic review
63
Interventions covered in this class
- COOP motor learning
- Sensory accommodation/integration
- School-based handwriting and assistive tech
- Feeding/Eating (safety/development accommodation)
- Mobility/seating
64
Interventions are successful when Based Upon:
- Goals that respect child-self-determination
- Family-centred/ecological approach
- Responsiveness to cultural diversity and decolonization perspectives
- an emphasis on participation and occupation as the end goal
- A focus on capacity building in the environments that children occupy
- Important but objective measures
65
Child-Self-Determination (CSD)
- When children have autonomy and experience that help them shape that autonomy relative to their strengths, they are more likely to achieve occupations
- when families recognize and promote CSD, they are the most ideal place to build capacity
- This is how to operationalize client-centred practice for kids
66
Issues Relating to Diversity Families
| practicing humility and reducing bias in practice
- General family choices
- What constitutes family
- Feeding and eating
- Routines
- Values about independence versus interdependence
67
Disregarding culture or exerting colonized practice
- Disregarding culture is a breach of person-centred principles
- There are deleterious consequences to children families and society
68
Disproportionate Bias: Children in Care
- Despite making up only 4.1% of the population in ontario under age 15, indigenous children represent approx 30% of foster children.
- This representation cannot be explained by poverty or other environmental factors alone
- Systemic resource depletion: diversion of funds from first nations housing to child welfare
- Bias in health and education referrals might be a major cause
69
Disability Practice for Kids
Traditionally
- Medical model dominates
- Developmental assessments (weakness/strength for chronological age)
- Diagnostics categories
ICF-CY
-Biopsychosocial framework of health for children and youth
70
ICF-CY framework
Part 1: functioning and disability
- Body Functions And Structure (Physiology, Anatomy)
- Activities: And Participation
- ->Activity: Execution Of Task/Action By An Individual
- ->Participation: involvement In A Life Situation
- Capacity (standard Environment) Vs Performance (Current Environment)
Part 2: Contextual Factors
- environmental Factors
- Personal Factors
Each Can Be Expressed in Positive or Negative Terms
71
ICF-CY Strengths
- A common language across disciplines, settings, and sectors
- Describing functional profiles associated with different conditions
- De-emphasizes diagnoses and illnesses in lieu of activity and participation
- Legitimizes OT focus on the interdisciplinary team
72
Building Capacity in Environments
Building Capacity for CSD and Developmental Perspective in Families And Schools
- More likely to be lasting than a focus on the child alone
- More likely for consultations to be implemented
- More likely for generalization to enable occupation in other areas
73
Partnering for Change
- Educators
- Students
- Therapists
- Parents
Pyramid
- Health promotion/universal design for learning
- Screening/differentiated Instruction
- Accommodation
as the pyramid rises:
- fewer students
- more intensive services
At the bottom
Relationship building
-Knowledge translation
74
Classifying Disability in Children
Classification is serious business. Classification can profoundly affect what happens to a child. It can open doors to services and experiences the child needs to grow in competence, to become a person sure of his worth, and appreciate the worth of others, to live with zest and to know joy
75
Choosing Outcomes to evaluate care
-Service Delivery
(primary outcome)
- Coordination of Care Among Providers
- Coordination of care patients providers and family
- Quality and Effectiveness of Cae Planning Tools
76
tools that measure how patients are doing
| Child
General Health of Quality of Life
- Quality of life
- Emotional Well-being
Specific Health and Health impact
- Physical pain
- Feeding and Swallowing Performance
- Access and satisfaction medical Technology and assistive devices
77
tools that measure how patients are doing
| Parent
General Health of Quality of Life
- Quality of life
- General Health Physical and Emotional
Specific Health and Health impact
- Energy
- Fatigue
- Out of Pocket Expenses/impact on Work
78
Understanding Change Scores
- T-tests/significance tests
- Effective size
- Difference scores
79
What are the notable differences between our values and the evidence?
- hierarchy
| - evidence-informed intervention
80
Functional mobility
Moving from one position or place to another
81
Community mobility
moving from oneself in the community and using public or private transportation
82
In-time mobility
introduction of mobility devices approximately the same time as peers start to move
83
Typical development
- Common Progression:
- Rolling, Sitting, kneeling, standing, crawling, cruising and walking
- most children learn to walk between 9-15 months
84
Motor development
- Locomotion and other mobility skills develop quickly during the first 3 years of life. These skills become the main avenue for learning and socialization; as well as, for the growth of a sense of independence
- Exploring = learning
- Toddlers and children who cannot walk/crawl/scott/cruise to get around their environments miss out on sensorimotor and developmental experiences that their peers, who can move, have achieved
- Development across all areas is connected = ripple effect
85
Conditions affecting mobility development
- Prematurity
- Genetic syndromes: Down's Syndrome, Prader Willi
- Neuromuscular disorders: Duchenne Muscular Dystrophy, Spinal Muscular Atrophy
- Neurological disorders: Cerebral Palsy, Brain injury, Seizure Disorder
- ->CP is the most common motor disability of childhood
- Medical conditions: heart, cancer
- Spina Bifida
86
Impaired mobility why?
- Physical disabilities
- Restricted experiences
- Less self-initiated or self-produced mobility
- Delays in development
- Less exploration, curiosity
- Motivational effects-learned helplessness
87
Factors affecting Children's mobility: Person-Environment interaction
- Person
- ->Capability
- ->Personal factors
- Environment
- ->setting
- ->context
88
Assessment
- Utilize: Utilize measures of both capability and performance
- Examine: Examine mobility in the child's everyday settings
- Measure: Measure contextual feature of everyday settings
- Identify: Identify personal factors that might influence mobility method
89
Mobility Assessments
Pediatric Powered Wheelchair Screening Test (PPWST)
-Screen ages 20-36 months with orthopedic disabilities
Canadian Occupational performance Measure
- embeds mobility choices in daily life priorities
Pediatric Evaluation of Disability Inventory COmputer Adaptive Test (PEDI-CAT)
-daily activities, transfer skills, body transportation
Wee-Functional Independence Measure (WeeFIM)
-6 months to 7 years - independence in mobility
90
Classification of Mobility Skills
- Never ambulate
- ->no opportunity for independent mobility
- Inefficient mobility
- ->ambulate but not at acceptable rate, speed, endurance
- Lost independent mobility
- ->acceptance of mobility aids may be an issue
- Temporarily require assisted mobility
- ->may progress to independent mobility with age
91
Gross Motor Function Classification System - Expanded and Revised
- 5-level classification system that describes the gross motor function of children and youth with cerebral palsy on the basis of their self-initiated movement
- Emphasis on sitting, walking and wheeled mobility
- Distinctions between levels are based on functional abilities, the need for assistive technology, including hand-held mobility devices (walkers, crutches or canes) or wheel mobility, and to a much less extent, quality of movement
92
Physical and Physiological Demands of Ambulation
-Energy requirements - Physiological
-Vision
-ROM
-Poor Alignment
-Bony changes
overall fitness and endurance
-Impact of gait pattern
-->children with CP
--->increased oxygen requirement
--->Diplegic CP - Crouched gait - increased flexion which increases stance phase and limits velocity
--> Children with spina Bifida
--->Require 200% more energy to ambulate than peers
--> Heat production due to increased metabolic cost increases thermoregulation and additional rest required to restore temperature
-->weakness
93
Demands of manual Wheelchair Propulsion
- Upper extremity strength and coordination (wheelchair weight in excess of 40 to 50 pounds)
- Hand grip - release and grip/hold the rimm
- Head and trunk control (tilt frame makes propulsion difficult)
- Endurance
- Higher oxygen consumption
- Vision
- Tolerate upright posture and ability to change position and/or manage pressure
- Minimally influenced by spasticity and reflex patterns
94
Demands of Power Mobility
Cognitive Readiness
-->Basic cause and effect, directional concepts, problem solving and spatial relationship, and judgement
Coping abilities
-->attention span, motivation, persistence
Sensorimotor abilities
-->Perception, processing, motor planning, reaction time
Ability to activate the access method consistently and purposefully
95
When to recommend a mobility device
As an OT you must consider all variables
Questions to ask yourself
- Is the child ready?
- What is the level of supervision/training needed to use the equipment?
- How will the mobility aid be transported?
- Where will the child be using the piece of equipment?
- Are the parents ready?
- ->If a mobility aid is recommended what. does the parent interpret that to mean?
96
Mobility Intervention
- Specialty/adapted strollers
- Support Walkers (PT)
- Standing Frames (PT)
- Scooters
- Power and manual wheelchairs
- Specialized devices for specific activities
97
Power mobility Evaluation and Intervention
- Define goals
- Determine how the child will access and drive the device
- Evaluate switch placement
- Input devices
- Factors that may interfere with driving ability
- Guidelines for teaching a child to use the powered device
98
Power Mobility Why?
- Some children will not progress to independent ambulation, and they may also not be able to independently propel a manual wheelchair
- Decreased endurance either walking or propelling a manual wheelchair.
- Power mobility allow children/adolescents to keep up with peers and engage in meaningful occupations that would not be possible without the use of power.
99
Power Mobility When?
- Previous research thought children needed to achieve certain milestones cognitively (ex. object permanence, cause and effect, and spatial awareness) before being introduced to power
- New research is showing that readiness skills develop with the mobility experience. Some researchers suggest 17-18 months old
- Training - the more cognitively impaired the child, the more structured training they will require
100
main objective with seating
-Function, alignment , comfort, and supporting growth
101
Wheeled Mobility Systems
Manual wheelchairs
- lighter
- Easier to transport
Power Wheelchairs
- Longer distances
- accommodates poor motor control and low endurance
Selection of wheelchair features
102
Wheelchair Features
- Style of frame
- Tilt-in space
- Recline
- Footrest style
- Armrest style
- Backrest height
- Backrest adjustability
- Height and adjustability features
- Floor-to-seat height
- Style and location of wheel locks or brakes
- Type, size, and placement of wheels and casters
- Additional feature
103
Seating Guidelines
- optimal alignment for function
- Stability to improve distal motor function
- Minimizing undesirable tone and reflexes
- Distribute seat pressures to maintain skin integrity
- Improve physiologic function (breathing, swallowing, digestion
- Increases ADLs
- Provides comfort
104
Factors that influence Successful Use of Mobility Devices
- Fit of child to device
- Features of the device
- Physical and social environments
- Ability of the professional or caregiver to determine accurate means for the child to access the device
- Changes the child may go through in the future
- Where and how augmentative communication equipment will be mounted
- Client education
105
Alternative Mobility Devices
- Adapted tricycles
- Prone scooters, caster carts
- Mobile stander
- Walkers
- Alternative powered mobility devices
106
Who pays
- Assistive Devices Program (ADP) Ontario Ministry of Health: must be registered, rules to follow.
- Assistance for Children with Severe Disabilities (ACSD)
- Organizations: Easter Seals Ontario, Muscular Dystrophy Canada, March of Dimes
- Private Insurance/Extended health benefits
- Community Funding options - do your research
107
Mobility summary
- Independent mobility plays a role in the child's development
- Mobility devices provide the child with greater opportunities to experience the environment
108
Mobility Assessments
- Interview with parent/child
- MAT assessment
- Assessment form/measurements
- Seating stimulation
- Product trial
109
Considerations in pediatric seating/mobility
- Parent readiness
- Equipment can trigger grief response
- Child vs Parent, school etc. and meeting their needs
- Growth and development and internal drive to move
- Potential for regression depending on diagnosis
- Transportation
- Environments where equipment will be used
- Level of supervision needed/safety considerations
- Comfort and function
