Typical Feeding Development Flashcards
What is the role of the SLP?
- specialists in communication/swallowing
- swallowing: dysphagia and mealtime management
Paediatric feeding/swallowing management: - oral phase (sucking, biting, chewing)
- pharyngeal phase (swallowing)
- coordination of suck, swallow and breathe
- communication: pre-verbal, infant cues, non-verbal
- counselling: providing sensitive explanations to families
- advocacy: liasion with the medical team, timely referrals
List the child, parent and staff focused services the SP provides
Child:
- assessment
- treatment
- consultation
Parent:
- training in reading and responding to infant cues
- training in feeding techniques
Staff:
- providing education
- providing input into multi-disciplinary team
What factors contribute to being able to feed/eat?
- normal anatomy
- normal oral reflexes
- intact cranial nerves
- physiologic control
- state control
- secure attachment/communication
- postural control
- intact sensory system
List features of the normal anatomy of the mouth/pharynx of newborns
- Soft palate - in approximation with epiglottis as a protective mechanism
- Tongue - appears to fill oral cavity, restricting movement to a forward-backward suckling motion
- Cheeks - sucking pads present which assist with stability for suckling (support tongue)
- Breathing - preferential nasal breathers because of approximation of soft palate and epiglottis
- Lower jaw - small and slightly retracted
- Hyoid - made of cartilage rather than bone
- Larynx - higher in the neck than in adults, which reduces the need for sophisticated closure to protect the airway during swallowing
What are oral reflexes?
- Infants are born with reflexes that facilitate survival → diminish as more mature skills emerge
- Reflexes are brainstem-mediated
- Progression of early reflexes can give important information regarding neurological development
What are the two types of oral reflexes?
- adaptive: facilitate getting food into the mouth and to the stomach
- protective: prevent foreign material from entering the airway
List the adaptive reflexes, including their purposes
Rooting reflex
Touch to cheek or mouth results in head turn towards the source of the stimulus
Purpose is to:
Suckling
- Develops before sucking
- Involves forward-backward movement of tongue
Sucking
- Develops around 6 months
- Involves up-down movement of the tongue
Purpose:
- positive pressure pushes fluid out of nipple
- negative pressure draws fluid out of the nipple
Discuss nutritive and non-nutritive sucking
- Important to be able to observe the difference between nutritive and non-nutritive sucking, especially for breastfeeding assessment
- Be aware that infants can use non-nutritive sucking at times to stimulate let-down reflex so you may see a combination of both types during a feed (but should be nutritive > non-nutritive)
Discuss the purpose, rhythm, rate, suck: swallow ratio and jaw movement of nutritive sucking
Purpose: obtain nourishment
Rhythm: initial continuous suck-burst, moving to intermittent suck bursts with pauses becoming longer over the course of feeding
Rate: one suck/second
Suck: swallow ratio: young infant 1:1 - older infant 2:1 or 3:1
Jaw movement: deep and slow
Discuss the purpose, rhythm, rate, suck: swallow ratio and jaw movement of non-nutritive sucking
Purpose: state regulation
Rhythm: repetitive pattern of bursts and pauses; stable number of sucks per burst and duration of pauses
Rate: two sucks/second
Suck: swallow ration: very high, 6:1 to 8:1
-Jaw movement: shallow and quick
List the protective reflexes
- gag
- cough
- tongue protrusion
- transverse tongue (lateralisation)
- phasic bite
Discuss the gag reflex in terms of its: stimulus, response, purpose and when it diminishes
Stimulus: touch to posterior 1/3 of tongue
Response: contraction of palate and pharynx
Purpose: expels foreign material from the pharynx
Diminishes: persists into adulthood but becomes less sensitive
Discuss the cough reflex in terms of its: stimulus, response, purpose and when it diminishes
Stimulus: foreign material entering airway
Response: epiglottis and vocal folds close and open again rapidly as air is pushed out of the lungs
Purpose: expel foreign material from airway
Diminishes: persists into adulthood
Discuss the tongue protrusion reflex in terms of its: stimulus, response, purpose and when it diminishes
Stimulus: touch anterior tongue
Response: tongue moves anteriorly and protrudes outside mouth
Purpose: pushes food out of the infants mouth when they are not mature enough to cope with it
Diminishes: 4-6 months
Discuss the tongue lateralisationreflex in terms of its: stimulus, response, purpose and when it diminishes
Stimulus: touch to lateral surface of tongue
Response: tongue moves towards stimulus
Purpose: pushes food to side of mouth in primitive chewing attempt -> integrates into more refined movement for chewing
Diminishes: 6-9 months
Discuss the phasic bite reflex in terms of its: stimulus, response, purpose and when it diminishes
Stimulus: pressure on gums
Responses: rhythmic opening and closing of jaw
Purpose: keeps material out of an infant’s mouth when they are not mature enough to manage it -> integrates into more sophisticated chewing
Diminishes: 9-12 months
What is a laryngeal chemoreflex?
- Young babies are more likely to experience apnoea (cessation of breathing) than overtly coughing in response to aspiration
This occurs due to the laryngeal chemoreflex:
- Vocal folds close for a prolonged period in response to presence of foreign material
- Presumably to protect the lungs
- Emerges during the third trimester and resolves within the first few months of life
Discuss the general role of the cranial nerves in the control of sucking, swallowing, and breathing - list the CNs involved also
- functions overlap, but very important to have an understanding of normal function with respect to feeding and swallowing
- Trigeminal
- Facial
- Glossopharyngeal
- Vagus
- Hypoglossal
Discuss the role of the Trigeminal Nerve in swallowing, and list some assessment tasks and potential deficits
Controls the muscles of biting and chewing, and provides sensation to the face
Assessment tasks:
- jaw opening to resistance
- jaw lateralisation
- sensation to face
Potential deficits:
- poor mastication and bolus formation
- poor bolus awareness
- reduced hyolaryngeal elevation
- impaired supraglottic closure
- decreased opening of upper oesophageal sphincter
Discuss the role of the Facial Nerve in swallowing, and list some assessment tasks and potential deficits
Controls the muscles of the face, submandibular and sublingual glands and provides sense of taste to anterior 2/3 of tongue
Assessment tasks:
- facial symmetry at rest and in movement (e.g. closing eyes, wrinkling brow, blowing a kiss)
- taste response
Potential deficits:
- paralysis of facial muscles
- poor lip strength
- impaired taste/salivation
Discuss the role of the Glossopharyngeal Nerve in swallowing, and list some assessment tasks and potential deficits
Responsible for sensation to the tongue, pharynx and soft palate, and sense of taste to posterior 1/3 tongue
Assessment tasks:
- Not able to be assessed clinically
- Gag reflex (*high risk of false positive; not recommended in clinical assessment)
Potential deficits:
- Reduced pharyngeal motility → post swallow residue
- Reduced supraglottic compression
- Decreased base of tongue to posterior pharyngeal wall movement
- Weak cough reflex and diminished gag reflex
Discuss the role of the Vagus Nerve in swallowing, and list some assessment tasks and potential deficits
Controls sensation of the larynx, base of tongue, pharynx, palate and their muscles
Assessment tasks:
- Vocal quality
- Volitional cough
- Swallow initiation
- Velopharyngeal closure (soft palate movement – velar elevation)
Potential deficits:
- Reduced velopharyngeal closure → hyper nasality & nasal regurgitation
- Diminished capacity for laryngeal adduction
- Decreased effectiveness of cough on aspiration
- Impaired opening of upper oesophageal sphincter
Discuss the role of the Hypoglossal Nerve in swallowing, and list some assessment tasks and potential deficits
Controls muscles of the tongue
Assessment tasks:
- Lingual movement: superior, lateral, protrusion, retraction
Impact on feeding:
- Poor bolus manipulation, preparation and propulsion
- Decreased base of tongue to posterior pharyngeal wall approximation
Why is physiological control important?
All include some signs a child is not coping
Basis for feeding management
If not physiologically stable:
- may not be ready for oral feeding
- may not have stamina for full volumes
- may be a safety risk
Signs a child might not be coping:
- frequent coughing/choking
- changes in vocal quality/breathing
- sweating
- breathing very quickly or holding breath
- increased breathing effort (e.g. nasal flaring, tracheal tug)
- watery eyes
- cyanosis
What is respiratory distress?
Difficulty breathing - child not getting enough oxygen
Child’s body may attempt to compensate for lack of oxygen by:
- increasing respiratory rate
- nasal flaring
- recessions (tracheal tug, substernal or subcostal recessions)
- may hear signs of effort such as stridor or grunting
- precursor to respiratory failure
What is state control?
= the level of alertness and environmental interaction patterns present in a child at a given point
State is modulated by stimulation:
- internal: hunger, pain, temperature
- external: noise, light, handling
List the state levels, and a description of each
- Deep/quiet sleep
- infant is asleep and has a regular respiratory pattern - Light sleep
- eyes are closed, although rapid eye movements may be seen beneath the eyelids. There is some low-level motor activity present - Drowsy/semi-dozing
- eyes are open but heavy-lidded/fluttering. movements are generally smooth with mild startles - Quiet alert
- infant is strongly focused on a stimulus. There is minimal movement - Active alert
- there is considerable movement. The infant often responds to stimuli with more movement. Brief ‘fussy’ periods may be observed - Crying
- the infant is crying intensely, and may be difficult to console
Make a comment about role of attachment on feeding
Successful feeding is reciprocal process -> relies on caregiver’s ability to interpret cues, and child’s ability to provide consistent messages
At ages 0-3 months, 2-6 months and 6-36 months, list infant development and parent behaviours typically seen
0-3 months:
(infant development) - homeostasis
(parent behaviours) - calm and organise the infant, respond to the infant’s cues
2-6 months:
(infant development) - attachment (achieving a positive state of affective engagement/purposeful movements for communication)
(parent behaviours) - reciprocate interactions, engage with the child, modulate arousal
6-36 months:
(infant development) - separation individuation
(parent behaviours) - provide the child with opportunities to explore, support drive for autonomy but welcome back when required, provide structure and set limits
What are infant cues?
The ways that infants communicate their needs with caregivers
- infants are born with the ability to respond in a predictable and organised way (consistent response from the parent reinforces behaviour)
- may be in response to external or internal stimuli
- engagement vs. disengagement cues
- subtle vs. overt cues
List some baby feeding cues
Early cues- ‘I’m hungry’:
- stirring
- mouth opening
- turning head
- seeking/rooting
Mid cues - ‘I’m really hungry’:
- stretching
- increasing physical movement
- hand to mouth
Late cues - ‘calm me, then feed me’:
- crying
- agitated body movements
- colour turning red
