Week 12 to 14 Flashcards
Topic Feeding: Define the following: -feeding -eating -swallowing
- Feeding – self feeding- process of setting up, arranging and bringing food from talbe, plate or cup to mouth
- Eating – ability to keep and manipulate food or fluid in mouth and swallow it
- Swallowing – complex act in which food, fluid, medication or saliva is moved from mouth through the pharynx and esophagus into stomach
Common Medical Diagnoses Associated with Feeding Disorders
Prematurity Cleft lip or palate GI conditions Ie GERD Visual impairments Tracheostomies Developmental delays Emotional and behavior issues Anxiety Dysregulation Rigidity Food allergies Feeding tube
Anatomy and Development of Oral Structure
Structures:
- Oral cavity
- Pharynx – funnels food to esophagus; allows food and air to share space
- Larynx – valve to trachea to close during swallow
- Trachea – allows air to flow into lungs
- Esophagus – carries food from pharynx to stomach
Newborn:
Oral cavity filled with fat pads inside tongue and cheeks to aid in grasping and compressing nipple
6 month old:
-oral cavity larger and tongue up and down movement now extract the liquid
- Sucking patterns become more voluntary
- Oral motor skills support the in take of lumpy textures and chewing
Important role in proper timing of breathing and swallowing during oral feeding (infancy/as child grows)
Infancy:
-Structures in close proximity in infancy – epiglottis and soft palate are in direct approximation so fluid safely moves from nipple to base of tongue to esophagus
-Very little aspiration first four months - they can feed in reclined position
As child grows:
-Space is created between hyoid, epiglottis and larynx and base of tongue – child needs greater coordination for suck swallow and breath
-Greater risk for aspiration in reclined position so child begins to eat upright
What are the 4 phases of swallowing?
Phases of Swallowing:
- Oral preparatory phase
- Reflexive in young infants; voluntary control for others
- Oral manipulation of food
- Form bolus - Oral phase
- Reflexive in young infants; voluntary control for others
- Tongue elevates against alveolar ridge of hard palate moving bolus posteriorly and ends with onset of pharyngeal swallow - Pharyngeal phase
- Primarily reflexive
- Swallow is triggered; movement of hyoid and larynx; epiglottis protects airway opening; upper esophageal sphinter opens - Esophageal phase
- Reflexive
- Starts with relaxation of upper esophageal sphinter and ends to relaxation of lower esophageal sphinter to allow food to move into stomach
What are the Stages and Ages of Feeding Development?
- In utero
Suck swallow develops 10-14 weeks gestation
16-20 months gestation mouths thumb
-New born
Premature infant may not be ready for oral feeds – then tube feedings
Healthy newborn has reflexes and physiological flexion that help with eating
Sensory and social experiences help them bond with the parent through touch, sounds, eye contact and smells
-3-6 months
More head and neck control so feeding becomes more upright
Brings hands to bottle
Brings toys to mouth – helps get ready for eating new textures in the future
Some start accepting pureed now
-6 months
Definitely ready for pureed via spoon
Learns to open mouth in response to spoon and clear puree from spoon
Still breast or bottle feeds
-8-12 months
Finger foods
Vertical chew develops at first then tongue lateralization
Cup drinking introduced with spillage
-12-24 months
Brings loaded spoon to mouth at 12 months
Masters scooping by 18-24 months
Wean from bottle/breast
Rotary chew – diagonal jaw movements and tongue lateralization
Soft and coarsely chopped table foods
By 24 months tougher foods mastered
-24 months to 5 years old
By 3 years old accepting a variety of table foods
By 5 years old feeding patterns are fully functional adult patters
What does a Comprehensive Evaluation of Feeding and Swallowing Skills includes?
1. Initial interview and Chart review: Health status Record review Developmental history Interview caregivers How is feeding going? What are your concerns? How much does the child eat and drink? Mealtime routine? How often does the child eat? Where does he/she eat?
- Observation of muscle tone, nueromuscluar status, sensory processing and developmental level
Low tone – decreased postural control
High tone – difficulty grading or sustaining oral motor patterns, poor coordination, drooling, decreased oral exploration, limited self feeding
Sensory processing difficulty – decrease attention, difficulty managing certain textures, poor tolerance to mealtime experiences - Structured Observation
- View the structures of the mouth – jaw lips tongue gums teeth palates
- Observe child eating
Have parent feed child to note the process and interactions
Use foods child prefers as well as some more challenging foods
Note signs of aspiration – food or liquid entering the airway beforem during or after swallow
Gagging
Coughing
Choling
Nasopharyngeal reflux
Increased congestion
Wet vocal quality
Frequent respiratory infections and/or pneumonia
What are additional medical tests used for Evaluation of Feeding and Swallowing Skills ?
1. Barium Swallow Study (MBSS) Looks at structures as well as the feeding and swallowing process Diagnoses and/or helps determines the following Aspiration Swallow mechanisms Head and neck positioning Bolus characteristics Rate and sequence of feeding Safe food and liquid consistencies Appropriate positioning Appropriate food textures
- Upper GI series
Diagnoses
Reflux
Structural abnormalities - Esophageal probe
Determines the severity of reflux - Endoscopy
Helps determine food allergies
Intervention Strategies for feeding?
Environmental Adaptations (may need trial and error to determine effectiveness)
- Meal time routines and schedules
Allows for time without food/juice/milk to increase hunger
Consistent location for eating
-Length of meal time
No longer than 30-40 minutes (15-30 minutes is best)
Children with reflux may benefit from smaller shorter meals more often
-Sensory stimulation during meal time
Decrease distractions
-Sequence of food offerings
-Positioning adaptations (always promote socialization) Providing external support can assist with self feeding as well as oral motor control Infants Side lying for bottle/breast may be best – gravity does not immediately draw fluid to pharynx Car seat can support infant Supine drinking of bottles is not generally recommended Toddlers High chair with towel rolls Tumble form feeder seat Older children Wheelchair may be best Optimal positioning Vertical head and trunk position Greater than 90 degrees hip flexion Knee flexion 90 degrees Feet supported flat
What are some adaptive equipment for feeding?
Adaptive equipment:
- Spoons
Shallow bowl helps with decrease lip closure
Bumpy spoon helps with decreased sensory awareness
Rubber coated spoon helps with bite reflex
Curved handles and large grips aid with self feeding - Straw
Short straw and/or small straw – results in smaller bolus for managing
One-way valve straw – helps with weak suck
Long straw – decrease hand use
Cup - Nosy cup – helps keep head in neutral
Interventions to Improve Self-Feeding
Encourage child to be interested in food
Encourage self feeding for portion of meal
Positioning equipment including raised tray or table
Dycem
Sticky foods for spoon use
Scoop dish
Light weight utensils
Universal cuff
Electronic feeding systems
Cup with wide base
Long straw with cup in holder
Backward chaining
Consistent orientation of food in plate
Constrasting colors
Napkin or wipes for messy hands
Modifications to food consistencies
Pureed is easiet to manage
Lumpy/pasty foods require more oral motor strength and sensory tolerance
Cruncky/sticky or uneven consistency are most difficult and require advanced chewing skills
Consider altering size of bite
Consider taste and temperature
Modifications to Liquids
-Thin liquid from an open cup is most difficult to manage
-Thickened liquid is easier to control with lips and tongue:
Easier to manage bolus for effectively swallow without spillage into pharnageal cavity
Helps to avoid aspiration
Helps when first learning cup drinking even without aspiration noted
Xanthan gum thickeners can cause serious intestinal issues (necrotizing enterocolitis)
Natural thickeners such as blending fruits for smoothies may be better choice
Intervntions for Dysphagia
Well-research options are limited
Tube feeding might be necessary and recommended by MD
Typical suggestions by Ots: Thickened liquid Carbonated liquids Chin tuck position for delayed swallow initiation but not when there is softening of cartilage of trachea or larynx Shorter meal time to avoid fatigue Multiple swallows to clear food – can offer empty spoon to elicit another swallow if needed Adapting pace of meal Difficulty foods first before fatigue Smaller amount of food offered each bite/sip Small spoon Controlled flow cup Small diameter straw Slow flow bottle
Interventions for Sensory Processing Disorders
Hypersensitivity
Causes of hypersensitivity
Medical interventions such as tracheostomies, feeding tubes, etc may cause sensitivity
Reflux can cause negative association with food
Diagnoses that commonly show hypersensitivity orally:
Autism
Cerebral palsy
Tbi
Sensory processing disorders especially tactile defensiveness
Treatment: Oral sensory exploration via play Child controls sensory input Songs/games touching face Dress up games Textured or vibrating toys Deep pressure/rocking before feeding Hand to mouth activities Nuk brush/toothbrush Deep pressure to body then face then gums Bubbles/blow toys Gradually introduce new flavors and textures Dip teether/lollipop in flavor Modifiy food they do accept slightly
Low registration/poor oral sensory awareness:
Treatment
Oral motor play
Strong flavors
Cold temperatures
If over stuff then small pieces and supervision
Feeding:
Behavioral interventions
Reasons for food refusal: Reflux Constipation Sensory processing issues resulting in gaging Austism – prefers same foods
Treatment:
Calm and happy meal time
Offer choices
Positive reinforcement with planned ignoring
Reinforecer needs to be meaningful to the child and not provided outside of feeding time
Regular exposure to non-preferred foods
Punisment or negative reinforcement not recommended
Break down meal time into small achievable steps
Visual timer/schedule
Ignore negative behaviors
Interventions for Food Refusal or Selectivity
Treatment:
Present the food many times
Rule out medical reasons such as reflux
Structured meal time and schedule
Decrease excessive grazing or liquid intake
Introduce foods that are similar to foods they are interested in
Strategies to reduce sensory defensiveness outside of feeding routines
Treatments for Delayed Transition to Textured Foods
Treatment:
Jaw strengthening
Crumbs on chewy tube
Rice flakes in pureed
Move from baby food to pureed for stronger tastes
Practice chewing foods in mesh bag feeder
Praise
Practice small bites outside primary meal time
Delayed Transition from Bottle to Cup
Possible reasons for delay Immature oral motor skill affecting child’s ability to manage bolus Decreased jaw, lip and/or tongue control Failure to thrive Hypersensitivity
Treatment: Activities to promote jaw control, lip closure, tongue movements and oral sensitivity Cut out cup and upright position Thickened liquid External jaw control
Nueromuscular Interventions for Oral Motor Impairments
Research shows oral motor therapy important to feeding support
Difficulties result from sensory motor impairments and lack of experience
Sensory difficulties
Tastes only
Jaw weakness
Bite and tug games
Chewing foods in mesh bag teether
Tongue thrust
External jaw support
Tongue lateralization activities
Lip/cheek weakness or tightness
Cheek stretches
Blowing/sucking
Transition from Nonoral feeding to oral feeding
Nonoral feedings put child at risk for sensory impairments or oral motor impairments
Treatment: If not food by mouth Textured toys, teethers, pacifier Blow/suck toys and games Sit with family during meal time
If food by mouth
When medically cleared for food by mouth
Tastes
Help them with motor and sensory needs
What does Cleft Lip and Palate looks like?
What are treatments like before surgery?
What are treatments like after surgery?
-Hole in the structures that usually join together at midline in the first weeks of fetal development Require surgery to repair Effect on feeding Difficutly latching Ineffective milk transfer Prolonged feeding times Milk leaking from nose Poor weight gain Can effectively breast or bottle feed if this is their only issue with a few adaptations
-Treatment before surgery
More upright posture in sitting
External support at cheek/lip
Adaptive nipples for bottle
One way valve – delivers milk with little or not suction
Longer nipple – deposits milk towards back for mouht
-Treatment after surgery Scar massage Sensitivity treatment Small amounts of liquid or food at each bite/sip Alternating food and drink
Food Transitions for 1 month 4-6 months 8 month 12 month 18 months
1 month – only liquid from bottle or breast
4-6 months – introduce pureed food
8 months – mashed table food
12 months – coarsely chopped table food
(ie. Easily chewed meat)
18 months – small pieces of table food
Positioning for feeding at 1 month 3 months 7 months 9 months 18 months
1 month – supine – head slightly elevated/reclined angle less than 45 degrees
3 months – reclined to angle 45-90 degrees
7 months – 90 degrees with restraint for support
9 months – 90 degrees with restraint for safety
18 months – sitting 90 degrees without restraint
Important components of sucking
Easily initiated Rhythmical Strong Sustained efficient
Biting: Under 5 months 5-6 months 9 months 12 months 24 months
Under 5 months – not appropriate
5-6 months – no controlled bite
9 months – holds cookie between gums without biting through; feeder breaks off
12 months – controlled, sustained bite
24 months – able to grad jaw opening when biting foods of various thickness
Chewing + Tongue Movement :
Under 5 months 6 months 9 months 15 months 24 months
Under 5 months – only sucking
6 months – munching – up and down jaw movement
9 months – some rotary jaw movement
15 months – diagonal rotary – jaw moves down and laterally or down and diagonally as food moves from mid tongue to side or side to mid tongue
24 months – circular rotary – circular or semi-circular jaw patterns with food moving across mid line to opposite sides – used for tougher/firmer foods
Lips under 6 months 6 months 9 months 12 months 18 months 24 months 3 to 4 years old
Under 6 months – sucking
6 months – does not use teeth or gums to clean food from lips
9 months – draws lips in when food on them
12 months – still may lose food when chewing; actively cleans lips
18 months – can chew with lips closed; loses some
24 months – no longer loses food
3 to 4 years – keeps lips closed for appropriate table manners
Define Jaw Instability
Insufficient tone allows jaw to slip and shift forward
Define Tonic Bite Reflex
Jaw tightly clenches when teeth are stimulated, may be difficult to release
Caused by – abnormal muscle tone
