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An Introduction to Pediatric Dysphagia

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Recognizes that feeding successfully depends on much more than age, weight and sucking ability ... and nipples that do not require negative-sucking pressure ... – PowerPoint PPT presentation

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Title: An Introduction to Pediatric Dysphagia


1
An Introduction to Pediatric Dysphagia
  • Anissa Meacham, MS, CCC-SLP
  • Owner, Speech Geek LLC
  • Doctoral Candidate, University of Tennessee

2
Contact Me
  • Anissa Meacham
  • Speech Geek, LLC
  • Abingdon, VA
  • Phone (276) 492-2069
  • Email anissa_at_speechgeek.net
  • Website www.speechgeek.net

3
You Make the Call
  • K What do you know?
  • W What do you want to know?
  • L What did you learn or do you need to learn
    in order to work with in pediatric feeding and
    swallowing?

4
  • What is Normal Development of Feeding? Or what
    do kids/babies need in order to feed/eat
    normally?
  • What Populations are Likely to present with
    Atypical Feeding Development? Why?

5
What they need
  • Intact Systems
  • Neurological Status
  • Development of the Sensory System
  • Respiratory Function
  • Digestive Tract Disorders
  • Joint Stability and Tone

6
Medical History
  • Conditions that impact the neurological system
    developing, respiration and digestion are going
    to impact feeding
  • Medications often have side effects that can
    cause nausea, stomach pain and irritation
  • Many special needs children are dehydrated and
    not meeting fluid needs

7
  • Children with Failure to thrive or poor
    nutritional status can experience altered taste
    of foods.
  • Nutrition should be the first priority and
    primary goal of any feeding program
  • If weight drops too low, childhood anorexia can
    be the result. Appetite is significantly
    decreased
  • Constipation, especially in the special needs,
    child will impact oral intake.

8
Digestive Tract Disorders
  • Pyloric Stenosis
  • Midgut Rotation with Volvus
  • Lactose Intolerance
  • Allergic Colitis
  • Vomiting
  • Celiac Disease
  • Eosinophillic Esophagitis
  • Motility Disorders
  • Gastroesophageal or Gastropharyngeal Reflux
    (GERD)
  • Uncomplicated reflux
  • Complicated reflux
  • Crohns Disease
  • Cyclic Vomiting Syndrome
  • Constipation

9
Reflux Interventions
  • Positioning
  • Limiting air intake with feeding
  • Bottle/nipple change
  • Formula change when appropriate
  • Thickening
  • Scheduled intake
  • Medical management
  • Anti-reflux surgery

10
Minimizing Impact of Medical Hx on Feeding
  • Does the feeding disorder have a physical
    component
  • Feeding is a process that uses all organs, all
    senses and all muscles
  • Feeding is the most complex task we do as humans
  • What conditions impact ability to eat?
  • Breathing is bodys 1 priority

11
Impact on Feeding
  • Has the child learned to coordinate the
    suck-swallow-breathe sequence?
  • Is there a foundation of pre-feeding
    readiness/oral motor skills?
  • What has the childs developmental process been
    like? (NICU, PICU for extended period?)
  • Growth and development o the sensory system is
    critical for transitioning to textured food
  • Feeding has a learned component. It is reflexive
    until age 6 months and then it is a learned
    behavior.

12
Impact on Feeding
  • What is the childs nutritional status?
  • What is the home environment?
  • What are the stressors on the family?
  • What do they know about feeding a baby?
  • Can they afford food?
  • Do they have equipment they need to feed the
    child?

13
Specific Populations
  • Premature Infants
  • Cerebral Palsy
  • Cleft Lip Palate
  • Down Syndrome
  • Failure to Thrive
  • Cardiopulmonary Disorders
  • Tube Feeders
  • Autism Spectrum Disorder

14
Premature or NICU Infants
  • Difficult delivery
  • aspiration, hypoxia
  • Impacts postural control, breathing regulation,
    state regulation, oral and pharyngeal reflexes
  • Cardiac issues
  • Start with limited respiratory reserves
  • Difficulty regulating cardio-respiratory function
  • Impacts energy, endurance, intake, coordination
    and safety

15
Common Complications in Premature Infants
  • Medical Instability
  • Neurological Immaturity
  • Problems with State Regulation
  • Abnormal Muscle tone
  • Immature or altered oral mechanism
  • Poor oral skills for sucking and swallowing
  • Oral hypersensitivity
  • Oral hyposensitivity
  • Slowed Growth
  • Disruption in the development of a positive
    feeding relationship

16
Premature or NICU Infants
  • Congenital Anomalies
  • A continuum from cleft lip only to major issues
  • Major structural/CNS/Neuromotor issues
  • Impacts ability to feed safely
  • Hyperbilirubinemia (Jaundice)
  • Impacts alertness, vigor, therefore intake

17
Premature or NICU Infants
  • Infant of a Diabetic Mother (IDM)
  • Impacts energy, vigor, breathing
  •  
  • Transient Tachypnea of the Newport
  • Impact work of breathing and therefore disrupts
    coordination of suck-swallow-breathe sequence

18
Premature or NICU Infants
  • Born prematurely
  • A continuum of difficulties from micropremies
    (respiratory issues paramount) to those with
    mild respiratory issues
  • The residual effects of Respiratory Distress
    Syndrome (RDS) often compromises the transition
    to nipple feeding

19
Issues that Impact Feeding
  • Immature State Control
  • Fatigue, drowsiness, decreased endurance, frantic
    or irritable behavior,
  • Impacts safety and intake
  • Immature Postural control
  • Impacts regulation of airway opening/closing and
    control of muscles for swallowing

20
Issues that Impact Feeding
  • Immature Physiological Control
  • Impacts heart rate, respiratory rate, WOB
  • Impact ability to cope with the aerobic demands
    of feeding

21
Problem Solving is Essential
  • Suck-swallow-breathe interaction
  • Influence of illness and immature CNS
  • Multi-system integrated nature of feeding
  • Interaction between medical diagnosis and
    feeding/swallowing

22
Multi-System Infant Focused Approach
  • Looks at the whole infant
  • Focuses on the many systems involved
  • Recognizes that feeding successfully depends on
    much more than age, weight and sucking ability

23
Two Key Strategies
  • Positioning
  • Flow Rate

24
Positioning is Critical
  • It impacts
  • Airway maintenance
  • Breathing regulation
  • Swallowing safety
  • Overall organization of the infant

25
Positioning is Critical
  • Head Neck Position influences
  • Airway caliber/size
  • Swallowing
  • Direction and speed of bolus flow
  • Timing of swallow-breathe sequence
  • Most of what infants do during feeding is related
    to airway maintenance or airway protection

26
Positioning is Critical
  • Swaddling
  • Provides overall postural support and
    containment
  • Base of support for feeding
  • Supports limbs to the body midline
  • Has an overall organizing effect for the infant

27
Semi-Upright
  • Cradle
  • On feeders lap, facing feeder
  • Disadvantages of Semi-Upright for Premies
  • Typically more shallow breathing
  • Head can easily be extended out of alignment
  • Gravity can pull the tongue into a more retracted
    position
  • Fluid can pool in the back of the mouth or
    approach the back of the mouth more quickly

28
Sidelying
  • Benefits
  • Easier breathing
  • More AP ribcage movement
  • Lung compliance increased
  • Airway resistance decreased
  • Better Head/Neck alignment
  • Easier to control fluid
  • Increased subglottic air pressure for airway
    protection

29
Flow Rate is Critical
  • One of the most critical factors, if not the most
    critical factor, for safe feeding in NICU babies
  • The greatest obstacle to safe and successful
    feeding is a high flow that may flood the
    pharynx, triggering repeat swallowing and lead to
    interruption of breathing

30
Flow Rate is Critical
  • The consequence of this deterioration is the
    potential for the penetration of fluids into the
    supraglottic space or aspiration of fluid. This
    poses a significant risk throughout nipple
    feeding

31
Flow Rate is Critical
  • Who created high/faster flow nipples? What was
    their goal? What were their underlying
    assumptions?
  • What formula companies didnt understand
  • Faster flow makings it harder to swallow
  • Faster flow makes it harder to organize
    breathing.

32
Impact of Flow on Swallowing
  • Overfilling of mouth
  • Overfilling of throat
  • High volume of fluid needs to be directed away
    from airway with exquisite timing and control of
    muscle movements
  • Airway opening and closing must be precise under
    these conditions in order to protect the airway

33
Impact of Flow on Breathing
  • Overfilling of mouth
  • Overfilling of throat
  • High volume of fluid needs to be directed away
    from airway with exquisite timing and control of
    muscle movements
  • Airway opening and closing must be precise under
    these conditions in order to protect the airway

34
Common Feeding Problems
  • Tires before finishing Feeding Why?
  • Low hematocrit (proportion of blood volume that
    is occupied by red blood cells)
  • Poor sleep between feedings
  • Fed too long at prior feeding and trouble
    recovering
  • Recently weaned from oxygen
  • Air hungry
  • Schedule is not optimal for infant
  • Allowed to feed too fast
  • Immature state control

35
Common Feeding Problems
  • Lacks spontaneous mouth opening Why?
  • Is too drowsy to be vigorous
  • Is breathing with too much effort to be willing
    to suck
  • The reluctance to suck may be an instinctive
    reaction, a purposeful respond to attempt to
    guard the airway.

36
Common Feeding Problems
  • Frantic during feeding Why?
  • Air hunger
  • Had to wait too long to be fed
  • Flow too fast
  • Smacking sounds during feeding Why?
  • Not maintaining tongue-palate seal (suction
    against hard palate)

37
Common Feeding Problems
  • Holding tongue against palate Why?
  • Compensation for increased work of breathing
  • An attempt to stabilize the head, neck,
    oral-pharyngeal area
  • Disorganized sucking Why?
  • Overall postural disorganization
  • Poor sucking rhythm, poor tongue stability

38
Common Feeding Problems
  • Trouble latching on Why?
  • Related to breathing or swallowing
  • Oral-tactile hypersensitivity
  • Had to wait too long to be fed and now frantic
  • Related to abnormal CNS

39
Common Feeding Problems
  • Poor sucking Why?
  • Ask
  • Is alertness, vigor sufficient?
  • How does non-nutritive suck (NNS) compare with
    nutritive suck (NS)? Why?
  • Could a weaker nutritive suck be purposeful?
    Why?

40
Common Feeding Problems
  • Drooling (loss of bolus control orally) Why?
  • Often perceived inaccurately as poor lip seal
  • May be purposeful on babys part
  • Respiratory effort is disrupting the swallow
  • Sort sucking bursts Why?
  • Is it purposeful? May be an adaptive
    compensatory response

41
Common Feeding Problems
  • Noisy swallows Why?
  • Normal swallows are quiet
  • Gulping sounds
  • Gurgling sounds
  • High-pitched crowing sounds/stridor
  • Hard swallows
  • Coughing and/or Choking
  • Highly concerning
  • VFSS/MBSS typically indicated

42
Common Feeding Problems
  • Color change during feeding Why?
  • Subtle or marked
  • Associated with desaturation
  • Loss of bolus control
  • Associated with coughing/choking or noted without
    overt signs
  • Clinical Observation Color change noted
    clinically/at bedside correlated with silent
    aspiration on MBSS/VFSS

43
Cardiopulmonary Disorders
  • Patients with compromised cardiac or respiratory
    function often have serious difficulties with
    hypoxia during the feeding
  • Many cardiac patients can feed well, but lack the
    endurance to take a sufficient amount of
    liquid/food in a timely manner
  • Treatment for endurance problems and try to make
    the feeding as efficient as possible

44
Cardiopulmonary Disorders
  • Position to support he body well and allow the
    easiest possible intake
  • Children with respiratory problems will struggle
    to met nutritional needs
  • Positional assistance and calorically dense
    formulas/foods are suggested.

45
Down Syndrome
  • 40-50 of children with DS develop a cardiac
    abnormality, a large percentage develop mitral
    valve prolapse by adulthood
  • Reduced tone in the cheeks and lips contributes
    to an imbalance in the forces on the teeth, the
    force of the tongue is greater contributing to
    open bite

46
Down Syndrome
  • Compromised immune system with corresponding
    decrease in the number of T-cells
  • Chronic URI associated with mouth breathing
    patter, xerostomia (dry mouth) and fissuring of
    the tongue, lips, acute necrotizing ulcerative
    gingivitis, decreased saliva and increased dental
    caries

47
Down Syndrome
  • Increased risk of GI congenital obstruction
    (duodenal atresia, Hirschsprungs disease)
  • Increased risk of leukemia
  • Sleep problems are common
  • Autism can co-occur in 10
  • 26 have psychiatric disorder
  • 15-25 have behavioral or emotional disorders

48
Down Syndrome
  • Vision 50 have refractive errors
    (myopia/hyperopia), 15 have cataracts
  • 5-10 have seizures
  • Thyroid may fail at any agefrom newborn to
    elderly
  • Celiac disease is more common
  • Congenital heart disease in half
  • 85 have IQ scores that range from 40-60 (mild to
    moderate MR)

49
Down Syndrome
  • Families with a child with DS cope better than
    families with a child with another disa8iblity
  • Most children with DS have at least 1 good friend
  • True macroglossia is rare relative
  • the tongue is of normal size but the oral cavity
    is reduced due to underdevelopment of the midface

50
Down Syndrome
  • Breastfeeding is a good option, lactoengineering
    or calorically dense formals for bottle-fed
    babies may be needed
  • Higher flow nipples may help with endurance
    (asses the swallow first!)
  • Oral sensory motor therapy is highly recommended
    (Talk Tools by Sara Rosenfeld Johnson, Beckman
    Oral Motor Therapy)

51
Feeding Aversions
  • Severe feeding aversion is defined as an extreme
    self-restriction of intake which leads to
    significant developmental, social and health
    problems (Kedesky Budd)
  • Incidence of minor feeding problems
  • 25 - 35 in normal children
  • 40-70 in children born premature or with chronic
    health issues.

52
Feeding Aversions
  • Feeding aversion can manifest as self
    restriction of foods of specific
  • Type
  • Texture
  • Amount

53
Feeding Aversions
  • Early Warning Signs
  • Reflux
  • Breast/bottle feeding difficulties
  • Difficulty transitioning from semi-solid to solid
    foods
  • Sensory issues/language delay
  • Poor mealtime routines
  • Poor parent/caregiver interaction with child
  • Difficulty with parent/child mealtime interaction

54
Feeding Aversions
  • Red Flags
  • Oral Motor Dysfunction
  • Dysphagia
  • Complicated Neonatal course
  • History of prolonged intubation
  • Supplemental tube feedings
  • Poor meal scheduling
  • Poor parental feeding strategies
  • Traumatic event

55
Is it behavioral or Sensory?
  • Answer It is normally both.

56
Autistic Spectrum Disorder
  • Co treatment with occupational therapy is
    strongly recommended
  • Treatment program for sensory issues is number
    one therapeutic priority
  • Use of picture schedules, social stories,
    concrete and consistent language
  • Environmental cues must be consistent
  • Food preparation routine (wash hands, help set
    table) as appropriate
  • Environmental cues must be consistent
  • Child will learn about food first by touching it

57
Autistic Spectrum Disorder
  • Meal/snack time schedule
  • Food Chaining as part of the treatment program
  • Allow child to have anchor foods
  • Child will have a phobic response to change
  • Consider how food looks, smells, feels, and
    sounds as child eats it
  • Shape or oral motor program to the sensory needs
    of the child
  • Allow child to set pace of the program, do not
    force
  • Meals 20-25 minutes, snacks 10-15 minutes

58
Failure to Thrive or Childhood Anorexia
  • Is the child ready for feeding therapy?
  • Organic or Non-organic debate?
  • Many children with FTT have subtle neuromuscular
    or oral-motor disorders.
  • Some may have an undiagnosed syndrome or disease.

59
Failure to Thrive or Childhood Anorexia
  • Organic
  • Non-organic
  • Mixed
  • Defined as height, weight and head circumference
    below the 5th percentile
  • Childhood anorexia characterized by loss of
    appetite due to very low body weight, altered
    taste to foods, very little interest in eating.

60
Failure to Thrive or Childhood Anorexia
  • Can be caused by
  • CNS damage
  • feeding problems
  • cardiopulmonary disorders
  • metabolic disorders
  • abnormalities of the endocrine system
  • Malabsorption
  • Reflux
  • chronic gastroenteritis
  • genetic disorder
  • Infection
  • Parasites
  • economic social and psychological problems.

61
Treatment of Failure to Thrive
  • Caloric supplements when needed and fade when
    appropriate
  • Structured meal times and parent education
  • Treatment of underlying disorders and conditions

62
Tube-fed children
  • Reasons to tube feed
  • Prematurity
  • Anatomical abnormalities
  • Neurological issues
  • Aspiration
  • Fatigue
  • Pending surgeries
  • Failure to thrive
  • Insufficient appetite

63
Tube-fed children
  • Treatment focuses on
  • Educating parents about tube feedings
  • Prevention problems from developing
  • Normalizing oral sensory perceptions for
    exploration and feeding
  • Optimizing oral motor control and oral enjoyment
    for exploration and feeding

64
Tube-fed children
  • Treatment focuses on
  • Educating parents about tube feedings
  • Prevention problems from developing
  • Normalizing oral sensory perceptions for
    exploration and feeding
  • Optimizing oral motor control and oral enjoyment
    for exploration and feeding
  • Transitioning to oral feeding, if indicated

65
Cleft Lip Palate
  • Clefting influences the mechanics of sucking and
    swallowing in varying degrees, depending on
    location and severity
  • Children with clefts frequently have a slower
    weight gain during the first 2-3 moths than other
    infants caused by difficulties with feeding

66
Cleft Lip Palate
  • Babies with cleft can often breast feed with
    minimal assistance from the feeder if the cleft
    is a lip only cleft palates need to be
    considered individually
  • Children with clefts frequently have a slower
    weight gain during the first 2-3 moths than other
    infants caused by difficulties with feeding
  • Infants with isolated cleft of lip or soft palate
    generally have less difficulty with breast/bottle
    feeding

67
Cleft Lip Palate
  • Effective compensations
  • Positioning the child in a more upright posture
    for eating
  • Using the fingers or mothers breast to provide
    closure or support for an open lip cleft
  • Using bottles and nipples that do not require
    negative-sucking pressure
  • Special Bottles Haberman Feeder, Hazelbaker
    Finger Feeder, Pigeon Feeder

68
Cleft Lip Palate
  • Effective compensations
  • Using palatal obturators to seal a portion of the
    palatal cleft Positioning Lip support
  • Palatal Obturator, also called a plate
  • plastic insert that forms an artificial palate
  • helps with tongue positioning for sucking
  • intraoral pressure is not changed

69
Cerebral Palsy
  • Five 5 basic causes of feeding disorders
  • Structural differences
  • Neurological conditions
  • Developmental delays
  • Behavior
  • Other medical conditions

70
Cerebral Palsy
  • Structural differences
  • Occasionally cleft will co-occur
  • Velopharyngeal incompetence with nasal
    regurgitation of fluids
  • Neuromotor Involvement
  • Abnormal movement patterns
  • Lip retraction, lip pursing, jaw thrust, lack of
    jaw grading, tonic bite, tongue retraction,
    tongue thrust

71
Cerebral Palsy
  • 3. Developmental delays
  • Primitive feeding skills persist beyond the time
    when those behaviors should have evolved into
    more mature behaviors
  • i.e. suckling munching pattern instead of
    rotary chew, graded jaw, substantiated bite, and
    tongue lateralization

72
Cerebral Palsy
  • Behavior
  • Often present as a primary cause of feeding
    problems by co-occur with other causes
  • Food refusal may be due to frustration or lack of
    control

73
Cerebral Palsy
  • Other Medical Issues
  • Reflux is common in kids and adults with CP
  • Results in frequent vomiting esophagitis, pain
    and discomfort associated with swallowing
  • Heart conditions can cause food refusal or
    anorexia secondary to fatigue or effects of
    medications
  • Dysgeusiaimpairment of the sense of taste can
    lead to food refusal, can be a side effect of
    some meds and present in individuals with kidney
    disorders
  • Poor saliva management

74
Sources
  • Fraker, C., Walbert, L. (2005). Treatment of
    Pediatric Feeding Disorders from NICU to
    Childhood. Atlanta, GA.
  • Shaker, C. (2003). Clinical Reasoning in the
    NICU Optimizing Swallowing Safety and Feeding
    Success. ASHA Convention. Chicago, IL.
  • Morris, S.E., Klein, M.D. (2000). Pre-Feeding
    skills, Second Edition. Therapy Skill Builders.
  • Workinger, M.S. (2005). Cerebral Palsy Resource
    Guide for Speech-Language Pathologists. Thomas
    Delmar Learning.
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