Pediatric Feeding and Swallowing

Take home exam

Name: Kim Caron
1.

Date: 11/29/15

What are the significant pre and postnatal developmental periods for the oropharyngeal cavity,
esophageal and upper airway growth in preparation for feeding and swallowing?
a.

Explain what happens during these periods relevant to deglutition.

b.

In your discussion, include the earliest gestational age at which oral, pharyngeal,
laryngeal skills associated with feeding/swallowing have been observed and when they
are consistently present. (15 points)

During the first eight weeks of gestation, embryonic formation of the orpharyngeal cavity,
esophagus, and trachea occurs. These anatomical structures continue to grow throughout fetal
development and the first 2 years of life. Myelination of the glossopharyngeal, hypoglossal, and
facial nerves (all required for sucking) occur by 20-24 weeks gestation. Sucking is established at
about 24 weeks.
Ultrasound technology has been used to assess fetal development and to observe the timing and
consistency of movements related to postnatal feeding and swallowing:
Mouthing action (jaw opening and closing): seen at 16 weeks; consistent
performance at 17 weeks
Tongue thrusting: seen at 15 weeks; consistent performance after 21 weeks
Swallowing: seen at 15 weeks; consistent performance between 22-24 weeks
Laryngeal contraction: seen at 15 weeks; consistent performance at 26 weeks
Tongue cupping: seen at 16; consistent performance at 28 weeks
Tongue protrusion/suckling: seen at 18 weeks; consistent performance at 28
weeks
Licking/munching: n/a; consistent performance at 31 weeks
Rapid, low-amplitude sucking: n/a; consistent performance at 32 weeks
Irregular sucking: n/a; consistent performance at 34 weeks
The oral and pharyngeal cavities continue to grow into adulthood. The oral structures reach
adult size earlier than pharyngeal structures with rapid growth of the pharyngeal structures
between 8 and 14 years. During the firs two years of life the larynx remains relatively high in the
neck. Between ages two and three, the upper border descends to the level of C3 and the lower
border to C5. This descent prevents the epiglottis from touching the soft palate.
TB 1 p. 151- 152
2.

Discuss the development of chewing skills. (5 points)

As children grow, they have an increasing reliance on the processes of chewing and swallowing
because solids become a major portion of their nutritional intake. Chewing requires muscle
activation and coordination of the jaw and lips. New studies using kinematic tracings and speed
measures have shown continued refinements of chewing skills until the age of three. As children
develop, the horizontal jaw motion used in rotary chewing as well as chewing speed are reduced
with pureed foods suggesting a refinement of chewing motion. Nine to 18-month-old children
are unable to modify their jaw movements to adjust to the consistency of different foods. At 18
months, children change their jaw movements as well as their bite force for puree, but the ability

to modify jaw movements for solid foods is not present even at 30 months of age, signifying that
rotary chewing is poorly developed at this age.
TB 1 p. 159
3.

What factors do we use to measure feeding performance in infants and children? (5 points)
The factors used to measure feeding performance in infants and children are chewing efficacy
and chewing rate. Chewing efficacy changes as children grow. Chewing patterns and efficiency
become consistent sometime after the age of three. EMG measurements show that there are
shorter bursts of muscle activation during chewing by older children when compared to younger
children. Chewing rate also changes with age. Chewing duration and the number of cycles
decrease with age, which suggests that infants chew at the same rate as adults across textures.
The findings of a study by Delaney (2010) demonstrated that oral skills emerge and plateau
before 8 months of age. Lip and tongue strength also increase with age.
TB 1 p. 160

4.

Compare and contrast the types of sucking and how we determine efficiency of each type as we
evaluate an infant. (10 points)
There are two types of sucking observed in infancy. Nonnutritive sucking comforts and soothes
the infant, and nutritive sucking provides the sole source of nutrient ingestion for infants until
they begin receiving complementary foods between 4 and 6 months of age. Normal nonnutritive
sucking is seen as a precursor to oral feeding. Nutritive sucking is required for normal growth and
development and is evaluated during the neonatal period. Nutritive sucking is defined as the
rhythmic alteration of suction and expression that extracts liquid from a breast or bottle for
swallowing. The frequency and periodicity of nonnutritive sucking and nutritive sucking differ.
Nonnutritive sucking occurs twice as fast as nutritive sucking with sucks segmented into bursts
and pauses. Nutritive sucking is equally spaced with a mean rate of 1 suck per second.
TB 1 p. 153

5.

Describe how oropharygeal temporal events and bolus flow measures for swallowing in infants
and children coincide with adult data? (5 points)
Oropharyngeal temporal events and bolus flow measures for swallowing in infants and children
from the limited data available coincide with adult data based on fluoroscopy, ultrasound, and
EMG. Casas et al. (1995) found that duration of liquids in the oral phase did not differ by age or
method of intake for infants. Oral transit times lasted for less than one second. Pharyngeal
transit time for liquids did not differ by age or method of intake for infants. Pharyngeal transit
times lasted for less than one second. Total swallow duration was 1.48 seconds without age or
gender-specific differences.
Newman and colleagues (1991) found that infants under 6 months collect the bolus equally
between the middle of the tongue and the hard palate and over tongue base within valleculae
prior to swallow initiation. Laryngeal closure was not observed until the bolus leading head
reached the valleculae in bottle-fed infants, and until the bolus was contained within the
valleculae for cup-fed children.
TB 1 p. 157

6.

What are the four factors that need to be present in infants, children and adults for successful
bolus propulgation during swallowing? (5 points)
Four factors are responsible for bolus propulsion during swallowing: tongue driving pressure,
contraction of the pharyngeal constrictors, negative hypopharyngeal pressure, and gravity. These

mechanisms are referred to as the oropharyngeal propulsion pump (OPP) and the
hypopharyngeal suction pump (HSP). The pressure generated from the anterior 2/3 of the
tongue and contraction of the pharyngeal constrictor muscles drives the OPP; the negative
hypolarungeal pressure is generated from expansion of the pharynx as well as the anterior
movement of the hyoid bone and larynx. These mechanisms work together to drive the bolus
through the pharynx. The upper esophageal sphincter opens by muscle relaxation, anterior
movement of the hyolaryngeal complex, intraboolus pressure, and UES compliance. The opening
is triggered at the initiation of the pharyngeal phase. The bolus reaches the esophagus,
indicating the end of the pharyngeal phase of swallowing.
TB 1 p. 173
7.

Discuss the variety of ways oropharyngeal dysphagia affects swallowing in infants and children
(Sheppard Chapter). (5 points)
Oropharyngeal dysphagia affects swallowing and eating function in infants and children in a
variety of ways. If underlying sensory motor physiology is impaired, it can affect eating
efficiency. When the sensory motor impairments occur before acquisition of developmental
skills for eating and swallowing, they impede emergence of the skills.

Acquisition of the complex, developmental sequence of the skills and subskills involved in
swallowing and eating may be delayed or disrupted in the absence of underlying physiological
issues. Many medical, psychological, and/or environmental conditions can interfere with the
childs access to sufficient eating skills and result in functional deficiencies. These functional
deficiencies can affect sucking, transition feeding from nipple to spoon, spoon-feeding, biting,
chewing, drinking from a cup/straw, and eating independence. Once the skill has been disrupted,
it is necessary to train the specific skill.
TB 2 p. 320
8.

Describe the sucking habilitation approaches outlined in the Chapter by J.J. Sheppard. Which
appear most promising and why? (5 points)
Oral motor interventions (OMI) that have been examined are nonnutritive sucking (NNS)
elicited by conventional pacifier, NNS entrained by a pacifier that provided patterned,
orocutaneous stimulation to mimc the temporal organization of normal NNS, and combined
modalities of peri- and intra-oral stimulation routines (OSR) and conventional NNS. There have
been two evidence-based reviews on the effectiveness of OMI in preterm infants. They found
that the strategies used during OSR and conventional NNS have shown promise for improving
swallowing physiology and acquisition of oral feeding, but because there have been mixed
results, clinicians are advised to use with caution.
*Conventional-nonnutritive sucking (C-NNS) is an exercise that requires the infant to suck a
pacifier during tube feedings or prior to oral feeding. Normal NNS is seen as a precursor to oral
feeding. When C-NNS was used prior to oral feeding, positive outcomes were attained in the
physiology of nutritive sucking during oral feeding. The volume consumed increased and the
duration of time to eat decreased. C-NNS has also shown positive effects to facilitate
breastfeeding.
*Entrained nonnutritive sucking (E-NNS) is used for infants who do not demonstrate rhythmic CNNS or nutritive sucking. This type of sucking habilitation uses a nipple programmed to pulsate
in a pattern that mimics typical NNS. It is used to improve their patterning of C-NNS and increase
oral intake.

Oral stimulation routines (Peri- and intra-oral stimulation) as an isolated intervention, results in
positive effects of the nutritive suck in preterm infants. This treatment resulted in earlier
initiation of oral feeding and earlier discharge from hospital...
Feeding maneuvers and exercises include frequency of oral feeding opportunities, oral (cheek
and chin) support, external pacing, and infant regulation of initiation and amount consumed.
Increased feeding experience is increasing the number of oral feeding opportunities from the
age that oral feeding began. Regardless of medical condition, infants with a higher number of
feeding experiences achieved oral feeding in fewer days than those with less experience.
Semi-demand feeding is feeding that is initiated when hunger cues occur in response to
periodic testing and ends when the infant has completed a prescribed volume. It has been
found to shorten the time of achieving oral feeding by 5 days.
In external pacing, the feeder regulates an infants sucking and breathing coordination by
removing the nipple from the mouth after 3-5 sucks and giving a 3-5 second pause before
returning to the nipple. It has shown to decrease bradycardia episodes, and improve sucking
efficiency.
C-NNS and E-NNS appear to have the most promise because of their positive outcomes. C-NNS
has shown to improve volume consumed and time to complete feeding in preterm infants. It has
also been used at the breast to facilitate the onset of breastfeeding. E-NNS treatment has shown
to improve patterning of C-NNS and increased the volume consumed orally.
TB 2 p. 326-328
9.

Compare and contrast OME and OST approaches in habilitation and rehabilitation of swallowing.
(15 points)
Oral motor exercise (OME) is a non-feeding strategy, whereas oral sensory-motor therapy (OST)
occurs during feeding. Both rehabilitative interventions are used for improving oral movement
and skill.
OME refers to a number of rehabilitative maneuvers and exercises that are applied in other
swallowing activities. According to Arvedson and colleagues (2010) described three categories of
OME: active OME, passive OME, and sensory applications. Active OME are non-eating exercises
in which the patient performs a task and experiences the mentation and sensations that are
associated with initiation, movement, and outcomes of the activity. Exercising tongue and
respiratory muscles are examples of active OME that have shown positive outcomes in adultonset dysphagia disorders (not yet been tested on children). Passive OME includes massage and
range of motion exercises imposed by the clinician. Sensory applications are a subset of passive
OME, in which sensory agents are applied to structures for certain physiologic effects (i.e.,
reducing delay in initiation of swallow). When considering OME, it is important to differentiate
those modalities for which effects have been durable, i.e., rehabilitative, from those that had
transient, i.e., compensatory.
Oral sensory-motor therapy (OST) is an approach in which the sensory receptors associated with
oral motor tasks are managed therapeutically to facilitate acquisition of a new skill or to improve
efficiency of an already acquired skill. The basic principles of OST are:
Sensory maneuvers are selected for their expected physiologic effects on the patients
specific motor movements.
Optimum, postural alignment and postural support are considered throughout

All exercises are conducted in the context of the target task

When possible, developmental skills and subskills are taught in the sequence in which
they are acquired in typical development
The difficulty of the exercise can be increased or decreased by altering the sensory
maneuvers
TB 2 p. 331-333
10. Describe behavioral treatments used for saliva management and drooling? (10 points)
Antecedent techniques. Instruction and cueing aim to reduce drooling. Instructions include
reminding to the child to keep his/her mouth closed and holding his/her head upright. Verbal
cues target to remind the child to swallow periodically; an electronic device set at timed intervals
may also be used.
Consequent techniques are maneuvers that provide feedback of adequacy of saliva
control/targeted behavior. Praise, food, and token rewards have been used as positive
reinforcement, while punishments such as time-outs have been used as negative reinforcements.
Consistent functional practice (CFP) involves habituation and generalization of control of saliva
when the child is focused on another function.
Self-management treatment (SMT). The child is trained to wipe his/her chin in response to saliva
accumulation or drooling. Instruction and positive reinforcement are paired during training.
TB 2 p. 342-343
11. Describe positions used for infant feeding and state the rationale for the use of these positions?
(10 points)
Establishing optimal positioning is an important aspect for infant feeding. Considerations for
positing include:
Cradle: Traditional standard position, infant is cradled in feeders arms, with midline
orientation of the trunk with neutral alignment of the head and neck; adjustments can
be made easily to bring infant in more upright positioning as needed
En face: Infant is arranged in feeders lap and facing the feeder, infants head is
supported with feeders hand; maximum control of head is possible, assists with
decreasing excessive head extension during feeding
Side lying: Infant is positioned lying on his/her side on feeders lap with trunk straight
and well-supported; feeder must be sure to not allow head to move into excess
extension in this position; may be helpful in bringing retracted tongue forward
Supine on lap: Infant is positioned on lap to facilitate keeping the infants trunk straight
and well-supported, and keeps the head in neutral position
TB 2 p. 352
12. Describe compensatory strategies used for infants and children with dysphagia and how do they
affect swallow function? (10 points)
Alterations in Positioning: Establishing optimal positioning during feeding tasks is crucial for
facilitating coordinated oral motor movements and swallowing safety. Postural modifications
differ depending on the type of muscle tone abnormality present. Variations in infant positioning
help to facilitate coordination of respiration and swallowing during feeding.

Use of Specialized Equipment: Specialized feeding equipment can be used for pediatric
dysphagia. Such equipment includes numerous bottle, nipple, cup, and utensils. There is limited
data on the clinical efficacy of specific feeding equipment. Clinical decisions are based on the
sensory and motor dysfunction along with the infants response during implementation.
Sensory Stimulation Techniques: Sensory stimulation techniques include altering fluid viscosity,
bolus modification, alternating liquid and solid bolus presentations, and nonnutritive oral sensory
stimulation.
Altering fluid viscosity: to assist with maintenance of airway protection during
swallowing. Increase liquid viscosity, and thus slower bolus flow allows for a greater
amount of time for the infant to control the bolus intraorally to achieve airway closure
prior to blous arrival in the hypophayrnx and swallowing initiation.
Bolus modification: Modifying volume, texture, taste, and temperature is commonly
used is pediatric dysphagia. The use of strong flavor is used to facilitate an efficient oral
and pharyngeal swallow response.
Altering liquid and solid bolus presentations: may assist with clearance of pharyngeal
residue and bolus transfer
Nonnutritive oral sensory stimulation: Sensory motor stimulation techniques include
tactile input to the body, orofacial, and intraoral area, encouragement of nonnutritive
sucking, oral exploration with oral sensory toys, and oral care. Stimulation can heighten
sensory awareness and facilitate motor action, prevent oral aversion, facilitate sucking,
and promote development of oral motor skills
TB 2 p. 351-354

Use your textbooks and include your page and text reference with your answer.
Work independently, no group or partnering as you prepare your answers. Thank you!