WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson

Pediatric Swallowing and Feeding:
Complex Decision Making
CSHA, Monterey
2010
WS7 – April 16, Friday, 8:30-11:30/2:00-5:00
Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S
Children’s Hospital of Wisconsin

Medical College of Wisconsin
jacrved@aol.com & jarvedson@chw.org

Joan C. Arvedson, Ph.D. 3/25/2010
Pediatric Dysphagia
with Health Issues & Complications Dysphagia: Health Considerations
Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S n Nutrition/hydration & undernutrition
jcarved@aol.com & jarvedson@chw.org
n Neurologic & neurodevelopmental issues
n Pulmonary/airway issues
n Gastroesophageal reflux disease (GERD)
n Medication effects
Diagnoses Seen in Feeding, Swallowing,

& Nutrition Center (FSNC) Common Nutrition Risk Indicators
Angelman Sy ndrome C os tello s yndrome P ierre Robin sequence
E agle-Barrett s yndrome
Sev ere atopy
Autism spectrum disorders
C raniosynostosis
C ri- du-chat Robinow s yndrome
n Failure to grow over 2-3 months
Breastf eeding dif ficulty Short gut
D andy Walker Syndrome
Canav an sy ndrome
Cat ey e sy ndrome
D iabetes Spina Bifida n Weight/height below 5th %ile
D own s yndrome Stic kler s yndrome
Chromosomal etiologies
Prematurity & complications E os inophilic G I disease
E s cobar s yndrome
TEF
Solid organ transplantation
n Chronic diarrhea/constipation
Orof acial malf ormations
H irs chsprung s yndrome Turner s yndrome
Airway malf ormations
Cockay ne syndrome H emolytic uremic V ATER n Long term use of drugs
Congenital diaphragmatic s yndrome V elocardiofacial s yndrome
hernia
Congenital heart disease
IU GR
Klinefelter syndrome Formula intolerance
n Excessive drooling
Cornelia DeLange M itochondrial disease C hoking phobia
N oonan s yndrome “Sleeper eaters”
P anhypopituitarism A bs ent hunger drive
C erebral palsy
Seizure disorders
Common Nutrition Risk Indicators Undernutrition and Growth

n Frequent reflux/emesis n Acute: decreased weight-for-height (wasting)
n Oral sensorimotor feeding difficulties n Chronic: decreased height-for-age (stunting)
n Metabolic disorders n Effect on linear growth may lag weight
n Abnormal CBC/urine screens effects by 4 months
n Suspected caregiver neglect n Children who survive malnutrition - generally
stunted
1
Undernutrition: Severity of Effects Pulmonary Disease with

Neurologic Impairment
n Respiratory complications of dysphagia
n Correlated with onset & duration uDisordered timing/incoordination
uAspiration
uAirway obstruction
n Most profound damage when period of
deprivation occurs during first 2 years n High risk infants (apnea & hypoxia)
n Older children: disorders of respiration
n Signs & symptoms of aspiration vary
Aspiration Generalizations Congenital Laryngomalacia

n Usually silent with neurologic deficits n Redundant supraglottic mucosa
n High index of suspicion for signs of n Common mechanisms
pharyngeal dysmotility uCuneiforms drawn inward during
uCongestion during feeds inspiration
uMultiple swallows per bolus uExaggerated omega shaped epiglottis
curls on itself
uDelayed initiation of pharyngeal swallow
uArytenoids collapse inward
uRespiratory distress (e.g., cough, wheeze)
Stridor in Severe CLM CLM: SLP Role for Feeding

n Determine most efficient oral feeding:
n Inspiratory position, liquid flow, pacing
n High pitched n Monitor inspiratory stridor & effect on PO
n Loudest when upset n Effects of GER & nipple feeding?
n More evident in supine n Reassurance to parents regarding positive
prognosis in coming months
n Spoon feeding & cup drinking may be focus
earlier than in typical infants
2
Pierre-Robin Sequence Pathophysiology: Chronic Aspiration

n Mandibular Hypoplasia n May be more insidious than acute aspiration
(Micrognathia) (direct & indirect)
n Glossoptosis (retroplaced tongue) n Most prone: Swallowing dysfunction &
neuromuscular disease
n Airway obstruction uClinical indicators may be scarce
uLaryngeal penetration (deep)

n U-shaped cleft palate (not primary uEndangerment to airway from aspiration
characteristic, seen in about 80%) uLife threatening physiologic alterations
Timing of Aspiration with Swallow Protection from Aspiration

n Normal swallow
n Before: Delay in onset of pharyngeal swallow
or abnormal tongue movements n Cough
n During: Ineffective laryngeal closure or timing uNot reliable predictor even in infants with
incoordination normal swallows

n After: Results in residue from multiple factors uBy 1 mo., 90% of infants have cough reflex
(e.g., decreased tongue base retraction, n Other protectors of lung (e.g., mucociliary
reduced sensation, incoordination of clearance, phagocytosis by alveolar
pharyngeal constrictors) macrophages, lymphatic drainage, gag)
Swallowing Problems & GI Disease GER Prevalence & Epidemiology

n Esophageal structural abnormalities (TEF) n Highest < 2 years of age
n Motility disorders uPreterm infants: 63%
n Inflammatory diseases uCP: 92% with GI symptoms & signs
n Constipation aggravates in neuro disorders uHealthy infants pH probe: esophageal
u74% of CP
acidification common
uMultiple causes (e.g., Ü PO with Ü fluid)
n 21% of all ped pts to GI clinic present
with signs/symptoms suggestive of GER
3
GER Prevalence & Epidemiology Reflexes Involved in Development

of Upper & Lower Airway Disease
n Typical symptoms of GER in < 50% in n Esophago-laryngeal reflex
children with upper airway manifestations uAcid is introduced into distal esophagus
uLaryngospasm results
n 25-30% of all children with GER have EER n Laryngeal chemoreflex

& upper aerodigestive tract symptoms/signs uDirect acid stimulation to larynx
uApnea, bradycardia, & hypotension result
n More active in infants & gradually disappear
GER Medications for Apnea

in Premature Infants Manifestations of GER are due to
n Theophylline or caffeine: neither drug
consistently eliminates apnea in all patients effects of gastric acid, BUT
n Note: caffeine exacerbates GER in adults &
older children!
abnormalities of motility &
n Antireflux medications do NOT reduce sphincter function cause GER
frequency of apnea in premature infants
n (Kimball et al., 2001)
Multiple Causes of GER Functional GER - “Happy Spitter”

n Infants, onset usually < 2-3 months
n Impaired LES function n Effortless regurgitation (spitting up)
n Increased intraabdominal pressure n Frequency decreases after 6 months
n Delayed gastric emptying n If infant grows well, no major work-up
n Impaired esophageal acid clearance needed
4
Risk Factors (Atypical Manifestations) Eosinophilic Esophagitis (EE)

n Entity emerged since 1997 – previously
n Lower airway diseases
confused with reflux esophagitis
n Upper airway n Inflammation due to allergic factors may
n Upper digestive also include upper airway disease
uchronic halitosis otalgia/chronic OM n Not correlate with ? GER
uloss of taste Sandifer’s syndrome n Endoscopy
ufood refusal chronic pharyngitis uDenser infiltrates of eosinophils relate to
nonacid-related cause of esophagitis
udental caries drooling
uFurrows or rings often noted
Steiner et al (2004)
Treatment of EE in Pediatrics GER Evaluation

n Lack randomized controlled trials
n Case series suggest n Clinical evaluation
uElemental diet n Radiographic study
uOral steroids n Scintigraphy
uTopical steroids n Esophageal pH testing (most sensitive)
n Lack of control group: impossible n Endoscopy & biopsy
to evaluate effect of interventions
Kukuruzovic et al. 2004, Cochrane Database Syst Rev
Treatment of GERD: Types of Medications & Dysphagia

Infants & Children
n Positioning n Sedatives
n Dietary treatments (e.g., thickening feeds) n Benzodiazepines
n Feeding schedule changes n Dopamine antagonists
n Pharmacologic therapy n Anticholinergics
n Surgery (fundoplication)
5
Clinical Assessment of Feeding

Presentations of Feeding Disorders
& Swallowing: Infants & Children
n Inadequate growth due to inadequate intake
Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S n Prolonged time for feedings (but with adequate
jcarved@aol.com & jarvedson@chw.org calories for growth)
n Delayed progression of oral feeding skills
(textures, variety, etc)
n Recurrent respiratory disease (question of
aspiration from above or below)
n Complicating factors: behavior, sensory,
relationship, social
4 Key Questions to Ask Parents

Global Feeding Evaluation Goal
n How long does it take to feed your child?
uLonger than 30 minutes, tip-off for problem n To determine safest & most efficient
n Are meal times stressful to child &/or parent? consistencies for a child to eat orally
uNeurologic based skill & safety issues? (to whatever extent possible) while
uBehavior and/or sensory issues? maintaining adequate nutrition &
n Is your child gaining weight OK? hydration
uIf no weight gain for 2-3 months, sign of problem
n Are there signs of respiratory problems?
ue.g., congestion ? during feeding; gurgly voice
Development in Typical Child Age of Introduction to Solids

n Liquid by nipple first 4-6 months
Age (months) Type of Solid
uBreast milk
4-6 Smooth puree (SP)
uFormula
n Strained smooth food by spoon (6 months) 6-9 SP; Textured puree;
Easily dissolvable solids
uSitting with minimal support
9-12 Soft, mashed, & diced solids
n Lumpy foods by 10-11 months
12-18 Toddler diet of chopped table food
uDifficult if delayed until 14-16 months
n Cup drinking before 12 months
6
Feeding/Swallow Evaluation Common Criteria for Referral

n History n Feeding periods longer than 30 to 40 minutes
n Physical examination n Unexplained food refusal & undernutrition
n Observation of typical feeding or mealtime n Weight loss or lack of weight gain for 2-3 mths
n Referral for additional examinations n Excessive gagging or recurrent cough with feeds
uInstrumental swallow study n Infants on nipple feeds
uMedical/surgical specialists uSucking , swallowing, breathing incoordination
uNutrition uWeak suck
uPsychology/Social Work uBreathing disruptions during feeding
uOT/PT
Common Criteria for Referral Common Criteria for Referral

n Airway related concerns n Drooling persisting beyond age 5 years
uHistoryof recurrent pneumonia & feeding difficulty n Nasopharyngeal backflow/reflux during feeding
uConcern for possible aspiration during feeds n Delay in feeding developmental milestones
uDiagnosis of disorders associated with dysphagia uNot spoon feeding by 9 months (dev. age)
n Irritability or behavior problems during feeds uNot chewing table food or self-feeding finger
food by 18 months
n New onset of feeding difficulty
uNot drinking from a cup by 24 months
n Lethargy or decreased arousal during feeds
n Craniofacial anomalies
Steps in Clinical Evaluation Clinical Evaluation: Airway Concerns?

If none: Develop plan in context of global needs
n Consultation received a Initial Assessment n
uOralsensorimotor intervention
n Possible next step depends on airway status
uNutritionguidelines
uIf respiration normal, clinical feeding uBehavioral therapy
evaluation uMonitor status & alter plan as needed
uIf respiration abnormal, airway evaluation n If yes: Instrumental examination or further
(hold feeds until airway is clear) medical workup
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Feeding History Factors Feeding History Factors

n Positions/posture/seating (gross/fine motor) n Respiratory status
n Duration of meal times (average & range) n Signs of stress & distress
n Intervals between meal times n Test results & medications
n Sleep patterns (waking, snoring, mouth breathing)
n Types of food (preferred, non-preferred)
n Cognition & communication
n Assistance/independence of feeding
n Behavior during meals; apart from meals
n Tube feeding (e.g., type, timing) n Therapeutic intervention (developmental/feeding)
n Food record: 2-3 days
Nervous System Exam Infant Evaluation

n Muscle tone n State & overall posture/positioning
n Reflexes
n Respiratory status (rate, patterns, voice)
n Cognition & language
n Resting heart rate
n Visual tracking
n Exam of oral peripheral mechanism
n Gross & fine motor skills
n Non-nutritive sucking
n Sensory function
n Nutritive suck/swallow/breathe
Clinic Airway Evaluation Clinic Airway Evaluation

n Voice quality variables
n Respiratory rate: at rest & feeding
uStrong, clear phonation, appropriate pitch
n Respiratory effort:
uWeak, breathy, husky to hoarse
u Stridor uGurgly, wet
u Stertor uVelopharyngeal function inferences
u Retractions: suprasternal, substernal (e.g., hypernasality, hyponasality)
n Pharyngonasal penetration/backflow/reflux
n Frequent burping (not clear implications)
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Airway Stability for PO Feeding Evaluation of Transition Feeder

& Older Child
n Airway stability is prerequisite for successful PO
n If airway concerns are noted during physical
n General observations
exam, possible next steps: n Posture, alertness, direction following
uOtolaryngology airway exam (FFL, DLB) n Oral sensorimotor function
uBedside/clinical oral feeding evaluation n Bolus formation & oral phase of swallow
uCombined FFL & FEES with ORL & SLP
n Pharyngeal phase inferences
uVideofluoroscopic swallow study (VFSS)
n Therapeutic trials
uMonitor status for a few days
Postural Control Evaluation Optimal Sitting Posture

n Muscle tone (hypotonia or hypertonia) n Neutral head position
n Central alignment relates directly to oral n Neck elongation (No chin tuck for infants)
sensorimotor system n Symmetrical shoulder girdle stability &
uPresence of primitive reflexes
depression
n Pelvis stability, hips symmetrical in neutral
uLevel of physical activity
n Hips, knees, & ankles at 90 degrees
uSelf oral stimulation
n Feet in neutral with slight dorsiflexion (never
n Use of eye contact, head turning, & touch plantar flexed), supported by firm surface
Cranial Nerve Evaluation

Gag Reflex
for Feeding/Swallowing
n Independent of swallow
n Lack of chewing: CN V
n Sensory: CN IX
n Facial asymmetry & lack of lip movement:
n Motor output: CN X, XII, & V
CN VII
n Elicited by touching posterior pharyngeal
n Delayed swallow & pharyngonasal
mucosa (standard testing)
penetration/backflow/reflux: CN IX & X
n Difficult to assess importance of changes
n Tongue thrust or atrophy: CN XII
in absence of other findings
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Tonic Bite Reflex Oral Sensory vs Motor Disorders

n Jaw moves up into clenched position n Nipple confusion n Inefficient suck breast & bottle
on presentation of spoon or other object
n Response to contact to biting surfaces n Not differentiate tastes in n Differentiates tastes
bottle even with intact suck in bottle
of side gums (molar tables)
n Persistence with neurologic deficit – n Manages liquids better than n Oral-motor inefficiency or
solid foods incoordination for all textures
should disappear by 9-12 months
n Cranial Nerve V n Sorts food in mixed texture n Swallows food whole when
given mixed textures
Oral Sensory vs Motor Disorders Oral Sensory vs Motor Disorders

n Holds food under tongue or in n Unable to hold & manipulate n Tolerates own fingers in n Tolerates others’ fingers in
cheek and avoids swallowing bolus on tongue, food falls out mouth, but not accept others mouth
n Vomiting only certain textures n Vomiting not texture specific n Does not mouth toys n Accepts teething toys, but not
to bite or maintain in mouth
n Gags when food approaches n Gags after food moves
or touches lip through oral cavity n Refuses tooth brushing n Accepts tooth brushing
n Hypersensitive gag with n Gags after swallow is

solids, normal liquid swallow triggered with liquid & solid
from Palmer & Heyman, 1993
Immature vs Abnormal Patterns Next Steps?

n Nutrition Analysis
n Patterns are likely to be distinguishable in n Medical Workup (Genetics, GI, ENT, etc)
usuck-swallow-breathe sequencing
n Behavioral Psychology
ujaw control or stability
n Occupational Therapy/Physical Therapy
utongue mobility
ulip closure
n Instrumental Swallowing Study
uNeed to define oral, pharyngeal, & upper
udissociation of tongue, jaw, & cheek movements
while drinking & chewing
esophageal components for management
n Oral Sensorimotor Intervention
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Patient Considerations
Criteria for Instrumental Evaluation
n Diagnostic & management needs
n Risk for aspiration by history or observation uNature of swallow impairment
n Prior aspiration pneumonia uPatient’s ability to feed safely
n Suspicion of pharyngeal/laryngeal problem uDevelopment of management plan
on basis of etiology n Ability or readiness to participate
n Gurgly voice quality uMedical stability
n Need to define oral, pharyngeal, & upper uAbility/willingness to cooperate
esophageal components for management uAge, cognitive, & developmental status
Flexible Endoscopic Evaluation

Procedural Considerations of Swallowing (FEES)
n Components of swallow process evaluated n No radiation
uPhase(s) of deglutition n Bedside exam possible
uAbility to detect aspiration or risks n Defines some aspects of pharyngeal
uCapacity to define nature of deficit physiology
uEstimate of agreement: specific n Can evaluate handling of secretions
procedure and usual patterns of feeding n Sensory testing can be done
Videofluoroscopic What VFSS is NOT

Swallow Study(VFSS)
n To rule out aspiration or determine if child
n Defines oral & pharyngeal phases aspirates with oral feeding (important finding
n Defines esophageal transit time, basic but not reason for exam)
motility n Simulation of a real meal
n Delineates aspiration related factors
n Evaluation of oral skills for bolus formation
uBefore, during, or after swallows
n Chewing evaluation
uTexture specificity
uEstimate of risk
n Esophageal function (only upper esophagus)
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Important Considerations
in High Risk Pediatric Patients VFSS Procedural Considerations
n Radiologist must be present n Purpose & questions formulated clearly
n Fluoroscopy time minimum
n Positioning/seating: typical & optimal
n Well formulated Q & A
n Cooperative patient imperative for
n Caregivers included
interpretation
n Findings shown to caregivers
n Shortest fluoroscopy time possible
n Findings interpreted & used as part of
total team approach: maximize safety n Review in slow motion, frame-by-frame
Feeding Supplies & Recipes

Preparation of PO Feeders
n Readily available when caregivers are
asked to bring food samples n Hungry, but not starving
n Textures & barium recipes need to be n Schedule close to feeding time if possible
standardized n Normalize the situation as much as possible
n Data lacking, especially in children uChild’s own utensils
n Poor relationship between viscosity of uVideo/music as needed
dysphagia diet foods & swallow barium
n GT + PO: same guidelines as for total PO,
test feeds of different viscosities
(Strowd et al., 2008) unless child gets slow, continuous tube feeds
Preparation of Tube Feeder: NPO Child’s “State”

n Child should demonstrate some level of oral n Typical feeding status appropriate
intake, at least for therapeutic “taste trials” n Increased risks for aspiration
uNG tube – remove in some instances uLethargy
uAmount per bolus: 2 to 3 cc uAgitation (fussing & crying)
uTotal of 10-15 cc preferred for validity & n Cooperative child: interpretation possible
reliability in reliable & valid ways
n Medication schedules maintained, or in n Always remember: Just a brief window
some cases, adjustments needed in time, not a typical meal
12
Procedural Decisions Lateral View

n No fixed order for presentations in pediatrics
n Encompassing
n Preferable to start with thinnest liquid uLips anterior
uControlled bolus size to start, e.g., spoon before uSoft palate superior
going to bottle or cup drinking uPosterior pharyngeal wall posterior
n Work toward thicker as needed uFifth to seventh cervical vertebrae inferior,
uNot want residue in pharynx that may varying with age of child
complicate interpretation with thinner later
n Simultaneous view of oral, pharyngeal &
n Exceptions: Parents tell us that child will not upper esophagus before food is presented
accept any thing else if he gets liquid first
Antero-Posterior View Oral Phase Swallow Problems

n When asymmetry is known or suspected n Lips (poor closing, drooling, leakage)
n Unilateral vocal fold paralysis or paresis n Hesitation/pooling
n Tonsil related questions n Tongue action deficits
n Other possibilities? n Gagging
n Poor posterior tongue thrust
uKeep inmind radiation exposure time
n Passive leakage over tongue base
uImportance of findings for management
n Delayed oral transit
Initiation of Pharyngeal Swallow Pharyngeal Swallow Problems

n Pharyngonasal (nasopharyngeal)
n Delayed swallow onset/trigger reflux or regurgitation or backflow
uMaterial in valleculae
n Penetration
uTo underside of epiglottis (superior)
uMaterial in pyriform sinuses
uTo laryngeal vestibule/vocal folds
n Failure to initiate/trigger swallow
n Aspiration
uResponse to aspiration
uClearance of airway
13
Pharyngeal Swallow Problems Esophageal Swallow Findings

n Pharyngeal contraction reduced n Upper esophageal sphincter
n Pharyngeal motility reduced uOpening, e.g., reduced, incoordinated
n Tongue base retraction reduced (usually pharyngeal phase problem)
n Post-swallow residue, e.g., uProminence
uValleculae n Bolus passage
uPyriform sinuses uSlow, interrupted
uPosterior pharyngeal wall n Retrograde movement of contrast (better
n Clearance of residue? term than reflux in this instance)
Aspiration Before Swallow: Causes? Aspiration During Swallow: Causes?

n Limited tongue action n Vocal fold paralysis/paresis
n Limited mandibular movement
n Reduced laryngeal excursion
n Reduced tongue & soft palate approximation
n Pharyngeal incoordination
n Delayed initiation/onset of pharyngeal swallow
uPremature spillage n Pharyngonasal (nasopharyngeal)
uMaterial in valleculae & pyriform sinuses
penetration, backflow, or reflux
n Pharyngeal dysmotility
Aspiration During Swallow Aspiration After Swallow

n Reduced tongue base retraction
n Neural control
uResidue in valleculae
uInitiation under voluntary control
uPenetration into laryngeal vestibule
uInvoluntary control for completion
n Reduced pharyngeal contraction/motility
n Airway
uResidue in pyriform sinuses
uCloses upon initiation of pharyngeal swallow
n Reduced hyolaryngeal excursion
uMultiple levels of airway protection common
n Cricopharyngeal dysfunction
n Pharyngonasal penetration/backflow may occur
14
Aspiration After Swallow Esophageal Dysphagia Diagnosis

n Neural Control
n Dysphagia for solids > liquids,
uInvoluntary for esophageal phase
structural cause likely
n Airway
uOpen
n Precipitating factors with open airway

n Dysphagia for solids & liquids similar,
dysmotility likely cause
uPharyngeal residue spills over
uGravity brings material in nasopharynx

lower into airway
Interpretation of VFSS Findings Recommendations After VFSS

n SLP reviews with caregivers & therapists or n Changes in route of nutrition/hydration
others involved in care n Nutrition guidelines
uFindings by phase of swallow n Position & posture changes
uTiming of penetration/aspiration related to n Alterations of food textures, temperatures
physiologic processes
n Utensil changes
n If review reveals a finding not anticipated or
n Changes in feeding schedule & pacing
noted during exam, SLP contacts PA or
radiologist to discuss or review together n Oral sensorimotor program with food
n Important that reports are not discrepant n Nonnutritive oral sensorimotor program
Management: Prognosis & Priority Principles for Repeat VFSS

n Oral feeding prognosis tied closely to
n Same as for initial VFSS
uUnderlying etiology & diagnosis
n Information needed for
uNeurologic
findings uDefinition of etiology or diagnosis
uCardiopulmonary status
uGuide for management decisions
n Feeding priorities established on basis of
n NOT some arbitrary time interval
uSeverity
n Child should be at baseline
uCombination of deficits
15
Infants in Need of Intervention

Nonnutritive Stimulation
n Prolonged stay in NICU
n Extensive exposure to negative oral stimulation, e.g., n Enhances oral sensorimotor skill
endotracheal tubes, suction, sticky tape development
n Before oral feeding introduction, time is needed n Builds on in utero experiences of sucking
uBreak oral & perioral aversion & swallowing
uOffer exposure to sucking via nonnutritive oral n Helps when size & shape of pacifier
sensorimotor therapy (e.g., pacifier) match infant’s mouth
NNS Cochrane Review Oral Stimulation for Preterm Infants

n 21 studies (15 randomized controlled trials, all n Exp. Group: oral stimulation of oral structures 15 min.
infants born < 37 weeks gestation) once per day for 10 days
n Main Outcome n Control group: sham oral stimulation
uNNS significantly decreased length of stay (LOS) n Started 48 hr after d/c of nasal CPAP
in preterm infants n Exp. Group reached independent oral feeding faster
uNo consistent NNS benefit revealed with respect (X=11 days, control = 18 days). No difference in length
of stay.
to other major clinical variables
n Positive clinical outcomes: Transition from tube to n Fucile, Gisel, & Lau, 2002
nipple & better bottle feeding performance
Pinelli & Symington, 2005
Nipple Feeding Principles Interventions

n Non-stressful for infant & feeder n Positioning
n Most efficient suck:swallow ratio is 1:1 n Limit feeding duration (poor endurance)
n Burst of rhythmic suck/swallows followed by cessation n Nonnutritive oral sensorimotor therapy
of sucking and a breath
n Jaw/cheek support
n Total feeding completed in about 20 min.
n External pacing
n No increased work of breathing, fatigue, or signs of
respiratory stress
16
Tools for Oral Feeding Evidence-Based Guideline:

n Bottles & nipples Introduce Oral Feeding (McCain 2003)
u Individualize
u Give infant time to adapt/learn n Requirements for oral feeding (PO)

n Thickeners – Be cautious!!! uSustain awake behavior
u May assist bolus formation, slow flow uCoordinate sucking-swallowing-breathing
u May slow gastric emptying
uMaintain cardiorespiratory stability for time to
u May increase coughing
ingest a caloric volume adequate for growth
u May interfere with digestion
n Neurologically immature preterm infant <32 wk
post conceptual age (PCA) cannot meet the
above requirements
Behavioral Organization Self-Regulation Readiness

n At 32 to 35 weeks PCA
n < 32 weeks: typically not express hard crying or
deep sleep with regular respirations n Feeding based on awake or restless behavior
n By 32 weeks, infant expresses full range of n PO progressing & concluding based on infant’s
behavioral states – important milestone for PO as ability to tolerate without fatigue or distress
need to sustain organized, awake behavior n Successful feedings: Increase in quiet sleep time
n From 32 wks PCA to term age, maturation of & shorter feeding times
brain structure is associated with improvement in n Adequate weight gain compared to infants fed
behavioral sate expression & motor organization prescribed volumes
n More opportunities to practice nipple feeding
Demand Feeding Principles of Management

n By 35 wks PCA n Whole child approach
n Functional suck-swallow-breathe pattern allowing n Total oral feeding cannot be the goal for all
for safe PO is not present until 32-34 wks PCA chidlren
(Volpe, 2000) n Nutrition & respiratory status critical
n Infants 32-36 wks PCA n GER managed optimally
uSuck-to-swallow ratio 3:1 & 4:1 with occasional n Changes in management needed
disruption in regular breathing with gains or regression
uOccasionally exhibit tongue twitching or
tremors
17
Food Rules Intervention Based on

n Scheduling Developmental Skill Levels
uMeal times < 30 min + planned snacks
uNothing between meals, except water n Oral stimulation for infants
n Environment n Spoon feeding & chewing readiness
uNeutral atmosphere - no forced feeding n Cup drinking
uNo game playing; no reward with food n Texture changes
n Procedures
uSolidsfirst; self-feeding encouraged
uMeal over if food is thrown in anger
uClean up only at end of meal
Spoon Feeding Learning Cup Drinking

n Use foods that stick to spoon n About 1-2 months after spoon feeding is well
n Avoid foods established
uToo much liquid (e.g., soups) n Open cup with thickened liquid (milkshake or fruit
“slush”)
uSlippery (e.g., sliced peaches) n Cup: wider at top, clear so feeder can control amount
per sip well
uRoll off spoon (e.g., peas)
n Child can “help” with hands
n Use spoon with flat bowl n Independent: Lip helps reduce spills
uPlastic coated non-breakable
Finger Foods
Chewing Practice
n Readiness
n 1-2 months after spoon started uPick up objects with thumb & fingers
n Gradual changes from smooth puree uBring fingers or objects to mouth
n One change at a time (e.g., taste, texture) uBite, chew, & swallow variety of textures
n Thin strip placed on molar table/surface
n Guidelines
n Alternate sides to promote later tongue action
uFood in small strips
uPlace food in front of child (2-3 pieces)
uGuide hand to mouth as needed
uFade help as appropriate
18
Common Problem Textures Modifying Textures

n Thin liquids n Modifier should match flavor of food
n Dry or lumpy foods uFine cracker crumbs in soup
uPureed food between bites of dry food uApple juice with applesauce
n Multi-textures foods (e.g., vegetable soup)
uMilk with yogurt or pudding
n Foods that do not dissolve with saliva
n When offering a new texture
uRaw fruits & vegetables
uFew spoons of familiar texture first
uThen new texture (e.g., blended
carrots, fork mashed)
Oral Sensorimotor Treatment

Oral Sensorimotor Treatment
for Anatomic Problems - Jaw
for Anatomic Problems - Lips
n Thrust: Ó tone n Mouth play: fingers, toys – Retrac n
Assisted toothbrushing Finger tapping, vibration
n Retraction: Ó tone tion: Ó
n Prone position; Forward tone n Varied textures, temps
n Clenching: Ô tone pull under jaw Tapping & stroking
n Limited upper lip
n Instability: Ô tone n Mouth play for gradual movement: Ó & Ô tone n Stroke & tap, esp. TMJ
n Tonic bite reflex: not opening n Cheeks: Ô tone n Varied textures, temps;
related to tone n Activities for jaw closure drop of liquid in corner
n Reduced sensory
n Pressure at TMJ; awareness of lips
sensory stimulation;
coated spoon
Oral Sensorimotor Treatment Oral Sensorimotor Treatment

for Anatomic Problems - Tongue for Anatomic Problems - Tongue
n Retraction: Ó or Ô n Prone position, tongue
n Thrust: Ó or Ô n Jaw stabilization, stroking back to front,
thickened liquid at tone
tone, or respiratory chin tuck for older
stress lip, food placed on child, upward tapping
sides, exercises for under chin
lateral tongue
n Vary textures & tastes
movement, spoon
to Ó sensory input;
at midtongue with n Hypotonia: Ô tone
Food or liquid added
downward pressure
gradually
19
Oral Sensorimotor Treatment Oral Sensorimotor Treatment for

for Anatomic Problems - Tongue Anatomic Problems – Soft Palate
n Deviation n Head at midline; n Nasopharyngeal n Upright or prone
stimulation of less reflux position; Angled
active side with bottle for prone
finger, toys, position; Cheek &
n Limited movement toothbrush tongue function
n Vary textures, activities; Thickened
temps, tastes; liquids (if swallow is
Vibration normal)
Mealtime Behavior Problems

Feeding with Gastrostomy Tube
n Refusal of new foods
n Upright position uIntroduce one at a time
n Pump or gravity delivery, air removed uAvoid power struggles
n Formula at room temperature n Refusal of groups of foods
n Feeding time minimum or > 20 min uRespect preferences
n Oral stimulation during feeding (or prior) uDo not beg, punish, or bribe
n Tubing flushed after feedings or meds uSet a good example
uPrepare foods in a variety of ways
uSelect other foods with same nutrients
Mealtime Behavior Problems Treatment Summary

n Wanting a particular food every day n Airway & nutrition highest priorities
uProbably change with boredom over time
n Oral sensorimotor practice can NOT jeopardize
uDo not call attention to behavior nutrition & pulmonary status
uParent controls what food is served n Forced feeding or prolonged feeding times:
FConsider food “jag” at snack never appropriate
FInclude other foods typically liked n GI tract (e.g., GER)
n Acting out umajor inhibitor of appetite
uIgnore undesirable behavior uaspiration risk
uAttend to & respond to desirable behavior n Whole infant/child approach is critical

uModel good eating behaviors
20

WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson

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WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson

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Pediatric Swallowing and Feeding:

Complex Decision Making

WS7 – April 16, Friday, 8:30-11:30/2:00-5:00

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S

Children’s Hospital of Wisconsin

jacrved@aol.com & jarvedson@chw.org

Diagnoses Seen in Feeding, Swallowing,

Common Nutrition Risk Indicators Undernutrition and Growth

Undernutrition: Severity of Effects Pulmonary Disease with

Aspiration Generalizations Congenital Laryngomalacia

Stridor in Severe CLM CLM: SLP Role for Feeding

Pierre-Robin Sequence Pathophysiology: Chronic Aspiration

uLaryngeal penetration (deep)

Timing of Aspiration with Swallow Protection from Aspiration

incoordination normal swallows

Swallowing Problems & GI Disease GER Prevalence & Epidemiology

n Inflammatory diseases uCP: 92% with GI symptoms & signs

n Constipation aggravates in neuro disorders uHealthy infants pH probe: esophageal

GER Prevalence & Epidemiology Reflexes Involved in Development

n 25-30% of all children with GER have EER n Laryngeal chemoreflex

GER Medications for Apnea

n (Kimball et al., 2001)

Multiple Causes of GER Functional GER - “Happy Spitter”

Risk Factors (Atypical Manifestations) Eosinophilic Esophagitis (EE)

Treatment of EE in Pediatrics GER Evaluation

Treatment of GERD: Types of Medications & Dysphagia

Clinical Assessment of Feeding

4 Key Questions to Ask Parents

Development in Typical Child Age of Introduction to Solids

n Cup drinking before 12 months

Feeding/Swallow Evaluation Common Criteria for Referral

Common Criteria for Referral Common Criteria for Referral

Steps in Clinical Evaluation Clinical Evaluation: Airway Concerns?

Feeding History Factors Feeding History Factors

Nervous System Exam Infant Evaluation

Clinic Airway Evaluation Clinic Airway Evaluation

Airway Stability for PO Feeding Evaluation of Transition Feeder

Postural Control Evaluation Optimal Sitting Posture

Cranial Nerve Evaluation

Tonic Bite Reflex Oral Sensory vs Motor Disorders

Oral Sensory vs Motor Disorders Oral Sensory vs Motor Disorders

n Hypersensitive gag with n Gags after swallow is

Immature vs Abnormal Patterns Next Steps?

Flexible Endoscopic Evaluation

Videofluoroscopic What VFSS is NOT

Feeding Supplies & Recipes

Preparation of Tube Feeder: NPO Child’s “State”

Procedural Decisions Lateral View

Antero-Posterior View Oral Phase Swallow Problems

Initiation of Pharyngeal Swallow Pharyngeal Swallow Problems

Pharyngeal Swallow Problems Esophageal Swallow Findings

Aspiration Before Swallow: Causes? Aspiration During Swallow: Causes?

Aspiration During Swallow Aspiration After Swallow

Aspiration After Swallow Esophageal Dysphagia Diagnosis

n Precipitating factors with open airway

uGravity brings material in nasopharynx

Interpretation of VFSS Findings Recommendations After VFSS

Management: Prognosis & Priority Principles for Repeat VFSS

Infants in Need of Intervention

NNS Cochrane Review Oral Stimulation for Preterm Infants

Pinelli & Symington, 2005

Nipple Feeding Principles Interventions

Tools for Oral Feeding Evidence-Based Guideline:

u Give infant time to adapt/learn n Requirements for oral feeding (PO)