Chapter 9: Pediatric Feeding and Swallowing Disorders Justice Communication Sciences and Disorders:...

Chapter 9:

Pediatric Feeding and Swallowing Disorders

JusticeCommunication Sciences and Disorders: An Introduction

Copyright ©2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

Focus Questions• What are pediatric feeding and swallowing

disorders?• How are pediatric feeding and swallowing

disorders classified?• What are the defining characteristics of

prevalent types of pediatric feeding and swallowing disorders?

• How are pediatric feeding and swallowing disorders identified?

• How are pediatric feeding and swallowing disorders treated?

9.1




Introduction• When eating/feeding is compromised, it

can impact physical, cognitive, psychological, and communicative development – Impact on communication: feeding promotes

bonding and attachment, and supports communicative routines (e.g., turn taking and joint attention)

• If disorder is present, feeding specialist (SLP) focuses on strengthening the oral-motor system, including functions, muscular tone, and sensation

9.2




Case Study #1: Lily• 2-year old Chinese-American girl with cerebral

palsy and oral motor dysfunction• At two weeks of age, modified barium swallow

study showed aspiration during bottle feeding and poor coordination of tongue during sucking– placed on a gastronomy tube

• Now 2 years old, parents would like to begin feeding Lily orally

• Lily is in a wheelchair, has use of her hands, and is cognitively delayed and unable to follow directions

9.3




Case Study #1 Questions

• How do you think Lily’s feeding and swallowing difficulties affect her family?

• Given that Lily has been on a feeding tube for two years, why would her parents want to pursue oral intake at this time?

• What other aspects of Lily’s life may be affected by her dependence on a gastronomy tube for nutrition?

9.4




Case Study #2: David• 3-month old child born prematurely (30

weeks) and has stayed in the NICU since birth – youngest of four children

• At first, demonstrated coughing and choking, so nurses thickened his formula – but then he became very fatigued during feeding and would not get adequate nutrition before falling asleep

• Placed on nasogastric tube for supplemental feeding

9.5





• How might David’s NICU admittance affect his family?

• What are some ways that David’s parents might be involved with his feeding while in the NICU?

9.6




Case Study #3: Cory• 2-year old boy with a normal birth• 6 weeks: began projectile vomiting during breast

feeding, was given medication, and the problem was resolved

• 6 months: refused introduction of baby foods, but still breastfeeding well

• 9 months: growth was slowing down and vomiting increased again

• 11 months: hospitalized for failure to thrive and diagnosed with “behavioral feeding aversion”, placed on a gastronomy tube

• Now, parents want him enrolled in intensive behavioral feeding program to wean off the tube feeding

9.7





• How might Cory’s feeding problems affect his family and his own psychological wellbeing?

• What are some possible causes for Cory’s food aversions?

• What are some factors that might predict whether Cory will successfully be weaned from the feeding tube?

9.8




I. What are Pediatric Feeding and Swallowing Disorders?

A. Feeding Disorders• “persistent failure to eat adequately” for a period of

at least one month which results in significant loss of weight or failure to gain weight

• Manifests prior to six years, but onset is usually in first year of life

• Usually demonstrates one or more of the following: unsafe or inefficient swallowing, growth delay, lack of tolerance to food textures and tastes, poor appetite regulation, and rigid eating patterns

9.9




B. Swallowing Disorders

• Specific type of feeding disorder in which child exhibits unsafe or inefficient swallowing pattern that undermines feeding process

• Swallowing (deglutition) is the act of moving a substance (bolus) from the oral cavity to the esophagus

• Increases the risk for:– Penetration: food or liquid enters the larynx– Aspiration: food or liquid passes through the

larynx into the lungs

9.10




Prevalence and Incidence• Difficult to estimate, although 10% of young

children experience malnutrition (not all because of feeding and swallowing disorders)

• Disorders are prevalent in the context of certain risk factors:– Low birth weight (8% of all babies in U.S.)– Neonatal Intensive Care Unit (NICU) – can

interfere with development of pleasurable oral experiences and exposure to foods, and may increase risk for food refusal, inappropriate meal time behaviors, and/or inefficient ingestion

9.11




Terminology – Nutrition• Nutrition: individual’s intake of calories and

nutrients to meet requirements for energy, growth, development, and learning

• National Academy of Sciences: recommended dietary allowances (RDAs), standards of nutrition for normal, healthy development

• Undernutrition and malnutrition: requirements are not met, usually due to environmental factors or developmental disabilities

9.12




Terminology – Growth• Growth: children’s height (length) and

weight achievements, and the relationship between them

• Growth charts: provide a child’s relative standing among all infants – allows for differentiation between small children and children whose growth is faltering

• Growth deficiencies:– Underweight: less than expected based on age– Wasting: less than expected based on height– Stunting: height is less than expected based on

age

9.13




Feeding and Swallowing Development

• Feeding is a reflexive activity, and should be effortless, efficient, effective, and pleasurable

• Proper nourishment is the most important job for parents of a newborn

• First two years of life: move from a reflexive feeder to an independent eater with specific preferences for taste and texture

9.14




Birth to Six Months• Four primitive reflexes facilitate feeding

outside the womb:– Suckling: stimulating the infant’s lips will result

in suckling, which will be followed by a swallow– Rooting: stimulating the area around the infant’s

mouth will elicit a head turn in the direction of stimulus

– Grasping: infant’s fingers will close tightly around a stimulus placed in the palm

– Gagging: protective reflex that triggers a strong physical reaction to substances entering the laryngeal area

9.15




Six to 12 Months

• Increased trunk support and head control for sitting – transition to solid foods

• Active biting and chewing – new teeth• Shift in position from reclining to upright – more

face to face engagement and social interaction• 8-9 months: independent sitting – everything

goes into the mouth as a way of exploring the world

• Critical period in the child’s future acceptance of foods

9.16




Twelve Months and Beyond

• Moving to be more independent eater – may no longer wish to be fed by the caregiver

• Increasingly has the words to express wants

• By 18 months, get many calories through regular table food (eating with the rest of the family)

• By 24 months, total mastery of all foods is expected

9.17




II. How are Pediatric Feeding and Swallowing Disorders Classified?

• Based on descriptive features– Focuses on clinical presentations or

observable symptoms

• Based on etiology– Focuses on known or suspected causes of

the disorder

9.18




Descriptive Features

A. Timeframe of Disorders

• Transient: short lived or readily correctable

• Episodic: occurs periodically

• Chronic: ongoing over months or years and cannot be resolved easily

9.19




Descriptive Features

B. Behavioral Characteristics• Three sets of feeding and swallowing

problems (Kessler):– Eating too little: excessive food selectivity

and severely restricted diet– Eating too much: excessive over-

consumption– Eating the wrong things: consume

inappropriate non-nutritive substances (e.g. pebbles, soap) - pica

9.20




EtiologyA. Organic Causes (66% of cases)

• Known physical causes for the disorder divided into three categories:

– Neuromotor dysfunction: impairment of neurological or motoric systems required for safe and efficient feeding and swallowing

– Mechanical obstruction: obstruction in the feeding and swallowing apparatus

– Medical/Genetic abnormality: illness, trauma, or disability

9.21




EtiologyB. Non-organic Causes (34% of cases)

• Causes= is not clearly evident

• Four likely causes:– Physical/emotional: reaction to the environment

(e.g., abuse, parental depression)– Educational: inadequate caregiver knowledge

concerning feeding, eating, and nutrition– Environmental: primarily financial constraints in

which food is under-available– Behavioral: feeding and/or swallowing deficits

resulting from learned behaviors

9.22




Biopsychosocial Perspective

• Early physiological or medical problem may trigger psychological and interactional issues which contribute to maladaptive behaviors

• Often difficult to categorize disorder as organic or non-organic – instead the disorder stems from a variety of biological, psychological, and social influences

9.23




Failure to Thrive• Widely-used term for children whose

weight or height deviates significantly from the norm for the age and gender – due to nutritional inadequacy:– Due to limited access to food, intake of food,

and/or limited retention or absorption of food

• Not all children with FTT have a feeding disorder and vice versa

• Some experts consider FTT a pejorative terms, so pediatric undernutrition and growth deficiency are preferred

9.24




III. What are the Defining Characteristics of Pediatric Feeding

and Swallowing Disorders?

• Children with disorder usually exhibit one or more of the following:– Feeding and/or swallowing that is unsafe– Feeding and/or swallowing that is inadequate– Feeding and/or swallowing that is

inappropriate

9.25




Unsafe Feeding and Swallowing• Unsafe feeding and swallowing poses a

risk for penetration or aspiration as well as poor nutrition– Unsafe swallowing (dysphagia) results from

dysfunction or damage of the child’s oral-motor system or an inappropriate eating rate (either too fast or too slow)

– Unsafe swallowing may result in a physician’s order for “nothing per oral” (NPO): child cannot ingest anything through mouth

9.26




Causes and Risk Factors• Accompanies several syndromes that feature

low muscle tone, delayed motor development, and physical deformities

• Cerebral Palsy: risk factor for dysphagia– First year of life:

• 57% exhibit problems with sucking• 38% exhibit problems with swallowing• 33% exhibit malnutrition or FTT

• Other conditions:– Significant anomalies of oral structures– Chronic or recurrent respiratory problems– Cardiopulmonary diseases

9.27




Inadequate Feeding and Swallowing

• Inefficiency: unable to meet caloric and nutritional needs because process of feeding and swallowing is not productive

• Overselectivity: restrictive in taste, type, texture, and/or volume of foods eatern

• Refusal: complete refusal to feed, due to ongoing medical issues, gastro-intestinal distress, or traumatic experiences

• Feeding Delay: delayed development of feeding skill milestones

9.28




Causes and Risk Factors• Low birth weight: low or very low birth weight at risk for

feeding/swallowing disorders• Developmental disabilities: Down syndrome, autism,

and cerebral palsy (and other conditions) may result in motor or muscular weakness and/or sensory defensiveness (autism)

• Prematurity: born at or before 37 weeks, may result in immature systems (e.g., digestive)

• Prenatal drug exposure: alcohol, tobacco, cocaine, heroin, etc. – linked to prematurity and low birth weight

• Diet restrictions: strict or modified diets (due to diabetes, PKU, etc.) may result in feeding challenges and resistance to eating

9.29




Inappropriate Feeding and Swallowing

• Children exhibit undesirable or disruptive behaviors during mealtimes that inhibits successful feeding– Examples: screaming, spitting, throwing,

hitting, drop food on the floor, eating at inappropriate rates

• Eating too slow: nutritional deficiencies

• Eating too fast: choking or aspiration

9.30




Causes and Risk Factors• Negative parent behaviors: over-stimulating,

under-stimulating, rigid and demanding, chaotic and frenzied, overly concerned or anxious

• For a positive feeding time…– Infants must exhibit the following characteristics:

positive, alert, calm, show readable cues for hunger and fullness, and willingness to try to tastes and textures

– Toddlers must exhibit the following characteristics: interested in eating, indicate hunger and fullness, follow a predictable meal schedule, positive behaviors

9.31




IV. How are Pediatric Feeding and Swallowing Disorders Identified?

• Early Identification and Referral

• Comprehensive Assessment

9.32




Early Identification and Referral• Children’s height and weight is carefully

monitored by the pediatrician on a growth chart at routine “well-child” visits

• When feeding or swallowing problems are suspected, pediatrician will make at least two referrals:– Ear-nose-throat specialist (ENT) or

gastroenterologist– Feeding specialist

9.33




Comprehensive Assessment

• Case history

• Physical feeding/swallowing evaluation

• Observation of mealtime interactions

9.34




Case History• Collected via interview• Most important: child’s feeding history,

including length of meals, quality of intake, progression from bottle to solids, and history of formulas used

• Also important: discussion of child’s developmental progression, including cognitive and language abilities, gross and fine motor skills, sensory processing, and temperament

9.35




Physical Feeding and Swallowing Evaluation

• Structural examination: physical nature of oral-motor structures, looks for asymmetry, drooling, and abnormal patterns or reflexes

• Functional examination: how the oral-motor structures work together, looks at safety and efficiency and quality of intake

• If any problems are seen, child may be referred for modified barium swallow study (MBS) – radiography follows a substance through child’s swallowing process

9.36




Observation of Mealtime Interactions

• Live observation by outside professional of the child during mealtime interactions – Examines for any breakdowns in child-

caregiver communication and for unsafe or inefficient oral feeding practices

• Feeding specialist studies scheduling of meals, environment, foods presented, and family traditions

9.37




V. How are Pediatric Feeding and Swallowing Disorders Treated?

Multidisciplinary Alliance:

• Collaboration of parents and professionals in working alliance to ensure effectiveness of treatment

• Most involved professionals:– Pediatrician– Nutritionist– Feeding specialist

9.38




Treatment Contexts• NICU: Neonatal Intensive Care Unit

– Evaluations and interventions of feeding and swallowing for medically fragile infants

– Encourages communication and stimulates oral-motor mechanisms

• Special Clinics– Inpatient treatment in an intensive, hospital-based

program– Accompanied by treatment in other contexts, like

home visits (allows specialist to study food prep, meal options and timing, discipline, child behavior, and feeding relationships in authentic context)

9.39




Treatment Goals and Approaches

• Physiology of Feeding and Swallowing

• Psychology of Feeding and Swallowing

• Alternative and Supplemental Feeding

9.40




Physiology of Feeding and Swallowing

• Focus on muscle tone, articulator movement, oral-motor sensitivity, and body posture

• Hierarchical continuum of training targets (short-term goals): start at child’s present skill level and progress towards independent eating (long-term goal)

9.41




Psychology of Feeding and Swallowing

• Focus on accepting certain food types or textures, decreasing resistance and fussiness during eating sessions, and following predictable meal schedule

• Uses behavioral principles for treatment:– Shaping – incrementally moves child towards

goal– Conditioning and reinforcement – training of new

behavior through positive reinforcement– Systematic desensitization – trains child to accept

an aversive sensory experience

9.42




Alternative and Supplemental Feeding

• Enteral or tube feeding – liquid nutrition is delivered through a tube (can be sole avenue for nutrition or supplemental to oral intake)– Short-term treatment: nasogastric tube

– Longer-term treatment: gastronomy tube or jejunostomy tube

• Special support also given to caregiver-child feeding relationship and to promoting oral abilities even when not used for feeding

9.43




Chapter 9: Pediatric Feeding and Swallowing Disorders Justice Communication Sciences and Disorders:...

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