Feeding and Swallowing Difficulties in Infants and Children with HIV

Vivienne NormanDivision of Communication Sciences

and DisordersUCT

Feeding and Swallowing Difficulties

• Feeding disorders:

– difficulty with any aspect of eating or drinking

– including caregiver-child interaction, appetite, swallowing, food refusal, food preferences, disruptive mealtimes

• Swallowing difficulties

– problem in 1 or more phases of swallowing

– Including poor sucking, poor co-ordination of swallowing and respiration, aspiration

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Arvedson, 2008

So, what can go wrong?

Oral phase:

• Poor latch

• Absent / weak suck

• Spillage

• Poor bolus formation & control

• Increased oral transit time

• Aversion / hypersensitivity

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Pharyngeal phase

• Delayed / absent swallow response

• Aspiration – material enters airway below vocal cords *

• Nasopharyngeal reflux

Signs of possible problem:

Coughing, choking, spluttering, wet/gurgly

voice, apnoea, hoarse voice

* Aspiration may be silent Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Typical reasons for referral

• Absent / weak suck• Suck-swallow incoordination• Coughing associated with

feeds• Gurgly / wet voice during /

after feeds• Vomiting / GOR• Not completing feeds• Increased feeding times• Hoarse voice• Feeding induced apnoea• Excessive spillage• Recurrent LRTI• Excessive gagging

• ?Aspiration• Breathing disruptions• Diagnosis of disorders

associated with dysphagia• Food refusal and FTT• Irritability with feeding• “Behaviour problems” with

feeding• New onset of feeding

problem• Transition from tube to oral

feeds• Delayed feeding milestones /

failure to progress

Arvedson & Brodsky, 2002; Hall, 2001 Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Consequences of dysphagia

• Growth faltering

• LRTI / respiratory compromise

(due to aspiration)

• Reduced social interaction & communication

• Increased stress for caregivers

• Pain / discomfort

• Constipation

• Dental problems

Andrew & Sullivan, 2010; Reilly et al., 2011Feeding and Swallowing Difficulties in HIV 2011

Vivienne Norman

Prevalence of feeding & swallowing difficulties

• 20 - 45% typically developing children

• 30 - 40% children with neurological involvement & others report 80%

• 40 - 70% infants / children with chronic medical problems

Arvedson, 2008; Calis et al., 2008; Lefton-Greif & Arvedson, 2007; Reilly et al., 1996; Rudolph & Link, 2002 Feeding and Swallowing Difficulties in HIV 2011

Vivienne Norman

Prevalence in infants and children with HIV and AIDS

USA:• 45% (N=55) – before ARVs

– Pressman & Morrison, 1988

• 20.8% (N=96) – screening only– Pressman, 1992

UK:• 50% (N=42) – feeding problems reported

– Melvyn et al., 1997

SA:• 12.5% (N=446) – of sample of dysphagic caseload

– Unpublished data: Oosthuizen, 2011

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Reported feeding and swallowing difficulties in HIV

• Slow feeding

• Aspiration

• Coughing

• Growth faltering

• Gags with solids / textures

• Odynophagia

• Food refusal

• Behavioural feeding problems

• Delayed feeding milestones

• Nausea & vomiting

• GOR

Pressman, 1992; 2010; Rabie et al., 2007Feeding and Swallowing Difficulties in HIV 2011

Vivienne Norman

Reasons for dysphagia in infants and children with HIV / AIDS

• Feeding difficulties associated with chronic illness

– Psychological and emotional effects on feeding

– Hospitalizations

– Tube feeding

– Caregiver factors

Schwartz & Rothlingova, 2011Feeding and Swallowing Difficulties in HIV 2011

Vivienne Norman

Reasons for dysphagia in infants and children with HIV / AIDS

• HIV-related

– Structure may be affected e.g. oesophageal abnormalities

– Function may be affected e.g. encephalopathy

– Medications may cause nausea, vomiting, and reduce appetite

– Candidiasis (oral, pharyngeal, laryngeal, oesophageal)

– Odynophagia

Halvorsen et al., 2003; Pressman, 2010; Rabie et al., 2007 Feeding and Swallowing Difficulties in HIV 2011

Vivienne Norman

What to look out for…

• Coughing with feeding• Frequently does not complete feeds• Frequently takes longer than 30 minutes to complete feeds• Caregiver reports of feeding difficulty• Tires with feeding• Changes in breathing during feeding• Changes in voice• Excessive drooling • Gags with feeds• Spits out milk / food• Chokes with feeding• Not eating age / developmentally appropriate foods• Complain of pain with swallowing

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Role of Speech-Language Therapist

• Clinical assessment– Skill

– Safety

• Instrumental assessment if indicated e.g. modified barium swallow

• Referral for other investigations if indicated

• Part of team management of feeding and swallowing

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Benefits of MBS• Defines oropharyngeal &

oesophageal anatomy & function

• Determines reason for difficulty e.g. aspiration due to pooling, fatigue

• Assesses treatment strategies e.g. changes to position, consistency, rate, utensils

• Aspiration may be silent or occur with fatigue

• Safest consistency that is developmentally appropriate

• Low clinical reliability in determining aspiration of solids when compared with VFSS

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

LIQUID THICKENED FEED

ASPIRATION

NORMAL

Multiple

Strictures

Management of infants and children with dysphagia

• SAFE

• Optimal nutrition

• Facilitates development

• Multidisciplinary team which includes the FAMILY

Andrew & Sullivan, 2010; Reilly et al., 2011Feeding and Swallowing Difficulties in HIV 2011

Vivienne Norman

Management may include

• Consistency modification – NB to remember to thicken medications too in consultation with doctor

• Positioning & seating

• Techniques / programme for oral sensorimotor difficulties

• Utensils

• Supplementing intake

• Caregiver counselling and training

• Alternative feeding e.g. gastrostomy

Arvedson & Brodsky, 2002; Reilly et al., 2011 Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

GORD and dysphagia

• Frequently co-occur

• Impact of GORD on swallowing

• Intervention may affect feeding and swallowing

• Managed by medical team

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

GORD

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

Monitoring and review

• SLT should monitor feeding and swallowing in terms of safety and skills

• Determine need for ongoing modifications or new intervention

• Facilitate development of feeding skills

Feeding and Swallowing Difficulties in HIV 2011Vivienne Norman

References

Andrew, M.J. & Sullivan, P.B. (2010). Feeding difficulties in disabled children. Pediatrics and Child Health, 20(7):321-326.

Arvedson, J.C. (2008).Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Developmental Disabilities Research Reviews, 14: 118-127.

Arvedson, J.C. and Brodsky, L. (2002). Pediatric Swallowing and Feeding: Assessment and Management (2nd Ed). Singular Thomson Learning, Canada.

Calis, E.A.C., Veugelers, R., Sheppard, J.J., Tibboel, D., Evenhuis, H.M. and Penning, C. (2008). Dysphagia in children with severe generalized cerebral palsy and intellectual disability. Developmental medicine and child neurology, 50:625-630.

Field, D., Garland, M. and Williams, K. (2003). Correlates of Specific Childhood Feeding Problems. Journal of Pediatrics and Child Health, 39:299-304.

Halvorsen, R.A., Moelleken, S.M.C. & Kearney, A.T. (2003). Videofluoroscopic evaluation of HIV/AIDS patients with swallowing dysfunction. Abdom Imaging, 28:244-247.

Lefton-Greif, M. A., and Arvedson, J. C. (2007). Pediatric feeding and swallowing disorders: State of health, population trends, and application of the International Classification of Functioning, Disability, and Health. Seminars in Speech and Language, 28, 161-165.

Melvyn, D., Wright, C. & Goddard, S. (1997). Incidence and nature of feeding problems in young children referred to a paediatric HIV service in London: FEAD screening. Child Care Health & Development, 23(4): 297-313.

Oosthuizen, N. (2011). Unpublished results – Masters Thesis (UCT).

Pressman, H. (1992). Communication disorders and dysphagia in pediatric AIDS. ASHA, 34(1): 45-47.

Pressman, H. (2010). Dysphagia and related assessment and management in children with HIV/AIDS. In Swanepoel, D. & Louw, B. (2010). HIV/AIDS: related communication, hearing, and swallowing disorders. Plural Publishing, San Diego.

Rabie, H., Marais, B.J., Van Toorn, R., Nourse, P., Nel, E.D., Goussard, P., Sellers, N. & Cotton, M.F. (2007). Important HIV-associated conditions in HIV-infected infants and children. SA Fam Pract, 49(4): 19-23.

Reilly, S., Morgan, A. & Wisbeach,A. (2011). The management of feeding in children with neurological problems. In In Southall, A. and Martin, C. (2011). Feeding problems in children: a practical guide (2nd Ed). Radcliffe Publishing, UK.

Rudolph, C.D. and Link, D.T. (2002). Feeding Disorders in Infants and Children. Pediatric Clinics of North America, 49(1):97-12.

Schwartz, A. & Rothlingova, Z. (2011). Management of feeding problems in children with a chronic illness. In In Southall, A. and Martin, C. (2011). Feeding problems in children: a practical guide (2nd Ed). Radcliffe Publishing, UK.