Feeding & Swallowing Disorders in ToddlersFeeding & Swallowing Disorders in Toddlers ASHA Online...
Transcript of Feeding & Swallowing Disorders in ToddlersFeeding & Swallowing Disorders in Toddlers ASHA Online...
Feeding & Swallowing Disorders inToddlers
ASHA Online ConferenceBirth to Three: Working Together to Serve Children and TheirFamilies 1
Feeding & Swallowing Disorders inToddlers
Memorie M. Gosa, PhD, CCC-SLP, BCS-S
Disclosures
• Financial
– Employee of The University of Alabama, Druid City Hospital,Le Bonheur Children’s Hospital
– Grant funding from ASHFoundation New Investigator Grant
– Financial compensation from ASHA for this presentation
• Nonfinancial
– Chairperson of the American Board of Swallowing andSwallowing Disorders
• No conflicts of interest to disclose
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Learning Objectives
You will be able to:
• Name the seven evaluation areas for clinical feedingassessment in toddlers
• Describe the intervention options available to treat feedingand swallowing disorders in toddlers
Typical Feeding/Swallowing DevelopmentTypical Feeding/Swallowing Development
Evaluation Areas for Clinical AssessmentEvaluation Areas for Clinical Assessment
Treatment Options & Evidence to SupportTreatment Options & Evidence to Support
Presentation Road Map
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Feeding & Swallowing Development
Feeding Progression
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Pediatric Swallowing Anatomy
Pediatric Swallowing Physiology
• Obligate nasal breathers
• Absence of oral preparatory phase – continuous with oraltransit
• Pharyngeal swallows are more frequent
• Less hyolaryngeal excursion
• Commonly trigger swallow at valleculae
• Residue in valleculae is common
(Newman, 2001)
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Swallowing Physiology Differences
Infants
• Volume per swallow: 0.2 ml(+/- 0.11 ml)
• 300 sucking & swallowingmotions to drink 1 ounce
Older Children/Adults
• Volume per swallow 20 ml-25 ml
(Morris & Klein, 2000)
Nipple Feeding
• Alterations of:
– Compression (+pressure)
– Expression (-pressure)Suction: Creation of negativeintraoral pressure
– Together, these draw milkinside the oral cavity
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Airway Protection
• Airway protection accomplished by:
– Elevation of larynx under base of tongue
– Anterior movement of the arytenoids toward the base of theepiglottis
– ??Epiglottic deflection??
(Thach, 2001, 2007; Crompton et al., 2008; Rommel, 2002)
Airway Protection, Cough
• Cough reflex
– Newborn, poorly developed
– More common to have period of apnea, then swallow, possiblecough after swallow
(Thach, 2007)
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Sucking, Swallowing, & Breathing
• Suckle-swallow-breathe
– Suckle and swallow 1:1
– 10-30 times before taking a breath and continuing
– More likely, suckle*swallow*breathe ratio is 1:1:1
– After bolus leaves the pharynx, air flows in (through) the noseand is followed by next S:S:B sequence
(Wilson et al., 1981; Gewolb et al., 2001)
Transition to Sucking and Spoon Feeding:4–6 Months of Age
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Transition to Chewing: 7–9 Months of Age
Transition to Regular Diet: 9–12 Months of Age
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Refinement of Oral Skills: 12–24 Months of Age
Behavioral Development
Sensorimotor
Birth–2
Preoperational
2–7
(Dodrill, 2016)
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Evaluation Areas for Clinical Assessment
Clinical FeedingAssessment
1. History/CurrentFunctioning Status
2. Parent/Child Interactions3. Child Feeding Behaviors4. Oral Mechanism Exam5. Feeding Skill Assessment6. Sensory Assessment7. Nutrition/Growth
(Arvedson, 2008; Dodrill &Gosa, 2015; Piazza, 2004)
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History & Current Functioning
• Birth history
• Medical history– Neurologic Hx
– Cardiac Hx
– Respiratory/airway Hx
– GI Hx
– Renal Hx
– Craniofacial Hx
– Hemolytic Hx
• Feeding history
• Allergies/intolerances
• Medications
• Weight/height growth charts
http://www.asha.org/Practice-Portal/Templates/
Parent/Child Interactions
Antecedent (Caregiver)
Verbal/Physical
Behavior (Child)
Verbal/Physical/Escape/Withdrawal
Consequence (Caregiver)
Verbal/Physical/Escape/Withdraw
(Marshall et al., 2014)
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Child’s Feeding Behaviors
• Behavioral Pediatric Feeding Assessment Scale (BPFAS)
– Valid tool for identifying childhood feeding difficulties
– High reliability and specificity
– Parent questionnaire
– Typically developing children display few undesirablefeeding behaviors & few behaviors are perceived asproblems by parents
– Children with a large number of feeding problems on thisparent-reported measure need further multidisciplinaryevaluation
(Crist & Napier-Phillips, 2001)
Oral Mech Exam
• Oral anatomy– Lips, palate, tongue, jaw, teeth, cheeks
– Structures are complete, symmetrical, appropriate size, tone,range of motion
• Oral reflexes– Adaptive reflexes, protective reflexes
• Oral motor control– Assess with non-nutritive & (when possible) nutritive tasks to
determine function of oral structures
• Oral sensory processing– Assess response to touch in and around oral cavity, response to
various sensory-diverse foods
– Typical, hypersensitive, or hyposensitive
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Quality of Feeding Skill Assessments
• Three basic elements of quality for an assessment
– Reliability: Measure of assessment’sconsistency
– Validity: Measure of an assessment’susefulness
– Standardization: Provides a mean (average)and standard deviation (spread) of assessmentscores
Available Feeding Skill Assessments
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Infant Feeding Skill Assessments
• 11 tools identified
• Early Feeding Skills (EFS): Assessment has most supportivepsychometric development and testing for assessment ofbottle- and breastfeeding in preterm infants through 52 weeksPMA & full-term infants with significant feeding difficulties
• Bristol Breastfeeding Assessment Tool (BBAT): Has the mostpsychometric support for assessment of breastfeeding inhealthy, full-term infants with minor feeding difficulties
Pediatric Feeding Skill Assessments
• 30 tools identified– 11 caregiver, 18 clinician, 1 caregiver or clinician
• Schedule for Oral Motor Assessment (SOMA)– Observation, infants and children 0–2 years old– Scales: Puree, semi-solid, solid, cracker, bottle, trainer cup, and cup– Mixed response scoring options– 15–20 minutes– Formal training required
• Dysphagia Disorder Survey (DDS)– Observation, children w/ DD 2–21 years old– Scales: Related factors (7), feeding/swallowing competency (8)– Binary scoring– 10–15 minutes– Formal training required
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Typical Outcomes Documented FromNonstandardized Feeding Skill Assessments
Volume ofIntake
Duration ofFeeding
Fussing/Refusal During
Feeding
PhysiologicMeasures
Stage of OralMotor
Development
Signs ofPossible
Aspiration
Sensory Assessment
• Sensory Profile
– Dunn (2002)
– Published assessment
– Standardized, reliable
– Used in several published studies
– Parent completed
– OTs assist with interpretation
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Sensory Assessment, Sensory Profile
• Infant/Toddler Sensory Profile
– Assessment covers 6 sections• General Processing, Auditory Processing, Visual Processing,
Tactile Processing, Vestibular Processing, and Oral SensoryProcessing
– Results are grouped into 4 quadrants• The quadrant scores reflect the child's responsiveness to
sensory experiences, and are based on Dunn's Model ofSensory Processing
• Sensation Seeking and Low Registration indicate different high-threshold responses
• Sensory Sensitivity and Sensation Avoiding reflect different low-threshold responses
Nutrition & Growth
• 24-hour diet recall
– Amount of intake
– Type of intake
– Texture of intake
– Frequency of feeds
– Duration of feeds
– Dietitian for advice regarding nutrient, energy, and fluid needs
• Anthropometric measurement
– Height and weight measured using standardized method
– Computation of BMI
– Plotting on growth chart
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Treatment Options & Evidence to Support
Multidisciplinary Management
Speech-Language
Pathologist
Speech-Language
Pathologist
DieticianDietician
PCPPCP
OT,PT,
Teacher
OT,PT,
Teacher
GI,Pulmonology,
Psychology
GI,Pulmonology,
Psychology
Social WorkerSocial Worker
PedsDysphagiaTreatment
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SuccessfulFeeding
SuccessfulFeeding
MedicalManagement
MedicalManagement
NutritionNutrition
SkillSkill
EnvironmentEnvironment
BehaviorBehavior
Management Considerations
• Oral motor interventions (OMI) include exercises andactivities designed to influence the actions of the tongue, lips,soft palate, jaws, larynx, and/or respiratory muscles forimproved strength, tone, range of motion, or coordinationduring feeding/swallowing and include traditional muscleexercises (active or passive), stretching, and/or sensorystimulation to the articulators and related structures
Treatment: Motor/Skill, Definition
(Gosa & Dodrill, 2017)
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Treatment: Motor/Skill, Examples
(Gosa & Dodrill, 2017)
Treatment: Motor/Skill, Goals
• Goals of oral motor or oral sensory motor interventionsinclude
– Assisting an individual in reaching their maximal functionalcapacity for feeding/swallowing/speech
• Target areas include:
– Oral structures (lips, tongue, cheeks, jaw, palate)
– Specific feeding skill (lip closure, jaw opening/closing, tonguelateralization)
– Neck, chest, posture, respiration
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Treatment: Motor/Skill, Evidence
Treatment: Motor/Skill, Evidence (Cont’d)
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Treatment: Behavioral Interventions
Medical Skill Behavioral
(Rommel et al., 2003)
Treatment: Behavioral Interventions, ABC
• Antecedent
– Prompt: Verbal, visual, tactile
• Behavior
– Desirable vs. undesirable
• Consequence
– Reinforcement – increases the likelihood of a behaviorhappening again
– Punishment – decreases the likelihood of a behavior happeningagain
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Treatment: Behavioral Approaches, OC
• Operant Conditioning (OC) Therapy Approach
– Goal is to change behaviors related to eating
– Typically incorporates information on general parenting skills
Treatment: Behavioral Approaches, SD
• Systematic Desensitization (SD) Therapy Approach
– Goal is to improve willingness to interact with food
– Also incorporates information on general parenting skills
https://theoriesinpsychologyf10.wikispaces.com/file/view/Desensitization.gif/177474605/Desensitization.gif
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Treatment: Behavioral Approaches, Evidence
What is the effect of behavioral-based interventions (includingapproaches that incorporate techniques with elements fromoperant conditioning, systematic desensitization, etc. …) onfunctional oral feeding outcomes in children?
• 37 studies
• 919 pooled participants, 86% were between 2 and 7 yearsold
• 70% were small sample size (N of 1–13), 30% had samplesizes of 24–490
Treatment: Comparison of Behavioral Approaches
• Determine whether OC or SD intervention results ingreater improvements in dietary variety/intake andgreater reductions in difficult mealtime behaviors
• Children, 2-6 years w/ ASD or NMC randomized toreceive 10 OC or SD sessions at 1x/week or for 1week
(Marshall et al., 2015)
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Treatment: Comparison of OC & SD
• In OC group:
• Trend toward greater increase in total number of foodsconsumed & total number of unprocessed fruits andvegetables
• In SD group:
• Trend toward greater reduction of difficult mealtimebehaviors
(Marshall et al., 2015)
Treatment: Mixed Modality Approaches, Evidence
What is the effect of applying mixed modality interventions onfunctional oral feeding outcomes in children?
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Treatment: Mixed Modality Approaches, Evidence(Cont’d)
• 23 of the 61 studies
• 395 pooled participants; majority of studies featured smallsample sizes (less than 10 participants)
• 95% of participants were between 2 and 10 years of age
• Mixed diagnostic population that included Down syndrome,ASD, Goldenhar syndrome, Rett syndrome, CP, rubellasyndrome, & feeding complications due to major organsystem impairments
• Included: Behavioral & OMI; behavioral & sensoryinterventions; behavioral, OMI, & sensory
(Gosa et al., 2017)
Treatment: Evidence Conclusions
• From this EBSR, clinicians recognize the importance ofbehavioral therapy techniques for remediating feedingdisorders (60/61 articles)
• Lack of evidence to support the singular use of OMI
• Moderate amounts of published evidence to support the useof behavioral interventions (37/61 articles) and the use ofmixed method interventions (23/61 articles)
• Various levels of evidence available to support the use ofbehavioral (32/37, 86% were found to be phase one research)and combined treatment options (all phase one research)
(Gosa et al., 2017)
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Go Do
• Consider how your facility performs pediatric clinical feedingassessments:
– Are you using clinically validated instruments?
– Is there a standardized approach to the assessment?
– What types of treatment are being offered?
– How is training provided within your facility?
• Considering your answers to the above questions, evaluatewhat (if any) changes should be implemented to improve thestandard of care for toddlers with feeding and swallowingissues
• Collaborate with multidisciplinary partners to implementquality improvement changes within your facility
Feeding & Swallowing Disorders in Toddlers, by Memorie Gosa
ASHA Online Conference Birth to Three: Working Together to Serve Children and Their Families
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Feeding & Swallowing Disorders in Toddlers, by Memorie Gosa
ASHA Online Conference Birth to Three: Working Together to Serve Children and Their Families
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