WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
Transcript of WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
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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
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Joan C. Arvedson, Ph.D. 3/25/2010
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Pediatric Dysphagiawith Health Issues & Complications
Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S [email protected] & [email protected]
Dysphagia: Health Considerations
Nutrition/hydration & undernutritionNeurologic & neurodevelopmental issuesPulmonary/airway issuesGastroesophageal reflux disease (GERD)Medication effects
Diagnoses Seen in Feeding, Swallowing,& Nutrition Center (FSNC)
AngelmanSy ndromeSevere atopyAutism spectrum disordersBreastf eeding diff icultyCanavan syndromeCat eye syndromeChromosomal etiologiesPrematurity & complicationsOrofacialmalf ormationsAirway malformationsCockayne syndromeCongenital diaphragmatic
herniaCongenital heart diseaseCornelia DeLange
Common Nutrition Risk Indicators
Failure to grow over 2-3 monthsWeight/height below 5th %ileChronic diarrhea/constipationLong term use of drugsExcessive drooling
Common Nutrition Risk Indicators
Frequent reflux/emesisOral sensorimotor feeding difficulties
Metabolic disordersAbnormal CBC/urine screensSuspected caregiver neglect
Undernutrition and Growth
Acute: decreased weight-for-height (wasting)Chronic: decreased height-for-age (stunting)
Effect on linear growth may lag weighteffects by 4 monthsChildren who survive malnutrition - generallystunted
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Co stello syndromeCran iosynostosisCri- du-chatDandy Wal ker SyndromeDiabetesDown syndromeEosinophilic GI diseaseEs cobar syndromeHirs chsprung syndromeHemol ytic uremic
syndromeI U G RKlinefelter syndromeMito chondrial diseaseNoo nan syndromePa nhypopituitarismCe rebral palsySeizure disorders
Pie rre Robin sequenceEagle -Barrett syndromeRobinowsyndromeShort gutSpina BifidaStickler syndromeTE FSolid organ transplantationTurner syndromeVATERVe locardiofacialsyndrome
Formula intoleranceCho king phobia
“Sleeper eaters” Abs ent hunger drive
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Undernutrition: Severity of Effects
Correlated with onset & duration
Most profound damage when period ofdeprivation occurs during first 2 years
Pulmonary Disease withNeurologic Impairment
Respiratory complications of dysphagiaDisordered timing/incoordinationAspirationAirway obstruction
High risk infants (apnea & hypoxia)Older children: disorders of respirationSigns & symptoms of aspiration vary
Aspiration GeneralizationsUsually silent with neurologic deficitsHigh index of suspicion for signs ofpharyngeal dysmotility
Congestion during feedsMultiple swallows per bolusDelayed initiation of pharyngeal swallowRespiratory distress (e.g., cough, wheeze)
Congenital Laryngomalacia
Redundant supraglottic mucosaCommon mechanisms
Cuneiforms drawn inward duringinspirationExaggerated omega shaped epiglottiscurls on itselfArytenoids collapse inward
Stridor in Severe CLM
InspiratoryHigh pitched
Loudest when upsetMore evident in supine
CLM: SLP Role for FeedingDetermine most efficient oral feeding:position, liquid flow, pacingMonitor inspiratory stridor & effect on PO
Effects of GER & nipple feeding?Reassurance to parents regarding positiveprognosis in coming monthsSpoon feeding & cup drinking may be focusearlier than in typical infants
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Pierre-Robin SequenceMandibular Hypoplasia(Micrognathia)Glossoptosis (retroplaced tongue)Airway obstruction
U-shaped cleft palate (not primarycharacteristic, seen in about 80%)
Pathophysiology: Chronic AspirationMay be more insidious than acute aspiration(direct & indirect)Most prone: Swallowing dysfunction &neuromuscular disease
Clinical indicators may be scarceLaryngeal penetration (deep)Endangerment to airway from aspirationLife threatening physiologic alterations
Timing of Aspiration with SwallowBefore: Delay in onset of pharyngeal swallowor abnormal tongue movementsDuring: Ineffective laryngeal closure or timingincoordinationAfter: Results in residue from multiple factors(e.g., decreased tongue base retraction,reduced sensation, incoordination ofpharyngeal constrictors)
Protection from AspirationNormal swallowCough
Not reliable predictor even in infants withnormal swallowsBy 1 mo., 90% of infants have cough reflex
Other protectors of lung (e.g., mucociliaryclearance, phagocytosis by alveolarmacrophages, lymphatic drainage, gag)
Swallowing Problems & GI Disease
Esophageal structural abnormalities (TEF)Motility disordersInflammatory diseasesConstipation aggravates in neuro disorders
74% of CPMultiple causes (e.g., PO with fluid)
GER Prevalence & EpidemiologyHighest < 2 years of age
Preterm infants: 63%CP: 92% with GI symptoms & signsHealthy infants pH probe: esophagealacidification common
21% of all ped pts to GI clinic presentwith signs/symptoms suggestive of GER
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Joan C. Arvedson, Ph.D. 3/25/2010
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GER Prevalence & Epidemiology
Typical symptoms of GER in < 50% inchildren with upper airway manifestations
25-30% of all children with GER have EER& upper aerodigestive tract symptoms/signs
Reflexes Involved in Development
of Upper & Lower Airway DiseaseEsophago-laryngeal reflexAcid is introduced into distal esophagusLaryngospasm results
Laryngeal chemoreflexDirect acid stimulation to larynxApnea, bradycardia, & hypotension result
More active in infants & gradually disappear
GER Medications for Apneain Premature Infants
Theophylline or caffeine: neither drugconsistently eliminates apnea in all patientsNote: caffeine exacerbates GER in adults &older children!Antireflux medications do NOT reducefrequency of apnea in premature infants
(Kimball et al., 2001)
Manifestations of GER are due to
effects of gastric acid, BUT
abnormalities of motility &
sphincter function cause GER
Multiple Causes of GER
Impaired LES functionIncreased intraabdominal pressureDelayed gastric emptyingImpaired esophageal acid clearance
Functional GER - “Happy Spitter”
Infants, onset usually < 2-3 monthsEffortless regurgitation (spitting up)
Frequency decreases after 6 monthsIf infant grows well, no major work-upneeded
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Joan C. Arvedson, Ph.D. 3/25/2010
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Risk Factors (Atypical Manifestations)
Lower airway diseasesUpper airwayUpper digestive
chronic halitosis otalgia/chronic OMloss of taste Sandifer’s syndromefood refusal chronic pharyngitisdental caries drooling
Eosinophilic Esophagitis (EE)Entity emerged since 1997 – previouslyconfused with reflux esophagitisInflammation due to allergic factors mayalso include upper airway diseaseNot correlate with ? GEREndoscopy
Denser infiltrates of eosinophils relate tononacid-related cause of esophagitisFurrows or rings often noted
Steiner et al (2004)
Treatment of EE in PediatricsLack randomized controlled trialsCase series suggest
Elemental dietOral steroidsTopical steroids
Lack of control group: impossibleto evaluate effect of interventions
Kukuruzovic et al. 2004, Cochrane Database Syst Rev
GER Evaluation
Clinical evaluationRadiographic studyScintigraphyEsophageal pH testing (most sensitive)Endoscopy & biopsy
Treatment of GERD:Infants & Children
PositioningDietary treatments (e.g., thickening feeds)Feeding schedule changesPharmacologic therapySurgery (fundoplication)
Types of Medications & Dysphagia
SedativesBenzodiazepinesDopamine antagonistsAnticholinergics
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Joan C. Arvedson, Ph.D. 3/25/2010
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Clinical Assessment of Feeding& Swallowing: Infants & Children
Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S [email protected] & [email protected]
Presentations of Feeding Disorders
4 Key Questions to Ask ParentsHow long does it take to feed your child?
Longer than 30 minutes, tip-off for problem
Are meal times stressful to child &/or parent?Neurologic based skill & safety issues?Behavior and/or sensory issues?
Is your child gaining weight OK?If no weight gain for 2-3 months, sign of problem
Are there signs of respiratory problems?e.g., congestion ? during feeding; gurgly voice
Global Feeding Evaluation Goal
To determine safest & most efficientconsistencies for a child to eat orally(to whatever extent possible) whilemaintaining adequate nutrition &hydration
Development in Typical ChildLiquid by nipple first 4-6 months
Breast milkFormula
Strained smooth food by spoon (6 months)Sitting with minimal support
Lumpy foods by 10-11 monthsDifficult if delayed until 14-16 months
Cup drinking before 12 months
Age of Introduction to Solids
Age (months) Type of Solid
4-6 Smooth puree (SP)
6-9 SP; Textured puree;Easily dissolvable solids
9-12 Soft, mashed, & diced solids
12-18 Toddler diet of chopped table food
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Inadequate growth due to inadequate intakeProlonged time for feedings (but with adequatecalories for growth)Delayed progression of oral feeding skills(textures, variety, etc)Recurrent respiratory disease (question of aspiration from above or below)Complicating factors: behavior, sensory,relationship, social
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Feeding/Swallow EvaluationHistoryPhysical examinationObservation of typical feeding or mealtimeReferral for additional examinations
Instrumental swallow studyMedical/surgical specialistsNutritionPsychology/Social WorkOT/PT
Common Criteria for Referral
Feeding periods longer than 30 to 40 minutesUnexplained food refusal & undernutritionWeight loss or lack of weight gain for 2-3 mthsExcessive gagging or recurrent cough with feedsInfants on nipple feeds
Sucking , swallowing, breathing incoordinationWeak suckBreathing disruptions during feeding
Common Criteria for ReferralAirway related concerns
History of recurrent pneumonia & feeding difficultyConcern for possible aspiration during feedsDiagnosis of disorders associated with dysphagia
Irritability or behavior problems during feedsNew onset of feeding difficultyLethargy or decreased arousal during feeds
Common Criteria for ReferralDrooling persisting beyond age 5 yearsNasopharyngeal backflow/reflux during feedingDelay in feeding developmental milestones
Not spoon feeding by 9 months (dev. age)Not chewing table food or self-feeding fingerfood by 18 monthsNot drinking from a cup by 24 months
Craniofacial anomalies
Steps in Clinical EvaluationConsultation received Initial AssessmentPossible next step depends on airway status
If respiration normal, clinical feedingevaluationIf respiration abnormal, airway evaluation(hold feeds until airway is clear)
Clinical Evaluation: Airway Concerns?If none: Develop plan in context of global needs
Oral sensorimotor interventionNutrition guidelines
Behavioral therapyMonitor status & alter plan as needed
If yes: Instrumental examination or furthermedical workup
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Feeding History FactorsPositions/posture/seating (gross/fine motor)Duration of meal times (average & range)Intervals between meal timesTypes of food (preferred, non-preferred)Assistance/independence of feedingTube feeding (e.g., type, timing)Food record: 2-3 days
Feeding History FactorsRespiratory statusSigns of stress & distressTest results & medicationsSleep patterns (waking, snoring, mouth breathing)Cognition & communicationBehavior during meals; apart from mealsTherapeutic intervention (developmental/feeding)
Nervous System ExamMuscle toneReflexesCognition & languageVisual trackingGross & fine motor skillsSensory function
Infant Evaluation
State & overall posture/positioningRespiratory status (rate, patterns, voice)Resting heart rateExam of oral peripheral mechanismNon-nutritive suckingNutritive suck/swallow/breathe
Clinic Airway Evaluation
Respiratory rate: at rest & feedingRespiratory effort:
StridorStertorRetractions: suprasternal, substernal
Clinic Airway EvaluationVoice quality variables
Strong, clear phonation, appropriate pitchWeak, breathy, husky to hoarse
Gurgly, wetVelopharyngeal function inferences(e.g., hypernasality, hyponasality)
Pharyngonasal penetration/backflow/refluxFrequent burping (not clear implications)
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Joan C. Arvedson, Ph.D. 3/25/2010
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Airway Stability for PO Feeding
Airway stability is prerequisite for successful POIf airway concerns are noted during physicalexam, possible next steps:
Otolaryngology airway exam (FFL, DLB)Bedside/clinical oral feeding evaluationCombined FFL & FEES with ORL & SLPVideofluoroscopic swallow study (VFSS)Monitor status for a few days
Evaluation of Transition Feeder& Older Child
General observationsPosture, alertness, direction followingOral sensorimotor functionBolus formation & oral phase of swallowPharyngeal phase inferencesTherapeutic trials
Postural Control EvaluationMuscle tone (hypotonia or hypertonia)Central alignment relates directly to oralsensorimotor system
Presence of primitive reflexesLevel of physical activitySelf oral stimulation
Use of eye contact, head turning, & touch
Optimal Sitting PostureNeutral head positionNeck elongation (No chin tuck for infants)Symmetrical shoulder girdle stability &depressionPelvis stability, hips symmetrical in neutralHips, knees, & ankles at 90 degreesFeet in neutral with slight dorsiflexion (neverplantar flexed), supported by firm surface
Cranial Nerve Evaluationfor Feeding/Swallowing
Lack of chewing: CN VFacial asymmetry & lack of lip movement:
CN VIIDelayed swallow & pharyngonasalpenetration/backflow/reflux: CN IX & XTongue thrust or atrophy: CN XII
Gag ReflexIndependent of swallowSensory: CN IXMotor output: CN X, XII, & VElicited by touching posterior pharyngealmucosa (standard testing)Difficult to assess importance of changesin absence of other findings
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Tonic Bite Reflex
Jaw moves up into clenched positionon presentation of spoon or other objectResponse to contact to biting surfacesof side gums (molar tables)Persistence with neurologic deficit – should disappear by 9-12 monthsCranial Nerve V
Oral Sensory vs Motor Disorders
Nipple confusion
Not differentiate tastes inbottle even with intact suck
Manages liquids better thansolid foods
Sorts food in mixed texture
Inefficient suck breast & bottle
Differentiates tastesin bottle
Oral-motor inefficiency orincoordinationfor a ll textures
Swallows food whole whengiven mixed textures
Oral Sensory vs Motor Disorders
Holds food under tongue or incheek and avoids swallowing
Vomiting only certain textures
Gags when food approachesor touches lip
Hypersensitive gag withsolids, normal liquid swallow
Unable to hold & manipulatebolus on tongue, food falls out
Vomiting not texture specific
Gags after food movesthrough oral cavity
Gags afte r swallow istriggered with liquid & solid
Oral Sensory vs Motor Disorders
Tolerates own fingers inmouth, but not accept others
Does not mouth toys
Refuses tooth brushing
from Palmer & Heyman, 1993
Tolerates others’ fingers inmouth
Accepts teething toys, but notto bite or maintain in mouth
Accepts tooth brushing
Immature vs Abnormal Patterns
Patterns are likely to be distinguishable insuck-swallow-breathe sequencing
jaw control or stabilitytongue mobilitylip closuredissociation of tongue, jaw, & cheek movementswhile drinking & chewing
Next Steps?Nutrition AnalysisMedical Workup (Genetics, GI, ENT, etc)Behavioral Psychology
Occupational Therapy/Physical TherapyInstrumental Swallowing Study
Need to define oral, pharyngeal, & upperesophageal components for management
Oral Sensorimotor Intervention
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
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Joan C. Arvedson, Ph.D. 3/25/2010
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Criteria for Instrumental Evaluation
Risk for aspiration by history or observationPrior aspiration pneumoniaSuspicion of pharyngeal/laryngeal problemon basis of etiologyGurgly voice qualityNeed to define oral, pharyngeal, & upperesophageal components for management
Patient Considerations
Diagnostic & management needsNature of swallow impairmentPatient’s ability to feed safelyDevelopment of management plan
Ability or readiness to participateMedical stabilityAbility/willingness to cooperateAge, cognitive, & developmental status
Procedural Considerations
Components of swallow process evaluatedPhase(s) of deglutitionAbility to detect aspiration or risksCapacity to define nature of deficitEstimate of agreement: specificprocedure and usual patterns of feeding
Flexible Endoscopic Evaluationof Swallowing (FEES)
No radiationBedside exam possibleDefines some aspects of pharyngealphysiologyCan evaluate handling of secretionsSensory testing can be done
VideofluoroscopicSwallow Study(VFSS)
Defines oral & pharyngeal phasesDefines esophageal transit time, basicmotilityDelineates aspiration related factors
Before, during, or after swallowsTexture specificityEstimate of risk
What VFSS is NOTTo rule out aspiration or determine if childaspirates with oral feeding (important findingbut not reason for exam)
Simulation of a real mealEvaluation of oral skills for bolus formationChewing evaluationEsophageal function (only upper esophagus)
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Joan C. Arvedson, Ph.D. 3/25/2010
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Important Considerationsin High Risk Pediatric Patients
Radiologist must be presentFluoroscopy time minimumWell formulated Q & ACaregivers includedFindings shown to caregiversFindings interpreted & used as part oftotal team approach: maximize safety
VFSS Procedural Considerations
Purpose & questions formulated clearlyPositioning/seating: typical & optimalCooperative patient imperative forinterpretationShortest fluoroscopy time possibleReview in slow motion, frame-by-frame
Feeding Supplies & RecipesReadily available when caregivers areasked to bring food samplesTextures & barium recipes need to bestandardizedData lacking, especially in childrenPoor relationship between viscosity ofdysphagia diet foods & swallow bariumtest feeds of different viscosities(Strowd et al., 2008)
Preparation of PO FeedersHungry, but not starvingSchedule close to feeding time if possibleNormalize the situation as much as possible
Child’s own utensilsVideo/music as needed
GT + PO: same guidelines as for total PO,unless child gets slow, continuous tube feeds
Preparation of Tube Feeder: NPOChild should demonstrate some level of oralintake, at least for therapeutic “taste trials”
NG tube – remove in some instances
Amount per bolus: 2 to 3 ccTotal of 10-15 cc preferred for validity &reliability
Medication schedules maintained, or insome cases, adjustments needed
Child’s “State”Typical feeding status appropriateIncreased risks for aspiration
Lethargy
Agitation (fussing & crying)Cooperative child: interpretation possiblein reliable & valid waysAlways remember: Just a brief windowin time, not a typical meal
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Joan C. Arvedson, Ph.D. 3/25/2010
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Procedural Decisions
No fixed order for presentations in pediatricsPreferable to start with thinnest liquid
Controlled bolus size to start, e.g., spoon beforegoing to bottle or cup drinking
Work toward thicker as neededNot want residue in pharynx that maycomplicate interpretation with thinner later
Exceptions: Parents tell us that child will notaccept any thing else if he gets liquid first
Lateral ViewEncompassing
Lips anteriorSoft palate superiorPosterior pharyngeal wall posteriorFifth to seventh cervical vertebrae inferior,varying with age of child
Simultaneous view of oral, pharyngeal &upper esophagus before food is presented
Antero-Posterior ViewWhen asymmetry is known or suspectedUnilateral vocal fold paralysis or paresisTonsil related questionsOther possibilities?
Keep in mind radiation exposure timeImportance of findings for management
Oral Phase Swallow ProblemsLips (poor closing, drooling, leakage)Hesitation/poolingTongue action deficitsGaggingPoor posterior tongue thrustPassive leakage over tongue baseDelayed oral transit
Initiation of Pharyngeal Swallow
Delayed swallow onset/triggerMaterial in valleculae
Material in pyriform sinusesFailure to initiate/trigger swallow
Pharyngeal Swallow ProblemsPharyngonasal (nasopharyngeal)reflux or regurgitation or backflowPenetration
To underside of epiglottis (superior)To laryngeal vestibule/vocal foldsAspiration
Response to aspirationClearance of airway
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
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Joan C. Arvedson, Ph.D. 3/25/2010
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Pharyngeal Swallow ProblemsPharyngeal contraction reducedPharyngeal motility reducedTongue base retraction reducedPost-swallow residue, e.g.,
ValleculaePyriform sinusesPosterior pharyngeal wall
Clearance of residue?
Esophageal Swallow Findings
Upper esophageal sphincterOpening, e.g., reduced, incoordinated(usually pharyngeal phase problem)Prominence
Bolus passageSlow, interrupted
Retrograde movement of contrast (betterterm than reflux in this instance)
Aspiration Before Swallow: Causes?
Limited tongue actionLimited mandibular movementReduced tongue & soft palate approximationDelayed initiation/onset of pharyngeal swallow
Premature spillageMaterial in valleculae & pyriform sinuses
Pharyngeal dysmotility
Aspiration During Swallow: Causes?
Vocal fold paralysis/paresisReduced laryngeal excursionPharyngeal incoordinationPharyngonasal (nasopharyngeal)penetration, backflow, or reflux
Aspiration During Swallow
Neural controlInitiation under voluntary controlInvoluntary control for completion
AirwayCloses upon initiation of pharyngeal swallowMultiple levels of airway protection common
Aspiration After SwallowReduced tongue base retraction
Residue in valleculaePenetration into laryngeal vestibule
Reduced pharyngeal contraction/motilityResidue in pyriform sinuses
Reduced hyolaryngeal excursionCricopharyngeal dysfunctionPharyngonasal penetration/backflow may occur
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Joan C. Arvedson, Ph.D. 3/25/2010
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Aspiration After SwallowNeural Control
Involuntary for esophageal phaseAirway
OpenPrecipitating factors with open airway
Pharyngeal residue spills overGravity brings material in nasopharynxlower into airway
Esophageal Dysphagia Diagnosis
Dysphagia for solids > liquids,structural cause likely
Dysphagia for solids & liquids similar,dysmotility likely cause
Interpretation of VFSS FindingsSLP reviews with caregivers & therapists orothers involved in care
Findings by phase of swallowTiming of penetration/aspiration related tophysiologic processes
If review reveals a finding not anticipated ornoted during exam, SLP contacts PA orradiologist to discuss or review togetherImportant that reports are not discrepant
Recommendations After VFSSChanges in route of nutrition/hydrationNutrition guidelinesPosition & posture changesAlterations of food textures, temperaturesUtensil changesChanges in feeding schedule & pacingOral sensorimotor program with foodNonnutritive oral sensorimotor program
Management: Prognosis & PriorityOral feeding prognosis tied closely to
Underlying etiology & diagnosisNeurologic findingsCardiopulmonary status
Feeding priorities established on basis ofSeverityCombination of deficits
Principles for Repeat VFSS
Same as for initial VFSSInformation needed for
Definition of etiology or diagnosisGuide for management decisions
NOT some arbitrary time intervalChild should be at baseline
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
http://slidepdf.com/reader/full/ws-7-pediatric-swallowing-and-feeding-complex-making-arvedson 17/21
Joan C. Arvedson, Ph.D. 3/25/2010
16
Infants in Need of Intervention
Prolonged stay in NICUExtensive exposure to negative oral stimulation, e.g.,endotracheal tubes, suction, sticky tapeBefore oral feeding introduction, time is needed
Break oral & perioral aversionOffer exposure to sucking via nonnutritive oralsensorimotor therapy (e.g., pacifier)
Nonnutritive StimulationEnhances oral sensorimotor skilldevelopmentBuilds on in utero experiences of sucking& swallowing
Helps when size & shape of pacifiermatch infant’s mouth
NNS Cochrane Review21 studies (15 randomized controlled trials, allinfants born < 37 weeks gestation)Main Outcome
NNS significantly decreased length of stay (LOS)in preterm infantsNo consistent NNS benefit revealed with respectto other major clinical variables
Positive clinical outcomes: Transition from tube tonipple & better bottle feeding performance
Pinelli & Symington, 2005
Oral Stimulation for Preterm InfantsExp. Group: oral stimulation of oral structures 15 min.once per day for 10 daysControl group: sham oral stimulationStarted 48 hr after d/c of nasal CPAPExp. Group reached independent oral feeding faster(X=11 days, control = 18 days). No difference in lengthof stay.
Fucile, Gisel, & Lau, 2002
Nipple Feeding PrinciplesNon-stressful for infant & feederMost efficient suck:swallow ratio is 1:1Burst of rhythmic suck/swallows followed by cessationof sucking and a breathTotal feeding completed in about 20 min.No increased work of breathing, fatigue, or signs ofrespiratory stress
InterventionsPositioningLimit feeding duration (poor endurance)Nonnutritive oral sensorimotor therapy
Jaw/cheek supportExternal pacing
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
http://slidepdf.com/reader/full/ws-7-pediatric-swallowing-and-feeding-complex-making-arvedson 18/21
Joan C. Arvedson, Ph.D. 3/25/2010
17
Tools for Oral FeedingBottles & nipples
IndividualizeGive infant time to adapt/learn
Thickeners – Be cautious!!!May assist bolus formation, slow flowMay slow gastric emptyingMay increase coughingMay interfere with digestion
Evidence-Based Guideline:Introduce Oral Feeding (McCain 2003)
Requirements for oral feeding (PO)Sustain awake behaviorCoordinate sucking-swallowing-breathingMaintain cardiorespiratory stability for time toingest a caloric volume adequate for growth
Neurologically immature preterm infant <32 wkpost conceptual age (PCA) cannot meet theabove requirements
Behavioral Organization
< 32 weeks: typically not express hard crying ordeep sleep with regular respirationsBy 32 weeks, infant expresses full range ofbehavioral states – important milestone for PO asneed to sustain organized, awake behaviorFrom 32 wks PCA to term age, maturation ofbrain structure is associated with improvement inbehavioral sate expression & motor organization
Self-Regulation ReadinessAt 32 to 35 weeks PCAFeeding based on awake or restless behaviorPO progressing & concluding based on infant’sability to tolerate without fatigue or distressSuccessful feedings: Increase in quiet sleep time& shorter feeding timesAdequate weight gain compared to infants fedprescribed volumes
More opportunities to practice nipple feeding
Demand FeedingBy 35 wks PCAFunctional suck-swallow-breathe pattern allowingfor safe PO is not present until 32-34 wks PCA(Volpe, 2000)Infants 32-36 wks PCA
Suck-to-swallow ratio 3:1 & 4:1 with occasionaldisruption in regular breathingOccasionally exhibit tongue twitching ortremors
Principles of ManagementWhole child approachTotal oral feeding cannot be the goal for allchidlrenNutrition & respiratory status criticalGER managed optimallyChanges in management neededwith gains or regression
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
http://slidepdf.com/reader/full/ws-7-pediatric-swallowing-and-feeding-complex-making-arvedson 19/21
Joan C. Arvedson, Ph.D. 3/25/2010
18
Food RulesScheduling
Meal times < 30 min + planned snacksNothing between meals, except water
EnvironmentNeutral atmosphere - no forced feedingNo game playing; no reward with food
ProceduresSolids first; self-feeding encouragedMeal over if food is thrown in angerClean up only at end of meal
Intervention Based onDevelopmental Skill Levels
Oral stimulation for infantsSpoon feeding & chewing readinessCup drinkingTexture changes
Spoon Feeding LearningUse foods that stick to spoonAvoid foods
Too much liquid (e.g., soups)Slippery (e.g., sliced peaches)Roll off spoon (e.g., peas)
Use spoon with flat bowl
Plastic coated non-breakable
Cup Drinking
About 1-2 months after spoon feeding is wellestablishedOpen cup with thickened liquid (milkshake or fruit“slush”)Cup: wider at top, clear so feeder can control amountper sip wellChild can “help” with handsIndependent: Lip helps reduce spil ls
Chewing Practice
1-2 months after spoon startedGradual changes from smooth pureeOne change at a time (e.g., taste, texture)
Thin strip placed on molar table/surfaceAlternate sides to promote later tongue action
Finger FoodsReadiness
Pick up objects with thumb & fingersBring fingers or objects to mouthBite, chew, & swallow variety of textures
GuidelinesFood in small stripsPlace food in front of child (2-3 pieces)Guide hand to mouth as neededFade help as appropriate
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
http://slidepdf.com/reader/full/ws-7-pediatric-swallowing-and-feeding-complex-making-arvedson 20/21
Joan C. Arvedson, Ph.D. 3/25/2010
19
Common Problem Textures
Thin liquidsDry or lumpy foods
Pureed food between bites of dry foodMulti-textures foods (e.g., vegetable soup)Foods that do not dissolve with saliva
Raw fruits & vegetables
Modifying Textures
Modifier should match flavor of foodFine cracker crumbs in soupApple juice with applesauceMilk with yogurt or pudding
When offering a new texture
Few spoons of familiar texture firstThen new texture (e.g., blendedcarrots, fork mashed)
Oral Sensorimotor Treatmentfor Anatomic Problems - Jaw
Thrust: toneRetraction: toneClenching: toneInstability: toneTonic bite reflex: notrelated to tone
Mouth play: fingers, toysAssisted toothbrushingProne position; Forwardpull under jawMouth play for gradualopeningActivities for jaw closurePressure at TMJ;sensory stimulation;
coated spoon
Oral Sensorimotor Treatmentfor Anatomic Problems - Lips
– Retraction:tone
Limited upper lipmovement: & toneCheeks: toneReduced sensoryawareness
Finger tapping, vibrationVaried textures, tempsTapping & strokingStroke & tap, esp. TMJVaried textures, temps;drop of liquid in cornerof lips
Oral Sensorimotor Treatmentfor Anatomic Problems - Tongue
Thrust: ortone, or respiratory
stress
Jaw stabilization,thickened liquid at
lip, food placed onsides, exercises forlateral tonguemovement, spoonat midtongue withdownward pressure
Oral Sensorimotor Treatmentfor Anatomic Problems - Tongue
Retraction: ortone
Hypotonia: tone
Prone position, tonguestroking back to front,chin tuck for olderchild, upward tappingunder chinVary textures & tastesto sensory input;Food or liquid addedgradually
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8/8/2019 WS 7, Pediatric Swallowing and Feeding - Complex Making, Arvedson
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Joan C. Arvedson, Ph.D. 3/25/2010
Oral Sensorimotor Treatmentfor Anatomic Problems - TongueDeviation
Limited movement
Head at midline;stimulation of lessactive side withfinger, toys,toothbrushVary textures,temps, tastes;Vibration
Oral Sensorimotor Treatment forAnatomic Problems – Soft PalateNasopharyngealreflux
Upright or proneposition; Angledbottle for proneposition; Cheek &tongue functionactivities; Thickenedliquids (if swallow isnormal)
Feeding with Gastrostomy TubeUpright positionPump or gravity delivery, air removedFormula at room temperatureFeeding time minimum or > 20 minOral stimulation during feeding (or prior)Tubing flushed after feedings or meds
Mealtime Behavior ProblemsRefusal of new foods
Introduce one at a timeAvoid power struggles
Refusal of groups of foodsRespect preferencesDo not beg, punish, or bribeSet a good examplePrepare foods in a variety of waysSelect other foods with same nutrients
Mealtime Behavior ProblemsWanting a particular food every day
Probably change with boredom over timeDo not call attention to behaviorParent controls what food is served
Consider food “jag” at snackInclude other foods typically liked
Acting outIgnore undesirable behaviorAttend to & respond to desirable behaviorModel good eating behaviors
Treatment SummaryAirway & nutrition highest prioritiesOral sensorimotor practice can NOT jeopardizenutrition & pulmonary statusForced feeding or prolonged feeding times:
never appropriateGI tract (e.g., GER)
major inhibitor of appetiteaspiration risk
Whole infant/child approach is critical
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