Pediatric Swallowing And Oral Motor/feeding Disorders

Front 1

Anatomy and Physiology

Back 1

Infants aren't miniature adults, Swallowing/feeding problems may reflect problems elsewhere, even subtle disruptions in sensory-motor control can impact feeding, shared pathways exist between the swallow/feeding & respiratory systems

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Most of what infant does during swallowing is related to

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airway maintenance and or airway protection

Front 3

Suck-swallow-breathe synchrony

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structures present by 3.5 weeks, swallow first occurs at 14-17 weeks, coordination of S-S-B BEGINS at 31-33 weeks, stabilizes at 38 weeks, anatomical link between SSB structures is the hyoid bone, 12-18 sucks per burst, then pause, can't learn, it is reflexive

Front 4

Developmental Milestones 0-3 mo

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Chin in contact with rib cage, jaw, tongue, cheeks and lips work as unit, tongue is large and completely fills oral cavity, reflexes - gag, rooting, phasic bite, suck-swallow, some loss of liquid from corner of mouth

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Developmental milestones 0-3 mo (sucking pads)

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Develop last 2 weeks in utero, fatty tissue pads surrounded by inactive cheek muscles

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Developmental Milestones 3-6 mo

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Head control increasing, muscles around face/cheeks develop, sucking pads are gone by 6 mo, everything elongates, neck gets longer, larynx is lower in the throat

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Developmental Milestones 3-6 continued

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Better coordination, munching pattern begins, rooting and suck reflexes fade, decreased loss of liquid at corner of mouth, bilabial closure and tongue tip elevation appear, begins to have "a choice" with foods vs. an automatic response, spoon feeding often introduced

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Developmental milestones 6-9 mo

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Shoulders and neck more stable, head moves independently of trunk, facial expressions are more pronounced, tongue sensitive enough to know it can't mash all foods learn about pressure (raspberries), strong active suck, biting using central incisors, graded jaw movement

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Developmental milestones 6-9 mo

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May see coughing or gagging on new foods, variety of foods in diet by 9 mo, cup drinking, gulping, tongue under cup surrounded by lower lip, Bite and gag reflexes fade, by this point, kids should be putting everything in their mouths

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Developmental Milestones 12-18 months

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Refining movements, quieter cup drinking with 4-5 sips continuously, active lips clean spoon, more controlled biting, rotary chewing begins, spits food, licks lower lip with tongue

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Developmental milestones 24 mo

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Tongue becomes major cleaner inside & outside of mouth, easy lip closure with no liquid loss from cup, controlled sustained bite, better grading of jaw opening to bite varying thickness of foods.

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Swallow vs. oral-motor/feeding

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Can't separate out, overlap, 1 out of every 4 children are thought to have some sort of aversion, aversions can be touch, taste, temperature, textures or smells,

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Clinical Bedside evaluation

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Medical history, milestones, previous evals, history and description of swallowing problem, feeding history, parent, family goal

Front 14

Clinical Bedside Eval - What to try

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Positions, Textures, Adaptive equipment, timing of feeding and meals, trials from both clinician and caregiver

Front 15

Clinical Bedside - What to watch for?

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Is the child considered "at risk", any aversions, oral motor problems? Any pharyngeal "red flags", Any signs of GERD?

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"At risk" children

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Neurological impairment (TBI & CP), Genetic disorders (Pierre Robin Syndrome), Drug/alcohol exposure, GI issues (reflux, fistulas, atresias), Broncho-Pulmonary dysplasia, cardiac deficits (rapid fatigue), Negative oral stimulation (intubation, suctioning), vocal fold paralysis

Front 17

Aversion Problems

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responses - crying, grimace, wiggle, arch away, keep his/her mouth closed, gag, vomit, or tongue glued to roof of mouth, obvious preference or desire for one consistency over another, Any kind of adverse reaction to environmental factors (taste, smell, texture, sight), weight loss or failure to thrive, decreased interest in eating, history of negative oral stimulation

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Pharyngeal "red flags"

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coughing/choking at meals, wet cry or wet voice, facial grimacing, excessive nasal regurgitation, failure to thrive, weight loss, drop in O2 saturation levels, Increase in respiration rate

Front 19

Gastro-Esophageal reflux

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Problem if it affects eating, growing & sleeping, 85% of low birth weight infants have GER, 75% of infants with neuro-musc problems have GER, Higher incidence in those with chronic lung disease, Only 25% show outward signs (spit up), In normal 60-80% free of symptoms by 18 mo, 13q14 chromosome recently discovered to be genetic marker for GERD

Front 20

GER Signs

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Couching/ choking during feeding, chronic hoarseness or cough, re-swallows/dry swallows seen during /after meals, frequent irritable, cranky, moody, sleep problems, frequent respiratory illness, disruptive breathing

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GER Signs Cont

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Increased sensitivity to sensory input, eats small a mouths, eats frequently, frequent wet burps, turns head to left during/after feeding (Sandifer sign) Limited movement patterns, weight gain suboptimal, recurrent aspiration pneumonia, teeth enamel problems or erosion of teeth, frequent ear infections

Front 22

GERD Diagnostic Evaluation

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Before diagnosing GERD, other medical problems or GI issues must be ruled out (milk allergies, esophageal web, hepatitis), history is essential

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Types of evaluations for GERD

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Scintigraphy, upper GI exam and fluoroscopy, 24 hr ph probe monitoring, endoscopy

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GERD management and treatment-Infants

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Parent counseling, formula changes (thickening or hypoallergenic formula), positioning changes (prone position), smaller, more frequent meals, H2 blocker may be tried, never use antacids with infants due to aluminum toxicity

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GERD management & treatment children

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Life style changes (dieting, avoid smoke, don't lie down at least 3 hours following a meal), Positioning (sleep on left side, head of bed elevated), diet restrictions, Mediations (H2 blockers, and PPIs)

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Clinical Bedside eval - What to conclude?

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Etiology?, Strategies? Need for therapy? Need for referrals? Goals?

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Modified Barium Swallow Study - Candidates

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Frequent or recurrent low-grade fevers, increased congestion during feeding, noisy breaths, any signs of fore-mentioned pharyngeal "red flags", frequent upper respiratory infections, neuro-motor involvement affecting SSB, Any structural problems with may cause aspiration

Front 28

Modified Barium Swallow Study - Criteria

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Exhibit an ability to swallow, alertness, ability to consume sufficient intake in a reasonable time, medically stable, not showing significant aversion and will actually eat

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Modified Barium Swallow Study - Family/Staff Prep

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Child shouldn't eat 3-4 hours prior, child should take meds at regular times, assure/inform parents about "x ray", Bring child's favorite utensils, Bring a typical meal

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Modified Barium Swallow Study - What to try?

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repositioning first, texture change, adaptive equipment

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FEES - Pros

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Portable, flexible in regards to positioning, time/length of exam, reduced radiation exposure

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FEES - Cons

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Invasive, aspiration during the swallow can only be inferred, need specialized equipment, increased training

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Treatment - Diet

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Tube feed? Orogastric (og), Nasogastric (ng), Percutaneous endoscopic gastrostomy (PEG), Gastrostomy (G-Tube), Jujunostomy (J-Tube), What texture?

Front 34

Food Texture Progression

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Thickened liquids, thin liquids, strained/ pureed foods, thickened pureed foods, lumpy foods, mashed table foods, chopped solid foods, whole solid/table foods

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Treatment - Techniques/therapy interventions

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If oral - try mouth play, educate family on how to make meals social time, don't force, If swallowing, implement diet changes, educate family on diet progression, "E stim"?, If oral motor - try oral motor program, excercises, different consistencies to help strengthen