Course Handout - Ohio Speech-Language

Transcription

2/17/2015
Pediatric Swallowing: The
Basic Ingredients For
Success
Colleen Vincent MS, CCC‐SLP
Nationwide Children's Hospital [email protected]
Agenda
• Development of swallowing • Anatomical differences between pediatrics and adults
• Common diagnoses for pediatric swallowing concerns
• Bedside Swallow vs. Video Swallow Studies
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES) • Therapy for Swallowing
• Passy Muir Valve for Swallowing
• Swallowing Scales
Swallowing
“Swallowing is one of the most complex functions that
humans carry out with several anatomic areas involved
for voluntary and involuntary components.
Neuromuscular coordination depends on the central
nervous system, brain stem, afferent sensory input,
motor responses and enteric nervous system.” (Arvedson,
2006)
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Prevalence of Dysphagia
• 25-45% in typically developing children
• 33-80% in children with developmental delay
• Dysphagia can lead to:
• aspiration
• pneumonia
• failure to thrive
• malnutrition
Gosa, et al, 2011
Fetal Development
• 9-12 weeks (fetus)
• Completion of facial, oral and pharyngeal structures
• Pharyngeal swallow observed at 10-11 weeks
• 17-20 weeks
• True suckling response with forward/backward
motion of tongue
• 21-25 weeks
• Suckling response continues to mature
Dailey, 2012
Fetal Development
• 26‐29 weeks
• Difficulty breathing air
• Suckle not mature
• 34 weeks
• Some “normal” infants born at 34 weeks can feed well enough to grow
• More rhythmic suck/swallow/breathe
Dailey, 2012
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Fetal Development
• 30‐34 weeks
• Potential for feeding begins
• 38‐42 weeks •
Considered “normal” and should be able to feed well enough to grow
Dailey, 2012
Pediatric Anatomy
• Jaw is small and retracted creating a small oral space
• Tongue fills the oral space and is limited in movement
• Hard palate is short and only slightly arched
• Soft palate and epiglottis are in approximation
• Sucking pads that consist of fatty tissue within the
muscles of the infant’s cheeks provide the infant with
stability in the oral system
• Eustachian tubes lie at the floor of the nasal cavity near
the junction of the hard and soft palates
• Early tongue movement is described as anterior-posterior
Arvedson, 2006
Pediatric Anatomy
• Obligatory nose breathers-the mouth is filled with the
tongue; soft palate and epiglottis are touching making the
flow of air more efficient via the nose
• Epiglottis and soft palate remain in direct contact until
approximately 3-4 months of age providing additional
protection against food randomly falling over the back of
the tongue and in to the airway
• Larynx is high and fully protected when it is elevated
during the swallow
• Hyoid bone is cartilaginous
Evans-Morris & Dunn-Klein, 2000
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Pediatric Anatomy
• Changes over time
• Mouth breathing in addition to nose breathing
• Laryngeal vestibule enlarges
• Anterior excursion of larynx primarily vs. elevation for
adults
• Structures involved in airway protection:
• Epiglottis
• Aryteniod cartilages
• False and true vocal folds
Arvedson, 2006
Pediatric Anatomy
• Larynx lowers in the throat as the neck elongates
• Epiglottis and hyoid also descend
• Airway is less protected – this challenges the
coordination of swallowing and breathing and helps
encourage their reciprocity
• Soft palate distances itself from the tongue and
epiglottis
• Pharyngeal coordination problems that may have been
a problem all along may now be apparent
Arvedson, 2006
Pediatric Anatomy
• Vocal cords have a lower attachment anteriorly
whereas adult VC are attached perpendicular to the
trachea – infants’ VC appear angled
• ** Swallowing initiates in the vallecular space **
• Milk/fluid collects in valleculae during suckling burst
and then is swallowed
• In mature suck/swallow pattern, swallow should be
initiated as soon as the milk reaches the valleculae –
there should be no hesitation or pooling
Ramirez, 2009
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Pediatric Anatomy
• Continued gradual changes in anatomy
• As the child grows, triggering the pharyngeal swallow
occurs further up the tongue
• Initiation moves up from the valleculae to the base of
the tongue
• Liquid can collect at faucial arches or in valleculae
before a pharyngeal swallow is initiated. (Weckmueller,
Easterling & Arvdeson, 2011)
• Gradually reaches the back of the tongue just past
the faucial arches as in adult swallows by the age of
5
Ramirez, 2009
Pediatric Anatomy: 3+ years
• True epiglottic inversion does not emerge until the age
of 3 & becomes more complete & consistent by the age
of 5
• The base of the tongue, the hyoid and the larynx
descend during the first 5 years of life
• Consistent full epiglottic inversion over airway should
be noted by 5 years
• Anatomy & physiology of swallow is the same as for
adults, just on a smaller scale, by 5 years
Ramirez, 2009
Anatomical Differences
Delzell, et al., 1999
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Neuroanatomy
• Recurrent laryngeal nerve (RLN) is primary innervation
of muscles for sphinter closure of upper airway
• Innvervation of laryngeal protective and respiratory
functions are location in brain stem
• Sensory innvervation to supraglottic and glottic areas is
provided by superior laryngeal nerve-which is a branch
of CN 10
Arvedson, 2006
Neuroanatomy
• Unilateral or bilaterial vocal cord paralysis is a factor in
pediatric population following various cardiac surgeries
likely to cause injury to RLN (Khariwala, Lee & Koltai, 2005)
• Most densely innervated area of larynx is the posterior
part of true vocal cords and superior surface of
epiglottis (Sasaki & Isaacson,1988)
Stages of Swallowing
• Oral Preparatory Phase (bolus formation phase)
• Biting, chewing, preparing and organizing bolus
• Oral Phase
• Actively propel bolus to back of the mouth
• Breaking food down to be easily swallowed
• Food collected into a bolus and held until it moves toward pharynx
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• Pharyngeal Phase
• Valving the nasal and laryngeal openings
• Movement of bolus through the pharynx
• Soft palate elevates to close nasal cavity
• Changing pressures and peristalsis transport bolus through pharynx
• Opening of cricopharyngeal segment to allow bolus into esophagus
• Esophogeal Phase
• Movement of bolus through the esophagus and into
stomach
• Coordinated effort of opening and closing of the UES
and LES
• LES should then close to prevent upward movement
of stomach contents
Common Referrals for Swallowing
Evaluations
• Apnea, bradycardia with feeds
• Coughing, choking with feeds
• Poor weight gain
• Neurologic diagnoses for infants (CP, syndromes,
stroke)
• Chronic congestion
• Recurrent pneumonia
• Prolonged intubation
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Common Referrals for Swallowing
Evaluations
• Anatomical issues
• TEF (tracheoesophageal fistula)
• Laryngeal cleft
• Vocal cord paralysis/paresis
• Laryngo/tracheomalacia (weak/floppy)
• Neurologic issues
• Acute changes in status-TBI, GBS
Bedside Swallow Evaluation
• Bedside Swallow/Feeding Evaluation
• Can be a change in status or a chronic issue related or
unrelated to admission
• Sometimes challenging to find out premorbid status
• Checking with nursing for NPO status for testing
• Paying close attention to other medical history – are
you concerned that this child is aspirating?
• If concerned for aspiration, can recommend VSS
Oral-Motor/Feeding Evaluation
• Gagging: a regurgitate spasm in the throat, as from
revulsion to a food or smell or in reflexive response to
an introduced object
• Feeding issues associated with a variety of
syndromes/conditions (i.e. craniofacial disorders,
Trach/Vent, etc.)
• Trouble with advancement of diet: transitioning textures
(i.e. changing from smooth purees to chunky purees
to soft foods to table foods, etc.)
• Trouble transitioning from bottle to sip cup
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Oral-Motor/Feeding Evaluation
• Food aversions/behavioral feeding problems
• Oral motor weakness and/or oral motor coordination
issues (i.e. difficulties with oral motor control of bolus)
• Trouble with oral skills during supplemental bottle
feeding
• Patient has never eaten by mouth
Pros/Cons of Bedside Evaluation
• Pros
• Non-invasive
• No radiation
• Can be seen in most ideal feeding position (“like
home”)
• Can evaluate breast feeding infants or with bottle
using breast milk
• Can use more preferable foods/drinks
• Less expensive
• More flexibility (with scheduling, positioning, etc.)
Pros/Cons of Bedside Evaluation
• Cons
• Silent aspiration?
• What if the child sounds congested at rest?
• Have to make your “best guess”
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Video Swallow Study Checklist
• Gagging/choking on solids after foods have been
cleared
from mouth (feeling like foods are stuck
“in throat”)
• Choking/coughing while drinking liquids
• Sudden increase in frequency of
colds/bronchitis/pneumonia/respiratory infections
• Prior history of aspiration/swallow dysfunction
• Significant medical history – Patient with Trach/vent,
craniofacial disorder, TEF, etc. would need a VSS prior
to beginning therapy to determine safety of swallow
Videofluoroscopic Swallow Study
(VSS)
• At NCH, performed with radiologist, SLP and OT
• Performed in fluoroscopy- video x-ray
• Barium presented in various liquid consistencies, purees
and solids
• Barium presented via bottle, cup, spoon, straw, syringe as
appropriate for the child
• Young children sit in supported chair similar to car seat
(Tumbleform)
• Parents are present and may be the “feeder”
• Usually performed in lateral position but child can be
viewed in anterior-posterior position or side lying
Primary goals of VSS
• Delineate physiology & function of swallowing
• Not to determine whether a patient aspirates
• Make modifications during the examination that can
help determine what food & liquid the child can eat &
drink
• Make specific guidelines for meal time effectiveness &
safety, as well as for therapy strategies to meet nutrition
& hydration needs & maintain pulmonary stability
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Pros of VSS
• Pros
• Document swallowing characteristics
• Identification of (silent) aspiration
• Identification of appropriate/safe consistencies
• Identification of risk factors for aspiration
• Asymmetries
• Changes in swallowing patterns over time
• Successful/unsuccessful use of compensatory strategies
Cons of VSS
• Cons
• “snapshot” of swallow
• radiation exposure
• “scary” environment
• Limited data for infants/children re: what is normal?
• Transferring difficult patients
• Traveling from floor for those that need nursing, RT
Infants & VSS
• Strive for assessment in “typical” feeding position
• Semi-reclined, side lying, upright
• Are usually cooperative
• NPO 2 hours before study – make them hungry!
• Use of intermittent fluoro to allow fatigue
• Modifications
• Presentation
• Position
• Viscosity or texture
Arvedson, 2006
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Infants and VSS
• No true bolus formation process for nipple feeding
• Once infants and children advance to spoon feeding &
cup drinking, the bolus formation/oral preparation
phase is more similar to the adult process
• Efficient “normal” infants taking nipple feeds
• 2-7 sucks per swallow is within normal range
• Infants produce a number of suck & swallow
sequences before they pause to take a breath
NIPPLE CONFUSION!!??!!
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Nipple Flow Rate
• Disposable nipples appeared to have more variability in
flow rate measurements between different disposable
units as well as between trials using the same unit
• Several commercially available nipples have slower
flow rates than disposable nipple units
• Commercially available nipples marketed as “slow flow”
have a wide variety of flow rates
• First Years Breast flow appears to have the slowest
flow
Jackman, 2013
Nipple Flow Rate
• Many nipples marketed as “slow flow” demonstrated
double or triple the flow rate of others
• Many disposable nipples appear to have poor
consistency in flow rate from one use to the next
• For high-risk infants needing the slowest flow, consider:
Playtex Ventaire, Similac slow flow, and Dr. Brown
premature
Jackman, 2013
Nipple Flow Rates
Jackman, 2013
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Side Lying
• Reason for using side lying technique is that lying down will hold residual bolus material to the pharyngeal walls instead of allowing it to drop into the airway, which may more readily occur as a result of gravity in an upright position. • Tilting the body to the non-paralyzed side (side lying)
makes it easier for the force of gravity to bring a food
bolus downward and pass through the non-paralyzed
side. (Kagaya, Inamoto, Okada, & et al., 2011)
Side Lying with Infants
Lau, 2013
• Very low birth weight infants were randomized to
being fed in the customary semi-reclined (control),
upright, or side lying position
• The primary outcome was days from start to
independent oral feeding
• Infants fed in the upright and side lying groups
attained independent oral feeding within the same
number of days as control counterparts. There was
no difference in the maturation of their oral feeding
skills.
Side Lying
• Unilateral or bilaterial vocal cord paralysis is a factor in
pediatric population following various cardiac surgeries
likely to case injury to RLN (Khariwala, Lee & Koltai, 2005)
• Right sidelying down-gravity may assist with passive
closure of left vocal cord to midline
• Can improve airway protection for infants who have this
issue
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Breastfeeding & Breast milk
• Must take into consideration with positioning for
swallow studies
• If infant has been solely breastfed, must take into
consideration that they have never attempted feeding
with a nipple and this may alter results
• No artificial nipple duplicates a breast nipple
• Viscosity of breast milk is different from infant formulas
• Breast milk is generally thinner than formula
Arvedson, 2006
Breast milk
• Thickening breast milk
• Breast milk breaks down infant cereal & powdered thickeners
• NCH policy is no artificial thickeners for those under 1 yo
• We discuss results of VSS with physician and they determine appropriate plan for this patient
Breast milk
• Almeida, & et al., 2011
• Determine viscosity of breast milk and infant formula when thickened with starched based thickener
• Infant formula thickened and was significantly thicker after 1 hour
• Human milk had decreased viscosity over time within 20 minutes
• Reduction in viscosity of breast milk is associated with presence of amylase enzyme. Promotes hydrolysis of starch in thickener.
• Importance of concentration of thickener and time that feeds are given after thickening
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Simply Thick
• Thickens breast milk, formulas and other liquids to
nectar and honey consistencies.
• SimplyThick® thickener is NOT intended for use with
preterm or infants under 12 months of age due to risk of
NEC.
• Ingredients
• Water
• Xanthan gum,
• Sodium acid sulfate, and
• Potassium sorbate
www.simplytyhick.com
Gelmix Thickener
• USDA organic thickener for breast milk, formula and other liquids
• Thickens breast milk, formulas and other liquids to nectar and honey consistencies
• Recommended for those with reflux and dysphagia
• Ingredients:
• Organic Tapioca Maltodextrin
• Organic Carob Bean Gum
• Calcium Carbonate
www.gelmix.com
Gelmix
• Side Effects
• Gassiness may occur for first 2 weeks, especially for
those under 3 months of age
• Stools with mild mucous appearance
• Contraindications
• Not for use with infants under 42 weeks gestational
age
• Not for use with infants under 6 lbs
• Very few cases of allergies noted
www.gelmix.com
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Gelmix
• Mixing Instructions
• Gelmix dissolves and thickens best in warm liquids
• Warm desired amount of liquid 100-120 degrees F
• Sprinkle in gelmix and mix well until dissolved
• Wait 5 minutes
www.gelmix.com
NEC
• Necrotizing enterocolitis
• A disease of the bowel (intestine) of newborn infants
• Exact cause is not known
• Usually occurs in infants who are premature and
have low birth weight
• The lining of the bowel cannot function
• The lining of the bowel is necessary for the baby to
absorb food normally
NEC
• “Affects 7% of premature infants with a birth weight
<1500 g”
• Assosciated with significant morbidity and mortality
• Often occurs after initiation of enteral feeds during first
month of life
• Usually involves ileum
Woods, Oliver, Lewis & Yang, 2012
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NEC
• 3 infants in case presentation
• Presented with NEC in 2nd month of life
• Following ingestion of feeds thickened with Simply
Thick
• Area of involvement was colon
• Xantham gum stimulates the gut and triggers
inflammatory process
Woods, Oliver, Lewis & Yang, 2012
Carob Gum and NEC
• Clarke & Robinson, 2004
• Extremely low birth weight infants have a risk of
developing (NEC)
• Report of two infants who developed fatal NEC
• Concern that carob gum may have contributed to
NEC
Children in Transition Feeding Stages
& VSS
• Approximately 6 months to 3 years
• Toddlers may be slightly less cooperative…
• Still important to have them hungry!
• Want to use the feeding method most used at home
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Modifications for Young
Children/Toddlers
• Texture variations
• Consider first item especially when fearing
behavioral concerns – starting with most concerning
consistency vs. starting with something more
successful
• Using items that require chewing – challenging to
mix w/ barium without creating a mixed texture; use
of barium cookies; allow us to see ability to chew and
swallow solid bolus
• Changing Presentation
Modifications for Young
Children/Toddlers
• Posture/position changes
• Important especially for neurologically impaired
• Mimic most common feeding position
• Neck hyperextension
CUP CONFUSION!!??!!
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Changing Presentation – Cup
Choices
• Cups for kids with motoric difficulties
• Nosey cup
• Honey bear cup
• Soft spout– can be used if kids don’t have a good suck,
but instead more of a “munch” to transition to sippy cup
• Valve versus no-valve
• Valve = no spill, slower flow, must suck
• No valve = spills, faster flow, don’t have to suck much
or at all
• Other options: hard/soft spout sippy cup, straw cup (or
regular straw), sports bottle, open cup
Older Children (3 years and up) & VSS
• Protocols & modifications more similar to those used
with adults than with infants & young children
• Posture/positional changes: must consider cognitive
ability of the child/adolescent to be able to follow these
modifications
• Consider therapeutic trials or feeding only in therapy as
a beginning to oral feeding (or with a difficult
consistency)
Pediatric Considerations
• Consecutive swallows/“Chugging”
• Would prefer to be able to evaluate after several
consecutive swallows
• Is there breakdown? Disorganization? Loss of
control of bolus? Residue?
• Neck hyperextension
• Common when kids self-feed w/ bottle or sippy cup
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Aspiration
• Occurs when food travels into the airway instead of into
the esophagus
• Often suspected by observation of apnea during
feeding, coughing, wet voice, throat clearing, or
diagnosis of pneumonia
• Aspiration may be seen on different textures so a child
could be perfectly safe eating purees and solids but
aspirate on thin liquids
• If aspiration is suspected - a VSS or FEES should be
recommended
Silent Aspiration
• Arvedson, 1994
• Study included children with CP, neuromuscular
disabilities.
• Aspiration was observed in 48 (26%) of 186 children,
primarily on liquid before or during swallows.
• Aspiration was trace (less than 10% of a bolus) and
silent in 94%.
Silent Aspiration
• Newmann, et. al, 2001
• More than half of the infants (22 of 43) who were
referred for dysphagia experienced laryngeal
penetration, aspiration, or nasopharyngeal backflow.
• The majority did not demonstrate these issues on
first few swallows, but with additional swallows.
• Eight of the 9 infants in this study did not cough or
clear their airway in response to aspiration (silent
aspiration).
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Silent Aspiration
• Rule out silent aspiration as it is more common in infants
and children
• Predictors of aspiration Include:
• Severity of delay initiation of swallow
• Penetration to vocal cords
• Residuals following swallow
• Increased pharyngeal incoordination overtime
• Important to continue to evaluate or time and with increased
volume
• Want to identify if swallow deteriorates with time and
increased volume
Ramirez, 2009
Cough
• Cough is primary protective function of larynx during
swallowing
• Provide back up protection when primary protection
fails
• Mediated in the brainstem
• Triggered by CN 10 in larynx
• Young infants often do not cough in response to
aspiration, especially in first 1-2 months
Arvedson, 2006
Cough
• “Only 25% of preterm infants and 25-50% of term
infants have a well functioning cough reflex.”
(Loughlin &
Lefton-Greif, 1994)
• “By 1 month, 90% of children have well developed
cough reflex (Holinger & Sanders, 1991)
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Laryngeal Penetration
• Delzell, et al., 1999
• Normal group of 34 patients with no evidence of
swallowing dysfunction
• 97% of normal patients had laryngeal penetration
• None of the patients aspirated
• Isolated laryngeal penetration is normal in infants
and children with no signs of dysphagia
• Freidman & Bolders Frazier, 2000
• Incidence of laryngeal penetration in 125 patients
from 7 days-19 years
• 60% demonstrated laryngeal penetration
• 31% demonstrated deep laryngeal penetration
• 85% of those with deep laryngeal penetration
aspirated
• Strong correlation with deep laryngeal penetration
and aspiration
• Freidman & Bolders Frazier, 2000
• Monitor laryngeal penetration, specifically deep
laryngeal penetration
• Children with deep laryngeal penetration typically
aspirate further into a feeding
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Evaluation of Results
• What can we modify before we must move to a more
restricted diet?
• Must take into account medical dx, pulmonary status,
neurologic status, potential for global developmental
gains
• Results offered to parents immediately following study
– with caveat that, ultimately, decisions regarding
thickening are up to their physician
Evaluation of Results
• No evidence to suggest that trace amounts of
aspiration is a reason to make someone a non oral
feeder
• Also no evidence to suggest how much aspiration of
what liquid or food can be tolerated until patient begins
to have chronic problems
• Diagnoses, medical status, pulmonary status,
neurological status must all be considered
• Limited data for young children
Arvedson, 2006
Fiberoptic Endoscopic Evaluation of
Swallow
• Fiberoptic scope is passed through nose to view laryngeal
area
• Performed with Otolaryngologist and SLP at NCH
• Food is colored with dye (usually green) and given to child
• Variety of liquid and consistencies can be given
• Parents can hold child or assist with giving foods
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FEES
Indications for FEES
• Transportation to Radiology is risky: medically fragile
• Positioning is problematic
• Neck halo, skull flap, drain, obese
• Concern about radiation
• Does not take up nursing/RT times
• Fluoroscopy not available
• Transportation is problematic: costly/stressful
Langmore, 2013
Indications for FEES: Clinical
Reasons
• Want to visualize larynx
• Voice suggests laryngeal involvement
• Anatomical changes: laryngeal trauma
• Post‐intubation
• Post‐surgery ‐‐ neurologic damage
• Visualize VP competence
Langmore, 2013
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Pros of FEES
• Pros
• No radiation exposure
• Easily repeated under a variety of clinical settings
• Real food and liquid are used
• Portable equipment
• No need for barium
• Can evaluate kids when they are too big for VSS
chair (>250 lbs)
Langmore, 2013
Cons of FEES
• Cons
• Need cooperation of child
• Limited view during actual swallow due to white
out, especially for infants
• Invasive
• May tells us that aspiration has occurred but may
not tell us why
Langmore, 2013
Referrals
• ENT
• Pulmonary or GI
• Psychology
• Interdisciplinary Feeding Clinic – for a child with needs
from multiple disciplines (developmental pediatrician,
dietician, SLP, OT, Psychology)
• Speech or OT for feeding therapy
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Therapy for Swallowing
• Difficult due to ages/cognitive abilities of the population
• Primary focus on modifications to diet, manner of
feeding (position, changing nipples/cups, safe feeding
techniques)
• May have a few sessions to be sure families are
comfortable with recommendations
• Can provide therapy for patients who have more oralbased issues
Therapy for Swallowing
• For older kids, therapy is similar to that for adults
• Compensatory strategies
• Swallowing exercises
• Thickening
• Thermal stim
• Vital Stim
Compensatory Strategies
• Chin Tuck
• Delay in triggering swallow, reduced BOT retraction
• Side lying
• Reduced pharyngeal contraction, vocal cord paresis
• Head turn
• Unilateral pharyngeal paresis/residue on one side of
pharynx
• Dry Swallows
• Decreased pharyngeal constriction/residue
• Alternating liquids/solids
• Decreased pharyngeal constriction/residue
Logemann, 1998
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Vital Stim
• Use is very controversial
• Limited data to support use in pediatric population
• We are not currently providing this at NCH
Vital Stim
Christiaanse,et al, 2011
Neuromuscular Electrical Stimulation is No More Effective
Than Usual Care for the Treatment of Primary Dysphagia in
Children
• Retrospective analysis of change in Functional Oral Intake
Scale (FOIS) level derived from videofluoroscopic
swallowing studies performed before and after NME
• Conclusion: NMES treatment of anterior neck muscles in
a heterogeneous group of pediatric patients with
dysphagia did not improve the swallow function more than
that seen in patients who
did not receive NMES
treatment.
Thickening with Cereal
Children Under 12 months with Formula
• Nectar Thick
• 1.5 tsp of dry infant/baby cereal (for EACH ounce of formula)
Examples of the recipe
4 ounce bottle = 6 teaspoons
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Thickening with Cereal
• Honey Thick
• 2.5 teaspoons of dry infant/baby cereal for EACH ounce of formula Examples of the recipe
Thickening Products for 1 and over
Thik & Clear
Nutra Balance
www.nutra-balanceproducts.com/nutrabalance_products_thickclear.php
Simply Thick
www.simplythick.com
Thick-It
www.thickitretail.com/wheretobuy.aspx
Thickening Products for 3 and Over
Thicken‐Up and Thicken‐Up Clear
TAD Enterprises
www..tadenterprises.com
Nestle Nutrition
www.nestlenutrition.com/departments/therapeutic‐nutrition/swallowing‐
difficulties/resource‐thickenup‐instant‐food‐thickener
Walgreens
www.walgreens.com
Thick & Easy
www.homecarenutrition.com
Thick & Easy Instant Food Thickener
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Natural Thickeners
• Adding milk to yogurt or pudding
• Mixing juice with baby food or blended fruits
• Mix flavored or non-flavored gelatin with juice in a
blender
• Add bread crumbs, potato flakes, crushed crackers, or
pureed meats to stews and soups
• Cornstarch
• Arrowroot
Thin Liquids
• Popsicles
• Ice cream
• Jello
• Milkshakes
• Broth based soups (cream based-ok)
• Liquid medications
Coverage for Thickeners
• Private insurance will not cover thickener
• BCMH will cover thickener
• If patients have BCMH, a script should be provided
• Families can take script to a BCMH accepting pharmacy
(CVS, Walgreens, mail) and get the script filled at the
pharmacy
• Or, the care coordinator can fax the script and the video
swallow study to a BCMH dietitian to expedite the process
• If they do not have BCMH, they need to try to apply and
attach the video swallow study to the application
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Purpose of Tracheostomy
• To relieve upper airway obstruction
• Foreign body or trauma
• Edema
• Structural abnormality
• Improve Respiratory function
• Need for long term ventilation/intubation
• Respiratory Paralysis
• Unconscious head injury
• Vocal cord paralysis
• Paralysis of diaphragm
Trachs and Swallowing
• Swallowing issues with trachs
• Decreased subglottic pressure
• Reduced sensation
• Reduced sense of smell and taste
• Tethering of larynx
• Cuffed trachs do not prevent aspiration
• Once material has reached the level of the cuff it has passed through vocal cords‐aspiration
• Patients can eat with trachs/vents
What is a Passy Muir Valve?
• Valve that is worn at the end of the trach
• On inhalation, the PMV opens and lets air enter the
trach and lungs.
• On exhalation, the PMV closes and forces air up
through the vocal cords and out of your mouth.
• Fits on all size/types of trachs
• Can also be used with patients on ventilators.
http://passy‐muir.com/home
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2/17/2015
Benefits of Passy Muir Valve
• Restores communication
• Supports speech/language development
• Improves swallowing, may reduce aspiration
• Improves quality of life
• Improves sense of smell and taste
• Helps with management of secretions
• Improves infection control
• Helps with weaning from ventilator and decannulation
• If patient has one, we use during VSS. http://passy‐muir.com/home
FOIS
Functional Oral Intake Scale
• TUBE DEPENDENT (levels 1‐3)
• 1 No oral intake
• 2 Tube dependent with minimal/inconsistent oral intake
• 3 Tube supplements with consistent oral intake
• TOTAL ORAL INTAKE (levels 4‐7)
• 4 Total oral intake of a single consistency
Crary, 2005
FOIS
• 5 Total oral intake of multiple consistencies requiring
special preparation
• 6 Total oral intake with no special preparation, but must
avoid specific foods or liquid items
• 7 Total oral intake with no restrictions
Crary, 2005
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ASHA NOMS
• Level 1: Not able to eat anything by mouth.
• Level 2: Nutrition and hydration met by non-oral means.
Child may take textures orally in therapy.
• Level 3: Some non oral-feeding, plus oral feeding with
consistent maximal assistance.
• Level 4: Swallow is safe for pureed, moderate
assistance; may need oral nutritional supplements, no
tube feedings.
ASHA, 2011
ASHA NOMS
• Level 5: Swallow is safe with modified/chopped table
food, minimal assistance. Total oral feedings.
• Level 6: Swallow is safe with typical table foods,
occasional minimal assistance. Child may avoid
specific food items or may need additional time.
• Level 7: Swallow is safe and efficient for all
consistencies. Rarely needs monitoring more than
expected for age matched peers.
ASHA, 2011
References
• Almeida, M., Almeida, J., Moreira, M., & Novak, F. (2011). Adequacy of human milk
viscosity to respond to infants with dysphagia: experimental study. Journal of Applied
Oral Science, 19 (6), 554-9.
• American Speech-Language-Hearing Association. (2011). National Outcomes
Measurement System: Pre-Kindergarten National Data Report 2011.
Rockville,MD:National Center for Evidence-Based Practice in Communication
Disorders.
• Arvedson, J. (2006) Interpretation of videofluoroscopic swallow studies of infants and
children. Gaylord, MI: Northern Speech Services.
• Arvedson, J., Rogers, B., Buck, G. , Smart, P., & Msall, M. (1994). Silent aspiration
prominent in children with dysphagia. International Journal of Pediatric
Otorhinolaryngology, 28, 173-181.
33
2/17/2015
References
• Christiaanse, M., Mabe, B., Russell, G., Long Simeone, T., Fortunato, J., &
Rubin,B. (2011) Neuromuscular electrical stimulation is no more effective than
usual care for the treatment of primary dysphagia in children. Pediatric
Pulmonology, 46, 559–565.
• Cichero, J., Nicholson, T., & September, C. (2013). Thickened milk for the
management of feeding and swallowing issues in infants: A call for interdisciplinary
professional guidelines. Journal of Human Lactation, 29 (2), 132–135.
• Clarke, P., & Robinson, M. (2004) Thickening of milk feeds may cause necrotising
entercolitis. Archives of Disease in Childhood: Fetal and Neonatal, 89, F280.
• Crary, MA, Carnaby-Mann, GD & Groher, ME. (2005). Initial psychometric
assessment of a functional oral intake scale for dysphagia in stroke patients.
Archives of Physical Medicine and Rehabiltation, 86, 1516-1520.
• Dailey, S. (October 2012) Management of feeding and swallowing disorders in
infants with cleft palate and craniofacial anomalies. Nationwide Children’s Hospital.
Columbus, OH.
• Delzell, P., Kraus, R., Gaisie, G., & Lerner, G. (1999) Laryngeal penetration: a
predictor of aspiration in infants? Pediatric Radiology, 29, 762-765.
References
• Evans-Morris, S., & Dunn-Klein, M. (2000). Pre-feeding skills: A comprehensive
resource for mealtime development. (2nd ed). Austin, TX: PRO-ED, Inc.
• Freidman, B., & Bolders Frazier, J. (2000). Deep laryngeal penetration as a
predictor of aspiration. Dysphagia, 15, 153-158.
• Gosa, M., Schooling, T., & Coleman, J. (2011) Thickened liquids as a treatment for
children with dysphagia and associated adverse effects: A systematic review. Infant,
Child & Adolescent Nutrition, 3 (6), 344-350.
• Hollinger, L., & Sanders, A. (1991). Chronic cough in infants and children: An
update. Laryngoscope, 101, 596-605.
• Jackman, K. T. (2013). Go with the flow: Choosing a feeding system for infants in
the neonatal intensive care unit and beyond based on flow performance. Newborn
& Infant Nursing Reviews, 13, 31–34.
• Kagaya, H., Inamoto, Y., Okada, S., & Saitoh, E. (2011). Body positions and
functional training to reduce aspiration in patients with dysphagia. Japan Medical
Association Journal. 54(1), 35–38.
References
• Khariwala, S.S., Lee, W. T., & Koltai, P. J. (2005). Laryngotracheal consequences of
pediatric cardiac surgery. Archives of Otolaryngology: Head and Neck Surgery, 131
(4), 336-339
• Langmore, Susan. (May 2013) FEES: A procedure for evaluating oropharyngeal
dysphagia. Boston, MA.
• Lau, C. (2013). Is there an advantage for preterm infants to feed orally in an upright
or sidelying position? Journal of Neonatal Nursing, 19, 28-32.
• Logemann, J. (1998). Evaluation and Treatment of Swallowing Disorders. (2nd ed.).
Austin, TX: Pro-Ed, Inc.
• Loughlin, G. M., & Lefton-Greif, M. A. (1994). Dysfunctional swallowing and
respiratory disease in children. Advances in Pediatrics, 41, 135-161.
• Newmann, L., Keckley, C., Peterson, M., & Hammer, A. (2001) Swallowing function
and medical diagnoses in infants suspected of dysphagia. Pediatrics, 108 (6) 1-4.
• Newmann, L. (2001). Optimal care patterns in pediatric patients with dysphagia.
Seminars in Speech Language, 21, 281-291.
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References
• Prasse, J., & Kikano, G. (2009) An overview of pediatric dysphagia. Clinical
Pediatrics, 48, 247-251.
• Ramirez, Kathy. (2009) MBS: The clear picture (online course)
• Sasaki, C. T., & Isaacson, G. (1998). Functional anatomy of the larynx.
Otolaryngology Clinics of North America, 21, 196-199.
• Weckmueller, J., Easterling, C., & Arvedson, J. (2011) Preliminary temporal
measurement analysis of normal oropharyngeal swallowing in infants and young
children. Dysphagia, 26, 135-143.
• Van der Burg, J., Didden, R., Jongerius, P., & Rotteveel, J. (2007). Behavioral
treatment of drooling a methodological critique of the literature with clinical
guidelines and suggestions for future research. Behavior Modification, 31 (5) 573594.
• Woods, C.W., Oliver, T., Lewis, K., & Yang, Q. (2012). Development of necrotizing
enterocolitis in premature infants receiving thickened feeds using SimplyThick.
Journal of Perinatology, 32, 150-152.
Contact
Please feel free to contact me with any questions or
comments
Colleen Vincent
[email protected]
614-722-8688
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Pediatric
Feeding: The
Basic Ingredients
for Success
Caitlin Sirois MS, CCC-SLP
Nationwide Children’s Hospital
[email protected]
Agenda
•
•
•
•
•
•
•
•
•
•
Oral motor development
Feeding skill sequence and food progression
Clinical feeding assessment
Factors that limit feeding development
Components of feeding
Oral motor components of feeding and therapy techniques
Sensory based difficulties and therapy techniques
Behavioral difficulties and treatment
Feeding difficulties in cleft lip/palate specific diagnoses
Tube feedings and oral stimulation
Oral motor Development
Newborn Oral Motor Reflexes
All oral and pharyngeal reflexes serve a purpose for baby’s survival.
• Rooting reflex
• Phasic bite reflex
• Suck-swallow reflex
• Suckle reflex
• Suckle-swallow reflex
• Cough – airway is protected from foreign objects
• Gag reflex is on the front third of tongue – reflex is a protective pattern
• Tongue is cupped to provide channel for liquids to move backward
• Fatty sucking pads, lips, tongue, palate all function together.
(Overland, 2010; Morris & Klein,
2000)
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Oral Motor Skills 0-3 Months
1 Month:
• Reclined (45 degrees or less), sidelying, supine with head slightly elevated or prone
position
• Suckling or sucking pattern used with breast/bottle.
– Tongue may protrude through lips (due to extension/retraction movement - suckle/swallow)
– Some liquid loss normal
3 Months:
• Supported semi-slightly reclined position (45-90 degrees)
• Primitive suckle-swallow response used for posterior bolus propulsion
– Liquid may be pushed out of mouth due to tongue extension/retraction movement
(Morris & Klein, 2000)
Oral Motor Skills 4-6 months
• Semi-reclined position
• Rooting reflex decreases between 3-6 months
• Biting:
– Phasic (bite-and-release) pattern is used (regular rhythm and stereotypic). Occurs reflexively (when food
touches teeth or gums) and decreases by 5 months of age.
– Phasic bite is also main pattern in chewing. May see some rotary movements if food is placed on the gum
surfaces, may see transfer to midline.
– Controlled, sustained bite not yet present, may suck solids instead
• Chewing:
– Munch chew pattern is active between 5-6 months (intermittent, non-stereotypic vertical movements of jaw)
• Breast/Bottle:
– Decreased coordination of suckle, swallow breath as sucking becomes more active
• Continues to use suckle in anticipation of spoon/solid and to swallow food/liquids
– As suckle becomes more active, you see decreased coordination of suckle, swallow, breathe
• Upper lip is not used for bolus removal.
• Gag reflex is moving back within mouth/slightly less sensitive
(Overland, 2010; Morris & Klein,
2000; Meyer, 2007)
• Breast/bottle:
– No liquid loss during sucking, however may see some when nipple is removed or when beginning/ending the
suck
– Long sequences of suck, swallow and breathe noted.
• Cup drinking:
– suckle or sucking pattern may be used (or a combination of the two), with extension/retraction tongue
movements as cup is offered/removed and during drinking. Liquid loss and wide jaw excursions are typical
– Less coordinated suck/swallow/breathe noted (vs breast/bottle).
• Jaw:
– remains stable in open position upon acceptance of spoon, less suckling (extension of tongue) with spoon
• Chewing:
– Vertical chewing pattern is more variable and less stereotypic/automatic.
– Diagonal/rotary movement noted when chewing foods placed on gum/molar surfaces
• Tongue:
– Right/left tongue lateralization emerging when solids placed to gum/molar surfaces
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• Begin more upright position (90 degrees) with external support for sitting at 7 months
and no external support needed by 9 months
• Tongue and Lips:
– Lateral tongue reflex resolves (6-8 month), becomes active with more lateralization when food is placed on
gum/molar surfaces.
– Beginning of active transfer of food from midline to side, side to midline
– Active lip movements: upper lip moves downward and forward to rest on spoon and remove food
• Suckling and sucking patterns still noted when bottle/breast feeding with tongue
protrusion to facilitate a swallow
• Cup drinking
– jaw is still unstable, may still have difficulty coordinating suck/swallow/breathe
• Chewing:
– Can bite and hold solids, needs assistance to break off pieces
– Vertical chewing (non-stereotypic in rhythm) present with diagonal/rotary chewing pattern for moving food to
sides, occasionally see phasic bite and release pattern
• Gag is on back third of tongue
• Teething begins between 5-9 months
(Meyer, 2007; Morris & Klein, 2000;
Overland, 2010)
• Lips:
– Improved lip closure for swallowing liquids
– Upper lip moves forward, down and inward to remove bolus from a spoon, while lower lip
moves inward as spoon is removed
• Cup drinking:
– Improved coordination
– Tongue may protrude to provide extra support/stability
•
Chewing:
•
•
Food or saliva loss may occur while chewing
Controlled and sustained bite with soft solids, may have phasic bite or sucking with hard
solids due to not able to sustain powerful bite
Diagonal then rotary chew pattern develops
•
• Tongue:
– Transfer of food from midline to side and side to center of mouth
– Gag moves back (toward pharyngeal wall)
(Overland, 2010 ; Morris & Klein, 2000)
•
Emerging dissociation of jaw, lips, tongue
•
Jaw:
•
Lip closure:
–
–
Stability for biting increases
Phasic bite reflex is integrated by 15 months, no longer present
–
Diagonal rotary chewing, movements are well coordinated
–
•
–
–
•
Some lip closure may start to be seen with chewing
Cup drinking/Spoon feeding:
During cup drinking, can maintain a continuous suck
Uses sucking pattern or combination of sucking and suckling for spoon feeding
Well coordinated suck/swallow/breathe pattern (by 15 months)
(Overland, 2010)
(Morris & Klein, 2000; Overland, 2010)
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• Jaw, lips, tongue move with increased separation/ smoother integration
• Lips:
– Good control of liquid with upper lip closed on cup edge for better seal
• Jaw:
– Controlled bite with possible slight head extension (backward) to assist with bite
– Can intermittently chew with lips closed, minimal to no liquid/food loss may occur while
chewing
– Some internal jaw stability, however for cup drinking external jaw stability obtained by biting
on edge of cup
• Tongue:
– Tongue-tip elevation used for swallowing (reduced tongue protrusion with swallowing)
• Uses tongue to clean lips
• Can straw drink with long sucking sequences
• Lips:
– Lip closure noted with chewing
• Jaw:
– Internal jaw stabilization emerging by 24 months
– Controlled bite without associated head movement (24 months)
– Diagonal rotary chewing pattern
• Cup drinking:
– Uses up-down sucking pattern; no liquid loss from cup (24 months)
• Tongue:
– Tongue tip elevation and tongue retraction used for swallowing and tongue moves
independently of jaw
– Right/left tongue lateralization of food without pausing at midline (center to side, side to center,
side to side across midline) (24 months)
• Should be able to eat any texture; chews meat completely
• Jaw:
– Appropriate jaw grading for biting and chewing foods of varying thickness
– Circular rotary chew pattern when transferring food
– Active sucking and internal jaw stabilization without biting the edge of cup (for cup drinking)
• Gradual refinement of tongue movements
– Tongue used in free, sweeping motion to clean food from lips
– Tongue elevation and depression are independent of jaw movement
– Tongue tip elevation used consistently for swallowing
• Mature swallow pattern with no loss of food/saliva
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Feeding skill sequence
• Transitioning from nipple to spoon to solid
– Positioning: move from semi‐reclined to upright
– Mouth opens from ungraded to graded movement (usually accurate by 2 years of age)
– Sucking to stripping spoon
– Bolus transport moves from inefficient to efficient
– Adding self‐feeding disrupts the original skill, so you have to make the task easier. • For example, if the child is chewing, you may want to offer mashed foods when targeting self‐feeding and then offer soft solid foods as the feeder to target chewing skills
Sheppard, 2012
Food progression
• Purees sequence
– Smooth (Stage 1 and Stage 2 baby foods)
– Grainy (cooked oatmeal)
– Ground (finely grain, even textured)
– Mashed (pieces about size of grain of rice, even consistency) • Chewing sequence
– Hard foods for oral exploration (stale licorice, SlimJims, biter biscuits)
– Puffs/”meltables” (brand name yogurt melts/ puffs, graham crackers, hulless
popcorn, Towne crackers, etc)
– Soft pieces (cooked vegetables, soft fruits/banana)
– One soft texture and then mixed soft foods (pasta, scrambled eggs moving to macaroni and cheese, french fries, chicken nuggets)
– Hard and fibrous foods (cookies, chips, hamburger, etc)
Sheppard, 2012
Referral for Clinical Feeding Assessment
• Typical Criteria for Referral:
• Failure to thrive (weight loss or lack of weight gain)
• Weak suck
• Suck-swallow-breathe incoordination
• Diagnosis associated with dysphagia
• Coughing/gagging during feeds
• Behavioral problems or irritability
• Pneumonia or concerns for aspiration
• Feedings taking more than 30 minutes
• Unexplained food refusal
• Vomiting with feeding
• Regression/change in medical status
• Breathing problems during feeding
• Delay in feeding milestones
(Arvedson & Brodsky, 2002)
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Why A Clinical Feeding Assessment?
• Clinical evaluation enables therapist to:
– Identify possible etiologies underlying the dysphagia
– Hypothesize the nature and severity of dysphagia
– Establish a baseline of patient’s skills
– Introduce therapeutic techniques/modifications
– Investigate safe feeding options for the child while being sensitive to family/cultural differences
– Determine if instrumental assessment is warranted; identify appropriate instrumental assessments
– Develop and execute your plan
Components of a Clinical Feeding Assessment
• Family and social history
• Prenatal/ birth history
• Medical and developmental history
• Medical Status
• Medical interventions
• Feeding history
• Physical exam: Oral-motor structures/function, sensory or motor-based
problems, postural control
• Feeding observation
Clinical Feeding Assessment:
Feeding History
• Feeding History
– Can differ among reporters because perceptions about child’s skills/abilities may vary
– Children often exhibit different feeding behaviors for different feeders, and different behaviors in different environments
– Caregivers’ descriptions of feeding behaviors are accurate from their perspective, but there may be inconsistent reports from one feeder/caregiver to another. – Important to gather information from multiple formats including a printed questionnaire that can be sent home prior to the evaluation, and an interview during the evaluation (to gather most comprehensive history)
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Clinical Feeding Assessment:
Feeding History (continued)
• Feeding history should include the following factors:
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Position for feeding/seating
Duration of feeding and how long in between feedings
Tube feeding
Breast or bottle feeding (type of nipple/bottle)
Types of foods (textures), consistencies (thickened liquids?)
Self-feeding/utensils used
Respiratory status (noisy breathing, coughing, choking, vocal quality, asthma, etc)
Other signs of distress (food refusal, fussy during feeds, falling asleep, arching, etc)
Tests (upper GI, VSS, surgeries, medications, etc)
Food diary
Sleep patterns
Cognitive and communication status
Behavior during meals
History of interventions
Clinical Assessment:
Physical Exam
• Must include attention to patient’s:
– Level of alertness
– Positioning
– Respiratory status
– Cognitive level of functioning
– Communication abilities
– Oral-motor and sensory skills
• Feeding difficulties may stem from broader deficits in central nervous system
or peripheral nervous system
• Feeding difficulties can also be influenced by respiratory and GI issues
• Assessment of feeding difficulties involves continuously evaluating a patient
to determine the nature of the problem in order to come up with the most
effective treatment.
• Must interpreter child’s cues for feeding readiness and rely on
parents/caregivers
(Arvedson & Brodsky, 2002),
Clinical Assessment:
Feeding Observation
• Naturalistic and Elicited Feeding observations
• Position
• Foods presented
•
•
Developmentally appropriate for child’s skill level?
Tools/utensils used
•
Response of feeder •
Response of child to feeder •
Signs of distress
•
•
•
•
How does parent/primary feeder respond during feeding (body language, attitude, etc)
Primary feeder and child mealtime communication and interactions
Avoidance or resistance to particular foods/ etc
Behavior
(Arvedson, 2008)
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Assessment Tools/ Scales
The Neonatal Oral-Motor Assessment Scale (NOMAS)
Revised Version of the NOMAS
The Holistic Feeding Observation Form
SOMA: Schedule for Oral Motor Assessment
The Multidisciplinary Feeding Profile (MFP)
Oral-Motor/Feeding Rating Scale
The Patient Profile for Swallowing and Feeding Function (The PPSFF)
Beckman Oral Motor Assessment
(Arvedson & Brodsky, 2002; Sheppard, 2012)
Feeding: A Team Approach
• It is important to consider the whole child when evaluating
their feeding skills. We often refer to other disciplines,
and a child’s multidisciplinary team may include:
• Physician, Gastroenterology, Clinical Nutrition, Psychology,
Otolaryngology, Nursing, OT and/or PT.
• We may also make referrals to Craniofacial team clinic, Dentistry,
Lactation.
(Fraker & Walbert, 2003)
Interdisciplinary Feeding Clinic
at Nationwide Children’s Hospital
• Outpatient service for children with feeding difficulties requiring the services of three or more disciplines.
• Depending on your patient’s needs, they have appropriate specialists available at the appointment.
• Our team consists of a variety of specialists including Pediatrics, Developmental Pediatrics, Psychology, Nursing, Clinical Nutrition, Occupational Therapy, and Speech Therapy. • This team provide a comprehensive assessment of children with feeding difficulties/ issues. The team assesses the child at one appointment and conferences together throughout your appointment time to collaborate on what they find.
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Interdisciplinary Feeding Clinic
• Every Thursday in Dublin Medical Office Building • Appointments are 1 ½ hours long
• All disciplines see the family and patient together.
• Family is asked to bring preferred and non-preferred
foods
• At the conclusion of clinic, the family will receive a
summary of findings and recommendations from all
disciplines
• Medical and limited behavioral follow-up
• Referrals: Please fax the Medical Specialty Clinic Patient Referral Form and fax to Nationwide Children’s Hospital Dublin Close To Home SM Center, Attention: IFC. Fax: (614) 355‐8410. Or call the office at (614) 355‐8400 Intensive Outpatient Interdisiplinary
Feeding Program at Nationwide Children’s
Hospital
• All patients initially seen through Interdisciplinary Feeding Clinic in Dublin
• Interdisciplinary with developmental pediatrician, feeding therapist, psychology, and dietitian • Family completes 3 meals per day, 5 days per week, for 6‐8 weeks
• See school teacher and other disciplines between meals
• All meals completed by psychology or feeding therapist and collaborate daily in treatment planning
• Family meeting 1 day per week
• Monitor weight twice per week
Who Attends the Intensive Program?
• Stalled progress in traditional outpatient therapies
• Fast need for treatment progress (e.g., prevent g tube
removal)
• Primary reasons for treatment to date (n=10)
• Decrease G tube dependence by increasing volume- 4
• Prevent G tube by increasing volume- 2
• Increasing variety of food/textures, pocketing, chewing skills- 4
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Factors that Limit Feeding Development
• Major functional issue is not whether the patterns are
“normal” but rather whether it limits further acquisition or
refinement of skills required for mealtime success
• Limiting factors may be influenced by all aspects of the
feeding environment in which they occur.
Structural Limitations
• Oral-facial:
• Cleft palate/cleft lip
• Micrognathia
• Macroglossia
• Gastrointestinal:
•
•
•
•
•
•
Pyloric stenosis
Esophageal stricture-narrowing of the esophagus
Esophageal atresia- esophagus with a blind pouch
Tracheoesophageal fistula- fistula between the trachea and the esophagus
Esophageal atresia
Short bowel syndrome
• Respiratory/Cardiac:
• Tracheomalacia/ laryngomalacia- trachea or walls of larynx lack adequate “tone”
• Pulmonary atresia/ pulmonary stenosis
• Holes in heart (i.e. Tetrology of Fallot) or underdeveloped heart (i.e. hypoplastic left
heart
Physiological Limitations
• Oral-pharyngeal:
• Aspiration
• Gastrointestinal
• Gastroesophageal reflux
• Esophagitis
• Esophageal dismotility
• Stomach dismotility
• Delayed gastric emptying
• Constipation
• Diarrhea
• Respiratory/Cardiac
• Bronchopulmonary dysplasia
• Hypotonia/Hypertonia
• Scoliosis or kyphosis
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Other Experiential Limitations
• Physical and Sensory Experiences:
• Respiratory distress
• Sensory modulation/ sensory defensiveness
• Gastrointestinal discomfort
• Allergies
• Orogastric/ nasogastric tubes
• Emotional Experiences:
• Physical or sexual abuse
• Fear or control issues
• Mealtime Experiences:
• Force-feeding
• Differences between parent and child expectations
• Disagreements about the feeder/child mealtime relationship
• Environment
Development of Feeding
• In designing and implementing effective treatment, several questions need to
be addressed:
• 1. “What pre-feeding and feeding skills does the child already have?”
• 2. “What sensorimotor difficulties are interfering with a continued progression
toward competent and efficient feeding skills?”
• 3. “What specific feeding areas is this child ready to work on, and what is the best
progression or sequence for teaching these skills?”
• Look at oral motor and feeding skills in the context of the whole body. The
mouth can be influenced by developmental issues and patterns throughout
the body.
• With stability comes mobility.
• Oral stability is dependent upon stable head/neck/shoulders, which are dependent
upon a stable trunk and pelvis.
Components of Feeding
• Oral Motor
• Sensory
• Behavior
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Oral-motor vs Sensory issues
• Oral-motor issues
•
•
•
•
•
•
•
•
Inefficient suck
Swallowing foods whole
Anterior bolus loss
Difficulty with bolus manipulation on tongue
Incoordination of oral motor skills
Gag with food and liquid AFTER food reaches tongue base, after swallow initiation
Mouths objects and tolerates toothbrushing
Vomiting is not texture specific
• Sensory issues
•
•
•
•
•
Nipple confusion
Vomiting is texture specific
Gag with food BEFORE it touches or AS it touches lips
Does not tolerate toothbrushing
Holding of foods in oral cavity
Tone, Posture and Positioning
• Hypertonia/ High muscle tone
– Structures may appear smaller because fibers are shortened and closer
together at rest
– What does this look like?
• Increased resistance to passive range of motion, spasticity, abnormal
movement patterns
• Hypotonia/ Low muscle tone
- Structures may appear larger because fibers elongate and there is more
space between fibers at rest
- What does this look like?
• Increased joint range of motion, decreased resistance to passive range of
motion, poor ability to move against gravity
(Morris & Klein, 2000; Swigert, 1998; Beckman,
1995)
Positioning and Feeding
• Safe and efficient feeding is dependent on good posture
• Abnormal postures provide a poor base of stability which in turn interferes
with the development of oral motor function
• “Problems with central alignment, tone, and positioning relate directly to
the oral sensorimotor system.”
• Observe the patient in their typical seating system for feeding
• Abnormal postures may be a compensatory strategy to provide stability
• For example, development of neck hyperextension and tongue retraction may be due to an
abnormal base of stability to lift and turn head and open mouth.
• Optimal positioning for oral motor function:
• Neutral head position, hips in line with lips (pelvic stability), shoulder girdle stability, support
under the feet for hips/knees/ankles
(Arvedson & Brodsky, 2002);
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Muscle Tone and Positioning
Hypertonia:
– Goal: Inhibit increased tone and facilitate movement
– Signs of hypertonicity: tongue retraction, tonic tongue tip elevation, tongue thrusting
– Therapy: relax musculature through massage and gentle shaking and vibration • Begin intervention at whatever level the child is comfortable w/food
Hypotonia:
– Goal: Improve stability, alignment and posturing
– Signs of hypotonicity: tongue protrusion, tongue retraction, limited tongue ROM, limited upper lip movement
– Therapy: massage, vibration, firm tapping, deep pressure, tactile input to lips/ cheeks/ tongue may increase tone
(Meyer, 2005; Beckman, 1995)
Jaw
Patterns
Normal Jaw Patterns:
•
•
•
•
•
•
•
•
Close and hold Wide Jaw Excursion Phasic biting Munching
Lateral jaw shift
Diagonal movement
Diagonal rotary movement
Circular rotary movement Abnormal Jaw Patterns:
•
•
•
•
•
•
•
•
Jaw instability
Exaggerated jaw movement
Tonic bite reflex
Jaw thrust
Jaw retraction
Micrognathia
Dystonic jaw movement
Bruxism
(Morris & Klein, 2000; Beckman, 2013)
Tongue Patterns
• Normal tongue patterns:
•
•
•
•
•
Suckling
Sucking
Tongue Tip Elevation
Munching
Lateral Tongue Movement
• Abnormal tongue patterns:
•
•
•
•
•
•
•
Exaggerated Tongue Protrusion
Tongue Thrust
Tongue Retraction
Tongue Fasiculations
Asymmetry
Macroglossia
Ankyloglossia
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Lip Patterns
• Normal lip patterns:
– Lip rounding
– Lip spreading
– Lip closure
• Abnormal lip patterns:
– Lip tremor
– Asymmetry
– Hypotonic lips
– Lip fasciculations
Oral Motor Treatment
• Ways to improve oral motor skills during the developmental period include:
–
–
–
–
–
–
Resolving/managing medical issues
Eliminating aversive elements
“Optimize environment, seating and postural alignment”
Encourage child to have sense of control by allowing him to chose foods and utensils
Adjust meal duration as needed based on child’s cues (depending on tolerance)
Habituate skills and generalize to natural environments (including familiar feeders)
• Ways to improve oral motor skills after the developmental period include:
–
–
–
–
–
–
Set up child for success by starting at a step that is easiest and repeat until child is comfortable
Change one variable at a time
Return to previous level of comfort if problems arise
Practice skills at snack time
Achieve acceptance before adding new skill
Reduce environmental stressors including complexity of task
(Sheppard, 2012)
Weak Suck/Poor Lip Seal/ Poor
Pacing
• Weak suck
– Jaw/cheek support (gentle but firm pressure on mandible)
– Increase flow rate if patient can tolerate it
– Honey bear cup with straw (if patient is older)
• Poor lip seal
– Jaw support and cheek/lip support (lip: use middle finger under lower lip,
cheek: use thumb and middle finger on cheeks)
• Poor pacing
– External pacing (leave nipple in the mouth and tip bottle base downward
to stop flow without breaking the seal)
– decrease flow rate to reduce frequency of swallow
(Swigert, 1998)
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Jaw Control and Tone
• Increase child’s ability to maintain jaw closure and jaw opening by assisting in
opening and closing without tension
• Treatment:
• Purpose: to assist with upward and downward jaw movement, to provide a
point of stability (at level of lower lip).
• Place your middle finger under the jaw
• Place index finger on chin just below lower lip
• Place thumb at TMJ
• Treatment for low tone:
• Create songs or sing nursery rhymes while tapping/patting/stroking –
provide proprioceptive and tactile stimulation of jaw muscles
• Treatment for increased tone:
• Positioning/postural alignment; gentle massage
Jaw Instability
• Jaw slips and/or shifts off-center or forward due to insufficient tone and
control of TMJ
• Treatment:
• Provide a point of stability (i.e. jaw shelf). Provide firm pressure on
mandible
• Sustain jaw closure (tug and pull “dog” game)
• Patting, tapping and other tactile stimulation to muscles that open/close
jaw
• Bruxing treatment: help explore pleasurable sensory experiences (teether,
chewy tube/theratubing, cold/frozen washcloth, crunchy snack)
Tonic Bite
• Mandible clenches on an object; caused or exacerbated by:
• Hypertonicity (jaw moves into clenched posture when teeth are stimulated)
• Related to poor sitting position‐ trying to stabilize
• Reaction to an over stimulating environment
• Treatment Ideas:
• Positioning • Reduce hypersensitivity
• Increase sensory input
• Tapping or lightly but firmly shaking object to face
• Reduce amount of multi‐sensory information (environment)
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Chewing
Resistive Chewing:
• Place item so that it is between upper and lower teeth at level of
molars/gums, perpendicular to gum line.
• Give steady pressure into upper jaw.
• Maintain contact between teeth for a maximum of 20 seconds.
• If no chewing occurs, provide pulsating pressure up into upper jaw with the
item at a rate of 1 per second.
• Utilize a tool such as a chewy tube, Ark probe, NUK brush
Practiced Chewing:
• First use a resistive chewing tool (such as a chewy tube) without food
• May also dip the resistive chewing tool in a food (such as a puree) or stick
small pieces of food in the end of a/on a tool (such as a chewy tube)
– May also use stale licorice stick, SlimJim.
• Work up to tolerating a piece of food wrapped in mesh/fabric pouch
• Then practice chewing without mesh
(Beckman, 2013; Meyer, 2007)
Tongue (Cupping and Bunching)
Treatment Ideas:
• Assisting with tongue cupping:
– Downward firm pressure with bowl of spoon on center of tongue blade
to encourage upward movement. Leads to anterior/posterior tongue
movement
– Lingual stroking/tapping and jaw support
• Treating bunched tongue:
– Lingual stroking/tapping
– Using textured bottom spoon with firm pressure on center of tongue
– Increase sensory awareness and feedback in tongue (vibration)
(Meyer, 2007; Swigert, 1998),
Tongue Retraction and Tongue Thrust
Tongue retraction: Occurs when the tongue pulls back into the oral cavity; may be caused or exacerbated by:
• Low or high tone that creates exaggerated extensor movements
• Positioning
• Treatment:
• Positioning (head/neck)
• Lingual stroking/tapping, Vibration/Stimulation to center of tongue
Tongue Thrust: Forceful protrusion of the tongue in an inconsistent/ intermittent
movement
• Treatment:
• Firm input
• Positioning changes
• External jaw support
• Side placement of the spoon
(Swigert, 1998; Morris & Klein,
2000)
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Limited Tongue Movement
• Limited tongue movement may be seen when eating or when mouthing toys; caused or exacerbated by:
• High tone‐ causes tongue to be stiff
• Low tone‐ causes tongue to be floppy
• Flaccid tongue due to cranial nerve (XII‐hypoglossal) damage
• Treatment: • Increase sensory input to tongue
• Start with toys/fingers in mouth • Vibrations to tongue and oral cavity
• Stimulation to lateral borders of tongue • Stimulation to lips or to area you want tongue to move‐target
• Improve active lip/cheek control
• Provide stimulation to the lateral borders of tongue during oral play (non‐
nutritive stimulation) for lateralization
Lip Movement
• Can be seen in eating, mouthing toys or vocalizing/verbalizing; caused or exacerbated by:
• High or low tone
• Facial weakness and/or decreased facial sensations due to cranial nerve damage
• Treatment:
• Vibrations/ tactile stimulation to face, cheeks and jaw muscles
• Increase sensory input to upper lip
• Increase control of upper lip through straw drinking
• Improved range of motion
Cup Drinking
• Wide lipped open cup is recommended (nosey cup, infatrainer)
• Discourage use of nonspill cups
• No spill sippy cups are difficult to learn to drink from
• Perpetuate oral motor movements used in bottle drinking
• Single sips at first
• Start with thicker liquids (for increased control)
• Start with giving child empty cup in play
• Put preferred baby food on cup to encourage child to bring to
mouth
• May transition to a recessed lid cup with two handles
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Drooling
• Control of drooling occurs gradually in a child’s development and can be
influenced by: “position, activity, oral motor control and level of motoric
innervation that has been achieved.”
• It may occur when a child is learning a new skills and continue until the
skill is mastered and becomes automatic.
• Very little saliva is produced before the infant is 3 months of age due to
the mouth only producing the minimal amount to keep the mouth moist.
Saliva mixture increases as child begins taking solids to assist with
binding food and digestion.
• By 6 months, infants should be able to control drooling in various positions
(supine, prone, supported sitting) unless they are teething or using hands
to reach/manipulate objects.
• Level of oral control may be reduced when child is concentrating or
completing a task requiring fine motor control, thus you may see more
drooling.
Drooling (continued)
• Drooling is the unintentional loss of saliva from the mouth.
• Normal infancy and usually subsides as oral motor function matures.
• Drooling while awake after 4 years of age is considered abnormal (Van der
Burg 2007)
• Various treatment strategies have been reported, such as oral motor
training, proper positioning, behavioral therapy, use of intraoral devices,
medication, and surgery (Blasco & Allaire, 1992)
Sensory based difficulties
• Hyposensitivity and hypersensitivity
• Food texture, temperature and taste may all influence sensory
based problems and altering these should be considered as
part of your treatment toolbox
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Oral Hypersensitivity
• Heightened awareness of stimuli in mouth; decreased sensory threshold to
oral input. May show a heightened response/ oversensitivity to taste,
temperature and/or touch in and around the oral cavity.
• What does this look like?
– A child may respond to a strong flavor by exhibiting a tongue thrust.
• Caused or exacerbated by:
•
•
•
•
•
•
•
Low threshold to stimuli due to neurological damage
Overall lack of oral stimulation
Oral motor delays due to food preferences (selectivity based on texture)
Limited experiences with PO
Negative oral experiences and respiratory issues (intubation, aspiration)
GI issues (constipation, delayed emptying, reflux)
Thinking that food “hurts” (aversion)
• A child may have different tolerance levels to different foods (i.e. they may be
able to eat crackers without difficulty but gag at the sight of pudding)
(Arvedson & Brodsky, 2002; Meyer, 2005)
Reducing Oral Hypersensitivity
•
Goal: Reduce hyper/ heightened sensitivity by gradually normalizing the fight or flight response to stimuli
• Therapy techniques for reducing hypersensitivity include:
– Beginning with whole body touch and working toward touch/input to
hands/fingers, then to the face, and then tolerance of input/touch to the
mouth
– Food play (starting with dry things like bowls of rice, working toward
finger painting with pudding/ whipped cream, sifting for gummy bears
in jello, etc)
• This gets child comfortable with feeling the foods on their hands and fingers first.
• Messy = a good thing!
– Encourage oral motor play with toys
(Meyer, 2005)
Food Play
• Children use hands to explore
• Encourage children to touch new textures themselves to increase
exposure
• Children may inadvertently put a new texture in their mouth
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Oral Hyposensitivity
• Reduced awareness of stimuli in mouth; heightened sensory threshold to oral
input. May show a diminished response to taste, temperature and/or touch in
and around the oral cavity.
• What does this look like?
• A child may crave foods that have strong flavors, crunchy textures, extreme temperatures –
foods that provide increased oral input. This child may overstuff their mouth, lose food or drool.
• Caused or exacerbated by:
• High threshold to stimuli due to neurological damage
• May be due to low tone or some weakness
(Meyer, 2005)
Normalizing Oral Hyposensitivity
•
Goal: Increase sensory input by offering strong sensory experiences. In
order for the child to feel the sensation, the mouth seeks/requires so
much more information.
• Therapy for normalizing oral hyposensitivity include alerting techniques:
– Facial massage (including tapping and vibration) with varying different
textures (rough/smooth washcloth, toys with ridges or bumps, ARK
probe, yellow propreefer, NUK brush)
– Using cold and tart as alerting tools (cold teether, lemon swabs)
– Strong flavors (salsa, BBQ sauce, Ranch, spices)
– Alter temperature (chilled vs room temperature vs warm)
(Meyer, 2005)
Therapy ideas for the feeder with
sensory issues
• Think about all sensory traits involved in feeding:
–
–
–
–
What do you see/ what does the food look like? (appearance, color, size)
What do you smell?
What does the food feel like? What does the mealtime experience/ the food sound like? • Overall goal with sensory feeding problems is to NORMALIZE the child’s response to sensory stimulation
• Change……
– texture
– color
– shape
– flavor
– location
(Meyer, 2005)
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Change by Texture
• Add small bit of smashed meltable/graham cracker to puree
• May need to transition slowly
• Put large amount of puree on spoon with “tiny amount” of
textured puree on tip of spoon
• Decrease amount of puree and increase amount of textured
puree
• Can gradually increase amount smashed meltable/graham
cracker in with puree until puree is more of a “lumpy puree”
• To transition from “lumpy puree” to ground presentations
• Change texture by putting through grinder
• Present in similar way as described with puree
(Arvedson, 2008; Fraker et al.,
2007)
Change by Color
• Pick preferred food and “bridge” to non preferred food by choosing a food similar in color
• Make sure you are only changing color‐ could also be changing texture and food group
(Fraker et al., 2007)
Change by Shape
• Pick preferred food and “bridge” to a new food by changing shape
• Chicken nuggets from Wendy’s versus my freezer or smaller versus larger sizes
• Applesauce from grinding apple bits • Cheese cut into strips similar to string cheese
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Intensify
• Add small amount of salt or pepper to pureed vegetables
• Add small amount of sugar to fruits
• Add gravy powders to meats
• Add small amounts of spices to foods
• tarragon, garlic, dill, Italian herbs
Change by… Location
• Take food out of the original container
• Put baby food jar in the bowl
• Have child help take out of container to bowl
• Remember not to overwhelm the child by expecting too
much too soon
Behavior Problems
• Behaviors during mealtime may be due to the parent-child relationship
• Children can sense caregivers who are controlling (over- or under-),
anxious, insensitive to child’s cues, etc.
• Disrupts the dynamic and may cause behavioral feeding problems
• Behaviors may also be due to child’s health status, dietary
restrictions, physical problems, temperament, feeding-related trauma
• Common feeding problems may include food refusal, selectivity by
type, selectivity by texture as well as oral motor and swallowing
problems. These can all be underlying causes for behavior problems.
(Kerwin, 1999; Piazza, 2008)
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• Antecedent: Parent asks if child wants to try an unfamiliar
food
• Behavior: Child cries and pushes the spoon away
• Consequence: Parent offers a preferred food instead
Antecedent management
• Repeatedly offer new foods
• Offer age appropriate portions/bite sizes
• Eliminate eating between meals & snacks
• Provide positive social interaction
• Eliminate distractions
• Get unpleasant foods done early in meal
• Schedule formula/tube feedings right after meals
• Decrease demand initially
• Decrease anxiety by slowly moving from exposure to interaction
• Smaller meals to build success
Resulting Behaviors
• Behaviors are usually to escape or gain
attention
•
•
•
•
•
•
•
Throwing food
Spitting
Hitting
Self‐Injury
Flat refusal
Tantrums/crying
Clamping mouth shut
• Parents are the FUNNIEST cause‐and‐
effect toys (and so are dogs)
(Kerwin, 1999; Piazza, 2008)
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Consequences
• Use preferred foods as rewards
• Use tangible nonfood rewards – Stickers, games, books, tv/video, toys
– If mid‐meal, 15‐20 seconds unless accept next bite
• Escape as a reward
– Set a goal for amount of food eaten before child leaves table; start small; slowly increase goal over time
• Token program
– Stickers, sticker charts, point system, poker chips
– After child earns so many, he can “cash in” for another reward such as game, preferred food, escape
– Gradually increase demand over time
• “Non‐Removal of Spoon”
• Grandma’s Rule
– You cannot do something you want to do until you do something you don’t want to do – Use “first, then” language
– Once you select a reward, be sure access to it is limited to mealtimes
• Co‐feeding
(Kerwin, 1999)
Behavior Modification Treatment
• Increase desired behavior (positive reinforcement)
• Decrease undesired behavior (extinction, time-out, ignoring)
• Preferred and non-preferred foods (i.e. 1 bite of non-preferred food and
then 3 bites of preferred food)
• Acquisition of new skills (shaping, prompting, (peer) modeling)
• Praise positive behaviors
• Ignore negative behaviors
• You are the boss- the meal ends when the parent says
• Children can feel in control when given choices
• Put a “No thank you” helping (1 tsp- 1 tbsp) of a new food on his/her plate,
even if they are not going to eat it.
(Sheppard, 2012; Arvedson, 2008; Kerwin, 1999)
Interventions for Specific Problems
• Escape (leaving the table)
• Escape prevention‐ do not allow child to leave table until he’s followed instruction (seating, continuously bring back to table)
• Allowing child to leave table after negative behavior (refusal, crying, vomiting) will reinforce neg. beh.
• Escape (purposeful expulsion/spitting out)
• Give smaller bites for ease of swallowing
• Withhold reinforcement until swallowed
• Re‐presentation: put the expelled food back in child’s mouth each time it’s expelled
• Anxiety
• Graduated exposure‐ start with tiny bites of food; less intimidating, easier to swallow
• Vomiting
• cover and continue with meal; use ignoring
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Interventions for Specific Problems
• Tantrums, throwing, batting at spoon, head turning
• Do not remove spoon, stay calm, keep neutral expression, give a “first,
then” statement (“first bite, then all done”), wait, be silent
• Gentle blocking with “hands down” prompt for batting only
• If throw bite on the ground, replace with similar sized bite of same food
• Clamping mouth shut
• If the child has the skill: Non-removal of spoon
• If the child does not have the skill: Use shaping
• Start with reinforcing child after you touch the spoon to his lips; ignore
inappropriate behavior
• Once this step is tolerated- go through next steps
• Tip of spoon between lips & remove
• Tip of spoon between lips and wait until mouth opens slightly
• Spoon at mouth and wait until half of spoon is accepted
• Spoon at mouth and wait until entire spoon is accepted
Praising
• Look at child and before saying anything, determine if he/she is
eating
• If eating, make a positive comment and praise eating behavior
• Praise is most effective when:
• Occurs immediately
• Describes behavior
• Is varied-using different phrases
Behavioral Feeding: Working from
Exposure to Eating
• Work with the family to create a list of foods that the child currently eats.
• Create a second list of foods that family/therapist/etc would like for the child to
try. Allow your child to help choose foods, as appropriate.
• Start at the step listed below that is easiest for the child to do comfortably.
• Exposure
•
•
•
•
Helping prepare/cook a meal
Tolerance
Allowing the food to be on the table, moving toward it being on the child’s plate
Interaction
•
•
•
•
•
Stirring yogurt, holding a carrot wrapped in paper towel, searching for a hidden food
inside jello
Touching food to your lips (“painting” it on or put on lipstick)
Holding the food between your lips, tapping it to your teeth, holding it between teeth
Biting off foods and “shooting rockets “(spitting food pieces into bowl)
Biting, chewing and swallowing
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Slow and steady…
• Stay at each step with each food to make sure the child is comfortable and
complies easily with the request.
• You may also find that you have to start at different steps depending on the
food that is introduced.
• You may need to make some adjustments to help your child proceed along
the way.
• Always provide lots of positive attention and praise for all attempts at
compliance with this program.
• Allow older kids to chart their own progress with a sticker chart, or to
document their new foods in a special notebook.
• These strategies will take time to work, but should help reduce the child’s
fear or nervousness in trying new foods. Slow and steady wins the race!
Food Chaining
• Part of a sensory and behavioral based approach to feeding
• “Food Chaining: The Sensible Six Step Solution to Picky and Problem Eating” by Cheri Fraker and Laura Walbert
• When introducing new foods, start with ones similar to currently eat (or previously ate) and gradually expand
– McDonald’s chicken nugget
– Tyson chicken nugget
– Chicken tenders
– Lightly breaded home tenders
– Chicken breast
The Rules of Mealtime
• Nutrition
• Offer foods from all basic food groups
• Schedule
• Meals and snacks happen at roughly the same time every day and should be at
evenly spaced intervals 2-3 hours apart
• Meals take 30 minutes or less
• No food or drink (except water) between meals and snacks, no grazing
• Structure
• Everyone sits together at the table, no forced feeding
• Appropriate seating
• Time limits
• Limit distractions
• Choices
• Choices help children feel like they have control.
• Allow children to assist in menu planning, cooking, and preparing the table as
able.
• Allow children to choose one food at each meal that they will eat.
• Allow the child to select a plate, cup and spoon.
(Arvedson, 2008; Chatoor, )
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Common feeding observations in babies
with cleft lip/palate
– Difficulty pulling nipple into mouth
– Difficulty sealing on nipple
– Difficulty creating negative pressure/suction
– Nasal regurgitation
– Ingesting more air
(Dailey, 2012)
Cleft palate bottle systems
• Mead Johnson
• Any nipple can go on this bottle.
• Squeeze it gently using a pulsing rhythm while the baby is sucking to help
your baby drink.
• Haberman
• This nipple has three flow rates: slow, medium and fast.
• It fits a regular bottle.
• It has a one way chamber to adjust the flow rate.
• Gently squeeze the nipple to help your baby suck
• Pigeon
• The Pigeon Nipple fits on any bottle.
• There is a notch (air vent) in the nipple that points up toward the nose
during feeding.
• The baby munches to get the fluid out of the bottle
Feeding tubes
• Enteral Tubes - deliver formula by tube directly into the gastrointestinal
system
• Orogastric Tubes (OG) - through mouth to stomach-often used for preemies/babies
whose nasal passages are too small for NG tube
•
•
•
•
•
Nasogastric Tubes (NG)
Nasojejunal Tubes (NJ)
Gastrostomy Tubes (G)
Jejunostomy Tubes (J)
Gastrojejunal Tubes (GJ)
• Parenteral - bypass GI system and deliver formula intravenously by
catheter to the bloodstream
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Feeding tubes
NJ-through nose, threaded through
stomach and ends in jejunum of small
intestines
-used when stomach is functioning
poorly
-must be continous feeds vs bolus feeds
as intestines require slower delivery
NG vs NJ TUBE
NG-through the nose to the stomach
-can be removed for feeding or left in
-advantage of being temporary
-bolus or continuous
-some debate on whether it affects
swallowing
-generally short term 2-3 months
Feeding tubes
G tube
‐ Bypasses mouth and goes to stomach
‐ Long term solution
G vs GJ vs J TUBE
GJ
‐ Two branched tube that goes into stomach and second branch goes to jejunum
‐ This is used b/c some medications must go through digestive process
‐ Medication goes thru gastric port (g), food into (j)
J‐tube
‐ Placed in jejunum
‐ Used when stomach is functioning poorly
Feeding tubes
Parenteral
TPN- total parenteral nutrition-nutrition is
delivered into a large central vein by
catheter
- Used for kids with major dysfunction of
GI tract
TPN
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Transitioning from Tube to Oral Feeds
• Important to work to strengthen cheeks, jaw and tongue before presenting food/liquid
• Food: 1. Increase quantity before increasing variety
2. Increase variety before increasing texture
3. Increase texture from smoothest tolerated, moving toward “regular” diet
• Liquid: 1. Increase quantity before increasing variety
(Beckman, 2013)
Oral Stimulation
•
•
•
•
Graded presentations to face, lips, tongue, teeth
Usually start with a positive texture and work toward mouth
Slow transitions
Use items such as a favorite toy, wash cloth, silky blanket, NUK
brush, infadent infant toothbrush, vibrating toy, Z-vibe, DuoSpoon, E-Z
spoon
(Morris & Klein, 2000; Fraker & Walbert, 2011)
Oral Stimulation
• Allow opportunities for your child to
explore toys with their mouth.
• Provide lots of loving and sensitive
touch around the face.
• Wipe face with warm or cold
washcloth in a slow playful way.
• Coordinate oral play with a song.
(Morris & Klein, 2000
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Swallowing Secretions and Therapeutic
Tastes
• Work on improving ability to manage secretions/ swallow saliva
• Provide some stimulation to increase saliva production and increase
saliva swallows
• Don’t add a bolus, only flavor saliva
• Flavor saliva with powders and dip toothette in powder to get an increase
in frequency of swallows
• If they don’t tolerate this, work on plain saliva
• Multiple reps 1x/day working toward multiple times per day
(Sheppard, 2012)
Biopsychosocial Model
• Promote positive feeding relationship between child
and feeder
• Determine child’s readiness
• Normalize feeding skills
• Oral stim, eating-related behaviors, establish hungersatiation cycles
• Regulate feeding environment
• Initiate behavioral feeding plan
• Bolus delivered on mealtime schedule
• Therapy
(Sheppard, 2012)
References
• Arvedson, J. (2008) Special Topics In Pediatric Feeding & Swallowing,
Professional Development Programs
• Arvedson, J & Brodsky, L. (1993) Pediatric Swallowing and Feeding, San
Diego, CA, Singular Publishing Group
• Beckman, D. (2007) Oral Motor Assessment and Training, Professional
Development Programs
• Chatoor, I. (2009) Diagnosis and Treatment of Feeding Disorders in Infants,
Toddlers, and Young Children, Washington, DC, Zero to Three
• Dailey, S. (October 2012) Management of feeding and swallowing disorders
in infants with cleft palate and craniofacial anomalies. Nationwide Children’s
Hospital. Columbus, OH.
• Fraker, C. & Walbert, L. (2011) Pre-Chaining Programs for Infants & Children
with Swallowing Disorders: Much to DO About Pediatric Dysphagia,
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References (continued)
• Fraker, C. & Walbert, L. (2003) From NICU to Childhood: Evaluation &
Treatment of Pediatric Feeding Disorders, Austin, TX. Pro-Ed
• Fraker, C., Fishbein, M., Cox, S., Walbert, L. (2007). Food Chaining: The
Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems and
Expand Your Child’s Diet
• Kerwin, M. E. (1999). Empirically supported treatments in pediatric
psychology: severe feeding problems. Journal of Pediatric Psychology, 24(3),
193-214.
• Meyer, J. (2005). Pediatric Feeding Birth to Three: The Big Picture.
• Morris, S. & Klein, M. (2000). Pre-Feeding Skills: A Comprehensive
Resource For Mealtime Development, 2nd Edition. Austin, TX. Pro-Ed.
• Overland, L. (2010). Feeding Therapy: A Sensory Motor Approach.
References (continued)
• Piazza, C. C. (2008). Feeding disorders and behavior: What have we
learned?.Developmental disabilities research reviews, 14(2), 174-181.
• Sheppard, J. (2012) Evaluation and Treatment of Pediatric Dysphagia:
Physiologic, Developmental and Behavioral Disorders, Professional
Development Programs
• Swigert, N. (1998) The Source for Pediatric Dysphagia, East Moline, IL,
LinguiSystems
• Special thanks to Dr. Rob Dempster, Psychologist at NCH.
Recommended Readings
• Diagnosis and Treatment of Feeding Disorders by Irene Chatoor
• Feeding and Swallowing Disorders in Infancy: Assessment and
Management by Wolfe and Glass
• Food Chaining: The Proven 6-Step Plan to Stop Picky Eating,
Solve Feeding Problems and Expand Your Child’s Diet by Fraker,
Fishbein, Cox and Walbert (2007)
• Nobody Ever Told Me (Or My Mother) That! (Everything from
Bottles and Breathing to Healthy Speech Development) by Diane
Bahr (2010)
• Pre-Feeding Skills: A Comprehensive Resource for Mealtime
Development (2nd edition) by Evans Morris and Dunn Klein (2000)
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Please feel free to contact me with any questions or comments
Caitlin T. Sirois
[email protected]
(614) 722-8689
32
Oral Motor/Feeding Evaluation or
Video Swallow Study Checklist
The below checklist can be used to help determine if a child needs referred for an oral motor/feeding
evaluation or video swallow study.
Outpatient Oral Motor/ Feeding Evaluation
Child has the following problem(s):
 G
agging: a regurgitate spasm in the throat, as from revulsion to a food or smell or in reflexive
response to an introduced object.
 F
eeding issues associated with a variety of syndromes/ conditions (i.e. Craniofacial disorders, Trach/
Ventilator kids, etc).
 A
dvancement of diet: Transitioning textures (i.e. changing from smooth purees to chunky purees to soft
foods to table foods, etc).
 T
ransition from bottle to sip cup, etc
 F
ood aversions/ Behavioral feeding problems
 Oral motor weakness and/or oral motor coordination issues (i.e. difficulties with oral motor control of bolus)
 P
osture/Positioning
 S ensory Issues-Body
 A
daptive Equipment
 S elf Feeding
 B
reastfeeding
 Patient has never eaten by mouth
** Outpatient oral-motor/feeding evaluations are to be done by a Feeding Therapist (which may be either OT or Speech)
Outpatient Video Swallow Study
Child has the following problem(s):
 Gagging/choking on solids after foods have been cleared from mouth (feeling like foods are stuck “in throat”)
 C
hoking/coughing while drinking liquids
 Sudden increase in frequency of colds; bronchitis/ pneumonia/ respiratory infections
 P
rior history of aspiration/ swallow dysfunction
 S ignificant medical history – Patient with Trach/vent, TEF (tracheoesophageal fistula repair), etc.
would need a VSS prior to beginning therapy to determine safety of swallow.
** Video Swallow studies are completely jointly by an Occupational Therapist, Speech-Language Pathologist and Radiologist.
If a patient fits any of these criteria, schedule an Oral Motor/Feeding Evaluation
or Video Swallow Study by calling 722-2200
9594
Cleft Palate: Feeding Your Baby
The palate, or the roof of the mouth, is made of bones and soft tissue. The palate separates
the mouth from the nose. A cleft palate is an opening in the bones and soft tissue. This
open space in the palate makes it hard for your baby to suck from a bottle or breast. Here
are some ways to help your baby feed.
Supplies for Feeding Your Baby
Feeding a baby with a cleft of the palate may not be easy at first. Most babies with a cleft of
the palate may not be able to breast feed. They are not able to create the suction needed to
express the milk from the breast. You can pump breast milk and put it in a bottle when your
baby is not able to breast feed. You can still place your baby at the breast for non-nutritive
sucking, which can be satisfying to both you and the baby.
Several types of nipples and feeders can help you feed your baby.
You may need to try more than one kind of bottle and one kind
of nipple before finding the best one for your baby. The nurses
will work with you until you are comfortable feeding your baby.
Feedings will become easier as your baby grows.
Examples of Feeding Systems
The Mead-Johnson cleft lip/palate nurser: This bottle is
soft. Any nipple can go on this bottle. You may prefer to
use an orthodontic nipple (NUK). Squeeze it gently using
a pulsing rhythm while the baby is sucking to help your
baby drink (Picture 1).
Picture 1 Mead Johnson Cleft
Palate Nurser with NUK nipple
SpecialNeeds Feeder®, also known as the Haberman Feeder™:
This nipple has three flow rates: slow, medium and fast. It
fits a regular bottle. It has a one way chamber to adjust the
flow
rate. Gently squeeze the nipple to help your baby suck
(Picture 2).
Picture 2 Haberman Feeder
HH-I-21
8/84, Revised 2/13
Copyright 1984, Nationwide Children’s Hospital
Cleft Palate: Feeding Your Baby Page 2 of 3
Examples of feeding systems, continued
Pigeon Nipple: The Pigeon Nipple fits on any bottle.
The nipple has a soft side and a hard side (Picture 3).
The hard side faces up and the soft side sits on the
baby’s tongue. There is a notch (air vent) in the nipple
that points up toward the nose during feeding. The
baby munches to get the fluid out of the bottle.
You may need to cut a larger hole in some nipples using
the cross-cut method. This helps the milk flow and
keeps your baby from getting too tired during feeding
(Picture 4).
Picture 3 Pigeon Nipple
How to Feed Your Baby
Here are some tips for feeding:
Cuddle for a few minutes before starting to feed. This will
help you both relax and make feeding time more pleasant.
Hold your baby in an upright position on your lap, tilted
back just slightly (Picture 5). This helps him or her
swallow. It will also help keep the milk or formula from
flowing into the baby’s nose or middle ear.
Picture 4 A cross-cut nipple.
Rub the nipple of the bottle on his lower lip to get the
nipple into his mouth. This starts the sucking reflex.
Burp your baby often (after every 1/2 to 1 ounce) since he
may swallow air during feeding.
Try to finish the feeding in 30 minutes so he does not get
too tired.
You may give a pacifier to your baby. Remember, he may
have trouble holding it in his mouth.
If you put baby to bed after the feeding, place him on his back
or side. You may also raise the head of the crib about 6 inches
if the baby spits up when he burps. This helps keep the formula
in the stomach. It also helps to keep formula from flowing into
the middle ear.
Picture 5 Hold your baby
As your baby gets older, he will need more than formula.
upright when feeding.
Be sure to ask the doctor when you can give cereal, fruits and vegetables to your baby.
Also ask about teething biscuits and finger foods.
Cleft Palate: Feeding Your Baby Page 3 of 3
Mouth Care
After each feeding:
Give your baby one half ounce of water to rinse his mouth.
Gently clean the nostrils with a twisted piece of cotton if needed.
Other Advice
A baby with a cleft palate is more likely to get ear infections. Watch for these signs of
infection:
Fever
Breathing faster than usual
Fussiness
Pulling at ears
Turning head side to side
No desire to suck
When Will My Baby Have Surgery
Your child will have surgery to repair the cleft palate when he is about one year old. Talk to
the doctor about surgery.
When to Call the Doctor
Call your child's doctor if your baby:
Is not gaining weight.
Has a lot of gas or discomfort.
Often spits up.
If you have any questions, be sure to ask your doctor or nurse, or call 614-722-6299.
You can find more information about feeding on the web site of the Cleft Palate
Foundation: www.Cleftline.org.
Passy-Muir Speaking Valve
For a Tracheostomy Tube
The Passy-Muir speaking valve is a small device that attaches to your child’s tracheostomy
(trach) tube. It allows your child to make sounds and use speech.
A speaking valve allows your child to breathe in through his
trach tube. After he or she inhales, the speaking valve closes.
Air is breathed out (exhaled) up through the vocal cords,
then through the mouth and nose. This allows your child to
produce sound (Picture 1).
A child who needs to be on a ventilator may use a speaking
valve. Talk to your child’s healthcare provider to find out if
he is able to use a speaking valve while on the ventilator.
Ventilator settings may need to be adjusted so that he can
use a speaking valve.
Your child needs to be assessed to see if he or
she is able and ready to use a speaking valve.
Picture 1 Inhaled air is exhaled
Evaluation for PMV Use
through the vocal cords, mouth
and nose to allow sound.
At Nationwide Children's Hospital, an advanced practice
Nurse (APN) tests your child to see if he or she has enough airflow around his trach tube to
safely use a speaking valve. This test will be done either while your child is in the hospital or at
an outpatient clinic visit.
If your child is in the hospital during the evaluation, a speech therapist or respiratory therapist
may also see him. When your child uses the speaking valve for the first time, the APN and
speech therapist will observe him for signs of difficult breathing. If your child can safely use the
PMV, the speech therapist will closely observe his use of the device for 3 to 5 days while he is in
the hospital. As your child uses the PMV successfully, his time using it will be increased.
If your child receives the PMV during a clinic visit, the APN will observe him for signs of
difficult breathing. If your child does well, you will be taught how to use the PMV. It is
important that all caregivers understand the risks and benefits before the child uses the speaking
valve. You will be taught what problems to watch for when your child wears the speaking valve
at home.
HH- II-194 3/04, Revised 8/11
Passy Muir Speaking Valve Page 2 of 3
Wearing a Speaking Valve
The speaking valve may be placed only on an uncuffed trach tube, or a cuffed trach tube with a
completely deflated cuff. Your child may wear the speaking valve only while awake. An adult
needs to observe him for difficulty breathing or signs of distress and remove the valve if needed.
What to Watch for When Your Child is Wearing the PMV
Frightene
d look
Flared
nostrils
Pale skin
Bluish nail beds
Skin pulls in
on neck and
chest
Rapid belly
breathing
Picture 2 Some signs of respiratory distress.
Watch for signs of increased effort in breathing such as:
 faster rate of breathing
 skin pulling around neck or ribs
 more pale skin color than normal, especially bluish color around the mouth
Your child’s healthcare provider may provide more specific symptoms to watch for if your child
is on an apnea monitor or pulse oximeter.
If it is harder than usual for your child to breathe, or there are other signs of respiratory distress,
(Picture 2) remove the speaking valve immediately.
A child using a speaking valve should be medically stable. Your child may need to stop using the
speaking valve while he is sick.
Restart its use after he returns to normal health.
Passy Muir Speaking Valve Page 3 of 3
Secretions and Suctioning
Suction your child as needed. He may need suctioning before putting on the PMV. Some
children may need periodic suctioning while using the PMV. A benefit of the speaking
valve is that it encourages the patient to clear his own secretions. This reduces the need
for suctioning. Ask your child’s care provider about suctioning recommendations for
your child.
Cleaning the PMV
 Swish the PMV in a mild, fragrance- free soap
 Use warm, not hot water
 Rinse the valve completely with water
 Allow the valve to air dry before placing in the storage container
 Do not use heat to dry it
 Do not use any harsh soaps, peroxide, bleach, vinegar, alcohol, brushes or swabs
on the device
The PMV usually lasts several months. If it becomes sticky, noisy, or it vibrates, a new one may
be needed.
Benefits of a PMV
A PMV may
 Improve your child’s speech and tone
 Improve your child’s swallowing
 Improve secretion management
 Improve sense of smell and taste
 Help with infection control
 Assist with ventilator weaning
 Assist weaning from a trach tube (decannulation)
 Improve quality of life
 Improve overall development
Enjoy your time with your child while he is using the speaking valve.
Talk to your child’s speech therapist or healthcare provider if you have any questions.
Videofluoroscopic Swallow Study (VFSS)
The oral motor evaluation (OME) and videofluoroscopic (VID ee oh floor oh SKOP ick)
swallow study (VFSS) is a special test that shows how safely your child can swallow food
and liquids.
How to Prepare for the Test

Explain to your child what will happen.
Use words he or she can understand.

Bring your child’s bottle, spoon, or cup.
We only stock a small variety of sip cups,
bottles and nipples.

There is no need to bring any liquids for
the study.

If your child is a picky eater, or has food
allergies, bring food that he or she will or
can eat.

You may give medicine to your child at any
time before the test.

You MUST bring the child’s insurance card
and a photo ID card of the caregiver who is
present during the study.


If you do not have legal custody of the child
you MUST bring written permission to attend
this test and receive any test results.
Please do not give your child food or drinks:

After 6:15 am

After 11:15 am
HH-III-80
Revised 10/14
For Outpatient Use Only
Child’s Name:
_____________________________
Appointment Time
Please come 15 minutes before your
time to register.
Date:_________________________
Check in time: _________________
Appointment Place
Bring your child to:

Nationwide Children’s Hospital
Crossroads Registration. Follow the
Blue Path to the Crossroads Lobby
of the main hospital building.
700 Children’s Dr. Columbus
Phone: (614) 722-3975.

Westerville Close-to-Home Center
Registration Desk.
433 N. Cleveland Ave. Westerville
Phone: (614) 355-8300
Please Note:
Patients who are more than 30
minutes late for their appointment
will need to be rescheduled.
Videofluoroscopic Swallow Study (VFSS) Page 2 of 3
How the Test Is Done
 Your child will sit in a chair that looks like a car seat
(Picture 1).
 He or she will usually be fed in the same feeding
position that you use at home. The Occupational
Therapist (OT) and the Speech Language Pathologist
(SLP) or the doctor may also want to watch your
child eat in other positions.
 Parents and caregivers may watch the test while it is
being done. Other children and pregnant women are
not allowed in the test room. They should not be
exposed to the x-ray.
Picture 1 Child having a
videofluoroscopic swallow study.
 The study is done in the Radiology Department by a radiologist, an SLP and an OT.
 Food and liquids used during the test will be mixed with barium (BARE ee um).
Barium makes the food and liquid show up on the X-ray screen so the doctor, the
OT and the SLP can see how well your child chews and swallows. The barium may
make the food taste a little different.
 Your child may be given several types of food and liquid during the test.
 There will be a large X-ray camera
on one side of your child and a large
X-ray table on the other side of him
(Picture 1).
 When the X-ray machine is turned
on, it will make a clicking noise. The
camera will record how your child
eats and drinks.
 The doctor, the OT and the SLP
will watch how the muscles in your
child's mouth and throat move the
food and liquid when the child is
drinking, chewing and swallowing
(Picture 2).
 The entire process usually takes
about 2 hours. It does not hurt
your child.
 If you have any questions during
the test, please ask the radiologist
or the therapists.
After the Test
Opening of
Eustachian tube
Hard palate
Adenoids
Upper jaw
Tongue
Soft palate
Lower jaw
Epiglottis
Esophagus
(food pipe)
Cartilage
Wall of pharynx
Larynx (voice box)
To the lungs
To the stomach
Picture 2 Inside a child’s
mouth and throat.
Videofluoroscopic Swallow Study (VFSS) Page 3 of 3
Your child will be sent home with the first of the findings and recommendations.
 It takes 24 to 48 hours for the full report to be completed. Your child's doctor will
receive the test results and will discuss them with you then.
 If necessary, we will teach you about the foods and liquids that are recommended for
your child.
 You may notice a small amount of white barium in your child's bowel movements
after the test. (It may look like chalk.) This will go away as the barium moves all
the way through the bowels.
If you have questions before the test or need to change the appointment, please call:
Nationwide Children’s Hospital Speech Pathology Department at (614) 722-3975.
How and Why to Thicken Liquids
Some children have trouble swallowing. This is called dysphagia (dis FAY geh ah).
Children with dysphagia need to have their food and drink changed so they can safely
eat and drink.
If your child has dysphagia, you may need to thicken the liquids your child drinks.
Thickened liquids move more slowly than thin liquids. This gives your child extra
time to control the liquid while swallowing. This may help protect the airway.
How to thicken liquids
If your child is under the age of 12 months it is recommended that you use infant cereal
to thicken liquids. DO NOT use infant cereal in breast milk. Breast milk breaks down the
cereal and it does not remain thickened. If you have questions, talk to your child’s doctor.
Use measuring spoons to figure amounts. Do not use regular kitchen spoons.
Nectar Thick: Use 1 ½ teaspoons of dry infant cereal (rice, barley, oatmeal, mixed)
for EACH ounce of formula. Infant cereal must be ground up or pulverized. Do
NOT use flake cereal.
Examples:
3 ounce bottle = 4 ½ teaspoons infant cereal (1 ½ Tablespoons)
4 ounce bottle = 6 teaspoons infant cereal (2 Tablespoons)
Honey Thick: Use 2 ½ teaspoons of dry infant cereal (rice, barley, oatmeal, mixed) for
EACH ounce of formula. Infant cereal must be ground up or pulverized. Do NOT use
flake cereal. Do NOT give real honey to children under 1 year old.
Examples:
3 ounce bottle = 7 ½ teaspoons infant cereal (2 ½ Tablespoons)
4 ounce bottle = 10 teaspoons infant cereal (3 Tablespoons + 1 teaspoon)
HH-IV-105
10/13
Copyright 2013, Nationwide Children's Hospital
How and Why to Thicken Liquids Page 2 of 4
Natural nectar
Examples of liquids that are naturally the thickness of nectar are:
Buttermilk
Tomato juice
Peach and apricot nectars (often found with Hispanic foods at the grocery store)
Thickening liquids naturally
If your child is over the age of 12 months and is not at risk for allergies you may try
the following natural ways to thicken:
Add milk to yogurt or pudding. Add the liquid slowly and stir to prevent clumping.
Mix juice with baby food or blended fruits.
Mix flavored or non-flavored gelatin with juice in a blender.
Add bread crumbs, potato flakes, crushed crackers, or pureed meats to stews and soups.
Use these recommendations once you are familiar with using infant cereal or artificial
thickener.
Tips for thickening:
Shake hard to mix the cereal and liquid well.
Thicken contents of each bottle just before feeding. The formula will keep getting
thicker as it sits.
Infant cereal does not mix well with breast milk. The enzymes in breast milk break
down the cereal. If you would like to keep breast feeding or using expressed milk
in a bottle, talk to your child’s doctor.
Check the nipple during the feeding to make sure the cereal has not clogged the
nipple. You may need to roll the nipple with your fingers or clean out the clog.
Important considerations
Talk with your child’s doctor about how to thicken liquid medicines.
Some foods melt to a thin liquid and must be considered a thin liquid (such as
popsicles, ice cream and Jell-o).
Speak with your child’s doctor or registered dietitian if you have questions about
how these changes may affect the amount of liquid and how many calories your
child is getting.
Continued on page 3
Important considerations, continued
You may need to change or modify your child’s bottle nipples to make sure the
thickened liquids are getting through. Talk with your child’s doctor and SpeechLanguage Pathologist or Occupational Therapist before you make any changes.
Let your child’s doctor know as soon as possible if the child is:
Not taking the amount of formula he should be
More irritable
Having problems with constipation
Not gaining weight as expected
Having problems with coughing or choking during feeds
Artificial thickeners
Do not use artificial thickeners unless your child is over 12 months of age (this is
the corrected age for your child. If you have questions about corrected age, ask
your child’s nurse or doctor.)
Follow manufacturer’s thickening instructions on the can or packet of thickener. See end of
document for a list of thickeners and how and where to purchase, as well as age restrictions.
Where can I buy artificial thickeners?
Several name brand thickeners can be found on the market. Follow each manufacturer’s
directions exactly. You can get artificial thickeners at your local pharmacy. You can also
order the thickener online or by phone. Containers of juice, milk and water pre-thickened
to either nectar or honey consistencies are available also.
Simply Thick
www.simplythick.com
1-800-205-7115
Can be used with breast milk as long as the child is over 12 months corrected age
Simply Thick packets can be purchased individually or in bulk; order online or via phone
Thick-It
www.thickitretail.com/wheretobuy.aspx
1-800-333-0003
Thick-It instant liquid and food thickener can be ordered at the following pharmacies:
Walgreens, CVS, and Rite Aid
Thik & Clear
www.nutra-balance-products.com/nutrabalance_products_thickclear.php
1-800-654-3691
Nutra Balance. Packets can be purchased individually or in a case.
THE FOLLOWING THICKENERS SHOULD ONLY BE USED FOR CHILDREN
OVER THE AGE OF 3.
Thicken-Up and Thicken-Up Clear
TAD Enterprises
www.tadenterprises.com
1-800-438-6153
Thicken-Up can be purchased individually or in cases. You may also purchase
pre-thickened juice, milk or water by the case.
Nestle Nutrition
www.nestlenutrition.com/departments/therapeutic-nutrition/swallowingdifficulties/resource-thickenup-instant-food-thickener
1-888-240-2713
Thicken-Up can be purchased individually or in cases.
Walgreens
www.walgreens.com
1-800-925-4733
Thicken-Up can be purchased by the case online and individually in stores.
Thick & Easy
www.homecarenutrition.com
1-888-617-3482
Thick & Easy Instant Food Thickener can be purchased in multi-paks. You may also
purchase pre-thickened beverages and foods.
Special Instructions
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Course Handout - Ohio Speech-Language

Transcription

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