SPHS 543 JANUARY 29, 2010  Failure to Thrive (FTT) …Poor weight gain/growth failure …Below 3 rd – 5 th percentile …No gain for three consecutive months  Often causes overlap …Illness, disorder, feeding difficulty, parent/child interaction  May impact cognitive development

GASTROESOPHAGEAL REFLUX  The return of gastric contents, either food alone or mixed with stomach acid, into the esophagus.  Reflux is normal!

BARRIERS TO REFLUX  LES – contains gastric contents; pressure differentials  Growth – longer esophagus, more upright, solid foods  Saliva …Acid neutralization …Clears refluxed materials …Polypeptide hormone  Respiratory protective systems …Cough/airway clearance (6 mos +)

GER  Delayed gastric emptying …Strictures …Esophageal spasm leads to odynophagia  Respiratory impact …Increased WOB …Lack of energy = slower digestion …Asthma subgroup  Pressure sensitive …constipation

GER OR GERD?  Weight loss or inadequate weight gain (FTT)  Persistent irritability  Food refusal/selectivity  Posture -arching  Coughing/choking  Pain  Apnea  Sleep disturbance  Recurrent pneumonia

CAUSES OF GERD  Food allergies/intolerance  Immature digestive system  Structural  Immature neurological system …Low tone

TREATMENT  Non-medical …Thickening …Positioning Feeding frequency

TREATMENT  Medication …Improves gastric motility  Metoclopramide  Erythromycin …Lowers gastric acid production  Ranitidine hydrochloride …Proton pump inhibitor  Omeprazole, lansoprazole

TREATMENT  Surgical …Fundoplication …Percutaneous endoscopic gastrostomy (PEG) …Jejunostomy feedings

TREATMENT  Child/Family …Food as power

NORMAL DEVELOPMENT AND FEEDING SKILLS  Everything is connected  Gradual disassociation of movements  Tactile senses give way to visual and auditory  Drive toward independence

STABILITY  Stability …Need a stable base from which to develop …movement (mobility) and functional skills  Central to distal  External (positional) stability …Supporting one body part against another …Against an external source …Achieve muscle balance on both sides of a joint

STABILITY  Internal (postural) stability …No reliance on external aid or support …Balance of contraction between agonist and antagonist muscles  Movement through space

STABILITY  Achieves external stability by lying supine  Initial success with a controlled reach

STABILITY  Balance of co-contraction of shoulder … begins to develop internal control  Positional stability of elbow on floor  Weight shifts

MOBILITY  Mobility develops from a proximal base of stability  Affects refined development of distal oral-motor skills …Dependent on neck/shoulder girdle stability …Dependent on trunk/pelvic stability

PROXIMAL AND DISTAL  Relative terms …Head/neck distal to body …Jaw is proximal to distal lips, cheeks, tongue

SEPARATION OF MOVEMENT  From gross motor to fine motor

GROSS-TO-FINE PROGRESSION  Present in all skill areas  Gradually develop isolation of a skill

REFINED ORAL SKILLS

STRAIGHT PLANES OF MOVEMENT TO ROTATION  Straight planes first …Random, undirected …Alternate pulls from extensor or flexor muscles  Then lateral/diagonal planes and rotary skills …Gain stability by balancing extensor/flexor systems …Graded function …Lateral righting reactions

 Tendency toward active movement of extensor muscles of neck and back  Gradual control of counterbalancing flexor muscles …Stability in head control

…Rolling and weight shifting …Diagonal and rotary movements

ORAL-MOTOR SKILLS  Parallel feeding and speech development  Develop from straight planes to lateral then rotary …Jaw opens and closes for munching …Lateral movement as food moves side to side …Circular rotational movement to grind food

MIDLINE DEVELOPMENT  Four midlines in the body …Vertical …Horizontal …Two diagonals  Develop our sense of midlines through weight shifts over proximal joints  Experience plays a major role

MIDLINE AWARENESS OF MOUTH  “Home base” resting place for the tongue …Newborn – tongue fills oral cavity …Grooved tongue = vertical midline …Tongue tip elevation = horizontal midline …Lateral movement = diagonal/rotational midline …‘Center of mouth’ = defined sense of horizontal, vertical, diagonal oral midlines

REVERSION TO EARLIER PATTERNS  As children acquire a new skill, some of the previously learned control and stability may be lost temporarily  Often seen in the development of oral-motor skills …Softer foods – munching with some tongue lateralization …Move to harder foods, may revert to forward- backward tongue pattern before using more controlled tongue lateralization

REVERT TO EARLIER PATTERNS …May revert to suckle-swallow with introduction of spoon before using lips …May cough/choke with cup when previously handled bottle well

ECONOMY/EFFICIENCY OF MOVEMENT  When two or more possibilities exist, the choice will be the one requiring the least effort  Rhythmicity and smoothness …Body rhythms …Timing …Coordination