+ Eating and feeding

Successful feeding goes hand in hand with developmental progress. Here are some aspects of that mutual relationship…

+ Feeding supports physical development and good health… Well nourished children grow well Well nourished children experience less illness

+ Feeding supports social development… It provides an important opportunity for babies and their parents or caregivers to bond to each other Meal time may be the only time of day when the family is together

+ Feeding supports speech development… Eating involves movement patterns similar to those used in speech Good feeding programs develop the muscles needed for speech acquisition

+ Successful feeding helps infants and children develop a sense of autonomy... Being able to feed or refuse food helps the child develop a sense of control over her environment

+ Eating/Feeding process 1. Food enters mouth 2. Moved to teeth by tongue 3. Jaw up and down and rotary 4. Teeth close around food 5. Food finely ground 6. Formed into bolus (saliva food mix) 7. Swallowed

+ Developmental Feeding skills Newborns: primitive reflexes (reflexive sucking, rooting) 6-9 months: repress sucking reflex to munch (vertical jaw movements) 9-24 months: use tongue and rotary chewing to process and grind food months: independently use spoon

+ 80% of children with developmental disabilities have difficulty with feeding- unlikely to outgrow them Primitive reflexes Oral defensiveness Impaired hunger, satiation clues Poor oral structures Delayed motor skills

+ Watch for these common “red flags”… Stagnated growth Frequent bouts with pneumonia due to aspiration Feedings which exceed 45 minutes in duration

+ Medical diagnoses in which feeding difficulties are commonly seen include… Autism Cerebral palsy Cystic Fibrosis Failure to Thrive Gastro-esophageal reflux Genetic disorders Metabolic disorders Prematurity Short bowel syndrome

+ Infants and children with delayed feeding skills or abnormal oral motor patterns… inadequate use of utensils difficulty in chewing textured foods swallowing difficulties

+ Infants or children with feeding tubes… those transitioning from tube feeding to oral feeding those who will continue to need tube feeds in order to meet nutrient needs, but would benefit from the social aspects of being able to consume some food orally would experience oral feeding as an enhancement to speech therapy

+ Infants or children with problematic feeding behaviors, including… significant distractibility during mealtimes unclear hunger and appetite signals disruptive feeding behaviors such as throwing food, gorging or rumination

+ A Multidisciplinary Feeding Team may include… Family Behavioral Psychologist Dental Hygienist Nurse Nutritionist Occupational Therapist Parent Advocate Physical Therapist Social Worker Speech Therapist

+ Feeding Activities

+ Feeding “When another person gives the child food or liquids, concentrating on the sucking, chewing, and swallowing process”

+ Eating “When the child is learning to take foods or liquids independently”

+ Food textures Liquid- then, nectar, syrup, honey Pureed- thin, pureed, thick Soft mechanical- thin, medium, thick Solids- soft chewy, chewy, hard Combination

+ Food textures

+ Food consistency

+ Developmental Process of Eating Sucking Vertical jaw movements (munching) Tongue Movements Eat independently using a spoon

+ Typical oral-motor function in feeding Automatic phasic bite release pattern Chewing Controlled, sustained bite Gag response Jaw stabilization Munching Rooting response Rotary jaw movements Sucking Suckling Tongue lateralization

+ Chewing Food enters the mouth which stimulates Jaw dropping and rebounding Teeth close around food Chewing to fine consistency, mixes with saliva, “bolus” At bolus stage, ready to be swallowed

+ Normal Swallow Normal swallow:

+ Swallowing Voluntary stage Pharyngeal Stage Esophageal stage

+ Abnormal Swallow Abnormal swallow:

+ Typical oral-motor function in feeding Automatic phasic bite release pattern Chewing Controlled, sustained bite Gag response Jaw stabilization Munching Rooting response Rotary jaw movements Sucking Suckling Tongue lateralization

+ Typical feeding and swallowing development Rooting response Automatic phasic bite-release pattern Gag response Bottle drinking Spoon feeding Cup drinking Solid food intake

+ Atypical oral movements Cheek/lip retraction Exaggerated jaw closure Exaggerated tongue protrusion Jaw thrusting Lip pursing Tongue retraction Tongue thrusting Tonic biting

+ Tongue Thrusting

+ Jaw thrusting with head and neck extension

+ Warning Signs of Feeding Problem Excessive drooling Excessive time needed to complete a meal Frequent coughing when eating Difficulty moving the food in the mouth prior to swallowing Children with imperfect articulation Tears while eating

+ Factors affecting eating and drinking Developmental readiness Oral-motor competency Sensory awareness and discrimination Medical stability Positive practice Environmental factors Motor control and position

+ Conditions and Feeding Problems

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+ Equipment for Feeding and Eating Spoons Gripping utensils Sandwich holders Bowls and plates Snack cap Non-skid surfaces

+ Spoons and Gripping Utensils

+ Sandwich Holders Neater Eater: Mk Mk Windsford Feeder: c c

+ Bowls and Plates

+ Cups

+ Non Skid Surfaces

+ Positioning a child in a high chair

+ Assistive Strategies for Feeding Lip movement Lip closure Jaw support Activating cheek muscles Jaw control Developing tongue lateralization

+ Oral control from the side

+ Oral control from front

+ Strategies for Lip Closure Feeder pauses with spoon resting on lower lip Use sideways presentation of the spoon to facilitate active upper lip movement If no upper lip movement, tip spoon up to touch upper lip while still resting spoon on lower lip

+ Strategies for jaw closure Feeder is in front of child with middle finger placed on upper jaw behind the chin to assist with upward jaw movement and reduce tongue protrusion Jaw support is provided in front of the child with the thumb under the jaw just behind the chin to assist with upward jaw movement

+ Strategies for jaw closure while chewing Chin cupping is provided by the feeder by cupping the chin with the thumb resting on the chin and the index and third finger supporting under the chin

+ Strategies for Activating Cheek Muscles for Chewing Facial molding Inner cheek massage Infa-dent finger massage

+ Strategies for developing tongue lateralization for chewing Feeding position Sensory input to the tongue Food placement Practice chewing

+ Cup drinking with graded lip movements

+ Spoon feeding with oral control

+ Presentation of solid food

Nutrition History What is the home life/meal pattern? How much is consumed? Food allergies or intolerances? Who is present at mealtimes? Is the child interested in eating? Any problems with chewing or swallowing? Gagging or choking? Are there any foods or textures that the child has difficulty with? Does the child eat non-foods ? Any weight change perceived? What religious or cultural backgrounds are present?

+ For children

+ For adults

+ Sample IEP Objectives

+ IHP Information

+ Tube Feeding

+ Reasons for a G-Tube Medication Relieving distention by removing fluids and gas Relieving nausea and vomiting Removing gastric samples for testing

+ Tube Feeding Methods Bolus Syringe barrel- quick Intermittent Gravity Drip Slow drip from bag

+ Basic steps 1. Consider environment 2. Wash hands 3. Gather equipment 4. Positioning 5. Involve student 6. Inserting tube 7. Fill syringe 8. Unclamp 9. Monitor student 10. Monitor syringe 11. Water flush 12. Remove tube 13. Remain elevated (30 min) 14. Document procedure

+ Mechanical Pump: G-tube feeding tube

+ Bolus:

+ Potential Issues & Emergencies Aspiration Tube Displacement Nausea, Vomiting, Cramping Diarrhea Site Infection Leakage of Stomach Contents Clogged Tube