1. 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

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

4. 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 +)

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

6. 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

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

8. TREATMENT  Non-medical …Thickening …Positioning Feeding frequency

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

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

11. TREATMENT  Child/Family …Food as power

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

13. 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

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

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

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

17. 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

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

19. SEPARATION OF MOVEMENT  From gross motor to fine motor

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

21. REFINED ORAL SKILLS

22. 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

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

24. …Rolling and weight shifting …Diagonal and rotary movements

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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