1. Chapter 9: Pediatric Feeding and Swallowing Disorders Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

2. Focus Questions What are pediatric feeding and swallowing disorders? How are pediatric feeding and swallowing disorders classified? What are the defining characteristics of prevalent types of pediatric feeding and swallowing disorders? How are pediatric feeding and swallowing disorders identified? How are pediatric feeding and swallowing disorders treated? 9.1 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

3. Introduction When eating/feeding is compromised, it can impact physical, cognitive, psychological, and communicative development –Impact on communication: feeding promotes bonding and attachment, and supports communicative routines (e.g., turn taking and joint attention) If disorder is present, feeding specialist (SLP) focuses on strengthening the oral- motor system, including functions, muscular tone, and sensation 9.2 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

4. Case Study #1: Lily 2-year old Chinese-American girl with cerebral palsy and oral motor dysfunction At two weeks of age, modified barium swallow study showed aspiration during bottle feeding and poor coordination of tongue during sucking –placed on a gastronomy tube Now 2 years old, parents would like to begin feeding Lily orally Lily is in a wheelchair, has use of her hands, and is cognitively delayed and unable to follow directions 9.3 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

5. Case Study #1 Questions How do you think Lily’s feeding and swallowing difficulties affect her family? Given that Lily has been on a feeding tube for two years, why would her parents want to pursue oral intake at this time? What other aspects of Lily’s life may be affected by her dependence on a gastronomy tube for nutrition? 9.4 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

6. Case Study #2: David 3-month old child born prematurely (30 weeks) and has stayed in the NICU since birth – youngest of four children At first, demonstrated coughing and choking, so nurses thickened his formula – but then he became very fatigued during feeding and would not get adequate nutrition before falling asleep Placed on nasogastric tube for supplemental feeding 9.5 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

7. Case Study #2 Questions How might David’s NICU admittance affect his family? What are some ways that David’s parents might be involved with his feeding while in the NICU? 9.6 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

8. Case Study #3: Cory 2-year old boy with a normal birth 6 weeks: began projectile vomiting during breast feeding, was given medication, and the problem was resolved 6 months: refused introduction of baby foods, but still breastfeeding well 9 months: growth was slowing down and vomiting increased again 11 months: hospitalized for failure to thrive and diagnosed with “behavioral feeding aversion”, placed on a gastronomy tube Now, parents want him enrolled in intensive behavioral feeding program to wean off the tube feeding 9.7 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

9. Case Study #3 Questions How might Cory’s feeding problems affect his family and his own psychological wellbeing? What are some possible causes for Cory’s food aversions? What are some factors that might predict whether Cory will successfully be weaned from the feeding tube? 9.8 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10. I. What are Pediatric Feeding and Swallowing Disorders? A.Feeding Disorders “persistent failure to eat adequately” for a period of at least one month which results in significant loss of weight or failure to gain weight Manifests prior to six years, but onset is usually in first year of life Usually demonstrates one or more of the following: unsafe or inefficient swallowing, growth delay, lack of tolerance to food textures and tastes, poor appetite regulation, and rigid eating patterns 9.9 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

11. B.Swallowing Disorders Specific type of feeding disorder in which child exhibits unsafe or inefficient swallowing pattern that undermines feeding process Swallowing (deglutition) is the act of moving a substance (bolus) from the oral cavity to the esophagus Increases the risk for: –Penetration: food or liquid enters the larynx –Aspiration: food or liquid passes through the larynx into the lungs 9.10 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

12. Prevalence and Incidence Difficult to estimate, although 10% of young children experience malnutrition (not all because of feeding and swallowing disorders) Disorders are prevalent in the context of certain risk factors: –Low birth weight (8% of all babies in U.S.) –Neonatal Intensive Care Unit (NICU) – can interfere with development of pleasurable oral experiences and exposure to foods, and may increase risk for food refusal, inappropriate meal time behaviors, and/or inefficient ingestion 9.11 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

13. Terminology – Nutrition Nutrition: individual’s intake of calories and nutrients to meet requirements for energy, growth, development, and learning National Academy of Sciences: recommended dietary allowances (RDAs), standards of nutrition for normal, healthy development Undernutrition and malnutrition: requirements are not met, usually due to environmental factors or developmental disabilities 9.12 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

14. Terminology – Growth Growth: children’s height (length) and weight achievements, and the relationship between them Growth charts: provide a child’s relative standing among all infants – allows for differentiation between small children and children whose growth is faltering Growth deficiencies: –Underweight: less than expected based on age –Wasting: less than expected based on height –Stunting: height is less than expected based on age 9.13 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

15. Feeding and Swallowing Development Feeding is a reflexive activity, and should be effortless, efficient, effective, and pleasurable Proper nourishment is the most important job for parents of a newborn First two years of life: move from a reflexive feeder to an independent eater with specific preferences for taste and texture 9.14 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

16. Birth to Six Months Four primitive reflexes facilitate feeding outside the womb: –Suckling: stimulating the infant’s lips will result in suckling, which will be followed by a swallow –Rooting: stimulating the area around the infant’s mouth will elicit a head turn in the direction of stimulus –Grasping: infant’s fingers will close tightly around a stimulus placed in the palm –Gagging: protective reflex that triggers a strong physical reaction to substances entering the laryngeal area 9.15 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

17. Six to 12 Months Increased trunk support and head control for sitting – transition to solid foods Active biting and chewing – new teeth Shift in position from reclining to upright – more face to face engagement and social interaction 8-9 months: independent sitting – everything goes into the mouth as a way of exploring the world Critical period in the child’s future acceptance of foods 9.16 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

18. Twelve Months and Beyond Moving to be more independent eater – may no longer wish to be fed by the caregiver Increasingly has the words to express wants By 18 months, get many calories through regular table food (eating with the rest of the family) By 24 months, total mastery of all foods is expected 9.17 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

19. II. How are Pediatric Feeding and Swallowing Disorders Classified? Based on descriptive features –Focuses on clinical presentations or observable symptoms Based on etiology –Focuses on known or suspected causes of the disorder 9.18 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

20. Descriptive Features A.Timeframe of Disorders Transient: short lived or readily correctable Episodic: occurs periodically Chronic: ongoing over months or years and cannot be resolved easily 9.19 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

21. Descriptive Features B.Behavioral Characteristics Three sets of feeding and swallowing problems (Kessler): –Eating too little: excessive food selectivity and severely restricted diet –Eating too much: excessive over- consumption –Eating the wrong things: consume inappropriate non-nutritive substances (e.g. pebbles, soap) - pica 9.20 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

22. Etiology A.Organic Causes (66% of cases) Known physical causes for the disorder divided into three categories: –Neuromotor dysfunction: impairment of neurological or motoric systems required for safe and efficient feeding and swallowing –Mechanical obstruction: obstruction in the feeding and swallowing apparatus –Medical/Genetic abnormality: illness, trauma, or disability 9.21 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

23. Etiology B.Non-organic Causes (34% of cases) Causes= is not clearly evident Four likely causes: –Physical/emotional: reaction to the environment (e.g., abuse, parental depression) –Educational: inadequate caregiver knowledge concerning feeding, eating, and nutrition –Environmental: primarily financial constraints in which food is under-available –Behavioral: feeding and/or swallowing deficits resulting from learned behaviors 9.22 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

24. Biopsychosocial Perspective Early physiological or medical problem may trigger psychological and interactional issues which contribute to maladaptive behaviors Often difficult to categorize disorder as organic or non-organic – instead the disorder stems from a variety of biological, psychological, and social influences 9.23 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

25. Failure to Thrive Widely-used term for children whose weight or height deviates significantly from the norm for the age and gender – due to nutritional inadequacy: –Due to limited access to food, intake of food, and/or limited retention or absorption of food Not all children with FTT have a feeding disorder and vice versa Some experts consider FTT a pejorative terms, so pediatric undernutrition and growth deficiency are preferred 9.24 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

26. III. What are the Defining Characteristics of Pediatric Feeding and Swallowing Disorders? Children with disorder usually exhibit one or more of the following: –Feeding and/or swallowing that is unsafe –Feeding and/or swallowing that is inadequate –Feeding and/or swallowing that is inappropriate 9.25 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

27. Unsafe Feeding and Swallowing Unsafe feeding and swallowing poses a risk for penetration or aspiration as well as poor nutrition –Unsafe swallowing (dysphagia) results from dysfunction or damage of the child’s oral- motor system or an inappropriate eating rate (either too fast or too slow) –Unsafe swallowing may result in a physician’s order for “nothing per oral” (NPO): child cannot ingest anything through mouth 9.26 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

28. Causes and Risk Factors Accompanies several syndromes that feature low muscle tone, delayed motor development, and physical deformities Cerebral Palsy: risk factor for dysphagia –First year of life: 57% exhibit problems with sucking 38% exhibit problems with swallowing 33% exhibit malnutrition or FTT Other conditions: –Significant anomalies of oral structures –Chronic or recurrent respiratory problems –Cardiopulmonary diseases 9.27 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

29. Inadequate Feeding and Swallowing Inefficiency: unable to meet caloric and nutritional needs because process of feeding and swallowing is not productive Overselectivity: restrictive in taste, type, texture, and/or volume of foods eatern Refusal: complete refusal to feed, due to ongoing medical issues, gastro-intestinal distress, or traumatic experiences Feeding Delay: delayed development of feeding skill milestones 9.28 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

30. Causes and Risk Factors Low birth weight: low or very low birth weight at risk for feeding/swallowing disorders Developmental disabilities: Down syndrome, autism, and cerebral palsy (and other conditions) may result in motor or muscular weakness and/or sensory defensiveness (autism) Prematurity: born at or before 37 weeks, may result in immature systems (e.g., digestive) Prenatal drug exposure: alcohol, tobacco, cocaine, heroin, etc. – linked to prematurity and low birth weight Diet restrictions: strict or modified diets (due to diabetes, PKU, etc.) may result in feeding challenges and resistance to eating 9.29 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

31. Inappropriate Feeding and Swallowing Children exhibit undesirable or disruptive behaviors during mealtimes that inhibits successful feeding –Examples: screaming, spitting, throwing, hitting, drop food on the floor, eating at inappropriate rates Eating too slow: nutritional deficiencies Eating too fast: choking or aspiration 9.30 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

32. Causes and Risk Factors Negative parent behaviors: over-stimulating, under-stimulating, rigid and demanding, chaotic and frenzied, overly concerned or anxious For a positive feeding time… –Infants must exhibit the following characteristics: positive, alert, calm, show readable cues for hunger and fullness, and willingness to try to tastes and textures –Toddlers must exhibit the following characteristics: interested in eating, indicate hunger and fullness, follow a predictable meal schedule, positive behaviors 9.31 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

33. IV. How are Pediatric Feeding and Swallowing Disorders Identified? Early Identification and Referral Comprehensive Assessment 9.32 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

34. Early Identification and Referral Children’s height and weight is carefully monitored by the pediatrician on a growth chart at routine “well-child” visits When feeding or swallowing problems are suspected, pediatrician will make at least two referrals: –Ear-nose-throat specialist (ENT) or gastroenterologist –Feeding specialist 9.33 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

35. Comprehensive Assessment Case history Physical feeding/swallowing evaluation Observation of mealtime interactions 9.34 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

36. Case History Collected via interview Most important: child’s feeding history, including length of meals, quality of intake, progression from bottle to solids, and history of formulas used Also important: discussion of child’s developmental progression, including cognitive and language abilities, gross and fine motor skills, sensory processing, and temperament 9.35 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

37. Physical Feeding and Swallowing Evaluation Structural examination: physical nature of oral-motor structures, looks for asymmetry, drooling, and abnormal patterns or reflexes Functional examination: how the oral-motor structures work together, looks at safety and efficiency and quality of intake If any problems are seen, child may be referred for modified barium swallow study (MBS) – radiography follows a substance through child’s swallowing process 9.36 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

38. Observation of Mealtime Interactions Live observation by outside professional of the child during mealtime interactions –Examines for any breakdowns in child- caregiver communication and for unsafe or inefficient oral feeding practices Feeding specialist studies scheduling of meals, environment, foods presented, and family traditions 9.37 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

39. V. How are Pediatric Feeding and Swallowing Disorders Treated? Multidisciplinary Alliance: Collaboration of parents and professionals in working alliance to ensure effectiveness of treatment Most involved professionals: –Pediatrician –Nutritionist –Feeding specialist 9.38 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

40. Treatment Contexts NICU: Neonatal Intensive Care Unit –Evaluations and interventions of feeding and swallowing for medically fragile infants –Encourages communication and stimulates oral- motor mechanisms Special Clinics –Inpatient treatment in an intensive, hospital-based program –Accompanied by treatment in other contexts, like home visits (allows specialist to study food prep, meal options and timing, discipline, child behavior, and feeding relationships in authentic context) 9.39 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

41. Treatment Goals and Approaches Physiology of Feeding and Swallowing Psychology of Feeding and Swallowing Alternative and Supplemental Feeding 9.40 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

42. Physiology of Feeding and Swallowing Focus on muscle tone, articulator movement, oral-motor sensitivity, and body posture Hierarchical continuum of training targets (short-term goals): start at child’s present skill level and progress towards independent eating (long-term goal) 9.41 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

43. Psychology of Feeding and Swallowing Focus on accepting certain food types or textures, decreasing resistance and fussiness during eating sessions, and following predictable meal schedule Uses behavioral principles for treatment: –Shaping – incrementally moves child towards goal –Conditioning and reinforcement – training of new behavior through positive reinforcement –Systematic desensitization – trains child to accept an aversive sensory experience 9.42 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

44. Alternative and Supplemental Feeding Enteral or tube feeding – liquid nutrition is delivered through a tube (can be sole avenue for nutrition or supplemental to oral intake) –Short-term treatment: nasogastric tube –Longer-term treatment: gastronomy tube or jejunostomy tube Special support also given to caregiver-child feeding relationship and to promoting oral abilities even when not used for feeding 9.43 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.