1. 1 Paediatric Dysphagia Grizelda Steyn Janet Smith Incorporated Audiologist & Speech Therapist St. Augustine’s Hospital

2. 2 Background of Dysphagia Feeding problems common in NICU/preterm infantsFeeding problems common in NICU/preterm infants Minor feeding problems in normal children 25-30%Minor feeding problems in normal children 25-30% 40-70% feeding problems in premature infants and infants with chronic illness40-70% feeding problems in premature infants and infants with chronic illness Feeding is very complex process which involve mouth, pharynx, larynx and esophagus and sucking reflex in infants in the first phase.Feeding is very complex process which involve mouth, pharynx, larynx and esophagus and sucking reflex in infants in the first phase. Cornerstones of infant feeding – suck/swallow/breathCornerstones of infant feeding – suck/swallow/breath Sucking reflex initiates swallowing in the infant by stimulation of the lips and deeper parts of the oral cavity.Sucking reflex initiates swallowing in the infant by stimulation of the lips and deeper parts of the oral cavity. The mandible, maxilla, upper gums, lips, palate and cheeks are necessary for compression of the nipple and expression of contentsThe mandible, maxilla, upper gums, lips, palate and cheeks are necessary for compression of the nipple and expression of contents

3. 3 General Background Any defect of lips, tongue, palate, mandible, maxilla or cheeks may create problems in the first phase of feeding in an infant.Any defect of lips, tongue, palate, mandible, maxilla or cheeks may create problems in the first phase of feeding in an infant. 3 stages of swallowing disorders – oral phase,pharyngeal phase and esopharyngeal phase)3 stages of swallowing disorders – oral phase,pharyngeal phase and esopharyngeal phase)

4. 4 What is Dysphagia? Difficulty swallowingDifficulty swallowing The inability of food or liquids to pass easily from the mouth, into the throat, and down into the esophagus to the stomach during the process of swallowing.The inability of food or liquids to pass easily from the mouth, into the throat, and down into the esophagus to the stomach during the process of swallowing.

5. 5 What could affect successful feeding in an infant? Conditions that impact the neurological system developing, respiration and digestion.Conditions that impact the neurological system developing, respiration and digestion. Medications often have side effects that could cause nausea, stomach pain and irritation.Medications often have side effects that could cause nausea, stomach pain and irritation. Cardiac patients often lack the endurance to take sufficient amount of liquid in a timely manner.Cardiac patients often lack the endurance to take sufficient amount of liquid in a timely manner.

6. 6 What about our Premature/NICU infants? Difficult deliveryDifficult delivery  Aspiration, hypoxia  Impacts : postural control, breathing regulation, state of infant, oral and pharyngeal reflexes Prolonged ventilationProlonged ventilation Cardiac problemsCardiac problems  Start with limited respiratory reserves  Difficulty regulating cardio-respiratory function  Impacts energy, endurance, intake, coordination and safety

7. 7 Premature/NICU infants Congenital anomaliesCongenital anomalies  Cleft lip- and palate Hyperbilirubinemia (Jaundice)Hyperbilirubinemia (Jaundice)  Impacts alertness, vigor and therefore intake. Infant of Diabetic motor( IDM)Infant of Diabetic motor( IDM)  Impact work of breathing and therefore disrupts coordination of suck-swallow-breathe sequence. Respiratory Distress Syndrome (RDS)Respiratory Distress Syndrome (RDS)  Compromise the transition to nipple feeding

8. 8 Common feeding difficulties in NICU Tires before finishing feedingTires before finishing feeding Lacks spontaneous mouth opening – breathing too much effort to be willing to suck.Lacks spontaneous mouth opening – breathing too much effort to be willing to suck. Feeding for long periods at a timeFeeding for long periods at a time Difficulty coordinating sucking, breathing and swallowingDifficulty coordinating sucking, breathing and swallowing Gagging during feedingGagging during feeding DroolingDrooling Congestion in the chest after drinkingCongestion in the chest after drinking Coughing or choking when drinking (or very soon afterwards)Coughing or choking when drinking (or very soon afterwards)

9. 9 Symptoms of Dysphagia Tiredness or shortness of breath while eating or drinkingTiredness or shortness of breath while eating or drinking Frequent respiratory infectionsFrequent respiratory infections Colour change during feeding, such as becoming blue or pale – silent aspirationColour change during feeding, such as becoming blue or pale – silent aspiration Spitting up or vomiting frequentlySpitting up or vomiting frequently Food or liquids coming out of the nose during or after a feedingFood or liquids coming out of the nose during or after a feeding Disorganized sucking – overall postural disorganization and poor sucking rhythm, poor tongue stabilityDisorganized sucking – overall postural disorganization and poor sucking rhythm, poor tongue stability Trouble latching – related to breathing, abnormal CNS or could be oral-tactile hypersensitivityTrouble latching – related to breathing, abnormal CNS or could be oral-tactile hypersensitivity Weight lossWeight loss

10. 10 Important to remember… The reluctance to suck may be an instinctive reaction, a purposeful respond to attempt to protect their airway.The reluctance to suck may be an instinctive reaction, a purposeful respond to attempt to protect their airway.

11. 11 Protocol for Oral feeding 34 weeks G.A34 weeks G.A Weight of 1.6kgWeight of 1.6kg No medical conditions that would interfere with feedingNo medical conditions that would interfere with feeding Respiratory rate: 70 breaths per minuteRespiratory rate: 70 breaths per minute Effort: no change in skin colourEffort: no change in skin colour Able to maintain a wakeful state of 10-15 minutesAble to maintain a wakeful state of 10-15 minutes Aspiration: none (Swallowing of Oral Secretions?)Aspiration: none (Swallowing of Oral Secretions?) Ability to gag and reflexively protect airway.Ability to gag and reflexively protect airway. Rhythmic, non-nutritive suckingRhythmic, non-nutritive sucking

12. 12 Treatment of Dysphagia Goal of treatment plan is safe, independent feeding(swallow). Changing bottle or teats – Premature infant – bigger teat provide internal stability. (Tongue position and mouth size).Changing bottle or teats – Premature infant – bigger teat provide internal stability. (Tongue position and mouth size). Positioning – impacts airway maintenance, breathing, safe swallow and organization of infantPositioning – impacts airway maintenance, breathing, safe swallow and organization of infant Swaddling – provides overall postural support and containmentSwaddling – provides overall postural support and containment Pacing of feedsPacing of feeds Flow rate – greatest obstacle to safe and successful feeding. Increased flow – poor endurance/weak suck. Reduce flow- poor coordination of SSB. Aspiration!!Flow rate – greatest obstacle to safe and successful feeding. Increased flow – poor endurance/weak suck. Reduce flow- poor coordination of SSB. Aspiration!!

13. 13 Treatment of Dysphagia Oral motor & Swallowing simulation techniquesOral motor & Swallowing simulation techniques PacifiersPacifiers Calorically dense formulas (Cardiopulmonary disorders)Calorically dense formulas (Cardiopulmonary disorders) NGTNGT PEGPEG

14. 14 Outcome of our babies in NICU Early interventionEarly intervention Good prognosis for babies with no severe or chronic illnessGood prognosis for babies with no severe or chronic illness Maturation of CNSMaturation of CNS Alternative feeding as part of goal towards successful feedingAlternative feeding as part of goal towards successful feeding

15. 15 Questions or Comments?