1. Modified Barium Swallows

2. Dysphagia Symptom of abnormal swallowing as it relates to aspiration of food and/or liquids, pooling, with or without residuals. Symptom of abnormal swallowing as it relates to aspiration of food and/or liquids, pooling, with or without residuals.

3. Typical Diagnoses exhibiting dysphagia CP CP Spina Bifida ( Arnold Chiari malformation) Spina Bifida ( Arnold Chiari malformation) Clefts/Pierre Robin Sequence Clefts/Pierre Robin Sequence Maxillofacial anomalies Maxillofacial anomalies CVA CVA TBI TBI SCI SCI MD MD Neuromuscular Dysfunction Neuromuscular Dysfunction Respiratory Dysfunction – BPD, laryngomalacia Respiratory Dysfunction – BPD, laryngomalacia

4. Cranial Nerve Involvement in Swallowing V. Trigeminal V. Trigeminal VII. Facial VII. Facial IX. Glossopharyngeal IX. Glossopharyngeal X. Vagus X. Vagus XI. Accessory XI. Accessory XII. Hypoglossal XII. Hypoglossal

5. 2 Assessments for Dysphagia MBS MBS Clinical Swallowing Assessment Clinical Swallowing Assessment

6. Modified Barium Swallow Procedure Patient’s medical history Patient’s medical history Feeding history including textures / consistencies with noted problems Feeding history including textures / consistencies with noted problems Lateral view in seated position Lateral view in seated position Anterior view if suspect asymmetry Anterior view if suspect asymmetry Offer variety of textures - typically start with “most unlikely to aspirate” / “most successful” consistency then progress. Offer variety of textures - typically start with “most unlikely to aspirate” / “most successful” consistency then progress. Ex.: thickened liquid Ex.: thickened liquid semisolid semisolid thin liquid thin liquid solid solid Assess swallow with each different consistency Assess swallow with each different consistency Educate family re: the results Educate family re: the results Communicate with MD to make feeding plan Communicate with MD to make feeding plan Make appropriate referrals. Make appropriate referrals.

7. Phases of Swallow Oral: tongue movement, premature spillage Oral: tongue movement, premature spillage Pharyngeal: timeliness of reflex, pooling, aspiration, residue after swallow Pharyngeal: timeliness of reflex, pooling, aspiration, residue after swallow Esophageal: motilty, obstruction Esophageal: motilty, obstruction

8. Typical problems noted on MBS Premature spillage Premature spillage Delayed swallow reflex Delayed swallow reflex Laryngeal penetration Laryngeal penetration Primary aspiration Primary aspiration Pooling Pooling Incoordination Incoordination Weakness/tone Weakness/tone

9. Characteristics of swallow dysfunction often related to specific problems Respiratory problems Respiratory problems--incoordination --primary aspiration Weakness / tone Weakness / tone--pooling --primary aspiration --delayed swallow reflex --residue

10. Understanding the Recommendations / Examples Thin liquids Thin liquids --small boluses given via spoon --no straws --controlled cup drinking – 1 swallow vs several continuous Thickened liquids Thickened liquids --As above --rice cereal, thick-it, simply thick --nectar or honey consistencies

11. Cont. Recommendations and Examples Semisolid (puree) Semisolid (puree) --consider texture – is it sticky, runny, lumpy --weakness- may recommend runny vs thick Solid Solid --mechanical soft – can chew and mash --crunchy- more proprioceptive input --meats – require grinding / rotary chew – more advanced oral skill

12. Cont. Recommendations and Examples Extra swallows – esp. if weak and unable to clear the pharynx – residue Extra swallows – esp. if weak and unable to clear the pharynx – residue Head in midline with chin tuck – Head in midline with chin tuck – Liquid between bites to “wash down” bolus – again if weak with residue, pooling, etc. Liquid between bites to “wash down” bolus – again if weak with residue, pooling, etc. In some cases of significant weakness, liquid is safer than thicker substances – would have to consider timeliness of swallow In some cases of significant weakness, liquid is safer than thicker substances – would have to consider timeliness of swallow

13. When to Refer for MBS Consistent choking Consistent choking Apparent incoordination Apparent incoordination Head and neck ext necessary to move bolus Head and neck ext necessary to move bolus Frequent respiratory illness Frequent respiratory illness Poor weight gain and limited intake Poor weight gain and limited intake