Pediatric dysphagia June 13, 2014.

Pediatric dysphagia June 13, 2014

Anatomy and physiology
Stability is provided positionally (structures are very close and large amounts of fat) Tongue fills entire oral cavity – touching cheeks, hard, and soft palate Tongue tip sticks out past the alveolar ridge and touches the lower lip Fat pads in the cheeks help support oral and pharyngeal function Soft palate is large, uvula close to the tip of epiglottis Faucial pillars touch the epiglottis Hyoid and larynx very close together, near the mandible and much higher in the neck Anatomy and physiology

Anatomy and physiology
Base of tongue and larynx Descend during the first 4 years of life By 4 years the base of tongue has descended far enough that it forms the anterior wall of the oropharynx Changes continue during childhood and accelerate during puberty Sucking pads disappear between 4 to 6 months of life Infants tongue fills its mouth and sits more anteriorly than an adults Mandible is smaller, makes the tongue look oversized Tongue, soft palate, pharynx and larynx are higher in the neck Facilitates to coordinate nasal breathing during the swallow Extremely important for an infant to coordinate the suck, swallow, breathe pattern. Anatomy and physiology

Not much space between epiglottis and soft palate
Larynx is much higher as well

Infant mandible is very horizontal whereas adults are vertical

Coordination between sucking, swallowing and breathing
Obligatory nose breathers because of their anatomy Swallow coincides with cessation of breathing (1 sec) Most infants begin with a suck(le) – swallow – breathe pattern (1:1:1 ratio) May change to 2:1:1 ratio towards the end of a feed Establish and maintain a rhythmic pattern Infants are nose breathers—big tongues in oral cavity in infancy and it’s hard to breathe through their mouths When swallowing they cease to breathe for 1 second. Coordination between sucking, swallowing and breathing

Four phases of swallow Oral prep phase When sucking occurs in infants
Longer in children who are eating solid foods that have to be chewed Manipulates food or liquid in the mouth to form a bolus Lips close around the nipple or cup so no liquid is lost Liquid is moved around the mouth to form a bolus Bolus is held between the tongue and hard palate Soft palate is pulled forward against the base of the tongue to keep the bolus from falling into the pharynx The airway is open and nose breathing continues Four phases of swallow

Four phases of swallow Oral voluntary phase
Begins as soon as the child moves the bolus posteriorly Ends when the bolus leaves the oral cavity Less than one second for an infant with normal development Tongue is elevated toward the soft palate Tongue presses against roof of the mouth in a peristaltic motion to squeeze food or liquid backward The bolus leaves the mouth Four phases of swallow

Four phases of swallow Pharyngeal phase
Begins with the initiation of the pharyngeal swallow True vocal folds close - arytenoids come together The false vocal folds close The hyoid and the larynx are pulled up and forward Epiglottis is pushed down to deflect the bolus to either side and to move it posteriorly away from the airway Bolus propelled through the pharynx by pressure created by base of tongue, movement of the upper esophageal sphincter (caused by lifting the larynx) In the pharynx the bolus divides, half moves through the pyriform sinus on each side of the pharynx Rejoins right above the level of the upper esophageal sphincter Four phases of swallow

Esophageal phase – persistent peristaltic wave moves bolus through the esophagus into the stomach
Wave associated with each pharyngeal swallow May be delayed or observed after 4 or more swallows Four phases of swallow

Suckling/sucking Non-nutritive suckle Infants start with a suckle
Sometime between 6-9 months it changes to a suck Engage in nutritive and non-nutritive suckle Nutritive suckle Continuous burst which changes to intermittent bursts Bursts become shorter with longer pauses as feeding proceeds One suck per second Swallow 1:1 ratio Suck more often than swallowing towards end of the feeding (2:1 ratio) Non-nutritive suckle More repetitive On a pacifier—more repetitive bc. nothing to swallow 6 sucks per second, 6-8 sucks per swallow Suckling/sucking

Suckling/suck In a suckle
Lips close around a nipple and turn outwards (inner part of the lips touch the nipple) Both positive and negative pressure used to expel milk Positive pressure occurs when fluid is compressed, squeezed or pushed out of the nipple (squeezing toothpaste out of the tube) Negative pressure similar to suction action (using a syringe to draw out liquid) Tongue, lower lip, mandible and hyoid move together Move down and forward and then up and back Downward movement causes negative pressure Up and back movement causes positive pressure Occurs 2 times per second Main difference: back and forth movement—tongue goes forward, squeezes against nipple, goes a little be backward Suckling/suck

Suckling/suck In a suck:
The front of the tongue pushes against the nipple and causes positive pressure Back of the tongue lowers which increases the volume of the oral cavity Causes negative pressure and suction Negative pressure more important especially during breast feeding Main difference: up and down movement *For children who maintain tongue thrusts when eating (ie. Someone with cerebral palsy) may need to be trained by drinking through the straw Suckling/suck

Response to stimuli Reflexes and responses to protect the airway
Reflexes are triggered from receptors in the nose, nasopharynx, upper airway and lungs Triggered by chemical receptors (responds to chemicals such as water, milk or secretions, acid, etc) or mechanical receptors (touch and pressure) Any time the infant has a pause in respiration because of these receptors it is called apnea Protective to shut the airway and close larynx If it continues causes hypoxia and bradycardia Response to stimuli

Kids with cerebral palsy or born pre-mature have heightened gag reflexes.
Gag not just stimulated by touching but also by smell Phasic bite reflex stimulated by touching teeth—they will clamp down on your finger Rooting: stroking the side of cheek to the corner of the mouth and their mouth will open

Primitive reflexes rooting suckling sucking swallowing
tongue thrusting biting gagging palmomental Primitive reflexes

Feeding and swallowing impairments
Infant who fails to suckle feed or who suckles or swallows poorly demonstrates problems of feeding readiness, illness or injury More concerned about the infant who continues to have feeding failure Causes lie in developmental history of the mouth, pharynx and representation of these areas in the brain Abnormalities of mouth and pharynx and/or of the brain Sharing of function between mouth/pharynx and the brain

Feeding and swallowing impairments
Sensory input from the mouth and the pharynx stimulate the development of various areas in the brain which further refine the oral and pharyngeal movements Hypoplasia of the tongue may achieve a suckle with compensatory functions of the pharyngeal constrictor wall, palatine folds Children with cleft palate may compensate by use of the tongue, and constrictors

Premature infants Gestational period is less than 36 weeks
Negatively affect their growth and development Not capable of oral feeding due to poorly organized sucking bursts Disorganized jaw and tongue movements Immature lungs Intolerant of apneic periods during swallowing Other circulatory or neurological immaturity Surfactant coats inside of lungs—if its not present the lungs may collapse; they may shrink…they have a sucking in movement (rather than expansion) during respiration—not god for breathing, swallowing, and apnea

Premature infants Maternal anxiety because infants are
Less interactive Less responsive Fussier with less positive affect Fewer vocalizations during feeding and play Chronic illnesses and significantly higher level of care giving Ultrasound show swallowing amniotic fluid as early as 13 weeks Suck, swallow and breath coordination develops after 34 weeks gestation Oral prematurity – lack of sucking pads (fattieness of cheeks) Maternal bonding helps improve the babies state of health Swallow is present as earlya s 13 weeks Premature infants

Premature infants Birth weight
An extremely low birth weight (ELBW) infant is defined as one with a birth weight of less than 1000g (2lb, 3oz) Most extremely low birth weight infants are also the youngest of premature newborns, usually born at 27 weeks' gestational age or younger Infants born at less than 1500g are defined as having very low birth weight (VLBW) Premature infants

Premature infants Birth weight Low birth weight infants are < 2500g
Infants whose weight is appropriate for their gestational ages are termed appropriate for gestational age (AGA). Infants who are heavier than expected are large for gestational age (LGA) Those smaller than expected are considered small for gestational age (SGA) and are also usually found to be intrauterine growth restricted (IUGR) prior to birth. Larger babies—may be because of gestational diabetes in the mom Small babies (not premature)—may be a twin; cysts or tumors in mother; child may swallow amniotic fluid Premature infants

Premature infants Intercranial hemorrhage Necrotizing enterocolitis
½ to 1/3 infants weighing less than 1500 gms Results in visual deficits, gross motor disorders, speech delays and swallowing disorders Location and extent of hemorrhage Necrotizing enterocolitis Excessive gas Mucosal injury in the esophagus Perforated bowel Short gut syndrome due to surgery Feeding intolerance abdominal distention, gastric retention of feedings Total NPO, bowel rest, antibiotics and surgery Necrotizing—cant tolerate feeding Premature infants

Premature infants Infant respiratory distress syndrome
Insufficient amounts of surfactant 70% of infants younger than 28 weeks develop IRDS Bronchopulmonary dysplasia Seen in infants with positive pressure ventilation Increased respiratory rates Decreased pulmonary compliance Impaired gas exchange and respiratory fatigue Infants under 1000 grams develop BPD (50-85%) Treated with oxygen, steroids, and diuretics Feeding difficulties due to inability to regulate breathing and swallowing, decreased endurance and orally defensive Pace the infant, frequent breaks, burp frequently and increase the amount of oxygen Iron lungs are better for the respiration than a ventilator. ---ventilator does all the work for the lungs Premature infants

Prematurity Congenital heart disease Deficits in cardiovascular system
Results in abnormal blow flow Increased heart rates and blood pressure Compensate for inability to pump enough blood Increased oxygen demands during feeding Use more external support Provide frequent breaks Higher caloric formula High flow nipple Proceed with caution not to overwhelm with too much formula Prematurity

Ventricular septal defect (hole between the right and left ventricles)
Narrowing of the pulmonary outflow tract (the valve and artery that connect the heart with the lungs) Overriding aorta (the artery that carries oxygen-rich blood to the body) that is shifted over the right ventricle and ventricular septal defect, instead of coming out only from the left ventricle A thickened muscular wall of the right ventricle (right ventricular hypertrophy) Tetralogy of Falot

Tetralogy of Fallot is common in children with Down’s
*Surgery for this has the risk of getting the recurrent laryngeal near the aorta cut—which would results in VF paralysis either in Abduction or Adduction

Gastroesophageal reflux disease
Contents of the stomach (acid) returning to the esophagus Lower esophageal sphincter does not work properly Increase in intra-abdominal pressure above the pressure of the LES During normal activities of crying, coughing, moving and defecating Gastrostomy tubes develop significant GERD within 6-12 months Symptoms include: Projectile vomiting Cough, choke, or gag Abnormal posturing (arching back) Exhibit irritability GERD- Gastro-esophageal Reflux Disease Contents of stomach come up through esophagus Gastroesophageal reflux disease

GERD Respiratory complications
Esophageal/gastroenterologic complications Failure to thrive Diagnosis Barium swallow PH Probe Upper endoscopy Scintigraphy Nuclear medicine Positron emission tomography Wall of esophagus becomes eroded GERD

GERD Management Behavioral
Position at 30 degree upright or on an incline Thickened feedings Smaller more frequent feedings Fasting before bed Medical Inhibits nocturnal acid secretions Tagamet Zantac Pepcid Axid Increases amplitude of peristaltic contractions Reglan Surgical Nissen fundoplication- sphincter sewn tightly shut so that it’s a one way valve downward—they would never be able to vomit

Short bowel syndrome Inability to absorb nutrients
Occurs after resection of the small intestine Caused by Multiple intestinal atresias Intestinal malrotation Necrotizing enterocolitis Abdominal wall defects Nutrition via central line Anti-motility drugs (Imodine or Lomotil) Recession or twisting of small intestines—there might be blockage Short bowel syndrome

Cerebral palsy Cerebral palsy
Occurring prior to or at birth or soon after Spastic cerebral palsy – excessive muscle tension, abnormal postures and movements, exaggerated gag reflex Infant unable to hold the nipple because of increased muscle tone and an arched posture Once the nipple is in place, the infant may gag and unrhythmical Delayed swallow – at risk for aspiration GERD makes ingestion of food painful 25% of older children have dysphagia Bite reflexes, drooling, poor trunk control, coughing or choking during meals Can occur prior to birth (anoxic event) During birth—prolong labor, also anoxic event Cord strangulation immediately after birth Cerebral palsy

Head injury With dysphagia stay in hospitals twice as long
Nutritional needs during coma Decorticate or decerebrate posturing need 20% higher basal energy 1½ times greater caloric intake for the healing process Dysphagia similar to those of adults however, differences include physiological differences, cognitive and behavioral issues, social impact on the family Start feeding at Rancho level III Head injury

Impulsive, taking large bites, failing to chew and swallow before taking another bite
GERD Treatment suggestions Upright posturing Reduce oral hypersensitivity Absent swallow reflex Bite reflex Used a rubber coated spoon Head injury

Autism spectrum disorder
Pervasive developmental disorder and autism Social withdrawal, communication deficits, and repetitive stereotypic behaviors Hypersensitivity to light, sound, pain, smell & touch Social withdrawal affects oral phase Impaired body posture and tone interferes with positioning for feeding Hypersensitivity to smell cause infants to recoil from food Hypersensitivity to touch and taste may interfere with the oral phase Lick, smell or attempt to eat nonfoods (pica) DSM V- Level 1, 2, 3 of severity of spectrum disorders (no longer aspbergers) Autism spectrum disorder

Spina bifida Spina bifida Spinal column malformation
Lack of closure of the neural tube Vertebrae do not completely fuse Limited sensation and motor control difficulties May experience difficulty in all phases due to limited sensation Pharyngeal and esophageal stages of swallow affected by the cranial nerve damage Suck and intake of food disturbed due to sensory impairment and dyspraxia (difficulty coordinating movements) -Depends on where in the spinal column is affected -These pts. have a lot of difficulties with lower extremities -May have problems with sensory impairment and dyspraxia *Children with spina bifida are allergic to latex -Language is characteristic of “cocktail party speech”—appear as if language is within normal limits, but it’s only fluff there is no substance…change topics quickly -Automatic speech comes out mostly Spina bifida

-Loop in that pocket is where the spinal cord has come out of the column
-Neural tube should close by 22 days after birth

Fetal alcohol syndrome
Airway feeding problems Choanal stenosis – atresia CHARGE – coloboma, heart disease, atresia of the choanae, retarded growth and development Genital hypoplasia and ear anomalies Pierre Robin sequelae Glossoptosis Inward palatal arches Lateral pharyngeal wall hypotonia Tracheo-esophageal fistulae or atresia Repair may cause tracheomalacia Laryngeal anomalies Pyloric stenosis Coloboma: slits in eyes Atresia of choanae: related to nasal cavity and nasopharynx Glossoptosis: tongue falls backwards Lateral Pharyndeal hypotonia: feeding and respiratory problems Tracheomalacia: cartilage of trachea is soft and gets sucked in—when pt. breathes you can hear stridor Pyloric valve stenosis: (pyloric goes from stomach to duodenum) Fetal alcohol syndrome

Moebius syndrome Moebius syndrome Damage to the cranial nerves
Weakness of the face, mandible, lips, and tongue Difficulty closing lips Food and liquid dribbles out of the mouth -Can’t close mouth/keep food in oral cavity—can’t move food to back of oral cavity -Cannot taste food so feeding is not enticing Moebius syndrome

Pediatric dysphagia Cognitive impairment and developmental delay
Motor coordination and delay interfere with self-feeding and oral phase of swallowing Communication disorders cause difficulty in expressing preferences Down syndrome and Prader-Willi syndrome Prader-Willi: can eat and eat and eat til they throw up and not stop—their center for satisfaction is missing, they do not realize they are full; also may have craniofacial anomalies Pediatric dysphagia

HIV/AIDS White blood cells, the brain, and other parts of the body are affected Transmitted in utero and/or through breast milk 45% have serious feeding problems Static encephalopathy – developmental delay, microcephaly, seizure, non-progressive Progressive encephalopathy – neurological deterioration due to direct brain infection Oral herpes, cognitive, language, and attention deficit disorders Odynophagia – pain while swallowing due to damage of the esophagus, crying after a couple of swallows -Automimmune disorder—contract everything they come in contact with -Neurological degeneration -Lots of language issues and ADD HIV/AIDS

Malnutrition – affects other systems in the body and puts them at risk for aspiration, increased fatigue during eating, slow feeders with poor sucking, chewing and bolus formation and food aversion to textures Effects of AIDS drugs caused nausea, vomiting, increased reflux and decreased appetite Treatment Analgesic 20 minutes before a meal Increase flow of oxygen Medicine in pudding or other flavorful foods Smooth cold foods Avoid strong flavor and acid foods *Smooth, cold foods are much better than acidic, strong flavored foods. HIV/AIDS

Failure to thrive Failure to thrive
Consistently below the third percentile for age or is less than 80% of the ideal weight for age Organic, non-organic and mixed etiology Organic factors include Endocrine deficiencies Chronic diseases Enzymatic defects Genetic anomalies Oral motor dysfunctions Non-organic factors include Poor mother infant interaction Psycho social issues Environmental deprivation Child abuse Poor feeding practices Failure to thrive

Craniofacial anomalies
Cleft palate Cleft lip Submucous cleft Surgical repair Positioning Nipple burping Type of bottle Frequency of feeding Craniofacial anomalies

Normal development of feeding
bottle/breast cup drinking straw drinking birth – 6 months 7 – 12 months (about 1 month after spoon feeding begins) 36 months Normal development of feeding

Spoon feeding Munching/chewing Controlled, sustained biting Rotary chewing 4-6 months 6-7 months 12 + months months Normal development of feeding

Evaluation for dysphagia
Screening to determine if an individual is at risk Silent aspiration (lack of cough when food or liquid enters the airway) Complete assessment as part of a team Determine appropriate intervention Failure to thrive Monitor for weight gain and development Non-instrumental Clinical Evaluation (NICE) Breathing and physical coordination Ability to form a seal and suck using nutritive and non- nutritive sucking Caregivers counseled and further evaluation scheduled if necessary Evaluation for dysphagia

Dysphagia evaluation Refer when Case history Clinical assessment
Difficulties observed relating to feeding and ingestion of food or liquid At risk for aspirating food or liquid Does not receive adequate nourishment Case history Clinical assessment Caregiver and environmental factors Cognitive and communicative functioning Head and body posture Oral-motor mechanism Laryngeal function Swallowing mechanism Case History is the FIRST thing to talk about Dysphagia evaluation

Case history Current status Social history Medical history
Medical diagnosis Present concerns Reason for referral Social history Family, parent/caregiver relationship, Siblings Home and feeding environment Medical history Neonatal/birth history Pregnancy and delivery history Apgar scores Perinatal complications Anesthesia during birth Respiratory, ventilatory support Current medications Past surgeries Case history

Case history Medical history contd. Feeding and swallow history
Genetic and neurological evaluation Lab reports Ear infections Sleep patterns Current interventions Allergies Motor and speech and language development Personality Feeding and swallow history Feeding develop Tube feeding history Weight gain history Reflux/emesis during and after meals Aversive behaviors Case history

Evaluation behavior/state/sensory integration Stage 1: deep sleep
Stage 2: light sleep Stage 3: drowsy semi dozing Stage 4: quiet alert Stage 5: active alert Stage 6: alert agitated Stage 7: crying Evaluation

Evaluation Tolerance for feeding
State-related: staring, panicked or hyperalert, silent crying, dozing, and startle Motor-related: facial grimacing, twitching, hyperextension of the trunk, arms, hands or legs Autonomic mild: gasp, sigh, sneeze, sweating, hiccup, tremor, startle, and strain Autonomic severe: coughing, gagging, reflux, skin color change, respiratory pausing, irregular respiration Evaluation

Evaluation General postural control/tone
Assess muscle tone/posture/movement abnormalities Evaluate head/neck/trunk alignment Disassociation of head/neck from shoulder girdle (head support) Note abnormal compensatory behaviors Respiratory function/endurance Respiratory patterns at rest and during activity Respiratory patterns Belly breathers Gulp breathers Ribcage flaring Sternum depression Reverse breathing Irregular shallow apnea Reverse breathing: common in premature kids; when they breathe in, rib cage expands but stomachs go in and vice versa. Evaluation

Evaluation Oral motor/cranial nerve evaluation Oral primitive reflexes
Oral structure and function Lips Observe lips at rest and note symmetry Observe bilabial closure Maintain lip closure for 5 seconds Upper and lower lip for strength increased, decreased or normal Anatomical deviations Symmetry and range of motion Lip opening and closing independent from the jaw Lip rounding Lip spreading Lip resistance Abnormal movement patterns, retractions, Evaluation

Evaluation Jaw Size of jaw
Position of jaw (protrusion, retraction, clenched) Symmetry and degree of jaw opening Side to side movement, in and out movement Strength Abnormal movements (jaw thrusting) Malocclusions Neutrocclusion: class I molars properly aligned Distocclusion: class II mandibular molars are too far posterior in relation to maxillary molars Mesiocclusion: class III mandibular molars are too far anterior in relation to maxillary molars Dental bite Open bite: upper and lower incisors and possibly canines do not meet Overbite: the upper incisors overlap the lower incisors with significant gap between them Overjet: the upper incisors project in front of the lower incisors creating a space Cross bite: maxillary and mandibular teeth are not vertically aligned Disto: overbite of molars Mesio: underbite of molars Dental bites: looking at incisors Evaluation

Evaluation Oral motor structures and function Tongue
Size micro or macroglossia Movement abnormalities Fasciculations Tremors Protruded or retracted Contour – flat, thick, or bunched Increased or decreased tone Lingual deviances – scarring, short frenulum, bifid tip Observe protrusion, retraction and lateralization independent of the jaw Tongue tip and back elevation Tongue cupping Lingual strength by pressing against cheeks on either side Abnormal movement Evaluation

Evaluation Swallow and feeding evaluation
Assess the oral/preparatory phase Make inferences about the pharyngeal stage Suspect problems with later refer for videoflouroscopy Bottle feeding Evaluate nutritive vs. non nutritive swallow Type of bottle, type of fluid, flow or nipple Note position Suckle initiation Strength of tongue seal (0-6 months) Strength of lip seal (6 months up) Suckle vs. sucking Mandibular excursion Suckle/swallow ratio at beginning vs. end of feeding Length of burst cycle Length of feeding (endurance) How long does feeding take? Longer than 30 minutes is way too long. Evaluation

Evaluation Cup drinking Straw drinking Lip/cheek movements
Tongue movements Jaw stability Biting cup Loss of material Straw drinking Lip/tongue/cheek movements Vary viscosity of liquids (control volume) Evaluation

Evaluation Spoon feeding Biting/chewing soft solid foods
Anticipatory open mouth Jaw gradation Lip/tongue/cheek movement Clean spoon? How? Biting/chewing soft solid foods Anterior munching patterns Straight up and down jaw movement Diagonal munch food moves side to side Mature rotary chewing pattern (later) Bite/grind Open mouth or lip closure Lip/tongue/cheek/jaw movements Evaluation

Evaluation Biting/chewing hard solids Cervical auscultation
Tongue lateralization Midline to side Side to midline to side Side to side Cervical auscultation Pediatric stethoscope is placed near the larynx and the sounds of swallowing/respiration are observed Start listening to normal respiration before introducing food Listen to cycles of sucking/swallowing/breathing Listen for timing of the swallow response Observe change in respiratory sound after the swallow Evaluation

Evaluation for dysphagia
Instrumentation Modified barium swallow study Videoflouroscopy Food coated with barium is ingested Head and body in different positions Views recorded for later analysis Real-time visualization of the swallow process Determine whether the individual should feed orally or not Fiber-optic endoscopic evaluation of swallowing Following topical anesthetic insert a flexible fiber-optic laryngoscope through the patient’s nose and down into the pharynx Cough, hold his breath, swallow different textures of food (dyed for visualization) Oral and esophageal phase not visible Stopped here Evaluation for dysphagia

Evaluation Videoflouroscopic swallow study
Responsibilities of the feeding specialist Positioning of the infant/child Assembling the feeding equipment Instructing the parents who act as feeders during the study Assuming the role of the feeder Working with radiologist to obtain an optimum view Helping infant/child to maintain midline head position Evaluating stages of swallow Making suggestions for intervention and compensatory strategies Responsibilities of the radiologist Reviewing the films Diagnosing anatomical abnormalities Assessing adequacy of airway protection and swallowing parameters in conjunction with feeding specialist Screening esophageal phase Reviewing video tape with feeding specialist to discuss objective findings Time 2-3 mins because of hazardous radiation SLP: mixes the barium, assemble feeding equipment, also observes the parent feeding the baby to see how they do it at home; watch for side effects (is something coming back up or have they cleared the esophagus) Evaluation

Evaluation Videoflouroscopic swallow study Getting started Positioning
Be sure the child is hungry Make feeding as familiar and natural as possible (familiar utensils) Parent/primary caregiver should feed the child Use simultaneous audio and video recordings to document techniques/flow rates Universal precautions Positioning Premature infants use small seat (Tumbleform with appropriate support for head/neck/trunk at a 45 degrees) For full term infants use larger seats or special seats such as a MAMA chair (multiple application, multiple articulation) Make sure the child is hungry—should not have been fed in the past 2-3 hours Feeding needs to be as familiar as possible—have parents bring utensils from home Parent feeds first (video/audio record) Use precautions for safety/hygiene Position child to 45 degree angle Test out different nipples/bottles—does it need a slower rate or faster rate of flow? Do they have a cleft palate? Start with the hardest liquid and then go to the easiest—thinner liquid is the hardest (easiest to aspirate) Do you need a syringe to get around a tongue thrust Evaluation

Evaluation Materials Several nipples and bottles
Poor feeders need to increase the flow rate Slow rate – 3.6ml/minute Fast rate – 16.2 ml/minute Have glucose, formula or breast milk that is not mixed with barium to continue with feeding between evaluations Hardest to the easiest consistencies of food Various cups Straw Spoons (one shallow bowl) Syringe Pacifier Evaluation

Evaluation Different types of utensils
Some are extremely pliable and soft, others are more broad, thin tip (premie’s with tongue thrust), Honey bear: good for teaching straw drinking, all you have to do is squeeze the bottle and the liquid comes up and out of the tube, then slowly decrease the amount of squeezing and let the child’s sucking take over Plastic liner inside bottle: ideal for child with cleft lip/palate—their openings cause them to suck in a lot of air—plastic liner squeezes as child drinks, less air escapes into oral cavity Curved bottle: good for cleft lip/palate again; you can position child upright while feeding Evaluation

Evaluation Videoflouroscopic swallow study Procedure Presentations
For infants start with NNS Introduce nipple feedings using regular or preemie nipple with regular flow rate Older children liquids may be presented via a spoon (2 ml) Increase quantity and texture and vary the utensils For infants with NPO Start with easiest consistencies Establish NNS Introduce familiar bottle feeding and compare NS and NNS With older children begin with spoon feedings Instruct the parents/caregivers to feed the infant the same way as they do at home Start with non-nutritive swallow—don’t give an empty bottle because they will just suck in air—use a pacifier Nutritive: NPO- start with the easiest liquids (thicken formula with a rice cereal)—make sure there is no penetration/aspiration Compare the two Evaluation

Evaluation Interpretations/recommendations
Infants trigger at the vallecula by tongue pressing the posterior pharyngeal wall Tongue back/down movement is more posterior than in older children Some infants may experience ventricular penetration during the initial suckle burst This penetration will clear after the first few swallows if normal Evaluation

Evaluation Videoflouroscopic swallow study Oral phase
Suckling from a nipple Latching on to nipple with a tight lip or tongue seal Initiates suckling Rhythmical suckling 1-2 sucks per swallow/breath Stripping the nipple Nipple compression Posterior nipple placement Do they have such a bad tongue thrust that they are pushing the nipple out? Place nipple behind tongue thrust Evaluation

Evaluation Removing food from a spoon Mouth opening
Closure around spoon Lip assistance to remove food Masticating (or munching) or mashing between gums or tongue and hard palate Manipulate the food from side to side to form a bolus Holding the food in midline on the dorsum of the tongue in preparation for the swallow Utensil use – spoon, fork, cup etc. Spoon feeding: don’t scrape food off spoon by pulling up Evaluation

Evaluation Videoflouroscopic swallow study Oral stage
Posterior transit of the bolus Oral transit time from the first posterior movement until the bolus reaches the head of the ramus of the mandible Lingual peristalsis with hard and soft palate Soft palate simultaneously with the triggering of the swallow response Evaluation

Evaluation Pharyngeal stage Esophageal phase
Begins with elicitation of swallow response and ends with bolus passing the CP segment Laryngeal elevation and anterior movement Epiglottic excursion Pharyngeal contraction, no residue CP dilation Esophageal phase Primary peristalsis Secondary peristalsis Importance of no residue: it could leak into trachea etc. Evaluation

Dysphagia treatment Feeding environment
Minimize auditory and visual distractions Light not too bright or too dark Noise reduced, music encouraged Caregiver should be relaxed and unhurried Respond to client signals regarding feeding speed, food choices, and quantity Communication strategies developed Utensils for feeding must be appropriate Slow-flow nipple Teflon coated spoon Shallow bowled spoon Cutout cups Dysphagia treatment

Dysphagia treatment Body positioning Body posture and stability
Upright 90 degree hip angle, symmetrical position with postural support to provide stability Head and neck secure to prevent extraneous movements Chin tuck Head rotation Chin tuck is always a good for difficulty swallowing Dysphagia treatment

Modification of foods and beverages
Dysphagia treatment

Dysphagia treatment Oral motor exercises and swallowing techniques
Range of motion of the tongue exercises Lip strengthening exercises Cheek strengthening exercises Jaw exercises Bubble blowing Straw sucking Dysphagia treatment

Dysphagia treatment Vital stimulation Different pediatric placements
Vital stim: very controversial **Do not do if child is having seizures just in case It gives a biphasic current—each pulse contains two phases Polarity between two electrodes changes—mm. between two electrodes contract Current should be between Hz depending on tolerance of patient Higher amplitude, greater number of muscle fibers will be stimulated Oral phase problems: place electrodes high up (placement A) Pharyngeal phase: a little lower down (B) Problems with both: Placement C Older child: all over to get the pharyngeal swallow (D) Dysphagia treatment

Pediatric dysphagia June 13, 2014.

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Pediatric dysphagia June 13, 2014.

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