Transcript Slide 1

Feeding and
swallowing
in infants and
children
Types Swallowing of problems
“Dysphagia”
(dis'fahjuh)
Dysphagia fall into three
categories based on the phase:
 Oral dysphagia – Problems occur due to issues with lips, tongue,
cheek muscles, and/or jaw movement. Children may hold food in
mouth, have difficulty chewing, drool or spill liquids and have
difficulty moving food to /from chewing surface and back of mouth.
 Pharyngeal dysphagia — These swallowing problems happen before
food reaches the esophagus and may result from neuromuscular
disease, obstructions or surgery. Patients experience difficulty starting
a swallow; food goes down the wrong pipe; or there is choking and
coughing. This may result in poor nutrition or dehydration, aspiration
(which can lead to pneumonia and chronic lung disease). Conditions
that may cause pharyngeal dysphagia include Lou Gehrig's disease,
brain injury, cerebral palsy, multiple sclerosis, muscular dystrophy,
spinal cord injury, stroke, cervical osteophytes or other obstructions.
Neurologic causes often result in Oropharyngeal Dysphagia.
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Esophageal dysphagia — These swallowing problems originate in
the esophagus. Food or liquids "stick" in the chest or throat and
sometimes come back up. Causes in children include eosinophilic
esophagitis, gastroesphageal reflux disease (GERD) and esophagealmotility disorders, as well as later stages of some of the neurological
diseases mentioned above.
Physical Factors
 There are 4 primary areas that impact feeding & swallowing:
• Respiratory system - airway restrictions: lg. tonsils/ adenoids,
choanal stenosis, laryngomalacia, jaw &/or tongue retraction
• GI system - GER and possible laryngeal closure and the
sensory feedback that result may ‘train’ them to eat less or
less often.
• Pharyngeal function-motility decreased strength or
coordination and sensory (hyper/hypo)impairments
• Oral function – Structure, muscle strength, coordination and
sensation impact feeding and are obviously the most easily
seen and reported
Physical Symptoms
Respiratory: destating, nasal flaring , change of color, coughing,
gagging, needing to ‘catch breath’, mouth breathing, frequent open
mouth posture, snoring/ noisy breathing, Hx of Frequent URI,
recurrent PNA, ‘asthma’, gets sleepy during meals.
GI: symptoms of GERD, ‘breath caught’, wet sound in throat,
coughing/gaging between feedings/meals.
Pharyngeal: avoiding solids, gagging on solids, oral defensiveness,
and “behavioral issues” around eating
Oral: prolonged eating at any stage, open mouth chewing, drooling
food preferences for smooth consistencies and crunchy food
Oral-Motor Tone and Feeding
Poor Muscle Tone
Poor Feeders
 Oral motor function is the very fine motor function of the
oral mechanism (i.e., jaw, tongue, lips, cheeks) for
purposes of eating drinking, speaking, and vegetative
activities.
 Oral motor function requires the feedback of sensory
processing to achieve the dissociation, grading,
direction, timing, and coordination of mouth movement
for eating, drinking, speaking, and other vegetative
activities.
 Children with specific oral motor deficits will exhibit
avoidance/ refusal of food texture types and may not
adapt to different nipples/cups.
Correlations & Complications:
• Premature birth
• Cerebral Palsy
• Down Syndrome & other facial syn.
• Cleft palate
• GERD
• Prolonged tube feeding
• Sensory Integration Deficits
All may lead to Failure to thrive
Feeding Milestones
 Oral Motor Development:
• Nipple feeding - 36wks gestational age
• Spoon feeding - introduced approx. @4
to 6 mos.
• Cup drinking - introduced by 8 - 9mos.
• Biting and chewing – development
window 4 -8 mos. Is best time to introduce
• Straw drinking – about 18 mos.
* Assuming normal gross & fine motor milestones
met.
Gastroesphageal Reflux
Feeding difficulties due to GER
Reflux vs. Spit up
 Lower esophageal
sphincter (LES) is less
developed in infants.
 Relaxed or weak lower
esophageal sphincter
muscle can allow acidic
contents of the stomach
to reflux to the
esophagus, oral and
pharynx and oral cavity.
 Diagnosis of GERD is
clinically inferred based
on
• Interview of Caregiver
• Association of signs and
symptoms of reflux
events
• Frequent or prolonged
duration of reflux events
• Absence of alternative
diagnoses
Common amongst
infants
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Mild vomiting or
regurgitation of milk,
food and saliva; does
not contain large
amounts of foods and
fluids
Not forceful
About 40% of infants
spit up on regular basis
Usually occurs after
feeding or burping
 Typically no further or
acute distress occurs after
“spitting up”
 Infant remains satiated
until next feeding time
GER
 Signs/ Symptoms may include:
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Heartburn
Nausea
Arching or stiffening of the body in response to swallowing
Facial grimacing during swallow
Pain, irritability, constant/sudden crying after eating
Frequent coughs, hiccups; “wet burp”
Frequent vomiting after eating; vomiting more than 1 hour
after eating; recurrent regurgitation that persist after 1 year
of age
Poor weight gain/loss
Constant eating or drinking
Inability to tolerate certain foods; decreased acceptance
or consumption of foods despite hunger
Coughing, gagging, choking
Frequent sore throats
Respiratory issues (pneumonia, bronchitis, wheezing)
Bad Breath
Drooling
Feeding therapy, planned programs, oral-motor
techniques, and positioning changes will not be successful
until GI symptoms/ issues are resolved
Food allergies
Almost as bad as GER
Food Allergies
 Foods that most commonly cause allergies
Cow’s milk
Fish. Shellfish
Wheat
Nuts, peanuts
Soy
 3 most common reactions
• Intestinal
• Respiratory
• Skin Reactions
 Can occur immediately or up to 48 hours after eating
• Typical allergic reaction manifests within 2 hours
 Food allergy or reaction caused by
• Food poisoning
• Enzyme deficiencies (e.g. lactose intolerance)
• Flavonoids and preservatives, toxins, naturally
occurring pharmacological substances
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Feeding/ Dietary Approaches
 If allergies or intolerance is suspected
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Food diary
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Elimination diet
• Record of type, amount, timing and description of any
symptoms that occur (consider keeping for a 2-4 week period)
• Exclusion of suspected foods or restrictive diet
• May not be nutritionally complete, should be done
in conjunction with or planned with assistance of a registered
dietician
• Slowly reintroduce foods thereafter
 Nutritional replacements for milk i.e., protein, calcium,
riboflavin, Vitamin A
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Leafy greens
Orange fruits
Vegetables
Meat
Meat alternatives (tofu, soy, legumes, poultry)
A look into Resistant and Picky
Eaters
Challenges
 Can permanently impair their long-term
growth
 Often have a low percentile for weight and
height
 Can interfere with a child’s ability to learn
properly and progress academically
 Can lead to hospitalizations
 Affect the child’s socialization and selfesteem
(Ernsperger & Stegen-Hansen, 2004)
Some Statistics
 Nearly 80% of children with severe mental
retardation have feeding difficulties and
inadequate diets (William, Coe, & Synder,
1998)
 75% of children diagnosed with Autism
Spectrum Disorders experience atypical
feeding patterns & have limited food
preferences (Mayes and Calhoun, 1999)
 45% of typically developing children
experience some level of eating problems
during childhood (Bentovim, 1970)
Picky Eaters vs. Resistant Eaters
 Picky eaters may
have certain
limitations or
aversions to foods
but they eventually
eat enough of a
variety of foods to
maintain a
balanced and
healthy diet
 Resistant eaters are
on the extreme
end of the
continuum and
have serious food
aversions and/or
medical
impairments that
prevent them from
eating a balanced
diet
(Ernsperger & StegenHansen, 2004)
Characteristics of a Resistant Eater
 Limited food selection. Total of 10-15 foods or
less.
 Limited food groups. Refuses one or more
food group.
 Anxiety and/or tantrums when presented
with new foods. Gag or become ill when
presented with new foods.
 Experiencing food jags. Require one or more
foods be present at every meal prepared in
the same manner.
 May be diagnosed with a developmental
delay or MR.
(Ernsperger & Stegen-Hansen, 2004)
Food Neopobia Scale (FNS)
 Simple 10-item questionnaire developed by
Pliner and Hobden (1992) that can be
administered to determine if the child is a
resistant eater.
 A score greater that 35 is considered high;
and that child may benefit from a
comprehensive tx program
 Typically developing two-to-four-year-olds
experience food neophobia for short periods
of time. By age five most children have
decreased their fear of new foods and are
willing to try new and novel foods.
SEE HANDOUT!
Resistant eaters and
Developmental Disabilities
 There is a high correlation between problem
eating and children with disabilities.
Specific characteristics include:
- Sensory Integration dysfunction
- Immature respiration
- Delayed oral-motor development
- Limited communication skills
- Rigid behaviors/routines
Sensory Integration Dysfunction
 Proprioceptive difficulties include positioning and
movement of the limbs and head, and motor planning.
(ex: jaw opening, holding utensils, positioning in a chair,
spilling cups etc…)
 Vestibular difficulties include balance and movement
from the eyes, neck, and head. (ex: focusing on how
they are moving, body position, fear of falling)
 Tactile Sensory difficulties can include hyposensitive or
hypersensitive (ex: little or no reaction to pain, difficulty
holding and using utensils, rub or bite their skin vs. prefer
food to be the same temperature, avoid lumpy or
mixed textured foods, dislike messy activities)
(Ernsperger & Stegen-Hansen, 2004)
Sensory Integration Dysfunction
(con’t)
 Taste Sensory difficulties include how the taste buds of
the tongue receive and interpret information (ex:
difficulty transitioning from water to juice or accept
milder dilute tastes)
 Olfactory Sensory difficulties include smell perception
(ex: children with chronic congestion or open mouth
posture may not interpret flavors effectively)
 Visual Sensory difficulties include when the brain is
unable to link visual info with auditory, touch, and
movement sensations or it inadequately processes the
sensory messages (ex: cover one eye or squints, have
difficulty shifting eye gaze from one object to the other
etc..)
 Auditory Sensory difficulties include localizing the
direction of sound and figure/ground discrimination , i.e.
between a wide variety of environmental and speech
sounds (ex: Overly stressed and anxious by loud noises,
unable to follow multi-step verbal instructions, trouble
attending to verbal instructions etc…)
(Ernsperger & Stegen-Hansen, 2004)
Treatments
We work with:
 Inconsistent or poorer oromotor skills with regard
delayed &/or atypical development, i.e. fewer
readiness behaviors spoon feeding/ solids/cup drinking/
ineffective chewing/ open mouth postures
 Any client who displays oral-motor difficulties as
compared to their typically developing peers for
feeding and speech:
• Reduced mobility
• Reduced agility
• Reduced precision
• Reduced endurance
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Aims of treatment
 To increase the Somatosensory awareness of the oral
mechanism
 To normalize oral tactile sensitivity
 To improve feeding skills and nutritional intake
 To increase differentiation of oral movements thru
 Dissociation: The separation of movement, based
on stability and adequate strength, in one or more
muscle groups.
 Grading: The controlled segmentation of
movement through the mid range of any particular
ROM.
 And by decreasing “Fixing”: An abnormal posture
used to compensate for reduced stability which inhibits
mobility.
 To improve the precision of volitional movements of
oral structures for speech production
Who to refer?
 Low birth wts. with slow gain. – children below 10th
percentile.
 Babies/kids not gaining well and taking more than 30
minutes to complete an age appropriate feeding.
 Resistant/ picky eaters.
 Clumsy, poorly ‘coordinated kids, especially with:
 Any droolers, open mouth posture kids (if not mouth
breathing b/c of huge tonsils)
 Children not babbling by 9 mos. and 15mo. olds with no
true words.
 Children whose parents do not understand most of what
they say in context.
 Children who ‘undertsand’everything said to them, but
have no or few true words.
References:
 Ernspereger, L., & Stegen-Hanson, T. (2004). Just Take a Bite. Easy,
Effective Answers to Food Aversions and Eating Challenges.
 Mayes & Calhoun, (1999). Symptoms of Autism in Young Children and
Correspondence with the DSM. Infants and Young Children., v. 12.
 Pliner and Hobden (1992). Development of a Scale to Measure the
Trait of Food Neophobia in Humans, Appetite, v. 19.
 Williams, K., Coe, D., & Snyder, A. (1998). Use of Texture fading in the
Treatment of Food Selectivity. Journal of Applied Behavior Analysis, v.
31
 Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint
Recommendations of the North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the
European Society for Pediatric Gastroenterology, Hepatology, and
Nutrition (ESPGHAN)
 Journal of Pediatric Gastroenterology and Nutrition 49:498-547 2009
European Society for Pediatric Gastroenterology, Hepatology, and
Nutrition and North American Society for Pediatric Gastroenterology,
Hepalogy, and Nutrition