Transcript Clinical Evaluation of Dysphagia in School-Aged Children Kelly Dailey Hall, Ph.D. CCC/SLP

Clinical Evaluation of
Dysphagia in School-Aged
Children
Kelly Dailey Hall, Ph.D. CCC/SLP
Pediatric Speech & Language Services, Inc.
Greensboro, NC
[email protected]
Swallowing/Feeding Disorders is
educationally relevant
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Students must be safe while eating at school
Students must be adequately nourished/hydrated so
they can attend fully to access the curriculum
Students must be healthy to maximize attendance at
school
Students must develop skills for eating efficiently
during meals/snack time so they can complete these
activities with their peers safely and in a timely
manner
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SLPs do not need a medical prescription or
medical approval to perform clinical
evaluations or implement intervention
services
We do have the responsibility to determine
whether the student’s medical condition
warrants medical clearance for clinical
procedures.
Roles of speech-Language Pathologists in Swallowing and Feeding Disorders, ASHA 2001a, b
Preschool/Elementary
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identifying students with swallowing and
feeding problems;
determining the strategies to maintain the
student's health and safety while
eating/drinking in the school setting;
facilitating developmental gains in swallowing
and feeding skills
Middle/High School
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improving the efficiency of the student's
swallowing and feeding behaviors;
generalizing swallowing and feeding skills for
varied social purposes in a variety of settings.
responding to and minimizing regression
Incidence of Pediatric Dysphagia
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25% in all children
80% in children with developmental
disabilities
Occur with greater prevalence in children with
physical disabilities, medical illness and
prematurity
(Manikam & Perman 2000)
Summarized in Oct. 2006 Brackett, Arvedson & Manno in SID #13 newsletter
Where did it start?
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Child who experience pain, nausea, fatigue
associated with eating may develop
refusal/aversive behaviors
Inadequate opportunities to develop/practice
skills (i.e. tongue lateralization, chewing,
swallowing)
Inadequate experience as an oral feeder
reduces the probability that the child can or
will eat in the future.
Piazza (2008)
Types of Feeding Problems
1. Food Refusal
Refusal to eat all or most foods so the extent that the
child fails to meet his/her nutritional needs
2. Selectivity
Eating a narrow range of food that is nutritionally
inappropriate
Refusal to eat food textures that are developmentally
appropriate
3. Oral Motor Problems
Difficulty with mastication, lip closure, tongue mvts
4. Pharyngeal dysphagia
Aspiration
The Big Question?
Is the student at risk for aspiration?
Yes?
Then you need to establish strategies for oral
intake that minimizes the risk.
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Most appropriate diet consistencies (e.g.thickening liquids)
Manuevers (e.g. chin tuck, double swallow)
Increase timing of swallow response
Increase strength of pharyngeal contractions
No?
Then you need normalize feeding behavior.
What Are Parents/Teachers Reporting?
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prolonged and/or stressful mealtimes
coughing and throat clearing when eating and drinking or from
accumulation of saliva
wet breath sounds and/or gurgly voice quality associated with
swallowing
spillage of food and liquid from the mouth
drooling
food remaining in mouth (pocketing) after swallowing
swallowing solid food without chewing
inability to drink from a cup
multiple swallows per bite of food or sip of liquid
effortful swallowing
gagging or vomiting associated with eating and drinking.
What Do You Find Out After Probing
Further?
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Food refusal-turns away, spits out food.
Extreme food selectivity-eats only a few foods or kinds of food.
Gastrostomy tube dependence
Accepts little or no food by mouth.
Behavioral problems related to mealtime crying, gagging, vomiting,
throwing food.
Poor hydration/fluid intake-doesn't drink enough fluids
Poor intake of food leading to failure to thrive
Significant respiratory
Oral-motor problem-tactile defensiveness, gagging
Delay in the development of self-feeding skills.
Consistently missing 2 or more food groups
Feeding habits differ significantly from family/peers and affect social life
(e.g. can’t go to birthday parties)
Potential Students on Our Caseloads
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Group 1
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History of feeding/swallowing disorder with
concomitant medical disorder
Previous VFSS and swallowing therapy by and
SLP and/or OT
70% of children whose pediatric
feeding/swallowing issues are not resolved by age
3 will have persistent feeding difficulties 4 to 6
years later (that puts them on your caseload in the
schools)
Piazza (2008)
Group 1
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History of:
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GER
Prematurity
Short Bowel Syndrome
Autism
Developmental Delay
Prolonged tube feeding
Group 2
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No previous feeding/swallowing intervention
History of “picky” eater
May or may not have a significant medical
history
Need to determine the etiology:
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Behavioral
Sensory
Physiological
Combinations
Sensory Issues
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Where do they come from?
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Prematurity
Chronic illness
Multiple medical interventions/medications
Underlying neuro issues
Diagnosis with SI as a component
Unpleasant oral-tactile experiences
Delayed introduction of oral feeds
GI issues
Behavioral Issues
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Where do they come from?
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Bad habits/desperation
Poor limit setting
Lack of mealtime structure and routine
Passive eating with distractions
Inconsistent expectations re: eating
Sensory Issues - Presentation
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Often avoids whole foods or texture groups
Difficulty tolerating sensory input –
sight/smell/touch/taste
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Eats the same regardless of people/place
Overstuffs oral cavity/takes tiny bites
Stores food “for later”
Gags as a sensory response
Excessive drooling
Behavioral Issues - Presentation
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Rarely selective avoidance
Eats better for certain people/places
Gags to get attention
Rarely underlying neuro or medical issue
Other factors to consider
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Adipsia
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the absence of thirst or the desire to drink
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Dysphagia can be a real or imagined difficulty
in swallowing
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phagophobia
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Kasese-Hara (2002) research suggest that
children with FTT lack the normal responses
to hunger and satiety cues to regulate food
intake.
Childen with feeding problems can be
minimally or completely unaffected by hunger
cues
Clinical Assessment of Feeding and
Swallowing
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History/Background
Oral Mechanism/CN exam
Swallowing Exam
Visual Evaluation of Structures
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Lips
Teeth - dental status, dentures
Oral mucosa
Tongue
Palate, faucial arches
Neck (larynx)
Visual Evaluation of Structures
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Relative size and symmetry
Abnormalities
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scarring
atrophy
asymmetry
resting movement (fasciculation)
CN V (Trigeminal – Mandibular
Branch
Lips (CN VII)
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retraction
rounding
Closure
Tongue (CN XII)
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elevation (ant.)
lateralization
protrusion
retraction
elevation (post)
VP port (CN V,IX, X)
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elevation
retraction
lateral wall mvt
posterior wall mvt
CN IX (Glossopharyngeal)
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Look at your neighbor saying “ah, ah, ah”
Laryngeal Exam (CN X)
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cough
voice quality
dry swallow (cervical auscultation)
Swallow Exam
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Listen (cervical auscultation)to respiratory
sounds at the level of the thyroid cartilage
Dry swallow (with CA)
Introduce 1iquids, small amount, via straw or
spoon (with CA)
Continue with thick liquids, pudding, and soft
solids
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Feel for laryngeal elevation and posterior
tongue mvt.
Check for timing of the swallow response
What are we looking for?
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lip closure
tongue mvt
laryngeal elevation/hyoid elevation
timing of swallow response
Residue
Signs/symptoms of aspiration
What does CA tell us?
Cervical auscultation during oral intake of
________________ revealed changes in the
respiratory sounds following the swallow
which may be indicative of aspiration.
Intervention
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Facilitative
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Facilitate recovery to “normal”
Compensatory
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Compensate for a disordered system
Compensatory
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Positioning
Utensils
Maneuvers
Most students who require compensatory strategies will
have these strategies identified on their MBSS. We implement
a program to be sure that the child is using these strategies
to reduce aspiration risk.
Compensatory/Manuevers
 Chin
Tuck
 Supraglottic Swallow
 Mendelsohn Maneuver
 Effortful Swallow
Facilitative
1. Oral Motor Exercises Lingual strengthening
 Sensory stimulation to increase awareness
 Increasing ROM
2. Development of Normal Feeding Skills
Food Chaining
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A systematic, child specific, home-based
treatment program
Builds on successful eating experiences
One part of a comprehensive treatment
program
Foods are used as desensitization
tools in treatment
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Foods are selected based on the
child’s preferences, this reduces
the risk of refusals
Currently accepted foods, rejected foods and
previously accepted foods are analyzed for
patterns in taste / texture / consistency
New food items are introduced that are very
similar to foods /liquids in the core diet.
Chains can be simple or extremely complex.
Food Chaining helps the Therapist to
determine:
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Core Diet: Foods child eats on a regular basis,
consistently accepted.
Patterns of Intake: Grazing, excessive liquid intake,
food jags, refusals.
Consistency of Intake: With parent, in the home,
extended family, at a restaurant, at school, with
peers—is there any difference?
Goal food items are selected that
have similar features (taste texture
temperature) to those in the child’s core
diet (consistently accepted foods)
 What Food to Select Next:
Rating scales (1-10) are used weekly to:
measure reaction to new foods, measure
change in preferences over time to help
select next targeted food items.
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How to Implement the Program:
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Parent implements the program at home
under direction of the team. Feeding therapy
continues at school.
Flavor Mapping involves analyzing the
child’s preferences. Are there patterns
between favorite foods? Does the child seek
strong or more bland flavor of food? What is
the most common texture of food.
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Transitional Foods involves using favorite foods
between bites of new food to encourage the child
and help mask after taste of a new food item.
Flavor Masking involves finding flavors that can be
used on a variety of newer food items. Masking
allows the child to experience a known accepted
taste paired with the new food item. Masks are then
faded as the child tolerates the targeted food items.
(Example: Ranch Dressing).
What is sensory integration?
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Sensory pertains to our senses:
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Hearing, sight, smell, touch, taste, and perception
of motion/movement and gravity
Integration refers to the process of unifying
and allowing the brain to use the information
that the senses gather and take into the body
Sensory-Based Feeding Problems
Non-nutritive Stimulation Protocol
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Oral stimulation of the lips, teeth/gums,
cheeks, tongue, and palate with Nuk brush
Develop tooth brushing protocol for therapy
and home
Introduce mild tastes on finger, cloths, and
brushes as tolerated
Sensory-Based Feeding Problems
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Visual
Olfactory
Tactile
Gustatory
Food Experiences
Visual
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Non-mealtime visual experience
Object-based, picture-based system
Establish comfort level with food proximity
Work on tolerating food on the table, on the
child’s plate, etc.
Food Experiences
Olfactory
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Introduce mild smells
Establish comfort with proximity to smells
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Handling directly
Presenting on another object
Increase intensity of smells
Scented therapy tools
Food Experiences
Tactile
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Water play/Sensory bean bags
Painting with food
Food activities (i.e., flower pots, boats,
gingerbread houses)
Cooking activities
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Pizza, muffins, waffles, fruit salad, soup
Food Experiences
Gustatory
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Hierarchical Approach (Toomey,
2000)
1. Kissing
2. Licking
3. Bite and remove
4. Bite, chew and spit
5. Bite, chew, swallow
6. Consider taste, temperature, texture
7. Structure movement through hierarchy with an “all done” bowl
Treatment of Poor Hunger/Satiety
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Guidelines for following normal mealtime
schedule including 3 meals and 2-3 snacks
daily
Pair tube feedings in high-chair/booster seat
with or immediately after the oral feeding
Medication may aid in stimulating hunger
Management of Behaviorally-Based
Feeding Problems
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Rule-out medical, motor, or sensory
involvement
Parent education
Promote ownership in older child
Referral to behavior specialist and/or
psychologist/psychiatrist
Use of Reinforcement as a Part of
Feeding Therapy
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Use reinforcers to develop new skills
Age appropriate reinforcers including
puppets, books, peg boards, card games
Natural reinforcers should be used at home
Homework sticker charts
Some Activities to Increase Oral Stimulation
Young children with feeding and swallowing issues related to a sensory
disorder may benefit from stimulation activities that can be done at
home by a caregiver at home or in a child care setting. Always consult
with a speech-language pathologist or occupational therapist before
embarking on a program to affect oral defensiveness.
Gentle massage with a NUK brush
Gentle massage with a small finger toothbrush brush
Offer a strong piece of sterile rubber tubing to practice biting and increase
jaw strength
Offer foods of different textures: pretzels, crackers, puddings, jell-o, ice
cream, mashed potatoes, etc.
Offer drinks of different temperatures and composition
Offer gentle vibrating toys for facial massage or oral exploration
Gentle facial massage with different textures of cloth
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Increase appropriate feeding behaviors.
2. Decrease inappropriate behaviors.
3. Motivate the child to demonstrate an
existing behavior more frequently.
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Food Rules for
(Arvedson, 1998)
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Maintain regular mealtimes
Meals last no longer than 30 minutes
No grazing.
Neutral feeding atmosphere
No game playing
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Solids come first
Liquids come last
Remove food after 15 minutes if s/he
is throwing it, playing with it or not
eating it.
Don’t wipe the child’s hands or mouth
until the meal is finished.
Getting Started
1. Allow the child to watch others eat.
2. Experience smells, tastes, and play
with food.
3. Mealtime should be fun/social.
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Get MD approval to begin bolus
feedings for exclusively tube fed
children.
Oral motor therapy should be separate
from mealtime.
Remember…
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The goal of all feeding therapy is a
pleasurable experience associated with
food. You must first determine if the
problem is a motivation vs skill deficit.