Pediatric Swallowing and Feeding: Complex Decision Making

CSHA, Monterey 2010

WS7 April 16, Friday, 8:30-11:30/2:00-5:00

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S Childrens Hospital of Wisconsin Medical College of Wisconsin
jacrved@aol.com & jarvedson@chw.org

Joan C. Arvedson, Ph.D.

3/25/2010

Pediatric Dysphagia with Health Issues & Complications

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S
jcarved@aol.com & jarvedson@chw.org

Dysphagia: Health Considerations

n n n n n

Nutrition/hydration & undernutrition Neurologic & neurodevelopmental issues Pulmonary/airway issues Gastroesophageal reflux disease (GERD) Medication effects

Diagnoses Seen in Feeding, Swallowing, & Nutrition Center (FSNC)

Angelman Sy ndrome Sev ere atopy Autism spectrum disorders Breastf eeding dif ficulty Canav an sy ndrome Cat ey e sy ndrome Chromosomal etiologies Prematurity & complications Orof acial malf ormations Airway malf ormations Cockay ne syndrome Congenital diaphragmatic hernia Congenital heart disease Cornelia DeLange C os tello s yndrome C raniosynostosis C ri- du-chat D andy Walker Syndrome D iabetes D own s yndrome E os inophilic G I disease E s cobar s yndrome H irs chsprung s yndrome H emolytic uremic s yndrome IU GR Klinefelter syndrome M itochondrial disease N oonan s yndrome P anhypopituitarism C erebral palsy Seizure disorders P ierre Robin sequence E agle-Barrett s yndrome Robinow s yndrome Short gut Spina Bifida Stic kler s yndrome TEF Solid organ transplantation Turner s yndrome V ATER V elocardiofacial s yndrome Formula intolerance C hoking phobia Sleeper eaters A bs ent hunger drive

Common Nutrition Risk Indicators

n n n n n

Failure to grow over 2-3 months Weight/height below 5th %ile Chronic diarrhea/constipation Long term use of drugs Excessive drooling

Common Nutrition Risk Indicators

n n n n n

Undernutrition and Growth

n n n

Frequent reflux/emesis Oral sensorimotor feeding difficulties Metabolic disorders Abnormal CBC/urine screens Suspected caregiver neglect

Acute: decreased weight-for-height (wasting) Chronic: decreased height-for-age (stunting) Effect on linear growth may lag weight effects by 4 months Children who survive malnutrition - generally stunted

Joan C. Arvedson, Ph.D.

3/25/2010

Undernutrition: Severity of Effects

n

Pulmonary Disease with Neurologic Impairment

Respiratory complications of dysphagia
uDisordered uAspiration

Correlated with onset & duration Most profound damage when period of deprivation occurs during first 2 years

timing/incoordination

uAirway
n n n

obstruction

High risk infants (apnea & hypoxia) Older children: disorders of respiration Signs & symptoms of aspiration vary

Aspiration Generalizations
n n

Congenital Laryngomalacia
n n

Usually silent with neurologic deficits High index of suspicion for signs of pharyngeal dysmotility uCongestion during feeds uMultiple swallows per bolus uDelayed initiation of pharyngeal swallow uRespiratory distress (e.g., cough, wheeze)

Redundant supraglottic mucosa Common mechanisms uCuneiforms drawn inward during inspiration uExaggerated omega shaped epiglottis curls on itself uArytenoids collapse inward

Stridor in Severe CLM

n n n n n

CLM: SLP Role for Feeding

Determine most efficient oral feeding: position, liquid flow, pacing Monitor inspiratory stridor & effect on PO Effects of GER & nipple feeding? Reassurance to parents regarding positive prognosis in coming months Spoon feeding & cup drinking may be focus earlier than in typical infants

Inspiratory High pitched Loudest when upset More evident in supine

n n n

Joan C. Arvedson, Ph.D.

3/25/2010

Pierre-Robin Sequence
n

Pathophysiology: Chronic Aspiration

n

n n

Mandibular Hypoplasia (Micrognathia) Glossoptosis (retroplaced tongue) Airway obstruction U-shaped cleft palate (not primary characteristic, seen in about 80%)

May be more insidious than acute aspiration (direct & indirect) Most prone: Swallowing dysfunction & neuromuscular disease uClinical indicators may be scarce uLaryngeal penetration (deep) uEndangerment to airway from aspiration uLife threatening physiologic alterations

Timing of Aspiration with Swallow

n

Protection from Aspiration

n n

Before: Delay in onset of pharyngeal swallow or abnormal tongue movements During: Ineffective laryngeal closure or timing incoordination After: Results in residue from multiple factors (e.g., decreased tongue base retraction, reduced sensation, incoordination of pharyngeal constrictors)

Normal swallow Cough uNot reliable predictor even in infants with normal swallows uBy 1 mo., 90% of infants have cough reflex Other protectors of lung (e.g., mucociliary clearance, phagocytosis by alveolar macrophages, lymphatic drainage, gag)

Swallowing Problems & GI Disease

n n n n

GER Prevalence & Epidemiology

n

Esophageal structural abnormalities (TEF) Motility disorders Inflammatory diseases Constipation aggravates in neuro disorders u74% of CP uMultiple causes (e.g., PO with fluid)

Highest < 2 years of age uPreterm infants: 63% uCP: 92% with GI symptoms & signs uHealthy infants pH probe: esophageal acidification common 21% of all ped pts to GI clinic present with signs/symptoms suggestive of GER

Joan C. Arvedson, Ph.D.

3/25/2010

GER Prevalence & Epidemiology

n

Reflexes Involved in Development of Upper & Lower Airway Disease

n

Typical symptoms of GER in < 50% in children with upper airway manifestations 25-30% of all children with GER have EER & upper aerodigestive tract symptoms/signs

Esophago-laryngeal reflex uAcid is introduced into distal esophagus uLaryngospasm results Laryngeal chemoreflex acid stimulation to larynx bradycardia, & hypotension result More active in infants & gradually disappear
uApnea, uDirect

GER Medications for Apnea in Premature Infants

n

Manifestations of GER are due to effects of gastric acid, BUT abnormalities of motility & sphincter function cause GER

Theophylline or caffeine: neither drug consistently eliminates apnea in all patients Note: caffeine exacerbates GER in adults & older children! Antireflux medications do NOT reduce frequency of apnea in premature infants
(Kimball et al., 2001)

Multiple Causes of GER

n n n n

Functional GER - Happy Spitter

n n n n

Impaired LES function Increased intraabdominal pressure Delayed gastric emptying Impaired esophageal acid clearance

Infants, onset usually < 2-3 months Effortless regurgitation (spitting up) Frequency decreases after 6 months If infant grows well, no major work-up needed

Joan C. Arvedson, Ph.D.

3/25/2010

Risk Factors (Atypical Manifestations)

n n n

Eosinophilic Esophagitis (EE)

n n

Lower airway diseases Upper airway Upper digestive uchronic halitosis otalgia/chronic OM uloss of taste Sandifers syndrome ufood refusal chronic pharyngitis udental caries drooling

n n

Entity emerged since 1997 previously confused with reflux esophagitis Inflammation due to allergic factors may also include upper airway disease Not correlate with ? GER Endoscopy uDenser infiltrates of eosinophils relate to nonacid-related cause of esophagitis
uFurrows

or rings often noted

Steiner et al (2004)

Treatment of EE in Pediatrics
n n

GER Evaluation
n n n n n

Lack randomized controlled trials Case series suggest uElemental diet uOral steroids uTopical steroids Lack of control group: impossible to evaluate effect of interventions

Clinical evaluation Radiographic study Scintigraphy Esophageal pH testing (most sensitive) Endoscopy & biopsy

Kukuruzovic et al. 2004, Cochrane Database Syst Rev

Treatment of GERD: Infants & Children

n n n n n

Types of Medications & Dysphagia

n n n n

Positioning Dietary treatments (e.g., thickening feeds) Feeding schedule changes Pharmacologic therapy Surgery (fundoplication)

Sedatives Benzodiazepines Dopamine antagonists Anticholinergics

Joan C. Arvedson, Ph.D.

3/25/2010

Clinical Assessment of Feeding & Swallowing: Infants & Children

n

Presentations of Feeding Disorders

n

Joan C. Arvedson, PhD, CCC-SLP, BC-NCD, BRS-S jcarved@aol.com & jarvedson@chw.org

Inadequate growth due to inadequate intake Prolonged time for feedings (but with adequate calories for growth) Delayed progression of oral feeding skills (textures, variety, etc) Recurrent respiratory disease (question of aspiration from above or below) Complicating factors: behavior, sensory, relationship, social

4 Key Questions to Ask Parents

n

How long does it take to feed your child?

uLonger

Global Feeding Evaluation Goal

n

than 30 minutes, tip-off for problem based skill & safety issues? and/or sensory issues?

Are meal times stressful to child &/or parent?

uNeurologic uBehavior

Is your child gaining weight OK?

uIf

To determine safest & most efficient consistencies for a child to eat orally (to whatever extent possible) while maintaining adequate nutrition & hydration

no weight gain for 2-3 months, sign of problem congestion ? during feeding; gurgly voice

Are there signs of respiratory problems?

ue.g.,

Development in Typical Child

n

Age of Introduction to Solids

Age (months) 4-6 6-9 9-12 12-18 Type of Solid Smooth puree (SP) SP; Textured puree; Easily dissolvable solids Soft, mashed, & diced solids Toddler diet of chopped table food

Liquid by nipple first 4-6 months uBreast milk uFormula Strained smooth food by spoon (6 months) uSitting with minimal support Lumpy foods by 10-11 months uDifficult if delayed until 14-16 months

Cup drinking before 12 months

Joan C. Arvedson, Ph.D.

3/25/2010

Feeding/Swallow Evaluation
n n n n

Common Criteria for Referral

n n n n n

History Physical examination Observation of typical feeding or mealtime Referral for additional examinations
uInstrumental

swallow study uMedical/surgical specialists uNutrition uPsychology/Social Work

uOT/PT

Feeding periods longer than 30 to 40 minutes Unexplained food refusal & undernutrition Weight loss or lack of weight gain for 2-3 mths Excessive gagging or recurrent cough with feeds Infants on nipple feeds
uSucking

, swallowing, breathing incoordination disruptions during feeding

uWeak suck uBreathing

Common Criteria for Referral

n

Common Criteria for Referral

n n n

Airway related concerns

uHistory

of recurrent pneumonia & feeding difficulty uConcern for possible aspiration during feeds uDiagnosis of disorders associated with dysphagia
n n n

Drooling persisting beyond age 5 years Nasopharyngeal backflow/reflux during feeding Delay in feeding developmental milestones
uNot uNot

Irritability or behavior problems during feeds New onset of feeding difficulty Lethargy or decreased arousal during feeds
n

spoon feeding by 9 months (dev. age) chewing table food or self-feeding finger food by 18 months uNot drinking from a cup by 24 months

Craniofacial anomalies

Steps in Clinical Evaluation

n n

Clinical Evaluation: Airway Concerns?

n

Consultation received a Initial Assessment Possible next step depends on airway status uIf respiration normal, clinical feeding evaluation uIf respiration abnormal, airway evaluation (hold feeds until airway is clear)

If none: Develop plan in context of global needs

uOral

sensorimotor intervention guidelines uBehavioral therapy uMonitor status & alter plan as needed
uNutrition
n

If yes: Instrumental examination or further medical workup

Joan C. Arvedson, Ph.D.

3/25/2010

Feeding History Factors

n n n n n n n

Feeding History Factors

n n n n n n n

Positions/posture/seating (gross/fine motor) Duration of meal times (average & range) Intervals between meal times Types of food (preferred, non-preferred) Assistance/independence of feeding Tube feeding (e.g., type, timing) Food record: 2-3 days

Respiratory status Signs of stress & distress Test results & medications Sleep patterns (waking, snoring, mouth breathing) Cognition & communication Behavior during meals; apart from meals Therapeutic intervention (developmental/feeding)

Nervous System Exam

n n n n n n

Infant Evaluation
n n n n n n

Muscle tone Reflexes Cognition & language Visual tracking Gross & fine motor skills Sensory function

State & overall posture/positioning Respiratory status (rate, patterns, voice) Resting heart rate Exam of oral peripheral mechanism Non-nutritive sucking Nutritive suck/swallow/breathe

Clinic Airway Evaluation

n n

Clinic Airway Evaluation

n

Respiratory rate: at rest & feeding Respiratory effort: Stridor Stertor u Retractions: suprasternal, substernal
u u

n n

Voice quality variables uStrong, clear phonation, appropriate pitch uWeak, breathy, husky to hoarse uGurgly, wet uVelopharyngeal function inferences (e.g., hypernasality, hyponasality) Pharyngonasal penetration/backflow/reflux Frequent burping (not clear implications)

Joan C. Arvedson, Ph.D.

3/25/2010

Airway Stability for PO Feeding

n n

Evaluation of Transition Feeder & Older Child

n n n n n n

Airway stability is prerequisite for successful PO If airway concerns are noted during physical exam, possible next steps: uOtolaryngology airway exam (FFL, DLB) uBedside/clinical oral feeding evaluation uCombined FFL & FEES with ORL & SLP uVideofluoroscopic swallow study (VFSS) uMonitor status for a few days

General observations Posture, alertness, direction following Oral sensorimotor function Bolus formation & oral phase of swallow Pharyngeal phase inferences Therapeutic trials

Postural Control Evaluation

n n

Optimal Sitting Posture

n n n

Muscle tone (hypotonia or hypertonia) Central alignment relates directly to oral sensorimotor system uPresence of primitive reflexes uLevel of physical activity oral stimulation Use of eye contact, head turning, & touch
uSelf

n n n

Neutral head position Neck elongation (No chin tuck for infants) Symmetrical shoulder girdle stability & depression Pelvis stability, hips symmetrical in neutral Hips, knees, & ankles at 90 degrees Feet in neutral with slight dorsiflexion (never plantar flexed), supported by firm surface

Cranial Nerve Evaluation for Feeding/Swallowing

n n n

Gag Reflex
n n n

Lack of chewing: CN V Facial asymmetry & lack of lip movement: CN VII Delayed swallow & pharyngonasal penetration/backflow/reflux: CN IX & X Tongue thrust or atrophy: CN XII

Independent of swallow Sensory: CN IX Motor output: CN X, XII, & V Elicited by touching posterior pharyngeal mucosa (standard testing) Difficult to assess importance of changes in absence of other findings

Joan C. Arvedson, Ph.D.

3/25/2010

Tonic Bite Reflex

n

Oral Sensory vs Motor Disorders

n

Jaw moves up into clenched position on presentation of spoon or other object Response to contact to biting surfaces of side gums (molar tables) Persistence with neurologic deficit should disappear by 9-12 months Cranial Nerve V

Nipple confusion Not differentiate tastes in bottle even with intact suck Manages liquids better than solid foods Sorts food in mixed texture

Inefficient suck breast & bottle Differentiates tastes in bottle Oral-motor inefficiency or incoordination for all textures Swallows food whole when given mixed textures

Oral Sensory vs Motor Disorders

n

Oral Sensory vs Motor Disorders

n

Holds food under tongue or in cheek and avoids swallowing Vomiting only certain textures Gags when food approaches or touches lip Hypersensitive gag with solids, normal liquid swallow

Unable to hold & manipulate bolus on tongue, food falls out Vomiting not texture specific Gags after food moves through oral cavity Gags after swallow is triggered with liquid & solid

Tolerates own fingers in mouth, but not accept others Does not mouth toys

Tolerates others fingers in mouth Accepts teething toys, but not to bite or maintain in mouth Accepts tooth brushing

Refuses tooth brushing

from Palmer & Heyman, 1993

Immature vs Abnormal Patterns

n
n

Next Steps?
n n n n

Patterns are likely to be distinguishable in

usuck-swallow-breathe ujaw

sequencing control or stability utongue mobility ulip closure udissociation of tongue, jaw, & cheek movements while drinking & chewing

Nutrition Analysis Medical Workup (Genetics, GI, ENT, etc) Behavioral Psychology Occupational Therapy/Physical Therapy Instrumental Swallowing Study
uNeed

to define oral, pharyngeal, & upper esophageal components for management

Oral Sensorimotor Intervention

10

Joan C. Arvedson, Ph.D.

3/25/2010

Criteria for Instrumental Evaluation

n n n n

Patient Considerations
Diagnostic & management needs uNature of swallow impairment uPatients ability to feed safely uDevelopment of management plan Ability or readiness to participate uMedical stability uAbility/willingness to cooperate uAge, cognitive, & developmental status

n n

Risk for aspiration by history or observation Prior aspiration pneumonia Suspicion of pharyngeal/laryngeal problem on basis of etiology Gurgly voice quality Need to define oral, pharyngeal, & upper esophageal components for management

Procedural Considerations
n

Flexible Endoscopic Evaluation of Swallowing (FEES)

n n n

Components of swallow process evaluated uPhase(s) of deglutition uAbility to detect aspiration or risks uCapacity to define nature of deficit
uEstimate

of agreement: specific procedure and usual patterns of feeding

n n

No radiation Bedside exam possible Defines some aspects of pharyngeal physiology Can evaluate handling of secretions Sensory testing can be done

Videofluoroscopic Swallow Study(VFSS)

n n n

What VFSS is NOT

To rule out aspiration or determine if child aspirates with oral feeding (important finding but not reason for exam) Simulation of a real meal Evaluation of oral skills for bolus formation Chewing evaluation Esophageal function (only upper esophagus)

Defines oral & pharyngeal phases Defines esophageal transit time, basic motility Delineates aspiration related factors uBefore, during, or after swallows uTexture specificity uEstimate of risk

n n n n

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Joan C. Arvedson, Ph.D.

3/25/2010

Important Considerations in High Risk Pediatric Patients

n n n n n n

VFSS Procedural Considerations

n n n

Radiologist must be present Fluoroscopy time minimum Well formulated Q & A Caregivers included Findings shown to caregivers Findings interpreted & used as part of total team approach: maximize safety

n n

Purpose & questions formulated clearly Positioning/seating: typical & optimal Cooperative patient imperative for interpretation Shortest fluoroscopy time possible Review in slow motion, frame-by-frame

Feeding Supplies & Recipes

n

n n

Readily available when caregivers are asked to bring food samples Textures & barium recipes need to be standardized Data lacking, especially in children Poor relationship between viscosity of dysphagia diet foods & swallow barium test feeds of different viscosities
(Strowd et al., 2008)

Preparation of PO Feeders
n n n

Hungry, but not starving Schedule close to feeding time if possible Normalize the situation as much as possible
uChilds uVideo/music as

own utensils needed

GT + PO: same guidelines as for total PO, unless child gets slow, continuous tube feeds

Preparation of Tube Feeder: NPO

n

Childs State
n n

Child should demonstrate some level of oral intake, at least for therapeutic taste trials
uNG

Typical feeding status appropriate Increased risks for aspiration

uLethargy uAgitation

tube remove in some instances uAmount per bolus: 2 to 3 cc uTotal of 10-15 cc preferred for validity & reliability
n

(fussing & crying)

Medication schedules maintained, or in some cases, adjustments needed

Cooperative child: interpretation possible in reliable & valid ways Always remember: Just a brief window in time, not a typical meal

12

Joan C. Arvedson, Ph.D.

3/25/2010

Procedural Decisions
n n

Lateral View
n

No fixed order for presentations in pediatrics Preferable to start with thinnest liquid
uControlled

Encompassing
uLips

bolus size to start, e.g., spoon before going to bottle or cup drinking

Work toward thicker as needed uNot want residue in pharynx that may complicate interpretation with thinner later Exceptions: Parents tell us that child will not accept any thing else if he gets liquid first

anterior uSoft palate superior uPosterior pharyngeal wall posterior uFifth to seventh cervical vertebrae inferior, varying with age of child
n

Simultaneous view of oral, pharyngeal & upper esophagus before food is presented

Antero-Posterior View
n n n n

Oral Phase Swallow Problems

n n n n n n n

When asymmetry is known or suspected Unilateral vocal fold paralysis or paresis Tonsil related questions Other possibilities?
uKeep in

Lips (poor closing, drooling, leakage) Hesitation/pooling Tongue action deficits Gagging Poor posterior tongue thrust Passive leakage over tongue base Delayed oral transit

mind radiation exposure time uImportance of findings for management

Initiation of Pharyngeal Swallow

n

Pharyngeal Swallow Problems

n

Delayed swallow onset/trigger uMaterial in valleculae uMaterial in pyriform sinuses Failure to initiate/trigger swallow

Pharyngonasal (nasopharyngeal) reflux or regurgitation or backflow Penetration uTo underside of epiglottis (superior) uTo laryngeal vestibule/vocal folds Aspiration uResponse to aspiration uClearance of airway

13

Joan C. Arvedson, Ph.D.

3/25/2010

Pharyngeal Swallow Problems

n n n n

Esophageal Swallow Findings

n

Pharyngeal contraction reduced Pharyngeal motility reduced Tongue base retraction reduced Post-swallow residue, e.g., uValleculae uPyriform sinuses uPosterior pharyngeal wall Clearance of residue?

Upper esophageal sphincter uOpening, e.g., reduced, incoordinated (usually pharyngeal phase problem) uProminence Bolus passage uSlow, interrupted Retrograde movement of contrast (better term than reflux in this instance)

Aspiration Before Swallow: Causes?

n n n n

Aspiration During Swallow: Causes?

n n n n

Limited tongue action Limited mandibular movement Reduced tongue & soft palate approximation Delayed initiation/onset of pharyngeal swallow spillage uMaterial in valleculae & pyriform sinuses Pharyngeal dysmotility
uPremature

Vocal fold paralysis/paresis Reduced laryngeal excursion Pharyngeal incoordination Pharyngonasal (nasopharyngeal) penetration, backflow, or reflux

Aspiration During Swallow

n n

Aspiration After Swallow

Reduced tongue base retraction uResidue in valleculae uPenetration into laryngeal vestibule Reduced pharyngeal contraction/motility uResidue in pyriform sinuses Reduced hyolaryngeal excursion Cricopharyngeal dysfunction Pharyngonasal penetration/backflow may occur

Neural control uInitiation under voluntary control uInvoluntary control for completion Airway uCloses upon initiation of pharyngeal swallow uMultiple levels of airway protection common

n n n

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Joan C. Arvedson, Ph.D.

3/25/2010

Aspiration After Swallow

n

Esophageal Dysphagia Diagnosis

n

Neural Control uInvoluntary for esophageal phase Airway uOpen Precipitating factors with open airway uPharyngeal residue spills over uGravity brings material in nasopharynx lower into airway

Dysphagia for solids > liquids, structural cause likely Dysphagia for solids & liquids similar, dysmotility likely cause

Interpretation of VFSS Findings

n

Recommendations After VFSS

n n n n n n n n

SLP reviews with caregivers & therapists or others involved in care

uFindings by uTiming of

phase of swallow penetration/aspiration related to physiologic processes

Changes in route of nutrition/hydration Nutrition guidelines Position & posture changes Alterations of food textures, temperatures Utensil changes Changes in feeding schedule & pacing Oral sensorimotor program with food Nonnutritive oral sensorimotor program

If review reveals a finding not anticipated or noted during exam, SLP contacts PA or radiologist to discuss or review together Important that reports are not discrepant

Management: Prognosis & Priority

n

Principles for Repeat VFSS

n n

Oral feeding prognosis tied closely to uUnderlying etiology & diagnosis findings uCardiopulmonary status Feeding priorities established on basis of
uSeverity uCombination uNeurologic

n n

Same as for initial VFSS Information needed for uDefinition of etiology or diagnosis uGuide for management decisions NOT some arbitrary time interval Child should be at baseline

of deficits

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Joan C. Arvedson, Ph.D.

3/25/2010

Infants in Need of Intervention

n n

Nonnutritive Stimulation
n

Prolonged stay in NICU Extensive exposure to negative oral stimulation, e.g., endotracheal tubes, suction, sticky tape Before oral feeding introduction, time is needed
uBreak

oral & perioral aversion uOffer exposure to sucking via nonnutritive oral sensorimotor therapy (e.g., pacifier)

Enhances oral sensorimotor skill development Builds on in utero experiences of sucking & swallowing

Helps when size & shape of pacifier match infants mouth

NNS Cochrane Review

n

Oral Stimulation for Preterm Infants

n n n n

21 studies (15 randomized controlled trials, all infants born < 37 weeks gestation) Main Outcome uNNS significantly decreased length of stay (LOS) in preterm infants uNo consistent NNS benefit revealed with respect to other major clinical variables Positive clinical outcomes: Transition from tube to nipple & better bottle feeding performance

Exp. Group: oral stimulation of oral structures 15 min. once per day for 10 days Control group: sham oral stimulation Started 48 hr after d/c of nasal CPAP Exp. Group reached independent oral feeding faster (X=11 days, control = 18 days). No difference in length of stay.
Fucile, Gisel, & Lau, 2002

Pinelli & Symington, 2005

Nipple Feeding Principles

n n n

Interventions
n n n n n

n n

Non-stressful for infant & feeder Most efficient suck:swallow ratio is 1:1 Burst of rhythmic suck/swallows followed by cessation of sucking and a breath Total feeding completed in about 20 min. No increased work of breathing, fatigue, or signs of respiratory stress

Positioning Limit feeding duration (poor endurance) Nonnutritive oral sensorimotor therapy Jaw/cheek support External pacing

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Joan C. Arvedson, Ph.D.

3/25/2010

Tools for Oral Feeding

n

Bottles & nipples

u Individualize u Give

Evidence-Based Guideline: Introduce Oral Feeding (McCain 2003)

n

infant time to adapt/learn

Thickeners Be cautious!!!
u May u May

assist bolus formation, slow flow slow gastric emptying u May increase coughing u May interfere with digestion
n

Requirements for oral feeding (PO) uSustain awake behavior uCoordinate sucking-swallowing-breathing uMaintain cardiorespiratory stability for time to ingest a caloric volume adequate for growth Neurologically immature preterm infant <32 wk post conceptual age (PCA) cannot meet the above requirements

Behavioral Organization
n

Self-Regulation Readiness
n n n

< 32 weeks: typically not express hard crying or deep sleep with regular respirations By 32 weeks, infant expresses full range of behavioral states important milestone for PO as need to sustain organized, awake behavior From 32 wks PCA to term age, maturation of brain structure is associated with improvement in behavioral sate expression & motor organization

At 32 to 35 weeks PCA Feeding based on awake or restless behavior PO progressing & concluding based on infants ability to tolerate without fatigue or distress Successful feedings: Increase in quiet sleep time & shorter feeding times Adequate weight gain compared to infants fed prescribed volumes More opportunities to practice nipple feeding

Demand Feeding
n n

Principles of Management
n n

By 35 wks PCA Functional suck-swallow-breathe pattern allowing for safe PO is not present until 32-34 wks PCA (Volpe, 2000) Infants 32-36 wks PCA uSuck-to-swallow ratio 3:1 & 4:1 with occasional disruption in regular breathing uOccasionally exhibit tongue twitching or tremors

n n n

Whole child approach Total oral feeding cannot be the goal for all chidlren Nutrition & respiratory status critical GER managed optimally Changes in management needed with gains or regression

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Joan C. Arvedson, Ph.D.

3/25/2010

Food Rules
n

Scheduling
uMeal uNothing

Intervention Based on Developmental Skill Levels

n n n n

times < 30 min + planned snacks between meals, except water

Environment
uNeutral uNo

atmosphere - no forced feeding game playing; no reward with food

Oral stimulation for infants Spoon feeding & chewing readiness Cup drinking Texture changes

Procedures
uSolids uMeal

first; self-feeding encouraged over if food is thrown in anger uClean up only at end of meal

Spoon Feeding Learning

n n

Cup Drinking
n

Use foods that stick to spoon Avoid foods

uToo

much liquid (e.g., soups) uSlippery (e.g., sliced peaches) uRoll off spoon (e.g., peas)
n

n n

Use spoon with flat bowl

uPlastic

About 1-2 months after spoon feeding is well established Open cup with thickened liquid (milkshake or fruit slush) Cup: wider at top, clear so feeder can control amount per sip well Child can help with hands Independent: Lip helps reduce spills

coated non-breakable

Chewing Practice
n
n n n n n

Finger Foods
Readiness uPick up objects with thumb & fingers uBring fingers or objects to mouth uBite, chew, & swallow variety of textures Guidelines uFood in small strips uPlace food in front of child (2-3 pieces) uGuide hand to mouth as needed uFade help as appropriate

1-2 months after spoon started Gradual changes from smooth puree One change at a time (e.g., taste, texture) Thin strip placed on molar table/surface Alternate sides to promote later tongue action

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Joan C. Arvedson, Ph.D.

3/25/2010

Common Problem Textures

n n

Modifying Textures
n

Thin liquids Dry or lumpy foods

uPureed

Modifier should match flavor of food

uFine

food between bites of dry food

n

n n

Multi-textures foods (e.g., vegetable soup) Foods that do not dissolve with saliva
uRaw

cracker crumbs in soup uApple juice with applesauce uMilk with yogurt or pudding
When offering a new texture
uFew

fruits & vegetables

spoons of familiar texture first uThen new texture (e.g., blended carrots, fork mashed)

Oral Sensorimotor Treatment for Anatomic Problems - Jaw

n n n n n

Thrust: tone Retraction: tone Clenching: tone Instability: tone Tonic bite reflex: not related to tone

n n

Mouth play: fingers, toys Assisted toothbrushing Prone position; Forward pull under jaw Mouth play for gradual opening Activities for jaw closure Pressure at TMJ; sensory stimulation; coated spoon

Oral Sensorimotor Treatment for Anatomic Problems - Lips

Retrac n tion: tone n
n

n n

Limited upper lip movement: & tone Cheeks: tone Reduced sensory awareness

n n

Finger tapping, vibration Varied textures, temps Tapping & stroking Stroke & tap, esp. TMJ Varied textures, temps; drop of liquid in corner of lips

Oral Sensorimotor Treatment for Anatomic Problems - Tongue

n

Oral Sensorimotor Treatment for Anatomic Problems - Tongue

n

Thrust: or tone, or respiratory stress

Jaw stabilization, thickened liquid at lip, food placed on sides, exercises for lateral tongue movement, spoon at midtongue with downward pressure

Retraction: or tone

Hypotonia: tone

Prone position, tongue stroking back to front, chin tuck for older child, upward tapping under chin Vary textures & tastes to sensory input; Food or liquid added gradually

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Joan C. Arvedson, Ph.D.

3/25/2010

Oral Sensorimotor Treatment for Anatomic Problems - Tongue

n

Oral Sensorimotor Treatment for Anatomic Problems Soft Palate

n

Deviation

Limited movement
n

Head at midline; stimulation of less active side with finger, toys, toothbrush Vary textures, temps, tastes; Vibration

Nasopharyngeal reflux

Upright or prone position; Angled bottle for prone position; Cheek & tongue function activities; Thickened liquids (if swallow is normal)

Feeding with Gastrostomy Tube

n n n n n n

Mealtime Behavior Problems

n

Refusal of new foods

uIntroduce uAvoid

Upright position Pump or gravity delivery, air removed Formula at room temperature Feeding time minimum or > 20 min Oral stimulation during feeding (or prior) Tubing flushed after feedings or meds

one at a time power struggles

Refusal of groups of foods

uRespect uDo

preferences not beg, punish, or bribe uSet a good example uPrepare foods in a variety of ways uSelect other foods with same nutrients

Mealtime Behavior Problems

n

Treatment Summary
n n

Wanting a particular food every day uProbably change with boredom over time uDo not call attention to behavior uParent controls what food is served FConsider food jag at snack FInclude other foods typically liked Acting out uIgnore undesirable behavior uAttend to & respond to desirable behavior uModel good eating behaviors

Airway & nutrition highest priorities Oral sensorimotor practice can NOT jeopardize nutrition & pulmonary status Forced feeding or prolonged feeding times: never appropriate GI tract (e.g., GER) umajor inhibitor of appetite uaspiration risk Whole infant/child approach is critical

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