Pediatric Dysphagia

CSD 625
Clinical Evaluation of Feeding

Myth #1
Eating is the bodys #1 priority.

Breathing is the bodys #1 priority.

Postural stability is #2. Eating is only #3.

Postural Stability Activity

Sit up straight Feet off floor

Round pelvis and fi through shoulders

Round pelvis and fix through head/neck

Postural Stability

is important because

2nd priority=protects the brain;

Stability frees up the motor brain to focus on the task of eating rather than not falling on your head;
Stability supports respiratory function; Stability provides security within the seating arrangement; Stability allows for better hand-to-mouth coordination and fine motor/tactile manipulation of the food; Stability allows for range of motion in the jaw for chewing;

Myth #2
Eating is instinctive. Eating is instinctive for only the first month of life

(instinctive appetite drive for the first 4-6 weeks)

Eating from 1-6 mos is reflexive Eating after this is a completely learned behavior

Clinical Assessment Goals

Presence/Absence of Swallowing/Feeding Problem Possible etiologies Nature and severity Baseline of behaviors

Introduce therapeutic modifications

Trial feeding Determine need for instrumental assessment

Key Components
Patient History
Current Status Social History Medical History
Prenatal Delivery

APGAR scores
Neonatal history Hospitalizations, surgeries, medications, etc. Ear infections Sleep patterns Allergies

Key Components (contd)

Feeding & Swallowing History

Feeding development Tube feeding history Weight gain history Reflux, emesis during/after meals Aversive behaviors associated with feedings 3-day food log stooling

Key Components (contd)

Physical Examination
Behavior. State of alertness (before/during/after feeding) Airway Status General postural Control & Tone (co-evaluation with OT/PT) Primitive reflexes Cognitive level of functioning Oral Motor/Cranial Nerve Evaluation (Arvedson Table 7-6) Oral structure & function

Key Components (contd)

Observation of feeding/swallowing
Assessing oral prep/oral state of swallow Typical performance

Volume of intake/time
Outward signs & symptoms of aspiration Body behavior

Key Components (contd)

Bottle or Breast Feeding Cup drinking Straw drinking

Spoon feeding
Biting & chewing soft solid Biting & chewing hard solid

Developmental Food Continuum

The developmental progression in learning to eat various

BOTH oral-motor functioning AND sensory processing.

food textures requires advancing

Developmental Food Continuum

Ages and consumption 2000

Birth 1 month: 2-6 ounces 3 months: 7-8 ounces, 5 months: 9-10 ounces (4-6 months: Purees introduced)

Morris & Klein,

7 months: 11 ounces+

Developmental Food Continuum

Food
Breast/Bottle Thin baby food cereals Slightly thicker baby food cereals mixed with thin baby food purees (stage 1) Thin baby food purees (stage 1)

Age
0-13 mos. 5-6 mos. 5 -6 mos. 6 mos.

Thicker baby food cereals and thicker baby food smooth purees (stage 2)
Soft mashed table foods and table food smooth purees

7 mos.
8 mos.

Developmental Food Continuum

Mashed table foods
(Table food smooth puree) 8 mos.

Hard Munchables
(8 mos).

Meltable Hard Solids

Soft Cubes

Soft Mechanical

Mixed Texture=cube + purees

Myth #3

Eating is easy. Eating is the most difficult sensory task that children do.

Myth #4

Eating is a two step process.

#1: you sit down; #2: you eat.

Its a 25-32 step process that begins with Sensory Integration.

2 questions

How do we identify picky eating from those with problem feeding?

What are the warning signs that a child may be experiencing a feeding problem?

Carruth & Skinner (2000)

3 thematic behaviors of picky eaters:

1. unwillingness to try new foods and refusal to eat unfamiliar foods; 2. limited # of acceptable foods and lack of variety in the diet; 3. refusal to eat certain whole nutritional groups of foods and/or types of foods within a group.

Carruth & Skinner (2000) (contd)

Study excluded children who were not growing, or had genetic or health issues Mean nutrient intake between picky and non-picky eaters was not significantly different Mean heights and weights were not significantly different, all were within normal range for age and gender

Picky vs. Problem

Picky
Decreased range/variety of foods but will eat 30 foods Foods lost due to burnout re-acquired after 2 weeks Tolerates new foods on plate, may touch, taste Eats 1 food from most all food texture groups or nutrition groups

Problem
Restricted range, usually <20 Foods lost are NOT reacquired Cries or falls apart with new foods Refuses entire categories of food textures or nutrition group

Picky vs. Problem

Picky
Adds new foods to repertoire in 15-25 steps Typically eats with family, but frequently eats different foods from family Sometimes reported as picky eater at well child cheks

Problem
Adds new foods in >25 steps Usually eats different foods from family and often eats alone Persistently reported as picky eater across multiple well child checks

Red Flags
Ongoing poor weight gain, weight loss; Ongoing choking, gagging, coughing during meals;

Ongoing problems with vomiting;

More than one incident of gastro-nasal reflux;

Red Flags
History of a traumatic choking incident; History of eating + breathing problems, with ongoing respiratory issues;

Inability to transition to baby food purees by 10 months;

Inability to accept any table food solids by 12 months;

Red Flags
Inability to transition to a cup by 16 months; Has not weaned off most/all baby foods by 16 months; Aversion or avoidance of all foods in specific texture or food group; Food range <20 foods, especially if foods are being dropped;

Red Flags
An infant who cries and/or arches at most meals (Sandifers sign); Family is fighting about food/feeding; Parent repeatedly reports child as difficult for everyone to feed; Parent history of an eating disorder + child with poor weight gain;

Reasons why children wont eat

Pain (current or history);

Malaise/discomfort, fatigue; Immature motor, oral-motor, and/or swallow skills; Sensory processing problems; Learning/behavioral; Nutritional; Child/parent/environmental factors;

Possible Interventions & Follow up

Individual tx Group tx Pediatric Oral Feeding Clinic follow up Consultation w/referral to school or community program

Referral for addtl med specialty, lab, or developmental evaluation

MBS (if indicated more on that next week) Nutrition follow up

Break

Lets revisit
Muddiest Points Cute Baby

&
Alexis

Case Study Videos

Practice

 Reminder: Next week, Exam 1; Can we do exam during 1st hour?

The End