An Introduction to Pediatric Dysphagia

1
An Introduction to Pediatric Dysphagia

• Anissa Meacham, MS, CCC-SLP
• Owner, Speech Geek LLC
• Doctoral Candidate, University of Tennessee

2
Contact Me

• Anissa Meacham
• Speech Geek, LLC
• Abingdon, VA
• Phone [phone]
• Email anissa_at_speechgeek.net
• Website www.speechgeek.net

3
You Make the Call

• K What do you know?
• W What do you want to know?
• L What did you learn or do you need to learn
  in order to work with in pediatric feeding and
  swallowing?

4

• What is Normal Development of Feeding? Or what
  do kids/babies need in order to feed/eat
  normally?
• What Populations are Likely to present with
  Atypical Feeding Development? Why?

5
What they need

• Intact Systems
• Neurological Status
• Development of the Sensory System
• Respiratory Function
• Digestive Tract Disorders
• Joint Stability and Tone

6
Medical History

• Conditions that impact the neurological system
  developing, respiration and digestion are going
  to impact feeding
• Medications often have side effects that can
  cause nausea, stomach pain and irritation
• Many special needs children are dehydrated and
  not meeting fluid needs

7

• Children with Failure to thrive or poor
  nutritional status can experience altered taste
  of foods.
• Nutrition should be the first priority and
  primary goal of any feeding program
• If weight drops too low, childhood anorexia can
  be the result. Appetite is significantly
  decreased
• Constipation, especially in the special needs,
  child will impact oral intake.

8
Digestive Tract Disorders

• Pyloric Stenosis
• Midgut Rotation with Volvus
• Lactose Intolerance
• Allergic Colitis
• Vomiting
• Celiac Disease
• Eosinophillic Esophagitis
• Motility Disorders

• Gastroesophageal or Gastropharyngeal Reflux
  (GERD)
• Uncomplicated reflux
• Complicated reflux
• Crohns Disease
• Cyclic Vomiting Syndrome
• Constipation

9
Reflux Interventions

• Positioning
• Limiting air intake with feeding
• Bottle/nipple change
• Formula change when appropriate
• Thickening
• Scheduled intake
• Medical management
• Anti-reflux surgery

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Minimizing Impact of Medical Hx on Feeding

• Does the feeding disorder have a physical
  component
• Feeding is a process that uses all organs, all
  senses and all muscles
• Feeding is the most complex task we do as humans
• What conditions impact ability to eat?
• Breathing is bodys 1 priority

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Impact on Feeding

• Has the child learned to coordinate the
  suck-swallow-breathe sequence?
• Is there a foundation of pre-feeding
  readiness/oral motor skills?
• What has the childs developmental process been
  like? (NICU, PICU for extended period?)
• Growth and development o the sensory system is
  critical for transitioning to textured food
• Feeding has a learned component. It is reflexive
  until age 6 months and then it is a learned
  behavior.

12
Impact on Feeding

• What is the childs nutritional status?
• What is the home environment?
• What are the stressors on the family?
• What do they know about feeding a baby?
• Can they afford food?
• Do they have equipment they need to feed the
  child?

13
Specific Populations

• Premature Infants
• Cerebral Palsy
• Cleft Lip Palate
• Down Syndrome
• Failure to Thrive
• Cardiopulmonary Disorders
• Tube Feeders
• Autism Spectrum Disorder

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Premature or NICU Infants

• Difficult delivery
• aspiration, hypoxia
• Impacts postural control, breathing regulation,
  state regulation, oral and pharyngeal reflexes
• Cardiac issues
• Start with limited respiratory reserves
• Difficulty regulating cardio-respiratory function
• Impacts energy, endurance, intake, coordination
  and safety

15
Common Complications in Premature Infants

• Medical Instability
• Neurological Immaturity
• Problems with State Regulation
• Abnormal Muscle tone
• Immature or altered oral mechanism
• Poor oral skills for sucking and swallowing
• Oral hypersensitivity
• Oral hyposensitivity
• Slowed Growth
• Disruption in the development of a positive
  feeding relationship

16
Premature or NICU Infants

• Congenital Anomalies
• A continuum from cleft lip only to major issues
• Major structural/CNS/Neuromotor issues
• Impacts ability to feed safely
• Hyperbilirubinemia (Jaundice)
• Impacts alertness, vigor, therefore intake

17
Premature or NICU Infants

• Infant of a Diabetic Mother (IDM)
• Impacts energy, vigor, breathing
•  
• Transient Tachypnea of the Newport
• Impact work of breathing and therefore disrupts
  coordination of suck-swallow-breathe sequence

18
Premature or NICU Infants

• Born prematurely
• A continuum of difficulties from micropremies
  (respiratory issues paramount) to those with
  mild respiratory issues
• The residual effects of Respiratory Distress
  Syndrome (RDS) often compromises the transition
  to nipple feeding

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Issues that Impact Feeding

• Immature State Control
• Fatigue, drowsiness, decreased endurance, frantic
  or irritable behavior,
• Impacts safety and intake
• Immature Postural control
• Impacts regulation of airway opening/closing and
  control of muscles for swallowing

20
Issues that Impact Feeding

• Immature Physiological Control
• Impacts heart rate, respiratory rate, WOB
• Impact ability to cope with the aerobic demands
  of feeding

21
Problem Solving is Essential

• Suck-swallow-breathe interaction
• Influence of illness and immature CNS
• Multi-system integrated nature of feeding
• Interaction between medical diagnosis and
  feeding/swallowing

22
Multi-System Infant Focused Approach

• Looks at the whole infant
• Focuses on the many systems involved
• Recognizes that feeding successfully depends on
  much more than age, weight and sucking ability

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Two Key Strategies

• Positioning
• Flow Rate

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Positioning is Critical

• It impacts
• Airway maintenance
• Breathing regulation
• Swallowing safety
• Overall organization of the infant

25
Positioning is Critical

• Head Neck Position influences
• Airway caliber/size
• Swallowing
• Direction and speed of bolus flow
• Timing of swallow-breathe sequence
• Most of what infants do during feeding is related
  to airway maintenance or airway protection

26
Positioning is Critical

• Swaddling
• Provides overall postural support and
  containment
• Base of support for feeding
• Supports limbs to the body midline
• Has an overall organizing effect for the infant

27
Semi-Upright

• Cradle
• On feeders lap, facing feeder

• Disadvantages of Semi-Upright for Premies
• Typically more shallow breathing
• Head can easily be extended out of alignment
• Gravity can pull the tongue into a more retracted
  position
• Fluid can pool in the back of the mouth or
  approach the back of the mouth more quickly

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Sidelying

• Benefits
• Easier breathing
• More AP ribcage movement
• Lung compliance increased
• Airway resistance decreased
• Better Head/Neck alignment
• Easier to control fluid
• Increased subglottic air pressure for airway
  protection

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Flow Rate is Critical

• One of the most critical factors, if not the most
  critical factor, for safe feeding in NICU babies
• The greatest obstacle to safe and successful
  feeding is a high flow that may flood the
  pharynx, triggering repeat swallowing and lead to
  interruption of breathing

30
Flow Rate is Critical

• The consequence of this deterioration is the
  potential for the penetration of fluids into the
  supraglottic space or aspiration of fluid. This
  poses a significant risk throughout nipple
  feeding

31
Flow Rate is Critical

• Who created high/faster flow nipples? What was
  their goal? What were their underlying
  assumptions?
• What formula companies didnt understand
• Faster flow makings it harder to swallow
• Faster flow makes it harder to organize
  breathing.

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Impact of Flow on Swallowing

• Overfilling of mouth
• Overfilling of throat
• High volume of fluid needs to be directed away
  from airway with exquisite timing and control of
  muscle movements
• Airway opening and closing must be precise under
  these conditions in order to protect the airway

33
Impact of Flow on Breathing

• Overfilling of mouth
• Overfilling of throat
• High volume of fluid needs to be directed away
  from airway with exquisite timing and control of
  muscle movements
• Airway opening and closing must be precise under
  these conditions in order to protect the airway

34
Common Feeding Problems

• Tires before finishing Feeding Why?
• Low hematocrit (proportion of blood volume that
  is occupied by red blood cells)
• Poor sleep between feedings
• Fed too long at prior feeding and trouble
  recovering
• Recently weaned from oxygen
• Air hungry
• Schedule is not optimal for infant
• Allowed to feed too fast
• Immature state control

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Common Feeding Problems

• Lacks spontaneous mouth opening Why?
• Is too drowsy to be vigorous
• Is breathing with too much effort to be willing
  to suck
• The reluctance to suck may be an instinctive
  reaction, a purposeful respond to attempt to
  guard the airway.

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Common Feeding Problems

• Frantic during feeding Why?
• Air hunger
• Had to wait too long to be fed
• Flow too fast
• Smacking sounds during feeding Why?
• Not maintaining tongue-palate seal (suction
  against hard palate)

37
Common Feeding Problems

• Holding tongue against palate Why?
• Compensation for increased work of breathing
• An attempt to stabilize the head, neck,
  oral-pharyngeal area
• Disorganized sucking Why?
• Overall postural disorganization
• Poor sucking rhythm, poor tongue stability

38
Common Feeding Problems

• Trouble latching on Why?
• Related to breathing or swallowing
• Oral-tactile hypersensitivity
• Had to wait too long to be fed and now frantic
• Related to abnormal CNS

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Common Feeding Problems

• Poor sucking Why?
• Ask
• Is alertness, vigor sufficient?
• How does non-nutritive suck (NNS) compare with
  nutritive suck (NS)? Why?
• Could a weaker nutritive suck be purposeful?
  Why?

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Common Feeding Problems

• Drooling (loss of bolus control orally) Why?
• Often perceived inaccurately as poor lip seal
• May be purposeful on babys part
• Respiratory effort is disrupting the swallow
• Sort sucking bursts Why?
• Is it purposeful? May be an adaptive
  compensatory response

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Common Feeding Problems

• Noisy swallows Why?
• Normal swallows are quiet
• Gulping sounds
• Gurgling sounds
• High-pitched crowing sounds/stridor
• Hard swallows
• Coughing and/or Choking
• Highly concerning
• VFSS/MBSS typically indicated

42
Common Feeding Problems

• Color change during feeding Why?
• Subtle or marked
• Associated with desaturation
• Loss of bolus control
• Associated with coughing/choking or noted without
  overt signs
• Clinical Observation Color change noted
  clinically/at bedside correlated with silent
  aspiration on MBSS/VFSS

43
Cardiopulmonary Disorders

• Patients with compromised cardiac or respiratory
  function often have serious difficulties with
  hypoxia during the feeding
• Many cardiac patients can feed well, but lack the
  endurance to take a sufficient amount of
  liquid/food in a timely manner
• Treatment for endurance problems and try to make
  the feeding as efficient as possible

44
Cardiopulmonary Disorders

• Position to support he body well and allow the
  easiest possible intake
• Children with respiratory problems will struggle
  to met nutritional needs
• Positional assistance and calorically dense
  formulas/foods are suggested.

45
Down Syndrome

• 40-50 of children with DS develop a cardiac
  abnormality, a large percentage develop mitral
  valve prolapse by adulthood
• Reduced tone in the cheeks and lips contributes
  to an imbalance in the forces on the teeth, the
  force of the tongue is greater contributing to
  open bite

46
Down Syndrome

• Compromised immune system with corresponding
  decrease in the number of T-cells
• Chronic URI associated with mouth breathing
  patter, xerostomia (dry mouth) and fissuring of
  the tongue, lips, acute necrotizing ulcerative
  gingivitis, decreased saliva and increased dental
  caries

47
Down Syndrome

• Increased risk of GI congenital obstruction
  (duodenal atresia, Hirschsprungs disease)
• Increased risk of leukemia
• Sleep problems are common
• Autism can co-occur in 10
• 26 have psychiatric disorder
• 15-25 have behavioral or emotional disorders

48
Down Syndrome

• Vision 50 have refractive errors
  (myopia/hyperopia), 15 have cataracts
• 5-10 have seizures
• Thyroid may fail at any agefrom newborn to
  elderly
• Celiac disease is more common
• Congenital heart disease in half
• 85 have IQ scores that range from 40-60 (mild to
  moderate MR)

49
Down Syndrome

• Families with a child with DS cope better than
  families with a child with another disa8iblity
• Most children with DS have at least 1 good friend
• True macroglossia is rare relative
• the tongue is of normal size but the oral cavity
  is reduced due to underdevelopment of the midface

50
Down Syndrome

• Breastfeeding is a good option, lactoengineering
  or calorically dense formals for bottle-fed
  babies may be needed
• Higher flow nipples may help with endurance
  (asses the swallow first!)
• Oral sensory motor therapy is highly recommended
  (Talk Tools by Sara Rosenfeld Johnson, Beckman
  Oral Motor Therapy)

51
Feeding Aversions

• Severe feeding aversion is defined as an extreme
  self-restriction of intake which leads to
  significant developmental, social and health
  problems (Kedesky Budd)
• Incidence of minor feeding problems
• 25 - 35 in normal children
• 40-70 in children born premature or with chronic
  health issues.

52
Feeding Aversions

• Feeding aversion can manifest as self
  restriction of foods of specific
• Type
• Texture
• Amount

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Feeding Aversions

• Early Warning Signs
• Reflux
• Breast/bottle feeding difficulties
• Difficulty transitioning from semi-solid to solid
  foods
• Sensory issues/language delay
• Poor mealtime routines
• Poor parent/caregiver interaction with child
• Difficulty with parent/child mealtime interaction

54
Feeding Aversions

• Red Flags
• Oral Motor Dysfunction
• Dysphagia
• Complicated Neonatal course
• History of prolonged intubation
• Supplemental tube feedings
• Poor meal scheduling
• Poor parental feeding strategies
• Traumatic event

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Is it behavioral or Sensory?

• Answer It is normally both.

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Autistic Spectrum Disorder

• Co treatment with occupational therapy is
  strongly recommended
• Treatment program for sensory issues is number
  one therapeutic priority
• Use of picture schedules, social stories,
  concrete and consistent language
• Environmental cues must be consistent
• Food preparation routine (wash hands, help set
  table) as appropriate
• Environmental cues must be consistent
• Child will learn about food first by touching it

57
Autistic Spectrum Disorder

• Meal/snack time schedule
• Food Chaining as part of the treatment program
• Allow child to have anchor foods
• Child will have a phobic response to change
• Consider how food looks, smells, feels, and
  sounds as child eats it
• Shape or oral motor program to the sensory needs
  of the child
• Allow child to set pace of the program, do not
  force
• Meals 20-25 minutes, snacks 10-15 minutes

58
Failure to Thrive or Childhood Anorexia

• Is the child ready for feeding therapy?
• Organic or Non-organic debate?
• Many children with FTT have subtle neuromuscular
  or oral-motor disorders.
• Some may have an undiagnosed syndrome or disease.
  

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Failure to Thrive or Childhood Anorexia

• Organic
• Non-organic
• Mixed
• Defined as height, weight and head circumference
  below the 5th percentile
• Childhood anorexia characterized by loss of
  appetite due to very low body weight, altered
  taste to foods, very little interest in eating.

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Failure to Thrive or Childhood Anorexia

• Can be caused by
• CNS damage
• feeding problems
• cardiopulmonary disorders
• metabolic disorders
• abnormalities of the endocrine system

• Malabsorption
• Reflux
• chronic gastroenteritis
• genetic disorder
• Infection
• Parasites
• economic social and psychological problems.

61
Treatment of Failure to Thrive

• Caloric supplements when needed and fade when
  appropriate
• Structured meal times and parent education
• Treatment of underlying disorders and conditions

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Tube-fed children

• Reasons to tube feed
• Prematurity
• Anatomical abnormalities
• Neurological issues
• Aspiration
• Fatigue
• Pending surgeries
• Failure to thrive
• Insufficient appetite

63
Tube-fed children

• Treatment focuses on
• Educating parents about tube feedings
• Prevention problems from developing
• Normalizing oral sensory perceptions for
  exploration and feeding
• Optimizing oral motor control and oral enjoyment
  for exploration and feeding

64
Tube-fed children

• Treatment focuses on
• Educating parents about tube feedings
• Prevention problems from developing
• Normalizing oral sensory perceptions for
  exploration and feeding
• Optimizing oral motor control and oral enjoyment
  for exploration and feeding
• Transitioning to oral feeding, if indicated

65
Cleft Lip Palate

• Clefting influences the mechanics of sucking and
  swallowing in varying degrees, depending on
  location and severity
• Children with clefts frequently have a slower
  weight gain during the first 2-3 moths than other
  infants caused by difficulties with feeding

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Cleft Lip Palate

• Babies with cleft can often breast feed with
  minimal assistance from the feeder if the cleft
  is a lip only cleft palates need to be
  considered individually
• Children with clefts frequently have a slower
  weight gain during the first 2-3 moths than other
  infants caused by difficulties with feeding
• Infants with isolated cleft of lip or soft palate
  generally have less difficulty with breast/bottle
  feeding

67
Cleft Lip Palate

• Effective compensations
• Positioning the child in a more upright posture
  for eating
• Using the fingers or mothers breast to provide
  closure or support for an open lip cleft
• Using bottles and nipples that do not require
  negative-sucking pressure
• Special Bottles Haberman Feeder, Hazelbaker
  Finger Feeder, Pigeon Feeder

68
Cleft Lip Palate

• Effective compensations
• Using palatal obturators to seal a portion of the
  palatal cleft Positioning Lip support
• Palatal Obturator, also called a plate
• plastic insert that forms an artificial palate
• helps with tongue positioning for sucking
• intraoral pressure is not changed

69
Cerebral Palsy

• Five 5 basic causes of feeding disorders
• Structural differences
• Neurological conditions
• Developmental delays
• Behavior
• Other medical conditions

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Cerebral Palsy

• Structural differences
• Occasionally cleft will co-occur
• Velopharyngeal incompetence with nasal
  regurgitation of fluids
• Neuromotor Involvement
• Abnormal movement patterns
• Lip retraction, lip pursing, jaw thrust, lack of
  jaw grading, tonic bite, tongue retraction,
  tongue thrust

71
Cerebral Palsy

• 3. Developmental delays
• Primitive feeding skills persist beyond the time
  when those behaviors should have evolved into
  more mature behaviors
• i.e. suckling munching pattern instead of
  rotary chew, graded jaw, substantiated bite, and
  tongue lateralization

72
Cerebral Palsy

• Behavior
• Often present as a primary cause of feeding
  problems by co-occur with other causes
• Food refusal may be due to frustration or lack of
  control

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Cerebral Palsy

• Other Medical Issues
• Reflux is common in kids and adults with CP
• Results in frequent vomiting esophagitis, pain
  and discomfort associated with swallowing
• Heart conditions can cause food refusal or
  anorexia secondary to fatigue or effects of
  medications
• Dysgeusiaimpairment of the sense of taste can
  lead to food refusal, can be a side effect of
  some meds and present in individuals with kidney
  disorders
• Poor saliva management

74
Sources

• Fraker, C., Walbert, L. (2005). Treatment of
  Pediatric Feeding Disorders from NICU to
  Childhood. Atlanta, GA.
• Shaker, C. (2003). Clinical Reasoning in the
  NICU Optimizing Swallowing Safety and Feeding
  Success. ASHA Convention. Chicago, IL.
• Morris, S.E., Klein, M.D. (2000). Pre-Feeding
  skills, Second Edition. Therapy Skill Builders.
• Workinger, M.S. (2005). Cerebral Palsy Resource
  Guide for Speech-Language Pathologists. Thomas
  Delmar Learning.