Clinical Evaluation of Dysphagia in SchoolAged Children

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Clinical Evaluation of Dysphagia in School-Aged
Children

• Kelly Dailey Hall, Ph.D. CCC/SLP
• Pediatric Speech Language Services, Inc.
• Greensboro, NC
• kdhall2_at_uncg.edu

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Swallowing/Feeding Disorders is educationally
relevant

• 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 students medical condition warrants
  medical clearance for clinical procedures.

Roles of speech-Language Pathologists in
Swallowing and Feeding Disorders, ASHA 2001a, b
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Preschool/Elementary

• 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

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Middle/High School

• 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

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Incidence of Pediatric Dysphagia

• 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

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Where did it start?

• 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)
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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

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The Big Question?

• Is the student at risk for aspiration?
• Yes? Then you need to establish strategies for
  oral intake that minimizes the risk.
• 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.

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What Are Parents/Teachers Reporting?

• 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.

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What Do You Find Out After Probing Further?

• 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. cant
  go to birthday parties)

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Potential Students on Our Caseloads

• Group 1
• 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)
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Group 1

• History of
• GER
• Prematurity
• Short Bowel Syndrome
• Autism
• Developmental Delay
• Prolonged tube feeding

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Group 2

• No previous feeding/swallowing intervention
• History of picky eater
• May or may not have a significant medical history

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Need to determine the etiology

• Behavioral
• Sensory
• Physiological
• Combinations

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Sensory Issues

• Where do they come from?
• 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

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Behavioral Issues

• Where do they come from?
• Bad habits/desperation
• Poor limit setting
• Lack of mealtime structure and routine
• Passive eating with distractions
• Inconsistent expectations re eating

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Sensory Issues - Presentation

• Often avoids whole foods or texture groups
• Difficulty tolerating sensory input
  sight/smell/touch/taste
• Eats the same regardless of people/place
• Overstuffs oral cavity/takes tiny bites
• Stores food for later
• Gags as a sensory response
• Excessive drooling

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Behavioral Issues - Presentation

• Rarely selective avoidance
• Eats better for certain people/places
• Gags to get attention
• Rarely underlying neuro or medical issue

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Other factors to consider

• Adipsia
• the absence of thirst or the desire to drink
• Dysphagia can be a real or imagined difficulty in
  swallowing
• 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

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Clinical Assessment of Feeding and Swallowing

• History/Background
• Oral Mechanism/CN exam
• Swallowing Exam

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Visual Evaluation of Structures

• Lips
• Teeth - dental status, dentures
• Oral mucosa
• Tongue
• Palate, faucial arches
• Neck (larynx)

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Visual Evaluation of Structures

• Relative size and symmetry
• Abnormalities
• scarring
• atrophy
• asymmetry
• resting movement (fasciculation)

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CN V (Trigeminal Mandibular Branch
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Lips (CN VII)

• retraction
• rounding
• Closure

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Tongue (CN XII)

• elevation (ant.)
• lateralization
• protrusion
• retraction
• elevation (post)

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VP port (CN V,IX, X)

• elevation
• retraction
• lateral wall mvt
• posterior wall mvt

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CN IX (Glossopharyngeal)

• Look at your neighbor saying ah, ah, ah

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Laryngeal Exam (CN X)

• cough
• voice quality
• dry swallow (cervical auscultation)

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Swallow Exam

• 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

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What are we looking for?

• lip closure
• tongue mvt
• laryngeal elevation/hyoid elevation
• timing of swallow response
• Residue
• Signs/symptoms of aspiration

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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.

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Intervention

• Facilitative
• Facilitate recovery to normal
• Compensatory
• Compensate for a disordered system

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Compensatory

• 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.
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Compensatory/Manuevers

• Chin Tuck
• Supraglottic Swallow
• Mendelsohn Maneuver
• Effortful Swallow

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Facilitative

• 1. Oral Motor Exercises Lingual strengthening
• Sensory stimulation to increase awareness
• Increasing ROM
• 2. Development of Normal Feeding Skills

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Food Chaining

• 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
• childs 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.

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Food Chaining helps the Therapist to determine

• 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
  peersis there any difference?

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• Goal food items are selected that
• have similar features (taste texture temperature)
  to those in the childs 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

• Parent implements the program at home under
  direction of the team. Feeding therapy continues
  at school.
• Flavor Mapping involves analyzing the childs
  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).

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What is sensory integration?

• Sensory pertains to our senses
• 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

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Sensory-Based Feeding ProblemsNon-nutritive
Stimulation Protocol

• 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

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Sensory-Based Feeding Problems

• Visual
• Olfactory
• Tactile
• Gustatory

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Food ExperiencesVisual

• Non-mealtime visual experience
• Object-based, picture-based system
• Establish comfort level with food proximity
• Work on tolerating food on the table, on the
  childs plate, etc.

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Food ExperiencesOlfactory

• Introduce mild smells
• Establish comfort with proximity to smells
• Handling directly
• Presenting on another object
• Increase intensity of smells
• Scented therapy tools

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Food ExperiencesTactile

• Water play/Sensory bean bags
• Painting with food
• Food activities (i.e., flower pots, boats,
  gingerbread houses)
• Cooking activities
• Pizza, muffins, waffles, fruit salad, soup

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Food ExperiencesGustatory

• 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

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Treatment of Poor Hunger/Satiety

• 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

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Management of Behaviorally-Based Feeding Problems

• Rule-out medical, motor, or sensory involvement
• Parent education
• Promote ownership in older child
• Referral to behavior specialist and/or
  psychologist/psychiatrist

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Use of Reinforcement as a Part of Feeding Therapy

• 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

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• 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.
• Decrease inappropriate behaviors.
• Motivate the child to demonstrate an existing
  behavior more frequently.

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Food Rules for (Arvedson, 1998)

• 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.
• Dont wipe the childs hands or mouth until the
  meal is finished.

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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.

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Remember

• 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.