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Intervention to promote chewing skills in children

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Positioning is highly individualised for a child with cerebral palsy so this may not work ... Physical and Occupational Therapy in Pediatrics 23(2): 19-44 Hulme ... – PowerPoint PPT presentation

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Title: Intervention to promote chewing skills in children


1
Intervention to promote chewing skills in children
  • Paediatric Feeding (Disability) Group

http//epicself.com/wpcontent/uploads/2009/02/chew
ing.jpg
2
To start Completed 2008 CAT
  • Clinical question
  • In Children with Cerebral Palsy (Spastic
    Quadriplegia), what is the evidence that upright
    positioning in midline is safest for eating and
    drinking?
  • Reasoning for question
  • General recommendations to clients with
    swallowing difficulties aim to position clients
    at the default position of 90-90-90 posture
    (upright at 90 degrees in the wheelchair as much
    as possible)

3
The clinical bottom line.
  • A 20 to 30 degree reclined position with neck
    flexion (chin tucked) is the safest positioning
    for feeding a child with tetraplegia and
    dystonia.
  • Chin tuck is a useful technique to improve
    closure of the airways. The tilting down of the
    epiglottis seems to be facilitated and this gives
    some protection to the laryngeal vestibule even
    if the vestibule is not completely closed.

4
Continued (positioning CAT)
  • Reclined (Tilted?) 30 degree position has
    evidence that it is the better than upright 90
    degree position for most children with cerebral
    palsy (aged 1-10 years).
  • Positioning is highly individualised for a child
    with cerebral palsy so this may not work for
    everyone.
  • Most importantly head and trunk alignment has the
    biggest impact on feeding skills for a child with
    cerebral palsy.

5
Search for a new clinical question
  • Anecdotally, Speech pathologists working with
    clients in the disability population can often
    encounter clients who bite non-nutritive objects
    and also having feeding difficulties.
  • Is there evidence that these items can assist
    develop chewing skills for these children?
  • The group sought to look at the evidence for
    using non-nutritive objects to develop chewing
    skills in children

6
Chewy Tubes
  • Chewy tubes are a popular product used by the
    disability population. They are promoted as being
    able to do the following
  • Chewy Tubes are an innovative oral motor tool
    designed to develop biting and chewing skills.
    (http//www.chewytubes.com/)
  • They are described as being suitable for the
    following disability populations Autism, Down
    Syndrome and Cerebral Palsy

http//mealtimenotions.com/ProductsTools/362007all
_three_chewy_tubesSMALLER.jpg
7
The question formed
  • P Population- In children who have eating and
    drinking difficulty.
  • I Intervention- will non-nutritive objects such
    as chewy tubes
  • C Comparison- N/A
  • O Outcome- improve chewing skills.

8
Searching the evidence
  • Weve searched from
  • ERIC SpeechBITE
  • Google Scholar PsychInfo
  • Medline
  • PubMED
  • OVID
  • CINAHL
  • PEDro

9
Search terms.
  • Chewy Tube, theratube, non-nutritive, chewing,
    disability, feeding difficulty, oro-motor
    dysfunction, food texture, bite

10
Clinical bottom line
  • We do not tend to recommend the use of
    non-nutritive objects to develop chewing skills
    if the clients are orally fed.
  • May be a more appropriate item for meeting
    sensory needs only not developing specific
    feeding skills (Scheerer, 1992)

11
Difficulty in researching/ question
  • Too specific in choice of intervention type to
    investigate (Chewy tubes/ non-nutritive chewing)
  • Basis of feeding difficulty not clear in clinical
    question (? Sensory based, neuro-muscular, oral
    structures)
  • No preliminary search (this may have saved the
    group long aimless searching).

12
Development of a new question
  • The search for a new question is to be based on
    the current clinical practice of clinicians
    working with clients with eating and drinking
    difficulties.
  • What are the current clinical practices that
    could lend themselves to a new CAT?

13
Current Clinical Practice
  • ADHC Hurstville has a lunch club with main
    objective is to address specific feeding issues
    such as starting solids and moving to the next
    texture.
  • The clients who attend have a range of
    disabilities Down Syndrome, Autism, Global
    Delay, Cerebral Palsy.

14
Current Recommendations and Rationale for develop
chewing skills
  • RECOMMENDATION
  • For client to hold and experience with hard
    munchable food where no bits come off e.g. chunky
    carrot stick
  • RATIONALE
  • To encourage chewing practice without requiring
    to swallow

15
Current Recommendations and Rationales for
develop chewing skills
  • RECOMMENDATION
  • Eat bite and dissolve foods, meltable hard solids
    e.g. milk balls, cheese bacon balls.
  • Placing the food to the side of the teeth
  • RATIONALE
  • Encourage client to feel and experience different
    textures and position by placing on one side of
    the mouth on the molars or the gums

16
Current Recommendations and Rationales for
develop chewing skills
  • RECOMMENDATION
  • Client is starting to bite bread so introduce
    other firm things like cooked vegetables, arrow
    root biscuits (progressively moving towards
    crunchy foods).
  • RATIONALE
  • Extending a new skill/generalising. Desensitising
    to different textures.

17
Current Recommendations and Rationales for
develop chewing skills
  • RECOMMENDATION
  • Client only eating sandwiches at preschool,
    introduce this food at home.
  • Introduce other foods similar to toast eg
    english muffins, crumpets, hard ends of cake.
  • RATIONALE
  • Extend food to other environments.
  • Generalising textures to extend range of foods
    consumed.

18
Current Recommendations and Rationales for
develop chewing skills
  • RATIONALE
  • Enable client to achieve appropriate hand grip to
    feed more easily and independently.
  • Encourage lateral chewing motion, strengthen,
    desensitising.
  • RECOMMENDATION
  • Use a left handed angled spoon.
  • Develop biting skills with placement at side
    using cruskits and arrow root biscuits.

19
Current Recommendations and Rationales for
develop chewing skills
  • RECOMMENDATION
  • Client is overfilling. Cut food into 2cm pieces.
  • RATIONALE
  • Reduce ability to overstuff, supervise, possibly
    supplement oral sensory seeking with something
    else if that is the reason for overstuffing.

20
Summary of recommendations as potential clinical
questions
Pt./Problem Intervention Comparison Outcome
Autism Down syndrome Oro-motor difficulties Eating/drinking difficulties Developmental delay Positive reinforcement, side placement, chewing training, texture fading Develop chewing, Encourage lateral chewing, strengthen, desensitise, improve bite, chewing generalisation, increase food variety
21
In 2010,
  • We will have access to ADHC library during our
    meeting time so that we can decide on the topic
    that has research evidence.
  • We will continue to monitor the outcomes of
    clients who need to develop their chewing skills
    and the rate of success from each of our
    recommendations with GAS goals
  • WATCH THIS SPACE!!

22
Where to from now.
  • Next year, our meetings will be at ADHC
    Hurstville
  • 390 Forest Road Hurstville
  • Ph 9701 6000
  • Please contact Nitha Thomson nitha.thomson_at_dadhc.
    nsw.gov.au
  • Ph 9297 6000 if you are interested

23
References
  • Dawes,M.,Badenoch,D and Goddard, O. Informed
    Clinical Practice. Centre for Evidence-Based
    medicine, Univ of Oxford,Nov 2000
  • Giselle EG, Tessler MJ, Laplerre G, Seidman E,
    Drouin E, Fillon G (2003) Feeding management of
    children with severe cerebral palsy and eating
    impairment an exploratory study. Physical and
    Occupational Therapy in Pediatrics 23(2) 19-44
  • Hulme JB, Shaver J, Acher S, Mullette L, Eggert
    C (1987) Effects of adaptive seating devices on
    the eating and drinking of children with multiple
    handicaps. American Journal of Occupational
    Therapy 41(2)81-9
  • Larnert G, Ekberg O (1995) Positioning
    improves the oral and pharyngeal swallowing
    function in children with cerebral palsy. Acta
    Paediatr Jun84(6)689-92
  • Scheerer, C.R, (1992), Perspectives on an Oral
    Motor Activity The use of Rubber Tubing as a
    Chewy, The American Journal of Occupational
    therapy, Volume 46 (4), pp 344-352
  • http//www.autism-pdd.net/testdump/test5659.htm
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