Title: Intervention to promote chewing skills in children
1Intervention to promote chewing skills in children
- Paediatric Feeding (Disability) Group
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2To 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)
3The 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.
4Continued (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.
5Search 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
6Chewy 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
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7The 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.
8Searching the evidence
- Weve searched from
- ERIC SpeechBITE
- Google Scholar PsychInfo
- Medline
- PubMED
- OVID
- CINAHL
- PEDro
9Search terms.
- Chewy Tube, theratube, non-nutritive, chewing,
disability, feeding difficulty, oro-motor
dysfunction, food texture, bite
10Clinical 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)
11Difficulty 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).
12Development 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?
13Current 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.
14Current 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
15Current 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
16Current 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.
17Current 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.
18Current 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.
19Current 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.
20Summary 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
21In 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!!
22Where 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
23References
- 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