Feeding and swallowing in infants and children

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Feeding and swallowingin infants and children

• Types Swallowing of problemsDysphagia(dis'fahj
  uh)

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Dysphagia fall into three categories based on the
phase

• Oral dysphagia Problems occur due to issues
  with lips, tongue, cheek muscles, and/or jaw
  movement. Children may hold food in mouth, have
  difficulty chewing, drool or spill liquids and
  have difficulty moving food to /from chewing
  surface and back of mouth.
• Pharyngeal dysphagia These swallowing problems
  happen before food reaches the esophagus and may
  result from neuromuscular disease, obstructions
  or surgery. Patients experience difficulty
  starting a swallow food goes down the wrong
  pipe or there is choking and coughing. This may
  result in poor nutrition or dehydration,
  aspiration (which can lead to pneumonia and
  chronic lung disease). Conditions that may cause
  pharyngeal dysphagia include Lou Gehrig's
  disease, brain injury, cerebral palsy, multiple
  sclerosis, muscular dystrophy, spinal cord
  injury, stroke, cervical osteophytes or other
  obstructions. Neurologic causes often result in
  Oropharyngeal Dysphagia.
• Esophageal dysphagia These swallowing
  problems originate in the esophagus. Food or
  liquids "stick" in the chest or throat and
  sometimes come back up. Causes in children
  include eosinophilic esophagitis,
  gastroesphageal reflux disease (GERD) and
  esophageal-motility disorders, as well as later
  stages of some of the neurological diseases
  mentioned above.

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Physical Factors

• There are 4 primary areas that impact feeding
  swallowing
• Respiratory system - airway restrictions lg.
  tonsils/ adenoids, choanal stenosis,
  laryngomalacia, jaw /or tongue retraction
• GI system - GER and possible laryngeal closure
  and the sensory feedback that result may train
  them to eat less or less often.
• Pharyngeal function-motility decreased strength
  or coordination and sensory (hyper/hypo)impairment
  s
• Oral function Structure, muscle strength,
  coordination and sensation impact feeding and are
  obviously the most easily seen and reported

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Physical Symptoms
Respiratory destating, nasal flaring , change
of color, coughing, gagging, needing to catch
breath, mouth breathing, frequent open mouth
posture, snoring/ noisy breathing, Hx of Frequent
URI, recurrent PNA, asthma, gets sleepy during
meals. GI symptoms of GERD, breath caught,
wet sound in throat, coughing/gaging between
feedings/meals. Pharyngeal avoiding solids,
gagging on solids, oral defensiveness, and
behavioral issues around eating Oral
prolonged eating at any stage, open mouth
chewing, drooling food preferences for
smooth consistencies and crunchy food
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Oral-Motor Tone and Feeding
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Poor Muscle Tone Poor Feeders

• Oral motor function is the very fine motor
  function of the oral mechanism (i.e., jaw,
  tongue, lips, cheeks) for purposes of eating
  drinking, speaking, and vegetative activities.
• Oral motor function requires the feedback of
  sensory processing to achieve the dissociation,
  grading, direction, timing, and coordination of
  mouth movement for eating, drinking, speaking,
  and other vegetative activities.
• Children with specific oral motor deficits will
  exhibit avoidance/ refusal of food texture types
  and may not adapt to different nipples/cups.

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Correlations Complications

• Premature birth
• Cerebral Palsy
• Down Syndrome other facial syn.
• Cleft palate
• GERD
• Prolonged tube feeding
• Sensory Integration Deficits
• All may lead to Failure to thrive

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Feeding Milestones

• Oral Motor Development
• Nipple feeding - 36wks gestational age
• Spoon feeding - introduced approx. _at_4 to 6 mos.
• Cup drinking - introduced by 8 - 9mos.
• Biting and chewing development window 4 -8 mos.
  Is best time to introduce
• Straw drinking about 18 mos.
• Assuming normal gross fine motor milestones
  met.

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Gastroesphageal Reflux

• Feeding difficulties due to GER

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Reflux vs. Spit up

• Lower esophageal sphincter (LES) is less
  developed in infants.
• Relaxed or weak lower esophageal sphincter muscle
  can allow acidic contents of the stomach to
  reflux to the esophagus, oral and pharynx and
  oral cavity.
• Diagnosis of GERD is clinically inferred based on
  
• Interview of Caregiver
• Association of signs and symptoms of reflux
  events
• Frequent or prolonged duration of reflux events
• Absence of alternative diagnoses

• Common amongst infants
• Mild vomiting or regurgitation of milk, food and
  saliva does not contain large amounts of foods
  and fluids
• Not forceful
• About 40 of infants spit up on regular basis
• Usually occurs after feeding or burping
• Typically no further or acute distress occurs
  after spitting up
• Infant remains satiated until next feeding time

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GER

• Signs/ Symptoms may include
• Heartburn
• Nausea
• Arching or stiffening of the body in response to
  swallowing
• Facial grimacing during swallow
• Pain, irritability, constant/sudden crying after
  eating
• Frequent coughs, hiccups wet burp
• Frequent vomiting after eating vomiting more
  than 1 hour after eating recurrent regurgitation
  that persist after 1 year of age
• Poor weight gain/loss
• Constant eating or drinking
• Inability to tolerate certain foods decreased
  acceptance or consumption of foods despite hunger
• Coughing, gagging, choking
• Frequent sore throats
• Respiratory issues (pneumonia, bronchitis,
  wheezing)
• Bad Breath
• Drooling
• Feeding therapy, planned programs, oral-motor
  techniques, and positioning changes will not be
  successful until GI symptoms/ issues are resolved

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Food allergies Almost as bad as GER
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Food Allergies

• Foods that most commonly cause allergiesCows
  milk Fish. ShellfishWheat Nuts, peanutsSoy
• 3 most common reactions
• Intestinal
• Respiratory
• Skin Reactions
• Can occur immediately or up to 48 hours after
  eating
• Typical allergic reaction manifests within 2
  hours
• Food allergy or reaction caused by
• Food poisoning
• Enzyme deficiencies (e.g. lactose intolerance)
• Flavonoids and preservatives, toxins, naturally
  occurring pharmacological substances

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Feeding/ Dietary Approaches

• If allergies or intolerance is suspected
• Food diary
• Record of type, amount, timing and description of
  any symptoms that occur (consider keeping for a
  2-4 week period)
• Elimination diet
• Exclusion of suspected foods or restrictive diet
• May not be nutritionally complete, should be done
• in conjunction with or planned with assistance
  of a registered dietician
• Slowly reintroduce foods thereafter
• Nutritional replacements for milk i.e., protein,
  calcium, riboflavin, Vitamin A
• Leafy greens
• Orange fruits
• Vegetables
• Meat
• Meat alternatives (tofu, soy, legumes, poultry)

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A look into Resistant and Picky Eaters
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Challenges

• Can permanently impair their long-term growth
• Often have a low percentile for weight and height
• Can interfere with a childs ability to learn
  properly and progress academically
• Can lead to hospitalizations
• Affect the childs socialization and self-esteem
• (Ernsperger Stegen-Hansen, 2004)

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Some Statistics

• Nearly 80 of children with severe mental
  retardation have feeding difficulties and
  inadequate diets (William, Coe, Synder, 1998)
• 75 of children diagnosed with Autism Spectrum
  Disorders experience atypical feeding patterns
  have limited food preferences (Mayes and Calhoun,
  1999)
• 45 of typically developing children experience
  some level of eating problems during childhood
  (Bentovim, 1970)

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Picky Eaters vs. Resistant Eaters

• Picky eaters may have certain limitations or
  aversions to foods but they eventually eat enough
  of a variety of foods to maintain a balanced and
  healthy diet

• Resistant eaters are on the extreme end of the
  continuum and have serious food aversions and/or
  medical impairments that prevent them from eating
  a balanced diet
• (Ernsperger Stegen-Hansen, 2004)

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Characteristics of a Resistant Eater

• Limited food selection. Total of 10-15 foods or
  less.
• Limited food groups. Refuses one or more food
  group.
• Anxiety and/or tantrums when presented with new
  foods. Gag or become ill when presented with new
  foods.
• Experiencing food jags. Require one or more foods
  be present at every meal prepared in the same
  manner.
• May be diagnosed with a developmental delay or
  MR.
• (Ernsperger Stegen-Hansen, 2004)

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Food Neopobia Scale (FNS)

• Simple 10-item questionnaire developed by Pliner
  and Hobden (1992) that can be administered to
  determine if the child is a resistant eater.
• A score greater that 35 is considered high and
  that child may benefit from a comprehensive tx
  program
• Typically developing two-to-four-year-olds
  experience food neophobia for short periods of
  time. By age five most children have decreased
  their fear of new foods and are willing to try
  new and novel foods.
• SEE HANDOUT!

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Resistant eaters and Developmental Disabilities

• There is a high correlation between problem
  eating and children with disabilities.
• Specific characteristics include
• - Sensory Integration dysfunction
• - Immature respiration
• - Delayed oral-motor development
• - Limited communication skills
• - Rigid behaviors/routines

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Sensory Integration Dysfunction

• Proprioceptive difficulties include positioning
  and movement of the limbs and head, and motor
  planning. (ex jaw opening, holding utensils,
  positioning in a chair, spilling cups etc)
• Vestibular difficulties include balance and
  movement from the eyes, neck, and head. (ex
  focusing on how they are moving, body position,
  fear of falling)
• Tactile Sensory difficulties can include
  hyposensitive or hypersensitive (ex little or no
  reaction to pain, difficulty holding and using
  utensils, rub or bite their skin vs. prefer food
  to be the same temperature, avoid lumpy or mixed
  textured foods, dislike messy activities)
• (Ernsperger Stegen-Hansen, 2004)

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Sensory Integration Dysfunction (cont)

• Taste Sensory difficulties include how the taste
  buds of the tongue receive and interpret
  information (ex difficulty transitioning from
  water to juice or accept milder dilute tastes)
• Olfactory Sensory difficulties include smell
  perception (ex children with chronic congestion
  or open mouth posture may not interpret flavors
  effectively)
• Visual Sensory difficulties include when the
  brain is unable to link visual info with
  auditory, touch, and movement sensations or it
  inadequately processes the sensory messages (ex
  cover one eye or squints, have difficulty
  shifting eye gaze from one object to the other
  etc..)
• Auditory Sensory difficulties include localizing
  the direction of sound and figure/ground
  discrimination , i.e. between a wide variety of
  environmental and speech sounds (ex Overly
  stressed and anxious by loud noises, unable to
  follow multi-step verbal instructions, trouble
  attending to verbal instructions etc)
• (Ernsperger Stegen-Hansen, 2004)

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Treatments
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We work with

• Inconsistent or poorer oromotor skills with
  regard delayed /or atypical development, i.e.
  fewer readiness behaviors spoon feeding/
  solids/cup drinking/ ineffective chewing/ open
  mouth postures
• Any client who displays oral-motor difficulties
  as compared to their typically developing peers
  for feeding and speech
• Reduced mobility
• Reduced agility
• Reduced precision
• Reduced endurance

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Aims of treatment

• To increase the Somatosensory awareness of the
  oral mechanism
• To normalize oral tactile sensitivity
• To improve feeding skills and nutritional intake
• To increase differentiation of oral movements
  thru
• Dissociation The separation of movement, based
  on stability and adequate strength, in one or
  more muscle groups.
• Grading The controlled segmentation of movement
  through the mid range of any particular ROM.
• And by decreasing Fixing An abnormal posture
  used to compensate for reduced stability which
  inhibits mobility.
• To improve the precision of volitional movements
  of oral structures for speech production

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Who to refer?

• Low birth wts. with slow gain. children below
  10th percentile.
• Babies/kids not gaining well and taking more than
  30 minutes to complete an age appropriate
  feeding.
• Resistant/ picky eaters.
• Clumsy, poorly coordinated kids, especially
  with
• Any droolers, open mouth posture kids (if not
  mouth breathing b/c of huge tonsils)
• Children not babbling by 9 mos. and 15mo. olds
  with no true words.
• Children whose parents do not understand most of
  what they say in context.
• Children who undertsandeverything said to them,
  but have no or few true words.

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References

• Ernspereger, L., Stegen-Hanson, T. (2004). Just
  Take a Bite. Easy, Effective Answers to Food
  Aversions and Eating Challenges.
• Mayes Calhoun, (1999). Symptoms of Autism in
  Young Children and Correspondence with the DSM.
  Infants and Young Children., v. 12.
• Pliner and Hobden (1992). Development of a Scale
  to Measure the Trait of Food Neophobia in Humans,
  Appetite, v. 19.
• Williams, K., Coe, D., Snyder, A. (1998). Use
  of Texture fading in the Treatment of Food
  Selectivity. Journal of Applied Behavior
  Analysis, v. 31
• Pediatric Gastroesophageal Reflux Clinical
  Practice Guidelines Joint Recommendations of the
  North American Society for Pediatric
  Gastroenterology, Hepatology, and Nutrition
  (NASPGHAN) and the European Society for Pediatric
  Gastroenterology, Hepatology, and Nutrition
  (ESPGHAN)
• Journal of Pediatric Gastroenterology and
  Nutrition 49498-547 2009 European Society for
  Pediatric Gastroenterology, Hepatology, and
  Nutrition and North American Society for
  Pediatric Gastroenterology, Hepalogy, and
  Nutrition