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A Learning Module for Pediatric Feeding & Swallowing

Lindsey Adams, B.A., Kyrsten Klein, B.A., JaLynn Otto, B.A., Amanda Starr B.A. Supervised by Dr. Ken Bleile, Ph.D CCC-SLP

Dr. Angela Burda, Ph.D. CCC-SLP

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TABLE OF CONTENTS

CONTENT AREA Abstract of Proposal ........................................................................................................ 3

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CONTENT AREA 1 Normal development of feeding and swallowing ............................................... 4 What is feeding and swallowing? Typical anatomy, physiology, and embryology CONTENT AREA 2 Assessment ........................................................................................................ 11 Recognition of atypical feeding and swallowing disorders Diagnosis Prognosis CONTENT AREA 3 Treatment of feeding and swallowing disorders ............................................... 19 Goal selection Specific therapy strategies CONTENT AREA 4 Dietary and nutritional considerations .............................................................. 24 Failure to thrive Food Aversion CONTENT AREA 5 Counseling ........................................................................................................ 30 Counseling strategies Discharge planning CONTENT AREA 6 Ethics and advocacy .......................................................................................... 33 ASHA guidelines CONTENT AREA 7 Scope of practice ............................................................................................... 35 Role of the SLP Role of the Cooperating professionals CONTENT AREA 8 Work settings .................................................................................................... 40 School Hospital Private Practice CONTENT AREA 9 Considerations for special populations ............................................................. 43 9a Craniofacial and midline disorders ......................................................... 43 9b Down Syndrome ..................................................................................... 46 9c Traumatic brain injury ............................................................................. 50 9d Premature infants in the NICU ................................................................ 53

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Abstract of Proposal Students need experiences across diverse clinical domains. Such experience may prove difficult to obtain with medically-involved populations, including children with feeding disorders. To meet this challenge, university departments around the country are implementing various strategies. The present research describes a learning module approach to provide basic information about pediatric dysphagia.

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Content Area 1 Normal Development

According to Arvedson and Brodsky (2002), anatomy, physiology, neurology, and embryology are an important factor in understanding the process in which a child swallows. Structures and functions are critical to know when assessing and diagnosing a child with a feeding and swallowing disorder. Through reading the resources in this section, you will have an understanding of the anatomical and physiological structures in infants as well as older children. You will also have an understanding as to why embryology plays a critical role in the development of feeding and swallowing. Typical feeding and swallowing development will be described in this section so that one may know what is disordered feeding and swallowing.

Introduction:

• In order to determine a pediatric feeding and swallowing disorder, it is crucial for a speech-language pathologist (SLP) to know normal development. Through reading Chapter 2 in Pediatric Swallowing and Feeding: Assessment and Management, competency will be attained in normal development, anatomy, physiology, and embryology. Typical feeding and swallowing patterns will be discussed. This will include the suck-swallow reflex, and the development of this reflex.

Readings:

• Throughout reading chapters 1, 4, and 6 in Developmental anatomy and physiology of children: A practical approach, students will understand the basic foundations of normal development in the areas of; the respiratory system and respiration, framework for development, and the control systems needed for sustaining life. An in-depth description of the oral cavity will be described and milestones will be given in regards to normal development. • In order to develop a better understanding of normal development in children chapter 2 in Dysphagia: Clinical management in adults and children should be read. This chapter gives an overview of normal term infant development and preterm infant development. • When reading section 1: Core knowledge in Pediatric dysphagia resource guide the student will be walked through the development of structures in gestation, as well as normal development throughout infancy.

Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management (2nd Ed.). Albany, NY: Singular Publishing Group.

Resources:

Chamley, C.A. (2005). Developmental anatomy and physiology of children: A practical

approach. United Kingdom: Elsevier Churchill Livingstone.

Groher, M.E., & Crary, M.A. (2010). Dysphagia: Clinical management in adults and children. St. Louis, MO: Mosby Elsevier.

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Hall, K.D. (2001). Pediatric dysphagia resource guide. San Diego, CA: Singular.

After completing the readings, answer the following questions. Study Questions:

1. Arvedson and Brodsky (2002 describe three systems involved in the suckling and

swallowing. a. Neurologic, respiratory, cardiovascular b. Cardiovascular, respiratory, and GI (gastrointestinal) c. Neurologic, cardiovascular, and GI d. Neurologic, respiratory, and GI

2. According to Arvedson and Brodsky (2002), deglutition is: a. semiautomatic motor action of the muscles of the respiratory and

gastrointestinal tracts that propels food from the oral cavity into the stomach b. swallowing c. a swallowing technique for a premature infant d. the integration of all systems during swallowing

3. What is the difference between the oral cavity in an infant and an older child? a. There is more space in the oral cavity in an infant than there is an older child. b. The infant has no teeth c. The tongue consumes most of the space in the mouth of an infant where an older child

had more space in the oral cavity. d. Both B and C

4. What is the difference in the pharynx between an infant and an older child? a. An older child has a 90 degree angle at the skull base b. An older child has an elongated pharynx c. There is no distinct oropharynx in an infant where there is one in an older child. d. All of the above

5. What is the difference in the larynx between an infant and an older child? a. An infant has a wide epiglottis where an older child has a narrow epiglottis b. The older child has a descended larynx; an infant’s larynx is elevated c. The larynx is small in an older child, making it easier for them to choke d. An infant has a large larynx, sometimes allowing too much air into the lungs.

6. What is the neural plate, and when does it start to form? a. The foundation of the Central Nervous System, 3 weeks during the embryonic

period b. The foundation of the Central Nervous System, 10 weeks during the embryonic

period. c. A plate in the spinal cord, 7 weeks during the embryonic period. d. The foundation of the Peripheral Nervous System, 3 weeks during embryonic period.

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7. What is the neural crest? a. The foundation of the spinal nerves b. The foundation of the cranial nerves c. The foundation of the Central Nervous System d. Both A and B

8. At 34 weeks, 8% of the body weight is white fat. Why is this a significant milestone for feeding?

a. The fat indicates that the infant is able to move his/her arms. b. The milestone shows that the infant is prepared to suck-swallow c. This indicates that the infant has “nutritional reserves” and is able to sustain

nutrition. d. The infant is ready for milk.

9. The facial development of gestation proceeds in the following order: a. Mandible forms, eyes move to the center of the cranium, ears elevate, hard

palate developed, soft palate developed, tongue descends. b. Mandible forms, ears elevate, eyes move to center of the cranium, hard palate

developed, soft palate developed, tongue descends c. Mandible forms, ears elevate, eyes move to center of cranium, soft palate develops,

hard palate develops, tongue descends d. Mandible forms, eyes move to center of cranium, ears elevate, tongue descends, hard

palate develops, and soft palate develops.

10. At what week does the oronasal membrane rupture? a. 10 weeks b. Between 11-13 weeks c. 6 weeks d. 34 weeks

11. What is the first stage of swallowing and between what weeks of gestation does this occur? a. Suckling; between 10-11 weeks b. Sucking; between 10-11 weeks c. Suckling; between 15-16 weeks d. Sucking; between 20-21 weeks

12. Arvedson & Brodsky (2002) describe suckling as the following: a. The upward, forward motion of the tongue during intake of liquids b. The upward, backward motion of the tongue during the intake of liquids. c. The tongue making any sort of movement in order to obtain enough liquids. d. The forward backward motion of the tongue during intake of liquids.

13. At what age does an infant crossover from a suckle pattern to a sucking pattern? a. 3 months b. 6 months

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c. 9 months d. 12 months

14. In regards to swallowing, what is necessary for the infant to maintain nutrition if born prematurely?

a. Sucking only b. Swallowing only c. Sucking and swallowing d. Suckling and swallowing

15. What allows the infant to keep the pharynx open for proper position of feeding?

a. Infant laying completely on their back b. Gravity c. Infant laying on their belly d. All of the above

16. Arvedson and Brodsky (2002) describe the purpose of the first 2-3 months of development. Which ones do they mention?

a. Achieve homeostasis in self regulation of eating and sleeping schedules b. Increase interaction with environment c. Nipple control, reaching, smiling, and social play d. All of the above

17. At what month do you wean from nipple feeding and introduce spoon feeding and cup drinking?

a. 3 months b. 6 months c. 9 months d. 12 months e.

18. What is the critical and sensitive period? a. The time when new textures are introduced to the child. b. The time when presenting new stimuli provides optimal learning opportunities c. The time when the child is severely ill and needs special dietary considerations. d. Both A and B

19. What does DQ stand for and what does it mean? a. Developmental Quotient; correlating level of functioning of infant to

introduction of solids b. Dairy Queen; introducing dairy products to infants c. Dairy Quotient; introducing dairy products to infants d. None of the above

20. How do infants communicate their feeding needs? a. Posture

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b. Vocalizations c. Head and mouth movements d. All of the above

21. Between what months does an infant get food from a spoon?

a. 3-6 mos. b. 8-9 mos. c. 5-7 mos. d. 7-8 mos.

22. At what month does the rotary jaw movement develop? a. 5 mos. b. 7 mos. c. 9 mos. d. 11 mos.

23. Late infancy (6 mos. – 1 year), what important things develop? a. Oral sensorimotor skills, fine coordination skills, body positioning and

communication b. Communication only c. Oral sensorimotor skills and body position skills d. Communication and fine coordination skills

24. At what stage does significant embryonic development begin where all major systems and

organs develop through organogenesis? a. 4-8 weeks b. 2-6 weeks c. 0-36 weeks d. 8-12 weeks

25. When does the palate begin development and when is the palate completely developed? a. Begins at 4 weeks and is completely developed at 8 weeks b. Begins at conception and is completely developed at birth c. Begins at 6 weeks and is completely developed at 10 weeks d. The palate does not begin to develop until after birth

26. Which cranial nerve is not directly involved with feeding and swallowing? a. Facial b. Hypoglossal c. Vagus d. Spinal accessory

27. Why is the facial cranial nerve important in infant feeding and swallowing? a. It provides motor movement for muscles of the face and provides sensory

information for taste in the tongue

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b. It provides motor movement for the muscles of the pharynx. c. It provides sensory information for the lips d. None of the above

28. The vagus nerve is responsible for innervating the following: a. Velum b. Pharynx c. Larynx d. Esophagus e. All of the above f. None of the above

29. The vagus nerve provides sensory information to the following: a. Velum b. Pharynx c. Esophagus d. Lips e. All of the above f. None of the above

30. What are the four phases of a swallow?

a. Oral phase, pharyngeal phase, esophageal phase, stomach phase b. Oral phase, esophageal phase, stomach phase, gastric phase c. Oral preparatory phase, oral phase, pharyngeal phase, esophageal phase d. Oral preparatory phase, pharyngeal phase, esophageal phase, stomach phase

31. What two regions in the medulla evoke swallowing and are known as the core pathway? a. Ventromedial group and dorsal group b. Ventromedial group and anterior group c. Anterior group and dorsal group d. None of the above

32. During the fourth week after conception, the pharyngeal arch develops; why is this important?

a. The pharyngeal arch lays the foundation for sensory development b. The pharyngeal arch lays the foundation for the development of the larynx and

pharynx c. The pharyngeal arch lays the foundation for the motor pathways d. All of the above

33. During the 18th week of gestation, what reflex is present?

a. Babinski reflex b. Suck-swallow reflex c. Gag reflex d. Rooting reflex

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34. The rooting reflex is noted by what week in gestation?

a. 32 weeks gestation b. 18 weeks gestation c. 36 weeks gestation d. 28 weeks gestation

35. The suck-swallow-breath pattern usually develops by ____ weeks in gestation.

a. 32 weeks gestation b. 28 weeks gestation c. 34 weeks gestation d. 24 weeks gestation

36. During the 12-13 weeks in gestation, the trigeminal nerve is stimulated. This results in: a. Gag reflex b. Oral chemoreception (taste) c. Rooting reflex d. Nasal chemoreception (smell)

37. At what week is the nasal chemoreception (smell) developed? a. 12-13 weeks gestation b. 8 weeks gestation c. 9-10 weeks gestation d. 11 weeks gestation

38. At 28 weeks, rooting, sucking, moro (startle), crossed extension, flexor withdrawal, and plantar grasp reflexes are all present. This is important because it helps establish stability throughout the body for the following:

a. Movement b. Protection c. Feeding d. All of the above e. None of the above

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Content Area 2 Assessment

According to Arvedson and Brodsky (2002), it is critical for the speech-language pathologist (SLP) to have a basic understanding and knowledge of assessment and diagnostic procedures, in order to thoroughly assess a child with a possible feeding and swallowing disorder. These diagnostic procedures allow the clinician to make appropriate recommendations and referrals. The purpose of content area two is for the clinician to have a well-developed understanding of the underlying principles of assessing a feeding and swallowing disorder. Throughout content area two, the clinician will develop competency in differentiating normal and abnormal feeding and swallowing behaviors. The clinician will also learn about different clinical evaluations and instrumental procedures that will help guide a clinical diagnosis of a feeding and swallowing disorder.

Introduction:

• To gain a basic understanding of pediatric feeding and swallowing assessment procedures, read Assessment of pediatric dysphagia and feeding disorders. Pay attention to the definitions of commonly used when assessing feeding and swallowing. Pay special attention to the different assessment procedures commonly used, diagnostic indicators of a feeding and swallowing disorder, and instrumental procedures.

Readings:

• To gain a more thorough understanding of clinical assessment procedures and differentiating

normal and abnormal feeding and swallowing behaviors, read Chapter 3 in Pediatric and neurodevelopmental assessment and Chapter 7 in Clinical feeding and swallowing assessment of Arvedson and Brodsky. Throughout Chapter 3, focus on the importance of a neurologic examination, and how one is conducted. Know the importance of assessing gross motor skills, reflexes, and cranial nerves. Throughout Chapter 7, become familiar with the clinical steps to follow during an evaluation (Arvedson & Brodsky, pp. 285). Know how to differentiate the nature of an oral sensory disorder and a motor disorder. Gain a thorough understanding of readiness for feeding and swallowing in premature infants.

• It is important to have adequate knowledge in instrumental procedures when assessing

feeding and swallowing. To gain knowledge and practice in instrumental assessment procedures, read Chapter 3 of Interpretation of Videofluoroscopic Swallow Studies of Infants and Children. It is crucial to develop knowledge in the appropriate procedures used with infants and children during a videofluoroscopic swallow study (VFSS). Following the reading, practice 3 cases of your choice. The case history will be provided for you on the front of the page. On the back of the page, the diagnosis and recommendations will be provided.

Arvedson, J. C. (2008). Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Developmental Disabilities Research Reviews, 14(1), 118-127.

Resources:

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Arvedson, J. C. (2006). Interpretation of videofluoroscopic swallow studies of infants and children: A study guide to improve diagnostic skills and treatment planning. Gaylord, MI: Northern Speech Services, Inc. Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management (2nd ed.). Albany, NY: Singular Publishing Group.


1. A comprehensive assessment means that following should be taken into consideration when

assessing a child with a possible feeding and swallowing disorder: a. Health status of child only b. Health status and parent-child interactions c. Parent-child interactions and environment d. Health status, environment, parent-child interactions, and parental concerns

2. What kind of approach is used when assessing a child with a feeding and swallowing disorder?

a. Interdisciplinary team approach b. SLP and physician only c. SLP and otolaryngologist d. SLP, OT, PT, and nurse

3. Why is it important to have a thoroughly defined etiology and diagnosis for the child when assessing?

a. Because in order to know their current functioning, you need to know their past functioning

b. Because treatment will vary based on the history and current functioning of the client

c. Because the etiology tells you why they are coming to see you d. None of the above

4. Arvedson (2008) states the primary goal for assessment is: a. For every child to receive adequate nutrition. b. For every child to receive adequate hydration. c. For every child to have no complications while feeding d. For every child to receive adequate nutrition and hydration without health

complication and with no stress to child or to caregiver

5. Why is it important to have thorough knowledge of feeding and swallowing when assessing? a. Poor decisions increase risk for inadequate nutrition b. Lack of management can lead to poor health outcomes c. A and B d. None of the above.

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6. Which of the following is NOT a described characteristic of teams in Arvedson (2008): a. Shared philosophy related to diagnostic approaches and management b. Team leadership with organization for evaluation and sharing c. Time commitment from all disciplines d. Team happy hours

7. Please chose which definition best describes “feeding disorders”:

a. Problems that arise during feeding activities, which may also co-occur with difficulties in swallowing food and liquid

b. Problems that occur when the child has a lack of sleep c. Feeding problems when the child may or may not have GI problems d. None of the above e. All of the above

8. Please chose which definition best describes “swallowing disorders” (dysphagia): a. Must have a problem in ALL four phases of the swallow (oral phase, initiation of

swallow, pharyngeal phase, esophageal phase) b. Problems in ONLY one of the four phases of swallowing c. Problems in the initiation of swallow phase only d. Problems in one or more of the phases of swallow

9. Please chose the definition that best describes “aspiration”:

a. Passage of food only through the true vocal folds b. Passage of liquid only through the true vocal folds c. Passage of any material through the true vocal folds into the trachea d. Passage of any material through the esophagus

10. No coughing or choking when food is entering the trachea is defined as:

a. Aspiration b. Silent aspiration c. Quietly aspirating d. Moderate aspiration

11. The World Health Organization (WHO) describes three different levels that should be included when performing a comprehensive evaluation. They are the following:

a. Participation (society level), Activities (personal level), and Impairment (body function level)

b. Participation (society level), Activities (personal level), and Physicality (body function level)

c. Activities (personal level), Impairment (body function level), Mental (state of mind level)

d. Impairment (body function level), Mental (state of mind level), and Physicality (body function level)

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12. What is the incidence of feeding disorders in children with developmental disabilities, and is it significantly higher than typically developing children?

a. 50%-yes b. 50%-no c. 80%-yes d. 80%-no

13. True or false: “Children who are slow to gain weight are at particular risk for both feeding problems and developmental delays”

14. What statement best describes a “Feeding Disorder Between Parent and Child”?

a. The child cannot eat in a natural environment because he/she is upset with the parent b. The parent refuses to feed their child nutritional food c. Negative feeding interactions have occurred between the parent and child,

whether it be in interactions, attitudes or expectations during mealtime. d. The child refuses to eat because of prior medical experience with the parent.

15. It is important to identify the following things when determining if a child has signs of a feeding or swallowing problem:

a. The child feeds for longer than 30 minutes b. The child requires assistance with positioning and hand-to-mouth control c. Mealtimes are stressful for both parent and child d. Child refuses food e. Lack of weight gain f. Gurgly voice quality indicating possible respiratory problems g. Lethargic during mealtimes h. All of the above i. None of the above

16. In general, which best describes the assessment process: a. Case history, physical examination, clinical feeding and swallowing evaluation b. Case history, physical examination, VFSS c. Case history, clinical feeding and swallowing evaluation, FEES and VFSS d. Case history and physical examination; wait for further notice for feeding and

swallowing evaluation

17. Because there are no standardized tests for breast feeding and bottle feeding, what are some other options for assessment?

a. NOMAS b. SAIB c. Scales and Checklists d. All of the above e. None of the above

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18. Why is it important to gain a thorough case history? a. The case history provides the past functioning of the child. b. The case history could indicate possible feeding and swallowing problems c. The case history is irrelevant; it is only important for the SLP to know the current

functioning d. Both A and B

19. Which of the following does NOT explain why is a physical examination (pre-feeding

assessment) crucial to the comprehensive assessment? a. The physical examination allows you to observe respiratory patterns b. The physical examination allows you to determine if the child aspirates or not c. The physical examination allows you to observe the child at an “at rest” position, thus

allowing you to note posture, position, tone, and strength d. The physical examination allows you to note alertness, sensory response, and self-

regulation which may or may not be the norm

20. What would a breathy voice indicate in an infant or young child? a. Unilateral vocal fold paralysis b. Possible difficulty with swallowing c. Both A and B d. None of the above

21. During the oral structure and function assessment, which of the following would be something to observe?

a. Respiratory patterns b. Oral reflexes c. Sensory stimulation d. None of the above

22. Which of the following are indicators as to whether or not the infant will be able to intake an adequate amount of nutrition?

a. Whether or not the infant is in a calm and alert state b. Whether or not the infant is fatigued c. Whether or not the infant demonstrates a rhythmic suck, swallow, breath pattern d. All of the above

23. How should an evaluation be set up for an older infant or child? a. Have the child feed as he normally would at home b. Do not make it like the home environment; the child will get scared and will refuse to

eat c. It doesn’t matter what you do, you will still get the same results d. ALWAYS place the child on the floor as you observe their feeding behaviors

24. Which of the following would you observe during feeding observations? a. Time it takes to produce and initiate a swallow b. Whether or not it takes multiple swallows to get the bolus to the esophagus

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c. Reactions to different textures, temperatures, and flavors d. Oral sensorimotor functions (i.e., lips around a spoon, etc.) e. All of the above

25. According to Arvedson (2008), what is one of the most important questions a clinician should want answered before proceeding to the next section of the evaluation?

a. “Can this child eat solid foods or purred foods?” b. “Can this child drink thin liquids or thickened liquids?” c. “Can this child eat and drink safely strictly orally?” d. “Will this child aspirate?”

26. If there are signs of aspiration, what should be done? a. Instrumental evaluation b. VFSS only c. FEES only d. Continue with informal observation to make further recommendations regarding

texture and positioning

27. When assessing a child during a neurodevelopmental examination, it is important to: a. Provide treatment plans according to their functioning age, not chronological age b. Provide treatment according to their chronological age, not functioning age c. Provide treatment based on cognitive and language skills d. Both A and C e. Both A and B f. None of the above

28. Why could feeding and swallowing problems arise for children with craniofacial anomalies and congenital disorders?

a. Because of the midline deficits, the child may get food and liquids into their nasopharynx

b. Because of midline deficits, the child may get liquids surrounding the heart c. Because of obstruction in the airways, suck-swallow patterns may be difficult d. All of the above e. Both A and B f. Both A and C

29. Children with cardiopulmonary problems are at risk for: a. Congestion and liquids surrounding the heart b. Silent aspiration c. Traumatic brain injuries d. All of the above

30. True or False: The tracheostomy procedure provides a greater problem than the tube itself.

31. True or False: Regurgitation is common among infants.

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32. True or False: FEES can be life-threatening to a premature infant.

33. Fiber-optic Endoscopic Evaluation of Swallowing (FEES) can provide the SLP and otolaryngologist with the following information:

a. The entire lateral view of the swallow b. Residue in the valleculae and pyriform sinuses c. Esophageal problems d. All of the above

34. A Videofluoroscopic Swallow Study (VFSS)’s primary purpose is to: a. Define the pharyngeal physiology of swallowing b. Determine whether or not the child aspirates c. Determine the structural function of the esophagus d. None of the above

35. True or False: A bolus forms in an infant when breast feeding or bottle feeding.

36. Reasons for delayed initiation in an infant could be: a. Delayed swallow b. Poor tongue action resulting in poor control c. All of the above d. None of the above

37. True or False: Breast milk is thinner than most formulas.

38. True or False: The lack of development in the neurological system can result in a neurogenic dysphagia; therefore, a neurodevelopmental assessment is a critical aspect of the assessment procedures.

39. During an examination, it is important to:

a. Observe parent-child interactions b. Scale the gross-motor activity c. Evaluation of reflexes d. Conduct a cranial nerve examination e. All of the above f. None of the above

40. At what age-milestone should infants be spoon-feeding? a. 6 months b. 9 months c. 12 months d. 15 months

41. At what age-milestone should children drink from a cup? a. 12 months

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b. 18 months c. 24 months d. 36 months

42. A low Apgar score after 5-minutes could indicate: a. Neurological abnormalities b. Normal pH c. No neurological difficulties d. None of the above

43. True or False: It is impossible for a child to have both an oral-sensory and motor-based problem.

44. Premature infants with increased muscle tone will have: a. Uncoordinated sucking b. A weak suck c. Poor initiation d. A normal suck-swallow pattern

45. How does an SLP assess a nonnutritive suck? a. Elicit a gag reflex b. The infant should be in an upright position c. The infant should suck on his/her thumb for 1 suck per second d. The infant should suck on the SLP’s fifth finger for 2 sucks per second for one

minute

46. You know an infant is ready to suck because: a. Rooting is present b. Normal voice quality c. Adequate lip seal d. All of the above

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Content Area 3 Treatment

Treatment and assessment of children with dysphagia and feeding and swallowing disorders involves significantly more considerations than a clinical observation of a feeding. In addition to status of feeding in the child, considerations include health status, broad environment, parent-child interactions, and parental concerns. These are all needed in developing the most suitable treatment plan for the child.

Introduction:

• When reading sections 3 Procedures and 4 Therapy of the Pediatric Dysphagia: Resource guide you will gain an understanding in the procedures that are necessary in treatment and therapy for children with feeding and swallowing disorders. In the procedures section you will be guided through the general diagnostic procedures that are used with children, as well as the latest feeding evaluations including; behavior, sensory integration, posture control, respiratory function, and oral-motor and cranial nerve examination. Throughout the therapy section you will understand treatment strategies including; feeding readiness, altering the environment, nonnutritive suck, oral stimulation program, chewing and feeding skills, and oral motor therapy.

Readings:

• Throughout reading the chapters by Groher and Crary (2010), you will develop a better understanding of the treatment considerations, options, and decisions that you will be making when working with children with a feeding and swallowing disorder. Chapter 12 Approaches to treatment discusses treatment options, food considerations and modifications, behavioral options as well as specific treatment planning for the individual. Chapter 13 Treatment for infants and children is an overview of feeding positioning, oral sensory and facial stimulation, theories for feeding treatment, goals, and developing a care plan. • When reading chapters 9 & 18 by Leonard and Kendall you will learn and understand assessment and treatment options for children with feeding and swallowing disorders. Chapter 9 Pediatric clinical feeding assessment walks you through the assessment procedures that are recommended for pediatrics, this will allow you to know what treatment option is best for your child. Chapter 18 discusses the importance of treatment planning. Compensatory strategies, behavioral therapies, endurance techniques, external stimulation, and bolus manipulation are all reviewed in this chapter as well.

Topics:The following topics will be addressed in this module.

• Procedure and treatment strategies • Establishing optimal infant feeding • Establishing non-nutritive suck, pacing, and rhythm • Altering consistencies, temperature, and texture • Development of chewing skills • Adaptive Utensils

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Resources:Groher, M.E., & Crary, M.A. (2010). Dysphagia: Clinical management in adults and children.

St. Louis, MO: Mosby Elsevier.

Hall, K.D. (2001). Pediatric dysphagia resource guide. San Diego, CA: Singular. Leonard, R., Kendall, K. (2008). Dysphagia assessment and treatment planning: A team

approach 2nd Ed. San Diego, CA: Plural Publishing.


1. In infants, what is needed before a treatment plan is achieved, to determine the adequacy

of respiratory support for swallowing? a. Pulmonary examination b. Reflex examination c. Oral musculature movements d. Alertness

2. According to Leonard and Kendall (2008), treatments can be classified into what

categories? a. Behavioral, sensory, emotional b. Behavioral, medical, surgical c. Sensory, emotional, surgical d. Emotional, behavioral, medical

3. What are the two treatment strategies that are recommended by Hall (2001)?

a. Compensatory strategies and facilitative strategies b. Facilitative strategies and developmental milestones c. All of the above d. None of the above

4. Which of the following is not a compensatory strategy that is recommended for pediatrics

with feeding and swallowing disorders? a. Optimal positioning b. Altering the environment c. Establishing optimal infant state/ feeding readiness d. Increase oral intake

5. What is the primary goal of dysphagia therapy as stated by Hall (2001)?

a. Promote adequate nutrition/hydration, and age appropriate feeding skills b. Promote adequate nutrition and hydration c. Development of appropriate feeding skills d. None of the above

Refer to table 4-1 by Hall (2001) for the following questions

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6. What therapy suggestions would you have for a child with a suckle lag? a. Establish a non-nutritive suck b. Change the nipple presented c. Lingual stroking d. Jaw tapping

7. For a child that has reduced tongue movements, and reduced oral sensation, what therapy

suggestions would you do? a. Oral stimulation only b. Tongue stroking along with oral stimulation, cheek support and pacing c. Apply pressure to middle of tongue d. Tongue exercises

8. Your child aspirates during a swallow, what therapy techniques do you use in therapy?

a. Refer patient for G-tube feeding only b. Increase the intake of foods orally c. Alter the position, utensil, and food consistency d. None of the above

9. Which is an example of a calming cue?

a. Swaddling the infant to provide a firm and deep pressure stability b. Provide arrhythmical movement, gentle tapping, alter directions c. Bright lights, and bright colors d. Bold tasting foods with more texture and smell

10. Why are alerting cues important for feeding and swallowing?

a. To decrease the child’s comfort level b. To distract the child during meal times c. Allow the parents feed their child quickly d. To establish optimal state in which the child is most alert and ready for feeding

11. True or False: Altering the environment is important in the success of children with

feeding and swallowing disorders?

12. If the child sustains subtle color changes over the course of the feeding, what is a possible solution? a. Stop the feeding permanently b. Impose periodic breaks during the feeding c. Pacing, the feeding d. Both B and C

13. Why is non-nutritive sucking important to the development of children?

a. It is a prerequisite for nutritive feeding, which allows adequate growth and development

b. Non-nutritive sucking is important to establish a gag reflex

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c. It is important in the development of the rooting reflex d. All of the above

14. True or False: The following is a technique for establishing a non-nutritive suck

Place a gloved finger or a pacifier into the child’s mouth. Press firmly down in the middle of the tongue 4-6 times. Pause to see if the infant continues unassisted sucking. Repeat as tolerated.

15. Why is external pacing/internal rhythm important during infant feeding and swallowing?

a. It allows the child time to sleep in between bites, or food presentations b. Helps with the coordination of the suck-swallow-breathe pattern c. Allows the child to have periods to play with the food d. All of the above

16. Which if the following is not a correct position when feeding a child?

a. Head should be forward b. Hands should be drawn to midline c. Neck elongation with the neck in a loose chin tuck position d. Splayed position

17. When should you use the oral stimulation for infants with feeding and swallowing

disorders? a. Always, it works for all feeding and swallowing disorders b. Children who are NPO, or children that are stimulable for feeding c. Never use this technique with infants d. Children with a pharyngeal delay in their swallow

18. What are the food and liquid consistencies?

a. Thin, nectar, honey thick, puree b. Thin, honey think, nectar, pudding c. Nectar, honey d. None of the above

19. True or False: You should never change the temperature, volume or taste of food

presented?

20. Why is the development of chewing skills pertinent to children with feeding and swallowing problems? a. To expand the child’s food repertoire and develop normal feeding skills b. To establish feeding success c. All of the above d. None of the above

21. When should you use a faster flow rate nipple?

a. When the child has a respiratory compromise, and poor endurance

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b. When children have an intact pharyngeal swallow, but fatigue early c. When a child cannot hold the adequate amount of liquid in their mouth d. When the child has a weak suck response

22. True or False: Oral motor therapy is important for infants with slow oral movements?

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Content Area 4 Dietary and Nutritional Considerations

Introduction:It is important to note that feeding problems are not a disease or due to disease but are due to medical, environmental, nutrition and social variables. As a speech-language pathologist (SLP) you will be part of a team that treats and manages feeding and swallowing disorders. In evaluating children with feeding disorders it is important to be aware of types of feeding disorders and how they have become manifested in the child.

Other common names for behavioral feeding disorders and food aversion are picky eaters, neophobia, oral aversion and problem eaters to name a few. The severity of each child is dependent on the factors that have led to the feeding disorder. It is critical to take each characteristic a child shows into consideration during assessment and treatment.

When considering children with feeding and swallowing disorders it is necessary to be aware of what is “normal.” You cannot begin treatment without some basis as to what a typical child at that age would be doing. When a child is born the most natural way to feed is by breastfeeding. Although it is controversial on how long a child should be breastfed and some mothers are not able to breastfeed it is an important first step to getting nutrition to the infant.

Another population that you may be working with when referring to dysphagia is getting the low birth weight infants to feed.

To gain knowledge and insight into this disorder you will want to refer to the reading list.

• For an overview of breastfeeding and overall guidelines to the amount an infant should breast feed read the following sections. When reading these sections pay attention to what could go wrong during this stage and how that might cause dysphagia. For instance if a child has an allergic reaction to the mothers breast milk and has reflux, what type of message might this sent to the infant about eating? Read sections 1.5, 1.9, 1.10 in Nutritional requirements of infants and young children: Practical guidelines.

Readings:

• In this reading you will find how many calories an infant who is breast feeding should have

per day. Read section 5.3 in Nutritional requirements of infants and young children: Practical guidelines.

• If the child is not meeting these requirements it will be your job to find out how to get there

child the correct amount of nutrients and calories needed to thrive. Read pp. 83 in the Pediatric nutrition handbook.

• As the child gets older nutritional requirements and risk factors change. It will be necessary

to know nutritional guideline if you plan to work with children with dysphagia. In this section you will find nutritional guidelines and what skills a child is acquiring for feeding

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themselves at each age, essentially the milestones of feeding. Read pp. 144 in Nutritional requirements of infants and young children: Practical guidelines.

• To find a brief overview of feeding disorders and its terminology, read pp. 149-156 Nutritional requirements of infants and young children: Practical guidelines.

• This will give you information on assessment, treatment and follow-up procedures. Read pp. 77-95 in Disorders of Feeding and Swallowing in Infants and Children.

• The role of and SLP in treating children with food aversions. Read pp. 77-113 in Disorders

of Feeding and Swallowing in Infants and Children.

• This article outlines a general assessment of children with feeding and swallowing disorders. Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches.

Thompson J.M. (1998). Nutritional requirements of infants and young children: Practical guidelines. Osney Mead, Oxford: Blackwell Science Ltd.

Resources:

Tuchman, D.N. & Walterm R.S. (1994). Disorders of Feeding and Swallowing in Infants and

Children. In Babbit, R.L., Hoch, T.A. & Coe, D.A. (Ed.), Behavioral feeding disorders (pp. 77-95). San Diego, CA: Singular Publishing Group, Inc.

Tuchman, D.N. & Walterm R.S. (1994). Disorders of Feeding and Swallowing in Infants and

Children. In -Greif, M.A. (Ed.), Diagnosis and management of pediatric feeding and swallowing disorders: Role of the speech-language pathologist (pp. 77-113). San Diego, CA: Singular Publishing Group, Inc.

Kleinman, R.E. (2009). Pediatric Nutrition Handbook (6th ed.), Elk Grove Village, IL: American Academy of Pediatrics.


1. What are two common reasons that a food aversion may develop? Answer: allergies, medical experiences related to feeding times, difficulty with breast-feeding

2. What are some symptoms of feeding and swallowing in children? Answer: arching or stiffening of the body during feeding, lack of alertness, irritability, refusal of food of liquid, failure to accept different textures of food, long feeding times, difficulty chewing, difficulty breast feeding, coughing or gagging, excessive drooling, incoordination, pneumonia or respiratory infections, less than normal weight gain or growth.

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3. What are two behaviors that may indicate a behavioral aversion to food? Answer: Vomiting, severe temper tantrums, refusal to eat, fever, gagging, pushing food away

4. List three people who would serve on a team in a child dysphagia case? Answer: Speech language pathologist, nurse, social worker, occupation therapist

5. What is a common environmental changes that can be made when treating children with food

aversions. Answer: routine, sitting in the same seat while eating, needs to come and sit even if he is not eating, removing TV or other distractions from the eating area

6. The influence of eating in children is affected by which of the following

a. Siblings in the home b. Environment c. Negative and positive events during eating routines d. Forceful feeding e. All of the above

7. For what reason is it important that the team approach is used when evaluating children with

possible feeding and swallowing needs. a. Coordinated consultation with the focus on the whole child b. A separate philosophy between professionals c. So school clinicians and medical professionals can have different goals and areas of

focus when working with the child.

8. List the four phases of swallowing that are discussed in the research that can be affected in children with dysphagia.

Answer: oral preparatory stage, oral stage, pharyngeal stage, esophageal stage 9. What percent of children with developmental disabilities are at risk for feeding disorders

according to Arvedson (2008) Answer: 25-45%

10. Give several reasons that a child would have a behavioral feeding disorder? Answer: Developmental delays, previous medical history, social experiences and difficulty breast feeding

11. What are two preventative measures that can be taken in regards to oral food aversions. Answer: removing televisions or other distractions, maintain a routine, everyone eats at the same time, and do not force feed.

12. What is the suggested age a child begin a mixed diet and weaning from breast milk?

a. 2 months b. 4months

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c. 6months d. 8 months

13. Between the ages of 0-2 months how many kcal/day should a breastfed infant consume to

thrive? a. 400 b. 530 c. 520 d. 500

14. Why would you want to delay weaning? Give an example from all three domains discussed

on page 46? a. Poor head control, spitting out reflex persists several months after birth, ability

to move food about the moth, hesitant to experiment with new textures or taste b. Renal function is limited, gut enzyme efficiency, giving solids increases the risk

of respiratory problems, early weaning increases eczema (allergy) c. Milk alone cannot supply all nutrients, solids reduce the intake of nutrients

versus breast feeding 15. Which one of these items in unsuitable for first stage foods?

a. Raspberries b. Natural yogurt c. Beef d. Carrots

16. Which of the following is an important reason to keep new food varied?

a. Increasing growth and nutrition b. Enjoying fruits and vegetables as an adult c. So that they will learn to like other foods d. So they can get adequate nutritional intake from the foods that they are

consuming.

17. What is the role of iron in an infant’s diet and why is it important to maintain a healthy balance of iron intake throughout growth? Answer: It is essential to the oxygen carrying role of hemoglobin and to the metabolism of many organs, including the brain. Iron deficiency is known to be associated with developmental delay, poor growth and weight gain and with recurrent infections.

18. At what age would you expect to see a child spoon feeding well?

a. 1 year b. 18 months c. 2 years d. 3 years

19. When can you expect a child to be predominately finger feeding?

a. 1 year

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b. 18 months c. 2 years d. 3 years

20. There are many considerations to environment that should be made when the child is eating.

Which one of the following is an appropriate consideration to make when thinking about the child’s eating environment

a. A television in the main dining area b. Setting up TV stands in the living room c. Scolding the child when not all the food is eaten d. A steady predictable routine

21. List three items of advice that were given in (Thompson, 1998 pp 149-156)

a. Try and identify the pattern of continuous breast or bottle feeding, restrict feeds initially to one or two specific times a day, give a feeding cup at other times, give plenty of attention, substitute other comforts, do not give in to tantrums, be patient

22. In the healthy pre-school diet, which one of the following is not a nutrition category? a. Energy b. Fats c. Protein d. Calcium e. Iron f. Vitamins

23. How might dental health affect a child’s ambitions to eat?

Answer: Could cause pain, discomfort, change the taste

24. In reference to Appendix I (Thompson, 1998) which one of these is not a risk when a child is born with a low birth weight?

a. Raised blood pressure b. Weight gain c. Developmental delay d. Abdominal fat storage

Additional Reading:

American Speech-Language-Hearing Association (2009). Feeding and Swallowing Disorders (Dysphagia) in Children. Retrieved from: www.asha.org

Arvedson, J.C. (2008). Assessment of pediatric dysphagia and feeding disorders: Clinical and

instrumental approaches. Developmental Disabilities Research Reviews, 14, 118-127.

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Carruth. B.R. & Skinner, J.D. (2000). Revisiting the picky eater phenomenon: Neophobic behaviors of young children. Journal of the American College of Nutrition, 19, 771-780.

Kerwin, M.E. (1999). Empirically supported treatments in pediatric psychology: Severe feeding problems. Journal of Pediatric Psychology, 24, 193-214. Skuse, D. (1993). Identification and management of problem eaters. Archives of Disease in Children, 69, 604-608.

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Content Area 5 Counseling

As you may have already been made aware a large part of our role as Speech Language Pathologist’s (SLP’s) is that of counseling. We are often one of the first professional to the parent and discuss treatment planning and ask them what their expectations are. As the patient ages you maybe counseling that patient but for this project we will focus mainly on counseling of the family.

Introduction:

There are many qualities that make effective counselors and to be able to deliver uncomforting news as well as good news you need to encompass all of these qualities. With these qualities you will be able to develop your counseling skills. You might want to ask yourself when is it appropriate or how do I know when it is appropriate to counsel a family? You should be familiar with these as well as the ASHA guidelines for counseling and your role as an SLP for that specific population. There are several different resources depending on population and the personality of the family that you are counseling.

When working with this population you should know the grieving process also known as the coping process and what encompasses each phase. You should also take into consideration that these stages are fluid and can a person and move around on the grieving process especially when the condition of their child changes from day to day.

• In this reading you will be able to identify what qualities make for a good counselor and what skills you can develop to encompass these qualities. LinguiSystems Guide to counseling for SLP’s 2009 edition.

Readings:

• It is important to be able to identify when it is appropriate that you are the person that is

going to counsel the family. There are several things that you should take into considerations and you will want to also preview the ASHA guidelines to counseling to make sure that you remain within your scope of practice. Applications of counseling in speech-language pathology and audiology, Crowe pp. 22 and ASHA guidelines to counseling.

• In this reading you will be able to familiarize yourself with the grieving process along with

the holistic approach to counseling and why this approach to therapy would be beneficial. In addition the LinguiSystems Guide to counseling for SLP’s 2009 edition outlines eight common counseling theories, Applications of counseling in speech-language pathology and audiology, Crowe Ch. 2.

Crowe, T.A. (1997). Applications of counseling in speech-language pathology and audiology. Resources:

Baltimore, Maryland: Williams and Wilkins.

Guide to Counseling for SLP’s (2009 ed.). East Moline, Illinois: LinguiSystems

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1. Which one of the following is a characteristic of an effective counselor?

a. Critical mind b. Competence c. Avoidance d. Blaming

2. Which of the following is one of the most critical counseling occasions an SLP may face?

a. Interpersonal nature of communication b. Prevention c. Guarded prognosis d. Parent’s shattered dreams

3. When counseling a family where the need for counseling is catastrophic, chronic, and

globally involving illnesses and conditions which of the following is the most important when counseling them?

a. Counseling them on other concerns that they might have b. Try and stay as close to the topic of their communication disorder as possible. c. Referring to another specialist d. Ignoring other deficits that they are facing

4. In the book they gave the example of the child who is at risk for stuttering and counseling

them on prevention. What is another example where you would be counseling a parent on prevention? In Crowe (1997) there are examples for counseling of other disorders but try and stick to counseling for dysphagia.

Answer: You could be counseling them on how to prevent further food aversions if they are having trouble feeding, tube feedings, failure to thrive etc.

5. Which one of the following is beneficial about the holistic approach to counseling?

a. It takes only one domain of the child’s development into consideration. b. It considers many domains of the child’s development and addresses many of

them at once

6. As discussed in Crowe 1997 what are the five stages to grieving? a. Denial b. Anger c. Bargaining d. Depression e. Acceptance

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7. What are some other emotions that can be experienced. a. Anxiety b. Guilt c. Isolation

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Content Area 6 Ethics & Advocacy

According to the American Speech-Language-Hearing Association (ASHA, Lefton-Greif, 2001), it is the role of the medical speech-language pathologist (SLP) to “balance basic ethical tenets with advances in biological and medical technologies.” When working with the pediatric population the demand to work ethically is greatly increased, as these patients cannot independently make informed decisions regarding their health. Many times a parent or guardian assumes this responsibility for the patient; however, ethical problems may emerge when caregivers do not appear to be making decisions which are in the child’s best interests. Additional ethical issues may arise when SLPs are pressured to alter or withhold services based on institutional policies or a lack of resources.

Introduction:

• To first gain a basic understanding of possible ethical problems clinicians may encounter when working with pediatric dysphagia patients, read Ethical decision making for infants and children with dysphagia (Lefton-Greif). Pay special attention to the possible ethical dilemmas SLPs may face when working with this patient population, resources to address such problems, and the SLPs role in terms of patient advocacy.

Readings:

• As members of a professional organization, it is important for all SLPs to be informed of the

rules and responsibilities outlined by ASHA. In the document Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit (ASHA, 2005), ASHA states that SLPs are responsible for public education and advocacy in the NICU. Additionally, the article by Wagner (1998) provides a case study that may help the SLP find solutions to difficult ethical dilemmas in the real world. For more specific information regarding ASHA’s views on public education and advocacy in the NICU, read the two articles mentioned in this paragraph.

American Speech-Language-Hearing Association. (2005). Roles and responsibilities of speech-language pathologists in the neonatal intensive care unit. Rockville, MD: Author.

Resources:

Lefton-Greif, M. (2001). Ethical decision making for infants and children with dysphagia.

Rockville, MD: ASHA. Wagner, L. B. (1998). Ethical dilemmas. Rockville, MD: ASHA.


1. What are the four hierarchical levels of the ethical decision-making and reasoning process

outlined by ASHA? Answer: The four hierarchical levels include theory, principles, rules, and judgment.

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2. What are the four basic types of ethical quandaries discussed in ASHA’s article (Lefton-Greif, 2001)?

Answer: The four basic types of ethical quandaries include distress, dilemma, dilemma of justice, and locus of authority.

3. How does ASHA suggest that the SLP provide public education and advocacy in a NICU

environment? Answer: ASHA suggests the SLP provide education and advocacy in the NICU through community outreach and interactions with administrative/professional staff.

4. How does Wagner (1998) suggest the majority of ethical dilemmas be solved? Answer: Wagner suggests the majority of ethical dilemmas can be solved through increased communication and conflict resolution.

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Content Area 7 Scope of Practice/Team Approach

According to the American Speech-Language-Hearing Association (ASHA, 2003), “children with feeding disorders are among the most complex pediatric patients speech-language pathologists (SLPs) treat.” Due to the complicated nature of treating children with dysphagia, a team, or interdisciplinary, approach is often used to assure the patient is receiving the highest level of care. Pediatric patients with feeding and swallowing disorders frequently present with numerous medical and treatment needs that must be addressed by professionals across disciplines.

Introduction:

• SLPs are often assigned to coordinate pediatric feeding and swallowing teams comprised of their colleagues and the patient’s family in order to achieve the best outcome. For more information regarding the SLP’s role as team leader, read Roles and responsibilities of speech-language pathologists in the neonatal intensive care unit (ASHA; 2005), Dysphagia teams (2009), and Medical speech-language pathology: A practitioner’s guide (1998, p. 38-45).

Readings:

• As the dysphagia team leader it is important to be knowledgeable of the possible team

members and their roles specifically related to pediatric dysphagia. To find more specific information regarding the roles of other pediatric dysphagia team members, read the following articles: Feeding and swallowing disorders (dysphagia) in children (ASHA; 2010), Dysphagia teams (2009), and Medical speech-language pathology: A practitioner’s guide (1998, p. 38-45).

• The importance of including the pediatric patient’s parents or caregivers should be given

special attention. These parties assist in gathering necessary case history and general patient information, and will likely implement intervention recommendations at home. Read Feeding and swallowing disorders (dysphagia) in children (ASHA; 2010), Roles and responsibilities of speech-language pathologists in the neonatal intensive care unit (ASHA; 2005), and Treating children with feeding disorders (2003) for more information regarding the role of parents/caregivers on a pediatric dysphagia team.

• Understanding the roles of parents/caregivers and other team members is very important in

functioning as an effective team and providing the patient with the best possible care. In terms of roles specific to the SLP on the team, ASHA and experts in the area of pediatric feeding and swallowing outline some of these responsibilities in the literature. See the following articles for more information regarding the roles of the SLP on a pediatric dysphagia team: Roles and responsibilities of speech-language pathologists in the neonatal intensive care unit (ASHA; 2010), Roles and responsibilities of speech-language pathologists in the neonatal intensive care unit (ASHA; 2005), Dysphagia teams (2009), and Medical speech-language pathology: A practitioner’s guide (1998, p. 38-45).

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Resources:

American Speech-Language-Hearing Association. (2010). Feeding and swallowing disorders

(dysphagia) in children. Rockville, MD: Author.

American Speech-Language-Hearing Association Special Interest Division 13. (2009). Dysphagia teams. Rockville, MD: ASHA.

Arvedson, J. C., & Rogers, B. T. (1998). Dysphagia in children. In A. F. Johnson & B. H.

Jacobson (Eds.), Medical speech-language pathology: A practitioner’s guide (pp. 38-64). New York, NY: Thieme Medical Publishers, Inc.

Pressman, H., & Berkowitz, M. (2003, Oct. 21). Treating children with feeding disorders. ASHA

Leader, 8, 10-11.


1. Why is the team approach necessary when treating pediatric patients with dysphagia? Answer: The team approach is necessary when treating pediatric dysphagia patients due to the complex nature of the case and the numerous medical/treatment needs these patients require.

2. What are three responsibilities of the SLP as the pediatric dysphagia team leader? Answer: Identify core team members and support services, facilitate team communication, maintain team focus and interaction, document team activity, and use appropriate consultation procedures for other team members/services.

3. What are four responsibilities of the SLP as a team member? Answer: See table below for the SLP’s responsibilities on dysphagia teams:

SLP’s roles on pediatric feeding and swallowing teams Increasing strength of muscles of the mouth and tongue Improving tongue movement and chewing Increasing use of the suck-swallow-breathe pattern (in infants) Improving sucking/drinking abilities Altering food and liquid texture and thickness for safety purposes Increasing acceptance of different foods and liquids Educate colleagues on typical communication and swallowing development in children Refer patient to other professionals as appropriate

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4. Name five dysphagia team members and their roles. Answer: See table below for team members and their roles:

Professional Role Physician • Performs general medical intervention

(e.g., medicine for reflux) • Gastroenterologist: diagnoses esophageal

and general GI tract problems, places feeding tubes if necessary

• Neonatologist: identifies dysphagia in infants and refers to SLP, oversees progress of patient

• Neurologist: diagnoses and treats neurological causes of swallowing

• Otolaryngologist: diagnoses oral, pharyngeal, laryngeal, and tracheal issues related to swallowing; may assist the SLP in the evaluation of swallowing disorders

• Pediatrician: identifies dysphagia in children and refers to SLP, oversees progress of patient

• Pulmonologist: Treats respiratory complications associated with dysphagia, specifically children presenting with aspiration or placed on a ventilator

• Radiologist: Helps with the evaluation of patients with dysphagia through administration of radiographic studies

Nurse • Implements recommendations (e.g., diet, compensatory strategies) to assist the patient in a safe swallow

Occupational therapist • Identifies sensory and motor impairments and treats accordingly

• Evaluates need for prosthetics or tools to assist in feeding and swallowing (e.g., special type of utensil, adaptive plate)

Physical therapist • Treats issues with body positioning and sensory/motor movements associated with swallowing

• Maintains safety of patient during feeding by recommending modified seating

Behavior analyst • Identifies the need for behavior management techniques and helps other professionals to implement these techniques

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Dietician or nutritionist • Evaluates need for diet modifications (e.g., consistencies of foods and liquids, calorie modifications)

• Ensures patient is receiving adequate nutrition orally or through a tube

Social worker • Counsels child and family/caregivers on adjusting to life with a feeding and swallowing disorder

• May assist in payment/insurance issues following a hospital stay

Dentist • May recommend prosthetics to assist in a successful swallow as the child gets older

Psychologist • Assists patient and family/caregivers in adjusting to dysphagia and feeding modifications

• Helps to manage stress and negative emotions associated with dysphagia

Teacher • Assists in the generalization of dysphagia treatment and strategies at school

• Educates child’s classmates on dysphagia, if necessary

Family or caregivers • The most important team member • Provides information of how patient is

progressing at home • Implements recommendations at home

5. What are the roles of the occupational (OT) and physical therapists (PT) on a pediatric

dysphagia team? Answer: The OT is responsible for identifying sensory and motor impairments and treating accordingly, and also evaluating the need for prosthetics or tools to assist in feeding and swallowing (e.g., special type of utensil, adaptive plate). The PT is responsible for treating issues with body positioning and sensory/motor movements associated with swallowing, and also maintaining the safety of patients during feeding by recommending modified seating.

6. Describe why it is important to include parents or caregivers on a pediatric dysphagia team. Answer: Parents and caregivers are necessary in gathering case history and general medical history, implementing intervention recommendations at home, and bridging the gap between patient and therapist.

7. What should be the three overall main goals of a pediatric dysphagia team? Answer: Maintaining safe feeding, adequate nutrition, and pleasant eating for the patient.

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American Speech-Language-Hearing Association. (2010). Getting started in pediatric hospitals. Rockville, MD: Author.

Additional Readings:

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Content Area 8 Work Settings

The speech-language pathologist (SLP) is often the professional designated to lead pediatric dysphagia treatment, regardless of the specific work setting. In all employment settings, the American Speech-Language-Hearing Association (ASHA) defines the SLP’s professional role as the evaluation, diagnosis, and treatment of speech, language, cognitive-communicative, and swallowing disorders. However, ASHA provides additional responsibilities of the SLP based on specific work settings and employers.

Introduction:

• It is important for SLPs to be aware of possible work settings in which they might seek employment. For more information regarding specific work settings recognized by ASHA, see Employment settings (ASHA; 2010b) and Fact sheet for speech-language pathology (ASHA; 2010c).

Readings:

• When discussing pediatric dysphagia, the majority of cases will be seen in three settings:

schools, hospitals, and private practice. In all three environments, the SLP will evaluate, diagnose, and treat feeding and swallowing problems, in addition to frequently serving as the primary contact person on the dysphagia team. To gain a basic understanding of the clinicians’ work in these three settings, read Current status of SLP employment in health care settings (ASHA; 2010a), Employment settings (ASHA; 2010b), Private practice in speech-language pathology (ASHA; 2010d), and Roles and responsibilities of speech-language pathologists in schools (ASHA; 2010e).

American Speech-Language-Hearing Association. (2010a). Current status of SLP employment in health care settings. Rockville, MD: Author.

Resources:

American Speech-Language-Hearing Association. (2010b). Employment settings. Rockville,

MD: Author. American Speech-Language-Hearing Association. (2010c). Fact sheet for speech-language

pathology. Rockville, MD: Author. American Speech-Language-Hearing Association. (2010d). Private practice in speech-language

pathology. Rockville, MD: ASHA. American Speech-Language-Hearing Association. (2010e). Roles and responsibilities of speech-

language pathologists in schools. Rockville, MD: Author.

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1. ASHA identifies 12 areas the SLP employed in the schools may be responsible for. Which of

these areas are most relevant to pediatric feeding and swallowing issues? Any of the following answers are acceptable: • Provide individual and small group services to infants, toddlers, preschoolers, school-

age children, and adolescents • Work with children with a wide range of disabilities, from mild and moderate to severe

and/or multiple disorders • Collaborate with other professionals and parents; provide speech-language services to a

number of schools • Conduct screenings and diagnostic evaluations • Write reports and participate in annual review conferences • Serve on program planning and teacher assistance teams • Develop IEPs and IFSPs • Serve as a consultant to families and other educators • Provide training to teachers and family members

2. ASHA identifies five areas the SLP employed in the hospitals may be responsible for. How

do each of these areas relate to pediatric dysphagia treatment and management? Answer: • Diagnose and treat a wide range of communication disorders – The SLP will be often be

the primary professional responsible for diagnosing and treating pediatric dysphagia. • Diagnose and treat swallowing problems – Self-explanatory. • Function as part of a multidisciplinary treatment team – The SLP will be responsible

for leading or participating as a part of a pediatric dysphagia team. See this section of the module for more detailed information.

• Provide counseling to patients and their families – Many families and patients will need counseling post-diagnosis, and this is often the SLP’s responsibility. See this section of the module for more detailed information.

• Educate other health care staff about communication and swallowing disorders – Many professionals are unaware of what dysphagia is, or the implications of this disorder; therefore, it is the SLP’s responsibility to provide education formally through in-services and informally through professional discussions.

3. After reading through all of the materials cited in the references (below), describe which

setting you see yourself working in with the pediatric dysphagia patient population, and why. What do you find interesting; what would be challenging?

Answer: Individual answers that address a specific work setting and the benefits/challenges of that particular setting are acceptable.

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American Speech-Language-Hearing Association. (2010f). Market trends. Rockville, MD: Author.


American Speech-Language-Hearing Association. (2010g). Recruitment and retention of SLPs in

health care. Rockville, MD: Author.

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Content Area 9 Considerations for special populations Content Area 9A Craniofacial and Midline Disorders

Introduction:Infants and children with craniofacial abnormalities and midline disorders frequently have feeding and swallowing problems as a result of the complex interactions between anatomical, medical, physiological, and behavioral factors. Feeding problems associated with craniofacial and midline disorders may cause feeding to be unpleasant, negative, or even painful because of choking, coughing, gagging or even emesis. The purpose of this module is to provide structure to the identification, intervention, management, and daily problems that are encountered in children who have craniofacial and midline disorders.

• When reading the Feeding and swallowing dysfunctions in genetic syndromes. Developmental Disabilities Research Reviews, you will develop a better understanding of feeding and swallowing dysfunction and how it relates to craniofacial and midline disorders. Cleft lip and palate, Velocardiofacial syndrome, Down syndrome, Williams syndrome, and Retts syndrome are thoroughly discussed in this article. Management, feeding techniques, repair, and interventions are explained for each individual disorder.

Readings:

• When reading chapter 4 Disorders in infants and children you will gain the background knowledge on a wide variety of disorders found in infants and children with craniofacial and midline abnormalities. You will also be able to identify a child with a craniofacial and midline abnormality and compare their development to a typically developing child.

Topics:The following topics will be addressed in this module.

• Craniofacial and midline disorders • Assessment and diagnostic evaluations • Procedure and treatment techniques • Feeding modifications

Resources:Cooper-Brown, L., Copeland, S., Dailey, S., Downey, D., Peterson, C., Stimson, C., & Van Dyke, D.C. (2008). Feeding and swallowing dysfunctions in genetic syndromes. Developmental Disabilities Research Reviews, 14, 147-157.

Groher, M.E., Crary, M.A. (2010). Dysphagia: Clinical management in adults and children.

Missouri: Mosby Elsevier.

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1. Can an individual have a cleft lip alone, a cleft palate alone or a combination of the both?

a. True b. False

2. Children with a cleft lip always experience feeding difficulties?

a. True b. False

3. Why is the palate an important structure during feeding in an infant?

a. Create negative intraoral pressure as lips form a seal b. Create positive pressure as lips form a seal c. A structure to place the tongue during feeding d. All of the above

4. How are children with a cleft lip only, able to eat?

a. G-Tube fed only b. Usually able to breastfeed c. Spoon fed liquids d. None of the above

5. According to Groher (2010), what is the main concern for an infant with a cleft lip and or

palate? a. Obesity b. Surgical repair c. Inadequate weight gain d. Appearance

6. Which of the following is not recommended for feeding an infant with a cleft lip and palate?

a. Different head positions b. Pump breast milk into a bottle c. Palatal obturators d. Continue feeding as normal

7. Which of the following is not a sign of problematic eating?

a. Poor weight gain b. Coughing, choking, or gaging during meals c. Laughing during mealtime d. Has not been weaned from baby foods at 16 months

8. When do changes of the oral-facial structure begin to appear?

a. 4-6 months

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b. 2-3 months c. 6-8 months d. Always changing

9. What is the most common facial and head defect among infants?

a. Velocardiofacial syndrome b. CHARGE syndrome c. Cleft lip, or cleft palate d. Pierre Robin sequence

10. What type of nipple is recommended for infants with a cleft lip?

a. A nipple that requires compression b. A nipple with a small hole for liquid c. A nipple that requires expansion for fluids d. Several small holes for liquids

Peterson-Falzone, P., Hardin-Jones, M.A., & Karnell, M. (2010). Cleft palate speech (4th Ed.). St. Louis, MO: Mosby Elsevier.


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Content Area 9B Considerations for special populations: Down syndrome

When working with children presenting with dysphagia, the speech-language pathologist (SLP) will often encounter concomitant diagnoses, including Down syndrome. Down syndrome is a developmental disability that is prevalent in approximately 13 in every 10,000 live births and typically causes hypotonia, hearing loss, congenital heart disease, hyperflexibility of joints, a small oral cavity, physical abnormalities (e.g., epicanthal folds), and varying levels of developmental delay and/or mental retardation. Upon completing the readings in this section, the student will understand the specific feeding and swallowing problems present in children with Down syndrome and the SLP’s role in managing these issues.

Introduction:

• The clinician must first be aware of the specific dysphagia-related characteristics associated with Down syndrome. To begin, find information regarding general feeding and swallowing issues in the child with Down syndrome in Speech-language pathology desk reference (1998, Table 9.5), Life cycle nutrition: An evidence-based approach (2009, p. 206-209), and Handbook of pediatric nutrition (3rd ed.). (2005, p. 290-291).

Readings:

• The child with Down syndrome and co-occurring feeding and swallowing difficulties will

present with much different energy, nutrition, and dietary needs than their typically developing counterparts. Because of their slower growth rate, low muscle tone, decreased gross motor activity, and sometimes poor dietary practices, children with Down syndrome require less energy than their age-matched peers. To find more information regarding energy needs of children with Down syndrome, read Life cycle nutrition: An evidence-based approach (2008, p. 206-209) and Handbook of pediatric nutrition (3rd ed.). (2005, p. 290-291).

• The literature is conflicted in regards to the specific nutrient needs of children with Down

syndrome; however, it should be noted that abnormal concentrations of certain chemicals are typical in the child with Down syndrome and should be further investigated on an individual basis. More specific dietary information on dietary needs and intervention can be found in Life cycle nutrition: An evidence-based approach (2008, p. 206-209), Handbook of pediatric nutrition (3rd ed.) (2005, p. 290-291), and Nutrition through the life cycle (3rd ed.) (2008, p. 253-254).

• The development of feeding and swallowing is much different in the child with Down

syndrome than their typical counterpart, specifically the progression from formula to solid food and from weaning to self-feeding. For more specific information regarding feeding milestones in children with Down syndrome versus their age-matched peers, read Schoolchildren with dysphagia associated with medically complex conditions (2008); Correlates of specific childhood feeding problems; Eating habits of young children with Down syndrome in The Netherlands: Adequate nutrient intakes but delayed introduction of solid food; and Life cycle nutrition: An evidence-based approach (2008, p. 206-209).

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• Two common nutrition problems for the child with Down syndrome are excessive weight gain and food aversion. For information regarding how to design a diet management program to combat excessive weight gain, see Life cycle nutrition: An evidence-based approach (2009, p. 206-209) and Nutrition through the life cycle (3rd ed.). (2008, p. 253-254). Then read Correlates of specific childhood feeding problems. Journal of Pediatrics and Child Health (2003) for more specific information regarding food aversion in children with Down syndrome.

Bluestone, Stool, Alper, Arjmand, Casselbrant, Dohar, & Yellon. (2003). Pediatric otolaryngology (4th ed., Vol. 2). Philadelphia, PA: Saunders.

Resources:

Brown, J. E. (2008). Nutrition through the life cycle (3rd ed.). Belmont, CA: Thomson

Wadsworth. Edelstein, S., & Sharlin, J. (2009). Life cycle nutrition: An evidence-based approach. Sudbury,

MA: Jones & Bartlett Publishers. Field, D., Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding

problems. Journal of Paediatrics and Child Health, 39, 299-204.

Hopman, E., Csizmadia, C. G., Bastiani, W. F., Engels, Q. M., DeGraaf, E. A., Cessie, S. L., & Mearin, L. (1998). Eating habits of young children with Down syndrome in The Netherlands: Adequate nutrient intakes but delayed introduction of solid food. Journal of the American Dietetic Association, 98 (7), 790-794.

Lefton-Greif, M. A., & Arvedson, J. C. (2008). Schoolchildren with dysphagia associated with

medically complex conditions. Language, Speech, and Hearing Services in Schools, 39, 237-248.

Roeser, R. J., Pearson, D. W., & Tobey, E. A. (1998). Speech-language pathology desk

reference. New York, NY: Thieme. Samour, P. Q., & King, K. (2005). Handbook of pediatric nutrition (3rd ed.). Sudbury, MA: Jones

& Bartlett Publishers.


1. What are the characteristics feeding- and swallowing- related characteristics present in most

children with Down syndrome? Answer: Children with Down syndrome typically display the following feeding- and swallowing-related characteristics: increased drooling, tongue protrusion, poor sucking and swallowing, reduced chewing, shortened buccal cavity, small oral cavity, high palate,

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obstruction of nasal passages, velopharyngeal dysfunction, small mandible, abnormal dental bite, and an unusually high pharynx.

2. What were the main reasons mothers reported for using formula instead of breast milk with

their child with Down syndrome, even when it was against physicians’ orders? Answer: The four main reasons reported were infants’ illness and admission to the neonatal unit, frustration or depression, perceived milk insufficiency, and difficulty in suckling.

3. Why is the progression to solid food delayed in children with Down syndrome? Compare

these findings with what you know about normal feeding and swallowing development. Answer: There is a delay in progression to solid food in these children mostly due to slower feeding and motor development, as opposed to solid foods at 4 to 6 months in typically developing children.

4. What is the foundation for early feeding, and why is this difficult for children with Down

syndrome to do? What implications might this have? Answer: The foundation for early feeding is the coordination of sucking, swallowing, and breathing. Impairments in this pattern might lead to malnutrition or an aversion to the feeding process.

5. How should energy needs be calculated for the child with Down syndrome? What is the

estimated caloric need for girls and boys with Down syndrome between the ages of 5-11? Answer: Energy needs for children with Down syndrome should be calculated per centimeter of height, as these children tend to be shorter than their typically developing peers. For example, a girl with Down syndrome between 5-11 years of age should receive approximately 14.3 Kcal/cm, and a boy about 16.1 Kcal/cm.

6. What factors should be considered when designing a diet management program for a child

with Down syndrome? Answer: A diet management program for a child with Down syndrome should include a well-balanced diet without energy restrictions, include vitamin and mineral supplementation, and an increased level of physical activity.

7. When a dietary intervention calls for an increase in fiber and water, what nutrition-related

problem is the SLP trying to combat? Answer: Constipation.

8. What age do children with Down syndrome begin weaning and self-feeding, compared with

their typically developing counterparts? Answer: Children with Down syndrome begin weaning and self-feeding at 15-18 months of age, about six months later than their typically developing peers.

9. What is the most effective intervention used to combat obesity in children with Down

syndrome?

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Answer: A well-balanced diet, no energy restrictions, vitamin and mineral supplementation, and increased physical activities should all be part of the weight management intervention in children with Down syndrome.

10. What percentage of children with Down syndrome have food aversion attributed to oral

motor delays? More specifically, what percentage of these children present with food selectivity solely due to texture?

Answer: Over 80% of children with Down syndrome present with food aversion attributed to oral motor delays; 51% of these children present with food selectivity solely due to texture.

11. In the study by Field, Garland, and Williams (2003), the authors stated that over 51% of the

children with Down syndrome in the study had food aversion related to some form of oral motor delays. What were the three specific oral motor deficits the authors mentioned?

Answer: Macroglossia, tongue thrusting, and difficulty chewing.

Cronk, C. E. (1978). Growth of children with Down’s syndrome: Birth to age 3 years. Pediatrics, 61, 564-568.


Zarate, N., Mearin, F., Gil-Vernet, J. M., Camarasa, F., & Malagelada, J. R. (1999). Achalasia

and Down’s syndrome: Coincidental association or something else? The American Journal of Gastroenterology, 94 (6), 1674-1677.

Zubillaga, P., Victoria, J. C., Arrieta, A., Echaniz, P., & Garcia-Masdevall, M. D. (1993).

Down’s syndrome and Celiac Disease. Journal of Pediatric Gastroenterology and Nutrition, 16 (2), 168-171.

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Content Area 9C Considerations for special populations: Traumatic brain injury

To treat dysphagia in a child who has been a victim of a traumatic brain injury (TBI) it is important to know different types of damage and to understand that each case will be different in relation to the amount of damage, deficits, and recovery time. In addition to knowing the severity of TBI you will want to be aware of the presence of co-occurring symptoms due to the TBI that may affect their ability to feed (i.e. tracheostomy, ventilation, postural deficits). Assessment and examination of the anatomical features and an oral mechanism and cranial nerve exam are the first steps prior to treatment.

Introduction:

• To gain a better understanding of what a traumatic brain injury is and clinical symptoms as well as diagnosis read Pediatric dysphagia: Resource Guide pp. 58-59.

Readings:

• There are many different types of brain injury. When treating persons with TBI it is

important to familiarize yourself with types of brain injury (i.e. open versus closed). In addition in order to treat and determine prognosis you need to be familiar with pathology of the injury. For example: you will want to know damage that could have occurred during the injury. You will not be determining the type of damage since that is the physician or neurologist’s job but you will be responsible for knowing terminology and selecting appropriate treatment in relation to pathology of the injury. In order to gain a better understanding of this content area read Dysphagia post trauma, pp. 31-36.

• In order to gain clinical knowledge of assessment and evaluation with persons with TBI read

the following Traumatic brain injury: Associated speech, language and swallowing disorders pp.331-354, Focus on function of the swallowing mechanism, rate of recovery, and relation to the extent of the injury

• There are several coma scales that are used when determining the severity of the injury as well as the level of coma they are in and what types of treatments can be provided by speech-language pathologists at this time. Two of those scales are the Glasgow Coma Scale and The Ranchos Los Amigos Scale. To become familiar with these scales read Dysphagia post trauma, pp. 28-43.

Hall, K.D. (2001) Pediatric dysphagia: resource guide. San Diego, CA: Singular Publishing Group.

Resources:

Murdoch, B.E. & Theodoros, D.G. (2001). Dysphagia following traumatic brain injury in adults and children: Assessment and characteristics. In W.C. Ward & M.T. Angela (Eds.), Traumatic brain injury: Associated speech, language, and swallowing disorders (pp.331 368).

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Ward, E.C. & Morgan, A.T. (2009). Dysphagia post trauma. San Diego, CA: Plural Publishing Inc.


1. True or False: Is TBI the most common cause of acquired disabilities in children?

2. Give several common causes for TBI in infants Answer: fall, motor vehicle accidents, and assault

3. When an injuring occurs to the head which ones are types of damage that can occur? a. Blood clots b. Contusions c. Hemorrhages d. Cerebral edema e. Ischemia f. All of the above g. Both A and D

4. True or False: Shaken baby syndrome is not considered an acceleration injury because the

brain damage occurs when the cranium strikes the skull.

5. What is the most severe prognosis for a child who has suffered a TBI? Answer: Remaining in a persistent vegetative state 6. Which on of the following is NOT a symptom of a TBI?

a. Lethargy b. Hyperactivity c. Irritability d. Initial vomiting e. Confusion f. Severe headaches g. Changes in speech h. Changes in motor movements i. Changes in vision

7. What is the significance between the length of a coma and severity of brain injury Answer: Generally the longer the coma and the more severe the brain injury was the poorer the prognosis. These are measured using observational scales like The Glasgow Coma Scale. 8. When considering someone who has suffered a TBI what functions might be impaired? Answer: jaw, lips, tongue, velum, larynx, pharynx, upper esophageal sphincter and esophagus.

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9. True or False: During an examination of the anatomical structures in a person who has dysphagia due to a TBI you exam movement or the lips, tongue, palate, pharynx, and respiration.

10. Which one of the following is the main focus when considering a patient with TBI? __Presence of a witness to TBI __Presence of tracheostomy __Duration of ventilation __Cognitive impairment __Control of feeding __Oral motor movements 11. What is the significance between the extent of brain injury and the swallowing mechanism? Answer: The greater the extent of brain injury the more likely they will have a more severe swallowing mechanism 12. True or False: A closed head injury is defined as exposure of flesh following skull or scalp

penetration.

13. Describe what a hematoma is. Answer: A result of a hemorrhage a pocket of blood in the blood vessel

14. True or False: Persons who have suffered a TBI have an increased risk of seizures and epilepsy.

15. When assessing persons with a TBI you use the Glasgow Coma Scale; what are the three categories that are scored on this scale?

Answer: Eye opening, best motor response, and verbal response

16. At what level in the Ranchos Los Amigos Scale may the patient be highly distractible and have difficulty learning new information but is still able to manage self-care tasks?

Answer: Confused-Inappropriate, Non-Agitated 17. On the Glasgow Coma scale what is the significance of a lower score on admission? Answer: The greater the neurological impairment 18. When considering someone who has suffered a TBI how can you determine the presence of a

deficit? Answer: Use the table on page 53 of Dysphagia post trauma. Then determine what swallowing tasks would be appropriate for that patient.

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Content Area 9D Considerations for special populations: Neonatal Intensive Care Unit (NICU)

When working with children presenting with feeding and swallowing disorders, the speech-language pathologist (SLP) may be responsible for premature infants in the NICU. In regards to feeding and swallowing intervention in the NICU, American Speech-Language Hearing Association (ASHA) states, it is the responsibility of the SLP to “include pre-feeding, assessment and promotion of readiness for oral feeding, evaluation of breast and bottle feeding ability and completion of instrumental swallowing evaluations.” Content Area 9D will thoroughly describe the role of the SLP in the NICU, as well as, provide information to adequately assess and treat the NICU population.

Introduction:

• To gain a basic understanding of the SLP’s role and responsibilities when working with premature infants in the NICU, read Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Guidelines (ASHA, 2005). Attend to the information provided regarding, Kangaroo mother care (KMC), nonnutritive sucking (NNS), oral stimulation, and breast and bottle feeding.

Readings:

• In order to gain clinical knowledge of assessment and evaluation in the NICU, read the

following pages: 303-309 in Pediatric Swallowing and Feeding: Assessment and Management (2nd ed.) by Arvedson and Brodsky (2002). Focus on differentiating factors between a preterm infant and a full-term infant. Know the importance of a nonnutritive suck (NNS) and a nutritive suck.

• Providing adequate services to premature infants in the NICU is one of the responsibilities of

the SLP. In order to gain knowledge in treatment strategies, read pages 422-427 and 429-431 in Pediatric Swallowing and Feeding: Assessment and Management (2nd ed.) by Arvedson and Brodsky (2002). Attend to pre-feeding techniques used to develop feeding and swallowing readiness. Focus on how nonnutritive oral sensorimotor stimulation techniques are used to prepare the infant for feeding.


Resources:

Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management (2nd Ed.). Albany, NY: Singular Publishing Group.


1. The role of the SLP in the NICU are the following:

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a. Assess infant feeding and swallowing behavior b. Identify disorders that may impact feeding and swallowing c. Make referrals to other professionals d. All of the above e. Both A and B

2. True or False: The SLP plays a crucial role in the discharge planning for the infant.

3. True or False: In the NICU, the SLP should not be concerned about communication

evaluation and intervention.

4. Which statement best describes “Family-centered care and developmentally supportive care”. a. Observation of the infant along with familial support is used to determine the best

care possible for the child. b. Parents need learning and guidance throughout the experience. c. The infant’s behavior provides the most adequate information needed to determine

the type of care needed. d. All of the above

5. How does the SLP support the family? a. Through education on nourishment b. Through education on feeding and swallowing c. Through education on feeding and swallowing and communication

6. When assessing in the NICU, it is important to observe the following: a. Parent-child interactions and observation of feeding and swallowing b. History and physical examination c. Developmental assessment ONLY d. History, developmental assessment, observation of feeding and swallowing, and

parent child interactions for feeding and communication

7. Why use a cotton swap dipped in water, formula, or breast milk as a technique for nonnutritive oral sensorimotor stimulation?

a. Because the clinician is trying to provide a correlated experience with sucking and sensation

b. Because the clinician is trying to introduce a new taste c. Because the clinician doesn’t want to move to solid foods until they can intake liquids d. None of the above

8. What are some ways to reduce the sensory stimuli in the NICU? a. Dim the lights b. Swaddle the baby to provide tactile input c. Reduce noise d. All of the above e. None of the above

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9. True or False: There is no possible way to give breast milk to a premature infant.

10. How would you treat a premature infant in the NICU with oral hypersensitivity?

a. Stroke the tongue b. Reduce the lights c. Rhythmically move a finger from periphery to the mouth d. Tap the lips

11. True or False: Tube-fed infants do not develop a sensation for hunger, putting these infants at risk for further feeding and swallowing problems.

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