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FEEDING & SWALLOWING
PROBLEMS IN PEDIATRICS:
IMPROVING FUNCTION &
CARRYOVER Erin Lewis, MS, CCC/SLP
Erin Ball, MA, CCC/SLP
ON GAME DAY, BUT…
NOT TODAY
WHAT IS A FEEDING PROBLEM?
When eating has an adverse effect on health or
functioning.
Difficulty consuming adequate nutrition by
mouth.
Food refusals
No advance of the diet
Disruptive mealtime behaviors
Undernutrition
Lack of consensus on the definition makes
diagnosis and treatment referrals difficult.
IN ESSENCE IT IS A MATTER OF
PERCEPTION
WHAT IS A SWALLOWING PROBLEM?
Can occur at different stages in the swallowing
processes.
Oral
Pharyngeal
Esophageal
OROPHARYNGEAL DYSPHAGIA SIGNS AND
SYMPTOMS
Infancy and Older
Disorganized/Abnormal Suck
Failure to Thrive
Drooling
Apnea
Desaturations
Wheezing
Stridor
Bradycardia
Congestion
Transition difficulty to solids
Gagging
Coughing
Oral Aversion
WHO DOES THE FEEDING &/OR
SWALLOWING PROBLEM IMPACT?
2/3 to half of parents report at least 1 mealtime
behavior problem; 1⁄4 report multiple mealtime
behaviors (Crist & Napier-Phillips:2001)
25% of all children are reported to have some
form of feeding disorder; 80% of developmentally
delayed children present with some kind of
feeding disorder (Manikum & Perman, 2000)
IMPLICATIONS FOR A CHILD’S LIFE
Aspiration
Failure to Thrive
Quality of Life
Nutrition
Overall Development
PARENTS NEED SUPPORT
Heweston, R. and S. Singh (2009)
Study of mothers with children with chronic
feeding disorders.
Mothers’ experiences can be understood as two
continuing journeys that are not mutually
exclusive.
Deconstruction & Reconstruction
DECONSTRUCTION
Losing the mother dream
Everything changes : living life on the margins
Disempowered : from mother to onlooker
RECONSTRUCTION
Letting go of the dream and valuing the reality
Self-empowered : enabling
Facilitating the journey
The continuing journey : negotiating balance
IMPLICATIONS IN THE LONG TERM FOR A
FAMILY
Frustration during meals
Frustration regarding food
Conflict
Stress
PARENTS GENERALLY RECOGNIZE MEALS
ARE A STRUGGLE HOWEVER…
May have trouble effectively describing the issue
to their child’s PCP
PCPs often lack the time and education to make
informed feeding and swallowing assessments
REFRAME THE QUESTIONS
Does your child have
any swallowing
problems?
Does your child
tolerate a variety of
foods?
Does your child cough
or choke during
meals?
Does your child sit
and eat a meal with
the family?
Does your child eat
over 30 foods without
refusing or gagging?
We may tend to say… Instead consider…
FEEDING MATTERS’ INFANT AND CHILD
FEEDING QUESTIONNAIRE (ICFQ)
Web based questionnaire designed to improve PCP
early identification and referrals for kids at risk
with feeding and swallowing problems.
Excellent tool for families to effectively
communicate with physicians.
http://www.feedingmatters.org/questionnaire
EXAMPLES OF THE QUESTIONNAIRE
ONLINE
DELINEATING
ETIOLOGY AND
UNDERLYING CAUSES
BIOMEDICAL FACTORS
Prematurity
flexion
Low tone
Respiratory
Supplemental oxygen
Asthma (risk into adulthood)
Cardiac
Surgeries
Hypoxic or ischemic events
Craniofacial
High/narrow palate
Tongue tie, lip tie
Enlarged tonsils and/or adenoids
BIOMEDICAL FACTORS - CONT’D
Digestive
Anatomy/structure
Motility/gastric emptying
Esophagitis
GERD is a symptom and not a diagnosis!!!!
Allergies
intolerance
Immune System
Reactions to foreign substances in the body
Usually proteins
Problems digesting enzymes
Milk, wheat, medications
ENVIRONMENTAL FACTORS
Physical environment
Family understanding and support
PSYCHOSOCIAL FACTORS
Stress
Feeding mismanagement
2 BIG CONCERNS
How do I get them to
eat?
How do I get them to
eat safely and
effeciently?
Parents Clinician
EXAMINING AND
IMPROVING ORAL
SKILLS
Oral feeding skill deficits contribute to more than
half of the children (427/700) diagnosed with a
feeding problem with 66% of those children under
the age of 2. (Rommel et al., 2003)
EFFICIENT ORAL MANIPULATION
CHEW
SWALLOW
BREATHE
LOOKING AT ORAL SKILLS
Rapid acquisition of oral skills occur in the first
year of life.
6 months – 2 years
Did the child miss a window of opportunity to
learn consistencies/develop skills?
Are they currently missing a window of
opportunity?
FACTORS THAT INFLUENCE ORAL SKILLS
AND CHEWING
Dentition
Jaw muscle and bite
force
Food properties
Saliva
More muscle activity
needed for harder foods
Number of chewing
cycles and duration
increased with hardness
and bolus size
Saliva required for
lubrication and assists
in bolus formation and
perception of taste and
flavor.
AS WE PROGRESS THROUGH
CONSISTENCIES AND SKILLS
Is the child comfortable with the skill we are
asking them to use?
If we challenge too much with food are we
creating the behavior?
Eating should not be scary.
Eating should be successful.
AL
L A
BO
UT
TH
E T
ON
GU
E
LAB SESSION
ANALYSIS OF CHEWING THE GUM
Central placement
Lateral shift
Dominant side?
Observe and feel for cheek activation with
different chewing patterns
Analyze and describe tongue movements used to
move the bolus
Analyze and describe cheek, jaw, tongue
coordination
Anxiety?
Compensations?
CAUSES OF POOR CHEWING
Typically a result of:
Medical issues
Oral motor skill issues
Sensory issues
MEDICAL ISSUES AND CHEWING FOOD
Delay learning at the appropriate age.
Neurological disorders
Genetic disorders
Prematurity
Developmental Delays
GI Issues
Allergies
ORAL MOTOR SKILL ISSUES AND CHEWING
FOOD
Use of immature chewing patterns or
compensations to break down food
Frontal chewing
Lips closed and pursed when chewing
Using vertical patterns and munch only
Swallowing food whole
Will not open mouth when asked to “show”
Difficulty clearing mouth of chewed food
Looks confused
SENSORY ISSUES AND CHEWING FOOD
Over or under responsive to sensation.
Fight or Flight
Gagging
Raking food out of mouth or spitting
Looking fearful
Crying
Behavior???
FEEDING THERAPY
It takes a LONG time!!!!
Look at all of the underlying issues.
Medical management
Missed developmental window
Oral motor, sensory, behavior
Build trust with the child.
FUNCTIONAL USE OF FOOD AND DRINK
This is the most successful strategy for gains and
carryover.
ADJUSTING THE DIET
Decrease exposure to foods the child is using
inappropriate skills to consume
Don’t want them to swallow table food whole.
Practicing the undesired skill.
Use a mix of foods. Minimize fatigue.
Remember you are working with muscle groups,
it is a slow process.
SPOON FEEDING
Maroon spoons
Beckman EZ spoon
Textured Spoons
Bolus Placement
Techniques
MUNCHING
Mesh bag feeder
Cheesecloth
Clinch rag
Techniques
BITING/CHEWING
Chewy tube-yellow
Biting blocks
Real food
carrots
celery
Dried twizzlers
DRINKING
Infa trainer
Honey bear straw cup
Lip block
Nosey cups
Wow cup
Nuk sipper
Recessed lid cup
MAKING FUNCTIONAL GAINS
To make gains your program must include all of
the following components.
EAT, EAT, EAT!!!!!
Oral motor
Sensory
Diet adjustments
Behavioral/Psycosocial
HOW DO WE
IMPROVE SENSORY
RESPONSES?
ALWAYS BE PROACTIVE
Anticipate that there will be a sensory issue.
Begin the session with proprioceptive input.
Whole body not just the mouth.
SENSORY PROCESSING-“THE WAY THE NERVOUS SYSTEM
RECEIVES SENSORY MESSAGES AND TURNS THEM
INTO RESPONSES”
Sensory Processing Disorder (SPD)-the sensory
signals don’t get organized into appropriate
responses; daily routines and activities are
disrupted; sensations are experienced differently
PREPARING THE SYSTEMS
Vestibular
Proprioceptive
Tactile
Olfactory
Visual
Auditory
Gustatory
VESTIBULAR
postural stability/control
alerting
calming
PROPRIOCEPTIVE
influences of muscle tone
motor planning
Proprioceptive input is largely ORGANIZING for
the child.
THE STANDARD 5
Tactile
Olfactory
Visual
Auditory
Gustatory
APPROACHES WITH
AND WITHOUT FOOD
WITHOUT FOOD
whole body massage/movement
handling techniques
sensory preparation
WITH FOOD
expand exposure
sensory “play”
getting to touch, smell, taste
expanding taste repertoire
expanding olfactory and visual repertoire
getting to texture
SYSTEMATIC DESENSITIZATION
All designed to improve
Trials with mesh
Foods meet oral motor skills
Fading new foods – food chaining methods
BEHAVIORAL ISSUES
RESULTANT OF
Medical
Motor
Sensory
A BALANCED APPROACH
Behaviors become conditioned so quickly.
We create more ‘behavior’ when we don’t operate
on relationship and trust.
Keep the child and parent KNOWING they are
100% safe with the task you are asking them to
complete.
POSITIVE EXPERIENCES
Will foster confidence and learning
Appropriate challenges
Understanding and acknowledging the problem
Providing a structure and routine
Positive reinforcement to enhance building a skill
Practice
Patience
MOTIVATION AND FOOD EDUCATION
ED
UC
AT
ING
FA
MIL
IES A
ND
CH
ILD
RE
N A
BO
UT
FO
OD
LAB SESSION
INVOLVING THE FAMILY & PRACTICAL
EDUCATION
What does the family do with the information you
give them each session?
Follow the formula:
What’s working
Food
Lifestyle
Exercises
Q & A
Problem solve your cases.
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