arwen jackson and jacklyn kammerer - parent lecture - the toddler with down syndrome; a perspective...

7/30/2019 Arwen Jackson and Jacklyn Kammerer - Parent Lecture - The Toddler With Down Syndrome; A Perspective on Feeding - English

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The Toddler withDown Syndrome:

a perspective onfeeding skills

Down Syndrome Educational

Symposium Series 2012

Arwen Jackson, MA, CCC-SLP

Jacklyn Kammerer, MS, OTR


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Who are we?

Arwen Jackson, MS, CCC-SLP is a speech-language pathologistwho has extensive training and specializes in feeding andswallowing within outpatient therapy services as well as severalmultidisciplinary clinics at Childrens Hospital Colorado. Arwen

also has interest in children with complex medical diagnosesincluding children with Down Syndrome, tracheostomy and

ventilator dependence, allergies, and voice disorders.

Jacklyn Kammerer, MS, OTR is an occupational therapist whohas extensive training and specializes in feeding and swallowingwithin outpatient therapy services as well as several

multidisciplinary clinics at Childrens Hospital Colorado. Jacklynalso has interest in children with sensory processing disorders,

complex airway and gastrointestinal issues (Aerodigestive

program), and infant development.


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Financial disclosure

We have no relevant financial relationships with any

commercial interests.

Arwen Jackson, MA, CCC-SLP

Jacklyn Kammerer, MS, OTR


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Learning Objectives

Review typical feeding development Understand atypical patterns common in children with

DS

Understand and familiarize with various food textures Review medical diagnoses that can impact feeding Discuss therapeutic perspectives to support feeding and

mealtimes with a child with DS

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Eating is a Learned Behavior

Anatomy + Physiology + Experience Need repetitive, consistent, & positive association with

mealtimes to learn to eat


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BRIEF REMINDERNormal Development to Support Successful Feeding

9-12 months of age Motor Skills Skilled dissociation with hands one to stabilize and one to play Engaging in independent finger feeding

Development of pincer grasp Active release

Bringing loaded spoon to mouth Oral Motor Skills Increased disassociation of oral structures

Tongue lateralization to move foods side to side Rotary chewing patterns - diagonal jaw movements Controlled bite on soft foods

Sensory Progressions Lots of sensory play with foods

To explore the taste, texture, temperature, smell, etc. Food Textures Liquids for continued nutrition Purees of varying thickness and texture Meltable solids Soft solids Some mashed and coarsely chopped table foods

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Normal Development to Support SuccessfulFeeding

12-24 months of age Motor Skills

Refinement of self feeding More precise grasp and release Orienting spoon to scoop and bring to mouth Independent cup drinking

Force and grasp accommodation to weight of object Improved overall balance and coordination

Transition from high chair to booster chair Oral Motor Skills

Refinement of diagonal jaw movements as more challenging foods are presented Able to drink from open cup without choking consecutive swallows Biting through hard cookie with sustained bite

Speech-Language Development Uses single words with two word combinations by 24 months Able to request AND refuse food items Steady increase in vocabulary Understands and uses no

Texture Progressions Liquids from sippy cup, straw, and beginning to use an open cup (transition away from breast and bottle) Purees, meltables, soft solids, and coarsely chopped table foods Avoid highly chokable foods raw vegetables, meats, nuts, small round foods

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24-36 months of age Motor Skills

Increased balance and core stability

Sitting at table no adaptations needed Continued refinement of fine motor skills

Independent self-feeding with utensils Oral Motor Skills

Refined jaw movements Diagonal and rotary movements Use of tongue to clean lips

Speech-Language Development Able to use and respond to simple sentences Noted increase in verbal refusal behaviors

Food Textures Wide variety of table foods and liquids Able to manage foods which are mixed in texture Continue to avoid chokable foods, especially raw vegetables, fruits, and nuts

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Transitioning from a bottle to a

cup Exposure to cups in late infancy/early toddler years Consideration of your childs unique feeding needs

Stage of development versus chronological age Oral motor control Oral sensory preference Childs tolerance of change/transition

How might you explore your options? Place the cup on tray for exploration Remember the value of modeling cup drinking

Parents and/or siblings Other peer groups (preschool, play group, etc)

Play with cups during bath time or sand box play

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A few examples because

..everybody sips

differently!

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3-4 years of age Motor Skills

Independent self-feeding Food Textures

Modifications still requiredfor foods with high texture

Continue to avoid chokablefoods, especially raw

vegetables, fruits, and nuts

Child is able to understandwhat is edible/inedible

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Gagging as a Protective

Mechanism

Does the food being presented match

developmental level

AND

oral motor abilities

of the child?


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PUREESThese foods offered by spoon, may vary in consistency from

smooth, thin, and runny to lumpy, thick, or stiff.

Any table foods that are blenderized

Grain Group

Hot cereal (rice cereal, oatmeal, cream of wheat, malt-o-meal)

Vegetable Group

Baby foods (sweet potatoes, squash, peas, beans)

Mashed potatoes or mashed sweet potatoes

Spaghetti sauce (marinara or alfredo)

Fruit Group

Baby foods (applesauce, peaches, pears)

Berry sauces

Applesauce

Mashed banana

Milk Group

Yogurt

Soft cheese spreads

Sorbet and sherbet (considered a thin liquid with respect toswallow function)

Soft cheese spreads

Milk/Fat

Pudding or custard

Ice Cream, frozen yogurt (considered a thin liquid withrespect to swallow function)

Meat Group

Refried beans

Hummus

Peanut butter (not recommended the first year due topotential for allergies)

Fats and Sweets

Cream cheese and flavored cream cheese

Ketchup

Barbecue Sauce

Gravy

Jelly, jam

Chocolate sauce, butterscotch, or caramel sauce

Mashed avocado

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____________________________________________________________Author: N. Creskoff OTR Approved by the Patient Family Education Committee

January 2011 2010 The Childrens Hospital, Aurora, CO


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MELTABLE SOLIDSThese foods which melt or soften readily with saliva and then

break apart easily with gumming, mashing, or some chewing.

Grain Group

Pirates Booty Puffed Rice/Corn Snacks(Veggie Booty, White Cheddar)

Gerber wheels Dehydrated veggie sticks Graham crackers Wafer cookiesGrain/Fat Group

Butter cookies Butter crackers Crushed cookies, cookie crumbsFruit Group

Fruit Booty

Fats and Sweets

Cheetos Butter cookies Butter crackers Graham crackers Chocolate Mini marshmallows Cotton candy Ice cream cone Wafer cookies Crushed cookies, cookie crumbs

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Soft Solids, Mechanical Soft SolidsThese foods can be mashed and then swallowed, or break apart easily in the mouth

without the need to chew.

Grain Group

Soft breads Soft, well-cooked pasta such as Ramen

noodles

Well cooked rice (may be more difficult forsome children to manage)

Pancakes, french toast, or waffles (softenedwith butter and syrup fats and sweets).

Grain/Fat

Muffin, cake Fruit and cereal bars Soft cookies such as Fig NewtonsVegetable Group

Soft, well-cooked vegetables such as thosefound in soups (carrots, potatoes, squash)

Fruit Group

Soft fruits (especially canned fruits such asmandarin oranges, pears, kiwi, bananas, andthinly sliced watermelons)

Milk Group

Thinly sliced cheeseMeat Group

Scrambled eggs (should not be given before 9months)

May be more difficult for some children tomanage without chewing.

Meat sticks or Vienna sausages Cooked legumes / beans Ground meat or tender meats, fish, or poultry

____________________________________________________________Author: N. Creskoff OTR Approved by the Patient Family Education Committee



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SOLIDSThese foods which require some manipulation and breakdown via chewing prior to

safely swallowing. Consider variety from semi-soft to crunchy to chewy, with increasingrequirement for thorough chewing.

Combined

Pizza Sandwiches (grilled cheese)Grain Group

Pasta, macaroni and cheese Dry cereal, such as Cheerios Crackers Pretzels Bagels, crusty breadsVegetable Group

Raw vegetables such as cucumber, celery,carrots, green beans

SaladFruit Group

Fruits (apple slices, strawberries, melon,pineapple)

Dried fruit, raisins

Milk Group

Cubed cheeseMeat Group

Deli meat Chicken, chicken nuggets Hamburger Steak Various other meats, including sausage and

bacon

Beef jerkey Fish sticks Hard boiled eggsFats and Sweets

Cookies Chips Licorice Carmel or taffy Olives

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MIXED TEXTURESThese foods which contain more than one food texture, and

require the most mature oral motor skills to manage.

Vegetable and Meat Groups

Casseroles Soups with vegetables, pasta, rice, meat Selected Stage 3 Baby foodsFruit and Milk Groups

Yogurt with fruit pieces

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Food lab

Exploring food textures

What does your mouth do to manage different foodtextures?

THINK ABOUT YOUR lips tongue jaw/teeth cheeks

Puree Meltable solid Soft Solid Solid

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A l l k f di


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A closer look at feeding

difficulties... More than what meets the eye, feeding is impacted by

several aspects: Oral motor skills Oral sensory development Motor control and muscle tone Sensory Processing Family context for feeding their child Other health issues

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Atypical Development of Motor Skills

Abnormal muscle tone Can affect positioning for successful oral feeding

High tone - spasticity Low tone flaccidity, floppy Fluctuating tone athetoid, ataxic

Fine motor/Gross motor skills delays Can impact development of self feeding skills

Diagnosis specific delays

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Atypical Development ofSensory Processing Skills

Types of sensory dysfunction that can influence typical feedingdevelopment: Oral hypersensitivity Oral hyposensitivity Global sensory processing challenges

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Oral Hypersensitivity

Clinical Signs Difficulty advancing food textures Reduced acceptance of tastes, temperatures and smells Aversive/exaggerated response to touch in and around the mouth Hyperactive gag response Aversion to teeth brushing Lack of age-appropriate oral exploration of hands/toys

Treatment Blendarize table foods gradually thicken Avoid mixing food consistencies Meltable or soft mechanical solids are often more easily accepted

foods Change only one sensory variable at a time Make gradual changes in taste/texture Work to normalize sensory response with desensitizing activities

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Oral Hyposensitivity

Clinical Signs Slow registration of food in mouth Poor awareness of food on face/lips Overstuffs mouth

May result in gagging or choking Pockets food in mouth Swallows food without adequately preparing the bolus to swallow

May result in gagging or choking Drooling Preference for strong tastes

Treatment Oral alerting activities Variety of textures of foods Variety of food temperatures Increase flavor of foods with spices/sauces Manipulate foods into safe proportions bite sized pieces

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A child with Down syndrome can present

with a feeding and/or swallowing difficultyFeeding/Swallowing

Chronic poor growth Compromised nutritional status Food refusal/picky eating Decreased variety and volume of oral

intake

Choking, gagging, coughing andvomiting while eating

Inability to chew/swallow Delayed attainment of self-feeding skills Inability to maintain oral skills when tube

fed

Difficulty transitions from tube to oralfeeding

Behavioral or learned feeding problems

Swallowing

Coughing or choking while eating orimmediately after eating

History of chronic pulmonary difficultieswhich may include diagnosis of

aspiration pneumonia

Chronic oxygen requirement Vocal cord dysfunction Weight gain is difficult and thought to be

secondary to oral motor or pharyngeal

dysfunction

Difficulty initiating a swallow


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Common medical diagnoses and/orstructural differences in children with DS

Cardiac Diagnoses that could impact fatigue Hypotonia (low tone) Tracheomalacia Laryngomalacia Subglottic Stenosis Dysphagia Late dental eruption Gastrointestinal

Constipation Celiac Reflux

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Other Atypical BehaviorsCommon in Children with DS

Orally seeking Intense chewing on unsafe or odd items

Atypical biting patterns Biting only with molars Avoiding front of mouth other than drinking or with purees

Reliance on pureed food textures, jarred baby foods, orhome blenderized foods

Reliance on caregivers for feeding purees due to lessefficient but functional fine motor grasping patterns

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A few things to keep in mind to

help encourage positive mealtimeexperiences..

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Consider your childs communication levelduring mealtime

Look at non-verbal communication such as eye gazeand facial expression

Food choices Present food item Augmentative and Alternative Communication

Device Picture Exchange Communication System (PECS) Real pictures of common foods

Sequence and routine for mealtime

Verbal Visual

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Non-Verbal Strategies to Encourage Eating

NON-VERBAL COMMUNICATION: This form of communication isimportant because we often give messages without using words. Consider

the following during mealtimes:

YOUR Position YOUR Facial Expressions YOUR Body Language Observe and Wait Imitation Allow for Equal Turn Taking Make Your Face Match Your Words Decrease Anxiety

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Verbal Strategies to Encourage Eating

VERBAL COMMUNICATION: What comes out of your mouth at the tableis just an important as what goes into it! Language can be a powerful tool

to guide, encourage, and positively reinforce food interaction and eating.Consider the following:

Direct Attention Pay Attention to All Aspects of the Meal and All Family Members Provide Appropriate Praise Teach the Basic Rule and Structure of Mealtimes Talk About Your Mouth and What You Do With It Describe Food Properties Provide Reassurance Offer Choices Avoid Questions and Commands; Provide Encouragement and Offer Suggestions

for Food Interaction

Keep Language Simple and Repetitive____________________________________________________________Author: N. Creskoff OTR Approved by the Patient Family Education Committee


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C id th i t f t l


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Consider the importance of posturalstability during feeding

Children need postural stability for distal mobility. What does that mean for a child with Down syndrome

and how does that affect feeding?

Support for comfortable and safe positioning for bottle feeding Impact on swallow function Impact on developmental skills to bring hands to bottle Multiple systems coordinating together for successful feeding

experience

Impact on tube feedings Support for a child in the highchair so they are able to easily

reach baby purees and spoon to grasp, touch, explore, learn!

Highchair designs vary significantly Adding rolled towels may provide lateral (side) support so that baby

can easily stay seated in the highchair without falling to either side

or leaning on the tray for support

Postural support will allow for more controlled oral movements34


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Food for Thought Think about your child with Down syndrome.

Are foods too challenging or just right for your child? Think about the environment during feedings, is it chaotic?

Music? Television? Bright lights? Others eating?

Is feeding with your child fun and social? Is your child positioned in the BEST way to support feeding?

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arwen jackson and jacklyn kammerer - parent lecture - the toddler with down syndrome; a perspective...

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