RITA L. BAILEY, ED.D., CCC-SLP, BRS-SBoard Recognized Specialist in Swallowing and Swallowing DisordersAssociate ProfessorDepartment of Communication Sciences and DisordersIllinois State University

Management of Dysphagia: Practical Strategies for Infants through School-age Children

Welcome and introduction to…

The SpeakerAttendeesCourse ObjectivesAgenda and ActivitiesQuestions?

Normal Oral-Motor and Swallowing Development

• Structures Involved in Normal Eating & their Functions - A review of Normal Swallowing• Normal Oral-Motor and Swallowing Development

Anatomy-Lateral View Superior Endoscopic View

Normal and Abnormal Infant Reflexes

• Oral• Hand-to-mouth

• Limiting Patterns• Motor

• Connection between Motor and Oral-Motor Development

“the results of motor development point to similar data between supine, prone, seated and standing positions; for the oral motor skills (during feeding/ breastfeeding, using spoon, cup and chewing). A similarity was observed in the acquisition of motor abilities related to the lips, tongue and jaw in each of the feeding situations. There was an association between motor and oral-motor skills; the results indicate that motor development (motor skills) occurred prior to the development of the oral skills from the 5th to 24 months and that the skills related to the jaw when using a cup and spoon occurred prior to the development of the skills related to the lips and tongue” (p. 117)

Research: Telles & Macedo, 2008

Motor Development Milestones(WHO Multicentre Growth Reference Study Group, 2006)

0 3 6 9 12 18

Oral-Motor Development Milestones (Guerra & Vaughn, 1994)

• Tongue tip elevates for swallow

• Cup drinking skills begin developing

• Lip closure with liquids

• Coordinated suck-swallow breath

• Lips clean spoon

• Swallow becoming independent of preceding suck

• Lower lip becomes active in spooning

• Most infantile reflexes integrated

• Strong, rhythmical suck

• Opens mouth in anticipation of nipple

• Suck-swallow pattern

• Tongue cups nipple

• Infantile reflexes predominate

• Responds to nipple by touch, not sight

• Sucking pattern is inefficient and often uncoordinated

Age in months

The Development of Biting and Chewing Skills (Evans-Morris, 1999)Let’s review normal feeding development in order to recognize developmental level of feeding skills

1st- The Development of BitingEarly BitingPhasic bite & release patternHold & break patternSustaining the biteBiting through hard foods

2nd- The Evolution of Chewing SkillsEarly chewing (phasic bite-release) Voluntary bite-release pattern ~ 6 mos.

It’s an early munchTongue flattens and spreads in the mouth as the jaw moves up & downThis pattern mixes with an earlier in-out suckle pattern

Next, increased voluntary control. The child stops & starts munching at will.

Tongue has some ability to move laterally without the jaw also moving to the side.

Earlier, this was a reflexive pattern called the transverse tongue reflex; now it’s voluntary.

Next, Early diagonal movements

~6-9 months, when food is placed between the biting surface of the gums, the jaw moves slightly toward the side and downward in a diagonal movement as the tongue shifts to find the food.

~ 1 year oldChild can transfer food to either side when presented in the centerReverts to in & out movements when the transfer is challengingBegin transferring from center to side, side to center, center to the other side

~ 15 months, jaw movements are smooth & well coordinated – tongue is developing some independence

Development of rotary jaw movement pattern continues

~2 - 3 years (usually, closer to 3), the child can transfer food from one side to the other

The tongue now moves independent of the jawJaw movements are gradedA circular, rotary chewing pattern is fully developedLips close with chewing & swallowing, tongue & jaw move in synchronyCheeks tense to prevent pooling

Dysphagia in Infants: Select Motor and Sensory Aspects

Select Issues with Physiological State

Select Issues with Respiratory Involvement

• Hypotonic to hypertonic -easily fatigued• Abnormal sensory awareness -physiologically stressed• Motor organization may be poor or transient -anatomical/physiological

issues• Reflexes may not be intact or strong; abnormal reflexes may be present• Poorly organized states of alertness• Difficult state transitions• Not easily consoled • Doesn’t organize well• Optimal states for feeding (quiet, focused, alert) may be very brief

• Postural issues may result in decreased muscular integrity to support airway • May have trouble maintaining airway with feeding -RDS• Reduced bolus control, trouble latching on -tracheomalasia• Regulation of airway open and closing may be poorly timed -Chronic lung disease

or• May have transient tachypnea of newborn (TTN) BPD• Micro fluid aspiration -Tracheostomy• Congenital heart problems/abnormalities -Apnea• Sequelae of difficult delivery (perinatal depression)• Increased work of breathing, poor endurance• Qualitative issues that may involve respiratory function such as noisy swallows,

noisy suck, coughing, choking, color changes, A’s & B’s…more

Select Oral-Motor Issues

Select Gastrointestinal Issues

• Ineffective and/or uncoordinated suck -• Uncoordinated S-S-B• Difficulty latching on• Impaired NNS or NS• Decreased O-M strength, coordination, range of motion• More…

• T-E fistula• Poor esophageal motility, physiological and/or structural problems with the esophagus or gut• GERD – Lack of effective management may result in:

• Failure to thrive (FTT), slow growth, weight loss • Respiratory difficulties - Aspiration of stomach contents can lead to apnea or

asthma-like symptoms. • Esophagitis • Poor sleep states, irritable baby• Anemia - Caused by bleeding in esophagus or stomach or due to nutritional

deficiencies secondary to inadequate intake. • Pain and/or nausea• Linked to development of oral aversion/hypersensitivities• Over time may lead to behavioral feeding problems

These Problems Can Result In:

• Poor feedings• Stress in family• Poor/limited intake• Poor growth• Weight loss or poor weight gain• Nutritional concerns• Abnormal responses• Problems protecting airway, aspiration• Additional health problems• Abnormal parent/child (caregiver) interaction• Delayed development• More…• AND-

•Delay infants’ discharge from NICU

Management of Dysphagia in the NICU

• Feeding success is often included in hospital discharge criteria

• Establishment of evidence-based NICU feeding policies and procedures may impact infants’ feeding success

Earlier, safe discharge• Helps to preserve important hospital and medical resources for those

infants and families who need them the most

• May allow infants to be cared for at home

• Saves individuals and hospitals money

Evidence-based Practice in the NICUAlthough the evidence-base in this area of study is limited, it is important to determine what established evidence-base exists to inform NICU feeding policies and practices.

This information is useful for helping SLPs and other medical personnel as they develop recommendations for evidence-based feeding policies and practices.

Related Research(Bartels & Bailey, 2008)

Completed a literature search to find evidence-based feeding policies and practices in neonatal intensive care units (NICUs) and created a list of evidence-supported practices using:

Cochrane Library ReviewsMedline, Pub-Med, ComDisDome, Cinahl

Databases

Consulted the American Speech-Language-Hearing Association practice documents Roles of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Position Statement (2004) and Roles of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Technical Report (2004)

In order to add to /confirm list of evidence-based practices

Methods

• Obtained hospital NICU feeding policies and protocols posted on hospital websites and/or called and requested written feeding policies from hospitals with Level II or III NICUsPhone call requests were made to hospitals with known Level III and II NICUs Google and Yahoo searches conducted

Search terms included ‘children’s hospital, feeding policies, feeding protocols, neonatal intensive care unit, feeding premature infants, dysphagia, feeding policies, nursery feeding policies’ and combinations of these terms• Document analysis

methods were used to compare each written policy/protocol list to created matrix of evidence-based NICU feeding policies and practices

Although many more attempts were made…

A total of 4 hospital feeding policies and protocols were obtained from:

1. Level II NICU in 200-399 bed hospital in Midwestern United States

2. Level III NICU in 399+ bed hospital, North Eastern United States

3. Level II and III NICU in 200+ bed Children’s Hospital in Southern United States

4. Level II and III NICU in 399+ bed hospital in Australia

Summary of Evidence-Based Practices and Select Supporting References

Non-nutritive Suck StimulationAucott, Donohue, Atkins, & Allen, 2002Hafstrom & Kjellmer, 2000Miller & Kang, 2007Narayanan, Mehta, Choudhury, & Jain, 1991Neiva & Leone, 2007Nyqvist, Sjoden, & Ewald, 1999Pinelli & Symington, 2001Pinelli, Symington, & Ciliska, 2002Spatz, 2004

Oral StimulationGaebler & Hanzlik, 1996Fucile, Gisel, & Lau, 1996Boiron, Nobrega, Roux, Henrot, & Saliba, 2007

Kangaroo CareConde-Agudelo, Diaz-Rossello, & Belizan, 2003 (Cochrane Review-*ES)Dodd, 2005Feldman & Eidelman, 2003Ludington-Hoe, Anderson, Swinth, Thompson, & Hadeed, 2004Moore, Anderson, & Bergman, 2007 (Cochrane Review-*ES)Swinth, Anderson, & Hadeed, 2003

(*ES-Evidence Supports)

Nipple Flow Rate Consideration or External Pacing to Control Flow

Lau, Sheena, Shulman, & Schanler, 1997Law-Morstatt, Judd, Snyder, Baier, & Dhanireddy, 2003Lemons & Lemons, 1996Vandenberg, 1990

External oral/jaw supportBoiron, Nobrega, Roux, Henrot, & Saliba, 2007Einarsson-Backes, Price, Glass, & Hayes, 1994Hill, Kurkowski, & Garcia, 2000

Feeding SchedulesAd-lib/Demand

Adibe, Nichol, Lim, & Mattei, 2007Pridham, Kosorok, Greer, Kayata, Bhattacharaya, & Grunwald, 2001Crosson & Pickler, 2004 Tosh & McGuire, 2008 (Cochrane Review-*IE) Semi-Demand or ComplimentaryMcCain, Gartside, Greenberg, & Lott, 2001(*IE-insufficient evidence concluded)

Plan for Transition from Enteral Feeding to Oral Feeding

Collins, Makrides, & McPhee, 2008 (Cochrane Review, IE)Evans & Thureen, 2001Lemons, 2001Lemons & Lemons, 1996McCain, 2003Premji, Paes, Jacobson, & Chessell, 2002

Family-Centered CareBauchner, 1996Browne & Talmi, 2005Shield, Pratt, Davis, & Hunter, 2007 (Cochrane Review, IE)

Neurodevelopmental Care Approach

Als, 1986Als & Gilkerson, 1995Als, Lawhon, Brown, Gibes, Duffy, McAmulty, & Blickman, 1986Aucott, Donohue, Atkins, & Allen, 2002Shaker & Woida, 2007

Benefits Specific to BreastfeedingFor Mother• Decreased risk of breast cancer (~25%)• Lower risk of uterine and ovarian cancer

due to less estrogen• Less risk of osteoporosis (non-breastfeeding

women: 4 times higher incidence)• Child spacing – delayed resumption of

ovulation• Promotes postpartum weight loss• Cost of formula feeding: $1200/year• Reduced healthcare costs• Reduced employee absenteeism• Attachment parenting

Known Benefits to Babies• Improved immunities• Enhanced developmental and

neurocognitive outcome• Greater enteral feeding tolerance, faster

progression to full enteral feedings• Enhanced retinal maturation & visual

maturity• Greater physiological stability during

breastfeeding than bottle-feeding

Support for Breast or Bottle Feeding

Bier, Ferguson, Anderson, Solomon, Voltas, Oh, & Vohr, 1993Callen & Pinelli, 2005 Dollberg, Lahav, & Mimouni, 2001Howe, Sheu, Hinojosa, Lin, & Holzman, 2007Limpvanuspong, Patrachai, Suthutvoravut, & O-Prasertsawat, 2007Rodriguez, Miracle, & Meier, 2005Schanler, Schulman, & Lau, 1999Schanler, Schulman, Lau, Smith, & Heitkemper, 1999Sheppard & Fletcher, 2007Singh, Sachdev, Nagpal, Bajaj, & Dubey, 2005Spatz, 2004Thomas, 2000

FINDINGS

Care Concepts Stated or Implied in Policies and Procedures

Level III NICU in 399+ bed hospital,

North Eastern United States

Level II NICU in 200-399 bed hospital in

Midwestern United States

Level II and III NICU in 200+ bed

Children’s Hospital in Southern United

States

Level II and III NICU in 399+ bed

hospital in Australia

Neurodevelopmental Approach

Non-nutritive suck stimulation +

Kangaroo Care + +

Oral Stimulation +

Nipple Flow Rate or External Pacing to Control Flow

+

Support for Breast and Bottle Feeding + + +

Feeding Schedule Decisions Addressed + +

Identified Plan for Transition from Enteral to Oral Feeding

External oral/jaw support

Family Centered Care +

Total: 7 8 5 3

DYSPHAGIA IN CHILDREN: PART I

COMMON SYMPTOMS OF SWALLOWING PROBLEMS IN CHILDRENDysphagia

• Coughing, Gagging, “Wet” Voice Quality, Choking (!)• Difficulty chewing or moving food around in mouth• Drooling, or food loss at the lips• Residue in mouth after meals or between bites• Weight issues (*usually weight loss, chronically low-weight)• Frequent upper respiratory infections/pneumonias• Extreme preferences for consistency, temperature, taste• Sensory Issues• Fussiness at meals, or food refusals• Breathing and/or color changes during or following eating• Recurrent/chronic fevers or spiking a temp. associated with eating• Wheezing or stridor associated with eating• History of vomiting and/or documented gastro-esophageal reflux

ETIOLO

GIES O

F FEEDIN

G PROBLEM

S

• Motor-based Problems• Sensory-based Problems• Behaviorally-based Problems

• Maladaptive mealtime behaviors• Issues of decreased independent functioning with

or w/o limited opportunities for development of self-determination skills

• * Combinations• Limiting Patterns • Frequent Causes and Associated Characteristics

Classifying Eating/Swallowing Problems

Oral-Motor and Oral-Sensory Skill Deficits

Involve deficiencies in oral-motor awareness and associated movements/necessary adjustments of tension of the oral structures (i.e., lips, tongue, jaw, cheeks) necessary for preparation, transport, and safe and efficient swallowing of a variety of food consistencies

Underlying deficits in feeding skills result in a variety of symptoms related to the area of dysfunction:

For example, motor and sensory deficits associated with lips & cheeks-

Lips that don’t close or are retractedLips that aren’t active in spooning and/or chewingLips that are pursedLips that don’t maintain closure with swallowingResidue in cheek cavities, cheeks that don’t “help” with

bolus control or chewing

Examples of Oral-Preparatory Phase ProblemsReduced tongue coordination = decreased control of the bolus, slow and/or increased effort to prepare it

Reduced tone in the cheeks =Reduced lip closure =Reduced tongue range of motion and/or delayed tongue movement patterns =Reduced/absent lateral tongue movements =Reduced/absent rotary jaw movement =

Reduced jaw closure and/or limited opening=Abnormal reflexes interfere (tonic bite, hyper-gag, rooting, startle, etc)=Reduced sensory awareness or hypersensitivities=Dental and/or structural abnormalities that limit functional abilities

COM

MO

N

PROBL

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WITHI

N THE

ORAL

PHASE O

F SW

ALLO

WIN

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• Reduced tongue control (decreased ability to form a bolus and control its movement from front to back of mouth) = can result in premature spillover to pharynx …

• Reduced/absent lip closure = • Reduced sensory awareness or hypersensitivities =• Dental and/or structural abnormalities that limit functional

abilities• Reduced tone in the cheeks = • Tongue thrust pattern = •

Examples of Oral Phase Problems

• Delayed (common) or absent (less common) swallow response = • Reduced closure of the velum = • Reduced tongue base retraction to contact pharyngeal wall = • Reduced contraction of the pharyngeal constrictor muscles = • Reduced coordination of pharyngeal phase with the airway

closure of the larynx = • Reduced laryngeal elevation and/or closure =

Examples of Pharyngeal Phase Problems

Pharyngeal phase problems can result in:

Penetration- foods or liquids that extend into the laryngeal vestibule but are swallowed ‘in time’ so that they do not progress beyond the false vocal folds or

Aspiration-foods/liquids that fall to the true vocal folds and farther into the airway

Absent/delayed & weak/productive cough reflex

COMMON PROBLEMS WITHIN THE ESOPHAGEAL PHASE OF SWALLOWING

• Most Common in children: Gastroesophageal Reflux!

• Less common:• Lax UES• Tracheo-esophageal fistula• Decreased esophageal peristalsis

Deficits in Chewing Skills Development

Children are different than adults in that they don’t typically lose skills they’ve had, but they go through normal developmental patterns slower and/or they “freeze” in their development of skills due to their physical limitations and associated limiting patterns.

Abnormal reflexes can/do interfere with development!

Oral-Sensory Differences

Oral-sensory awarenessHyposensitivities

Tend to like strong flavors (spicy, sweet, sour, etc)Usually require increased stimulation to respond in a more normal fashion (i.e., firm pressure to tongue body with spooning helps initiate tongue cupping bolus and raising tip to alveolar ridge)React negatively to light touch

HypersensitivitiesTend to like bland flavorsReact negatively to flavor and consistency changesGag easilyAversive to touch in/around the mouth and faceMay also be hypersensitive to touch of the hands, arms, etc.

END OF PART I