sphsc 543 february 12-19, 2010
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Sphsc 543 February 12-19, 2010. Questions?. Transitional feeding. Begins at 4-6 months in normal infants Primarily related to CNS and anatomic changes Allows new patterns of food manipulation Eruption of teeth is the most notable change Mandibular before maxillary Girls before boys - PowerPoint PPT PresentationTRANSCRIPT
SPHSC 543FEBRUARY 12-19, 2010
Questions?
TRANSITIONAL FEEDING Begins at 4-6 months in normal infants
… Primarily related to CNS and anatomic changes… Allows new patterns of food manipulation
Eruption of teeth is the most notable change… Mandibular before maxillary… Girls before boys
20 teeth by second year, 32 by adult
TRANSITIONAL Teeth as sensory receptors versus motor
purposes
Molars important for crushing and grinding food
Tongue movements are basic to food manipulation… Anterior-posterior (AP) movement … Lateral movement
TRANSITION FROM LIQUIDS Smooth solids – homogeneous or with fine
granular bits … Mashed by tongue gestures at midline
Semifirm solids – soft but holds together… Tongue moves laterally and tongue/jaw make
vertical motions… A prelude to molar chewing
Solids – require more mature mastication… Vertical movements become associated with
alternating lateral motions… Fully matures between 3-6 years
TRANSITIONS Solid foods characterized by:
… Handles lumps and textures with ground or mashed foods
… Coarsely chopped foods cooked ground meats, lunch meats, soft cooked chicken/fish
… Coarsely chopped table foods, most meats, many raw vegetables/fruits.
Brain development from sensory input related to feeding extending to midbrain, cerebellum, thalamus and cerebral cortex
With maturity, children begin to evaluate their food and you start to see food preferences.
TASTE AND SMELL Important roles in feeding
Experience
Preference
“Supertasters”
CESSATION OF NIPPLE-FEEDING
Multi-factorial… Age, culture, maternal desire, lifestyle
Need appropriate CNS development and coordination to manage cup drinking… Open cup… Sippy cup
Prolonged nipple-feeding and dental caries
OVERALL DEVELOPMENT Take away information:
Changing feeding experiences are just a portion of a more general evolution of the developing child
Sensory and motor skills improve and the child acquires food preferences.
METHODS OF FEEDING DELIVERY
Oral includes bottle, breast, cup, straw, fingers, utensil
Orogastric Nasogastric
… Short term usage Gastrostomy
… Longer term Continuous or bolus
But wait….new information is afoot.
Duodenum or jejunum
FEEDING DELIVERY METHODS Parenteral
… For severe GI disorders that prevent use of the GI tract
… Peripheral vein access… Central venous catheter
CLINICAL FEEDING EVALUATION
Observation is the key component of the clinical feeding evaluation… Eyes… Ears… Hands
Need to understand the normal functions and how they interact … Interaction of reflexes… Developmental changes… Respiration… Gastrointestinal… Etc.
CLINICAL FEEDING EVALUATION
Consider the ‘whole’ infant Gather information from all sources Plan the feeding observation
… Equipment… Food textures… Physiologic monitors… Naturalistic and/or elicited
CLINICAL FEEDING EVALUATION
Structured feeding history… Parent description of the problem – allows
them to be in control for the first part of the interview
… State/behavior – of infant… Schedule – basic nutritional intake and amount
of time spent feeding each day… Method of feeding – helps determine a ‘typical’
feeding … Feeding problems observed by parent – alerts
the clinician for what to look for
TREATMENT EXPLORATION – HINT FOR FINAL EXAM
Develop hypotheses Synthesize information
… What is the child’s level of function? … What factors interfere with feeding function? … How well does the child’s feeding performance
“match” the caregiver concerns or expectations?
… Is additional information necessary? … Are there treatment techniques available that
appear to improve oral feeding function?
KEY AREAS Physiologic control Motoric control Behavior and state Response to tactile input Oral-motor control Sucking, swallowing and breathing General observations
CLINICAL FEEDING EVALUATION
From Wolf & Glass, 1992
From Wolf & Glass, 1992
CLINICAL FEEDING EVALUATION
An infant’s responses to the environment can indicate how stressful the baby finds the environment and how well she is able to adapt
Response to the environment is manifested through behaviors in any of the following systems: … Autonomic or physiologic … Motoric … State … Attention
What is happening during the feeding at the time of the stress cue?
AUTONOMIC/PHYSIOLOGIC
Heart rate… Initial and post-feeding … Highest/lowest values… Abrupt changes
Respiratory rate… Pre/post-feeding… Highest, lowest, trends… Returns to baseline
BREATHING Quality of respiration
Parameters: respiratory effort, changes in respiratory pattern, sound of respirations.
Work of breathing
Endurance
AUTONOMIC/PHYSIOLOGIC Oxygen saturations
… Amount of o2 in blood and avail for exchange at tissue level
… Generally expressed as a percentage of 100 Color
… Face, neck, mouth (circumoral) … Eyes (circumorbital). … Pale … Blue/purple … Red or ruddy
AUTONOMIC STRESS CUES
From Wolf & Glass, 1992
MOTORIC Overall neuromotor control
… Disorganized… Tone
Muscle tone… At rest… Change with activity… Quality of movement… Tonal variations versus movement disorder
MOTORIC Reflexes
… Primitive … Integration… extinguish
Posture… Development of antigravity postural control… Feeding position
Motor Response to environment Knowledge of feeder
MOTORIC STRESS CUES
From Wolf & Glass, 1992
FEEDING POSITION Normally feeding babies – adaptable Even slight feeding problems might need help
for optimal feeding. Overall body posture reflects slight flexion Trunk is neutrally aligned and well supported
in a semi-reclined position, with orientation of the head and extremities about the midline.
Using proper positioning during feeding not only affects respiratory mechanism, oral-motor control and swallowing control, but it may also assist in the development of early head/neck postural responses.
STATE States of alertness
… State 1 – deep sleep… State 2 – light sleep… State 3 – drowsy or semi-dozing… State 4 – quiet alert… State 5 – active alert… State 6 – crying
STATE Not one optimal state for every baby
FT (full term) – should have clear differentiation between states
Preemies – may seem more disorganized and lack clarity of state
Older babies – spend more time awake/alert and have clearer/more predictable state changes
STATE-RELATED STRESS CUES
From Wolf & Glass, 1991
STATE Is state or state control interfering with
feeding?
How does parent respond or support baby?
What is the baby’s state throughout the feeding?
Factors interfering with state control (immaturity or neurological impairment) may require prolonged need for state-related intervention.
TACTILE INPUT Tactually elicited reflexes present at birth allow
the infant to seek out and obtain nutrition safely.
Ability to accept touch to the cheeks, lips, gums and tongue is a prerequisite for feedings and the infant’s survival.
Expression of oral reflexes varied depending on a number of factors.
Must adapt to the tactile components of the tools used in feeding
TACTILE INPUT Face
… Cheeks to lips to gums to tongue… Head, trunk, extremities
Input –graded … firm and smooth (pressure from fingers or toy) to … soft and smooth (stuffed animal or soft finger
touch) to … prickly or unusual (rubber hedgehog toy). … Same with sold foods … move from smooth/pureed to chunky (baby
food/cottage cheese) to crunchy (crackers)
DEGREE/PERSISTENCE OF RESPONSE
Absent responses
Hyposensitive
Hypersensitive and Aversive… Immaturity… Chronic illness… Experience… Neurologic impairment
ORAL MOTOR – TONGUE Resting position
… Soft, thin, flat, moderately rounded tip Size
… Relative to oral cavity Deviations
… Tongue-tip elevation… Humped/bunched/retracted
Tone… Clonus… Fasiculations… Asymmetric
JAW Resting position
… Stable platform for tongue, lips, cheeks Size
… Micrognathic… Retrognathic
Deviations… Asymmetrical or lateral
Range of motion… Poorly graded… Clenching, biting
LIPS/CHEEKS Resting position
… Soft, symmetrical… Well-defined
Fat or sucking pads… Positional stability
Deviations… Tight, pulled back… Pursed or floppy
Tone… Hypotonia
PALATE Shape
… Intact… Smooth contour… Roughly approximates shape of tongue… Narrow, grooved, arched or flat
Clefting… Interferes with ability to achieve negative
intraoral pressure for suction Asymmetry
SUCKING-SWALLOWING-BREATHING
Evaluate the integrity of each as well as their coordination/organization
Rhythmicity – hallmark of normal sucking Suction Nutritive VS Non-nutritive Coughing/choking Oral secretions Noisy breathing Nasal regurgitation Frequency of respiratory infections
GENERAL OBSERVATIONS Method of feeding
Bottle/nipple used
Length of feeding, amount taken
Reason for ending the feeding
Spitting/emesis
Parent-child interaction
RED FLAGS Prolonged feeding time Limited volume Uncoordinated SSB Coughing, choking, sputtering with feeds Recurrent respiratory problems Persistent drooling Slow weight gain/FTT Food aversion/sensitivity Problems transitioning to next diet level Poor oral motor skills
DIAGNOSTIC TESTS/PROCEDURES
Basic understanding of common tests regardless of professional practice setting.
Strengths/limitations Implications of results Integrate data into clinical feeding
observation Is additional information needed? Most developed for adults; lack of normative
data with children (manometry, FEES, scintigraphy)
PHYSIOLOGICAL MONITORING Heart rate, respiratory rate, oxygen
saturation
Cardiorespiratory monitor … Numerical and visual display of heartbeat and
respiration … Averaged over a given period of time (e.g., 10
secs… Strengths – quick approximation of infant’s
status.… Movement artifact /not always accurate
PHYSIOLOGICAL MONITORING Oximetry –
… Oxygen saturation of capillary blood flow through an external sensor.
… Expressed as a percentage of 100. Normal infant -- sats above 95% Below 90% generally indicate some degree of
hypoxia.
… Baseline, changes in response to work/handling, effectiveness of O2 treatment
PHYSIOLOGICAL MONITORING Strengths –
… Easy to transport, non-invasive… Ongoing, instantaneous info … More reliable index than observation
Limitations – … Very sensitive to movement … Natural pigment of baby … Ambient light/infrared heating sources
PHYSIOLOGICAL MONITORING Pneumogram –
… Two-channel study based on chest wall excursion and heart rate
… Computerized –multichannel recording of parameters such as heart rate, RR, O2 sats, nasal airflow, esophageal pressures
… Gives exact values rather than averaged values so subtle changes in parameters are identified.
PHYSIOLOGICAL MONITORS Polysomnogram – “Sleep study”
… Multichannel recording of respiration, airflow, chest and diaphragm movement, oxygen and carbon dioxide levels, heart rate and esophageal pressures
… EEG recordings for length of two complete sleep cycles
… Measures the greatest number of variables… Differentiates between central and obstructive
apnea, apnea secondary to seizures, obstructive apnea due to GER or airway collapse
… Limitations – specialized sleep lab, expertise
GASTROINTESTINAL Technetium scan (AKA GE scintigraphy or a
milk scan) … Small amount of radionuclide isotope is added
to the feeding… Images are made every 30 seconds over a one
hour period after the feeding looking for material in the esophagus.
… Number/height of reflux episodes calculated and compared with standards
… Gastric emptying computed by measuring the percentage of food remaining within the stomach after on hour.
GASTROINTESTINAL Strength
… Info on several important parameters of GER: Acidity/alkaline reflux
… Unlikely to miss reflux events… Height of reflux in esophagus… Contribution of delayed gastric emptying… Radioactive tracer not absorbed and total radiation
exposure is low Criticized
… Overly sensitive to reflux … High false positive rate
GASTROESOPHAGEAL Barium swallow (AKA esophogram or upper GI)
… Evaluates structure and function of esophagus and stomach
… Ba delivered either orally or NG tube… Fluoroscopy – real-time events observed… Still photos taken for later review… Esophageal motility can be evaluated… Presence of spontaneous reflux or attempt to elicit
by giving pressure to abdomen … Rad exposure is proportional to time of exposure,
but generally brief… Not sensitive enough to GER, may detect aspiration
UGI
From Wolf & Glass, 1992
GASTROINTESTINAL pH probe –GER
… Sensor inserted through nose to an area just above LES to continuously measure acidity of esophagus
… At least a 24 hour hospital stay… Record kept at beside of baby’s activities for
later correlation with changes in pH. Data is recorded on the total number of
episodes of pH <4.0, total time with pH<4.0, number of episodes greater than 5 mins, and longest episode of pH<4.0. Typically, episodes of pH<4.0 must last longer than 10 secs to be recorded.
GASTROINTESTINAL pH probe –GER
… Sensor inserted through nose to an area just above LES to continuously measure acidity of esophagus
… At least a 24 hour hospital stay… Record kept at beside of baby’s activities for
later correlation with changes in pH. Data is recorded on the total number of
episodes of pH <4.0, total time with pH<4.0, number of episodes greater than 5 mins, and longest episode of pH<4.0. Typically, episodes of pH<4.0 must last longer than 10 secs to be recorded
GASTROESOPHAGEAL Data generates a reflux score
‘Gold standard’ for evaluation of GER
AIRWAY/GASTROINTESTINAL Pediatric Endoscopy
… Esophagoscopy/esophageal manometry, laryngoscopy, bronchoscopy
Rigid or flexible tube Directly observes structures within the body Obtain tissue via biosy or aspiration Treatment Advances in fiberoptics permitted flexible
endoscopes that can be used with even extremely small infants
VIDEOFLUOROSCOPIC SWALLOWING STUDY (VFSS)
VFSS aka MBS … Specifically designed to assess the pharyngeal
swallow… Normal feeding situation is simulated but may
need to use ‘tricks’… Purpose –document aspiration, reason for
aspiration and the point at which it occurs … Assess possible therapeutic interventions… Positioning can be customized
VFSS
From Wolf & Glass, 1992
CFE LIMITATIONS Info not readily obtained at bedside:
… VP function… Laryngeal elevation and closure… Pharyngeal motility, transit time… Pooling of secretions and contrast in valleculae
and pyriform… Number of swallows to clear material… Presence and timing of aspiration in relation to
the swallow.… Bolus movement through UES and esophagus
VFSS SLP/MD
… Observations relating to timing of swallow… Coordination in oral/pharyngeal phase … Phary peristalsis… Pooled material prior to swallow or residue
after … Esophageal transit time… Aspiration before, during, after swallow
VFSS Seating/postioning –
… Support of trunk, neck and head … Semireclining angle of approx 45 degrees. … Tumbleform chair… Child’s own seating system … Most wheelchairs don’t fit; some have
removable parts … Height of seat in relation to floor
VFSS Need careful guidelines for appropriate
… Radiologic risks to infant versus the yield of info from the test
… How will information be used? Personnel involved varies –
… OT, SLP, MD, tech … Regardless, should have expertise in infant and
skill in interpreting images Parent participation
VFSS Emergency back up equip and personnel as
needed
Flexible enough protocol to address each baby’s needs
Endurance
VFSS -- FEEDING TECHNIQUE Multiple variables
… Nipple, syringe, nipple alternating with pacifier to look at NNS and NS, spoon, cup, straw, liquid thickness, solids
Bolus type, amount, texture, temperature, timing can be varied
Risk of aspiration kept at minimum Caregivers provide samples of food
… Regularly given… Causing trouble … Introduction
Lateral view -- most important and most information
VFSS AP view—
… Documenting asymmetry/pooling … Head positions
Therapeutic changes Flexed, extended, turned, etc.
Neurologically impaired … Better at handling homogeneous consistency
VFSS Alternate feeding methods with plans for oral-
motor stimulation Repeat studies:
… Significant change in medical or neurological status… Recurrence of previous symptoms… Previous documentation of silent aspiration… Tx program changes are indicated for diet textures
or compensation techniques Improved oral-motor function in profoundly
neurologically impaired children have not shown to be directly correlated with improved pharyngeal transit time.
VFSS -- LIMITATIONS Lack of standardization –
… Positioning … Amount and order of presentation … Therapeutic modifications… Overly sensitive
VFSS VS CLINICAL FEEDING EVALUATION (CFE)
Benefits of CFE first – … Establish baseline behaviors to compare with
feeding during VFSS.… Feeding during VFSS is often not representative
Paradoxical performance Has significant feeding d/o but swallows Ba without
difficulty
Pre-determine types/textures of foods, order of presentation, optimal positioning, equipment needed
Able to formulate and test treatment strategies
VFSS Confirms need for VFSS
… Radiation exposure Signs during CFE
… Coughing/choking … Noisy, wet respirations… Subtle signs –unexplained respiratory infection
or illness, difficulty managing oral secretions. Aspiration can be silent
… Logemann reports 40% of adult patients who asp during VFSS not identified during bedside
VFSS Pay particular attention to medical history,
parent descript of feeding, subtle indicators of potential swallow dysfunction
Generalizability of feeding sample has been questioned… Relatively brief sampling … Ba may alter baby’s swallowing response
Not intended to identify GER as objective, but can be seen