Anatomical and Physiological Changes Due to Growth. The ABCs of Pediatric Dysphagia: Evaluation & Treatment

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1 The ABCs of Pediatric Dysphagia: Evaluation & Treatment Rima I. Polikaitis, MA, CCC-SLP Michele Wesling, MA, CCC-SLP Marianjoy Rehabilitation Hospital Wheaton, IL Anatomical and Physiological Changes Due to Growth oral cavity jaw/mandible tongue lips/cheeks hard palate soft palate/velum epiglottis larynx Eustachian tubes Anatomical Differences Between the Newborn & the Adult Mouth and Pharynx Source: Morris, S.E. & Klein, M.D. (1987). Pre-Feeding Skills: A Comprehensive Resource for Feeding Development Basic Normal Oral-Motor Reflexes of Newborns & Infants rooting suckling sucking swallowing tongue thrusting biting gagging Babkin s palmomental Feeding Development and Transitions: Liquids bottle/breast cup drinking straw drinking birth 6 months 7 12 months (about 1 month after spoon feeding begins) 36 months 1

2 Feeding Development & Transitions: Solids Spoon feeding Munching/chewing Controlled, sustained biting 4-6 months 6-7 months 12 + months Dynamic System Normal adult swallowing function is complex, but being fully mature, is stable. In children, growth and development create an undercurrent of change which dynamically affects swallowing behavior as it evolves from suckle feeding in infancy to the complete competence of the adult. An appreciation of this maturation process is basic to the understanding of all children. Rotary chewing months Source: Kramer & Eicher. (1993).The Evaluation of Pediatric Feeding Abnormalities. Causes of Dysphagia in Children Organic (anatomical, neuromuscular) Developmental (dysfunctional, uncoordinated) Functional (conversion, conditioned) Source: Culbert, Kajander, Kohen, & Reaney (1996). Populations at Risk for Development of Feeding/Swallowing Disorders neurological problems congenital anomalies metabolic disorders cognitive or behavioral limitations psychosocial problems chronic illness GI disorders Common Symptoms for Referral for Feeding/Swallowing Evaluations difficulties during feeding pulmonary status general health/gi issues neurological problems structural/anatomical differences Diagnostic Methods Case History Pediatric/developmental History Clinical Bedside Swallowing Evaluation Videofluoroscopic Swallowing Evaluation Video Nasal Endoscopic Swallowing Evaluation 2

3 Case History pertinent medical history language comprehension alertness nutritional status hydration status respiratory status pulmonary disease neuromuscular integrity method of intake Pediatric Case History developmental history caregiver s perception environment experiences nonverbal signs related information, family history Pediatric Clinical Bedside Swallowing Evaluation environment observation of caregiver oral mechanism examination positioning assessment utensils consistencies deglutitive evaluation communicative issues Abnormal Reflex Patterns in Children with Feeding Disorders jaw thrust tongue thrust lip retraction tonic bite reaction tongue retraction nasal regurgitation Disorganized vs. Dysfunctional Feeding Patterns Disorganized feeder - difficulty initiating movements - inconsistent, uncoordinated, arrhythmic tongue and jaw movements - immature suck pattern - fatigues easily Source: Palmer, M.M. (1990). Neonatal Oral-Motor Assessment Scale. Disorganized vs. Dysfunctional Feeding Patterns (continued) Dysfunctional feeder - movements may be excessive or minimal, if at all present - abnormal tongue postures (humped, retracted, flaccid) - asymmetrical Source: Palmer, M.M. (1990). Neonatal Oral-Motor Assessment Scale. 3

4 Pediatric Videofluoroscopic Swallowing Evaluation efficacy environment positioning foods and amounts contrast material presentation tools: liquids and solids Positioning Guidelines for Children during VFSS Infants at 45 degree recline By 3 months of age, 45 degree recline to 90 degree angle position By 7 months of age, upright at 90 degree angle Pediatric Videofluoroscopic Swallowing Evaluation (continued) compensatory techniques fatigue field of view radiation safety flexibility Radiation Exposure for Children Acquire maximum information in a minimal amount of time. no more than 120 seconds of exposure infants should only be exposed for seconds total (Arvedson & Christensen, 1993) Only radiate the part of the body that is being examined. Flexibility Patient and family comfort Pre-planning and practicing in radiology suite prior to VFSS Time Movement management Behavior management Pediatric Video Nasal Endoscopic Swallow Evaluation Protocol: - positioning to avoid spontaneous or reflexive movements - bolus presentation - compensatory strategies Source: Role of the SLP in the Performance and Interpretation of Endoscopic Evaluation of Swallowing:Guidelines. ASHA Special Interest Division 13 Committee,

5 Pediatric Video Nasal Endoscopic Swallow Evaluation (continued) Special Considerations: - instrumentation endoscope diameter - patient and caregiver preparation - breathing challenges with NG tubes - topical anesthesia Treatment Goals and Techniques in Pediatric Oral-Motor/ Feeding/Dysphagia Therapy Source: Role of the SLP in the Performance and Interpretation of Endoscopic Evaluation of Swallowing:Guidelines. ASHA Special Interest Division 13 Committee, What is the real goal of therapy with the child? Meeting all nutrition and hydration needs orally? Achieving partial oral feeding nutrition and hydration? Providing taste stimulation safely and pleasure orally? Goal of Oral-Motor Treatment the development of appropriate use of the mouth, respiratory and phonatory systems in exploration, sound play, and as much oral feeding as possible. oral-feeding is the by-product of the program, not its major goal. Goal of Feeding Therapy oral feeding improving the mechanisms of swallowing and sucking works toward the use of food and liquid in the program feeding is both a long-term and short-term goal Treating Problems with Function of Individual Oral Structures jaw thrust and jaw retraction tonic bite reflex tongue retraction tongue protrusion and tongue thrust tongue asymmetry and limited tongue movements lip retraction and pursing nasal regurgitation sensory oral defensiveness 5

6 Reducing Jaw Thrust and Jaw Retraction position child in prone across lap - gravity reduce sensitivity of contact to teeth - tooth brushing assist mouth closure - hand on jaw (from sides or front) provide jaw stability - biting on towel while shaking/ growling - biting down on thin object as long as possible Reducing Tonic Bite Reflex reduce hypersensitivity of teeth when touched by finger, toothbrush or coated spoon during feeding may get bitten - do not pull out and away! reduce frequency with which bite is elicited - present cup or spoon on lower lip Reducing Tongue Retraction build tone in trunk, shoulders, neck - use handling techniques; provide proximal stability position child in prone across lap or bolster improve tongue stability - tap gently under chin in muscular area while child in chin tuck flatten tongue - stroke forward and outward with deep pressure Reducing Tongue Protrusion and Tongue Thrust change the consistency of food - so that tongue protrusion is not necessary to move it backward place hand on jaw and finger under chin while applying deep pressure place flat bowl of spoon horizontally onto middle of the tongue and apply downward pressure Reducing Tongue Asymmetry and Increasing Limited Tongue Movements stimulate the less active side of the tongue - toys, finger, toothbrush increase sensory input to the tongue - play, food selection Reducing Lip Retraction and Pursing create a relaxing environment massage - draw cheeks forward between fingers - draw fingers down on cheeks from sides of nose toward corners of mouth 6

7 Reducing Nasal Regurgitation improve cheek and tongue function so bolus formation is more efficient thicken formula and pureed foods stimulate muscles of the palate thru massage to decrease velo-pharyngeal insufficiency palatal lift prosthesis when older Reducing Sensory Oral Defensiveness introduce slow vestibular stimulation use music and rhythm use firm pressure and touch build ability to enjoy hands in mouth build ability to enjoy toys in mouth use tooth brushing and massage announce touch or food presentation Treating Problems with Feeding Processes facilitating a normal sucking pattern facilitating mature oral movements during spoon feeding of soft foods facilitating mature oral movements during cup drinking facilitating a mature swallowing pattern facilitating normal controlled biting and mature chewing drooling Facilitating a Normal Sucking Pattern place child in prone maintain tongue in mouth with chin/jaw support; firm pressure to base of tongue use music and rhythm (1 beat/sec) establish suckle of liquids from finger tip and spoon massage body of tongue rhythmically with upward-downward motion 1x/sec provide cheek support while introducing thicker consistencies Facilitating Mature Oral Movements During Spoon Feedings of Soft Foods teach that the mouth can be quiet and ready as the spoon approaches use gentle pressure on the tongue with the spoon allow food to remain on the child s lower lip Facilitating Mature Oral Movements During Cup Drinking teach that the mouth can be quiet and ready as the cup approaches maintain stable degree of jaw opening maintain constant contact of cup and lower lip encourage child to hold onto the edge of cup with teeth thicken liquids 7

8 Facilitating a Mature Swallowing Pattern explore positioning during VFSS explore compensatory strategies explore different food placements Facilitating Normal Controlled Biting and Mature Chewing teach that the mouth can be quiet and ready before food enters for biting and chewing hold cookie between teeth and break off outside piece ensure stable jaw opening and closing thicken and add lumpy soft foods increase awareness of teeth through rhythmical biting wrap food in gauze and tie it to a string Reducing Drooling improve head and trunk control improve sensory awareness on the face and within the mouth improve jaw, lip and cheek control emphasize dryness teach straw drinking to improve movement and control of lips and cheeks provide drooling bib or arm band consider surgery to redirect saliva flow The Role of the Family in Pediatric Dysphagia Feeding is the one essential thing that parents feel they should be able to do for their child. Parents know their children the best they are the experts!! Special Considerations in Pediatric Dysphagia Treatment Strategies and Outcomes for Pediatric Phagophobia 8

9 Symptoms of Phagophobia fear and avoidance of swallowing food, fluid, or pills sensation of foreign body in throat throat pressure or constriction of throat difficulty initiating the swallow weight loss secondary to decreased oral intake avoidance of eating in public malnutrition Source: Chorpita, Vitali & Barlow. (1997). Incidence and Prevalence more often in females than males onset childhood to old age prevalence is unknown Source: McNally (1994). Phagophobia an eating disorder? psychogenic dysphagia rather than eating disorder (Barofsky& Fontaine, 1998) Developmental vulnerability - co-existing developmental conflicts exacerbated by choking event (Chatoor, Conley& Dickson, 1988) no intentional weight loss; displeased with loss no distorted body image (Shapiro, Franko & Gagne, 1997) troubled by problems and gratified by successful treatment (Greenberg, Stern & Weilburg, 1986) Etiology Most patients acquire after episode of choking on food (McNally, 1994) May develop into a preoccupation with choking (Chatoor, Conley & Dickson, 1988) Speech-Language Pathology Evaluation Duration of symptoms Sensation or occurrence of bolus sticking Localization of where bolus feels stuck Maneuvers required to move bolus Sensation of aspiration Weight loss or dietary modification Symptoms of eating disorder Relevant antecedent event or stressors Family history of dysphagia Related symptoms: odynophagia, globus, nasal regurgitation, ptosis, diplopia, dysarthria, dysphonia, diffuse muscle weakness, heartburn (Shapiro, Franko & Gagne, 1997) Summary Multiple possible causes of phagophobia Team approach: get the child to eat/address the underlying disorder Improvement in the variety of foods eaten and reduction of anxiety related to eating was achieved in all cases and appears to be due to specific treatment techniques. 9

Electrical Stimulation for the Treatment of Pediatric Dysphagia Uses of Electrical Stimulation in Rehabilitation Medicine exercise strengthening musculature after surgery retarding disuse atrophy of

Electrical Stimulation for the Treatment of Dysphagia recently introduced into the literature (Sabet et al, 2005; Chetney & Waro, 2004; Singh et al, 2004; Leelamanit et al, 2002; Freed et al, 2001;

10 Electrical Stimulation for the Treatment of Pediatric Dysphagia Uses of Electrical Stimulation in Rehabilitation Medicine exercise strengthening musculature after surgery retarding disuse atrophy of denervated muscles relieving peripheral neuropathic pain accelerating wound healing Source: Leelamanit et al. (2002). Electrical Stimulation for the Treatment of Dysphagia recently introduced into the literature (Sabet et al, 2005; Chetney & Waro, 2004; Singh et al, 2004; Leelamanit et al, 2002; Freed et al, 2001; Sellars et al, 1999; Park et al, 1997) FDA approved for treatment of adult and pediatric dysphagia limited evidence in the literature that examines the effectiveness of this treatment in the pediatric population Summary The effectiveness of electrical stimulation for remediation of pediatric dysphagia has demonstrated mixed results in these case studies Further research is indicated for examining the use of electrical stimulation in children of varied diagnoses resulting in dysphagia and of a variety of ages. What do YOU think? Questions? Comments? Contact Information: Rima I. Polikaitis, MA, CCC-SLP rpolikaitis@marianjoy.org Michele Wesling, MA, CCC-SLP mwesling@comcast.net 10

The ABCs of Pediatric Dysphagia: Evaluation & Treatment BY KEUMSUN HWANG

The ABCs of Pediatric Dysphagia: Evaluation & Treatment BY KEUMSUN HWANG Contextual influences on mealtime Family composition Cultural beliefs & values Family s socioeconomics statues Social context Anatomical