Feeding / Swallowing Development and Disorders in Children: For Graduate Students

Transcription

1 Feeding / Swallowing Development and Disorders in Children: For Graduate Students ASHA November 18, 2010 Maureen A. Lefton-Greif, PhD, CCC-SLP, BRS-S Associate Professor, Dept. of Pediatrics The Eudowood Division of Pediatric Respiratory Sciences Johns Hopkins University School of Medicine

2 No Disclosures

3 Learner Outcomes Participants will be able to: ID factors that may interrupt feeding/swallowing development Determine the appropriateness of a VFSS by applying information obtained from the clinical evaluation Describe the VFSS process including its planning, ID of radiologic abnormalities, and interpretation of findings ID factors that influence management plans by incorporating assessment information in the context of health, medical, and developmental issues

4 Deglutition: the semiautomatic motor action of the muscles of the respiratory and gastrointestinal tracts to propel food from the oral cavity to the stomach. Miller, 1986 [French déglutition, from déglutir, to swallow, from Latin dgltre : d-, de- + gltre, to gulp.] "Deglutition" is a French word, which evolved from the Latin "deglutire" (to swallow down). Related to "glutton" (someone who eats too much).

5 Swallowing Begins during Pre-natal Development Plays a role in the regulation of amniotic fluid volume and contributes to development of GI tract and fetal growth Frequency increases as infant approaches term Grassi, R. et al. Am. J. Roentgenol Ell-Hddad et al. J.Soc Gynecol Investig Copyright 2006 by the American Roentgen Ray Society

6 Pharyngeal Swallowing wks True Sucking wks Efficient Swallowing wks Full Term Infant

7 Fetal Swallowing Grassi, R. et al. Am. J. Roentgenol Attainment of oral feeding does not depend on the present of a fully mature suck-swallow pattern suggesting that as with acquisition of other motor milestone, learning continues to occur. Bringham. J Child Neuol, 2009

8 Frequency of Deglutition Occurs: 24 / 7 (most often during meals) Adults: X = 585 (SD: ± 208.9, range: ) per day 1 Children (8.6 ± 2.9 yrs): during sleep X = 2.8 (SD: ± 1.7) per hour 2 1 Lear et al. Arch.Oral Biol Sato & Nakashima. Ann.Otol.Rhinol.Laryngol. 2007

9 Regardless of Age, Deglutition Must Be... Safe Adequate (hydration & nutrition) Enjoyable

10 Post Natal Swallowing One component of feeding development Simple Involves 26 muscles in the mouth, throat, and esophagus Involves multiple cranial nerves Is coordinated with breathing

11 Normal feeding and swallowing development is biopsychosocial process that involves children, their caregivers, and a host of other factors (e.g., culture, professionals). Stevenson & Allaire, 1991

12 Feeding and Swallowing are linked during infancy and early childhood Feeding: provides children and caregivers with communication and social experiences that form the basis for many future interactions. Swallowing: process of deglutition that occurs after liquids or foods enter the mouth Lefton-Greif MA (2008) Phys Med Rehabil Clin N Am (19)

13 Post-natal Feeding / Swallowing Development Family / Caregiver Factors Other Factors Interaction of Multiple Factors Feeding / Swallowing Behaviors Prior Feeding Experiences Child Factors

14 Feeding and Swallowing are linked during infancy and early childhood Mealtime disruptions that occur early in life may result in long-term feeding problems or exacerbate pre-existing swallowing problems Lefton-Greif MA (2008) Phys Med Rehabil Clin N Am (19)

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16 Post-Natal Swallowing: Primary Functions Direct food, liquid, & saliva from the mouth to the stomach while keeping airway protected Provide enough of the right types of liquids & foods for: adults to stay healthy children to grow and develop *Corollary adapting

17 Deglutition Must Adapt to: Alterations in anatomic relationships of pharyngeal structures Normal developmental changes, including aging Changes in head & neck posture alterations in anatomic relationships of pharynx

18 Deglutition Must Adapt to: Bolus variablity Consistency, viscosity, elasticity, volume, & temperature Changes in head & neck posture alterations in anatomic relationships of pharynx Normal development & aging Buchholz et al, 1985

19 Feeding/Swallowing Must Adapt to: Demands of typical feeding progression: Development and oral-motor skills

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21 Feeding/Swallowing Must Adapt to: Demands of typical feeding progression: Development and oral-motor skills Infant/child caregiver interactions Feeding is an interactive process that depends on the ability and characteristics of both the parents and the child. Satter, 1999

22 Must Be Enjoyable...: Consistent w/ Developmental Skills & Child/Caregiver Interactions (Satter, 1999) 0-2 or 3 mos. Homeostasis Regulation of sleep & wake states 2-6 mos. Attachment Learning to love 1st year 6+ mos. Separation / Individuation Discovery of autonomy

23 Feeding/Swallowing Must Adapt to: Demands of typical feeding progression: Development and oral-motor skills Infant/child caregiver interactions Feeding is an interactive process that depends on the ability and characteristics of both the parents and the child. Satter, 1999 Unexpected changes

24 Normal Swallowing For Review of Neurobiology of Oral Feeding and Swallowing, See: Delaney, A L and Arvedson, JC. (2008): "Development of swallowing and feeding: prenatal through first year of life." Dev Disabil. Res. Rev 14,

25 Normal Swallowing: Sensory Input Cranial Nerve Sensory or Afferent Function Trigeminal (V) General sensation, anterior 2/3 of tongue Soft palate, nasopharynx, mouth Facial (VII) Glossopharyngeal (IX) Vagus (X) Taste, anterior 2/3 of tongue Touch sensation to lips and face Taste & general sensation posterior 1/3 tongue Sensation to tonsils, pharynx, soft palate Pharynx, larynx, viscera Base of tongue

26 Normal Swallow: Efferent Controls Phase of Swallow Oral Pharyngeal Structures Muscles of mastication Lip sphincter & face muscles Tongue - Intrinsic muscles Extrinsic muscles Palatoglossus Stylopharyngeus Palate, pharynx, & larynx, Tensor veli palatini Hyoid & laryngeal movement Innervation Trigeminal (V 3 ) - mandibular branch Facial (VII) Hypoglossal (XII) Ansa cervicalis (C 1 -C 2 ) Vagus (X) Glossolpharyngeal (IX) Vagus (X) Trigeminal (V 3 ) V3, VII, C 1 -C 2 Esophageal Esophagus Vagus (X)

27 Supranuclear Descending Pathways Cortical and Subcortical Primary Afferents Cranial Nerves V, VII, IX, X Fasciculus Solitarius Nucleus Tractus Solitarius & Ventral Medial Reticular Formation Central Pattern Generator Primary Efferents Cranial Nerves V, VII, IX, X, XII Motor Nuclei Cranial Nerves V, VII, IX, X, XII PONS

28 Four Phases of Swallowing Oral preparatory Oral Pharyngeal Esophageal Adapted from : Arvedson and Lefton-Greif(1998)

29 Oral Preparatory Phase Bolus preparation Variable length Voluntary Airway is open

30 Oral Phase Transport bolus to back of oral cavity Duration 1 sec. regardless of texture Voluntary Airway is open

31 Pharyngeal Phase Transport thru pharynx / protected airway Duration Adults 1.0 second Infants seconds Voluntary & involuntary Airway closed

32 Esophageal Phase Transport bolus into stomach Duration 6-10 seconds Involuntary Airway open

33 Normal Infant Swallow

34 Normal Swallowing: Older Child

35 dysphagia (dǐs-fā jē-ă) [G. dys, difficult + G. phagein, to eat] Inability to swallow or difficulty swallowing

36 Dysphagia is not a disease. Rather it is a symptom of a disease that may be affecting any part of the swallowing tract from the mouth to the stomach. Donner,1986

37 Swallowing Disorders: Incidence in United States Older individuals with neurologic disorders 300, ,000 annually (AHCPR, 2002) No comparable data in pediatrics, presumed increasing incidence Better diagnostic tools and recognition Increased survival rates of children with complex and medically fragile conditions

38 Factors that May Interfere with Feeding/Swallowing Development Anatomic anomalies Neurologic conditions Complex medical conditions Environmental factors Lack of or delayed introduction of feeding

39 Post-natal Feeding / Swallowing Development Family / Caregiver Factors Other Factors Interaction of Multiple Factors Feeding / Swallowing Behaviors Prior Feeding Experiences Child Factors

40 Pediatric Populations at Increased Risk of Dysphagia Anatomic or structural anomalies Congenital Acquired Neurologic conditions Preterm + low birth weights Cardiopulmonary disease Medically fragile Genetic anomalies Misc.

41 Why is Swallowing Dysfunction so Problematic for Pediatric Patients? Babies and young children are at risk for airway and nutritional compromises and disrupted interactions with caregivers, which in turn may have long lasting consequences.

42 Regardless of Age, Deglutition Must Be... Safe Adequate (hydration & nutrition) Enjoyable

43 Regardless of Age, Deglutition Must Be... SAFE Provide adequate airway protection

44 Levels of Airway Protection 1. Swallow Cough Mucociliary action Immune system

45 Aspiration Aspiration

46 Dysphagia: Common Acute or Episodic Airway Presentations During / immediately after feeding Coughing, choking or gagging Change in respiratory rate, effort or respiratory or phonatory sounds (noisy breathing) Decline in activity or alertness Arvedson & Lefton-Greif, 1998

47 Dysphagia: Chronic Airway Presentations in Young Children Coughing (chronic bronchitis) Recurrent pneumonia Asthma (difficult to control) Frequent or long lasting upper respiratory infections Unexpected poor resolution of airway related issues (e.g., URI s or airway diseases associated with prematurity)

48 Dysphagia: Chronic Airway Presentations Aspiration possible lung injury to developing lung. In turn, injury to developing lung may be associated with long-term pulmonary sequalea Almost 90% of alveolar growth occurs postnatally. (Thurlbeck, 1982)

49 Regardless of Age, Deglutition Must Be... ADEQUATE / ENOUGH Poor nutritional intake can result in Adverse development Compromised CNS growth

50 Support Childhood Growth Age Weight Height Birth 6-10 lbs ins 4-5 mos BW x 2 1 yr BW x 3 BH + 50% 2 yrs + 7 lbs / yr 2.5 ins / yr

51 Potential Impact of Fetal and Infant Malnourishment Behavioral and cognitive deficits Slower language development Slower fine motor development Lower IQ s Poorer school performance

52 Dysphagia: Common GI/Nutrition Presentations Weight or growth compromise, Failure to Thrive (FTT) Poor nutritional status Emesis, regurgitation, or gastroesophageal reflux (GER) Arvedson & Lefton-Greif, 1998

53 Growth chart Growth Charts: CDC

54 Regardless of Age, Deglutition Must Be... ENJOYABLE Disrupted child/infant- caregiver interactions Disrupted feeding/swallowing development Behavioral problems

55 Pediatric Feeding / Swallowing Teams: Primary Goals Maximize child s potential for growth and development Facilitate positive interaction between caregiver and child

56 Caregiver Questions What is the cause of the problem? How can it be fixed? When will it be fixed? Answer: When the dysphagia resolves enough for the child to tolerate the sequalea associated with the swallowing dysfunction.

57 Major Components of a Feeding/Swallowing Evaluation History Physical examination Observation of mealtime Response Non-nutritive or nutritive Clinic or Bedside Evaluation

58 History: Sample Areas to Probe Define concerns Past medical history Temporal manifestation of problem(s) Health issues Developmental history Diet / feeding history and routines Medications

59 Manifestation Potential Influences Anatomic Neurologic Medical Status Impact of Potential Influences: Dysphagic Characteristics Developmental + O-M External to Child Prognosis Chronic Acute Static Progressive Adapted from Rogers, 1996

60 Physical Examination General appearance Examination of oral-peripheral structures and functions Structural symmetry Rooting Gag For infants, non-nutritive pre-requisites for feeding/swallowing

61 Observation of a Meal Patient's stability Caregiver child interactions Introduction of therapeutic techniques

62 Why a Bedside/Clinic Evaluation? To. Determine if a feeding/swallowing problem is present Establish a baseline of function Determine if an instrumental evaluation is needed? Phases of swallowing Ability AND willingness of child to cooperate

63 Why a Bedside/Clinic Evaluation? To. Determine which instrumental assessment is needed? Specific questions Suspected phases of swallowing Ability AND willingness of child to cooperate

64 Instrumental Assessment Procedures Upper Gastrointestinal Examination (UGI) Flexible Endoscopic Evaluation of Swallowing (FEES) Videofluoroscopic Swallow Study (VFSS)

65 Routes of Airway Contamination Direct from swallowing Indirect from regurgitation Direct + indirect Communication between airway & GI tract (e.g., TEF)

66 Upper Gastrointestinal Series (UGI)

67 Flexible Endoscopic Evaluation of Swallowing (FEES)

68 Aspiration Pre-swallow Post-swallow Langmore (2001) Endoscopic Evaluation and Treatment of Swallowing Disorders

69 FEES: Potential Candidates are Children who Have structural or suspected structural abnormalities Have abnormal VFSS + question re: airway / respiratory interaction Are eating or drinking too little to participate in VFSS Need repeated exams

70 Instrumental Assessment Procedures Upper Gastrointestinal Examination (UGI) Flexible Endoscopic Evaluation of Swallowing (FEES) Videofluoroscopic Swallow Study (VFSS)

71 Instrumental swallowing assessment is indicated, when there s a need to Define physiology / pathophysiology of swallowing Develop diagnostic or management plans that depend upon swallowing function Determine risks, presence, or potential causes of aspiration

72 Modified Barium Swallow Study (MBS): Dr. Jeri Logemann (1983) The MBS procedures is designed to study the anatomy and the physiology of the oral preparatory, oral, pharyngeal and cervical esophageal phases of swallowing MBS was not only to address whether the patient is aspirating, but also the reason for the aspiration, so appropriate treatment can be initiated.

73 by another name Videofluoroscopic Swallow Study (VFSS) Modified Barium Swallow Study (MBS) Cookie Swallow Three-phase or two-phase swallow

74 VFSS is a tool But it s NOT an

75 VFSS: Indications Suspected oropharyngeal dysphagia AND Diagnostic or management needs which would be clarified by VFSS findings AND Patient is ready, willing, and able to participate

76 VFSS is a tool that Provides information which enhances the safety and efficiency of swallowing Bolus and positioning variables Feeding strategies Therapeutic maneuvers

77 However, a VFSS does not Define feeding and swallowing development Rule out aspiration Determine the impact of the swallowing problem on a specific child Predict the progression of the feeding / swallowing problem or timing of its resolution

78 VFSS Procedure = Process Decision Planning Carrying it out Reading Interpreting Documenting

79 VFSS Procedure Decision: yes / no Planning Carrying it out Reading Interpreting Documenting

80 VFSS: Decisions & Indications Suspected oropharyngeal dysphagia AND VFSS findings would assist with diagnostic process and / or management AND Patient is ready, willing, and able to participate

81 Determinants: Ready, Willing, & Able Medical stability Cardio-pulmonary stability Nutritional stability Alertness, maturity, and organization or state Ability to tolerate bolus feeds

82 Determinants: Ready, Willing, & Able Ability to swallow Ability to ingest sufficient oral intake in a reasonable period of time For infants, non-nutritive suck (NNS) NNS is pre-requisite, NOT guarantee of successful oral feeding

83 VFSS Procedure Decisions: yes / no Planning Carrying it out Reading Interpreting Documenting

84 VFSS Procedure: Planning Preparation: Caregivers & children Oral vs. non- feeders Medications Physical set-up Radiologic considerations Seating and positioning

85 VFSS Procedure: Planning Contrast preparation Utensil selection Caregiver involvement Other considerations Suctioning Monitors

86 VFSS Procedure Decisions: yes / no Planning Carrying it out Reading Interpreting Documenting

87 VFSS Procedure: Carrying it out Technical Aspect of VFSS Remember reasons for doing VFSS Get as much information, as quickly as possible Know when to terminate VFSS Needed information obtained Not likely to get information

88 Mean Duration of Radiation Exposure During VFSS Exams Source of Information Mean Duration (minutes) Range of Duration (minutes) Literature 2.48 ± to 8.12 Weir et al. Pediatric Radiology 2007;37:

89 VFSS Procedure Decisions: yes / no Planning Carrying it out Reading = what you see Interpreting Documenting

90 Levels of Airway Protection 1. Swallow Disruptions Cough Mucociliary action Immune system

91 Penetration (Supraglottic) Entry of secretions or ingesta into the larynx ABOVE the true vocal folds. Penetration

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93 Aspiration Entry of secretions or ingesta into the larynx BELOW the true vocal folds. Aspiration

94 Aspiration Penetration Aspiration

95 Aspiration

96 What is the relationship between penetration and aspiration?

97 Landmark for Deep Penetration Deep Penetration Friedman & Frazier: Dysphagia 2000, 15:153

98 What s known about the pen-asp relationship in children? Relationship bet. depth of penetration & aspiration 1 85% children (n = 125, 7 days -19 yrs) w/ deep laryngeal pen asp Temporal relationship 2 Asp. occurs later than laryngeal pen. on VFSS 1 st pen = sec 1 st asp = 65.41sec. 1 Friedman & Frazier, Newman et al, 2001

99 Levels of Airway Protection Swallow Cough Mucociliary action Immune system

100 Silent Aspiration Aspiration without any external behavioral signs such as coughing or choking.

101 If aspiration is silent by is it a problem? Primary airway response to aspiration is absent Caregivers keep feeding children because primary signal of feeding difficulty is absent

102 How common is silent aspiration? Population Age Range (Years) % pts. with aspiration Young peds Older peds + adults Varied Median Very old >

103 Standardization

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106 Standardization of Interpretation of VFSS Images is Important to. Enable objective characterization and tracking of the natural history of swallowing impairments Provide outcome measures for interventions in dysphagia Define biomarkers for clinical trials for children with diagnostic conditions associated with dysphagia

107 Standardization of Interpretation of VFSS Images is Important to. Decrease variability in exchange of pt. information Standardize VFSS practices Potentially reduce unnecessary exposure to radiation

108 Pediatric Tool Developed from: The literature Clinical experience Expert consensus survey monkey Currently 24 components

109 VFSS Procedure Decisions: yes / no Planning Carrying it out Reading Interpreting Documenting

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111 After VFSS: Interpretation for Individual Child in Context of Underlying diagnostic conditions (history) Clinical examination Physical examination Clinical findings Phase of swallowing Ability to tolerate impact of dysphagia

112 After VFSS: Interpretation for Individual Child in Context of Phases of swallowing: structure + function Summary of swallowing function Risk of aspiration Risk of nutrition / hydration compromise Ability to tolerate impact of dysphagia Short term Long term

113 Impact of Dysphagia: Potential Influential Host Factors Age Diagnostic condition(s) Medical, health, nutritional, neurodevelopmental status Severity of swallowing dysfunction Frequency of aspiration Amount of aspiration Duration of dysfunction

114 Factors that May Modify the Respiratory Status in Children with Dysfunctional Swallowing Host Characteristics Diagnostic condition(s) Co-morbidities Severity of dysphagia Age / Timing of Exposure Growth and development Susceptibility to injury Environmental / Social Factors Feeding techniques Health care access and management Exposure to environmental stressors Lefton-Greif + McGrath, 2007

115 Reporting of VFSS Findings in Relation to Findings and interpretations are discussed with other team members to develop a plan that addresses basic team goals feeding/swallowing teams

116 Children at Increased Risk of Dysphagia Anatomic or structural anomalies Neurologic conditions Preterm + low birth weights Cardiopulmonary disease Medically fragile Misc.

117 Diagnostic Conditions Anatomic or structural defects Congenital Acquired Neurologic deficits Cerebral Palsy Traumatic Brain Injury (TBI) Genetic syndromes Arvedson & Lefton-Greif, 1998

118 Laryngeal Cleft None Otherwise Healthy Static, Compensate No Concerns

119 Case Presentation: L.C. (3 mo. male) UGI Copious gastroesophageal reflux (GER) Nasopharyngeal reflux Aspiration VFSS Direct laryngoscopy Type I laryngeal cleft

120 Types of Laryngeal Clefts I Supraglottic interarytenoid clefts II Partial cricoid defects III Complete cricoid defect +/- cervical tracheal involvement IV Laryngotracheoesophageal clefts into thorax

121 Benjamin / Inglis Classification of Posterior Laryngeal Clefts Thoracic Inlet Congenital laryngeal clefts are characterized by posterior midline deficiency in the separation of the larynx and trachea from hypopharynx and esophagus and incomplete development of the tracheoesophageal septum. Ann of Otology 1989, 98:

122 Laryngeal Cleft None Otherwise Healthy Static, Compensate No Concerns

123 VFSS Thin Liquid Thick Liquid

124 Case: LC

125 Diagnostic Conditions Anatomic or structural defects Congenital Acquired Neurologic deficits Cerebral Palsy Traumatic Brain Injury (TBI) Genetic syndromes Arvedson & Lefton-Greif, 1998

126 Laryngeal Cleft None Otherwise Healthy Static, Compensate No Concerns Diffuse CNS Progressive Resp + Nut Probs. Progressive Worsening Worsening support needs

127 Case Presentation: Neuro Etiology CASE: P.N., 15 mo. female PMH: Unknown but progressive neurodegenerative process CC: Loss of milestones, increasing respiratory distress, & weight loss

128 VFSS: P.N. Thin liquid (cup) Rice cereal (syringe) Pre & post swallow aspiration, silent Post swallow aspiration

129 Case: PN

130 Decisions: yes / no Planning Carrying it out Reading Interpreting VFSS Procedure Documenting

131 After VFSS: Documentation Description of phases of swallow: structure & function ID potential etiology underlying swallowing dysfunction Comment on Risk of aspiration Risk of nutrition / hydration compromise

132 After VFSS: Documentation Prognostic statement Recommendations

133 Hierarchy for Development of Therapy Strategies: Pediatric Dysphagia Adhere to basic management principles ID and support management and therapy decision-making guidelines Determine level of intervention Select specific therapeutic goals and strategies

134 Basic Management Principles: Pediatric Dysphagia Maintain cardiopulmonary stability Maintain nutritional stability Whole child approach (e.g., safety, comfort, enjoyment)

135 Management Corollaries: Pediatric Dysphagia Oral feeding is NOT always the goal Adjust management / therapy with gains or regression re-evaluate Account for developmental levels and child/caregiver interactions when planning interventions

136 Management & Therapy Decisionmaking Guidelines risk of aspiration risk of nutrition compromise Maximize growth & development Facilitate appropriate child/caregiver interactions

137 Management & Therapy Recommendations Route for nutrition / hydration Feeding routine modifications Position Liquid & food characteristics (e.g., textures, temperature) Timing and pacing (e.g. meals, liquids, & food presentations Selection of utensils

138 Management & Therapy Recommendations Specific therapy recommendations SLP OT / PT Additional recommendations CPR Other evaluations Plans for follow-up or re-evaluation

139 Determine Level of Intervention Prevent problems, early detection "Normalize" function / support "optimal" developmental progression Manage well-established patterns or deficits with specific phase(s) of swallowing

140 Focus of Specific Therapeutic Goals General development Tone Sensori-motor integration Speech, language, & communication Phases of swallowing Child / caregiver interactions

141 Selection of Specific Therapeutic Goals and Strategies Promote compensatory patterns Changes in position Modifications of food or liquid Strengthen or improve movement patterns of swallowing structures Stimulation for non-nutritive sucking Tongue lateralization exercises / chewing

142 Selection of Specific Therapeutic Goals and Strategies Therapy maneuvers Older children

143 CASE: L.C., 3 month male

144 Laryngeal Cleft None Otherwise Healthy Static, Compensate No Concerns Diffuse CNS Progressive Resp + Nut Probs. Progressive Worsening Worsening support needs

145 VFSS Interpretations: JC Known anatomic anomaly c/w swallowing dysfunction Apparently normal infant Improved swallow w/ modifications Family w/ solid support systems

146 Management: L.C. Route of feeding Feeding suggestions Liquid characteristics Timing Medications

147 Management: L.C. Therapy recommendations Additional suggestions Plans for follow-up

148 Laryngeal Clefts Type I + II: Conservative Treatment Medical Management + Feeding Therapy Proton pump inhibitor for GERD Upright position during feeding Thickened feeds Other therapeutic interventions based on VFSS/FEES findings Chien et al, IJPO, 2006

149 Prognosis / Expectations for L.C. Swallowing function in general? Higher textured foods? Liquids?

150 Developmental Changes: L.C. No medical problems (6 & 9 months) OK w/ intro to higher textured foods OK w/ intro to thick liquids by cup Lost to f/u after 9 months

151 Case Presentation: Progressive Neurologic Disease

152 Laryngeal Cleft None Otherwise Healthy Static, Compensate No Concerns Diffuse CNS Progressive Resp + Nut Probs. Progressive Worsening Worsening support needs

153 CASE: P.N., 15 mo. female PMH: Unknown but progressive neurodegenerative process

154 Etiologies of Neurogenic Dysphagia in Childhood (Adapted from Rogers, 1996) Manifestation CNS Prognosis Site of Pathology Anterior horn cell PNS Acute Chronic Static Progressive Neuromuscular junction Muscles

155 VFSS Interpretations: P.N. Unknown neurologic process c/w swallowing dysfunction Progressive Prognosis

156 Management: P.N. Route of feeding Feeding suggestions Therapy recommendations

157 Opportunities Special Interest Division 13 Swallowing and Swallowing Disorders Specialty Board Recognition in Swallowing and Swallowing Disorders (BRS-S)

158 Special Interest Division 13 Swallowing and Swallowing Disorders Why join ASHA Division 13: Swallowing and Swallowing Disorders? Perspectives Newsletter 4 per year with CEUs and information you can use in your practice Discounts on Division sponsored short courses at the ASHA convention and other ASHA educational offerings Networking with colleagues through a Division list and web forum Tools to help you advocate for yourself and your patients Policy documents to guide your practice Grants to support your research & practice including 2 new investigator grants for first time presenters at DRS Learn about Specialty Recognition in Swallowing and Swallowing Disorders All this for a remarkably small investment $35.00 year $10.00 year/students Make an investment in lifelong learning

159 Special Interest Division 13 Swallowing and Swallowing Disorders 2010 ASHA Convention Activities Division 13 Business Meeting Friday, November 19 12:30 a.m. 1:30 p.m. Franklin 5 & 6 Please join us. Your input is very important! Please note: we are not able to provide refreshments, so please bring your own lunch to the meeting.

160 Board Recognition for Swallowing and Swallowing Disorders (BRS-S) Two Track Program: Clinical & Academic/Administrative What is Specialty Recognition? Acknowledgement of advanced knowledge, skills & experience beyond the Certificate of Clinical Competence. Recognition by consumers, colleagues, referral and payer sources and the general public. Why is BRS-S important to my career? Personal and professional satisfaction Provides the opportunity to demonstrate and publicize the achievement, potentially facilitating career advancement. Marketing of clinical services. Each candidate must submit a completed application pass a written examination and renew every 5 years. Visit:

161 Maureen A. Lefton-Greif, PhD, CCC/SLP, BRS-S Associate Professor, Dept. of Pediatrics Johns Hopkins Medical Institutions