Feeding and Swallowing Problems in the Child with Special Needs

Feeding and Swallowing Problems in the Child with Special Needs

Joan Surfus, OTR/L, SWC Amy Lynch, MS, OTR/L Misericordia University

This presentation is made possible, in part, by the support of the American people through the United States Agency for International Development (USAID). The content of this presentation is the sole responsibility of the author(s) and does not necessarily reflect the views of USAID or the United States Government. The opinions and views expressed by the authors in this document do not necessarily reflect the views and opinions of KPMG.

Why Is Feeding Important?

Physiological Needs for Feeding/Eating: Sustained nutrition ensures: promoting growth ensuring energy organ system function Decreased nutrition can yield: hair changes skin problems organ malfunction Decreased energy for activity participation

Feeding/Eating: Participation in Life Skills to promote independent feeding enable participation in: Social functions Cultural events Relationship building Lack of independence in age typical feeding and eating can be extremely isolating, impacting the self esteem of the individual, the caregiver, and others in the environment

What is a Feeding Problem?? The inability to consume by mouth, either in quantity or quality, nutrition which is developmentally appropriate for that child.

Implications of Feeding Problems Failure to thrive/malnutrition Nutrient deficiencies Dependence upon supplemental feeding Low-self esteem Low energy for participation in activity Avoidance of meal Social isolation for child and family unit Caregiver and family stress

Assessment of Feeding and Swallowing Problems An interview with the primary caregiver(s) regarding what and how the child is eating and drinking is very important. Medical information (i.e. frequent respiratory illnesses, history of poor weight gain etc.) is also important before direct contact is made with the child.

Assessment of Feeding and Swallowing Problems Based on the information obtained one or both of the following assessments are done: Videofluoroscopic Swallow Assessment (VSA) also know as a Modified Barium Swallow Study Informal Swallow Assessment

How Do we Eat?

Dysphagia = abnormal swallowing May be associated with aspiration, which is the passage of food or liquid into the trachea or lungs To address dysphagia, need understanding of normal swallow

Stages of Swallowing

Stages of Swallowing: Oral Preparation Voluntary control Recognition of food/liquid bolus being placed in the mouth Chewing of the bolus in a cohesive and rotary lateral manner Lips seal to control bolus movement time for oral preparation stage varies on consistency Starts with placement of food in mouth Ends when food is formed into a bolus

Stages of Swallowing: Oral Phase Voluntary control Amount of time 1-3 seconds Starts when tongue lifts up against alvelor ridge and begins posterior movement of the bolus (e.g. front of mouth to back of mouth) Ends with trigger of pharyngeal swallow at anterior faucial arches

Stages of Deglutition: Pharyngeal Phase Involuntary control Amount of time 1-3 seconds As tongue propels bolus to back of mouth Sensory receptors in the oropharynx and the tongue itself are stimulated sending information to brain about swallowing

Stages of Swallowing: Pharyngeal Phase (continued) Starts with trigger of swallow at anterior faucial arches ( bolus head ) reaches the anterior faucial arches. Must be effectively coordinated and have adequate timing Ends with opening/relaxation of the cricopharyngeal sphincter ****You MUST protect your airway during this phase****

Stages of Swallowing: Esophageal Phase Involuntary control Amount of time 8-20 seconds Starts with contraction of cricopharyngeus muscle (UES--upper esophageal sphincter) Ends with food entering the stomach at the LES--lower esophageal sphincter Motility of the bolus is accomplished via the peristaltic wave

Swallowing Problems Occur When Inability to maintain adequate nutrition Inability to maintain adequate hydration Risk of Penetration Risk of Aspiration

Videofluoroscopic Swallow Assessment A formal assessment of swallow under fluoroscopy Oral, pharyngeal and esophageal phases of swallow with different food and liquid consistencies can be evaluated.

Videofluoroscopic Swallow Assessment The study allows the radiologist and clinician to observe the food or liquid as it progresses through all the stages of swallow. identify the presence or absence of penetration and/or aspiration of food or liquid into the airway identify whether silent aspiration is occurring determine which strategies may be implemented to eliminate the risk of aspiration

Example of Adult Videofluoroscopy

Example of Adult Lateral View Videofluoroscopy

Example of Adult Anterior- Posterior View Videofluoroscopy

Example of Pediatric Videofluoroscopy

Example of Aspiration on Videofluoroscopy

Types of Swallowing Evaluations/Diagnostic Procedures Videoendoscopy/Flexible Fiberoptic Endoscopy (FEES/FEEST) (continued) Provides direct view of anatomy and has been shown to detect aspiration and penetration White out occurs during swallow so unable to determine what occurs at exact time of swallow No radiation exposure

Example of FEES/FEEST

Example of FEES/FEEST with Food

Clinical Signs & Symptoms When you do not have a VideoFluroscopy Screening for high risk factors Often another discipline will identify the presence or absence of symptoms and make the referral for a clinical bedside evaluation or diagnostic procedure conducted by the swallowing therapist

. Medical Diagnosis Linked To Feeding Problems GER Constipation Malabsorption Esophagitis Slow Gastric Emptying Allergies Celiac Disease Presence of bacteria, such as H-pylori, c-diff, etc. Gastro-intestinal obstruction or malrotation Metabolic disease Bowel disease (such as Hirshprungs) Other organ problems (renal, liver, etc) Metabolic Disorders Tracheomalacia Respiratory Illness or Compromise Structural Anomalies (cleft, TEF, etc) Trach/Vent

Clinical Signs & Symptoms of Problems in Feeding Symptoms Poor Oral Feeding Loss of weight or inability to gain weight Coughing or choking before, during or after a meal Weak, ineffective cough Gargly/gurgly wet sounding voice after swallowing Residue/pocketing in oral cavity or oral seepage or drooling Copious secretions/difficulty managing secretions Oral motor weakness Difficulty controlling food/chewing Fullness around sternum/increased time to eat

Clinical Signs & Symptoms Signs History of aspiration pneumonia Patient complains of swallowing difficulty Avoidance of certain food consistencies Food catching in the throat Takes longer than 10 seconds to swallow a bolus Decreased appetite/weight loss Low grade fever (of unknown etiology) Temperature spikes (especially at night) Acoustic changes in the lung fields Chest X-ray findings (RLL infiltrate) Significant cognitive or visual impairment Poor cardiopulmonary status/physical endurance

Final Definitions you can use with Dysphagia Identification of swallowing risk factors may lead to: Aspiration: The entry of liquid or food into the lower airway, e.g. below the true vocal folds Penetration: The entry of liquid or food into the laryngeal vestibule but not below the level of the true vocal folds

Most children with dysphagia are SILENT aspirators

Medical Diagnosis Associated with Swallowing Problems

Infancy and Toddler Years Prematurity Tracheo-Esophogeal Fistula Mechonium Aspiration Tracheomalacia Craniofacial Issues PVL/ IVH Tetrology of Fallot/ Cardio-Respiratory problems SMA/ Neuromuscular Dystrophies Mitochondrial Disorders Cystic Fibrosis GER Failure to thrive Down syndrome Cerebral palsy

School Age and Adolescent Years Cerebral Palsy Down syndrome Spina bifida Head Trauma Oncology Diagnosis s/p chemotherapy or radiation or tumor resection Psychogenic Dwarfism Anorexia/Bulemia

Adult Years with Developmental Disabilities: Our Kids Grow Up! Advancing motor involvement Aging process occurs earlier & at faster rate Nutritional issues; dehydration; constipation Strokes Arthritis Hypertension Endocrine Disorders Dementia

Case Study 1

Group Activity Starting to Assess Structures in Feeding: Mouth Lips Teeth/Jaw Cheek Tongue Respiratory Positioning

Group Activity: Introducing Positioning