FEEDING & SWALLOWING

PROBLEMS IN PEDIATRICS:

IMPROVING FUNCTION &

CARRYOVER Erin Lewis, MS, CCC/SLP

Erin Ball, MA, CCC/SLP

ON GAME DAY, BUT…

NOT TODAY

WHAT IS A FEEDING PROBLEM?

When eating has an adverse effect on health or

functioning.

Difficulty consuming adequate nutrition by

mouth.

Food refusals

No advance of the diet

Disruptive mealtime behaviors

Undernutrition

Lack of consensus on the definition makes

diagnosis and treatment referrals difficult.

IN ESSENCE IT IS A MATTER OF

PERCEPTION

WHAT IS A SWALLOWING PROBLEM?

Can occur at different stages in the swallowing

processes.

Oral

Pharyngeal

Esophageal

OROPHARYNGEAL DYSPHAGIA SIGNS AND

SYMPTOMS

Infancy and Older

Disorganized/Abnormal Suck

Failure to Thrive

Drooling

Apnea

Desaturations

Wheezing

Stridor

Bradycardia

Congestion

Transition difficulty to solids

Gagging

Coughing

Oral Aversion

WHO DOES THE FEEDING &/OR

SWALLOWING PROBLEM IMPACT?

2/3 to half of parents report at least 1 mealtime

behavior problem; 1⁄4 report multiple mealtime

behaviors (Crist & Napier-Phillips:2001)

25% of all children are reported to have some

form of feeding disorder; 80% of developmentally

delayed children present with some kind of

feeding disorder (Manikum & Perman, 2000)

IMPLICATIONS FOR A CHILD’S LIFE

Aspiration

Failure to Thrive

Quality of Life

Nutrition

Overall Development

PARENTS NEED SUPPORT

Heweston, R. and S. Singh (2009)

Study of mothers with children with chronic

feeding disorders.

Mothers’ experiences can be understood as two

continuing journeys that are not mutually

exclusive.

Deconstruction & Reconstruction

DECONSTRUCTION

Losing the mother dream

Everything changes : living life on the margins

Disempowered : from mother to onlooker

RECONSTRUCTION

Letting go of the dream and valuing the reality

Self-empowered : enabling

Facilitating the journey

The continuing journey : negotiating balance

IMPLICATIONS IN THE LONG TERM FOR A

FAMILY

Frustration during meals

Frustration regarding food

Conflict

Stress

PARENTS GENERALLY RECOGNIZE MEALS

ARE A STRUGGLE HOWEVER…

May have trouble effectively describing the issue

to their child’s PCP

PCPs often lack the time and education to make

informed feeding and swallowing assessments

REFRAME THE QUESTIONS

Does your child have

any swallowing

problems?

Does your child

tolerate a variety of

foods?

Does your child cough

or choke during

meals?

Does your child sit

and eat a meal with

the family?

Does your child eat

over 30 foods without

refusing or gagging?

We may tend to say… Instead consider…

FEEDING MATTERS’ INFANT AND CHILD

FEEDING QUESTIONNAIRE (ICFQ)

Web based questionnaire designed to improve PCP

early identification and referrals for kids at risk

with feeding and swallowing problems.

Excellent tool for families to effectively

communicate with physicians.

http://www.feedingmatters.org/questionnaire

EXAMPLES OF THE QUESTIONNAIRE

ONLINE

DELINEATING

ETIOLOGY AND

UNDERLYING CAUSES

BIOMEDICAL FACTORS

Prematurity

flexion

Low tone

Respiratory

Supplemental oxygen

Asthma (risk into adulthood)

Cardiac

Surgeries

Hypoxic or ischemic events

Craniofacial

High/narrow palate

Tongue tie, lip tie

Enlarged tonsils and/or adenoids

BIOMEDICAL FACTORS - CONT’D

Digestive

Anatomy/structure

Motility/gastric emptying

Esophagitis

GERD is a symptom and not a diagnosis!!!!

Allergies

intolerance

Immune System

Reactions to foreign substances in the body

Usually proteins

Problems digesting enzymes

Milk, wheat, medications

ENVIRONMENTAL FACTORS

Physical environment

Family understanding and support

PSYCHOSOCIAL FACTORS

Stress

Feeding mismanagement

2 BIG CONCERNS

How do I get them to

eat?

How do I get them to

eat safely and

effeciently?

Parents Clinician

EXAMINING AND

IMPROVING ORAL

SKILLS

Oral feeding skill deficits contribute to more than

half of the children (427/700) diagnosed with a

feeding problem with 66% of those children under

the age of 2. (Rommel et al., 2003)

EFFICIENT ORAL MANIPULATION

CHEW

SWALLOW

BREATHE

LOOKING AT ORAL SKILLS

Rapid acquisition of oral skills occur in the first

year of life.

6 months – 2 years

Did the child miss a window of opportunity to

learn consistencies/develop skills?

Are they currently missing a window of

opportunity?

FACTORS THAT INFLUENCE ORAL SKILLS

AND CHEWING

Dentition

Jaw muscle and bite

force

Food properties

Saliva

More muscle activity

needed for harder foods

Number of chewing

cycles and duration

increased with hardness

and bolus size

Saliva required for

lubrication and assists

in bolus formation and

perception of taste and

flavor.

AS WE PROGRESS THROUGH

CONSISTENCIES AND SKILLS

Is the child comfortable with the skill we are

asking them to use?

If we challenge too much with food are we

creating the behavior?

Eating should not be scary.

Eating should be successful.

AL

L A

BO

UT

TH

E T

ON

GU

E

LAB SESSION

ANALYSIS OF CHEWING THE GUM

Central placement

Lateral shift

Dominant side?

Observe and feel for cheek activation with

different chewing patterns

Analyze and describe tongue movements used to

move the bolus

Analyze and describe cheek, jaw, tongue

coordination

Anxiety?

Compensations?

CAUSES OF POOR CHEWING

Typically a result of:

Medical issues

Oral motor skill issues

Sensory issues

MEDICAL ISSUES AND CHEWING FOOD

Delay learning at the appropriate age.

Neurological disorders

Genetic disorders

Prematurity

Developmental Delays

GI Issues

Allergies

ORAL MOTOR SKILL ISSUES AND CHEWING

FOOD

Use of immature chewing patterns or

compensations to break down food

Frontal chewing

Lips closed and pursed when chewing

Using vertical patterns and munch only

Swallowing food whole

Will not open mouth when asked to “show”

Difficulty clearing mouth of chewed food

Looks confused

SENSORY ISSUES AND CHEWING FOOD

Over or under responsive to sensation.

Fight or Flight

Gagging

Raking food out of mouth or spitting

Looking fearful

Crying

Behavior???

FEEDING THERAPY

It takes a LONG time!!!!

Look at all of the underlying issues.

Medical management

Missed developmental window

Oral motor, sensory, behavior

Build trust with the child.

FUNCTIONAL USE OF FOOD AND DRINK

This is the most successful strategy for gains and

carryover.

ADJUSTING THE DIET

Decrease exposure to foods the child is using

inappropriate skills to consume

Don’t want them to swallow table food whole.

Practicing the undesired skill.

Use a mix of foods. Minimize fatigue.

Remember you are working with muscle groups,

it is a slow process.

SPOON FEEDING

Maroon spoons

Beckman EZ spoon

Textured Spoons

Bolus Placement

Techniques

MUNCHING

Mesh bag feeder

Cheesecloth

Clinch rag

Techniques

BITING/CHEWING

Chewy tube-yellow

Biting blocks

Real food

carrots

celery

Dried twizzlers

DRINKING

Infa trainer

Honey bear straw cup

Lip block

Nosey cups

Wow cup

Nuk sipper

Recessed lid cup

MAKING FUNCTIONAL GAINS

To make gains your program must include all of

the following components.

EAT, EAT, EAT!!!!!

Oral motor

Sensory

Diet adjustments

Behavioral/Psycosocial

HOW DO WE

IMPROVE SENSORY

RESPONSES?

ALWAYS BE PROACTIVE

Anticipate that there will be a sensory issue.

Begin the session with proprioceptive input.

Whole body not just the mouth.

SENSORY PROCESSING-“THE WAY THE NERVOUS SYSTEM

RECEIVES SENSORY MESSAGES AND TURNS THEM

INTO RESPONSES”

Sensory Processing Disorder (SPD)-the sensory

signals don’t get organized into appropriate

responses; daily routines and activities are

disrupted; sensations are experienced differently

PREPARING THE SYSTEMS

Vestibular

Proprioceptive

Tactile

Olfactory

Visual

Auditory

Gustatory

VESTIBULAR

postural stability/control

alerting

calming

PROPRIOCEPTIVE

influences of muscle tone

motor planning

Proprioceptive input is largely ORGANIZING for

the child.

THE STANDARD 5

Tactile

Olfactory

Visual

Auditory

Gustatory

APPROACHES WITH

AND WITHOUT FOOD

WITHOUT FOOD

whole body massage/movement

handling techniques

sensory preparation

WITH FOOD

expand exposure

sensory “play”

getting to touch, smell, taste

expanding taste repertoire

expanding olfactory and visual repertoire

getting to texture

SYSTEMATIC DESENSITIZATION

All designed to improve

Trials with mesh

Foods meet oral motor skills

Fading new foods – food chaining methods

BEHAVIORAL ISSUES

RESULTANT OF

Medical

Motor

Sensory

A BALANCED APPROACH

Behaviors become conditioned so quickly.

We create more ‘behavior’ when we don’t operate

on relationship and trust.

Keep the child and parent KNOWING they are

100% safe with the task you are asking them to

complete.

POSITIVE EXPERIENCES

Will foster confidence and learning

Appropriate challenges

Understanding and acknowledging the problem

Providing a structure and routine

Positive reinforcement to enhance building a skill

Practice

Patience

MOTIVATION AND FOOD EDUCATION

ED

UC

AT

ING

FA

MIL

IES A

ND

CH

ILD

RE

N A

BO

UT

FO

OD

LAB SESSION

INVOLVING THE FAMILY & PRACTICAL

EDUCATION

What does the family do with the information you

give them each session?

Follow the formula:

What’s working

Food

Lifestyle

Exercises

Q & A

Problem solve your cases.