Serving Children with Swallowing and Feeding Disorders in the Schools Judy Mikami, MA CCC.

Serving Children with Swallowing and Feeding Disorders in the Schools

Judy Mikami, MA CCC

Incidence

• Research on the prevalence of swallowing and feeding disorders ranges between 25-35 % in normally developing children;

• 40-60 % among children with disabilities

What’s the Educational Relevance ? • Safety-appropriate personnel, food, and

procedures need to be in place to minimize risks for choking during meals and snacks.

• Students must have sufficient nutrition and hydration to attend and benefit from the learning environment.

• Students will miss school due to health if they are chronically aspirating.

Educational Relevance (continued) • An unsafe saliva swallow and/or poor

oral hygiene are creating considerable health risks.

• Poor efficiency with eating and drinking interferes with nutritional intake- if the student is under time constraints- and educational opportunities and fatigue if too lengthy.

Dysphagia Effects Across Childhood

• “Swallowing and feeding disorders apparent in early childhood may resolve, persist, or deteriorate throughout a child’s preschool, elementary and/or secondary education. The health, education, and social emotional effects of dysphagia change across the educational continuum”

Manifestations of Swallowing and Feeding Disorders: Examples

• Prolonged and/or stressful meal times;• Coughing and/or throat clearing while

eating or drinking;• Wet breath sounds and/or a gurgly

voice quality associated with eating/drinking;

• Spillage of food from the mouth;• drooling

Manifestations of Swallowing and Feeding Disorders: Examples

• Food remaining in the mouth (pocketing);• Swallowing solid food without chewing;• Inability to drink from a cup;• Multiple swallows per bite of food or sip of

drink;• Effortful swallowing;• Gagging or vomiting associated with eating

and drinking.

Manifestations of Swallowing and Feeding Disorders: Other Relevant Issues

• Weight loss or poor weight gain for age;• Frequent respiratory illnesses impacting

attendance;• Digestive concerns: diarrhea,

constipation, other gastrointestinal tract problems;

• Need for special strategies or distractions at meal times to encourage eating.

Common Conditions for which Swallowing and Feeding Disorders are Prevalent

• Anatomical differences: cleft palate, laryngeal clefts, TEF/EA, tonsils & adenoids, Pierre Robin, kids with trachs;

• Global developmental delays: need to consider “feeding age” in comparison to other skills;


• Neurologic conditions: cerebral palsy (25-80 % incidence;90 % incidence for spastic quadraplegia);

• Metabolic conditions/muscular dystrophies;

• TBI• Genetic conditions: down syndrome,

VCFS


• Sensory based feeding disorders;• GI problems-esophageal motility

disorders, GERD, TEF/EA;• Complex medical conditions-heart and

respiratory disorders;• Renal disease-growth failure, GER,

poor appetite, etc.

If We Know or Suspect a Swallowing

and/or Feeding Disorder-then what ?

• Does the school system you are in have policies for addressing dysphagia ?

• Is there a clinical feeding evaluation in place for the child ? How recent ? Sufficiently thorough to protect child, school district and your license ?

• Has a swallow study been done ? How recent ? Do you have actual records ?

Components of a Clinical Feeding Evaluation • Information gathered from medical history, parent/child interview,

primary care provider and/or observation of behaviors: Pertinent medical history (respiratory, GI, Neurological)/

diagnosis, current medications Meal and Snack routines; current textures Body wide tone, strength, stability and coordination &

positioning for meal times Examination of oral structures Respiratory Status before, during and after eating Concerns for digestion Sensory processing for mealtimes Bottle feeding, cup drinking, spoon feeding, finger feeding,

chewing What is the child’s “feeding age” & how does this compare

with their overall development ?

Current Diet: Meal and Snack Routines

• Go through a typical “day” (we get a 3 day diet history)

• Are meals and snacks scheduled/cue-based/ a combination ?

• How does the parent know when the child is hungry ? Full ?

• Child is fed alone ? Fed with family members ?• How are beverages organized around offering food? • Advice given to parents around organizing meals &

snacks for their child

Tone, strength & coordination, positioning

• Get information from those who are doing “hands on” motor work with the child, neurology reports, etc. on body-wide tone, strength and coordination.

• Look at all the different positions in which the child naturally eats and drinks.

• Height of tray/table in relation to the child.• Is the child self feeding ? Equipment being

used• Foot support ?

Positioning……..

Does the child use unusual positioning ?

• Head and neck hyperextension

• Head tilting

• Rocking during meals

• Head turning at the time of the swallow

• Chin tuck

• Feed in recline on their back or one side

Positioning………………..

Hypothesize: What purpose is the unusual positioning or movement pattern serving the child ?

• Safety• Efficiency • Sensory seeking • Habit-child and/or caregiver• Cultural reasons • How can these be methodically &

sensitively sleuthed out ?

Positioning, the evidence…

Larnert & Ekberg (l995) cont. …• 2:5 demonstrated premature spillage in reclined position

with neck flexion.• 4:5 demonstrated aspiration of purees positioned in

slight recline with head and neck flexion.• All demonstrated a in aspiration of liquids positioned in

recline in head and neck flexion.*

Examination of Oral Structures• Overall oral motor tone & symmetry;• General condition of the teeth/ gums, alignment of

the teeth and jaw-possible sources of pain/ discomfort ?

• Height, shape and integrity of hard & soft palate• Tongue; attachment of frenulum; tissue• Jaw: position, alignment, micro versus retrognathia• Tonsils, saliva ducts

MUSCLE TONE/Coordination – “RED FLAGS”

• Vulnerable to poor jaw stability.• Hypertonia: Retracted or bunched tongue;

tongue thrust to transport. Difficulty with controlling jaw opening and closing. Poor cheek activation.

• Hypotonia: Humped tongue. Difficulty achieving and maintaining mouth closure and with tongue-tip elevation. Tongue pumping to transport.

• The child with mixed tone.

Pertinent History

• Feeding history-feeding tube and oral;

• Health history including any significant respiratory, digestive and neurological information;

• Current medications

• A brief developmental “snap shot”

RESPIRATORY CONSIDERATIONS – “RED FLAGS”

• On oxygen• Coughing, gagging, choking, sneezing,

stridor, gurgly voice quality• Unexplained pneumonias, bronchitis, chronic

colds, asthma, sinusitis,frequent low grade fevers

• Respiratory rate is > 60 BPM• Duskiness/apnea spells during eating/drinking

Respiratory Information• Resting respiratory rate, respiratory rate

during eating and drinking;• Respiratory patterns: regular/irregular• Shift to nasal breathing during eating and

drinking;• Coordination of swallowing with breathing;• Any color change, gurgly voice quality,

coughing, congestion.• Pulse oximetry readings at rest and during

eating and drinking.

DIGESTION/GER – “RED FLAGS”

• Excessive spitting up/vomiting• Frequent spitting up/vomiting an hour post

feeding• Spitting up on specific food sources• Constipation• Growth/FTT• Hunger drive ? Detection of fullness ?

Feeding Equipment • Type of bottle, spoon, syringe, cup the

family is using. How did they choose ?

• Goodness of “fit” between the equipment used and the child.

• Equipment preferences of different feeders.

• Child’s ability to shift between different nipples, spoon types, cups ?

SENSORY PROCESSING – THINGS TO CONSIDER

• Sensations of hunger versus fullness• Resiliency/vulnerability to environment during

eating and drinking, best feeding envir. , ? communication of overload.

• Alertness during meals• Responses to the presentation of food and

drink (habituation as well as defensiveness)• Responses to the sensations of eating: color,

shape, smell, temperature, texture.

Spoon feeding• Does the child open as the spoon

approaches ?• How does the child remove the food

from the spoon ?• Head and neck position while removing

the bite ?• Do the lips effectively contain the

bolus ?• How is the bolus transported ?

Cup feeding• Cup style ? Reasons it was chosen ?• Does the child open with the approach

of the cup ?• How does the child stabilize the cup ?• By what means to they draw in liquid ?• Single sips ?, Consecutive sips ?• Coordination of swallowing with

breathing ?• Efficiency of intake

Chewing development & finger feeding

• Does the child place the bite ? If so, where in their mouth to they put it ?

• Jaw movement ?• Tongue movement ? • Efficiency ?• Do the bites appear to be chewed ?• Types of food the parent feels the child

is safe to handle ?not safe to handle ?

INSTRUMENTAL EVALUATION OF THE SWALLOW – WHEN IS IT NECESSARY?

• Proven or strongly suspected aspiration pneumonia.

• Chronic respiratory illnesses/asthma that cannot otherwise be explained.

• Patterns of low grade fevers with congestion every 2-3 weeks.

• Gurgly voice quality with eating/drinking.• Condition for which there is a high incidence of

swallowing disorders • Or because ……

SWALLOW STUDY – Purpose

• Should be designed based on specific questions.• Defines the oral and pharyngeal phases.• Defines esophageal transit time and basic motility.• Delineates aspiration related factors, aspiration

before, during or after the swallow, type of texture aspirated

• Clinical troubleshooting with the advantage of fluoroscopy.

SWALLOW STUDY- DESIGN • Questions developed from clinical evaluation

and/or day to day observations (e.g. sneezing, coughing, congestion, refusal of certain consistencies of food).

• Where in meal/snack times do symptoms occur?• Selection of food and drink. • What do we need to do to replicate a typical meal

time ? • What do we need to do to help the child

participate comfortably ?

Phases of the Swallow and Possible Impact of Neurological Conditions

Oral Preparatory Phase• Sipping, biting and chewing to prepare bites and sips

for swallowing. Chewing is to reduce bites to a ground/pureed texture.

• After chewing or taking a sip the tongue helps to shape the food/drink into a ball (called a bolus) in readiness for controlled transport for swallowing.

Possible Neurological Impact on Oral Preparation

• Humped versus grooved tongue (low tone).

• Retracted tongue (high tone).• Poor jaw stability (for low or high tone)• Is the child really chewing ?• Is the chewing pattern the child has truly

sufficient to break down the food they are being offered ?

Oral Initiation Phase• The tongue tip elevates followed by retraction of the

tongue base to propel bites and sips back for swallowing.

• Transport of bites and sip typically requires one second.

• It is the feeling of the bolus against the back of the tongue, soft palate and faucial pillars that sends the message to the various parts of the brain involved in swallowing.

• These trigger the needed motor responses, a series of contractions that begin the pharyngeal phase of the swallow.

Possible Neurological Impact on the Oral Initiation Phase

Child relies upon:

• tongue pumping/tongue thrusting

• head and neck hyperextension

• rocking action

• volume of bites and sips

• atypical feeding patterns (e.g. bird feeding, syringe feedings, etc.)

Pharyngeal phase

• This phase involves a series of no less than 6 reflex actions mediated by the cranial nerves.

• These reflex actions: retract the tongue base to allow the bolus to move from the mouth into the pharynx; elevate the soft palate to close off the nasal airway; activate the structures in the pharynx to close off the lower airway; activate peristalsis.

Possible Neurological Impact on the Pharyngeal Phase

• Premature spillage (from disordered oral phases)• Delayed initiation of the pharyngeal phase.• Nasopharyngeal reflux.• Reduced laryngeal elevation.• Sluggish deflection of the epiglottis/poor rebound.• Reduced peristalsis, fatigue of peristalsis.• Penetration/ aspiration-before, during or following the

initiation of the swallow function.

Esophageal Phase

• This stage begins with relaxation of the cricopharyngeous muscle to allow bites and sips to move from the throat into the esophagus.

• Structurally the upper 1/4 to 1/3 is constructed of skeletal muscle; the lower half is smooth muscle.

• Peristalsis propels food through the lower esophageal sphincter into the stomach.

Possible Neurological Impact on the Esophageal Phase

• Difficulty with relaxation of the UES causing pooling in the pharynx.

• Poor function of the LES• High rate of reflux-silent or not so silent• Poor peristalsis, discoordinated peristalsis or

vulnerability to fatigue of peristalsis.

Case Study: Toddler with a Metabolic Disorder

Pertinent History:• Born full-term; 3 week NICU stay due to apnea spells and

seizures• Discharged home on oral feedings and seizure medications• Four subsequent hospital stays to monitor seizure activity and to

change medications• MRI indicates extensive white matter damage• Work up for a metabolic disorder is underway with muscle

biopsy pending• Frequent colds; tx for pneumonia 2x proactively

Pertinent History:• Born full-term; 3 week NICU stay due to apnea spells and

seizures• Discharged home on oral feedings and seizure medications• Four subsequent hospital stays to monitor seizure activity and to

change medications• MRI indicates extensive white matter damage• Work up for a metabolic disorder is underway with muscle

biopsy pending• Frequent colds; tx for pneumonia 2x proactively

Initial Evaluation Findings Cont. • Drinks from a sippy cup. Her mother

presents one sip at a time. Eats purees from an infant spoon.

• Relies on tongue pumping and her reclined position to bring bites and sips back for swallowing.

• Congestion with drinking mid feeding: pulse oximetry baseline: HR 115, 97% SpO2 with drinking HR 144; 88 %SpO2.

Swallow Study

Swallow Study Findings

Oral Prep: high vaulted palate, little to no grooving of the tongue

Oral Initiation: gravity dependentPharyngeal: premature spillage; delayed

initiation of the swallow function; penetration and aspiration of thin liquids (limited laryngeal elevation and epiglottic deflection; reduced peristalsis.

Tries to use a chin tuck to protect her airway.

In the meantime….

• Diagnosed with mitochondrial disorder complexes I and V

• Put on numerous nutritional supplements

• Placed on a very low carb diet to assist with seizure control.

Recommendations

• Enlist OT’s support to modify tumble form seat for a gentle chin tuck;

• Thicken liquids & meds with Simply Thick;

• Alternate thicker foods with runny puree or a sip of drink to predictably wash remnants from her throat.

• Other therapeutic feeding ideas ?

Sophie eating after the swallow study

QuickTime™ and a decompressor

are needed to see this picture.

Sophie’s now in preschool…her safe eating plan

Purpose of the Plan: This plan is to provide guidelines for the safe delivery of food and drink. Sophie is a student with a swallowing disorder indicated by three swallow studies with the most recent conducted in February 2008. Her swallowing difficulties are characterized by: aspiration of thin liquids, difficulty coordinating sucking, swallowing and breathing across different thicknesses of liquids, safe swallowing on regular and slightly thick purees.

Sophie’s Safe Eating PlanGuidelines………………..

Positioning: For Sophie to positioned in her SAS chair for meals and snacks at school:

When rested and healthy: use shoulder guides and supports.

If ill or fatigued : strap, guide, shoulder supports if fatigued.


Consistencies of food and drink:

Foods: are to be of a regular puree (like a pudding or yogurt). Or slightly thick pureed consistency.

Drinks: Need to be of a honey consistency. A honey consistency is sufficiently thick to support a straw in standing for several seconds. Sophie is on “Simply Thick” as a thickener. She requires one package of “honey thick” thickener per 4 ounces.


Presentation of food and drink:

Present bites of puree: using Sophies spoon + a verbal script “bite of _what the food is)” wait for Sophie to open her mouth to accept the bite.

Presenting Drinks: Healthy & Rested: offer sips from her cup from home using the

script: “Drink”. Pace her drinking: “sip, sip, stop”. To stop, tip the spout so fluid cannot come out. Sophie needs pacing to support her coordination of breathing and swallowing.

Ill or fatigued: Present drinks from Sophie’s “sipping spoon” (large maroon spoon with mylar tassle)Using the script: “Sip”.


If coughing, congestion, gurgly voice quality or choking occurs:

Stop eating, encourage her to vocalize (to help clear material off the vocal cords).

Document the event indicating type of food/drink, how far into the snack it occurred, feeding environment (noisy, quiet, people entering, etc.) on her feeding log.

If Sophie clears of congestion, voice quality etc. you may resume. If she does not notify her parents in writing.


Special Events:

• If there is a special occasion in the classroom which involves food (e.g. a learning theme, special party, etc.) staff can include Sophie by:

using “back up thickeners” for a special beverage

or solid foods that do not exude a thin liquid- these can be put into a mesh feeder bag (e.g. cake put in the bag and the bag dipped in pudding) so that it breaks down to a puree or thick puree when “munched”on.

Treatment

We need to be mindful there is potential “harm” in

every treatment option

Treatment: Ideas and Evidence by Category

• Oral sensorimotor therapy to promote the development of feeding skills

• Dysphagia

• Behavioral

• Sensory Based Feeding Disorders

Oral Sensorimotor Therapyand the

Development of Feeding Skills

Positioning/Postural Modifications

Common recommendations:• Chin tucks, head turn to weak side, head tilts to

stronger side, etc.

• 90- 90- 90 ankles, knees, pelvis + use of tray/table top

What is the evidence that these are effective ?

Positioning…. The evidence…

Larnert & Ekberg (l995)• 5 children with quadraplegia and

dystonia with severe motoric involvement.

• VFSS of 3 ml boluses of barium puree and uncontrolled amount of liquid barium studied in upright and 30 reclined with neck flexion

Oral Sensorimotor Therapy

Specific techniques may include:

• Stimulation and facilitation of specific muscle groups

• Stretching, strengthening and developing coordination of movement for eating and drinking.

Oral Sensorimotor Therapy

Goal: to facilitate the oral patterns necessary for a child to safely, comfortably and efficiently:

• Accept, draw and contain food and drink in the mouth;• Chew food (if age and devel. Appropriate);• Form a bolus;• Transport bites and sips to the pharynx for swallowing.

Oral Sensorimotor Therapy • Strategies are selected to address specific

neuromuscular impairments interfering with a specific feeding function.

• Optimum postural alignment and postural control are essential facilitators of performance.

• Tx strategies are applied just prior to or during efforts to facilitate the feeding skills.

• Follow a developmental progression.• As function > tx facilitation is <.

OST: The evidence……From Justine Joan Sheppard, (June 2005),The

Role of Oral Motor Therapy in the Treatment of Pediatric Dysphagia.

• Much to be learned about the use of exercise treatments in habilitation of pediatric dyphagia;

• Much research is needed provide an evidence base for efficacy.• For now: research suggests that oral prep, oral initiation and pharyngeal phases

of the swallow may be improved by OST• Treatment effects appear to be specific for individual strategies.• Improvement from OST is “dose-specific” for frequency and duration.• OST appears appropriate for use in settings for which involvement with the SLP

and can be continued over relatively long periods of time. • Using OST effectively requires substantial clinical skills

What about other OST tools & programs?

• There is no evidence yet on the value of chewy tubes, ark grabbers, etc. on functional outcomes for feeding and swallowing.

• Evidenced based research is in process for the Talk Tools program.

• No evidence on Beckman OM exercises.

Facilitating Spoon Feedingthe basics

• Begin at 4-6 months DA• Feeder is positioned at eye level with

child.• Use flat hard plastic/coated spoon and a

small amount • Wait for the child to open mouth as the

spoon approaches.• Remove the spoon along the tongue-

don’t scrape off the roof of mouth.

Facilitating Spoon Feeding

• If the child needs help closing the lips place one finger between the lower lip and chin to guide the lower lip closed or push upward on the chin to close the mouth.

• Allow the child to clear the spoon on own• Go with gradual texture changes.• Only change one sensory property at a time (e.g.

thicken a familiar food to add challenge)

Facilitating Cup Drinkingthe basics

• Builds off of spoon feeding.• Child is able to sit upright with a chair

with good back support.• Choosing a cup: wide-lipped clear cup• Start with a thick,but a familiar and

preferred liquid.

Facilitating Cup Drinking

• Place the cup on the lower lip so the tongue is under the edge of the cup.

• Ease the cup into the corners of the mouth to spills and add to sensory cues.

• Begin one sip at a time. • If the child has no swallowing concerns, transition

gradually from the thicker liquid to their regular thin consistency they were bottle drinking(e.g. formula/milk).

• If the child wants to self-feed, move to a cup with a recessed lid (versus a spout).

Facilitating cup drinking through side spoon feeding……

• Place the spoon side to side• Tilt the spoon• Promotes lip/jaw closure & tongue retraction• Controlled/predictable bolus size• Have the child clear half the bowl of the

spoon• Shift the spoon to the other side to clear the

otherhalf of the bowl.

Facilitating Chewing Development

the basics• The child’s “feeding age” should be around 7-9

months.• “backward chaining” (e.g. starting with one of the last

oral motor skills and working forward).• Place a small strip of soft, chewable food (e.g. rapid,

dissolving solid, steamed fruit/vegetable) on the molar surfaces of teeth/gums.

• Talk-Tools chewing hierarchy• Use of dental floss method.

Facilitating Chewing Development

the basics

• Choose a food for which the flavor is already familiar, which will not scatter when compressed by the jaw.

• Insure the parent knows that the target skill is tongue lateralization.

• Once tongue lateralization is established to both sides you can move towards taking bites from the front.

Getting into the Thick of It

Modifications of Food and Drink to Support Safe Swallowing

Liquids: A quick tutorial

• Viscosity: the tendency of a fluid to resist flow

• Density: mass per unit of volume (closely equates to the weight of the fluid)

• Yield stress: the stress above which flow occurs.

Liquids: A quick tutorial

Thin liquids: are volatile with no cohesive properties; flow is determined by subtle changes in position of the oral structures.

Thickened liquids: have “bolus cohesion”

(the thicker the more the bolus holds it’s shape) Slower movement allowing more time for airway protection mechanisms to engage.

ORAL HYGIENE

ｷｷ Oral bacteria from dental plaque are carried to the lower respiratory tract in saliva (Abe, 2005).

ｷｷ Bacteria carried in saliva have been linked to pathogens involved in pneumonia (Abe, 2005).

ｷｷ These bacteria are also linked to other systemic diseases.

Oral Hygiene• The concern is for candida (yeast over growth) and • Overgrowth of pathogenic bacteria• Without proper oral hygiene the pathogenic bacteria. • These can become shed into the saliva and the saliva

aspirated. • For children with “dry mouth”, they do not have the

saliva to help buffer the teeth/gums from the pathogenic bacteria.

Oral Hygiene

• For effective oral care there needs to be the use of a brush or at least gauze.

• Toothettes are not sufficient to clean the gums of harmful bacteria.

• For the child with a swallowing disorder for thin liquids, toothbrushes with suctioning is recommended. As is the use of fluoridated products.

• Rinse toothbrushes in water and air dry. • If gum bleeding occurs keep going !

Plak vak

QuickTime™ and aTIFF (Uncompressed) decompressor

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Serving Children with Swallowing and Feeding Disorders in the Schools Judy Mikami, MA CCC.

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Transcript of Serving Children with Swallowing and Feeding Disorders in the Schools Judy Mikami, MA CCC.