ped feeding/swallowing exam 1

Nose

- crucial for respiration

- important for speech resonance

- soft palate deals nasal cavity during swallowing

Nose function

cleans, warms, humidifies inspired air

Mouth function

food digestion, vocalization, and oral respiration

Pharynx is made up of

nasopharynx, oropharynx, hypopharynx

Nasopharynx function

- drains sinuses & middle ear

- resonator for speech

- sealed off during swallowing by soft palate

Hypopharynx function

- part of common airway-foodway intersection

- direct food to esophagus

Larynx function

airway protection, respiration, and phonation

Esphagus

helps maintain empty esophagus between swallows

UES

prevents air ingestion

LES

prevents gastric reflux

Phases of swallowing

1. oral prep

2. oral transit

3. initiation of pharyngeal swallow

4. pharyngeal phase

5. esophageal phase

Oral prep and oral transit

- voluntary

- manipulation of food and liquid

- bolus formation

Pharyngeal swallow

initiated at anterior tonsillar pillars, BOT, vallecula, or pyriform sinuses

Mechanoreceptors

touch and pressure

Nocireceptors

pain

Proprioceptors

sense shape, position

Chemoreceptors

detect chemical composition

Special receptors

for taste, smell, temperature

Pharyngeal swallow function

- elevation of soft palate

- UES opening

- laryngeal closure

- tongue ramping

- tongue propulsion

- pharyngeal clearance

Esophageal swallow

- automatic

Infant oral cavity

- tongue fills mouth

- cheeks with sucking pads

- small mandible

- sulci for sucking

Infant pharynx

no distinct oropharynx

Infant larynx

- 1/3 adult size

- half TVF cartilage

- narrow/vertical epiglottis

- high in neck

Older child oral cavity

- large mouth

- dentulous

- tongue rests behind teeth

Older child pharynx

- elongated pharynx

- distinct oropharynx

- 90º angle at skull base

Older child larynx

- less than 1/3 TVF cartilage

- flat/wide epiglottis

- by 2yrs old, adult positioning of larynx

Embryonic period

weeks 1-8

Ectoderm

skin and nervous system

Mesoderm

muscle, blood, and connective tissue

Endoderm

gut, respiratory system, and digestive linings

Weeks 9-12

face forms, limb development

Weeks 13-20

skeleton ossifies, movement felt

Weeks 21-25

weight gain, lungs begin surfactant production (mature)

Weeks 25-29

lungs can exchange air, eye opening, temperature control begins

Weeks 30-34

white fat = feeding readiness (32 wks)

Weeks 35-40

growth finalizes, ready for birth ~38 weeks

Pharyngeal swallow appears

10-14 weeks gestation

Non-nutritive sucking seen at

15 weeks

Suckling begins

18-24 weeks

Sucking emerges

~4 months postnatal

CNS originates from

neural tube

Forebrain becomes

cerebral hemispheres

Midbrain becomes

adult midbrain

Hindbrain becomes

pons, medulla, cerebellum

CNS regulates

swallowing

Critical period for brain development

3-16 weeks

Rooting reflex

a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple

Tongue protrusion reflex

In response to tactile stimulation at the anterior portion of tongue

• Protects airway by pushing food away from mouth when skills are not mature enough

Tongue transverse reflex

touch to tongue causes baby's tongue to make lateral motion

Gag reflex

A normal reflex mechanism that causes retching; activated by touching the soft palate or the back of the throat.

Sweet taste

stimulates suck and swallow reflexes

Breast odor and maternal scent

influence newborn feeding behavior and recognition

Oral sensorimotor skills

improve alongside CNS maturation and general muscle control

Posture and muscle tone

head/trunk stability for safe, efficient feeding

Psychosocial development

supports bonding, social interaction, and emotional regulation

Cultural influence

techniques, timing, and experience around feeding vary by culture

Aspiration can

- cause or worsen respiratory disease

- lead to chronic lunch disease

Infants have

- higher respiratory rates that limit time for swallowing

- immature immune systems

- developing lungs

More risk for aspiration

- uncoordinated swallow-breath timing

- gastresophageal reflux

- congenital abnormalities

Most common aspiration occurrences

- oral feeds

- secretions

- refluxed gastric content

- structural abnormalities

How to manage aspiration

- least restrictive diet

- diet texture modifications

- NG or G tube

Acute aspiration symptoms

coughing, choking, wheezing, oxygen desaturation, fever, and respiratory distress

Chronic aspiration symptoms

stridor, persistent cough, wheezing, recurrent pneumonia, increased respiratory effort

Nasal cannula

used for chronic lung disease, oxygen can help prevent desaturation

Noninvasive Positive Pressure Ventilation (NIPPV)

CPAP, nasal CPAP, BiPAP

Trache tubes

may not alter swallowing but underlying conditions often do

Typical drooling

- occurs within teething

- outgrows by age 4

Physical impacts of drooling

- incoordination of lips, tongue, palate, jaw, pharynx, larynx, and respiratory muscles

- structural issues

- facial skin issues, clothing changes, risk of infection, chilling in cold weather

Social impacts of drooling

- reduced physical contact from caregivers

- social isolation and low self-esteem

- decreased access to education or employment

Qualitative assessment of drooling

- # clothing/bib changes per day

- neurological function level

- school setting

- communication modality

- family and social impact

Decision making factors for drooliing treatment

- severity and impact of drooling

- previous interventions and outcomes

- evidence based knowledge

- neurologic function and family attitudes

- cognitive awareness

Oral sensorimotor therapy

aims to improve motor and sensory function in the oral cavity for better swallowing, saliva control, and speech

Behavior modification and biofeedback

- for motivated individuals with sufficient cognitive ability

- uses verbal prompts, timers, or auditory

Oral appliances and orofacial interventions

prosthetic devices and myofunctional therapy

Pharmacologic therapy

used when noninvasive methods are insufficient

Botunilum toxin injection

injections into major salivary glands, preferred for neurologic cases

Surgical treatment options

- rerouting surgery

- saliva reduction surgery

gross motor milestone 3 months

trunk and neck stabilization, midline head and hand orientation

gross motor milestone 5-7 months

reaching, grasping, picking up objects

gross motor milestone 7-8 months

efficient finger feeding in most infants

gross motor milestone 9 months

cause-effect play = purposeful chewing skills emerging

gross motor milestone 19-20 months

use of tools, feeding skills like using a spoon and cup with minimal spillage

Typical positioning

physiological flexion, reflexes intact and assimilating on time, trunk alignment during prone suspension, symmetry

Atypical positioning

Preference for one side of body, increased hip/knee flexion, fingers splaying/thumb adduction, hypotonia, asymmetries in posture, early "rolling", and signs of seeking stability outside of trunk

Noonan syndrome

- short stature, broad forehead, webbed neck

- language delays, articulation abnormalities, low average intelligence

- poor suck, food refusal, reflux, constipation

Costello syndrome

- coarse facies, macroencephaly

- intellectual disability

- severe feeding problems resulting in FTT

Russel-Silver syndrome

- small for gestational age, normal head circumference

- developmental delay

- poor appetite, fussiness, slow feeding, problems associated with oral-motor dysfunction

22q11/DiGeorge Syndrome

- congenital heart disease, palatal abnormalities, recessed mandible

- developmental delay, autism/ASD

- trouble coordinating suck/swallow pattern, immature oral transit pattern

BBB syndrome

- prominent forehead, widow's peak, broad nasal bridge

- developmental delay and intellectual disability

- swallowing problems with aspiration

Prader-Willis syndrome

- obesity after 1st year, short stature

- hypotonia

- suck and swallowing difficulties

Coffin-Siris syndrome

- ties can be affected, where the finding tends to involve multiple digits

- oropharyngeal dysphagia

Pierre Robin

- mandibular hypoplasia, cleft secondary palate

- respiratory distress with oral feeding

Mobius sequence

- facial weakness with limited abduction of one or both eyes

- speech problems

- feeding problems, poor growth leading to tube feeding

Trisomy 18

- pre- and post-natal growth retardation, microencephaly, 5-10% of children survive beyond 1st year

- hypotonia in infancy, hypertonia in older children

- tube feeding for reflux

Angelman syndrome

- pale blue eyes, deep-set eyes, large mouth, and widely spaced teeth

- intellectual disability, severe speech impairments, gait ataxia

- breast/bottle feeding, reflux

Audiologist

identifies and monitors hearing and middle ear status

Clinic coordinator

coordinates appointments and directs clinic

Dentist

monitor after primary teeth erupt, active intervention in early years, coordinate with orthodontist for function and aesthetics

Geneticist

dysmorphology exam, recommends medical studies and genetic testing, and determines diagnosis and multi-system management

SLP

assists in coordination of care, provides information about resources, assessment/treatment of swallowing/feeding problems, anticipatory guidance for early communication development, assessment/treatment of disordered speech and language development