PMI Exam 3

Feeding and Swallowing

What are the general anatomical differences between infants and adults/older kids?

Infants have:

• Smaller jaw

• Relatively larger tongue

• Smaller hard & soft palate

• Larger Buccal and fat pads

• Uvula/epiglottis closer together

What pressure changes are involved with bottle feeding?

Compression (+ pressure) and Suction (- pressure)

How is compression created?

Upward movement of the tongue and jaw toward the palate during suckling.

What happens if there is only positive or negative pressure, instead of both?

Less efficient, take more time, and more energy.

What is the purpose of surfactant?

Provide greater gas exchange and respiratory performance, doesn’t let lungs collapse during exhale.

What are the protective reflexes?

• Tongue protrusion

  • Baby sticking out tongue

• Tongue lateralization

  • Moves food in mouth

• Phasic bite

  • Pressure on gums causes open and closing of jaw

• Gag

  • Prevents choking 

• Coughing

  • Airway protection

What are the adaptive reflexes?

• Rooting

  • Locate source of food

• Suckling

  • Reflexive oral pattern, self-soothe and feed from breast or bottle

What are the types of foods, their examples, and ages they are used?

• Breastfeed/Bottlefeed

  • 0-24 mnths

• Pureed foods: rice cereal, yogurt, pureed fruit/veggie/meat

  • 4-6 mnths

• Mashed foods: mashed potato, squash, pumpkin, banana, avocado

  • 7-9 mnths

• Soft pieces: pieces of banana/avocado, cooked pieces of potato/squash

  • 9-12 mnths

• Soft mechanicals: cheese, roast chicken, meatballs, boiled veggies, pasta

  • 12-18 mnths

• Hard mechanicals: beef steak, pork, raw apple, raw carrot

  • 18-24 mnths

• Mixed textures: pieces of cooked chicken and pasta in mashed veggies

  • 12-18 mnths

What are the developmental feeding milestones for 0-4 months?

• Sidelying, cradle hold, upright supported

• Breastfed/bottle fed

• Can’t chew/bite

What are the developmental feeding milestones for 4-6 months?

• Supported sitting position posture for a period of time

• Hands to mouth

• Breastfed/bottle fed, pureed foods

• Can’t chew/bite

What are the developmental feeding milestones for 7-9 months?

• Sit upright, needs support

• Hands to mouth.messy self-feeding

• Breastfed/bottle fed, open cup/weighted straw

• Mashed solids, early chewing/no bite

• Starting to get teeth

What are the developmental feeding milestones for 9-12 months?

• Sit upright with minimal support

• Self-feed + some help

• Breastfed/bottle fed, open cup/straw cup

• Chewing

• Soft pieces

What are the developmental feeding milestones for 12-18 months?

• Sit upright without support

• Mainly self-feeding

• Some breastfed/bottle fed, cup/straw drinking

• Chewing, bites through soft foods

• Soft mechanicals

What are the developmental feeding milestones for 18-24 months?

• Sit upright without support

• Mainly self-feeding

• Cup/straw drinking, may still breastfeed/bottle feed

• Hard mechanicals

When is it recommended to start solid foods?

After 4 months, but should be closer to 6 months

What are some examples of feeding difficulties in infants/children?

• limited range of food

• restricted volume of oral intake

• poor weight gain

• choking on bottles

• long meal times

• family stress related to child’s feeding

What are some disorders that commonly affect feeding?

• Prematurity

  • Less than 37 weeks

• Respiratory and cardiac disorders

  • Apnea, Pulmonary hypoplasia, respiratory distress, bronchopulmonary dysplasia, aspiration pneumonia

  • Cyanotic and Acyanotic heart defects

• Gastrointestinal disorders

  • NEC (dying bowel), TEF (fistula between esophagus & trachea), CDH (hole in diaphragm allows abdomen to herniate into chest), GERD (abnormal reflux)

• Neurological disorders

  • Microcephaly, Hydrocephalus, Cerebral Palsy, Acquired brain injury, Seizures

• Congenital abnormalities

  • Cleft lip/palate, VPI, Down Syndrome

• Maternal and Perinatal conditions

  • Diabetes, Jaundice, Drug/substance abuse

• Iatrogenic complications

  • Tube feeding

• Misc complications

  • Tonsillitis, Tongue-tie, sensory processing disorder 

What GI disorder is this?

Tracheoesophageal fistula (TEF)

What GI disorder is this?

Congenital diaphragmatic hernia (CDH)

Who is tube feeding for?

For preterm infants/children who cannot feed by mouth or do not have sufficient skill or endurance to support full, independent oral feeding

What are the types of tube feeding for babies?

• NG tube: nasogastric; through nose into stomach

• G tube: gastronomy; surgically inserted into abdomen 

What is hypersensitivity regarding feeding?

“sensory defensiveness”

• Picky eater

• Hands off

• May have food avoidances

• Gags on certain foods

• Unusual feeding like may not pick up certain foods but accept by spoon

What is hyposensitivity regarding feeding?

“sensory under registration”

• Sloppy or messy eater

• Messy hands/face

• Overstuffs mouth, drools, choking (poor oral processing)

• Oral stimulation through chewing, licking, eating non-food

• Prefers rich flavors and textures

What are the alert states?

Deep sleep: Relaxed, sleeping soundly with no movement

Light sleep: Sleeping but moving, startles at noises, in REM

Drowsy: May doze, eyes may open and close with a gazed look

Quiet alert: Eyes open, body relaxed, may be focused on surroundings

Active alert: Eyes open, move around a lot, may be fussy

What is the best alert state for feeding?

Quiet alert

What’s the difference between FEES vs VFSS/MBSS regarding assessment?

FEES

• Scope camera through nose and down throat

• Difficult in infants

VFSS/MBSS

• Video through x-ray of swallowing food in barium

• More frequently used since less discomfort

What types of questions should be asked on case history?

• Medical history

• Growth

• Diet

• Early feeding history 

• General development

• Cognitive skills

• Onset of feeding difficulties

• Current eating/drinking ability

• Behavior during mealtimes

• Parent stress with mealtimes

• Details of any specific concerns with child’s eating/drinking

What is a good latch vs a bad latch to breast?

Good latch

• Lips widely spread around nipple

Poor latch

• Lips are closely sucking nipple

What structures are you looking at/assessing during an OM exam for feeding?

Assessed

• Lips

• Palate

• Tongue

• Jaw

• Teeth (if present)

• Cheeks 

Observed

• Structure

• Symmetry

• Appropriate size

• Tone

• Range of motion

What is aspiration?

Material passing through vocal folds and going below into trachea. Can occur on refluxed or regurgitated stomach contents.

What is penetration?

Material entering larynx but staying above vocal folds

Wet voice, cry, ratty chest, coughing, cyanosis, stress cues like tearing & finger splaying are signs of?

Aspiration or penetration

What is the purpose of thickened liquids?

• Children with swallowing problems

  • Slows rate of fluid flow, allowing more time to close airway before swallow

  • Hold together better than thin fluids so easier to control in mouth

• Infants who display regurgitation

  • Are less likely to be regurgitated from stomach back into esophagus

What is Operant conditioning?

Improves feeding difficulties and increases oral intake through specific prompted food goals and a reinforcement system.

What is Systematic desensitization?

Improves feeding difficulties and increases oral intake by exposing children to a range of foods in play-based activities, which become gradually more challenging; used now.

What are the pros and cons to Oral-Sensory Motor Therapy?

Pros

• Modifies child’s current oral motor skills and sensory processing in relation to eating and drinking

Cons

• Lack of specificity

• Insufficient evidence to its effectiveness 

What is important to consider about positioning for feeding?

• Fluids flow faster vertically

• More upright position/side-lying position to slow feeds

• Older children can do chin-tuck and avoiding neck extension to slow feeds

What is important to consider about pacing for feeding?

• Taking breaks to interrupt flow of liquid -> allowing baby time to swallow safely

• Infants: feeder actively imposes breaks to allow swallow/catch breath -> SSB

• Older children: done based on cues or a set schedule

What is important to consider for using swallowing maneuvers for feeding infants?

• Many strategies for adults don’t work on children due to cognitive skills

• Require modeling

• Generalization limited

What is important to consider about modified foods?

• 2-3 years, most children eat most solids

• Children with developmental delay may require modified food textures beyond

• Consider if child can chew a hard solid or cognitively understand what to do with food

What is important to know about feeding equipment?

• Slow flow of fluids

• Infants: slow-flow nipples, nondrip/compression based nipples

• Older children: weighted straw cups, cut-out cups, infatrainer cup

Downward movement of the tongue and jaw creates ____ pressure.

negative

Upward movement of the tongue and jaw creates _____ pressure.

positive