Pediatric Dysphagia Exam

what are the causes of pediatric dysphagia

prematurity, respiratory/cardiac/neuro/GI disorders, anatomic abnormality, genetics, maternal issues

what is the role of an SLP in a medical setting for pediatric dysphagia

services are provided in a setting where physician orders are required and medical diagnosis is noted ; addresses goals and strategies that modify the client's feeding and swallowing skills in different settings

what is the role of an SLP in a school setting for pediatric dysphagia

services are provided in an educational setting and focuses on integrating the student's swallowing needs into educational structures like lunch or snack.

what are the general goals of the educational model

increase swallow safety, increase nutritional intake, increase quality of feeding during school day while meeting educational needs

who is involved in the medical model interprofessisonal team

SLPs, developmental pediatrician, physician specialists, nutritionist, social workers, psychologist, OT/PT, radiologist

who is involved in the school based inter professional team

SLP, OT, school nurse, PT, teacher, caregivers, special education staff

how does the oral phase work in pediatrics

suckling transitions to sucking, begins with posterior propulsion of food by the tongue, elevate posterior movement of tongue, bolus goes into pharynx, ends with onset of pharyngeal swallow

how does pharyngeal phase work in pediatrics

elevation and retraction of soft palate to close nasopharynx, constrictors contract to propel bolus down, larynx closes to protect airway, UES opens, laryngeal closure allowing complete pharyngeal clearance

how does the esophageal phase work in pediatrics

peristaltic waves carry bolus to stomach, ends when food passes through gastro-esophageal junction, LES prevents reflux going up, connects to the stomach from LES

what is the oral prep phase in pediatrics

gathering and preparing liquid/bolus in the mouth for swallowing

how do the oral, pharyngeal, laryngeal anatomies differ in infants compared to adults

infant's tongue fils their mouth, cheeks have sucking pads, larynx is 1/3 of adult size, narrow epiglottis, soft palate and epiglottis are in contact to provide additional airway protection

what are the components involved in oral motor assessment

adaptive, protective, lips/cheek/jaw/tongue/palate

how do you assess adaptive oral motor components

assess rooting, sucking, licking - if there is NO sucking reflex, then something is wrong neurologically

how do you assess protective oral motor components

coughing and gagging

what is typical versus atypical anatomy when assessing oral motor

there should be labial closure around the lips when a pacifier is put in, the jaw should not be too tight and should open/close, when baby cries see if the tongue protrudes and moves

what structures should be assessed during the oral motor exam that may impact feeding and swallowing

lips, jaw, tongue, palate, cheeks

for a normal term infant, what is the typical sucks per burst

20-30 sucks per burst

at 32 weeks gestation age, what is the sucks per burst

anywhere from 2-3 suck cycles

what is a typical development for a healthy infant

suckle reflex on the nipple, suck swallow ratio, volitional sucking

T/F: infants need to learn immature pattern of sucking first and as they transition to the mature pattern they can scaffold down when fatigued

true

when evaluating sucking, what does NNS look like

no nourishment, oral motor skill, 2 sucks per second, 6:1 ratio, 7-8 sucks per burst

what is typical for preterm infants at 34 weeks compared to 36-38 weeks

non nutritive sucking bursts show significant frequency modulation which depends on respiratory health status

how does sucking burst change from the start of oral feeding in infants to the end of feeding

starts with 20-30 sucks per burst and ends with a sucking pattern that is present and moving towards different feeding

how many sucks per swallow is at the beginning and end of feeding due to fatigue

the suck swallow ratio at beginning of feeding is 1:1, during feeding is 2:1, and end of feeding is 3:1

what does a disorganized sucking pattern look like

uncoordinated suck swallow breathe, inconsistent rhythm, stress cues, prolonged feeding time

what types of patients exhibit a disorganized sucking pattern

preterm infants, infants with neurological conditions, NAS babies

what are oral symptoms of dysphagia in infants and pediatrics

anterior loss of bolus, abnormal sucking pattern, abnormal reflexes, abnormal movement of structures

what are pharyngeal symptoms of aspiration or dysphagia in infants and pediatrics

coughing, gagging, stridor, apnea, increase work of breathing, wet breathing, refusal, eyebrow raise

what types of dysphagia symptoms would you observe in an infant or child with cardiac and respiratory (congenital heart disease, aspiration pneumonia, respiratory distress syndrome) comorbidities

feeding fatigue, aspiration, coughing/choking

what types of dysphagia symptoms would you observe in an infant or child with neurological (microcephaly, CP, CVA, TBI) comorbidities

poor oral motor control, uncoordinated suck swallow breathe, aspiration

what types of dysphagia symptoms would you observe in an infant or child with airway/structural (laryngeal cleft, tongue tie, laryngomalacia) comorbidities

stridor due to narrowing

what types of dysphagia symptoms would you observe in an infant or child with genetic (Down syndrome, Pierre robin syndrome, cleft lip) comorbidities

poor oral motor function, hypotonia

how does neurological disorders impact swallowing

may cause neuromuscular oral and pharyngeal dysphagia due to low or high tone

how does respiratory and cardiac disorders impact swallowing

poor laryngeal elevation, epiglottic inversion, ineffective bolus prep, vallecula pooling

what should you look for when assessing maternal history and delivery history

maternal - fertility issues and antepartum

delivery - delivery type and any complications

when assessing family framework, what should you ask/discuss

parents goals for the child and cultural beliefs that may impact feeding

what did Dr. Als come up with

synactive theory of development

what are the components of the synactive theory of development / what are the stress cue symptoms

autonomic, motor, state

what should you look for each component of the synactive theory

physiological stability, motor organization, behavioral state organization, attention and interaction, self regulation

what are the stress cues for oral feeding for autonomic system of synactive theory

Brady or tachycardia, apnea, work of breathing, skin color changing, tremors

what are the stress cues for oral feeding for motor system of synactive theory

flaccidity, hypertonic, eye brow raise, finger spreading, tongue thrust, frowning, extension of extremities

what are the stress cues for oral feeding for state system of synactive theory

diffuse, periods of crying, low alertness, gaze aversion, uncoordinated eyes

how many stages are there in the state system and which is the stage we want the baby in for feeding

6 stages, we want the baby in stage 4 which is the quiet alert stage

what are stability cues for autonomic systems in the infant

stable heart rate, smooth respiration, stable color and digestion

what are stability cues for motor systems in the infant

hand clasping, trunk flexion, sucking, hands to face, modulated tone

what are stability cues for state systems in the infant

smooth transitions, self consoling, appropriate responses, focused

how does neuromotor (posture, tone, alignment) impact feeding

proper alignment and postural support allows for appropriate suck swallow breathe and safe swallowing, and having normal tone allows for stability with oral motor control

what is considered atypical and typical within neuromotor category

atypical - hypo and hypertonia, misalignment for posture

what are you assessing in the sensory category

tactile, vestibular, olfactory, gustatory, auditory, visual

what was the sense program that Dr. Bobbi Pineda created and what does it do in each category

supporting and enhancing NICU sensory experiences

tactile - tolerate touch, vestibular - handling transfers, olfactory - responding to milk presentation, gustatory - responding to diet, auditory - sounds and stimuli reactions, visual - responding to light

how does the environment impact oral feeding

direct lighting should be avoided when feeding, and having sound levels beneath 50db

what can you modify (to the environment) to help with oral feeding and stability and regulation for the infant

telemetry, positioning, bed space, phototherapy

what are signs and symptoms of dysphagia in infants

disengagement with feedings, stress cues, wet vocal quality, increased congestion, stridor, wheezing, coughing

when is it possible for an infant to silently aspirate

the cough doesn't integrate until 52 weeks, so the infant could be silently aspirating before

what are oral phase deficits seen typically in infant with neuro diagnosis

poor bolus control or formation causing spillage into airway, hypotonia

what are oral phase deficits seen typically in infant with respiratory diagnosis

incoordination sucking and breathing, shallow and short sucking bursts

what are oral phase deficits seen typically in infant with cardiac diagnosis

fatigue with sucking, weak oral intake, reduced endurance

what are oral phase deficits seen typically in infant with genetic diagnosis

hypotonia, enlarged tongue, poor suck strength

what are oral phase deficits seen typically in infant with airway/structural diagnosis

nasal regurgitation, difficulty with oral transport

what are pharyngeal phase deficits seen in infants with neurological diagnosis

delayed swallow reflex, inadequate laryngeal elevation, vallecular pooling

what are pharyngeal phase deficits seen in infants with respiratory diagnosis

incomplete airway protection, swallowing during inhalation

what are pharyngeal phase deficits seen in infants with cardiac diagnosis

reduced coordination due to fatigue, ineffective airway protection

what are pharyngeal phase deficits seen in infants with genetic diagnosis

reduced pharyngeal strength, delayed initiation of swallow

what are pharyngeal phase deficits seen in infants with airway/structural diagnosis

abnormal anatomy, incomplete glottic closure

when should you recommend alternative nutrition and hydration

if the child's swallowing safety and efficiency cannot reach a level of adequate function or isn't supporting nutrition and hydration

what are the types of alternative nutrition and hydration

nasogastric, transpyloric tube, gastronomy tube

who makes the decision for what alternate nutrition method is used

swallowing and feeding team will consider which tube is best meeting of needs and how long it will be placed

when do you recommend a G tube

when there is a long term inability to meet nutritional needs such as other medical conditions

when do you recommend a home NG tube

when swallowing ins't safe and can be monitored safely at home by family for short term

what is the cue based feeding and infant driven feeding approach

approaches that start feeding when behavioral and physiological cues are shown rather than a specific time or age

how do you assess the quality of feeding (infant driven approach) and what signs do you look for

extended airway closure, fluid threats to airway, reduced rate and depth of breathing

what are the oral motor cues readiness cues for infant driven feeding approach

leaning towards nipple, hands to mouth, positive vocalization, rooting

what are the physiological stability readiness cues for infant driven feeding approach

quiet alert state, stable cardio-respiratory status, active engagement

what are the engagement and disengagement cues infants demonstrate during oral feeding to show good quality or poor quality with symptoms of stress and dysphagia

engagement cues like rooting, sucking, coordinated suck swallow breathe shows the infant is engaged in feeding and disengagement cues like turning head away, spreading fingers, crying shows there may be some distress

why do you use a flow rate/bottle equipment and how does it help the infant with suck/swallow/breathe coordination

we use bottle equipment because respiration, feeding ability, and swallowing are all affected by the flow rate; a slower flow rate allows for feeding efficiency, shorter duration, and quicker skills

why do you use pacing and how does it help the infant with suck/swallow/breathe coordination

it uses breaks to help facilitate improved burst/pause rhythm, breathing regulation, and bolus control leading to skill development and positive stress free experience

why do you use swaddling and how does it help the infant with suck/swallow/breathe coordination

provides an external support for postural stability resulting in increased endurance and focusing on feeding

why do you use positioning and how does it help the infant with suck/swallow/breathe coordination

changing positioning may help with stability and increasing oxygen saturation, swallowing safety, and endurance for feeding

what are the IDDSI levels

foods - regular, soft and bite sized, minced and moist, puréed, liquidized

drinks - thin, slightly thick, middle thick, moderately thick, extremely thick

how does IDDSI work and how do you use it

created to create a global terminology for textures and used when describing the state of foods/liquids

what does IDDSI stand for

International dysphagia diet standardization initiative

what are types of thickening agents

rice cereal, oatmeal cereal, gel mix, simply thick, thick it, Pura thick

what age are thickening agents safe for

depends on the type, but many can be used to thicken breastmilk indicating they are safe for infants

what are the indications for using different types of thickening agents

doing an MBS/VFSS, reduced oral control, uncoordinated suck/swallow/breathe,

what are the contraindications for thickening agents

newborns or preterm infants, allergies or intolerances to the agent, compromised GI, not looking at instrumental assessments first

what factors impact how liquids thicken

what the primary ingredient is, if it needs to be heated

how do you thicken breastmilk vs formula

breastmilk breaks down over time and needs appropriate temperature and timing to thicken, while formula is more stable and easier to mix

why might pre-thickened formula be used

is the baby needs additional help to tolerate the milk, they may need a more pre-digested and thicker formula to keep it down

how do you manage reflux with pre thickened formula

choosing the most appropriate formula mixture, properly preparing the bottle, adequate positioning during feeding

do you recommend thickened liquids without an instrumental assessment

no - instrumental assessment shows us if there is aspiration or any issues with thickened liquids

how does IDDSI get utilized in instrumental assessment

helps with standardization of test materials, utilized to describe levels during documentation, helps match test textures to real life recommendations

how might IDDSI be used and discussed with parents

shows a visual and scale to define texture which allows for clear communication of the child's needs

what are the 4 pillars of PFD

medical, psychosocial, nutrition, feeding skill

what are the considerations under medical pillar of PFD

cardio and respiratory problems during feeding, aspiration

what are the considerations under nutritional pillar of PFD

malnutrition, nutrient deficiency's, reliance on oral supplements

what are the considerations under feeding skill pillar of PFD

needing texture modifications, modifying equipment and positioning

what is the considerations under psychosocial pillar of PFD

avoidance behaviors when feeding, inappropriate caregiver management, disruption of social functioning due to feeding

what is the criteria needed for a child to qualify in a pillar of PFD

needs at least 1 of the pillars and considerations, must be ongoing for 2 weeks

what feeding milestones are expected for 4-6 months and what IDDSI levels should they be expected to eat

breast and bottle fed liquids, introducing smooth pureed food, gagging acts as protection, spoon eating

what feeding milestones are expected for 6-9 months and what IDDSI levels should they be expected to eat

thin liquids may be introduced like water, sippy cup drinking introduced, tongue lateralization