Feeding

Feeding, Eating & Swallowing: DX

• Prematurity

• Neuromuscular abnormalities

• Structural malformations

• Gastrointestinal conditions

• Visual Impairments

• Tracheostomies

• Autism Spectrum Disorder (ASD)

Indicators of swallowing problems

• Clinical Observation of the following:

  • Gagging

  • Coughing

  • Choking

  • Nasopharyngeal Reflux

  • Wet vocal quality

  • Respiratory infections and/or pneumonias

Dysphasia

• Difficulty swallowing

  • It can affect child ability to eat SAFELY

• INTERPROFESSIONAL COLLABORATION IS IMPORTANT!

  • Collaborate or Refer to SLP

Feeding, Eating & Swallowing: Structures

• Oral cavity houses the structures that allow successful management of food and liquids

  • Hard and soft palate

  • Faucial arches

Functions of Oral Structures

• Pharynx

  • Funnels food into the esophagus

• Larynx

  • Valve to the trachea that closes during swallowing

• Trachea

  • Allow air to flow into bronchi and lungs

• Esophagus

  • Carries food from the pharynx into the stomach

Phases of Swallowing

• Oral Preparatory Phase : “ Preparation is pleasant”

  • Oral manipulation of food resulting in a bolus

• Oral Phase “Moving the food back”

  • Bolus is moved posteriorly towards the pharynx, elicits swallow response

• Pharyngeal Phase “Pharynx, Swallow”

  • Swallow triggered, larynx (epiglottis) covers the airway, esophagus opens

• Esophageal Phase “Esophagus”

  • Bolus enters esophagus and into stomach

CHEWING PATTERS

• 3-6 MONTHS: SYMMETRIC oral motor movements

  • MUNCHING, symmetric up and down movements

• 8-12 MONTHS: VERTICAL chewing movements

  • DISASSOCIATION between the jaw and tongue

• 12 MONTHS: Rotary chewing skills

  • Diagonal jaw movements and lateral tongue movements

• BY 5 YO: Fully functional adult patterns have developed

HIGHLY CHOKABLE FOODS should be introduced w/CAUTION at 3 YO

COMPREHENSIVE EVALUATION

• Begin w/ gathering information

  • Interviews, chart reviews, questionnaires, feeding hex

• Hands on Evaluation

  • Muscle tone, movement, sensory processing, development

• Structural observations

  • Outer oral structures (symmetry, tone, ROM) then intraorally

• Observe the child eating

  • W/ caregivers using familiar home routines

ADDITIONAL DIAGNOSTIC EVALUATIONS

• Swallow Studies:

  • Video Fluoroscopic Swallow Study (VFSS) or Upright Modified Barium Swallow Study (UMBSS)

    • Identifies:

      • Aspiration or risk of aspiration

      • Positioning issues

      • Determine safe food and liquid consistencies

FOOD TEXTURE LEVELS

• LEVEL I: Puréed- Pudding

• LEVEL II: Mechanically Altered- Moist & Minced or Mashed

  • Ground or minced meats, fork-mashed fruits/vegetables

• LEVEL III: Advanced- Animal Crackers, Asparagus (cooked)

  • Crackers, breads. Cooked vegetables, soft fruits, meats

• LEVEL IV: Regular- No Restrictions

LIQUID CONSISTENCY

• Thin: Consistency of water, juice, and milk

  • Broth and foods that melt (ice & ice-cream)

• Nectar: consistency of tomato juice

  • Natural fruit nectars and yogurt smoothies

• Honey: consistency of honey

  • Slow drips off the spoon

Grading Self-feeding

• Grading-Mastery, Then, Grading-Mastery

  • Build tolerance over-time (physical or sensitivity)

  • If sensitive to textures/flavors gradually introduce them or combine them w/ something they like

Layman’s Term

• Prioritize Safety!

• NPO/Safety concerns: Get them used to having things in their mouth ( explore mouth, crewing on toys, dip toy in juice (only if medically permitted)

• Motor skills: Adapt w/ equipment, practice motor skills in a low-risk way, feed w/foods that are safe.

• Position: Supported up-right or slight recline, midline neck and trunk

Proximal Stability leads to distal mobility!

• Trunk stability > Head/neck stability > Jaw stability > Tongue/lip control

• CHIN TUCK is always relevant for feeding

Cranial Nerves (CNs)

• I OLFACTORY

• V TRIGEMINAL: sensory fibers from check, nose, upper lip, teeth, skin over mandible, and lower lip

  • Motor fibers to muscles for mastication

• VII FACIAL: Sensory fibers from taste receptors to the anterior 2/3 of the tongue

  • Motor for facial expression and saliva glands

• IX GLOSSOPHARYNGEAL: Sensory for the posterior 1/3 of the tongue

  • Motor for swallowing and salivary glands

• X VAGUS: Sensory from the pharynx, larynx, esophagus, and stomach

  • Motor for pharynx, and larynx

• XII HYPOGLOSSAL: Motor to the muscles of the tongue

Feeding Intervention: Positioning

• Provide stability in the trunk and support the child in midline, with head/neck aligned in neutral/ slight flexion

  • Elevated supine or upright (SPECIALLY WHEN TURNED 4-6 MONTHS)

  • Face-to-face

  • Adaptive stroller (Kid Kart or Rifton Chair): kids w/ trunk support problems

  • Tumble forms feeder chair

  • Side-lying: Kids that are extremely week

• CONTRAINDICATION: Flat supine and propping the bottle on infant’s chest

Feeding Interventions: Environment

• Lack of Hunger/interest: Consistent mealtimes

• Wandering around: Consistent sitting location

• Limited intake: Longer meals (15-30 minutes)

• Weakness: Short duration meals

• Distracted: Limiting distractions (dim lights, reduce noise, soft music)

Feeding Interventions: Oral Motor

• Tonic bite/tongue thrust (sticking out): Place food laterally

• Immature tongue control: Facilitate tongue movements

• Suckling: Place finger on the tongue to apply pressure down

• Lip/cheek tightness: Cheek stretches

Feeding Interventions: Motor Control CONT

• Jaw Weakness: Non-nutritive chewing (sucking on toys,etc)

• To clear throat: Second swallow w/ verbal cues or offer an empty spoon

• Fatigue/ weakness: Controlled flow cup, smaller straw or spoon

Feeding Interventions: Adaptive Equipment

• Decreased Lip Closure:

  • Shallow bowl/ spoon

  • 1-way valve straw

• Sensory Integration:

  • Chilled spoon (temperatures)

  • Bumps or ridges in spoon

• Bite reflex

  • Rubber spoon

• Impaired oral suction

  • Shorter straw

• Fine Motor issues

  • Cup with a handle

• Neck Positioning

  • U-SHAPED (aka cut out cup/nosey cup)

Feeding Interventions: Delayed Transitioning

• Food Textures: Non-nutritive, tubing, mesh (put food inside)

• Drinking from cup: Oral motor, spouted cup, thickened liquid

• Oral feeding delays (NG TUBE): Oral exploration, tethers, desensitization, dip toy in juice

Hypo & Hyper-sensitivity

• Hypo- Arousal tecniques

  • Cold temperatures

  • Vibrating toys

  • Strong flavors

• Hyper-Calming/ desensitizing

  • Non-nutritive activities

  • Self-directed body (you can start body before oral) or oral play

  • Deep pressure

  • Gradually introduce textures and flavors

Feeding Interventions: Behaviours

Food selectivity can be very stressful for kids and parents!

• Structured, CONSISTENT ROUTINES, choices

• REDUCE GRAZING outside of meal time

• ALTERNATING non preferred foods w/ preferred foods

• POSITIVE REINFORCEMENT when they try new things

BEHAVIOR W/ FOOD SELECTIVITY

• If food selectivity is bad and there is concerns they aren’t eating enough our INITIAL ACTION IS:

  • Recommend a physician to RULE OUT MEDICAL CONCERNS

    • “ If they won’t eat fries there must be something wrong, CALL THE DOCTOR”

Feeding Intervention: Self-feeding

• Physical Impairments: Smaller snacks, shorter mealtime

• Postural Stability: Raised tray/table, elbows on table

• Uncoordinated: Dyced, lids, long straws, sticky food

• Cognition/behavior: Backward chaining, provide choices

• Poor Vision: Food orientation, contrasting colors

• Weakness: Lightweight utensil, built-up handle, universal cuff, mobile arm support, electronic feeding system

Cleft Lip and Palate

• Problems latching, prolonged feeding times, and milk leaking from nose

  • Strategies:

    • Upright feeding (>6o degrees)

    • Specialized bottles (squeezing)

    • Long soft nipple w/ one-way valve

FEEDING KEY LINE

“Don’t eat your PETS (eat French fries instead)

• Positioning

• Equipment

• Transitions

• Sensation