Treatment of feeding and swallowing difficulties in infants and children

Setting therapy goals

• effective interventions need to target the cause of the problem (think about providing compensatory strategies but it’s most important to get rid of the root of the problem)

• a thorough assessment is required to guide intervention

• once the nature of the problem has been established, the treatment plan can be developed

Models of service delivery

• providing therapy in different ways for different clients

Service delivery: location of services

• inpatient: don’t get the patient for long, most important to make sure they have psychogically ability

• outpaitent: client comes and sees the SLP

Service delivery: primary recipient of input

• child: can work one-on-one w/ the child

• parent or caregiver: parents can provide care for children

• staff (eg. hospital, daycare, school)

Problem with parent or caregiver giving the intervention

• sometimes kids don’t respond to their parents during intervention

Service delivery: members involved in sessions

• individual: more attention on one client

• group: social behavior learning, may not work for every child

Service delivery: frequency of sessions

• Weekly or intermittently

• intensive

• consult only

Pediatric therapy focuses: swallowing and airway protections

• thickened fluids

• positioning

• feeding equipment

• pacing

• modified foods

Pediatric therapy focuses: feeding and mealtime behavior

• oral sensory-motor therapy

• feeding utensils and equipment

• behavioral feeding therapy

Use of thickened fluids

• improves swallowing and airway protection

1. children with swallowing problems (dysphagia)

a. to slow the rate of fluid flow, thereby allowing more time to close the airway prior to the swallow. - flow rate will decrease

b. thickened fluids “hold together” better than thin fluids so are easier to control in the mouth

2. infants who display regurgitation

rational: thickened feeds may be less likely to be regurgitated from the stomach back to the esophagus

Considerations regarding thickening fluids

• too thin → increased risk of aspiration

• too thick → increased work of breathing → increased fatigue

Factors affecting the thickness of thickened fluids

• type of thickening agent: 2 main types starch based and gum based

• type of base fluid: water vs. milk vs. juice

• amount of base fluid: how much base fluid vs. amount of thickener is not linear

• temperature: get thicker at cooler temperature, stay thinner when warmer

• standing time: overall fluids get ticker w/ time, don’t prep way ahead of time (even like 10 minutes)

Positioning while breast feeding

• because of the effects of gravity, fluids flow faster vertically than horizontally

• positioning an infant in a more upright position versus a reclined supine position can slow the flow of feeds.

Position images

• 

• faster b/c of more angled milk jumps back of throat quicker

slower

Positioning laying down

• by positioning a infant side-lying position versus a supine position may also SLOW the flow of feeds

• for older children, encouraging a chin-tuck position for airway protection and avoiding neck extension while drinking can slow the flow of drinks

feeding equipment for infants

• aim: to slow the flow of fluids

• for infants:

-slow-flow nipples: one hole, give more reaction time

-nondrip nipples: as soon as they stop sucking there’s no drip

feeding infants: for older children

• slow the flow of fluids

-straw

-cut-out cups

Pacing

• intentionally slowing things down during feeding by imposing breaks during feeding and drinking to interrupt the flow of fluids

Pacing for infants

• for infants: the feeder may actively impose breaks to allow the child to swallow and catch his or her breath

Pacing for older children

• it can be done based on infant cues or on a schedule

• may prompt the child to take a break from drinking by using verbal cues or by manually controlling the cup

Swallowing Maneuvers

• many of the therapeutic strategies used with adults may not be possible with young children

• Main reason: they do not have the cognitive skills to understand or follow detailed instructions or the self-awareness to voluntarily control movement of anatomic structures

• Some therapeutic strategies may be possible to elicit with positioning change or modeling (chin tuck, head turn)

• generalization is limited

Modified foods

• by 2 to 3 years of age, most children have the oral skills to eat most solid foods

• some children with developmental delay and neurologic impairment may require modified food textures beyond this age

- special considerations:

• developing motor skills

• developing cognitive ability

Oral Sensory-Motor Therapy (OSM)

Aim: to modify the child’s current oral motor skills and sensory processing ability in relation to eating and drinking

• mostly applied for preterm infants

• insufficient evidence exists regarding the effectiveness of OSM therapy

• Example of commercial OSM programs: MORE program, the beckman protocol, and the Talk Tools approach

• The main criticism: lack of specificity in OSM programs

Feeding utensils and equipment

• Easier for younger kids than older kids

• a variety of feeding utensils and equipment are available commercially

special feeding equipment:

• teething toys

• oral stimulation toys (pacifiers, teething rings, gum brushes, vibrating oral toys)

• mouth toys (tubing for chewing, bite blocks, tongue depressors, oral blow toys)

Shape of nipple: Normal vs. Orthodontic nipple

• orthodontic nipple: requires less muscle strength b/c nipple is thinner

• slows rate of overall feed

Flexibility of nipple: latex and silicone

• silicone nipple: firmer harder to suck milk

• latex nipple: softer and easier to compress, require less effort

Length of nipple: long vs. short

Long: beneficial for cleft palate and reaches further back requiring less work needed

Flow rater: slow, medium, fast nipples

• BIGGEST FACTOR

• Size and number of holes

• faster slow can overwhelm a baby

Slow: recommended: requires more work from child

medium: 3-6 months (6 holes)

fast: 6+ months (9 holes)

Bottle feeding: some nipples are designed for restricted flow

• flow type (restricted flow or nondrip nipple)

• Pressure release valves: (e.g. one-way valves/tube or air release holes): help them save energy later

  

Outcome to consider when comparing bottle nipples:

• volume taken during bottle feed

• duration of bottle feed (minutes)

• rate of bottle feed intake (mL per minute or oz per minute)

• incidence of physiologic abnormalities during bottle feeds

• number of breaks needed during bottle feeds

• infants fussing or refusal behaviors during feeds

• number of bottle feeds taken per day

• time take to transition from first oral bottle feed to exclusive oral feeding

Behavioral Feeding Therapy

Goals:

• increasing desirable mealtime behavior

• decreasing undesirable mealtime behavior

• improving adequacy of dietary intake from food versus supplements

• improving dietary variety

• maintaining or improving growth

• reducing parent stress

Operant Conditioning

• Change behavior directly

• designed to improve feeding difficulties and increase oral intake through specific prompted food goals and a reinforcement system

• top-down driven approach caregiver is guiding the feeding and reinforcing the behavior

• take a bite → get a reward

Systematic desensitization

• change child’s relationship

• designed to improve feeding difficulties and increase oral intake by exposing children to a range of food in play-based activities, which become gradually more challenging

• bottom-up, exposure therapy, help child become more comfortable and regulated

• learning to self-regulate around food

Operant Conditioning: antecedent Prompt

• verbal prompt

• visual prompt

• physical prompts

Operant conditioning: consequence for desirable behaviors

• spontaneous social reinforcement

• specific verbal reinforcement

• object reinforcement

Operant conditioning: consequences for undesirable behavior

• preventing escape

• verbal redirect

• withholding attention

• withholding reward

Operant conditioning: primary outcome measures

• volume consumed

• reduction of undesirable behaviors

Operant Conditioning: size of group

• usually individual, as it is difficult to provide contingent reinforcement to multiple children at once

Systematic Desensitization: Antecedent Prompt

• modeling

Systematic Desensitization: consequences for desirable behavior

• spontaneous social reinforcement

Systematic Desensitization: consequence for undesirable behavior

• withholding attention

• verbal redirect, if needed

Systematic desensitization: primary outcome measures

• variety (number) of foods consumed, level of interaction with food

Systematic Desensitization: size of group

• may be individual

• often in group format, extra participants adds to the amount of modeling and spontaneous social reinforcement to which the child is exposed

Measuring therapy outcomes: feeding skills

• oral skills

• swallow safety

• variety of foods texture consumed

• variety of food types consumed

• number of foods and fluids consumed across key food groups

• self-feeding skills

• mealtime duration

• mealtime behavior

Measuring therapy outcomes: diet

• work w/ dieticians

• nutritional adequacy from oral diet (overall energy intake, intake of key nutrients)

Measuring therapy outcomes: growth

• change in weight

• weight for height and body mass index

Measuring therapy outcomes: social factors

• parent-child interaction

• parent stress

• parent satisfaction

• child satisfaction