PMI Exam 3

Anatomical differences between infants & older children

• smaller jaw

• larger tongue

• smaller palates

• fatter cheeks

• smaller oral cavity

How many branchial arches are there? When do they morph?

6 original that morph into 5

morph around 4 weeks gestation

Birth before __ weeks is considered __?

37

premature

When is gut development complete?

by 20 weeks, but still maturing post natal and into early infancy

When does lung development start and end?

starts at 23 weeks and is fully developed by 37 weeks

How does the central nervous system develop?

bottom up

• 1st trimester: early synapses form at the spinal cord

• 2nd trimester: brainstem begins to mature

• 3rd trimester: cerebral volume and surface area increase

T or F: the brainstem is the most highly developed area of the brain at birth and controls all life-sustaining reflexes

true

In bottle feeding, how does a child achieve NEGATIVE pressure?

by moving their tongue and jaw in a downward motion to create suction

In bottle feeding, how does a child achieve POSITIVE pressure?

by moving their tongue and jaw in an upward motion to force fluid out of the end on the nipple

T or F: you don’t need both compression and suction to be efficient and successful at bottle feeding

false

What is the purpose of lung surfactant?

to increase pulmonary compliance and prevent lung collapse

• present by 28 weeks

• fully mature by 37 weeks

• adequate respiration between 32 and 34 weeks

What is tongue protrusion? (PROTECTIVE)

the anterior propulsion of the tongue to push food out of the mouth to protect the air way

• present late in the third trimester and diminishes by 3-5 months of age

What is tongue lateralization? (PROTECTIVE)

moving the tongue towards the stimulus and serves to protect the airway by pushing the food to the side of the mouth where it can be held between the gums or chewed

• emerges late in the third trimester and by 6-9 months of age it is integrated into more refined, voluntary tongue movements for chewing

What is phasic bite? (PROTECTIVE)

a response to tactile stimulation of the gums

it protects the airway by holding food between gums and breaking up large food particles

• emerges late in the third trimester and diminishes by 9-12 months of age

What is gagging? (PROTECTIVE)

a response to tactile stimulation to the posterior two thirds of the tongue and PPW

tongue protrusion and pharyngeal contraction to eject the bolus from the pharynx and soft palate elevation to prevent nasal regurgitation

• emerges in the third trimester, becomes less prevalent around 6-9 months of age

• can be highly variable between individuals

What is coughing? (PROTECTIVE)

response to the presence of material in or near the entrance to the laryngeal vestibule

• emerges early in the third trimester and continues into adulthood

• “down the wrong tube”

What is rooting? (ADAPTIVE)

tactile stimulation to the side of the lips or cheek

infant will turn their head laterally towards the stimulus and open their mouth

• emerges during the third trimester and continues to 3-6 months of age

• occurs earlier in infants who are bottle fed

What is suckling? (ADAPTIVE)

tactile stimulation occurs to the top of the tongue or middle of the hard palate

infant will move the tongue in a forward-backward motion in the horizontal palate

• emerges early in the third trimester and continues to 3-6 months of age

What is the difference between sucking and suckling?

SUCKING: volitional pattern used by older infants/children/adults to draw fluids into the mouth

SUCKLING: reflexive pattern used by young infants to feed from the breast of bottle and to self-soothe

What are examples of pureed foods? What age should you introduce them?

4-6 months

thin cereals, pureed fruits/veggies

apple sauce, pureed carrots

What are examples of mashed/lumpy solid foods? What age should you introduce them?

7-9 months

mashed bananas, soft cooked vegetables with small lumps

What are examples of soft foods? What age should you introduce them?

9-12 months

boiled pasta, soft cooked vegetables, soft pieces of fruits

very ripe pear

What are examples of soft mechanical foods? What age should you introduce them?

12-18 months

small pieces of bread, soft cheeses, chopped cooked meats

scrambled eggs

What are examples of harder solid foods? What age should you introduce them?

18-24 months

raw fruits and vegetables (with supervision), firmer bread, crackers

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

• fully supported positioning (sidelying, cradle hold, upright supported)

• not self feeding

• need oral skills for breastfeeding and bottle feeding (suckling)

• no oral skills for solids as they are unable to bite or chew

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

• able to maintain supported sitting position posture for a short period of time (high chair with straps)

• oral skills for self feeding: hands to mouth (bilateral), reduction in gag reflex and tongue thrust/protrusion

• oral skills for liquids: breastfeeding and bottle feeding (suck)

• oral skills for solids: reduction in tongue protrusion, purees from spoon, unable to bite or chew

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

• can sit upright but need support

• oral skills for self feeding: hands to mouth (unilateral), messy self-feeding

• oral skills for liquids: breastfeeding or bottle feeding, introduce open cup or weighted straw cup

• oral skills for solids: early chewing, early tongue lateralization, early teeth, introduce textures solids, offer spoonable foods

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

• can sit upright with minimal assistance

• self feeding: combination of self-feeding and requiring assistance

• oral skills for liquids: breastfeeding, bottle feeding, open cups or straw cups

• oral skills for solids: chewing, improving tongue lateralization, more teeth, offer soft pieces, hold food between teeth, offer teething toys

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

• can sit upright without support

• self feeding: largely self feeding

• oral skills for liquids: cup or straw drinking, often still breastfeeds or bottle feeds

• oral skills for solids: efficient chewing, good tongue lateralization, most teeth present, biting through firm foods, offer hard mechanicals

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

• can sit upright without support

• self feeding: predominately self feeding

• oral skills for liquids: cup or straw drinking, may still breastfeed or bottle feed

• oral skills for solids: efficient chewing, good tongue lateralization, most teeth present, biting through firm foods, offer hard mechanicals

What are some feeding difficulties in infants?

• irregular SSB pattern

• changes in respiratory patterns during feeding

• irritability during feeding/refusals

• excessive drooling, gagging, vomiting

• slowed or delayed swallows with residue

• prolonged meal times

What are some feeding difficulties in children?

• coughing, choking, gagging

• crying and arching

• vomiting

• difficult to feed

• poor weight gain

• indication of feeding/breathing + ongoing respiratory issues

• failture to transition through food types

• food aversions to specific textures or food types

What are some respiratory and cardiac disorders that can affect feeding?

• congenital heart disease

• bronchopulomary dysplasia

• respiratory distress syndrome

What are some gastrointenstinal disorders that can affect feeding?

• hirschsprung’s disease (no nerves in large intenstines)

• tracheoesophogeal fistula (eating but not absorbing)

What are some neurologic disorders that can affect feeding?

• cerebral palsy

• hypotoxic ischemic encephalopathy

What are some congenital abnormalities that can affect feeding?

• cleft lip/palate

• craniofacial abnormalities

• VPI

• Pierre Robin Syndrome

What are some maternal and perinatal conditions that can affect feeding?

• jaundice

• gestational diabetes

• fetal alcohol syndrome

• neonatal abstinence syndrome

What are some iatrogenic complications that can affect feeding?

• caused by medical errors or adverse drug reactions

• traumatic birth

What are some miscellaneous complications that can affect feeding?

• tonsillitis

• tongue-tie

• sensory processing disorders

• ASD

CDH

TEF

When is tube feeding used and what are the common types?

• when an infant or child cannot safely feed by mouth or does not have the skill, coordination, or endurance for oral feeding

• NG, G-tube, J-tube

What are some potential complication of tube feeding?

• development of oral sensitivity or oral aversion

• inefficient oral motor patterns

• poor postural and muscle control

• delay in developing normal oral feeding skills

what is HYPERsensitivity in regards to feeding? Symptoms?

sensory defensiveness

• overreaction to sensory input

  • picky eating; refusal of certain foods

  • gagging or vomiting in response to textures or smells

  • reluctance to touch food with hands

  • accepting food only when spoon-fed, but not self-feeding

What is HYPOsensitivity in regards to feeding? Symptoms?

sensory under-registration

• reduced awareness or response to sensory input

  • messy eating; food all over face

  • over-stuffing mouth with food

  • drooling

  • choking due to poor oral processing

  • seeking strong flavors and textures

  • oral stimulation behaviors

What are some treatment strategies for hyper/hyposensitivity?

• non food and food based sensory preparation before meals

• prepare feeding environments (minimize distractions)

What are the alert states?

deep sleep, light sleep, drowsy, quiet alert, active alert

What alert stage is best for feeding and why?

Quiet Alert

• the infant is calm, focused, and can coordinate sucking, swallowing, and breathing effectively

What is a VFSS/MBSS?

x-ray video of swallowing while eating/drinking foods mixed with barium

it shows all the phases of swallowing

• requires radiation exposure, special seating, and cooperation

• good for viewing aspiration, penetration, and timing of swallow across multiple textures

What is FEES?

small camera scope passed through the nose to view the pharynx and larynx during swallowing

• no radiation exposure

• provides a direct view of airway protection before and after the swallow, but cannot see the swallow during “white-out”

• can also assess sensory responses with air puffs (FEESST)

Which imaging technique is used more frequently with children?

VFSS/MBSS

What should be asked/included in a case history?

medical history, growth history, dietary intake, early feeding history, developmental history, current feeding ability, mealtime behavior, parent concerns, bowel movements

Why is it important to ask about bowel movements?

could indicate constipation or signs of GI issues

What does a GOOD breast latch look like?

wide mouth opening (taking in both the nipple and large portion of areola)

lips flanged outward

rhythmic, strong, SSB coordination

audible swallowing sounds (ka or gulping)

no clicking or smacking sounds

minimal to no maternal nipple pain

infant has steady weight gain and appears satisfied after feeding

What does a POOR breast latch look like?

shallow latch (only the nipple in mouth, little to no areola)

lips tucked in or pursed tightly

clicking, smacking, or noisy sucking sounds

inconsistent or weak SSB pattern

maternal nipple pain, cracking, and/or bleeding

infant shows signs of frustration, fatigue, or inadequate intake

What structures get ASSESSED in an oral mech?

• lips (closure)

• palate

• tongue

• jaw (muscle tightness) —> PT

• teeth (if present)

• cheeks

What structures get OBSERVED in an oral mech?

• structure

• symmetry

• appropriate sizing

• tone (hyper/hypo)

• range of motion

What is the difference between aspiration and penetration?

aspiration is BELOW the vocal folds

penetration is ABOVE the vocal folds

What is nutritive suckling? What is the ratio?

used for feeding

1:1 ratio initially, 2:1 or 3:1 by end of feed

suck rate: approximately 1 per second

What is non-nutritive sucking?

used for self-soothing

6:1 to 8:1 ratio

suck rate: approximately 2 per second

What is the purpose of thickened liquids?

to slow the flow of liquids, giving the child more time to close the airway before swallowing

• helps improve swallow safety for children with dysphagia

• helps reduce aspiration risk and reflux-related complications

What is operant conditioning?

a reward-based system used to shape feeding behaviors

• the child is given specific food-related goals (take one bite) and then receives a reward (praise, toy) for meeting the goal

• the main focus is on reinforcing desired behaviors and reducing undesirable mealtime behaviors

not ideal to reward with “bad food”

What is systematic desensitization?

a gradual exposure approach to reduce food-related anxiety or refusal

• children are slowly exposed to different foods through play-based activities that gradually become more challenging

• goal is to build tolerance to new foods over time without pressure

What are three PROS to OSM?

• improves oral motor skills (chewing, tongue movement) and sensory processing for eating and drinking

• may help children with hypersensitivity or oral-motor weakness

• incorporates a variety of tools and programs

What are three CONS to OSM?

• limited research evidence supporting its effectiveness

• criticism of lack of specificity

• outcomes may vary widely between children, with no standardized method to measure success

What is feeding positioning in infants?

feeding is more upright or side-lying to allow a slower flow of liquids by reducing gravity’s pull, helping to prevent choking and aspriation

What is feeding positioning in older children?

encouragement of a chin tuck during drinking to protect the airway and avoid neck extension, which can increase aspiration risk

What does pacing look like in infants?

the caregiver imposes breaks during feeding (removing the nipple briefly) to allow time for safe swallowing and breathing

What does pacing look like in older children?

children may be prompted to take breaks (verbal cues or controlled cup delivery) to regulate intake and breathing coordination

What does feeding equipment look like in infants?

use slow-flow nipples or non-drip designs to control the milk flow rate

What does feeding equipment look like in older children?

use of weighted straw cups, cut-out cups, or InfaTrainer cups to make swallowing sager and more manageable