PEDS: FEEDING, EATING, NICU

Oral feeding is acknowledged as one of the first

neuro-developmental milestones for an infant

T or F

No one profession has sole ownership of the feeding and swallowing area

TRUE

T or F

OT can practice in the NICU at entry level

FALSE

OT treating in the NICU is NOT an entry level skill and requires specific training

T or F

AOTA states that OT's are able to provide evaluation and treatment of feeding, eating, and swallowing. Feeding/eating basic level.

TRUE

What should you do before working on feeding with a client

- Full chart review

- caregiver report

- get an update from nursing staff

- Know pts current medical status

Diet & Feeding History

• Oral or No oral feedings

• How being fed

• What are they eating

• Consistency (Formal assessment?)

• Length of time to feed

• Volume

• Swallowing Concerns

• Caregiver Concerns

Evaluation of Infant

• Facial Feature/Structures

• Reflexes

• Tone

• Arousal level

• Sucking Performance

• Suck-swallow-breathe Coordination

• Feeding Endurance

• Swallowing Coordinatio

Normal A&P of the Oral Motor Cavitity

• Palate: Intact surface with slight arch

• Lips: Full, symmetrical and approximate each other

• Tongue: Fills the oral cavity. Soft with cupped sides and rounded tip

• Cheeks: symmetrical fat pads

• Jaw: Upper and lower alignment

Patient Medical History

• Gestational age and Corrective age

• Past Medical

• Diagnoses: high risk are HIE, IVH's MAS, TEF, NEC, Genetics

• Surgical history

• Respiratory or Airway issues

• Previous hospitalizations

• Structural : Diagnoses and surgeries

• Days of oral intubation, # of times

• Social History: Primary language, learning style

Rooting reflex

- 0-3 months

- When the corner of the mouth is touched, the infant turns towards the sou

Phasic Bite Reflex

- (0-6 months)

- Rhythmic series of up/down jaw movements produced after pressure stimulation to the gums

Sucking Reflex

- (0-9 months)

- Triggered by touching the tip of the tongue and the incisive papilla. Allow for milk removal.

Suck-Swallow reflex:

- (0-9 months)

- Triggered by stimulating the posterior region of the tongue, soft palate, pharynx, and epiglottis with milk

Gag reflex

• Independent of swallowing

• Elicited by touching posterior tongue, pharyngeal mucosa or soft palate.

• Important with solid

Cough reflex:

• Important with liquids.

• By one month, 90% of infants have cough reflex

Positional Stability

provides decreased risk for aspiration in normal newborn infants at birth by close proximity of the following structures:

• Chin in contact with ribcage

• Jaw, tongue, and lips work as a unit

• Tongue is large and fills the small oral cavity

• Large, fat sucking pads provide stability

Low Tone

• Elongated neck with hyper- extension

• Jaw and tongue move separately or uncoordinated

• Tongue is elevated and retracted or can be flaccid

• Undeveloped sucking pads and low tone

CN V:

Lack of chewing and phasic bite

CN VII

Facial asymmetry and lack of tongue movement

CN IX & X:

Delayed swallow & Nasopharyngeal reflux

CN X, XII & V:

Gag motor

Left Recurrent Laryngeal Nerve

o Left vocal cord paralysis (PDA

ligation)

o Compression or stretched: needs time to recover

o Weak cry or cough

o Branch off the Vagus CN X

Behavior States

1: Deep sleep

2: Light sleep

3: Drowsy*

4: Quiet alert/awake*

5: Actively awake and aroused*

6: Highly aroused, agitated, upset

T or F

Always assess the behavioral state of a child before beginning, continuing, or ending a feeding session

TRUE

How Does Infant Suck?

• Lateral edges of tongue curl around the nipple

• Buccal pads stabilize the nipple

• Tongue grooving to allow fluid transit

• Lingual stripping of nipple - tongue tip elevation with anterior to posterior movement

• Mandibular protraction/ retraction

Burst

- Consecutive sucking pattern. - Longer sucking burst equals maturation of infant and efficiency of respiratory syste

Pauses

breathing breaks between continuous sucking patter

Sucking rate

1 suck per second

Sucking Rhythm

- Continuous sucking burst initially.

- As feed progresses, duration of sucking burst declines while pauses increase

Mature pattern:

lasts a duration of 30 seconds or 10-30 sucks per burst (SPB)

Rhythmicity

key component to good nutritive skills. Normal burst pause pattern

Inspiration

occurs before swallowing

Expiration

occurs after the swallow

Pattern

Infant sucks→ breathes in→ swallows → breathes out→ repeats pattern

Effects of SSB Incoordination

- Difficulty handling flow & taking a breath before the next suck

- Increased respiratory compromise or decreased ventilation

- Apnea or short sucking burst

- Inefficient feeding & greater respiratory compromise

Clinical Signs of Aspiration

• Frequent coughing or choking during swallow

• Inability to handle oral secretions

• Noisy, wet upper airway sounds during feeding

• Apnea, respiratory compromise, or wheezing during swallow and after feeding

• Multiple swallows to clear a single bolus

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• A FEES is where a thin, flexible score that has a tiny camera and light is passed through the nose and is placed above the epiglottis.

• Can assess salvia management and swallowing of liquid or food.

Signs of Feeding Readiness

+32 weeks PCA

• Intact oral motor reflexes

• Showing appropriate behavior state and hunger awareness

• Stable medically-respiratory system

• Tolerate basic handling without any significant signs of distress

Ideal Positioning

Infant swaddled in a blanket: Provides postural support and helps maintain the upper limbs/hands in midline for sensory-motor organization

Elevated Sidelying Position

Head and shoulders oriented to the side

• Head higher than belly

• Position used to slow the flow of the milk by lessening the effects of gravity on the liquid as it is transferred into the posterior pharynx

External Pacing

- Tilting of the Bottle or Infant

- Tilting of the bottle downward or infant forward to completely drain milk from the nipple

- Tilting the bottle so the nipple is ½ full of milk as the infant sucks

- Avoid air intake!

How to pace

• Allow infant to suck only a desired # of times

• Usually every 3-5 SPB or based on infant's cues

• Infant may require more aggressive pacing at beginning of the feed

• ½ nipple fill: decreases the orthostatic pressure

T or F

Infant should be doing more of the work than the feeder

TRUE

Behaviors That The Infant Demonstrates As Signs Of Stress

• Extreme changes in vital signs or color

• Excessive Straining or Squirming

• Startling, Tremoring or Twitching

• Coughing, Sneezing, or Yawning

• Stiff legs, arms or Splaying of fingers

• Excessive Arching back and neck

• Having a dull, tired, glassy eyed appearance

• Extreme arousal level changes: Suddenly going to sleep or fussy

T or F

No evidence that inclined HOB

prevents Reflux

TRUE

Birth to 5 months

Suck/swallow, tongue thrust, rooting, gag

4-6 months

• Draws in upper/lower lip as spoon removed

• Up and down munching movement

• Can transfer food front to back of tongue to swallow

• Tongue thrust and rooting start to disappear

• Gag diminishes

5-9 months

• Control position of food in mouth

• Up and down munching

• Positioning food between jaw for chewing

6-7 month

• Consistent tongue lateralization- food presented on side.

• Mature tongue laterally emerging

8-11 months

• Moves food side to side in mouth

• Begins to curve lips around rim of cup

• Begins to chew in rotary pattern to diagonal pattern

10-12 months:

• Rotary chewing

• More controlled biting

Feeding difficulties are commonly seen when

a child is transitioning between types of feeding

Feeding becomes a concern if difficulties persist after

3 months

Food Transitions

- 1 month: Liquids from breast or bottle

- 4 to 6: months Introduced to cereals and pureed foods

- 8 months Liquids, pureed foods, mashed table foods

- 12 months: Liquids, coarsely chopped table foods, including easily chewed meats

- 18 months: Liquids, coarsely chopped table foods, including most meats and many raw vegetable

T or F

Position in the least supportive position

False

Always want the most supportive position

T or F

Eating begins with sensory processing?

TRUE

Progression of Utensil Use

• 6 months: accept spoon, open mouth as spoon approaches

• 10-12 months: Begin holding spoon and bringing it to mouth, messy

• 12- 18 months: Learn to scoop food more accurately and effectively

• 2 years: independence with self-feeding, like an adult

9-12 months:

Introduce cup/straw drinking

What does a feeding assessment look like?

- Parent report pt's current feeding status (what works, didn't work, what they have tried at home)

- Have parents to bring some of the items they have been practicing with at home.

• Have parents show me what they are doing/ how they do it.

• Clinical observations of child's behavior/oral motor skills/gross motor skills

• Based on child's behavior/ skill level, therapist then offers training, guidance on how to progress feeding or new suggestions of things to try at home

- It's a lot of trial and error each child is unique and may need to trial several types of utensils/ cups/ bottles before finding one they like.

- For some kids, oral feeding is not always successful or appropriate when first attempted. It may take a while for them to get the hang of it.