Disorders Affecting Feeding & Swallowing in Infants & Children

Pediatric Feeding Disorder (PFD)

Oral intake that is not age appropriate, associated with medical, nutritional, feeding skills, and / or psychosocial dysfunction

• Choking

• Aspiration

• Adverse cardio respiratory events

• Adverse mealtime events

What are some unsafe oral feeding signs / symptoms of PFD?

• Unsafe oral feeding

• Delayed feeding skills

• Inefficient oral feeding

What are some general problems that are associated with PFD?

• Restricted volume of oral intake (insufficient intake of energy, nutrients, or fluid)

• Limited range of food in the diet

• Limited range of textures in the diet (often a reliance on “easy to eat foods” which are puréed, soft, or dissolvable)

• Prolonged mealtime duration (> 30 minute sat mealtimes, ? 2 hours a day spent trying to feed a child)

• Battles or problematic behavior at mealtimes

• Family stress related to the child’s eating patterns

What are some key indicators of pediatric feeding disorders?

Mild PFD

Problem in one or more of areas associated with PFD but grow sufficiently

Moderate PFD

Problems across several areas, would not grow sufficiently without nutritional supplementation

Severe PFD

Problems across all areas & unable to meet fluid, energy, & nutritional requirements from an oral diet

85%

What % does PFD affect in children with disabilities and complex medical issues/

Increasing

Is prevalence in PFD increasing or decreasing?

• More children are surviving severe infant and childhood illnesses

• Lifestyle changes

What are 2 main reasons as to why prevalence of PFD is increasing?

5%

What % of PFD occurs in typically developing children?

• Parents often isolated from family and may be unsure how to feed their child

• Fewer families eat meals together, so children have less opportunities to see parents’ model mealtime behaviors

• More parents rely on convenience food

What are some reasons as to how lifestyles change that cause PFD prevalence to increase?

• Neuromuscular

• Structural

• Inflammatory

• Behavioral

• Cardiopulmonary

What are some Dysphagia etiologies?

True

T or F: Parents may focus on weight rather than nutrition and use high energy processed foods rather than addressing malnutrition

• Increased mealtime

• Fear based aversion of healthier foods which may be less predictable in terms of temperature, taste, texture than junk foods

What are some reasons as to high energy processed foods can result in children becoming fussy and inefficient eaters?

Energy balance

Adequate energy balance needed for growth and development

Positive energy balance

Energy exceeds needs

Negative energy balance

Energy intake is less than needs

• Growth faltering

• Weight loss

What are some things that could occur during a negative energy balance?

37-42 weeks

What is normal gestation for pregnancy?

37 weeks

Children born prior to this gestational age is considered preterm

• Less responsive

• Less interactive

• Fussier

• Fewer vocalizations

Preterm infants tend to display these characteristics

• May not have developed fat / sucking pads which results in less stability in oral cavity and reduced compression between cheek and tongue

• Immature lungs resulting in inability to tolerate apnea period

• Poorly disorganized sucking bursts

• Disorganized jaw and tongue movements

• Other neurological and circulatory immaturity

What are some aspects of prematurity that have an impact on feeding?

Apnea of newborn

Cessation of breathing lasting more than 10 seconds OR accompanies by hypoxia (less oxygen) or bradycardia (slowed heart rate)

• Obstructive

• Central

• Mixed

What are respiratory and cardiac disorders classified as?

Obstructive respiratory and cardiac disorders

• May result from low pharyngeal tone or inflammation of soft tissue

• May occur when infants neck is hyperflexed or hyperextended

Central respiratory and cardiac disorders

Lack of respiratory effort that may result in CNS immaturity, medications or illness

Mixed respiratory and cardiac disorders

Many episodes of apnea in prematurity begin as either central or obstructive but then involve elements of both

Pulmonary hypoplasia

Incomplete development of lungs and a reduced number of bronchopulmonary segments or alveoli

Lung

Pulmonary hypoplasia typically occurs with other fetal abnormalities that interfere with the development of THIS

Respiratory distress syndrome

Infant respiratory distress syndrome that has a deficiency in surfactant and is generally related to premature births

Surfactant

Lipid-protein compound that increases surface tension of alveoli and prevents collapse during exhalation

• Inefficient feeding skills

• Poor suck-swallow-breathe coordination

• Inability to feed or feed safely

• Surgical procedures for cardiac disease

• Reduced stamina due to poor energy reserves

• Feed refusal due to pain, nausea, lack of appetite, or learned aversion

• Frequent fasting for medical procedures

What are some potential contributors to negative energy imbalance?

Increased

Do the physiologic demands of respiratory and cardiac disease have an increased or decreased energy expenditure?

Fluid restrictions

Pulmonary edema or edema of limbs / abdomens may require what?

Vomiting & reflux

What are some things that are more common in respiratory disease than the general population?

Mechanical ventilation

Attempts to achieve adequate airflow with lowest possible airway pressure

Positive pressure ventilation

Delivers air into airways / lungs under positive pressure and produces positive pressure during inhalation

Negative pressure ventilation

Generating negative pressure outside the chest and is used to expand lungs and allow air to flow in

Cycle

Switching from inspiration to expiration and is set to either pressure or volume control

Strategy

Refers to control of respiratory rate / frequency of breaths controlled by patient or ventilator

Cyanotic heart defects

Allow deoxygenated blood to bypass lungs and enter systemic circulation (decreased oxygen - blue tinge)

• Tricuspid valve atresia

• Transposition of the great arteries

• Tetralogy of Fallot

• Pulmonary atresia

Cyanotic heart defects are usually caused by these examples of structural defects

Acyanotic heart defects

Allow oxygenated blood to mix with deoxygenated blood or obstruct outflow from left heart

Velopharyngeal insufficiency

Velum unable to close off nasal cavity from oral cavity due to structural deficiencies or functional restriction

Glossoptosis

Incorrect placement or displacement of the tongue that can block the airway and impact breathing and swallowing

• Poor labial seal

• Unable to generate adequate negative pressure / suction to draw fluid from nipple effectively

What are some feeding difficulties associated with cleft lip?

• Inability to generate sufficient negative pressure to draw fluid from nipple

• May result in nasal regurgitation

• May cause increased swallowing of air resulting in possible emesis and an increased amount of belching

what are some feeding difficulties associated cleft palate and VPI?

• Inability to form sufficient positive pressure (compression) to draw fluid

• Potential airway obstruction during feeding

What are some feeding difficulties associated with micrognathia and glossoptosis?

• Feeding equipment

• Positioning

• Possible surgical intervention

What are some strategies for feeding for craniofacial abnormalities?

Increased energy requirements

Inefficient feeding skills may lead to excess energy expenditure

Increased energy loss

Low tone, increased swallowing of air resulting in loss of feeds

Reduced energy intake

Inefficient feeding skills due to structural impairments and reduced stamina

• Jaundice

• Diabetes

• Fetal alcohol syndrome

• Neonatal abstinence syndrome

What are some maternal and perinatal conditions that could cause disorders in feeding in kids?

• Lethargy / decreased stamina

• Feed refusal

• Caregiver’s ability to provide / prepare foods, respond to hunger cues, provide assistance

Why would there be a reduced energy intake?

• Inefficient feeding skills resulting in excessive energy expenditure

• Physiological demands of illnesses

What are some reasons as to why a child will need increased energy requirements?

Altered insulin control and blood sugar metabolism can result in ineffective digestion of feeds

Why would a child have an increase in energy losses?

• Airway latency

• Airway protection

• Need for mechanical ventilation

What are 3 main reasons for tracheostomy in children?

Airway patency

• Usual route for breathing is impaired or obstructed

• Need for an open airway

Airway protection

Frank aspiration risk - half or more of the bolus or secretions being aspirated consistently

Need for mechanical ventilation

• Severe lung disease

• Prematurity

• Cervical spine injury

• Present or absent?

• Sufficient expiratory airflow for voicing and coughing

What are some common extubation criteria for airway patency?

• Protect from aspiration of saliva, foods, fluids, stomach contents?

• Swallow secretions?

• Swallow fluid and food or have non oral nutrition / hydration?

What are some common extubation criteria for airway protection?

• Can patient ventilate through noninvasive means?

• Spontaneous breaths?

• Achieve sufficient tidal volume?

What are some common extubation criteria for mechanical ventilation?

• Impaired airway protection

• Food aversion

• Fear of choking

What are some common difficulties from corrosion of tissues?

Tonsillitis

Inflammation of palatine tonsils caused by a bacterial or viral infection

Ankyloglossia

Congenital condition that decreases the mobility of the tongue tip and may cause inefficient breast feeding

• Developmental delay

• Disordered motor patterns

What are some causes of oral motor impairments?

• Low or high tone

• Presence of primitive reflexes

• Apraxia

What are some disordered motor patterns that may cause oral motor impairments

Pain

Painful sensory stimulus associated with tissue damage

Sensory sensitivity

Abnormally high pressure to sensory stimulus

Food aversion

Behavioral response to stimulus or anticipation of a stimulus which may persist beyond anticipation of a stimulus which may persist beyond initial pain or sensory processing problem

Behavioral feeding therapy

This type of therapy may help address oral aversion but is unlikely to be effective if underlying pain or sensory sensitivity

Autism Spectrum Disorder

Group of Neurodevelopmental disorders that cause developmental delays in sensory processing disturbances and motor development

• Restricted dietary variety

• Food refusal

• Tendency toward being overweight

What are some typical difficulties and nutritional deficiencies in ASD?

Parent-Child Interaction

Parents who attend to their child’s needs and development tend to have children who are better able to regulate their own emotions and interact well with others

Secure attachment strategy

Creates confidence in the availability of a specific protective caregiver if needed and supports exploration when it is safe to do so

Ambivalent attachment strategy

Refers to an organized strategy of attachment that overemphasizes the demonstration of closeness and proximity while underemphasizing the exploration aspects of the relationship

Avoidant attachment strategy

An organized strategy of attachment that overemphasizes the exploratory aspects of the relationship while underemphasizing the need for emotional closeness and comfort to stay as close as possible to the caregiver while expressing a minimum emotional need

Disorganized attachment strategy

Refers to the attachment of a child to a caregiver who is either frightened of the child or frightening to the child

Authoritarian

A parenting style that has a high level of control and a low level of warmth and affection

Bigger, stronger, wiser, and kinder

A parenting style with a high level of the caregiver being “in charge” matched with a high level of caregiver warmth and affection

Permissive

A parenting style that has a low level of control and a high level of warmth and affection

Reflective Capacity

The ability to stand back, observe, and understand one’s own behavior, motivation, and needs, and to observe and understand the behavior, motivation, and needs of others