Peds Feeding and Swallowing A&P

pediatric feeding disorder

• “impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction

• ages 0-17

• acute is less than 3 months duration

• chronic is over 3 months duration

diagnostic criteria of PFD

a disturbance in oral intake of nutrients, inappropriate for age, lasting at least 2 weeks and associated with 1 or more of the following:

1. medical dysfunction

2. psychosocial dysfunction

3. feeding skill dysfunction

4. nutritional dysfunction

   AND the absence of the cognitive processes consistent with eating disorders and pattern of oral intake is not due to lack of food or congruent cultural norms

medical signs and symptoms

• labored breathing with and without feeding

• color changing lips or face when eating or drinking

• sweating when eating or drinking

• gurgle or squeaking sounds with and without feeding

• reoccurring upper respiratory infections

• crying, arching, coughing, grimacing when eating or drinking

• suspected food allergies

• multiple formula changes

• vomiting

• never seems hunger

• physical discomfort when eating or drinking

nutritional signs and symptoms

• unable to eat or drink enough to grow or stay hydrated

• insufficient or too rapid of a change in weight or height

• lack of certain nutrient (ex: iron, calcium)

• need for nutritional supplements

• reliance on a particular food nutrition

• need for enteral feeds for nutrition

• constipation

• limited dietary diversity for age

general feeding skills signs and symptoms

• labored, noisy breathing or gasping

• coughing, choking, gagging or retching

• gurgles or wet breaths

• loud and/or hard swallows or gulping

• unable to eat or drink enough for optimal growth

• excessively short mealtimes (<5 minutes)

• excessively long mealtimes (> 30 minutes)

• need for thickened liquids

• need for special food or modified food textures

• need for special strategies, positioning or equipment

feeding difficulties in infants (12 months or less)

• should be nipple feeding

• unable to latch to breast or bottle without help

• weak suck

• need for pacing, flow management or rest breaks

• need for special equipment to breast or bottle feed

• often too tired to eat or quickly falls asleep when eating

• breast or bottle feeds best when asleep

• unable to transition to solids

• unable to wean from breast or bottle

feeding difficulties in children (> 12 months)

• grazing between scheduled mealtimes

• refusal to eat, drink, or swallow certain food textures

• needs distraction to eat such as screen time

• needs excessive praise, threats, bribes to eat

• difficulty chewing age-appropriate foods

• unable to eat in new or unfamiliar situations

psychosocial signs and symptoms

• unable to come to or stay with the family at meals

• refusal to eat what is offered or to eat at all

• disruptive mealtimes behaviors

• unable to eat with others present at mealtimes

• child exhibit stress, worry, or fear during meals

• caregiver exhibits stress, worry, or fear during mealtimes

• presences of bribes, threats, yelling at mealtimes

• need for distraction and/or rewards for eating

• unpleasant mealtime interactions between caregiver and child

feeding (ASHA)

• process involving any aspects of eating or drinking, including gathering and preparing food and liquid for intake, sucking or chewing, and swallowing

• provides kids and caregivers opportunities for communication and social experience that form the basis for future interactions

swallowing (ASHA)

complex process during which saliva, liquids, and foods are transported from the mouth into the stomach while keeping the airway protected

phases of swallowing

• oral prep: voluntary phase during which food/liquid is manipulated in the mouth to form a cohesive bolus

• oral transit: voluntary phase that begins with the posterior propulsion of the bolus by the tongue and ends with initiation of the pharyngeal swallow

• pharyngeal: begins with the initiation of a voluntary pharyngeal swallow which in turn propels the bolus through pharynx via involuntary peristaltic contraction of pharyngeal constrictors

• esophageal: involuntary phase during which the bolus is carried to the stomach through the process of esophageal peristalsis

ARFID

• avoidant/restrictive food intake disorder

• “extreme picky eating that has a psychological component”

• SLPS CANNOT DIAGNOSE ARFID BC OF THE PSYCHOLOGICAL COMPONENT

nose

• important for infants/neonates as they are obligatory nasal breathers

• cleans, warms, and humidifies air

• opens to the nasopharynx

• soft palate elevation and retraction seal off the nasal cavity from the oropharynx and oral cavity

oral cavity

• part of ingestion, vocalization, oral respiration

• lips, mandible, maxilla, floor of mouth, cheeks, tongue, hard palate, soft palate, anterior surface of anterior tonsillar pillars, and teeth

pharynx

• 3 areas: nasopharynx, oropharynx, and hypopharynx

• infants - nasopharynx and hypopharynx blend together (no oropharynx)

larynx

• superior entrance to the trachea

• arytenoid cartilages - protect against the aspiration

• epiglottis - plays a role in airway protection

  • flattened lingual surface acts to direct food laterally into the recesses formed by the pyriform sinus

  • food is directed away from midline and laryngeal inlet (glottis)

• valve like function of false and true VF is most critical level of laryngeal structures in airway protection

esophagus

• muscular tube lines with mucosa that propels food from the hypopharynx to the stomach

• includes the UES and LES

infant anatomy

• oral cavity

  • tongue fills mouth

  • edentulous

  • tongue rests b/w lips & sits against palate

  • cheeks have sucking pads

  • relatively small mandible

  • sulci important in sucking

• pharynx

  • no definite oropharynx

  • obtuse angle at skull base in nasopharynx

• larynx

  • 1/3 adult size

  • narrow, vertical epiglottis

  • high in neck

adult anatomy

• oral cavity

  • mouth is larger

  • dentulous

  • tongue rests on floor of mouth

  • buccinators are muscles for chewing only

  • sulci have little functional benefit

• pharynx

  • definite oropharynx

  • 90 degree angle at skull base

• larynx

  • flat, wide epiglottis

  • in adult position by 2 years of age

gag reflex

• protective mechanism; moves posteriorly as infant grows older

• contraction of the palate and pharynx

• stimulated by touching posterior tongue or pharynx

• involves cranial nerves IX, X

transverse tongue reflex

• used later for moving food during chewing

• lateral tongue motion

• arises around 6-8 months

• stimulated by racing lower gum line and brush sides of the tongue

• involves cranial nerve XII

phasic bite

• early munching pattern

• rhythmic closing of the jaw

• arises 9-12 months

• stimulated by applying pressure to the gums

• involves cranial nerve V

root reflex

• required for early survival; helps infant find nipple/food source

suck/suckling reflex

• non-nutritional (pacifier, hand) - 2 sucks/sec

• nutritive (eating) - 1 suck/sec

• infant begins sucking

• arises around 4-9 months

• stimulated by putting nipple in mouth or stroke top of tongue

• involves cranial nerves V, VII, IX, XII

lingual protrusion

• used to expel food/objects

• tongue protrudes out

• arises around 4-6 months

• stimulated by touching the front of tongue

• involves cranial nerve XII

• if child does not have this, they are not ready for solid foods

newborn to 3 months

• diet: breastmilk and/or formula

• respiratory system: around 40 breaths/minute; infants are obligatory nasal breathers

• state development: begin to establish waking and sleeping patterns

• sensory system: learn to prefer sweeter tastes; learn to discern between hunger and satiation

• motor system: learn to bring hands to mouth in supine and prone by 2 months and move from extension to flexion

3-5 months

• diet: breastmilk or infant formula

• respiratory system: around 40 breaths/minute; infants are obligatory nasal breathers

• state development: begin to establish waking and sleeping patterns

• motor system: learn to bring hands to mouth in supine and prone by 2 months and move from extension to flexion

5-7 months

• diet: breastmilk or formula UNTIL 6 MONTHS

• visual systems: new colors, textures, and experiences around solid foods/mealtime routines

• auditory system: more interaction with caretakers during mealtimes with face to face

• motor system: sitting unsupported, truncal rotation, crawling begins, pull to stand, reaching/bringing to mouth

• sensory system: heightened sensory reaction to textures, tastes, smells

• oral motor systems: more active movement of bolus, sucking still present, may observe tongue thrusting, phasic bite may inhibit spoon feeding

10-24 months

• diet: breastmilk, formula, purees, soft solids, cut chicken, cheese, beans NO WHOLE MILK OR HONEY UNTIL 12 MONTH

• sensory system: some kids become neophobic (hesitant to new things)

• cup drinking: can drink with straw by 12 months; drink from open cup by 15-18 months by biting cup

• motor system: walking around 12 months, up to 16 months is normal too

• cognitive system: assertion of self as shown by rejection of foods, activities, etc that were previously liked

• oral motor system: can dip stich shaped foods into sauces, begin using utensils, lip scraping, rotary chewing by 26 months