Pediatric Dysphagia Flashcards

Scope of problem

100,000 children have feeding/swallowing disorder

40% of them are premature births

• Higher incidence of chronic lung disease, raising swallowing dysfunc risk

25-40% of typically developing children have a feeding disorder

As high as 80% in cerebral palsy

Dysphagia

oral, pharyngeal and esophageal disorders with symptoms of aspiration, dehydration and decreased nutritional status

Feeding Disorders

Sensory or behavioral feeding concerns (not necessarily a swallow-safety problem).

SLPs role

Treat in hospitals, outpatient, schools, clinic, HH, and ECI

Causes of Pediatric Dysphagia

Often multifactorial (med, psychological, or behavioral)

• impact depends on comorbidities

premature births, respiratory, cardiac, gastrointestinal, and neuro disorders have a risk of dysphagia

• low birth weight and complex conditions play a factor

Anatomic abnormalities (cleft, atresia)

Motor deficits (reduced muscle tone)

coordination deficits (coordinate swallow/breathe)

Sensory deficits (poor reception)

Medical causes of dysphagia

neuromuscular disorders, upper airway/digestive tract anatomical and genetic abnormalities

Oral Feeding

critical milestone for proper growth and development

• prominent developmental issue in infants in NICU

  • 30% experience difficulty

coordination deficits: gestational age, psysiologic stability, feeding practices, presence of respiratory devices

Premature birth

before 37 weeks

have issues establishing oral feeding due to immaturity of oral structures, postural control, underdeveloped lungs, and poor behavioral state

Healthy preterm babies achieve independent feeding by 36-38 weeks of postmenstrual age (PMA)

Failure leads to poor nutritional status, growth failure, long-term growth

Models of care

medical

Educational

Medical model of care

provided in setting where physician orders are required or med dx is noted

focuses on providing service to address goals and strategies to modify feeding/swallowing

addresses quality of feeding based on functional assessment

Educational model of care

integrating student’s swallowing needs to educational setting

addressed are functional for school setting

gen goals: increase safety of swallow, nutritional intake, increase quality of feeding

MEET EDUCATION NEEDS OF CHILD

Team-based care

Team based care is an approach to health care in which a group of people work together to accomplish a common goal, solve a problem, ​or achieve a specific result

Interprofessional collaborative practice

students or member of two or more professions learn with from and about each other to improve collaboration and the quality of care they can give as patients

Assessment of Pediatric Dysphagia

1. Overview A&P

2. Oral motor and swallowing development

3. Medical diagnosis and swallowing feeding disorders

4. beside swallow eval

5. instrumental eval

6. documentation

7 categories for pediatric dysphagia

1. Neurological

2. Anatomical

3. Genetic

4. Pulmonary

5. Prematurity

6. Gastrointestinal

7. Psychological

Neurological disorders

CP, hydrocephalus, encephalopathy, IV hemorrhage, hypoxic-ischemic encephalopathy (HIE), seizures, Periventricular Leukomalacia (PVL)

IVH & PCL: seen in extreme prematurity, may result in learning disability or CP

Hypoxia may occur with prematurity or due to near drown episode, resulting in the death of neural tissues

Hydrocephalus: abnormal accumulation of CSF in ventricles, causing intracranial pressure, may cause seizures, intellectual impairment

Neurological disorders and dysphagia

oral and pharyngeal dysphagia secondary due to hypo and hypertonia

neuromuscular weakness may cause laryngeal penetration

Oral phase: poor bolus control, formation, propulsion, causing spillage to airway

Pharyngeal: delayed/absent swallow reflux, reduced peristaltic action causing vallecular or pyriform sinus pooling

Anatomical

Congenital:

tracheoesophageal fistula: fistula between esophagus and trachea

ankylossia (tongue tie)

Laryngomalacia: posterior part of larynx, can collapse into airway and cause obstruction (floppy tissue blocking airway in inspiration

laryngeal cleft: incomplete separation of larynx and trachea from pharynx and esophagus due to a cleft in the interarytenoid muscle or cricoid cartridge

Acquired:

VF immobility, stenosis

Genetic

Trisomy 21: down syndrome

Pierre Robin Sequence: cleft of soft palate, micrognathia, retraction of tongue

Angelman syndrome

Pulmonary

apnea, respiratory distress, laryngo/tracheo/bronchomalacia, heart defects, PDA

Pulmonary: incoordinated/sensory based oral aversion feeding disorder

Bronchopulmonary dysplasia: chronic lung condition with inflammation and scarring of the lungs​

Respiratory Distress Syndrome or Hyaline Membrane Disease: insufficient surfactant production (surfactant is a liquid protein compound increases surface tension of alveoli that helps prevent collapse of lung​

Congenital Heart Defects: structural defects of the heart with poor blood circulation or abnormal circulation causing decreased oxygen overall – many children need surgery and are weak overall ​

Pulmonary Hypoplasia: incomplete development of the lungs

Gastrointestinal

Can cause sensory base oral aversion and oral and pharyngeal disorders

Necrotizing enterocolitis: portions of bowel under necrosis

gastroschisis, fistula, hernia, GERD

Eosinophilic Esophagitis: allergic inflammatory condition of esophagus

Psychological

Behavioral feeding disorders

Coordination deficits influences

gestational age - youngers have less mature neuromotor control

psysiological stability - heart rate, respiratory rate, oxygen

presence of respiratory devices - nasal cannula, CPAP can disrupt seal and rhythm for swallow, breathe, and suck

Feeding - pacing, positioning, and flow rate

Infant anatomy

Tongue - fills mouth, small oral cavity, b/w lips and against palate

• less room for bolus manipuation, supporting suckling

cheeks - have sucking pads

• stability for suck generation

larynx - 1/3 adult size

• smaller airway = smaller margin for penetration/aspiration

epiglottis - narrow/vertical

• protective mechanics

soft palate & epiglottis - contact with one another

• airway protection during suckling

Mandible - relatively smaller

• limits oral cavity space and jaw excursion

Infant breathe and sallow simultaneously

infant larynx sits higher and soft palate and epiglottis being in contact, babies have more direct protected pathway from nose to lungs

larynx descends, anatomic protection is lost

3 phases of swallowing

oral → pharyngeal → esophageal

oral phase is involuntary (becomes voluntary across infancy)

pharyngeal and esophogeal is involuntary whole life

Oral Phase

suckling (reflexive, anterior/posterior tongue movement)

• transitions to sucking at 4-6 months

posterior propulsion of bolus by tongue; propels into pharynx

less than 1 sec for liquids

Pharyngeal phase

aspiration/penetration highest at this stage

elevation/retraction of soft palate closes nasopharynx

pharyngeal constrictors contract to propel bolus

larynx closes simultaneously to protect airway

UES opens

laryngeal closure occurs at laryngeal vestibule

Laryngeal protection during pharyngeal phase

laryngeal elevation and anterior movement brings larynx under tongue base

epiglottis diverts bolus laterally into pyriform sinuses, simultaneous cricopharyngeal sphincter opening

aryepiglottic folds move anteriorly/medially to cover glottis

false and true FV adduct

cough reflux triggers by sensation receptors

Esophageal phase

automatic peristaltic wave carries bolus to stomach

phase ends when food passes through gastroesopho junction

Feeding/swallowing disorders can cause GI and vice versa

LES prevents gastric content reflux into esophagus

SLPS DON’T TREAT ESOPHAGEAL PROBLEMS

Non-Nutritive Sucking (NNS) and Breathing

as early as 12-18 weeks gestational age

• 2-13 suck cycles cycle rate of 2 Hz, 2-5 sec pause

32 weeks

• 6-7 suck cycles at 2 Hz, 17 cm H2O compression pressure

34 weeks

28 weeks more consistent suck-swallow organized movements

• preterm at 28 weeks not ready for oral feeding, due to lack process of sensory feedback, which modifies intrinsic dynamics

Typical Feeding development: Full-term infant (0-4 months)

• able to recline when fed

• Suckle reflex: nipple, extention/retraction of tongue, reflexive

• Incomplete lip closure and drooling are normal

• Suck/swallow ratio: 1:1 start of feeding → 2:1 in middle → 3:1 end of feeding

• Sucking: volitional, up-and-down tongue movement, emerges b/w 4-6 months

• Sucking Burst: 20-30 per burst in typ dev

• Nutrition: breast or formula, 2-8 oz feeding depending on weight

Typical Feeding development: 4-6 months

able to sit w/ support

breast or bottle

lips begin active movement/aprx for spoon feeding

sucking pattern present

Intake: 6-8 oz every 4-6, 1/4-1/2 cup servings of baby food

Smooth pureed introduced at 4-6 by MD rec

may gag on thicker textures

Typical Feeding development: 7-9 months

sit upright needs some support

messy self-feeding

breast fed or bottle

sippy cup at 6-7 months

early immature chewing/munching with early tongue lateralization

Typical Feeding development: 9-12 months

cup drinking occurs with successive swallows

self finger-feeding

improved tongue lateralization

tongue tip elevate; emerging lateral tongue movements separate from jaw move

emerging lat and diagonal jaw movements

weaning from nipple

diet: milk continues; smooth pureed; lumpy pureed; soft chopped solids

Typical Feeding development: 12-18 months

Rotary chew develops

biting through soft foods

straw drinking initiated around 12 months

taste/food preferences developing

cup drinking controlled

whole milk can be given

15 months, increased ability to eat mixed textures

Typical Feeding development: 18-24 months

swallows with complete lip closure

self-feeding predominates

swallows chewable foods with no loss of food or saliva

coarsely chopped table foods

Normal infant NNS

6-8 sucks per burst on pacifier

Premmie: develops progressively with gestational age, short/irregular

Atypical: very short, disorganized bursts with poor rhythmicity

Nutritive sucking

Healthy full-term: typical sucking bursts: 10-30 sucks

Preterm at 34 vs 36-38: shorter and suck-swallow-breath pattern is less mature

• irregular rate/rhythm, weak or absent suck bursts

Feeding progresses from start to end, suck-to-swallow ratio increases, more needed later in feeding as flow/fatigue change

Assessing infant feeding is a whole body sensory task

Suck: lingual cupping, tongue-jaw dissociation, 2/sec NNS, 2/s NS, jaw depres

Swallow: jaw elevation, audible, visible neck tension

Breathe: nares flare, audible

Breastfeeding

benefits preterm infants from a nutritional, gastrointestinal, immunological, developmental, & psychological perspective​

Tracheostomy

surgical incision through front of neck to trachea for airway hole

permanent or temp

Diagnostic criteria

Medical dys: cardiorespiratory compromise during feeding; aspiration

Nurtritional dys: malnutrition; nutrient deficiency;reliance on supplements

Feeding skill: need for texture mod; modified feeding position

Psychosocial: active/passive avoidance behaviors in feeding; inappropriate management of feeding; disruption

Mech vent

ventilator machine provides triggers a cycle of breath through pressure

Family centered care

protects personhood, value, integrity of infant and parent, recognize signs and symptoms of trauma exp

consistency of care: increases confidence, promotes sense of security

Parent and medical staff: actively listen to feelings and concerns; acknowledge where family is in stages of grief

Trauma informed care

Healing environment: emanates teamwork, soothing

Family collaborative care: parents are integral, support well-being

Pain and stress: assessed, managed, reassessed

Protected sleep

Activities of daily living: postural alignment, feeding, skin care routines

Infant risk factors

• Age at birth​

• APGARS​

• Delivery/amniotic fluid​

• IVF​

• Low birth weight/IUGR​

• Multiples​

• Teen Parent

Co-morbidities

• IVH ​

• PDA ligation​

• Birth depression​

• Neurological involvement​

• Infection​

• GI, pulmonary, cardiac, endocrine, metabolic complications​

• Airway abnormalities

framework for assessing infant behavior

first way for preterm infants and neonate may communicate

Postponing bottle feeding based on physiologic instability can cause:

1. worsened physiologic instability during feeding

2. practice disorganized behaviors to manage feeding

3. increased chance of solidifying unorganized behaviors

4. feeding-associated aversive experience

Theory of Neuronal Grouping Selection suggests that neural maps in the cortex of the brain are established through repetitive experiences and behaviors in the present as well as the past

Synactive theory

frames infant as continuously balancing five interacting subsystems:

• physiological stability: autonomic

  • stable color, HR, RR, O2 sat, regular breathing

  • Color, HR, RR changes, gagging, apnea, sneezing (instability

• motor organization: tone and movement

  • smooth, well-modulated movement; flexed, tucked posture

  • Flaccidity, hypertonia, finger splaying (irregular)

• behavioral state organization

  • level of arousal (deep sleep → light sleep → drowsy → quiet alert → active alert

• attention/interaction

  • inability to integrate with other sensory input

• self-regulation

  • presence of stress in lower subsystems to point that balance across is lost

Feeding readiness depends on infant stability, not instability

FENNSS

Family

Environment

Neurobehavior

Neuromotor

Sensory

Swallowing (or nutrition)

Family history

Maternal: preg complications, substance use, infections, maternal diabetes

Delivery history: gestational age at birth, mode of delivery, complications, weight

Parent goals: family want/expect from feeding

Cultural: impacting feeding practice and decision-making

Typical neuromotor alignment

flexed, midline-oriented posture; balanced tone that allows controlled, graded movement

physiological flexion: cephalocaudal, proximal to distal

physiological flexor tone: caudalcephalic, distal to proximal

Atypical neuromotor alignment

hypotonia (poor head/trunk control) or hypertonia (rigidity)

Poor postural control undermines jaw stability, lip seal, and alignment needed for coordinated suck-swallow-breath sequence

SENSE program

Supporting and Enhancing NICU Sensory Experiences

Comp approach to ensure multi-modal sensory exposure for high-risk infants

education to engage families in sensory exposure

• medical term

• fetal development

• sensory dev in NICU and general

• reading infant cues

• provide sensory exposure

Sensory system

assess tactile responses, response to movement, auditory and visual

impact on feeding: over-responsivity (defensive to touch/taste) or under-responsivity

Goals for oral feeding

Safe

Functional

Nurturing

Dev and indiv appropriate

Nutritive sucking: seeing

Jaw depression

Rate of movement: Rate of 2/second = NNS​, Rate of 1/second = NS​

Tongue-jaw dissociation

tension in throat

neck tension in inhale/exhale

nasal flaring

head bobbing

clavicular muscle recruitment

Nutritive sucking: feel

lingual cupping = intra oral seal, pulling nipple to see suction

buccal tension

laryngeal excursion

muscle movement on back

chest expansion

neck tension

Nutritive sucking: hear

Sucking

Swallows

Clicking

gulp

audible exhalation

grunt/vocalization

Nutrition

adequacy of growth, calori/fluid needs, efficienty of oral intake

Consider alts when: infant can’t meet nutrition/hydration needs by mouth

types: NG or g-tube

Breastfeeding eval

promote breastfeeding exclusively for first 6 months at least

Infants control flow rate

• physiology differ on breast than bottle

Provides higher oxygen sat

Edu on cued based feeding, infant maturational process, skin-skin facilitation

goal of intervention is to decrease stress of manipulations and increase infant functional strats

Assessing for infant development

​

1. Infant's current developmental progression and testing/assessing the degree the infant can ascend to the next system ​

2. Balance and smooth integrate smoothly between the systems ​

3. The infant's threshold for disorganization; including behaviors of defense and avoidance ​

4. Distinguish the degree of modulation and regulation the infant requires in accomplishing a task ​

5. Effectiveness of rebalancing the sub-systems ​

6. Environmental restructuring or modifications ​

7. Degree of support to bring smooth, integrated functioning

Cue-based/infant driven feeding

clinician reads infant’s behavioral and physiological cues to guide pace and continuation of feeding

evaluate quality of feeding

• fluid threats are due to lack of synchrony b/w breathing/swallowing

Physiologic stability readiness cues

Awake/alert

smooth movement, stable breathing

appropriate tone

active engagement in feeding

maintain attention and energy, organized oral motor, stability

Oral motor readiness cues

moves toward nipple, hands to mouth

positive vocalization

rooting

actively sucking

smacks lips

maintain organized oral motor and coordinated suck-swallow-breathe

oral aspiration

Anterior loss of bolus​

Abnormal sucking pattern​

Abnormal or absent oral reflexes​

Abnormal/absent movement of oral structures​

pharyngeal aspiration

Coughing/choking/gagging​

Stridor/stertor/nasal congestion​

Apnea/bradycardia/tachypnea​

Increase work of breathing/head bobbing/nasal flaring/retractions​

Audible sounds of wet breathing​

Neck extension/turning away/refusal​

Eyebrow raise/grimace/state changes​

Wet/gurgly vocal quality/hoarseness/aphonia​

Symptoms of aspiration

Coughing and wheezing during or after swallowing​

Laryngeal gurgling (wet vocal quality)​

Recurrent pneumonia or upper respiratory infections​

Poor weight gain​

Tearing of the eyes​

Arching or physical display of discomfort​

Oral Aversion to oral feeds​

May show cessation of breathing and turning blue around mouth

Neurological impairment is at greatest risk

Effects of aspiration

chronic respiratory illness/aspiration pneumonia

weaken the lungs

high degree of acidity of aspirated content

higher fat molecules are harder on the lungs

Compensatory strategies in the NICU

Environmental modifications

oral motor intervention (NNS to NS)

positioning and swaddling

change equipment-slower flow nipple

pacing

Environmental modifications

Reduce light, distraction, noise

Positioning and swaddling

Swaddling: provides containment and boundaries the infant needs for swallowing

• support to infant’s postural stability while reducing extraneous movement

• less distress, more motor organization and self-regulatory ability

positioning:

• upright: above mother with mother reclined in chair

• Sidelying: horizontal flow of milk for bottle feeding, allows milk to flow anterior out of mouth if too fast

• more O2 sat, regulation, swallowing safety, physiologic stability, endurance for feeding

• Less work of breathing, HR variability

Pacing

imposed breaks during feeding improves:

• burst/pause rhythm

• breathing regulation

• bolus control

Flow Rate

Reduces infant stress and liquid misdirection to airway

Higher flow rates make coordination more challenging, inhibits self-regulation

ventilation decreases and flow increases

Slowing liquid flow helps reduce frequency of swallowing, more time to organize pattern

Slow rate can assist in maintaining respiratory baseline

Formal feeding eval tools

Infant Driven Feeding (IDF)​

Early Feeding Skills (EFS)​

Baby Related Organization Of Subsystems & Sucking (BROSS)​

Supporting Oral Feeding In Fragile Infants (SOFFI)​

Neonatal Oral Motor Assessment Scale ​

(NOMAS)​

Neonatal Eating Assessment Tool ​

(NEO-EAT)​

Neonatal Eating Outcome Assessment (Neo)​

Oral Feeding Scale (OFS)​

Infant driven feeding scale

3 behavioral assessment: feeding readiness, quality of feeding, caregiver support

5 categories intended as method of communication with caregivers

readiness for infant progress toward independent oral feeding

Baby regulated organization of subsystems and sucking

organized an infant’s feeding skill and neurobehavioral status into integrated developmental profession

Supporting oral feeding in fragile infants

uses algorithm which guides feeder to determine how infant is managing physical stability, motor skills, swallow

Early feeding skills assessment tool

infant’s ability to regulate response to environmental stimulation and maintain energy for feeding

Neonatal eating outcome assessment

identifies problematic feeding behaviors while considering developmental changes occurring from preterm to term, tracks feeding process

neonatal eating assessment tool

identifies infants in need of specialty assessment and monitor response to treatment, parent-report measures of bottle-feeding

Preterm oral feeding readiness scale

subscales include corrected age, behavioral organization, oral posture, oral reflexes, and NNS

neonatal oral motor assessment scale

28-scale evals infants jaw and tongue movements to classify sucking patterns

12 assessment of NS organization

8 assessments for NS function

trial of oral feeding and integrates oral motor skills

measures pertaining to maturational and pathologic signs

oral feeding skills assessment

classifies infant skills to 4 ofc levels by factors related to volume prescribes and consumed and min of feeding time

Instrumental swallowing assessment

Underlying condition associated with dysphagia​

Assess oropharyngeal anatomy and physiology​

Anticipated utility a specific examination is likely to yield​

Age and ability of the patient to participate in the procedure​

Projected impact of the information on a child’s diagnosis or management decisions​