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Management
- 1. Primary Goal-adequate nutrition/hydration for growth
- 2. Supplementary Goal-safe oral feeds
G-tubes will be recommended more quickly for children than adults due to the need for adequate nutrition/hydration for growth
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Pediatric Dysphagia Basic Principales
- 1. The relationship between child & caregiver is an important part of a feeding evaluation & management plan
- 2.The child & family should be included in treatment planning & implementation
- 3. Oral, respiratory, & neurologic systems within a child should be examined carefully
- 4. Tone & movement patterns throughout the entire body must be changed before making specific changes to the oral sensorimotor systems (got to have stability from the trunk up)
- 5. Tone & movement patterns in the jaw, tongue, lips, & palate must be altered when necessary to reduce the impact of oral reflexes that may interfere with feeding
- 6. Normal patterns of movement must be facilitated to replace abnormal patterns that interfere with feeding.
- 7. Normalizing the ability to accept & to integrate visual, auditory, tactile, balance, taste, & temperature information is necessary before direct facilitation of new oral feeding pattern attempts can be made.
- 8. Oral sensorimotor treatment may be included during a child's typical daily activities to include play, mealtime, & toothbrushing.
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What are some considerations needed for the family
- 1. Cultural consideration
- 2. Developmental level the parents want for the child
- 3. When foods are introduced
- 4. The child is in the context of the family-not a clinical determination
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What can affect the caregiver/child relationship?
- -Depression
- -Neglect
- -Not reading the child's cues
- -Environment
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Who is on the feeding team & what do they do?
- 1. PT-posture/positioning
- 2. OT-food to mouth
- 3. SLP-food in mouth
- 4. Dietician & Pediatrician-adequate intake
- 5. Pulmonologist or ENT-pulmonary status
- 6. Gastroenterologist-GI status
- 7. Other-Developmental Pediatrician, Geneticist, Neurologist, Psychologist, Social Worker
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General Considerations-What to do:
- -Fun activities
- -Watch each child
- -Know the child's developmental age
- -Build up toward goal
- -Look at the big picture
- -Make sure the recommendations are doable
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General Considerations-What not to do:
- -Create an antagoistic environment
- -Overload the parents
- -Try to push progression when the child is not developmentally ready for it
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Principles of Manual Oral-Motor Therapy
(Beckman)
- 1. Used to develop/refine range, variety, strength, & control of movement as well as response to pressure & movement
- 2. These are accomplished through:
- -Muscle compression before elongation
- -Muscle elongation to activate contraction
- -Movement against resistance to build strength
- -Movement toward midline
- -Slow movement
- -Deep pressure
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Manual Oral-Motor Therapy
- 1. Upper/lower lip stretch; side-to-side stretch:
- -Limited lip ROM/strength; asymmetry
- -Poor lip rounding/closure; drooling; abnormal lip patterns
- 2. Diagonal nasal bridge stretch; Z-stretch
- -Limited lip & cheek ROM/strength
- -Flat affect; poor lip rounding/closure; drooling; abnormal lip patterns
- 3. Gum massage
- -Bleeding or sensitive gums; no tongue movement toward pressure
- -Drooling; poor chewing; overstuffing mouth; pica
- 4. Cheek stretches
- -Limited cheek ROM/strength; asymmetry
- -Drooling; poor lip rounding/seal; overstuffing; pocketing; pica
- 5. Resistive chewing
- -Limited cheek ROM/strength; asymmetry; weak jaw
- 6. Lateral pressure to tongue; pressure to inner upper/lower gum
- -Poor tongue movement; asymmetry; poor jaw strength/ROM; poor cheek strength/ROM
- -Drooling; poor bolus control; poor chewing, swallowing, clearing; increased fluid/food loss; overstuffs; poor contact/control for consonants
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Indirect Modification
- 1. Posture
- 2. Respiration
- 3. Environment
- -Hyperreactive-decrease environmental stimuli
- -Hyporeactive-increase environmental stimuli
- 4. Oral preparation
- -Increase sensory awareness and mobility
- -Hypertonic kids: Gentle vibration down sides of nose; elongate muscles down & in; myofascial release
- -Hypotonic kids: Quick upward strokes on cheeks; tapping; blowing activities
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Toweling
- Goals-increase midline orientation, symmetry, sensory awareness, & mobility
- See diagram pg 6a of notes
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Oral Cavity Prep
- -Reduce hypersensitivity or increase sensitivity in hyposensitive kids with toothette or Nuk:
- *Teeth & gums
- *tongue, center first, then sides
- *hard palate
- *cheek-go to midline
- Anterior-Posterior-start in center
- Laterally-start in center of hard palate but be careful not to trigger soft palate
Helps sometime with those kids that pocket to be aware of what is in their mouth.
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Enhancing Coordination-For ROM, not strength
- 1. Tongue-tip elevation-place food on alveolar ridge
- 2. Tongue lateralization-place food on corners of lips & outer gum; Ice enhances tongue movement
- 3. Lip closure/mobility-faces in mirror; vibration; blowing activities; roll cold/flavored toothette under upper lip
- 4. Jaw Strength-tug-of-war games, chewing activities
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Support (from most support to least support)
- 1. "Chin pinch" for head/jaw/lips
- 2. "C" shape for jaw & lips
- 3. "V" or "L" shapes for jaw
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Bottle Feeding
- 1. Positioning & support-hytone kids can be fed in prone (stomach) b/c of their head extension, this is still a functional position for this child
- 2. Disorganized sucking pattern-due to neurologically immaturity but they can become organized eaters by swaddling, warm temp.,
- 3. Dysfunctional sucking pattern-doesn't have an organized suck pattern
- 4. Bottle types
- -Gravity flow-the milk flows with gravity, when babies suck intra-orally creates a negative pressure & the liquid flows from (+) pressure to (-) pressure.
- -Negative pressure flow-all of the air is squeezed out & the bottle can be tipped up or down
- 5. Nipple types
- -Short cylindrical, long, "orthodontic"
- -Soft, hard, preemie
- -Slow flow, fast flow, cross-cut
- 6. Comforting-rock, swaddle, soothe, burp more often
- 7. Stimulating-suck-massage cheeks, rock baby, vibration, move nipple around, tilt head forward, soak cloth in cold &/or sweet
- 8. Thicken the liquid
- -Commercial products, ground baby cereal
- -Adjust nipple
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Problems with Bottle Feeding and Factors to consider
- 1. Noisy/inefficient suck-could be a suck/swallow/breathe pattern; could be respiration; nipple might be a good fit, & he is not getting a good seal
- 2. Loss of fluid-Uncoordinated suck/swallow/breathe; alignment problem; poor labial seal; tongue/palate seal; nipple flow speed is too fast & too much fluid is going into mouth
- 3. Falls asleep-Getting tired b/c of too much effort to eat; check to see if the nipple is clogged, too much sensory overload
- 4. No suck, but mouths-Can't get enough of a seal to generate a suck; Check the nipple to see if it's clogged; could be a weakness issue.
- 5. Clamps on nipple-Weakness or stability issue, is the baby getting enough support?
- 6. Poor weight gain-Combination of all of the above
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