Pediatric Dysphagia

  1. 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
  2. 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.
  3. 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
  4. What can affect the caregiver/child relationship?
    • -Depression
    • -Neglect
    • -Not reading the child's cues
    • -Environment
  5. 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
  6. 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
  7. 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
  8. Principles of Manual Oral-Motor Therapy
    • 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
  9. 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
  10. 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
  11. Toweling
    • Goals-increase midline orientation, symmetry, sensory awareness, & mobility
    • See diagram pg 6a of notes
  12. 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.
  13. 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
  14. 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
  15. 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
  16. 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
Card Set
Pediatric Dysphagia
Final Exam for Pediatric Dysphagia