Pediatric Dysphagia

• 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

• 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.

• 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

• -Depression
• -Neglect
• -Not reading the child's cues
• -Environment

• 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

• -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

• -Create an antagoistic environment
• -Overload the parents
• -Try to push progression when the child is not developmentally ready for it

• 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

• 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

• 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

• Goals-increase midline orientation, symmetry, sensory awareness, & mobility
• See diagram pg 6a of notes

• -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.

• 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

• 1. "Chin pinch" for head/jaw/lips
• 2. "C" shape for jaw & lips
• 3. "V" or "L" shapes for jaw

• 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

• 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