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Tube Feedings-Problems
- 1. Unpleasant oral associations-due to NICU, surgeries, NG tubes, intubated
- 2. Reflux
- 3. No association between hunger & eating-they never feel hungry b/c of tube feedings & they don't associate feeling hungry & eating
- 4. Decreased pleasurable oral experience-won't put toys in mouth, doesn't take pacifiers
- 5. Decreased functional oral experience
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Weaning from Tube Feedings
- 1. Bolus feeds
- 2. Typical feeding environment-as the child is receiving the tube feeding, have him in a high chair so he associates fullness w/ environment
- 3. Oral experiences-provide a functional oral activity while he is being tube fed. Pacifier, cloth dipped in formula/milk, anything pleasurableto get him use to becoming an oral eater
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GERD
- Common recommendations
- -Frequent burpings
- -Thickened feedings
- -Specialized bottles
- -Post-prandial positioning-stay up for 30 min after feeding
- Evidence-whether these things actually work is debatable, they are not going to hurt/may help
- Often improves with maturation.
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Cup Drinking
- 1. Proper positioning
- 2. Liquid types-thin, nectar, thicker-than-nectar, honey
- 3. Cup types-cut-out cups, sunken lid
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Benefits of Cut-out cups
- We can see the point at which the liquid is entering the child's mouth
- We are able to tip the cup up without the child going into extension
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Benefits of Sunken lid cups
- -Two handles for child can hold
- -clear so liquid is visible
- -One big hole that straw can fit into so straw training is possible
- -Controlled amount of liquid is possible
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Skills needed to transition from breast/bottle to open cup
- 1. Labial seal around the rim of the cup
- 2. Lip rounding
- 3. Graded jaw opening & control (stability)
- 4. Tongue elevation to hard palate
- 5. Vertical trunk stability (on own or assisted)
- 6. Liquid bolus control
- 7. Head/neck control for extension/flexion
- 8. Coordination of suck/swallow/breathe
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Problems with Cup Drinking
- 1. Tongue protrusion-single sips with lip closure in between, want to get them in the habit of bringing the tongue back in the mouth
- 2. Limited lip activity-place cup at corners of mouth, push in the corners of the mouth & encourage lip closure
- 3. Jaw instability-use teeth for stability, more acceptable than tongue
- 4. Disorganization-encourage rhythmic drink-pause sequencing, keep the cup at the lip to provied organization
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Skills needed to transition to assisted straw drinking
- 1. Lip ronding-more than cup/bottle
- 2. More strength intra-orally (cheeks, lips, etc.)
- 3. More anterior than the bottle but posterior to cup so tongue elevation is needed.
- 4. Negative pressure to pull bolus into mouth
- 5. Tongue elevation to hard palate
- 6. Liquid bolus control, coordination of suck/swallow/breathe
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Straw Drinking
- 1. Head flexion-head has to be in flexion for straw drinking, beneficial for those kids that stay in extension
- 2. Teaching straw drinking:
- -Place in mouth
- -Hold for child at varying angles (dip straw in liquid holding the liquid in with a seal at one end with finger & let the child get a seal aroung the straw & let go of the liquid. Continue like this lowering the angle until he has to suck to get the liquid out.)
- -Squeeze bottle to bring liquid into the child's mouth
- 3. Straw position-control the amount of straw that goes into the mouth, use a bite blocker, should only be 1/4" to 1/2" of the straw in the mouth
- 4. Tongue protrusion-go in at side, then slide to midline
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General Consideration with Spoon Feeding
- 1. Use small amounts
- 2. Stay with one consistency until easily managed
- 3. use proper spoon size & type
- 4. Present spoon at appropriate level-don't want extension b/c child has to look up to get to the angle of the spoon.
- 5. Present spoon straight into mouth
- 6. Give them time to anticipate the spoon
- 7. Dont' present to the side
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Types & sizes of Spoons
- Maroon spoon-flat bowl so easy to clean food off compared to deep bowl
- Latex-covered-helps with biting of the spoon
- Metal
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Skills necessary to transition to spoon feeding
- 1. Jaw stability and control
- 2. Lip rounding & control
- 3. Tongue tip elevation, lateralization (needed for combination texture, i.e. cereal with milk)
- 4. Bolus control (tongue & cheeks)
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Spoon Feeding Therapy
- 1. Maintain "quiet" mouth
- 2. Facilitate mouth opening-tap on lip, firm pressure, stroking face (not for children clenching their mouth shut, but for those that need sensory awareness for the spoon)
- 3. Facilitate active lip/tongue movements-stimulate suckle/suck with finger, nipple, stroking
- 4. Encourage lip closure:
- -press down on front 1/3 of tongue
- -feed corner-to-corner-turn the spoon sideways & press the side of the spoon on the corner of the mouth
- 5. Tongue protrusion following:
- -Vibratory pressure on the tongue with spoon-push down with spoon & move it from side to side
- -Move quickly from side to side
- 6. Tongue thrust:
- -OM exercises to increase laterlization & decrease tone
- -Iced pressure to midblade
- -vibration under the chin
- -Salty flavors on tongue
- -Place spoon sideways at corners
- -Firm pressure with spoon
- 7. Hyperactive gag reflex:
- -Play with textures & spoons
- -Provide over-flexion
- -Walk back on tongue
- 8. Hyperactive bite reflex:
- -2-minute oral prep
- -Place spoon sideways at corners
- -Release with down/out pressure to TMJ, gentle head extension, circular pressure under chin
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Finger Foods
- 1. Encourage biting/chewing/graded jaw movements:
- -Nuk, chewy tubes, toys, vibration
- -Fabric bolus
- -Ice straws
- -Ice sticks
- 2. Encourage tongue lateralization-present foods at side of mouth
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Chewing Hierarchy
(Rosenfeld-Johnson)
- 1. Teach lateral chew with tongue-tip dissociation & movement across midline:
- -Bolus at lateral molar ridge (alternate)
- -Bolus at lateral incisor then molar ridge
- -Bolus at lateral incisor then opposite incisor
- -Five-point bite
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Progression of Food Textures
- 1. Pureed-Commercial foods may make transition to table foods harder
- 2. Thickened pureed-can be handled with sucking action (tongue tip elevation); no lateralization needed
- 3. Ground-introduce when child displays vertical chewing (scrambled eggs, mashed veggies)
- 4. Chopped-offer whe child moves foods to side with tongue & has enough strength to break up pieces
- 5. Coarsley chopped-offer when child has mature rotary chew & strength
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Potential Problems with foods
- 1. Sticky consistency (potatoes, peanut butter)-weak or poorly coordinated tongue movement, hypersensitivity to pressure
- 2. Dry foods (crackers)-Weak or poorly coordinated tongue movement; hypersensisivity to movement (break into a lot of different pieces)
- 3. Slippery/wet (pureed fruits/fruit cocktail)-weak or poorly coordinated tongue movement, slow oral transit. (the food can move much faster b/c thsi can go into pharynx or larynx too quickly)
- 4. Choking hazards-nuts, popcorn, grapes, hot dogs, raw veggies, meat, strong flavors, hard to chew.
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Drooling Management
- 1. Different food products affect secretions
- -Milk products thicken mucous
- -Broth & animal fat thin mucous & increase drooling
- -Sweet foods increase drooling & thicken mucous
- -Acidic juices increase drooling
- 2. Encourage swallow
- -Maintain head in flexed position
- -Gentle pressure stroking upward/downward under chin
- -Rub ice from sternal notch up neck
- -vibrate laryngopharyngeal musculature
- -Apply cold stimulation to faucial arches
- -Apply cold/tart to tongue surface
- 3. Oral awareness program
- -wet vs dry in environment
- -vet vs dry on chin
- -chewing
- -clean sweep
- -wiping chin
- -swallow
- -dry swallow
- -wiping & swallowing
- -lip closure
- -tone up the face
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Sensory Motor Overview
(Shannon Anderson-OTR)
- 1. Child can be hypersensitive, hposensitive, or a combination
- 2. Hypersensitive-brain registers sensation to intensely, can't screen out the unnecessary, getting too much input & thus avoids input
- 3. Hyposensitive-brain registers less of the information, not getting enough inpus, needs extra stimulation to respond
- 4. Dysfunction can occur in one or several systems
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Vesitbular/Movement
- 1. Gravitational security
- 2. Movement/balance
- 3. Bilateral coordination
- 4. Sensation processed through the inner ear
- 5. Linked with the processing of sound for Audiory Training Programs
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Signs of Vestibular Dysfunction
- 1. Dislikes being tossed in the air
- 2. Fearful in space (changing tables)
- 3. Clumsy
- 4. Resists head tipped back during bath
- 5. Obsessive with movement i.e. tossing in the air/jumping
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Tactile System
- 1. Protective system linked to fight/flight response
- 2. Body awareness
- 3. Emotional security
- 4. Motor planning
- 5. Social skills
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Tactile System Dysfunction
- 1. Dislikes cuddling/prefers not to be held (obsessive with car seat)
- 2. Obsessive about shoes either on or off
- 3. Dislikes having hair/face/nose washed
- 4. Avoids food with texture-hard to transistion to toddle foods or overstuffs mouth
- 5. Pushes others
- 6. Gets upset when messy (does not play in own cake)
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Auditory System
- 1. Gives us directional information
- 2. Necessary for speech development
- 3. Articulation
- 4. Mechanisms for processing sound & movement are the same mechanisms in the inner ear
- 5. Movement & sound are linked & this is why you may facilitate/hear more sounds/language during movement tasks
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Auditory Dysfunction
- 1. Have to speak loudly/touch child to gain attention
- 2. Makes sounds for no known reason
- 3. Startles easily
- 4. Dislikes places with multiple sound sources i.e. the Mall/Restaurants/Parties
- 5. Attempts to escape from noise environment (buries head in Mom's chest)
- 6. Covers ears with hands.
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Visual Dysfunction
- 1. Enjoys looking at spinning objects (this may also be related to the vestibular system)
- 2. Avoids eye contact; may not be able to look & think at the same time.
- 3. Does not recognize self in mirror
- 4. Sensitive to light
- 5. Falls asleep in crowds
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Olfactory Dysfunction
- 1. Avoids smells, i.e. cries when near the kitchen
- 2. Ignores noxious odors
- 3. Dislikes grandma who wears strong perfume
- 4. Smells objects/hands with intensity
- 5. Avoids new foods
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Oral Dysfunction
- 1. Licks/chews nonfood items
- 2. Mouths objects
- 3. Does not lick lips to clean food
- 4. Refuses new foods/hard to transition to toddler foods
- 5. Resists tooth brushing
- 6. Wants same cup, spoon, fork
- 7. Does not respond to strong flavors
- 8. Hard to transition from bottle to cup
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Proprioceptive Sense
- 1. Informs us about body position in space
- 2. Where our body parts are in space
- 3. Rate and timing of movement
- 4. How much force we are exerting
- 5. Efficient use of movement
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Proprioceptive Dysfunction
- 1. Moves in inefficient ways
- 2. Rigid, stiff, and uncoordinated
- 3. Bumps into objecst
- 4. Stamps feet
- 5. Avoids playground activities that require good body position, i.e. climbing into tunnels
- 6. Has to think about movement; cannot move & think at the same time.
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Sensory/Behavioral/Feeding Issues
- 1. Oral Aversion
- -Non-food items near/in child's mouth
- -Experience different textures, temperatures, flavors, smells
- 2. Extreme Oral Exploration
- -Provide appropriate oral input
- 3. Create a specific routine-same schedule, limit choices
- 4. Positive reinforcement-praise, access to favorite toy/video
- 5. Ignore inappropriate behaviors-negative to neutral behaviors
- 6. Desensitization-utensils with no food, sprays
- 7. Masking-"hide" non-preferred foods in preferred ones
- 8. Shaping-reward successive approximations of targeted behavior
- 9. Focus on social aspects of eating-eating together, positive interactions
- 10. Modeling-caregivers & peers
- 11. Talk about food in play-to foods, toy dishes with real food bits, characters
- 12. Experience food in different ways-dried beans or rice, use food for play
- 13. Change the food timing & presentation-offer every other day, change shape, color, taste, texture
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Hierarchical Steps for Eating
- 1. Tolerating food-same room, same table, in front of
- 2. Interacting with foods-stirring, transferring, assisting in preparation/serving
- 3. Smelling food-in room, at table, in front of, leaning into
- 4. Touching food-clothing, hand, chest, head, face, lips, teeth, tongue
- 5. Tasting food-from lips, biting & spitting out, chew, swallow
- 6. Eating on own
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