Treatment of Pediatric Swallowing Disorders

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DISCLAIMER
The information in these notes were developed from the three primary
sources cited below. These notes are intended to supplement course materials
and ARE NOT intended to replace the textbooks. It is expected that students
will purchase the textbooks and that these notes will be used only by
students enrolled in the Pediatric Dysphagia course.
Sources:

Arvedson, J. C. & Brodsky, L. (1993). Pediatric swallowing and feeding: Assessment and management. San Diego: Singular.
Cherney, L. R. (1994). (Ed.) Clinical management of dysphagia in adults and children. 2nd Edition. Gaithersburg, MD: Aspen.
Wolf, L. & Glass, R. (1992) Feeding and swallowing disorders in infancy: Assessment and management. Tuscon, AZ: Therapy Skill Builders.
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  1. Primary foci
    1. reduction or elimination of factors that potentially contribute to airway compromise
    2. maintenance of adequate nutrition and hydration intake
    3. facilitation of positive interaction between parent and child
  2. Ultimate goal: development of coordinated movements of the mouth, respiratory, and phonatory systems for communication and for oral feeding
  3. Principles:
    1. evaluation should take into account the relationship between the caregiver and the child, as well as the subsystems within the child
    2. must consider tone and movement patterns of the entire body
    3. tone and movement patterns in the jaw, tongue, lips, and cheeks must be altered when necessary to reduce the impact of reflexes
    4. normal movement patterns must be facilitated
    5. facilitation of integration of sensory information may precede any attempts to address feeding
  4. Preparation
    1. Preparing the infant (addressed in detail below)
    2. Preparing the environment
      1. visual stimuli
      2. noise
      3. temperature
    3. Preparing the feeder
      1. relaxation
      2. mindset
  5. State
    1. Increasing arousal
      1. vestibular or movement stimulation
      2. auditory
      3. tactile (including temperature)
    2. Calming
      1. tactile
        1. swaddling
        2. firm touch
        3. massage
      2. rhythmic movement
      3. auditory
        1. white noise
        2. rhythmic
  6. Tone, posture, & position
    1. general characteristics
      1. overall flexion
      2. orientation about midline
      3. shoulders symmetric
      4. hips flexed 45 to 90 degrees
      5. neutral A/P alignment of the head (slight flexion)
    2. treatment techniques
      1. movement activities
      2. feeding positions
        1. standard
        2. en face
        3. supine in lap
        4. sidelying on lap
        5. increasing head flexion
        6. slight head extension
  7. Swallowing
    1. delayed swallow reflex
      1. thermal stimulation
        1. feeding
        2. non-nutritive suck
      2. improve bolus formation
        1. single boluses
        2. small boluses
        3. thickened liquids
    2. aspiration during the swallow
      1. improve laryngeal closure
        1. head flexion/chin tuck
      2. thicken feedings
    3. aspiration after the swallow
      1. modify food consistency
      2. encourage dry swallows
      3. improve pharyngeal pressure (velopharyngeal valving)
  8. Oral motor control
    1. oral-facial hypotonia
      1. causes & contributing factors
        1. prematurity
        2. neurological deficit
        3. weakness
      2. treatment techniques
        1. tapping
        2. vibration
        3. quick stretch
    2. oral-facial hypertonia
      1. causes & contributing factors
        1. neurological deficit
        2. underlying hypotonia
      2. treatment techniques
        1. preparatory movement (neurodevelopmental treatment)
        2. firm pressure
        3. shaking/vibration
    3. tongue retraction
      1. causes & contributing factors
        1. hypertonicity
        2. neck hyperextension
        3. hypotonicity (passively retracted)
        4. micrognathia
      2. treatment techniques
        1. postural support (head & neck alignment)
        2. modify tongue tone
          1. proximal to distal pressure/stroking
        3. longer nipple
    4. lack of central grooving
      1. causes & contributing factors
        1. hypertonicity
        2. lack of internal stability
      2. treatment techniques
        1. proprioceptive input
          1. downward pressure at midline
          2. slight stroking forward
          3. firm, straight nipple
    5. excessive tongue tip elevation
      1. causes & contributing factors
        1. prematurity
        2. stabilization pattern
      2. treatment techniques
        1. postural support (decrease neck extension)
        2. facilitation of tongue movements
          1. quick swiping or vibration
          2. followed by downward pressure
        3. assist with mouth opening
    6. tongue protrusion
      1. causes & contributing factors
        1. hypotonia
        2. organization difficulties
        3. increased neck extension
        4. increased tone
      2. treatment techniques
        1. postural support
        2. increase tongue tone
        3. facilitate appropriate tongue movements
          1. firm downward pressure at tongue midline
          2. firm straight nipple
          3. use finger to facilitate NNS
        4. facilitating lip activity
          1. use thumb and index finger to provide pressure over fat pads
    7. lack of spontaneous mouth opening
      1. causes & contributing factors
        1. reduced alertness
        2. hypertonia
      2. treatment techniques
        1. arousal techniques
        2. elicit rooting reflex
        3. assist mouth opening
          1. gentle downward pressure and traction to jaw
        4. inhibit jaw clenching
          1. vibration to the mouth
          2. touch/pressure to gums
    8. weak suck
      1. causes & contributing factors
        1. overall weakness
        2. respiratory or endurance problems
      2. treatment techniques
        1. facilitating stronger suck
          1. provide oral stability
            1. optimal positioning
            2. cheek and jaw support
          2. small bottle
          3. slight traction on nipple
        2. increase flow of liquid
    9. excessive jaw movement
      1. causes & contributing factors
        1. jaw instability
        2. prematurity
        3. low tone
        4. hypertonicity leads to thrusting
        5. neck hyperextension
        6. abnormal tongue movement
      2. treatment techniques
        1. postural support
          1. head and neck alignment
        2. external support
          1. firm pressure by finger under jaw
        3. increased neck flexion
        4. neuromotor preparation
        5. facilitating appropriate tongue movements
    10. poor lip seal
      1. causes & contributing factors
        1. low tone or weakness
        2. excessive jaw movement
        3. abnormal tongue movements with thrusting
      2. treatment techniques
        1. treat underlying problems
        2. external support
    11. poor cheek stability
      1. causes & contributing factors
        1. facial hypotonia
        2. small or diminished sucking pads
      2. treatment techniques
        1. increase tone
        2. external cheek support
    12. poor initiation of sucking
      1. causes & contributing factors
        1. excessive root reflex
        2. orienting to nipple with extreme mouth opening
        3. ineffective tongue protrusion or lapping pattern
        4. poor state or organizational abilities
      2. treatment techniques
        1. treatment of underlying problems
        2. controlling excessive rooting
          1. provide firm stabilization
          2. place nipple firmly on the midline with slight downward pressure
          3. cheek support
        3. assist with mouth closure
          1. firm jaw control
        4. facilitate appropriate tongue movement
    13. poor palatal movement
      1. causes & contributing factors
        1. abnormal tone
        2. submucous clefts
      2. treatment techniques
        1. maturation
        2. palatal training appliances
    14. Treatment by structure (Arvedson & Brodsky)
      1. Jaw
        1. thrust
          1. mouth play
          2. assisted tooth brushing
          3. soft object held between teeth
        2. clenching
          1. mouth play
          2. stimulation on face
        3. retraction
          1. prone positioning
          2. forward pull under jaw
        4. tonic bite reflex
          1. pressure at TMJ
          2. sensory stim
          3. coated flat spoon
      2. Lips and cheeks
        1. finger-tapping or vibration to cheeks and lips
        2. varied food textures and temperatures
        3. straw drinking
      3. Tongue
        1. thrust
          1. thickened liquid
          2. food placed at side of gums
          3. exercises for lateral tongue movement
          4. spoon placed at midtongue with downward pressure
        2. retraction
          1. prone position
          2. stroke tongue from back to front
          3. chin tuck
          4. submental upward tapping
        3. hypotonia
          1. varied textures and tastes to increase sensory input
          2. food or liquid added gradually
          3. blow toys
        4. deviation
          1. maintenance of head at midline
          2. stimulation of less active side
      4. Palate
        1. upright or prone position
        2. angled bottle
        3. cheek and tongue exercises
        4. thickened liquids
  9. Oral-tactile Hypersensitivity
    1. causes & contributing factors
      1. immaturity and illness
      2. delayed introduction of oral feeding
      3. unpleasant oral-tactile experiences
    2. treatment techniques
      1. reduce aversive oral-facial stimuli
        1. modify care routines
      2. grading
        1. area of face
          1. most tolerance away from lips and tongue
          2. may have to start with arms
        2. type
          1. texture (smooth is generally better)
          2. pressure (firm is generally better)
          3. food (puree is generally better)
      3. touch pressure
        1. rub child's face, arms, body with various types of stimuli
        2. firmly rub gums or stroke the tongue
          1. place finger at front of tongue, "walk back"
        3. provide during ADL's
        4. key concepts
          1. work from least sensitive are to most sensitive
          2. firm touch is usually tolerated better than light touch
          3. broad surfaces are usually tolerated better than small surfaces
          4. stationary may be better than moving touch
          5. brief touch may be better tolerated than sustained touch
          6. child may tolerate self-touch and touch by familiar people or objects most easily
      4. vibration
      5. oral exploration
        1. ensure variety
  10. Coordination of sucking, swallowing, and breathing
    1. prolonged sucking--feeding induced apnea
      1. causes & contributing factors
        1. prematurity
        2. may be precursor to future problems
      2. Treatment techniques
        1. external pacing
          1. count sucks and remove nipple
          2. leave nipple on lips
        2. allow increased maturity
        3. decrease rate of flow
          1. thicken liquid
          2. low-flow nipple
    2. short sucking bursts
      1. swallowing related incoordination -- VFSS
      2. respiratory related incoordination
        1. reduce expectations
        2. increase respiratory support
    3. disorganized sucking
      1. assist with external organization
        1. swaddling
        2. reduce external distractions (light, noise)
        3. provide external rhythms
      2. acknowledge respiratory problems
        1. external pacing
      3. reduce flow rate
      4. massage hyoid musculature
      5. introduction of small amounts of liquid on non-nutritive stimulus
        1. pacifier
        2. finger
      6. adjust nipple opening (smaller?)
      7. offering liquids by spoon or cup
  11. Endurance and Respiratory compromise
    1. reduced endurance
      1. regulate liquid flow
        1. increase amount at beginning
      2. manipulate feeding schedule
        1. limit length of feeding
        2. allow rest between feedings but increase frequency
        3. move to demand schedule
      3. nutritional supplements
        1. increased caloric density
        2. may affect fluid balance
      4. realistic expectations
    2. respiratory compromise
      1. realistic expectations
      2. dealing with increased respiratory rate
        1. resting RR should not be avoe 70-75 breaths/minute; may need to postpone oral feeding
        2. RR during feeding above 80 or 85 bpm, feeding should be stopped
      3. provide additional respiratory support--issues:
        1. increasing amount of oxygen will not be effective for all respiratory problems
        2. may use oximetry to monitor saturation
        3. should assess response to supplemental oxygen
      4. external pacing
      5. increased nutritional requirements
  12. Non-oral and supplemental Feeding Methods
    1. Establishing the need for non-oral feeding
      1. risk of aspiration
      2. effectiveness of oral feeding
      3. expected medical course
      4. social factors
    2. Options for non-oral feedings (see table 5.1, Wolf & Glass)
  13. Oral-motor treatment with tube feedings
    1. types of tubes
      1. OG--orogastric
      2. NG--nasogastric
      3. if GER
        1. nasoduodenal
        2. nasojejunum
      4. G tube
        1. preferred for reasons cited below
    2. risks
      1. nasal irritation
      2. facial defensiveness
      3. decreased sucking
    3. Stimulation of nonnutritive sucking--overhead
      1. stroking face & tongue
      2. providing taste experiences
      3. reducing sensory stimuli
    4. Special concerns for infants with neurological impairment
      1. may need more extensive and specific stimulation
      2. tapping
        1. inner & outer surfaces of gums, tongue
        2. adding liquid when adapted to tapping
  14. Oral feeding with infants
    1. readiness: full feeding in less than 30 minutes
    2. stress signals
      1. irregular breathing
      2. gagging, choking, yawning, hiccuping
      3. body changes
      4. change in color
      5. unusual gaze patterns
      6. crying
  15. Transitional feeding
    1. food texture progression
      1. thin or thickened liquids
      2. strained/pureed
      3. thickened pureed
      4. lumpy
      5. mashed table foods
      6. chopped solid foods
      7. whole solids/table foods
    2. spoon feeding
      1. not until 4-6 months
        1. tongue thrust pushes material out
        2. when ready, child will remove material with lip
      2. jaw control
      3. gradual taste and texture changes
    3. cup drinking
      1. type of cup
        1. transparent
        2. wide lip
        3. narrow base
      2. jaw control
      3. head positioning
      4. thickened liquid may be a better start
    4. straw drinking
      1. follows cup drinking
    5. chewing
      1. avoid particulate solids
      2. avoid bread--gumminess
      3. add strips of food as chewing develops