Pediatric Dysphagia part 2

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meadsre
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163539
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Pediatric Dysphagia part 2
Updated:
2012-07-23 00:13:45
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Ped Dys II
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Swallowing
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  1. 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
  2. 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
  3. 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.
  4. Cup Drinking
    • 1. Proper positioning
    • 2. Liquid types-thin, nectar, thicker-than-nectar, honey
    • 3. Cup types-cut-out cups, sunken lid
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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)
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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.
  19. 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
  20. 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
  21. 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
  22. 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
  23. Tactile System
    • 1. Protective system linked to fight/flight response
    • 2. Body awareness
    • 3. Emotional security
    • 4. Motor planning
    • 5. Social skills
  24. 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)
  25. 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
  26. 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.
  27. 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
  28. 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
  29. 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
  30. 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
  31. 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.
  32. 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
  33. 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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