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Paediatric Paediatric Dysphagia Dysphagia

Grizelda SteynGrizelda SteynJanet Smith IncorporatedJanet Smith Incorporated

Audiologist & Speech TherapistAudiologist & Speech Therapist

St. Augustine’s HospitalSt. Augustine’s Hospital

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Background of DysphagiaBackground of Dysphagia

• Feeding problems common in NICU/preterm infantsFeeding problems common in NICU/preterm infants• Minor feeding problems in normal children Minor feeding problems in normal children 25-30%25-30%• 40-70%40-70% feeding problems in premature infants and feeding problems in premature infants and

infants with chronic illnessinfants with chronic illness• Feeding is very Feeding is very complex processcomplex process which involve which involve mouth, mouth,

pharynx, larynx and esophagus and sucking reflex in pharynx, larynx and esophagus and sucking reflex in infants in the first phase.infants in the first phase.

• Cornerstones of infant feeding – Cornerstones of infant feeding – suck/swallow/breathsuck/swallow/breath• Sucking reflex initiates swallowing in the infant by Sucking reflex initiates swallowing in the infant by

stimulation of the lips and deeper parts of the oral stimulation of the lips and deeper parts of the oral cavity.cavity.

• The mandible, maxilla, upper gums, lips, palate and The mandible, maxilla, upper gums, lips, palate and cheeks are necessary for compression of the nipple and cheeks are necessary for compression of the nipple and expression of contentsexpression of contents

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General BackgroundGeneral Background

• Any defect of lips, tongue, palate, mandible, maxilla or Any defect of lips, tongue, palate, mandible, maxilla or cheeks may create problems in the first phase of feeding cheeks may create problems in the first phase of feeding

in an infantin an infant..• 3 stages of swallowing disorders – oral 3 stages of swallowing disorders – oral

phase,pharyngeal phase and esopharyngeal phase,pharyngeal phase and esopharyngeal phase)phase)

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What is Dysphagia?What is Dysphagia?

• Difficulty swallowingDifficulty swallowing• The inability of food or liquids to pass The inability of food or liquids to pass

easily from the mouth, into the easily from the mouth, into the throat, and down into the esophagus throat, and down into the esophagus to the stomach during the process of to the stomach during the process of swallowing.swallowing.

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What could affect What could affect successful feeding in an successful feeding in an

infant?infant?• Conditions that impact the Conditions that impact the

neurological system developing, neurological system developing, respiration and digestion.respiration and digestion.

• Medications often have side effects Medications often have side effects that could cause nausea, stomach that could cause nausea, stomach pain and irritation.pain and irritation.

• Cardiac patients often lack the Cardiac patients often lack the endurance to take sufficient amount endurance to take sufficient amount of liquid in a timely manner.of liquid in a timely manner.

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What about our What about our Premature/NICU infants?Premature/NICU infants?

• Difficult deliveryDifficult deliveryAspiration, hypoxiaAspiration, hypoxia Impacts : postural control, breathing regulation, Impacts : postural control, breathing regulation,

state of infant, oral and pharyngeal reflexesstate of infant, oral and pharyngeal reflexes• Prolonged ventilationProlonged ventilation

• Cardiac problemsCardiac problemsStart with limited respiratory reservesStart with limited respiratory reservesDifficulty regulating cardio-respiratory functionDifficulty regulating cardio-respiratory function Impacts energy, endurance, intake, Impacts energy, endurance, intake,

coordination and safetycoordination and safety

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Premature/NICU infantsPremature/NICU infants

• Congenital anomaliesCongenital anomalies Cleft lip- and palateCleft lip- and palate

• Hyperbilirubinemia (Jaundice)Hyperbilirubinemia (Jaundice) Impacts alertness, vigor and therefore intake.Impacts alertness, vigor and therefore intake.

• Infant of Diabetic motor( IDM)Infant of Diabetic motor( IDM) Impact work of breathing and therefore disrupts Impact work of breathing and therefore disrupts

coordination of suck-swallow-breathe sequence.coordination of suck-swallow-breathe sequence.

• Respiratory Distress Syndrome (RDS)Respiratory Distress Syndrome (RDS) Compromise the transition to nipple feedingCompromise the transition to nipple feeding

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Common feeding Common feeding difficulties in NICUdifficulties in NICU

• Tires before finishing feedingTires before finishing feeding• Lacks spontaneous mouth opening – breathing Lacks spontaneous mouth opening – breathing

too much effort to be willing to suck.too much effort to be willing to suck.• Feeding for long periods at a timeFeeding for long periods at a time• Difficulty coordinating sucking, breathing and Difficulty coordinating sucking, breathing and

swallowing swallowing • Gagging during feeding Gagging during feeding • Drooling Drooling • Congestion in the chest after drinking Congestion in the chest after drinking • Coughing or choking when drinking (or very Coughing or choking when drinking (or very

soon afterwards) soon afterwards)

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Symptoms of DysphagiaSymptoms of Dysphagia

• Tiredness or shortness of breath while eating or drinking Tiredness or shortness of breath while eating or drinking • Frequent respiratory infections Frequent respiratory infections • Colour change during feeding, such as becoming blue or Colour change during feeding, such as becoming blue or

pale – silent aspirationpale – silent aspiration• Spitting up or vomiting frequently Spitting up or vomiting frequently • Food or liquids coming out of the nose during or after a Food or liquids coming out of the nose during or after a

feeding feeding • Disorganized sucking – overall postural disorganization and Disorganized sucking – overall postural disorganization and

poor sucking rhythm, poor tongue stabilitypoor sucking rhythm, poor tongue stability• Trouble latching – related to breathing, abnormal CNS or Trouble latching – related to breathing, abnormal CNS or

could be oral-tactile hypersensitivitycould be oral-tactile hypersensitivity

• Weight lossWeight loss

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Important to remember…Important to remember…

• The reluctance to suck may be The reluctance to suck may be an instinctive reaction, a an instinctive reaction, a purposeful respond to attempt to purposeful respond to attempt to protect their airway.protect their airway.

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Protocol for Oral feedingProtocol for Oral feeding

• 34 weeks G.A34 weeks G.A• Weight of 1.6kgWeight of 1.6kg• No medical conditions that would interfere with No medical conditions that would interfere with

feedingfeeding• Respiratory rate: 70 breaths per minuteRespiratory rate: 70 breaths per minute• Effort: no change in skin colourEffort: no change in skin colour• Able to maintain a wakeful state of 10-15 minutesAble to maintain a wakeful state of 10-15 minutes• Aspiration: none (Swallowing of Oral Secretions?)Aspiration: none (Swallowing of Oral Secretions?)• Ability to gag and reflexively protect airway.Ability to gag and reflexively protect airway.• Rhythmic, non-nutritive suckingRhythmic, non-nutritive sucking

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Treatment of DysphagiaTreatment of Dysphagia

Goal of treatment plan is safe, independent Goal of treatment plan is safe, independent feeding(swallow). feeding(swallow).

• Changing bottle or teats – Changing bottle or teats – Premature infant – Premature infant – bigger teat provide internal stability. (Tongue position bigger teat provide internal stability. (Tongue position and mouth size).and mouth size).

• Positioning – Positioning – impacts airway maintenance, breathing, safe impacts airway maintenance, breathing, safe swallow and organization of infantswallow and organization of infant

• SwaddlingSwaddling – provides overall postural support and – provides overall postural support and containmentcontainment

• Pacing of feeds Pacing of feeds • Flow rate – Flow rate – greatest obstacle to safe and successful greatest obstacle to safe and successful

feeding. Increased flow – poor endurance/weak suck. feeding. Increased flow – poor endurance/weak suck. Reduce flow- poor coordination of SSB. Aspiration!!Reduce flow- poor coordination of SSB. Aspiration!!

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Treatment of DysphagiaTreatment of Dysphagia

• Oral motor & Swallowing simulation Oral motor & Swallowing simulation techniquestechniques

• PacifiersPacifiers• Calorically dense formulas Calorically dense formulas

(Cardiopulmonary disorders)(Cardiopulmonary disorders)• NGTNGT• PEGPEG

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Outcome of our babies in Outcome of our babies in NICUNICU

• Early interventionEarly intervention• Good prognosis for babies with no Good prognosis for babies with no

severe or chronic illnesssevere or chronic illness• Maturation of CNSMaturation of CNS• Alternative feeding as part of goal Alternative feeding as part of goal

towards successful feedingtowards successful feeding

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Questions or Comments?Questions or Comments?