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Joan C. Arvedson, Ph.D.
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Management of Infants & Children with Feeding & Swallowing Disorders
SAC Conference, May 4, 2018Joan C. Arvedson, PhD, CCC-SLP, BCS-S, ASHA Honors & Fellow
[email protected] & [email protected]
Postural Control EvaluationMuscle tone (hypotonia or hypertonia)Central alignment relates directly to oral
sensorimotor systemPresence of primitive reflexesLevel of physical activitySelf oral stimulation
Use of eye contact, head turning, & touch
Principles of ManagementWhole child approachTotal oral feeding is not always the goalNutrition & respiratory status criticalGER managed optimallyChanges in management needed
with gains or regression
Joan C. Arvedson, Ph.D.
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Management Recommendations
Direct & indirect approaches for oral sensorimotor function
Types of abnormal sensory responses need to be considered
Oral sensorimotor treatment for anatomic structure problems
Intervention Based on Developmental Skill LevelsOverall gross & fine motor skill levelsCognitive, language, communicationAdjusted age for first year or two in
case of prematurityImportant that all involved with a child
understand & respect the child
Intervention Factors
Cognitive statusPosture, movement, motor skillsMuscle toneMedicationsReflexesCranial nerve findingsDysmorphology diagnosis
Joan C. Arvedson, Ph.D.
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Ongoing Monitoringfor Potential Changes
Airway statusGI tract disease (e.g., GER)Clinical ongoing assessment
Postural/positional observationsCaregiver/child interactionsOral sensorimotor feeding statusObservation of respiration
Intervention forDysfunctional SwallowingDietary changesPosition & postureBolus placement in mouthTiming between bolus presentationsThermal sensitization - caution for
infants & young children
Bolus Formation (Oral-Motor Focus for Function of Structures)
JawLipsCheeksTonguePalate
Joan C. Arvedson, Ph.D.
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Oral Phase Management
PositioningSensory aspectsPresentationTextureMovement patterns
Pharyngeal Phase Management
Indirect oral sensorimotor treatment(e.g., improve tongue base propulsion)
Position changes
Textures changes
Nutrition Support
Boost calories in a variety of waysSpecial formulas or foodsCut back calories/volume
Close monitoring with tube feeds Infants with cardiac conditions along
with neurologic problems may be fluid restricted
Joan C. Arvedson, Ph.D.
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Positioning & SeatingCritical as underpinning to oral
sensorimotor considerationsAdaptations may be needed with
HypotoniaHypertoniaGrowthRegression
Therapeutic Techniques: Pros & Cons for Discussion
ThickenersOral sensorimotor therapyElectrical stimulationEscape extinction (part of ABA)
Thickening: QuestionsWhat effect might thickened feeds have on
the GI tract?Young infants may face ↑ risk of life-
threatening condition (NEC)Simply Thick banned by FDA for infants
Some companies now marketing for ages 3 years & above
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Thickeners: QuestionsWhat happens to timing & coordination with
prolonged use of thickened liquid when no practice is given to work toward thinner liquidThickened fluids & water absorption in rats &
humans (adults) – no evidence that absorption rate of water from the gut was different (Sharpe et al, 2007, Dysphagia)
International Dysphagia Diet Standardisation Initiative (IDDS)Working committee working to standardize
terminology related to texture modificationTrends with thicker liquidsReduce risk of penetration-aspiration Increase risk of post-swallow residue in
pharynxFood texture: properties of hardness,
cohesiveness & slipperiness are relevant
IDDSI Processes10 international researchers collaborated to
review articles: started 10,147 screened for relevance; 488 met inclusion criteria
36 articles contained specific info re oral processing or swallow behaviors for at least 2 liquid consistencies or food textures
Steele, CM et al Dysphagia 2015
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CP: Risks with Thin Liquids
Cochrane review – no studies found to support or refute water for children with cerebral palsy (Weir & Chang, 2005)
Are there safe thin liquids if intermittent minimal aspiration occurs? If so, what conditions?
How can practice/experience be provided?
Oral-Motor Exercises
Evidence in literature: very limited with mixed quality of reportsArvedson et al 2010: 16 studies of variable
quality Insufficient evidence to determine effectsWell-designed studies are needed
Oral-Motor ExercisesLikely sensory involved as wellWork only on bolus formation & bolus transit
– hoping to facilitate pharyngeal functionFarther off task they go, the greater difficulty
to bring around to desired functionMust be pleasurable & not stressfulHow much time to spend on OM vs use of
food or liquid leading to functional feeding?
Joan C. Arvedson, Ph.D.
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Electrical StimulationElectrodes placed on surface of skin – not
adjacent to muscles involved in swallowingGoal: Increase speed of pharyngeal initiation
of swallow and improve strength of pharyngeal contractorsOne report: no more effective than usual
care for primary dysphagia in childrenChristiaanse et al, 2011, Pediatr Pulmonol.
Escape Extinction
Reports in psychology literatureUsually part of ABA therapy especially for
children with autismNonremoval of spoon is typical focus to
increase acceptance & mouth cleanUsed with positive reinforcement often
Escape Extinction: QuestionsNon-psychologists carry out?Is non-removal of the spoon really negative
reinforcement?Could this approach ever be perceived as
“forced” feeding?Can negative reinforcement ever be
considered positive to the child?For what types of children, is this useful?
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Management with Feeding Tubes
Considerations for Initiating Tube FeedingIncapacity or limited ability to eat & drinkInability to meet nutrition needs by oral
feeding alone (>75% calorie needs even with high calorie supplements)Inability to maintain adequate hydrationLengthy feeding timesHigh risk for aspiration – Impaired swallowDisordered gastrointestinal systeme.g., Gottrand & Sullivan (2010)
Long Term Tube Feeding?Beyond 4-6 weeks, gastrostomy tube
should be considered (ESPGHAN Committee on Nutrition)PEG routine for all ages, including neonates
weighing as little as 2.5 kgGtube – replaced by button once site
healed, some endoscopic 1-step button procedures now available
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Goals of Tube FeedingAlleviate undernutrition in chronic conditionsMaintain or improve nutrition statusMinimize GI signs & symptomsImprove/maintain quality of life for child &
caregiversEasier administration of fluids & medicationMore time for education & rehabilitation
Management with Feeding TubesEnteral route: through digestive tractParenteral route: bypass digestive tract
Total Parenteral Nutrition (TPN) or hyperalimentation
Peripheral intravenous or central arterial lines
Conjunction with oral or non-oral enteral feeding
Types of Feeding Tubes
Orogastric (OG)Nasogastric (NG)Duodenal (ND)Gastrostomy (GT)Jejunostomy (JT or GJT)
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Nutrition Support for Tube FeedingAdjust formula as needed for
GrowthMedical needsFamily needs
Adjust schedule to optimize interest in & ability for oral feeding (bolus vs continuous)Maintain feeding therapy – encourage PO
Formulas for Tube FeedingsCommercial formulasSpecialized formulas with food allergies or
sensitivitiesBlenderized tube feedingsKetogenic diets with intractable seizure
disorderOthers?
Bolus Feeding with Gastrostomy
Upright positionPump or gravity delivery, air removedFormula at room temperatureFeeding time minimum of about 20
minutes to no more than 30 minutesOral stimulation during feeding (or prior)Tubing flushed after feedings or meds
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Contributing Factors to WeaningProlonged experiences with invasive oral
proceduresInability to regulate self hunger/satietyMissing out on critical or sensitive period of
oral exploration & exposure (6-12 months)Oral aversions leading to continued
dependence on supplemental feeding tube
Transitioning Off Tube FeedingsEstablish patient’s medical & nutrition
stabilityAdjust TF schedule: bolus vs night dripDecrease TF in 10-25% increments to
stimulate hungerMonitor weight on regular basis
Transitioning Off Tube FeedingsEstablish regular schedule for oral feeding
Use appropriate textures of foodUse high calorie diet as neededMonitor fluid intake & provide free water
by tube as neededUse supplements as needed
Communicate feeding plan with all team members
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Criteria: Discontinue Tube Feeding
Patient able to take >75% of estimated calorie need orally & maintain weight
May be able to discontinue calories by TF before discontinuing all water by TF
Consider removal of feeding tube when child has maintained weight, hydration, & adequate oral intake for > 2 months & during period of illness
Who is a Picky Eater?
Child with limited or decreased Dietary varietyQuantity of food
Generalized resistance to foods
Normal or Picky?Toddlers – 2nd year of life
Decrease in growth velocityRelative tapering off in appetite
Parents’ expectations often challengedNatural progression in growth & feeding
can be misinterpreted by caregiversLeads to impression of picky eating
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Fundamental Principles for Eating
Children eat best when parentsdo their part in feedingprovide children with appropriate support
for their developmental age avoid putting pressure on feeding
Fundamental Principles for Eating
Health care providersmust be careful about setting
expectations for how much children should eat
need to be aware that caloric densities may need manipulation under guidance of dietitians with physician monitoring
Food RulesScheduling
Meal times < 30 min + planned snacks Nothing between meals (except water)
Environment Neutral atmosphere - no forced feeding No game playing; no reward with food
Procedures Solids first; self-feeding encouraged Meal over if food is thrown in anger Clean up only at end of meal
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Picky vs Non-Picky EatersPicky eaters: Less varietyToddlers perceived as picky by mothers
Lower dietary variety & diversityNutrient intake & growth parameters
not significantly different
Picky Eaters: Children with Special Health Care NeedsPrevious negative experiences
Medical interventionsPhysical condition that made eating
scary, painful, or dangerousDesire to avoid eating may continue
after physical condition is corrected
Treatment StrategiesMedical (e.g., GER/aspiration management)Nutrition (e.g., calorie boosters, fortifying
foods, cap on juices, multivitamin/mineral supplement, fiber & fluid considerations)Educational opportunities (for parent & child)
Role play for selected parents Nutrition classes & snack time sessions
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Meal Time StrategiesConsistent meal & snack time schedules
Average child:1/3 of calories from snacksFor child who consistently rejects certain
foods, provide nutritious alternativesReintroduce previously rejected foodsIncrease exposure to new food
Meal Time StrategiesAlteration of food & liquid
TemperatureTasteTexture or consistency
Use appropriate serving size: SmallMaterial must be appropriate for oral
sensorimotor skill levels
Guide for Parents:Building Foundation of Understanding
Typical development around growth & development
Challenges that children may bring to tableWays parent find themselves stuck in
unpleasant & counterproductive feeding patterns
Rowell & McGlothlin 2015
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STEPS: Supportive Treatment of Eating in PartnershipS
Decrease stress, anxiety, & power strugglesEstablish a routineEnjoy pleasant family mealsBuild skills in “what” and “how” to feedStrengthen & support oral motor & sensory skillsUnderstand progress in short & long term –different for every child & family
Rowell & McGlothlin 2015
Behavioral InterventionsDivision of responsibility: parent & child
Adults are responsible for what food is presented to eat & manner in which it is presented
Children are responsible for whether they eat & how much they eat
Behavioral InterventionsEmpower parents with clear guidelines
Focus on aspects under controlUnderscore that you can’t force
another person to eatSet time limits for meals & snacks
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Behavioral Intervention Strategies
Feeding structureManipulation of hungerContingency managementShaping Parent training
Feeding StructureManipulation of factors known to increase
desirable behaviors & reduce problem behaviorsAll meals at the tableChild securely seated in appropriate chairConsistent meal & snack time scheduleMeal free from distractions
Manipulation of HungerPromotion of hunger to ↑ motivation at
mealtime - ↑ range & volume of foods & beverages consumedElimination of grazing ↓ supplemental feedingsAllow child to “fail” a meal to experience
natural consequences of increased hungerUse of appetite stimulants
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Videos Demonstrating Strategiesfor Discussion: What Else?
What Else?What about sensory approaches (SOS)?Do children who play in food readily end of
putting that food into the mouth?What other functional approaches can we
use to facilitate improved oral skills along with hunger for children?
Other ideas? How do we measure outcomes?
Intervention SummaryAirway & nutrition highest prioritiesOften cannot depend on clinic observations
alone with suspicion of pharyngeal problem Effort expenditure must be consideredDevelopmental skill levels criticalFunctional techniques/processes
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Summary
Children with neurologically based feeding and swallowing problems are COMPLEX
Feeding/swallowing status changes over timeRealistic goals are critical & must be
established with parents & professionals working closely together with mutual respect & coordination/collaboration