Evaluation Of Deglutition
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Evaluation Of Deglutition

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  • We need to understand normal suction-swallowing and breathing maturation process, because its important to therefore obtain an early diagnose of a swallowing disorder. Breathing usually does not require active effort except in those infants with problems, instead coordination of sucking-swallowing and breathing needs an effort. And it will be successful if the baby or infants gain weight and has an adequate growth without any pulmonary problems. Thats the relevance about knowing prenatal and postnatal critical periods, as follows.
  • Deglutition pattern is generated at the reticular formation and some brain cortex area. Deglutory activity initiates at the 10th week in utero. And its possibly to observe this first motor response in the pharynx, this swallowing process mantains amniotic fluid volume and composition. Trigeminal nerve activity also begins at this time because its possible to observe baby's hand reaching and stimulating cheeks and lips just before initiating suction. At 18th week, tongue can move backward and foreward that's the begining of swallowing, that's all movement that can be expected because it fills the whole mouth. True sucking will be completed during 18th and 24th week. At week 28th suction reflex will be present and at the 32nd rooting will be spected to be effective. 32nd week its also important due to the suction-swallowing and breathing pattern that in first place will be a respiratory pause then deglutition followed by another respiratory pause, at the 34th week change will occur and inspiration, deglutition and expiration will be the new pattern, finally at the 37 th week pattern matures developing suction-swallowing and breathing and baby will be able to sustain nutrition totally by mouth.
  • Deglutition pattern is generated at the reticular formation and some brain cortex area. Deglutory activity initiates at the 10th week in utero. And its possibly to observe this first motor response in the pharynx, this swallowing process mantains amniotic fluid volume and composition. Trigeminal nerve activity also begins at this time because its possible to observe baby's hand reaching and stimulating cheeks and lips just before initiating suction. At 18th week, tongue can move backward and foreward that's the begining of swallowing, that's all movement that can be expected because it fills the whole mouth. True sucking will be completed during 18th and 24th week. At week 28th suction reflex will be present and at the 32nd rooting will be spected to be effective. 32nd week its also important due to the suction-swallowing and breathing pattern that in first place will be a respiratory pause then deglutition followed by another respiratory pause, at the 34th week change will occur and inspiration, deglutition and expiration will be the new pattern, finally at the 37 th week pattern matures developing suction-swallowing and breathing and baby will be able to sustain nutrition totally by mouth.
  • Coordination of the process of sucking, swallowing and breathing is the most complex sensorimotor process the newborn must face. Anatomically and functionally babies that are preterms differs from full terms babies. Anatomically at birth breathing process begins, so larynx will be higher to facilitate aire entrance, epiglottis its long and also high to DERIVAR food and liquids to esophagus. Preterms doesn't have BICHAT FAT? That's fundamental for sucking. Preterm volume of the tongue its bigger than retrovelar space and with the high position of the larynx Functionally preterms don't have a good negative suction pressure. Leading to a non-effective suctioning process, therefore lactant wouldn't gain weight.
  • Coordination of the process of sucking, swallowing and breathing is the most complex sensorimotor process the newborn must face. Anatomically and functionally babies that are preterms differs from full terms babies. Anatomically at birth breathing process begins, so larynx will be higher to facilitate aire entrance, epiglottis its long and also high to DERIVAR food and liquids to esophagus. Preterms doesn't have BICHAT FAT? That's fundamental for sucking. Preterm volume of the tongue its bigger than retrovelar space and with the high position of the larynx Functionally preterms don't have a good negative suction pressure. Leading to a non-effective suctioning process, therefore lactant wouldn't gain weight.
  • Coordination of the process of sucking, swallowing and breathing is the most complex sensorimotor process the newborn must face. Anatomically and functionally babies that are preterms differs from full terms babies. Anatomically at birth breathing process begins, so larynx will be higher to facilitate aire entrance, epiglottis its long and also high to DERIVAR food and liquids to esophagus. Preterms doesn't have BICHAT FAT? That's fundamental for sucking. Preterm volume of the tongue its bigger than retrovelar space and with the high position of the larynx Functionally preterms don't have a good negative suction pressure. Leading to a non-effective suctioning process, therefore lactant wouldn't gain weight.
  • At the first three months of life infants don't distinguish between liquids and solids. They have an excitatory reflex when lower lip is depressed, and the tongue goes forward (video) it disappear between 4th and 6th mo. Rooting reflex will disappear after 1th mo when you touch baby´s face and cheek the head will rotate to that side. Its evocade by the trigminal nerve. Sucking in newborns its regulated by brainstem, allowing to suck and breath regulary. Pressure to lips produces a the tongue tu cupping, and its in an anterior position. It will act as a deposit can meanwhile the baby is braething. The jaw produce only vertical movements. Pump-like reflex gag reflex presents at the anterior portion of tongue because is like a protective reflex that prevent's choking.
  • Transition feeding describes the readness for and intiation of spoon feeding. Lactant develop skills to mantain an upright position sitting without minimal support, midline head position. Hand to mouth motor skills (foto y video de bebe llevándose el tetero a la boca). Dissociation of lip and tongue motions. Anatomic changes, more space for the tongue in oral cavity. Greater period of independence. Rootiong reflex disappears.
  • Transition feeding describes the readness for and intiation of spoon feeding. Lactant develop skills to mantain an upright position sitting without minimal support, midline head position. Hand to mouth motor skills (foto y video de bebe llevándose el tetero a la boca). Dissociation of lip and tongue motions. Anatomic changes, more space for the tongue in oral cavity. Greater period of independence. Rootiong reflex disappears.
  • The oral preparatory and oral phases of swallowing involve biting and bolus transfer. Anatomical structures must be intact and their function in function with each other must be appropiately timed. This requires integrity of both the motor and sensory nervous system
  • Postnatal pulmonary problems, weight gain. Steady appropriate weight gain is particulary important in the first 2 years of life for brain development as well as overall growth. A lack of weight gain in a young child is like a weight loss in a older child or adult.
  • Postnatal pulmonary problems, weight gain. Steady appropriate weight gain is particulary important in the first 2 years of life for brain development as well as overall growth. A lack of weight gain in a young child is like a weight loss in a older child or adult.
  • We use a videocamera to record the preparatory and oral phase. Depends on age
  • We use a videocamera to record the preparatory and oral phase. Depends on age
  • Vegetable green dye to stain de liquids, semisolid, solid (3 main consistencies)
  • Vegetable green dye to stain de liquids, semisolid, solid (3 main consistencies)
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath
  • Gastroesophageal reflux is frecuent in a 7 mo baby it gets better until 18 mo sheath

Evaluation Of Deglutition Evaluation Of Deglutition Presentation Transcript

  • Dra. Myrian Adriana Pérez García
    • Venezuelan Otorhinolaringologist
    • Former coordinator of the laryngology, fonation and swallowing unit of Children´s Hospital “J.M de los Ríos”
    • Former Specialist of Instituto de Otorrinolaringología de Caracas
    • Chair of the UNILAR Unidad Laringológica del Este (Estern Laryngological Unit). Caracas - Venezuela
    • Autor of the Book:
      • MANUAL DE DISFAGIA PEDIÁTRICA
    • Professor of the Diplomado Teórico-Práctico de Laringología Básica
  • Dr. Myrian Adriana Pérez García BARCELONA, SPAIN. JULY: 2nd-6th Evaluation of Deglutition in Children www.unilar.com.ve [email_address]
  • Contents
    • Suction-swallowing and breathing process maturation (Anatomy/physiology).
    • Otorhinolaryngologist evaluation of deglutition (functional endoscopic evaluation of swallowing).
    • Pediatric Laryngopharyngeal reflux (It´s relationship with dysphagia).
    • Swallowing disorders: Diagnose and Management.
  • Dysphagia
    • Difficulty:
    • Sucking-Swallowing-feeding
    • Motor-Sensitive
    • Safety-Efficiency
  • Background
    • Poor Epidemiological data: incidence/prevalence.
    • Relatively common in early infancy
    • 35% infants presents food selectivity
    • 80% Neurological diseases presents dysphagia (Cerebral palsy).
    • 90% Associated with malnutrition.
    • 80% Oral and pharyngeal phase altered.
    • 78% Pediatric Laryngopharyngeal reflux it´s related to dysphagia.
  • Anatomy and Physiology Suction-swallowing and breathing process maturation www.unilar.com.ve
  • Suction-swallowing and breathing process maturation
    • Critical and Sensitive Periods
      • Prenatal
      • Postnatal:
        • Preterm
        • Full-term
  • Prenatal
    • Swallowing 10th-12nd w
    • Sucking 18th- 24th w
    • Sucking reflex 28th w
    • Rooting reflex 32nd w
  • Prenatal
    • Patterns: Reticular formation and brain cortex area
      • Respiratory pause-swallowing-respiratory pause(32nd)
      • Inspiration-swallowing-expiration(36th)
    • Nutrition totally orally(34th-37th)
  • Postnatal
    • Anatomically/Functionally
    • Preterm
    • Full-term
            • PRETERM
    • Cannot coordinate suction-swallowing and breathing
    • Immature sucking
    • Poor negative pressure
    • Pharyngeal phase not well coordinated.
            • FULL-TERM
    • Coordinate suction-swallowing and breathing
    • Food-seeking behavior: rooting
    • Effective sucking
    • Normal pharyngeal phase coordination
    Postnatal
  • Postnatal
    • FULL-TERM
    • 1st-3rd mo
    • 4th-6th mo (transitional)
    • 6th-7th mo (developmental)
    • 10th-12nd mo
    • -36th mo
  • 1 st - 3 rd mo
    • Excitatory reflex
    • Rooting reflex
    • Sucking reflex (pump-like reflex)
    • Normal rate:
      • Suck/Swallow 1:1 - 3:1
    • Liquids and solids equal
    • Gag reflex
  • 4 th / 6 th mo - 9 th (Transitional)
    • Preparatory and oral phase
    • No excitatory lower lip reflex
    • No rooting reflex
    • Posterior gag reflex
    • Preparatory and oral phase
    • Solid food- posterior tongue positioning
    • 5th months, small bites
    • Spoon feeding initiation: some developmental skills
  • 4 th / 6 th mo - 9 th (Transitional)
    • Rithmic bites
    • Spoon feeding for thin, smooth puree
    • Upright position
    • Both hands to hold bottle
  • 9 th - 18 th mo (Developmental)
    • Precise picking small pieces of food
    • Pincer grasp
    • Cup drinking
    • Finger feeding
    • Teeth
  • Normal Swallow
    • Oral Preparatory Phase
    • Oral Phase
    • Pharyngeal Phase
    • Esophageal Phase
    • Craneal Nerve: IX, X, XI
    • Swallow center: pons
    • 5 events:
      • Velarpharyngeal sphincter
      • Pharyngeal muscle
      • Hyoid bone
      • Vocal fold
      • UEE
  • Functional Endoscopic Evaluation of Swallowing Otorhinolaryngologist Evaluation of deglutition www.unilar.com.ve
  • Feeding Goals
    • Preserve and guarantee
      • Good nutrition/ hydration status
    • Safety and efficiency
  • Clinical Feeding Evaluation
    • History: Prenatal, Postnatal
    • Physical Examination
      • Non-instrumental/Instrumental
    • Feeding Observation
      • Non-instrumental/Instrumental
  • Clinical Feeding Evaluation
    • History:
    • Description of child´s mealtimes:
      • Food types
      • Frequency
      • Duration
      • Respiratory system
    • Weight
  • Clinical Feeding Evaluation
    • History:
    • Alert!:
      • Feeding time more than 30-40 min
      • Respiratory Distress
      • Not gaining weight (2-3 m)
  • Clinical Feeding Evaluation
    • Physical Examination:
    • Baseline health
    • Medical status
      • Non-instrumental
  • Clinical Feeding Evaluation
    • Physical Examination:
      • Instrumental:
        • Anatomical abnormalities
        • Pooling secretions
        • Vocal folds
        • Safety
  • Clinical Feeding Evaluation
    • Feeding Observation
      • Non-instrumental:
        • Feeding position
        • Sucking reflex
        • Rooting
        • Mouth/lips closure
        • Jaw Movements
        • Spliting
  • Clinical Feeding Evaluation
    • Feeding Observation
      • Non-instrumental:
        • Feeding position
        • Sucking reflex
        • Rooting
        • Mouth/lips closure
        • Jaw Movements
        • Spliting
  • Clinical Feeding Evaluation
    • Feeding Observation
      • Instrumental
  • Clinical Feeding Evaluation
    • Feeding Observation
      • Instrumental
  • Clinical Feeding Evaluation
    • Feeding Observation
      • Instrumental:
        • FEES (FEEST)
        • VFES
  • Clinical Feeding Evaluation
    • FEES Protocol:
    • NB- 4mo: Bottle, water, milk
    • 4 - 6mo: Bottle, water, juice, apple sauce, condensed milk, spoon.
    • 6mo- 1y: + yoghurt, small cup, jelly, cake.
    • 1y - older: + straw, , worst meal
  • Clinical Feeding Evaluation
  • Clinical Feeding Evaluation
  • Clinical Feeding Evaluation
  • Clinical Feeding Evaluation
  • And Dysphagia Pediatric Laryngopharyngeal Reflux www.unilar.com.ve
  • Pediatric LPR
    • Laryngopharyngeal Reflux (LPR)
    • UES Dysfunction
    • Backflow to the larynx
    • Esophagus clearance normal
    • Respiratory symptoms
    • Cough and hoarseness
    • Regurgitation
    • Dysphagia
    • Gastroesophageal Reflux (GERD)
    • LES Dysfunction
    • Backflow to esophagus
    • Esophagus clearance altered
    • GI symptoms
    • Heartburn
    • Regurgitation
  • Pediatric LPR and Dysphagia
    • Laryngopharyngeal Reflux (LPR)
    • Endoscopic findings:
    • Belafsky Scale:
    Subglottic edema (pseudopsulcus) Ventricular Obliteration Arytenoid Erythema/Hyperemia Vocal fold edema
  • Pediatric LPR and Dysphagia
    • Laryngopharyngeal Reflux (LPR)
    • Endoscopic findings:
    • Belafsky Scale:
    • Results:
    • < 7 (no reflux)
    • 7-11 (mild reflux)
    • > 11 (severe reflux)
    Laryngeal Edema Posterior comissure hypertrophy Granuloma / Granulation tissue Laryngeal mucus
  • Pediatric LPR and Dysphagia
    • Laryngopharyngeal Reflux (LPR)
    • Endoscopic findings:
    Laryngomalacia Regurgitation
  • Pediatric LPR and Dysphagia
    • Laryngopharyngeal Reflux (LPR)
    • Endoscopic findings:
  • Pediatric LPR and Dysphagia
    • Physiopathology
    • Sensitive:
      • Hyposensivity: Laryngeal Adductor Reflex
      • Hypersensivity: Oral
    • Motor: LES low pressure
    • Air pulse- Arytenoids
    • Normal response: 2-4mmHg
    • Reflex:
      • Vocal fold closure
      • Swallowing
      • Cough
  • Pediatric LPR and Dysphagia
    • Physiopathology
    • LPR
    • Regurgitation
    • Acid/Pepsin
    • And/or
    • Oral and Pharyngeal erythema
    • Laryngeal edema
    • Altered Sensitivity
    • Oral
    • Larynx
    • Vomiting
    • Adductor reflex
    • Microaspiration
    • Dysphagia
  • Pediatric LPR and Dysphagia
    • Diagnosis
    • Esophageal Manometry
    • 24 pH double probe
    • Esophagoscopy
    • Fiberoptic nasopharyngolaryngoscopy
    • Videofluoroscopy
    • Fibro endoscopic evaluation of swallowing
  • Pediatric LPR and Dysphagia
    • Management
    • Upright position
    • 2 hours after meal
    • Avoid citric, lactose products
    • Small Frequent meals
    • Pump-bomb Inhibitors
    • Prokinetics
    • H2 antagonists
  • Diagnose and Management Swallowing Disorders www.unilar.com.ve
  • Dysphagia
    • Interdisciplinary team approach
    • Otorhinolarygologist
    • Speech Pathologist
    • Nutritionist
    • Gastroenterologist
    • Pediatric surgeon
    • Pediatrician
    • Neumologist
    • Neurologist
    (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Diagnosis
    • Primary problem areas
    • Severity of swallowing disorder
    • Saliva pooling
    • Other diseases (LPR, pulmonary infection)
    • Nutritional/Hydration status
    • Actual Skills
    (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Severity Swallowing Disorder
    Phonoaudiological Protocol for dysphagia risk evaluation (PARD) (1) . Severity levels: 7 Consistencies, strategies/time/cough-> Management Level I: Normal Deglutition Level II: Functional Deglutition Level III: Mild Oropharyngeal dysphagia Level IV: Mild to moderate Oropharyngeal dysphagia (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Diagnosis
    Phonoaudiological Protocol for dysphagia risk evaluation (PARD) (1) . Severity levels: 7 Consistencies, strategies/time/cough-> Management Level V: moderate Oropharyngeal dysphagia Level VI: moderate to severe Oropharyngeal dysphagia Level VII: severe Oropharyngeal dysphagia (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Severity Swallowing Disorder
    Level I : Normal Deglutition Level II : Functional Deglutition More time Level III : Mild Oropharyngeal dysphagia Diet changes, may need some therapy Level IV : Mild to moderate Oropharyngeal dysphagia One (1) consistency restriction. Therapy for avoiding aspiration risk. Need nutritional suplement (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Severity Swallowing Disorder
    Level V : Moderate Oropharyngeal dysphagia Oral and feeding tube. Therapy. Restriction two (2) consistencies Level VI and VII : Moderate to severe Oropharyngeal dysphagia Non-oral feeding (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Non-surgical management
    • Posture-positioning changes
    • Volume, consistency, texture, temperature bolus changes
    • Non-nutritive program
    • Nutritive program
    • Botulinum toxin if needed
    (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Dysphagia
    • Surgical management
    • Nasogastric feeding tube
    • Gastrostomy tube
    • Surgical management of salivary glands
    • Vocal fold medialization
    • Cricopharyngeal miotomy
    • Tracheostomy
    • Laryngopharyngeal Division
    (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Conclusions
    • Emphasis in whole infant status (safety, comfort, pleasure).
    • Oral feeding is not always the “GOAL”.
    • Real Goals : Pulmonary stability and Nutritional well-being
    • If we diagnose LPR we must give treatment for it!
    • Close follow up to make changes when needed
    (1) Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
  • Thank you www.unilar.com.ve