. Neural networks that are responsible for this automatic swallowing are known as the central pattern generator (the brainstem, including the nucleus tractussolitarius and the nucleus ambiguus , with the reticular formation linked to cranial motoneuron pools, is thought to be the central pattern generator).
Feeding & swallowing difficulties among children with multiple disabilities doc
Dr Sheelu SrinivasConsultant ENT Surgeon & Department CoordinatorFortis Hospital B.G. Rd
Nothing would be more tiresome than eating anddrinking if God had not made them a pleasure aswell as a necessity. ~Voltaire
Feeding & swallowing Feeding includes the act of preparing food and getting it to the child either orally or through alternative means. Swallowing includes the manipulation of food in the mouth and directing its passage from the oral cavity down to the stomach.
Age (months) Development/posture Feeding/oral sensorimotorSource: Adapted from Arvedson and Brodsky10 (pp. 62–67). Neck and trunk with balanced flexor Nipple feeding, breast, or bottle and extensor tone Hand on bottle during feeding (2–4 Visual fixation and tracking months)Birth to 4–6 Learning to control body against gravity Maintains semiflexed posture during Sitting with support near 6 months feeding Rolling over Promotion of infant–parent interaction Brings hands to mouth Sitting independently for short time Feeding more upright position Self-oral stimulation (mouthing hands Spoon feeding for thin, smooth puree and toys) Suckle pattern initially Suckle suck Extended reach with pincer grasp Both hands to hold bottle6–9 (transition feeding) Visual interest in small objects Finger feeding introduced Object permanence Vertical munching of easily dissolvable Stranger anxiety solids Crawling on belly, creeping on all fours Preference for parents to feed Pulling to stand Cup drinking Cruising along furniture Eats lumpy, mashed food First steps by 12 months9–12 Finger feeding for easily dissolvable Assisting with spoon; some become solids independent Chewing includes rotary jaw action Refining pincer grasp Refining all gross and fine motor skills Self-feeding: grasps spoon with whole Walking independently hand12–18 Climbing stairs Holding cup with 2 hands Running Drinking with 4–5 consecutive swallows Grasping and releasing with precision Holding and tipping bottle Improving equilibrium with refinement of upper extremity coordination. Swallowing with lip closure Increasing attention and persistence in Self-feeding predominates>18–24 play activities Chewing broad range of food Parallel or imitative play Up–down tongue movements precise Independence from parents Using tools Circulatory jaw rotations Chewing with lips closed Refining skills One-handed cup holding and open cup Jumping in place24–36 drinking with no spilling Pedaling tricycle Using fingers to fill spoon Using scissors
Three phases of swallowing • oral preparatory phaseOral phase 1 s liq 20 s solid • oral propulsive phase • aspiration is most likely to occurPharyngeal phase 1s • involuntary and totally reflexive • lower esophageal sphincterEsophageal phase 8-20 s • gastroesophageal reflux.
Factors leading to feeding & swallowing disordersArvedson and Brodsky, (2002), ASHA (2002), Kurjan, Newman (2000) and Swigert (1998) central nervous system abnormalities or injuries (e.g., neural tube defects; genetic Premature birth/LBW Anatomic defects like clefts syndromes; • cerebral palsy; pre-, peri- or post-natal trauma, such as stroke or traumatic brain injury oral and upper digestive tract and/or food texture hypersensitivity (e.g., some Intellectual disability Dysphonia children with autism; • secondary to use of nasogastric tube in some children
Inter relationships among development of feeding &swallowing & other developmental domain Ability to Delay in self Motor skills hold things feed Communication Ability to Attitude development express need towards food Delayed Need to be Medical feeding fed with food condition patterns textures
Early assessment & intervention “Feeding and swallowing skills changedramatically during the first three years of life.Developmental gains in feeding and swallowing aredue to the combined influences of anatomicgrowth, neuromotor maturation and learning”(ASHA, 2004).
Why aversion/hypersensitive later? lacks the opportunity to build associations between positive sensations in the mouth and the reduction of hunger, or the social interaction Tube feedings cause GER-associate feeds with discomfort & pain Negative and invasive stimulation to the face and mouth -suctioning, intubation, tube insertion Mouth becomes unfamiliar with touch, taste, texture, and other stimuli that had pleasurable associations &become physically hypersensitive to touch and taste
Behavioral expression fall in 3categories resistance to accepting food orally; lack of energy and endurance to do the work of eating; oral-motor -disabilities resulting in an inability to produce the necessary motor skills for ingestion. Determine if the problem has a strictly physiologicorigin or whether it may be exacerbated by the feedinginteraction between child and feeder.
Role of ENT Surgeon Feeding issues 20 % swallowing / dysphagia
Establishing a feeding & swallowingTeam Individualized SLP,OT Therapy to enhance strength, range of motion & coordination of the lips ,tongue, cheek & jaw muscles Decrease oral aversion due to sensory problems Decrease behavioral resistance to feeding Decrease risk of aspiration Others: food texture, feeding equipment & compensatory strategies
Components of the Plan. environment positioning during feeding equipment for food preparation and feeding diet content (including food and liquids), quantity and texture feeding techniques precautions, including emergency procedures training plans for personnel implementing the plan, monitoring safety, progress and effectiveness of the plan process for communicating with families
strategies Oral awareness Mouthing Special utensils school-based PT has knowledge and training to provide input to the school team that includes: positioning (tonal issues, head/trunk control);• seating options (e.g., wheelchair, adapted chair); and• assistance with assistive technology needs.• Dietitian or Nutritionist.