Feeding

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Outline:
Introduction to Feeding
Anatomy and Physiology
Development of Feeding Skills
Dysphagia
Assessment
Treatment

Published in: Health & Medicine, Business

Feeding

  1. 1. OutlineIntroductionAnatomy and PhysiologyDevelopment of Feeding SkillsDysphagia in Pediatric PopulationAssessmentTreatment
  2. 2. ADLFeeding
  3. 3. Feedingprocess of setting up, arranging and bringing offood from the plate or cup to the mouthEatingSwallowing
  4. 4. SSB synchronyMust be rhythmically synchronized so that infantcan receive adequate nutrition from mother’sbreast or nipple of a bottleAllows individuals to breathe whilesimultaneously and unconsciously sucking inand swallowing food, drink, and saliva
  5. 5. Feeding ProblemsMedical conditionsDevelopmental disabilitiesOral motor dysfunctionBehavioral problems
  6. 6. Feeding ProblemsClinical findings may include foodrefusal/selectivity, vomiting, swallowingdifficulty, prolonged mealtimes, poor weight gainand failure to thrive.
  7. 7. Oral Structures• Intact = pre-requisite for normal eating anddrinking
  8. 8. NewbornSmall oral cavity filledwith fat pads inside thecheeks and tongue.Can feed safely ininclined position
  9. 9. Infantneck elongates and theconfiguration of the oraland throat structurechangesOral cavity becomeslarger and moreopen, tongue becomesthinner and moremuscular, and the cheekslose much of their fattypadding
  10. 10. < 1 yearHyoid epiglottis, and larynx descend, creating aspace between these structures and the base ofthe tongue.The hyoid and larynx become more mobileduring swallowing, elevating with each swallow.
  11. 11. Functions of OralStructures in FeedingOral cavity =Contains the foodduring drinking andchewing andprovides for initialmastication beforeswallowing
  12. 12. PharynxFunnels food intothe esophagusand allows foodand air to sharespace
  13. 13. LarynxValve to thetrachea thatcloses duringswallowing
  14. 14. TracheaAllows air to flowinto bronchi andlungs
  15. 15. EsophagusCarries food fromthe pharynx,through thediaphragm andinto the stomach
  16. 16. Phases of SwallowingOral preparatoryOralPharyngealEsophageal
  17. 17. Oral Preparatory Phasevoluntary controlOromotor feeding interventionOral manipulation results in the formation of aBOLUSamount of time varies depending on the texture offood/liquidCranial nerves V, VII, IX, and XII
  18. 18. Oral Phasevoluntary controlBegins when the tongue elevates against thealveolar ridge moving the bolus posteriorlyEnds with the onset of pharyngeal swallow.1-3 seconds
  19. 19. Pharyngeal Phaseinvoluntary controlStarts with the trigger of the swallow at the anteriorfaucial archesHyoid and larynx move upward and anteriorly and theepiglottis retroflexes to protect the opening of the airwayEnds with the opening /relaxation of the cricoesophagealsphincter1-3 seconds
  20. 20. Final/Esophageal Phaseinvoluntary controlStarts with the contraction of thecricopharyngeus muscle and ends with therelaxation of the lower esophageal sphincter,allowing the food into the stomach.8-10 seconds
  21. 21. Sucking reflexpredominant method of feeding of fetus duringthe first 8 - 10 months of lifeEither:NutritiveNon-nutritive
  22. 22. Premature infants33 weeksgestational age orlessnasogastrictube/an IV line
  23. 23. 2 factors that determineability to feedSucking rhythmTypes of suction
  24. 24. Amount of liquid isdetermined by 3 factors:Rate or speed of suckingForce of sucking/compressionLength of feeding time
  25. 25. Sucklingfirst sucking patterntongue moves back and forth, and the jaw opensand closes, following the movement of tongue1st 4 months of life
  26. 26. True Sucking4 months of ageHallmark: tongue begins to move up and down6 months: Sipper cup with a spout12 months: bottle to cup, bites on rim of cup15-18 months: excellent coordination of SSB24 months: efficiently drink from cup
  27. 27. Biting and ChewingInfant: reflexive4-5 months: phasic bite and release7-9 months: Munching12 months: rotary movements18 months: well-coordinated rotary chewing
  28. 28. Biting and Chewing24 months: circular jaw movements
  29. 29. Drinking6 mos: interest in drinking from a cup12 mos: emerging cup drinking skillsCup with a lid and spout24 mos4-6 ounce cup without a lidDrinks from straw
  30. 30. DysphagiaDifficulty in swallowingResults when obstacles in normal developmentarise and are not overcomeLimiting variations in feeding:Problems in individual oral structuresProblems in sensory processing
  31. 31. JawMost important partner of the feeding teamPoor postural tone and poor central stability ofneck and trunkJaw thrust, tonic bite reflex, jaw clenching
  32. 32. Jaw Thrust1 year olds use visual input and knowledge ofsize to guide jaw movementsLack of jaw gradingStrong downward extension of the lower jaw
  33. 33. Tonic Bite ReflexWhen child doesn’t release the bite easily orwhen there is tension associated with the biteelicited from the biting surfaces of the gums orteethMay have resulted from an experience ofdiscomfort in the mouth from oralhypersensitivity, constant suctioning or oralhygiene
  34. 34. Tonic Bite ReflexResults to jaw clenching  more constantclosure  risk of contractures LOM of the Jaw
  35. 35. Jaw ClenchingInvoluntary tight closure of the jaw
  36. 36. Tongueproblems in the muscles that attach the tongueto other structures of the body and move it indifferent directionsLow or high toneTongue retraction, tongue thrust
  37. 37. Tongue RetractionResults from abnormal postural toneBreathing difficultiesChild may compensate by pressing tongueagainst hard palate
  38. 38. Tongue ThrustVery forceful protrusion of tongue from themouthMovement is arrhythmical
  39. 39. Lips and cheeksThese two work togetherLow tone:Cheeks become inefficient barrier to food movedagainst gums and teeth = food easily falls intocheek cavityLips are not able to retain food and saliva in mouthHigh tone: retracted position
  40. 40. Lip Retractionlips are drawn back so they form a tighthorizontal line over the mouthDifficulty in sucking, removing food orliquid, transferring or retaining food placed inmouth
  41. 41. Lip PursingSeen when child attempts to counteract effectsof lip retractionPuckered lips
  42. 42. Cleft Lipseparation of the upper lip and often the upperdental ridge
  43. 43. Palatethe anatomical divider between the oral andnasal cavities
  44. 44. Cleft Palateseparation of the hard or soft palate
  45. 45. Cleft PalateThe infant has difficulty building up sufficientnegative pressure within the mouth to obtain anefficient feeding patternFood/liquid/tongue may pass through theopening
  46. 46. Sensory ProcessingCNS is unable to control and process andappropriate amount of sensory information at alevel that is comfortable for the childHypersensitivity  HyperresponsivityHyposensitivity  HyporesponsivitySensory defensiveness and Sensory overload
  47. 47. Sensory ProcessingSSB synchrony is the center of sensoryorganization for the entire bodyInstability = poor SSB coordination
  48. 48. Sensory ProcessingOften manifests as behaviors like teethgrinding, tongue sucking, nail or fingerbiting, prolonged bottle feeding, thumbsucking, and pacifier usageINPUT TO TMJPreferred reactions to stress e.g. bite nails, talksincessantly, chew gums  stability
  49. 49. Sensory ProcessingTreatment: satisfying the need for stimulation tothe TMJ, and increasing strength, stability andgrading in the muscles of the jaw
  50. 50. Questionsquestions about feeding, eating, and swallowingAssess mealtime participationDevelopmental status and health historyFeeding history = any possible frustration andthe parents’ ability to cope with the child’sfeeding issues
  51. 51. Neuromotor Evaluationgeneralized muscle tone, neuromuscularstatus, and general development leveluse of adapted seating systems = helpsdetermine the optimal position for feedingUpright position or reclined
  52. 52. Evaluation of Oral Structures& Oromotor ProblemsObservation of symmetry, size and ROM of oralstructuresIncreased oral tone may cause the tongue to beretracted, humped, or have tip elevation andmay often be the primary cause of feedingdifficultiesHypotonia may cause tongue to be flat, lack amidline groove and extend beyond the lips
  53. 53. Eating and FeedingPerformanceFinal aspect: observation of the actualfeeding/eating and swallowing process to assesslevel of performance and to analyze howmotor, sensory, cognitive and communicationskills contribute to performanceparent-child interaction = clues about factorsthat may affect the child’s food intakeVariety of textures
  54. 54. VideofluoroscopicSwallow StudyTo confirm or rule out swallowing problemsmodified swallow study = identifying aspirationor risk of aspirationdetecting problems related to head and neckpositioning, bolus characteristics, rate andsequence of presentation, and food/liquidinconsistencies.
  55. 55. Penetration vs Aspirationflow of liquid/foodunderneath theepiglottis into thelaryngeal vestibule butnot into the airway.It does not passthrough the vocal folds.may be silentIt refers to foodentering theairway before,during or afterswallow.
  56. 56. Feeding TeamPlanning and implementing a feeding programdepends on the treatment setting and needs ofthe childPediatrician, nutritionist/dietitian, SLP, OT, childbehaviorist, developmental psychologist,dentist, nurse, social worker, teachers, childcareproviders, parents/caregivers
  57. 57. Global ConsiderationsFeeding problems persist = new problems/skillimpairments to complicate intervention needsconsider medical and nutritional problems thatcoexist with the feeding d/o and collaborate withphysician and nutritionist for optimum interventionplanOTs have to work closely with families and othercaregiver to ensure carryover within daily routines
  58. 58. OTs use a holisticapproachChild factorsPerformance skillsActivity demand, contextFamily patterns
  59. 59. Safety and Healthchild’s nutritional status and prioritize treatmentgoals to meet basic nutritional needsuse of gloves during therapy services whenthere is potential contact with oral mucousmembranesunderstanding that certain foods carry a highchoking risk and require modifications or closesupervision with young children
  60. 60. EnvironmentalAdaptationsregularly scheduled meals at consistent times orlocations from day to dayLimit sensory stimulationConsider order of presentation of foods andliquids during meal sessions
  61. 61. Positioning AdaptationsPositioning of the feet, legs and pelvis  trunkstabilityStability, muscle tone and activity in the trunkmuscles affect the child’s ability to move or stabilizethe head and neckposition and muscle activation of the child’s headand neck influence jaw movementsGood jaw stability and freedom of movementinfluence the child’s lip and tongue control.
  62. 62. positioning adaptations provide stability in thetrunk and support the child in midline orientationwith the head and the neck aligned in neutral orslight flexion during feeding
  63. 63. InfantsSide-lying in caregiver’sarmSupineadapted seat with smallrolls to provide head andtrunk support or Rshoulder protraction tohelp an infant hold his orher own bottle
  64. 64. Older infants/ToddlersRegular high chair -may provideadequate trunksupport and mayeasily be adaptedwith small towel rollsfor additional footsupport or lateralsupport
  65. 65. Older Children withNeuromuscular ImpairmentsRifton chair - toprovide optimalsupport duringoral feeding
  66. 66. Optimal positioning(Hulme)Vertical head and trunk positionHip flexion greater than 90 degreesKnee flexion at 90 degreesFeet supported in flat surface
  67. 67. PositioningA chin - tuck positionSlightcontraindicated foryoung infants who havelaryngomalacia ortracheomalacia
  68. 68. 5 steps to extinguish oralhabits:1. Root cause of behavior?2. Why should the habit be eliminated?3. Program with alternative means to address jawweakness and sensory stimulation4. Conference with family/caregivers/supportteam
  69. 69. 5 steps to extinguish oralhabits:5. Convince child to give up the habitIntroduce a substitute
  70. 70. General TreatmentStrategiesOral sensory stimulation:Nuk brush, cold washcloth, or vibrating deviceStrong flavors and cold temperatures
  71. 71. Oral DefensivenessIncrease child’stolerance to differenttextures, tastes andtemperaturesWilbarger intraoral(inside the mouth)techniqueJaw-tug techniquedeep pressuretechniques
  72. 72. Hyposensitivity totaste/textureNoted to have less efficient patterns of movingfood around in the mouth, including chewing andswallowing secondary to decreased muscle toneand generalized weaknessIntroducing increased food texture consistency= choking hazardAt risk nutritionally
  73. 73. General TreatmentStrategyWork for better sitting posture on the lap or in achair: trunk and pelvis should be in goodalignment with the shoulder girdle in forwardand abducted position, the cervical spine (neck)is elongated with capital flexion (chin-tuck).changes in feeding position should be donegradually.
  74. 74. JawWeakness: nonnutritive strengthening axUse quiet background music or music withtempo of 60 bpm to create a calm feedingenvironment
  75. 75. Jaw RetractionIn prone on feeder’s lap with arms forward acrossthe feeder’s thighAngle the support surface on the feeder’s lap so thatthe child’s shoulders are higher than the hipsGravity may cause the tongue and jaw to drop into amore forward positionGently place a hand under the child’s jaw producinga slight traction forward to further enlarge theairway.
  76. 76. JawApply carefully graded firm pressure to face,gums, and teeth while maintaining the jaw inclosed positionlow facial tone: Apply patting, tapping, strokingand other types of tactile and proprioceptivestimulation of the muscles that open and closethe jaw
  77. 77. Tonic Bite ReflexAssist the child into tonic flexion of neck withtrunk and shoulder supportapply firm pressure on the upper and lowergums then into the biting surface of the teethUse coated spoon to protect child’s teeth fromharm or discomfort
  78. 78. Tongue Retraction1. (prone) stimulate the lips, move into the mouthand stroke the tongue rhythmically and entice itto follow your finger as it slides forward in frontof the mouth2. (chin-tuck) gently tap under the chin on themuscular area to provide greater tonguestability and give it more tone for movingforward
  79. 79. Tongue Retraction(Prone) move into the mouth entering the cheekpouch from the side then gently work your fingertowards the gums and tongue in which you begina downward vibration of the finger in the centerof the tongue to flatten iton the middle of the tongue, press evenlydownward
  80. 80. Tongue ThrustReduced by being in a well-supported andslightly flexed positionfacilitate tongue lateralizationencourage the child to make silly faces in themirror or to lick lollipops or favorite flavors at thecorners of the mouth or within the cheeks
  81. 81. Tongue elevationfacilitated through;touching the tip of the tongue with an oral motordeviceproviding slight pressure on the anterior hardpalate just behind the front teeth
  82. 82. CheeksLow tone place fingers on the side of the child’s nose andvibrate downward toward the bottom of theupper lip slowly and evenly providing a long-lasting relaxation of upper lip tightness
  83. 83. Lips Retraction & PursingSlow perioral and intraoral cheek stretches canhelp promote lip closureuse cotton swabs with drops of liquid placed atthe corner of the lip or in the cheek pocket
  84. 84. Lipsteach straw drinking beginning with squeezebottle and aquarium tubingClose the child’s lips as you slowly squeezeliquid to the edge of the lipsGradually lessen liquid squeezed into thestraw
  85. 85. Cleft PalateModifying feeding position and of the nipplesemi-upright position and use angle-neckedbottles
  86. 86. Cleft PalateFootball hold forbreast-feeding:infant is held alongthe side of themother’s body,facing her ratherthan across her lap
  87. 87. Cleft PalateThe Habermann nipple: forinfants with cleft palate todeliver flow without requiringsuctionhas a one-way valve that allowsinfant to express fluid throughcompression alone, withoutrequiring suction
  88. 88. Post-surgical Repair ofCleft Palateperform scar massageinitiate activities to reduce oral hypersensitivity
  89. 89. Adaptive Equipmentadaptive spoon, forks, cups and strawspromote independence and improvement in oralmotor controlincrease independence in self-feedingcompensate for a motor or sensory impairment
  90. 90. Consider properties ofspoon & fork usedspoon withshallow bowl mayhelp a child withdecreased lipclosure
  91. 91. spoon with bumps orridges in the bottomof the bowl or achilled metal spoon provide additionalsensory input for achild w/ decreasedsensory registrationBites utensil Rubber
  92. 92. Utensils with shorterhandles or large gripdiameters  help achild to self feed moreindependentlyLearning to use straw:use a shorter orsmaller strawrelatively short strawwith a large diameter children whorequire thickenedliquids or those withdecreased lip closure
  93. 93. cup with a handle Poor FMSU shaped cut out cupshelp to maintain aneutral head positionwhen drinking liquidClear cut-out cupsallow to easily seeliquid entering thechild’s mouth whenphysical assistance isprovided whendrinking
  94. 94. Modifications to Food andLiquid PropertiesThickened liquids > thin liquidseasier to control with the lips and tongue, movemore slowly within the mouth, and allow child toorganize bolus for effective swallowing
  95. 95. Modifications to Food andLiquid PropertiesExamples:Simply thickPureed or baby food fruits and vegetablesDried infant cereals or mashed potatoYogurt or pudding may be added to createblenderized milkshakes
  96. 96. Behavioral power strugglesmay develop during mealtimesencourage parents to offer small amounts of anew food across multiple meal sessionsThx should try to create new positiveinteractionsOffering choices and turn taking may help childhave a sense of control and increase willingness toparticipate in feeding
  97. 97. Behavioral power strugglesmay develop during mealtimesprovide clear expectationsbreak the activity down into small, achievablesteps
  98. 98. Prematurity and Tubefeedingdecreased tongue mobility, exaggerated jawexcursions, decreased lip seal, diminishedsucking pads, and irregular respiratory patterns
  99. 99. Other problems:neurological immaturityabnormal muscle tonelack of proximal stabilityweakened stateexaggerated extensorpatterns of movement,irritable stateinsufficient energy toconsume sufficientquantity of fooddislike of mealtimesdepressed oral reflexesdecreased tonguemobilityoral hypersensitivity dueto tube feedingsdisorganization of SSBpattern
  100. 100. Prematurity and TubeFeedingmanifestations may still vary depending on theinfant’s gestational age
  101. 101. Components of OromotorTreatment Program1. Improving postural control of head, neck andtrunkcapital flexion and activation of lateral anddiagonal control of the abdominal musclesin supine, sidelying and prone
  102. 102. Components of OromotorTreatment Program2. Improving control of pharyngeal airwayin prone to bring tongue forward to clear theairway
  103. 103. Components of OromotorTreatment Program3. Using touch and movement communicativelyfind a comfortable holding position on the lap fortube feedings, for play around the face and mouth,and for general interaction
  104. 104. Components of OromotorTreatment Program4. Normalizing response tostimulation5. Identifying and facilitatingswallowing reflexstimulation of faucial area withcold temperatures
  105. 105. Components of OromotorTreatment Program6. Reducing impact of Gastroesophageal refluxmedical management precedes surgicalmanagement
  106. 106. Components of OromotorTreatment Program7. Improving tone and movement in the lips andcheeksvocalizing, patting lips to make interesting soundsand firmly applying facial lotion to cheeksStroking firmly with circular motions around lipsencourage greater lip activity and a forwardposturing for suck
  107. 107. Components of OromotorTreatment Program8. Improving tone and movement in the tonguedownward bouncing or patting on the tongue withfinger, toy, teether or Nuk brushdone in the context of sound play or with rhythm offolk music
  108. 108. Components of OromotorTreatment Program9. Facilitating a rhythmical suckle swallowinitially stroke the tongue downward and forward bytherapist’s or infant’s fingeras suckling rhythm emerges, water, juice or smallamounts of pureed fruits and vegetables can beplaced on stroking fingereventually use a plastic medicine dropper, syringe,modified pacifier or a moistened cotton swab
  109. 109. Prematurity and TubeFeedingeach component of the program is important, the most basic underlying elements of functionor dysfunction should receive the greatestemphasis in the program
  110. 110. Blindnessneed to control rate of eating and size ofspoonfuls in order to feel safe and to preparemouth to swallow food and breathe in arhythmical coordinated fashion
  111. 111. BlindnessPut the child in a familiar position or chair foreating and develop a routineTell the child that the food is approaching ortouch the upper or lower lip in a familiar place sothe child will open the mouth
  112. 112. BlindnessGradually fade the supportkeep tastes separate as much as possibleVerbal directions + physical prompts  allowthem to experience and kinestheticallyunderstand movements and sequences that areefficient and socially acceptable
  113. 113. BlindnessHelp to establish a personal frame of referenceat the tableConsistencyTeach him to bend the trunk forward so that theface is directly above the plate to help avoidmajor spills
  114. 114. BlindnessTeach the child to usecharacteristics that can besensed using utensils toidentify foodWeight in utensil/cup =different-sized bites ordifferent amounts of liquid
  115. 115. Blindness
  116. 116. Minimal Movementactivation of righting and equilibrium reactionsfor higher level of Sensorimotor integration andcoordinationdeveloping greater stability in the trunk andshoulder girdle
  117. 117. References:[1] Case-Smith, J. (2001). Occupationaltherapy for children. St. Louis Missouri, USA:Mosby, Inc.[2] Solomon, J. (2006). Pediatric skills foroccupational therapy assistants. St. LouisMissouri, USA: Mosby, Inc.[3] Wagenfeld, A. (2005). Foundations ofpediatric practice for occupational therapyassistants. USA: SLACK Inc.

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