Sphsc 543 February 12-19, 2010

1. Sphsc 543February 12-19, 2010 • Questions?

11. Transitional feeding • Begins at 4-6 months in normal infants • Primarily related to CNS and anatomic changes • Allows new patterns of food manipulation • Eruption of teeth is the most notable change • Mandibular before maxillary • Girls before boys • 20 teeth by second year, 32 by adult

13. transitional • Teeth as sensory receptors versus motor purposes • Molars important for crushing and grinding food • Tongue movements are basic to food manipulation • Anterior-posterior (AP) movement • Lateral movement

14. Transition from Liquids • Smooth solids – homogeneous or with fine granular bits • Mashed by tongue gestures at midline • Semifirm solids – soft but holds together • Tongue moves laterally and tongue/jaw make vertical motions • A prelude to molar chewing • Solids – require more mature mastication • Vertical movements become associated with alternating lateral motions • Fully matures between 3-6 years

15. transitions • Solid foods characterized by: • Handles lumps and textures with ground or mashed foods • Coarsely chopped foods cooked ground meats, lunch meats, soft cooked chicken/fish • Coarsely chopped table foods, most meats, many raw vegetables/fruits. • Brain development from sensory input related to feeding extending to midbrain, cerebellum, thalamus and cerebral cortex • With maturity, children begin to evaluate their food and you start to see food preferences.

16. Taste and Smell • Important roles in feeding • Experience • Preference • “Supertasters”

17. Cessation of nipple-feeding • Multi-factorial • Age, culture, maternal desire, lifestyle • Need appropriate CNS development and coordination to manage cup drinking • Open cup • Sippy cup • Prolonged nipple-feeding and dental caries

25. Overall development • Take away information: • Changing feeding experiences are just a portion of a more general evolution of the developing child • Sensory and motor skills improve and the child acquires food preferences.

26. Methods of feeding delivery • Oral includes bottle, breast, cup, straw, fingers, utensil • Orogastric • Nasogastric • Short term usage • Gastrostomy • Longer term • Continuous or bolus • But wait….new information is afoot. • Duodenum or jejunum

27. Feeding Delivery methods • Parenteral • For severe GI disorders that prevent use of the GI tract • Peripheral vein access • Central venous catheter

28. Clinical Feeding Evaluation • Observation is the key component of the clinical feeding evaluation • Eyes • Ears • Hands • Need to understand the normal functions and how they interact • Interaction of reflexes • Developmental changes • Respiration • Gastrointestinal • Etc.

29. Clinical feeding evaluation • Consider the ‘whole’ infant • Gather information from all sources • Plan the feeding observation • Equipment • Food textures • Physiologic monitors • Naturalistic and/or elicited

30. Clinical feeding evaluation • Structured feeding history • Parent description of the problem – allows them to be in control for the first part of the interview • State/behavior – of infant • Schedule – basic nutritional intake and amount of time spent feeding each day • Method of feeding – helps determine a ‘typical’ feeding • Feeding problems observed by parent – alerts the clinician for what to look for

31. Treatment exploration – Hint for final exam • Develop hypotheses • Synthesize information • What is the child’s level of function? • What factors interfere with feeding function? • How well does the child’s feeding performance “match” the caregiver concerns or expectations? • Is additional information necessary? • Are there treatment techniques available that appear to improve oral feeding function?

32. Key areas • Physiologic control • Motoric control • Behavior and state • Response to tactile input • Oral-motor control • Sucking, swallowing and breathing • General observations

33. Clinical feeding evaluation • From Wolf & Glass, 1992

34. From Wolf & Glass, 1992

35. Clinical feeding evaluation • An infant’s responses to the environment can indicate how stressful the baby finds the environment and how well she is able to adapt • Response to the environment is manifested through behaviors in any of the following systems: • Autonomic or physiologic • Motoric • State • Attention • What is happening during the feeding at the time of the stress cue?

36. Autonomic/physiologic • Heart rate • Initial and post-feeding • Highest/lowest values • Abrupt changes • Respiratory rate • Pre/post-feeding • Highest, lowest, trends • Returns to baseline

37. Breathing • Quality of respiration • Parameters: respiratory effort, changes in respiratory pattern, sound of respirations. • Work of breathing • Endurance

38. Autonomic/physiologic • Oxygen saturations • Amount of o2 in blood and avail for exchange at tissue level • Generally expressed as a percentage of 100 • Color • Face, neck, mouth (circumoral) • Eyes (circumorbital). • Pale • Blue/purple • Red or ruddy

39. Autonomic stress cues • From Wolf & Glass, 1992

40. Motoric • Overall neuromotor control • Disorganized • Tone • Muscle tone • At rest • Change with activity • Quality of movement • Tonal variations versus movement disorder

41. Motoric • Reflexes • Primitive • Integration • extinguish • Posture • Development of antigravity postural control • Feeding position • Motor • Response to environment • Knowledge of feeder

42. Motoric Stress cues • From Wolf & Glass, 1992

43. Feeding position • Normally feeding babies – adaptable • Even slight feeding problems might need help for optimal feeding. • Overall body posture reflects slight flexion • Trunk is neutrally aligned and well supported in a semi-reclined position, with orientation of the head and extremities about the midline. • Using proper positioning during feeding not only affects respiratory mechanism, oral-motor control and swallowing control, but it may also assist in the development of early head/neck postural responses.

44. State • States of alertness • State 1 – deep sleep • State 2 – light sleep • State 3 – drowsy or semi-dozing • State 4 – quiet alert • State 5 – active alert • State 6 – crying

45. state • Not one optimal state for every baby • FT (full term) – should have clear differentiation between states • Preemies – may seem more disorganized and lack clarity of state • Older babies – spend more time awake/alert and have clearer/more predictable state changes

46. State-related stress cues • From Wolf & Glass, 1991

47. state • Is state or state control interfering with feeding? • How does parent respond or support baby? • What is the baby’s state throughout the feeding? • Factors interfering with state control (immaturity or neurological impairment) may require prolonged need for state-related intervention.

48. Tactile input • Tactually elicited reflexes present at birth allow the infant to seek out and obtain nutrition safely. • Ability to accept touch to the cheeks, lips, gums and tongue is a prerequisite for feedings and the infant’s survival. • Expression of oral reflexes varied depending on a number of factors. • Must adapt to the tactile components of the tools used in feeding

49. Tactile input • Face • Cheeks to lips to gums to tongue • Head, trunk, extremities • Input –graded • firm and smooth (pressure from fingers or toy) to • soft and smooth (stuffed animal or soft finger touch) to • prickly or unusual (rubber hedgehog toy). • Same with sold foods • move from smooth/pureed to chunky (baby food/cottage cheese) to crunchy (crackers)

50. Degree/persistence of response • Absent responses • Hyposensitive • Hypersensitive and Aversive • Immaturity • Chronic illness • Experience • Neurologic impairment