Pediatric Feeding Development and Disorders; Basic Management and Treatment Techniques

1. Pediatric Feeding Development and Disorders; Basic Management and Treatment Techniques Ana Feliz M.S., CCC-SLP Lindsay A. Murray-Keane M.S., CCC-SLP Emily Stoddard M.S., CCC-SLP Monica Walchak M.A., CCC-SLP

2. Participant Learning Objectives • Review of normal neonatal and infant anatomy of the swallow mechanism • Understand neonatal and infant feeding development • Physiology of the normal swallow • Know when the infant is ready to feed and being able to identify signs of difficulty • The clinical feeding assessment • List common recommendations • Transition feeding from bottle to solids • Define dysphagia and signs of aspiration • Objective tests available and intervention • Knowledge of various diets recommendations, positioning techniques, and modifications that can be made to feeding equipment. • Dealing with trauma and injuries to the head, neck and face / TBI • Management of cleft palate and lip

3. Neonatal and Infant Feeding development • Oral feeding is a complex process by which numerous physiological functions (neurological, cardiopulmonary, respiratory, and digestive) of the human body must work in synchrony to establish a functional efficient means of achieving oral alimentation. • A common myth is that the body’s first function is feeding, however the body’s primary function is efficient respiration. • To understand pediatric feeding, we must analyze anatomic structures, physiologic systems and the alterations/changes that happen with growth/development. • Infants and children are not simply small adults therefore; we must analyze their anatomy, physiology and needs separately.

4. Anatomy of Toddler vs. Adult

5. Anatomy of Infant/Toddler • Significantly higher laryngeal position (thus smaller space between mandible and hyoid), which provides anatomic protection of the airway
- Permanently heightened until first 2 years of life
- Adult-like anatomy by age 4
 • The velum and tongue fill more of the oral cavity 
 • Tongue 
 • Very large relative to oral cavity 
 • Does not have musculature and motor control to manually move tongue, jaw, and lips
 • Velum: 
 • Large, fills space between epiglottis and tongue 
 • Makes contact with top of epiglottis (unlike in adults)
 • Anatomic protection of airway during repetitive suck burst that precedes each swallow 
 • Infants are obligatory nasal breathers 
 • Velum lowered to allow nasal breathing

6. Anatomy of Infant vs. Adult

7. Anatomy of Child through Adulthood • Laryngeal position migrates inferiorly by age 4 years • Size of oral cavity increases with jaw growth • Tongue 
 • Becomes relatively smaller in oral cavity 
 • Musculature and motor control are developed to volitionally move tongue, jaw, and lips
 • Velum: 
 • Hypopharynx is elongated; Velum no longer in contact with epiglottis • May make contact with Base of Tongue • Anatomic protection of airway requires more coordinated muscultature contraction and coordination. 


8. Airway of an Infant

9. Head and Neck Anatomy

10. Congenital Defects of Anatomy • Being a pediatric clinician, It is important to understand congenital anomalies to prepare for management pre and post medical management • DX examples: • Micrognathia • Hypoplastic nasal bones and mid face • Pyriform aperature stenosis • Clefts • Laryngomalacia • tracheomalacia • Further explanation later in slides

11. Physiology of Normal Swallow • Each swallow passes liquid or food from the mouth to the stomach as it moves through 3 phases, called the oral,pharyngeal and esophageal phases. • Valves within the system assist with the control of flow of bolus material. The valves are the lips, soft palate, the epiglottis, and the larynx. • Video

12. Oral Stage of Swallowing • Oral Phase consists of: • Acceptance of the liquid into the oral cavity • Initiation of latch (Labial seal to nipple, tongue cupping and creation of compression/suction pressure.) • Expression of milk/formula from the breast/nipple • Ability for the tongue and jaw to rhythmically and efficiently transport milk/formula posteriorly within the oral cavity. • Terms in which and Oral stage of Swallow can be described are: • Organized • Disorganized • Dysfunctional

13. Pharyngeal Stage of Swallow • Pharyngeal Phase involves: • Velopharyngeal port closure to seal off nasopharynx and eliminate liquids being nasally regurgitated • Initiation of pharyngeal constriction when bolus of liquids leaves to oral cavity posteriorly • Timing of pharyngeal swallow may be normal when bolus leaves the oral cavity passing the faucal arches and passes into the valleculae • Coordinated movement of multiple muscles: • Pharyngeal constriction • Hyolaryngeal excursion • Epiglottic retro flexion • Laryngeal closure • Bolus transport through the hypopharynx to the cervical esophagus • Terms in which and Pharyngeal stage of Swallow can be described are: • Coordinated • Uncoordinated

14. Neural control of the pharyngeal phase of swallow

15. Esophageal Stage of Swallow • Esophageal Phase is initiated with: • The opening of the upper esophageal sphincter • Peristalsis of bolus down esophagus • Opening and closing lower esophageal sphincter

16. Physiology of Infant Nursing *Establishment of latch to nipple *Initiate suck (compression and suction) utilizing tongue and jaw movement to express liquid from nipple. *Lingual cupping and wave to channel and transport liquids posteriorly *Anatomy is supportive of rapid and consecutive suck/swallow bursts *Suck-Swallow-Breath triad with respiratory pausing allowing for nasal breathing for respiratory recovery

17. Swallowing

18. Patterned Sucking Behavior • Sucking is observed inutero as early as 15 to 18 weeks gestation. In the extra-uterine environment, mouthing activity may be observed in a disorganized pattern by 27 to 28 weeks • By 32 weeks, stronger sucking is noted and a burst-pause pattern is emerging. • Sucking is generally not well established until 34 weeks.

19. Various States of a Neonate/Infant • Active sleep • Drowsy • Quiet sleep • Quiet alert • Active alert • Irritable

20. Various States of a Neonate/Infant • Preterm neonates make have challenges with state control, regulation and transitions. State control and transitions should improve with maturation to infancy. • Of note, the environment (lights, sounds, interactions with caregiver, positioning and expectations) all impact a patient’s state.

21. Various States of a Neonate/Infant • Cases: • A 36 week premature neonate is sleeping in an open crib in a crowded hospital ward. Fluorescent lights above head, monitors beeping, MD/RN teams are speaking in competition with each other’s volumes for rounds. The PT. is unswaddled and Moro (Startle reflexes) are being triggered. RN must conduct a heel stick for glucose monitoring. The diaper is then changes and the baby is startled by the cool air and wipes. The baby is then picked up rapidly, seated in the RNs arms in a feeding position without swaddling. The nipple is inserted into her mouth. • How is the Patient going to perform in feeding?

22. Various States of a Neonate/Infant • Cases: • A 36 week premature neonate is sleeping in an open crib swaddled. The lights are dim, professionals are speaking but out of range of the crib and monitors are attended to in a timely manner. The RN knows it is about feeding time, so she gently unswaddled the neonate allowing for movement of limbs and gradual rousal. Pt. increases her activity, transitions to light sleep and then the diaper hygiene care is performed. Pt. begins mouthing her hands and lip smacking. RN provides the pacifier and then conducts the heel stick for glucose monitoring. RN swaddles the patient with her arms out and picks her up gently placing her into feeding position. Provided pacifier for ~1 minute to allow for state regulation then transitions to bottle/nipple for feeding. • How is the Patient going to perform in feeding?

23. Feeding Readiness

24. Infant Reflexes • Root reflex: • Elicited by stroking the corner of the baby's mouth • The baby will turn his or her head and open his or her mouth to follow and "root" in the direction of the stroking • Helps the baby find the breast or bottle to begin feeding • Emerges around 24-28 weeks in utero. Is fully present at birth and is integrated/inhibited at 3-4 months • Suck reflex: • When the roof of the baby's mouth is touched, the baby will begin to suck. • This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability. • Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or hands. • Moro reflex: • Occurs in response to a loud sound. Often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. A baby's own cry can startle him or her and trigger this reflex. • The infant throws back his or her head, extends out the arms and legs, cries, then pulls the arms and legs back in. • This reflex persists until about 5 to 6 months. • Tonic neck reflex: • When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. • The tonic neck reflex lasts until about 6 to 7 months. • Grasp reflex: Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp. The grasp reflex lasts until about 5 to 6 months of age • Babinski reflex: When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age. • Step reflex.: This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his or her feet touching a solid surface

25. Distinctions of Neonates • Premature Baby • Late Pre-term Baby • Full Term Baby • A premature baby who is now at term is not the same when compared to a baby who is born at full term. • Example: • 27 weeker now PMA= 36 weeks • Will Act developmentally, medically and physiologically different then a Pt. born at 36 weeks.

26. Premature Neonate • Respiratory distress likely requiring a form of positive pressure respiratory support. • A baby’s body’s primary purpose is to maintain physiologic stability and respiration. • Growth issues due to higher alimentation needs and increased demand on an immature GI system

27. 28 Weeks Gestation • State • Not well differentiated • 97% sleep state • Transient drowsy and alert states – brief and fragmented • Oral -Motor • Onset of rooting • Onset of suck-swallow • Non-nutrive suck noted at 27-28 weeks • Reflex pathways between taste buds and facial muscles are established.

28. 30 Weeks Gestation • State • Capable of a well defined quiet alert state which appears spontaneously • Oral-Motor • Non-nutritive suck not coordinated with swallowing • Rooting response slow

29. 32 Weeks Gestation • State • More distinctive • Quiet sleep increases while active sleep decreases • Increase in alert and drowsy states • Oral Motor • Brief periods of hand to mouth activity • Non-nutritive suck more organized • Some single sucks still noted • Swallow occurs before or after suck burst

30. 32 Weeks Gestation (con’t) • Oral Motor • 1 to 1.5 sucks per second on suck bursts • Can coordinate sucking and swallowing • Reflexive smile

31. 34 Weeks Gestation • State • More clearly defined • Clear difference between wake and sleep • Active and quiet sleep alternate regularly with more time spent in active sleep • Self comforting behaviors • Oral Motor • May not be ready for po • Suck rate and rhythm stable within in suck burst • Coordination of suck and swallow

32. Late Pre-term Baby • A late pre-term baby can fool many caregivers because they are larger in size and do not have as many of the respiratory sequelae of smaller premature neonates. • We must remember that a baby inutero at this age would be developing their fat layers and refining their suckling without the added pressure of full GI alimentation. • Many studies focus on this population and there are specific issues in terms of medical management, growth and development.

33. 36 Weeks Gestation • State • Arouses and controls self • More alert just after feeding or between feeding • Oral Motor • Rooting complete • Suck consistent • Fat/Suck pads begin to develop

34. 38 Weeks Gestation • State • Full control of state cycles • Oral-Motor • Excellent suck reflex • Rooting complete • Suck pads developed

35. 40 Weeks Gestation • State • Clear distinct behaviors • Attention is generally 4-10 seconds • Oral-Motor • Bitter, sour and sweet taste receptors • Strong suck

36. Full Term Infant • Birth Trauma • Acclamation to life outside the womb • Small appetite • Promote Maternal bonding, kangaroo care and Breastfeeding as soon as possible.

37. Pre-Feeding Skills • Involve the infant’s ability to • Engage and remain engaged in a physiologically and behaviorally challenging task • Organize oral-motor movements so as to have long term functional benefits • Coordinate breathing with swallowing to avoid prolonged apnea or aspiration of fluids • Regulate the depth and frequency of breathing to maintain physiologic stability

38. Internal Factors that affect progression in the ability to feed orally: • The infant’s state of health • The ability to regulate oxygen • Development of alertness • Development of sucking strength and organization of the sucking pattern • Thoyre S, and Carlson J. 2003.

39. Newborn Stomach Size

40. Oral Feeding Skills • Oral feeding skills have commonly been conceptualized by health care providers as an infant’s ability to organize and coordinate oral-motor functions to efficiently consume enough calories for growth. • Early feeding skills are much more complex than that.

41. Provide a Stable environment conducive to neurodevelopment • Take home message is: WE have to make changes to medical and feeding plans however; we must be in tune with how these changes/ alterations may affect the Patient’s feeding environment and ultimately performance • Early feeding skills can vary from feeding to feeding and even across a given feeding. • Changes in the plan of care during the learning period add to the inherent variability in an emergent skill. • Infants are weaned to open cribs • Supplemental oxygen is decreased or eliminated • Medications are discontinued of adjusted

42. Medical Conditions Affecting Feeding: • Abnormalities of the Upper Aerodigestive Tract • Genetic Syndromes • Sensory Defects • Anatomic abnormalities of the larynx or trachea • Disorders affecting suck-swallow-breathing coordination • Craniofacial Congenital Defects

43. Common Diagnoses with associated difficulties with Eating orally. • Prematuritiy < 32 weeks G.A • RDS; BPD; CLD requiring respiratory support • Prolonged respiratory support (intubation, NIPPV, NCPAP, HFNC) • Tracheoesophageal fistula • Esophageal Atresia • Congenital Cardiac Anomalies • GI anomalies including structural anomalies or NEC. • Tracheostomy or ventilation dependence. • Pierre robin sequence • Cleft lip and palate • Trisomy 21 • Neurological involvement (i.e., seizure, IVH, congenital anomalies) • Hypontonia • Vocal cord dysfunction s/p PDA ligation • Hypoplastic midface • Pyriform aperture stenosis • Choanal atresia

44. Red flags for feeding difficulties • Suspected airway compromise • Diagnosis of failure to thrive • Suspicion of oral-motor dysfunction • Sucking and swallowing incoordination • Weak suck • Apnea during feeding • Severe irritability during feeds • History of recurrent pneumonia • Lethargy during feeds

45. Feeding and Swallowing Abnormalities-Requiring attention • Difficulty coordinating sucking and swallowing • Weak suck • Gagging during eating/drinking • Congestion after eating/drinking • Wet/Gurgly vocal quality during/after feeding • Excessive Feeding times • Unexplained food refusal and refusal to textures • If considering non-oral means of nutrition (ND or NG tube placement) • Tracheostomy/Respiratory distress/Oxygen dependence • Spitting up • Feeding only when asleep • Shortness of breath during/after feeding • Short sucking bursts • Tension of the body during feeding/stress reactions • Inability to manage secretions • Suspected airway compromise • Diagnosis of failure to thrive • History of recurrent pneumonia • Lethargy during feeds

46. Criteria for Nipple Feeding • Initiation of nipple feeding is dependent on • Post-conceptual age of at least 32-34 weeks. • Physiological Stability (RR <60BPM; stable HR; SPo2 stably maintained on NC or NCPAP < 4cm H20 Fio2 <30%) • Stable Respiratory Status • Patients on elevated respiratory support, such as high flow nasal cannula or nasal CPAP (continuous positive airway pressure) should undergo clinical dysphagia evaluation prior to initiation of oral feeding. • Enteral feeding schedule transitioned to bolus feeding • Demonstration of feeding readiness at due feeding times (awakens and fusses, roots, hands to mouth, initiates suckling, Etc.)

47. Neonate and Infancy Positioning • Swaddling • Elevated sidelying position • Semiupright positioning

48. Non-nutritive suckling • Purpose • State regulation, satisfy sucking desire, oral exploration • Rhythm • Stable number of sucks per burst and duration of pauses • Rate • Two sucks per second • Suck/Swallow Ratio • Very high ratio; 6:1 or 8:1

49. Markers for Assessment of Non-Nutritive and Nutritive Suck • Strength • Initiation • Suction • Compression • Breaks Suction • Rhythmic • Coordination • Liquid Loss (Nutritive only) • Endurance • Efficiency

50. Nutritive Sucking • Purpose • Obtain nourishment • Rhythm • Initial continuous sucking burst, moving to intermittent sucking bursts with burst becoming shorter and pauses longer over the course of the feeding. • Rate • One suck per second, constant over course of the feeding • Suck/Swallow Ratio • Young infant 1:1