The Basics of Feeding: A Workshop in Pediatric Dysphagia. Part I.

1. The Basics of Feeding:A Workshop in Pediatric Dysphagia. Part I. Stacy Antoniadis, MA, MPH, CCC/SLP Lisa McCarty, MS, CCC/SLP Julie McCollum Daly,BS, OTR/L Cindy Straub, BS

2. This workshop is sponsored by Early Intervention Technical Assistance through the Pennsylvania Departments of Health, Education and Public Welfare

3. About the Authors Stacy Antoniadis has been a consultant with Early Intervention Technical Assistance of Pennsylvania (EITA) since 1991. She provides technical assistance and training to provider agencies who serve Pennsylvania’s early intervention (birth to five) population. She holds the M.A. in Speech Pathology and M.P.H in Community Health Education. Ms. Antoniadis had over 14 years of clinical experience working with infants and toddlers in a variety of settings before joining EITA. Currently she is the Chair of the American Speech-Language Hearing Association’s “Communication Disorders Prevention and Epidemiology Study Group”.

4. About the Authors Lisa C. McCarty graduated cum laude with her Bachelor’s Degree in Secondary English Education at Millersville University in Pennsylvania where she concentrated in linguistics. She received her Master’s Degree in Communication Disorders from the Pennsylvania State University at University Park. Lisa is currently a licensed speech language pathologist in the State of Pennsylvania and has been employed with the Capital Area Intermediate Unit as a pre-school speech-language pathologist since 1994. She has attended and presented dysphagia training workshops and has served as a consultant regarding feeding/swallowing issues. She has attended workshops by Jerilyn Logemann,Ph.D. and the oral motor courses presented by Debra Beckman, M.S. CCC-SLP. She lives in New Cumberland, PA with her husband, Andrew and daughter,Catherine.

5. About the Authors Julie McCollum Daly, is a licensed Occupational Therapist. She is a graduate of Thomas Jefferson University in Pennsylvania. She is currently employed at Ken-Crest Services in the birth to three early intervention program and is a member of the Ken-Crest home and community based feeding team.

6. About the Authors Cindy Straub has been Developmental Specialist at Tiny Tot Child Development Center in Rochester, PA since 1993. She currently provides early intervention services including feeding to children with special needs (birth to five) and their families in their natural environment.

7. The Basics of. . . • swallowing • typical feeding development and nutrition • medical conditions contributing to feeding problems • nutritional problems in feeding disorders • feeding safety practices

8. Anatomy and Physiology Related to Pediatric Feeding Disorders • Introduction • Overview of Structures -Lips, Teeth, Tongue, Palate, Larynx Esophagus, Lungs • Phases of Swallowing -Oral Preparatory Phase, Oral Phase Pharyngeal Phase, Esophageal Phase

9. Introduction • People swallow 600-800 times per day • Purposes: Eliminates nasal mucous, saliva and food • Feeding and swallowing (as related to nutrition) affect our ability to concentrate and learn

10. A Few Definitions • Feeding: Generally considered the act of getting the food from the cup, dish or bowl to the mouth • Swallowing: Generally considered the next step. After the food gets to the mouth, the swallowing process includes preparing the food to be swallowed, moving it to the back of the mouth and triggering the swallow

11. Overview of Structures Activity: Jot down the body parts crucial for swallowing

12. Activity: Observe Lip Movements • Part 1: Chew an animal cracker. Watch someone else do the same, or watch yourself in the mirror. • Observe: What are the lips doing? How are they doing it? • Part 2: Now, take another bite, pretend that the lips aren’t working very well. • You might notice they are very weak or they don’t close.

13. Lips • Removes food from spoon, and liquid from cup • Need adequate ability to move (range of motion) • Need adequate strength • Need ability to maintain closure while chewing and swallowing

14. Teeth • Need to adequately chew food • If food is not chewed, choking may occur • Nutrients may not be adequately broken down and used by the body if not properly chewed and broken down first (masticated) • If not cared for can lead to drooling • Poor jaw alignment may impact feeding

15. Tongue • Needs adequate strength to break down foods, transfer foods, and maintain control of foods • Needs adequate range of motion to clear oral cavity • Needs stamina to maintain strength and agility throughout a meal

16. Cheeks • There are many muscle groups in the cheeks • In feeding they help to control the liquid and food in the mouth • If the cheeks do not work properly, food can fall into the lateral sulci (between the outer gums and cheek walls) If the tongue is not working either, the food and nutrients cannot be retrieved

17. Soft Palate • Elevates at the point of the swallow to prevent nasal reflux • If cleft, there is no prevention for the nose • Lost food means lost nutrients • Nasal obstruction may prevent palate from closing properly; may cause difficulty maintaining a closed mouth posture and mean a potential loss of food/nutrients

18. Larynx • PROTECTS AIRWAY • Epiglottis flips over the larynx • Vocal folds close over the trachea (windpipe) • Larynx elevates to allow food to pass into the esophagus

19. Esophagus • Hollow muscular tube with sphincters at each end: peristalsis moves that food down • UES-Upper Esophageal Sphincter: muscle that opens to the pathway from larynx to stomach • LES-Lower Esophageal Sphincter: muscle that opens from the esophagus to the small intestine

20. Lungs • Not important in swallowing itself • If food is not swallowed properly and gets into the trachea and lungs, pneumonia can result • “Aspiration is the action of material penetrating the larynx and entering the airway below the true vocal folds” (Logemann, 1983) • Aspiration can generally be seen in the right lower lobe on an x-ray of the lung

21. Aspiration: Signs and Symptoms • Fever spike five minutes after the episode • Coughing • “Wet” voice quality • Medical history of frequent upper respiratory infections / pneumonias • Weight loss

22. Phases of Swallowing • Oral Preparatory Phase • Oral Phase • Pharyngeal Phase • Esophageal Phase

23. Oral Preparatory Phase • Lip closure • Cheek tone • Rotary and lateral jaw movement • Rotary and lateral tongue movement • Anterior bulging of the soft palate • Tongue forms a bolus with the food

24. Oral Phase • Bolus is held between the tongue and palate • Tongue pushes bolus to the back of the mouth • Tongue elevates and retracts squeezing the bolus along the palate • If tongue control is poor, food may go into pharynx (throat) and be aspirated

25. Pharyngeal Phase • When food reaches anterior faucial pillars, the pharyngeal phase is triggered • Velum (soft palate) closes • Larynx elevates (epiglottis flips, true and false vocal folds slam together) • Tongue has a major role in triggering the swallow

26. Practice Feeling for the Swallow • Use 4 fingers on the neck to feel for the swallow • Under chin (above the bone) • Bottom of the bone • Top and bottom of the thyroid cartilage • Normally should take 1-2 seconds

27. Esophageal Phase • Begins when the UES opens and the food is transferred to the esophagus • Peristaltic action pushes the food down into the stomach • This phase lasts 8-20 seconds • Ends when the LES opens and the food is passed into the stomach