Pediatric Feeding and Swallowing Difficulties Following Brain Injury

1. Pediatric Feeding and Swallowing Difficulties Following Brain Injury Lynnley Moore, MA, CCC-SLP, Melissa Kravulski, MS, CCC-SLP & Dana Wanyo, M.A., CCC-SLP,CBIS

2. Disclosures and Intended Audience • Presenters have no disclosures • This presentation is intended for caregivers, educators or therapists who seek a basic understanding of pediatric feeding and swallowing disorders in brain injured patients.

3. Course Description • Provide a basic overview of pediatric feeding and swallowing difficulties following brain injury. • Presentation will cover assessment, functional therapy and feeding strategies and adapted equipment recommendations. Basic anatomy and physiology and common feeding and swallowing terms will be included within presentation.

4. Learning Outcomes • Participants will be able to understand at least 3 different dietary modifications to improve safety and ease of meal. • Participants will be able to understand/identify at least 3 different feeding strategies to improve safety/independence or ease of meal. • Participants will identify 3 different kinds of adaptive equipment to improve safety/independence or ease of meal.

5. Dysphagia • Oral phase • Pharyngeal phase • Esophageal phase

6. Readiness Signs • Neurological/medical status • Feeding status • Dietary limitations • Cognitive status • Physical status

7. Signs and Symptoms of Dysphagia • Arching or stiffening of the body during feeding • Refusing food or liquid • Failure to accept different textures of food (e.g., only pureed foods or crunchy cereals) • Long feeding times (e.g., more than 30 minutes) • Difficulty breast feeding • Difficulty chewing

8. Signs and Symptoms of Dysphagia • Coughing or gagging during meals • Excessive drooling or food/liquid coming out of mouth • Difficulty coordinating breathing with eating and drinking • Increased stuffiness during meals • Gurgly, hoarse, or breathy voice quality • Frequent spitting up or vomiting • Recurring pneumonia or respiratory infections • Less than normal weight gain or growth • Throat clearing

9. Bedside Swallow Evaluation The bedside evaluation is the first phase for evaluating Dysphagia. The second phase, videofluoroscopy, is only completed if recommendations cannot confidently be made based on the bedside evaluation. This evaluation will be completed by Speech-Language Pathologists working in acute care hospitals, rehabilitation settings, or nursing homes.

10. Oral Mechanism Examination • Examine the oral cavity in order to define the normalcy of structure and any obvious physical impairment.

11. Consistencies Solids Liquids Pudding thickened Honey thickened Nectar thickened Thin • Purees • Ground • Chopped/Minced & Moist • Mechanical Soft/Soft & Bite sized • Regular

12. Modified Barium Swallow Study (MBS) • X-ray test that takes pictures of the patient’s mouth and throat while he or she swallows various foods and liquids that are mixed with a special liquid called barium. • An MBS shows the SLP and doctors if food or liquids are entering the patient’s trachea (aspiration) during swallowing. 

13. Modified Barium Swallow Study (MBS) A MBS gives the SLP and doctors detailed information about the safety of the patient’s swallowing that they cannot learn from a physical examination such as which parts of their mouth and throat may not be working well, what kinds of food are safest for them to swallow, and if certain positions or strategies help them swallow better.

14. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) A small endoscope is advanced through the nasal passages to the back of the throat, where it can directly visualize the movement of foods through the esophagus (or, in cases of aspiration, into the larynx or lower airways).

15. Anatomy and Physiology of Swallowing

16. Feeding and Meal Time Accommodations • Positioning • Environmental- distractions vs. quiet room • Behavioral Strategies • Visual Accommodations (lighting and equipment) • Dietary – National Dysphagia Diet (NDD) • Meal Time Protocols and Strategies

17. Positioning • Supported seating • 90/90? • Appropriate sized chair and table • Feet on floor • Reflux considerations Consider seating/equipment recommendations with respect to use in home and community environment.

18. Environmental Accommodations Minimize environmental distractions to increase food intake for patients who are distracted, impulsive, and/or have confusion/memory concerns (quiet room, 1:1 meals, clear table space) Provide distractions for patients who are confused, need to gain weight, and/or state feel full after first few bites, but continue to eat when redirected (nutrition or doctor has already determined safe daily calorie and liquid intake requirements)

19. Behavioral Strategies • Modify environment as appropriate • Identify antecedent behaviors to minimize refusals, increase acceptance (ex: keep food log for weekend) • Use of behavioral reinforcement strategies, including use of positive reinforcement (ex; interact with people, toys, videos during meals)

20. Ways To Improve Swallowing Safety SLP may recommend any or all of the following: • Changes to diet texture • Changes to fluid consistencies • Suggest swallowing strategies ( chin tuck, effortful swallow, etc.) • Prescribe exercises to support swallow

21. Dietary Accommodations– National Dysphagia Diet (NDD) The National Dysphagia Diet (NDD) was published in 2002 by the American Dietetic Association. It aims to establish standard terminology and practice applications of dietary texture modification in dysphagia management.

22. National Dysphagia Diet • Developed through consensus by a panel of dietitians, SLPs, and a food scientist. It contains eight textural properties, and anchor foods to represent each level. • A hierarchy of diet levels is then proposed, which includes and excludes foods at each level based on subjective comparison with these anchor foods. National Dysphagia Diet Task Force (2002). National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association

23. National Dysphagia Diet There are four levels of semisolid/solid foods: • NDD Level 1: Dysphagia- Pureed • NDD Level 2: Dysphagia- Mechanical Altered • NDD Level 3: Dysphagia – Advanced • Regular National Dysphagia Diet Task Force (2002). National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association

24. NDD 1-Dysphagia Pureed: (Internationally known as “Extremely thick” or “4”) • All food should be pureed to a homogenous, cohesive, smooth texture. Foods should be “pudding-like” and hold its shape on a spoon. Requires very little to no chewing • Pureed foods can be piped or molded and will not spread out if spilled. The prongs of a fork make a clear pattern when drawn across the surface of the puree. • Contains no lumps. Not sticky. • All liquids are thickened at this level

25. NDD 1-Dysphagia Pureed: (Internationally known as “Extremely thick” or “4’) How to puree foods at this level: • Use blender, and or food processor • Add small amounts of gravy, sauce, juice, milk or half and half to the food. Puree the food and add water as needed to get same texture as pudding • Potato flakes can be used to thicken your food if you thinned it too much

26. NDD 1-Dysphagia Pureed: (Internationally known as “Extremely thick” or “4’) • Examples include: cream of wheat, puree well cooked pasta, puree cooked vegetables, puree fruits, yogurt, pudding, egg soufflés • Avoid: purees with pulp, seeds or chunks, fruited yogurts, soups, oatmeal, and peanut butter • Pureed foods can be frozen in small portions and reheated later (ex: ice cube trays)

27. NDD 2- Dysphagia Mechanical Soft Diet: (Internationally known as “Minced and moist” or “5”) •  Foods with a moist, soft texture. Foods have cohesive, moist, semisolid texture, This texture requires some chewing. • Ability to tolerate mixed textures needs to be assessed. Meats need to be chopped or ground. Vegetables need to be well cooked and easily chewed. Foods should be in small pieces (1/4” or smaller than size of your pinky’s fingernail) • All liquids thickened at this level

28. NDD 2- Dysphagia Mechanical Soft Diet: (Internationally known as “Minced and moist” or “5”) How to prepare these foods: • Use blender, food processor, grinder or potato masher to soften food • Add gravy, sauce, vegetable or fruit juice, milk or half and half, (allow sauces & syrups to soften food before serving) • Cook vegetables so they are tender enough to be mashed with fork

29. NDD 2- Dysphagia Mechanical Soft Diet: (Internationally known as “Minced and moist” or “5”) Examples of foods to eat include: • Soft pancakes with syrup, French toast with syrup, cooked cereals like oatmeal, ripe banana, mashed potatoes, well cooked vegetables (less than ½ inch pieces or smaller than thumbnail), pudding, cottage cheese, tuna/egg or meat salad without large chunks or hard to chew vegetables, poached, scrambled or soft-cooked eggs, mashed cooked beans, peas, baked beans

30. NDD 2- Dysphagia Mechanical Soft Diet: (Internationally known as “Minced and moist” or “5”) • NO hard, chewy, fibrous, crisp or crumbly bits. • NO husk, seed, skins, gristle or crusts. • NO “floppy” textures such as lettuce and raw spinach. • NO foods where the juice separates from the solid upon chewing, like watermelon. Foods to Avoid: rice pudding, raw fruits and undercooked vegetables, cooked corn/peas, pineapple, fruits with seeds, dried fruit, coconut, nuts, seeds, peanut butter, sliced cheese, pizza, and sandwiches

31. NDD Level 3: Dysphagia Advanced Soft Diet (Internationally known as “Soft” or “6”) • Foods of “nearly regular” textures with the exception of very hard, sticky or crunchy foods. This texture requires chewing and tongue control. • Foods should be tender and easy to break into pieces with a fork. Presented in moist, bite sized pieces (about size of thumbnail) • Level of liquids depends on current oral motor swallowing skills

32. NDD Level 3: Dysphagia Advanced Soft Diet (Internationally known as “Soft” or “6”) Ways to prepare this level of food: • To moisten food and add flavor, serve food with gravies and sauces • Pour sauces over foods and allow food to soften before serving • Cook vegetables until tender

33. NDD Level 3: Dysphagia Advanced Soft Diet (Internationally known as “Soft” or “6”) Examples of foods include: • Pancakes, French toast, rice, dry cereal softened with milk, cooked/boiled/baked potatoes, shredded lettuce, soft, peeled fruits (peaches, nectarines, kiwi), pudding, cottage cheese, ground meat, fish, poultry, eggs, casseroles with small chunks of tender meat or ground meats, strained corn

34. NDD Level 3: Dysphagia Advanced Soft Diet (Internationally known as “Soft” or “6”) Avoid these foods: Dry toast, crusty breads, coarse cereals (shredded wheat), dry cakes, cookies, raw vegetable, cooked corn, fruits that are difficult to chew (apples, pears), stringy fruits (pineapple), grapes, dried fruits, coconut, nuts, seeds, peanut butter, tough dry meats (steak, chicken and turkey), pizza

35. Regular Texture Foods- (Internationally known as “7”) • All foods are acceptable. Foods may be hard and crunchy, tough, crispy and may contain seeds, skins and husks. • Persons on a regular diet have the ability to produce saliva and chew for as long as it takes for the food to form a cohesive “ball” (bolus) for safe swallowing. Patient must also be able to lateralize tongue to move bolus to biting surfaces. • Mixed textures are no problem.

36. NDD Liquids- 4 Terms To Label Levels Of Liquid Viscosity There are four proposed terms for liquids and correlating viscosity ranges (i.e., thickness or resistance-to-flow): • 1. Thin 1–50 centiPoise (cP) • 2. Nectar-like 51–350 cP • 3. Honey-like 351–1,750 cP • 4. Spoon-thick >1,750 cP National Dysphagia Diet Task Force (2002). National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association.

37. NDD Liquids- 4 Terms To Label Levels Of Liquid Viscosity

38. NDD Liquids: Pudding Thick liquids (Internationally known as “Moderately thick and Liquidized” or “3”) Pudding Thick liquids: liquid stays on a spoon in a soft mass but will not hold its shape. It pours slowly off a spoon and is sip-able. This consistency is difficult to draw though a wide-bore straw.

39. NDD Liquids: Honey-like (Internationally known as “Mildly thick” or “2”) Honey-like liquids: liquid is thicker than “nectar thick” and flows off a spoon in a ribbon, like actual honey. This consistency allows for a more controlled swallow. This consistency is difficult to drink through a standard straw.

40. NDD Liquids: Nectar-like (Internationally known as “Slightly thick” or “1”) Nectar-like liquids: liquid coats and drips off a spoon like a lightly set gelatin. This consistency also allows for more controlled swallow. It requires a little more effort to drink than thin liquid. It can flow through a straw or nipple.

41. NDD Liquids and Solids Summary- Thickened Liquid Considerations For Different Dietary Levels Patients on NDD 1 and NDD 2 level diets require thickened liquids, and very little chewing Patients on NDD 3 or regular diet, require chewing and may or may not require thickened liquids

42. Thickening Liquids Effective Method To Reduce Aspiration Risk In a survey study investigating the practice patterns of Speech-Language Pathologists, the majority of respondents reported thickened liquids to be an effective method to reduce the risk of aspiration in individuals with dysphagia.

43. Why Thicken Liquids? • Thickened liquids increases the cohesion of the bolus, reduces the flow rate of the bolus through the pharynx, and potentially improves clearance of the bolus. • Although the direct effect thickened liquids have on health outcomes remains under investigation, it endures as a common management technique to minimize the risk of aspiration in individuals with dysphagia.

44. Liquid Consistencies Most Commonly Recommended Nectar-like liquids were more commonly prescribed than honey-like liquids. Most commonly recommended for: delayed swallow onset, poor oral control of thin liquids, and laryngeal penetration/aspiration.

45. Compliance and Safety Patients often are unaware of various thickening options, how to mix the product with the desired beverage, how the viscosity can change over time and/or temperature, the influence of a particular beverage on the viscosity.

46. Thickeners and Thickened Drink Options • Instant Food Thickeners: Powders and Gels • Corn Starch Based • Xanthan gum thickeners • Prethickened liquids • Naturally Nectar-like Liquids

47. Instant Food Thickeners: Powders Historically, instant food thickeners made from refined cornstarch have been used to thicken liquids for individuals requiring a modified diet. Cornstarch thickeners are inexpensive but they're high in sugar, may contain gluten, can negatively influence taste and smell, add calories, and contribute to constipation. Must be manually mixed so may be subject to human error.

48. Instant Food Thickeners: Gels Recently, thickeners using refined xanthan gum have become commercially available. Xanthan gum thickeners are more stable over time and don't alter taste or smell but are more expensive, aren't readily accessible, and can change viscosity over temperature changes. Must be manually mixed so may be subject to human error.

49. Prethickened Liquids Medical nutrition companies also market beverages that come pre-thickened or ready to pour. These beverages maintain their viscosity over time and are convenient for consumers. However, these products are typically more expensive and less accessible to consumers. In addition, Studies comparing thickening products have revealed substantial variability between and within thickened liquid products.

50. Determining Which Thickener Is Right For You Patients and caregivers should work with a trained SLP to discuss which form of thickener may work best for you and your specific circumstances. American Speech-Language and Hearing Associations noted that it is important to customize diet recommendations to meet the diversity of patients’ individual needs, preferences and abilities, and do not apply a specific diet as a “formula.”