Welcome and introduction to…

1. Welcome and introduction to… The Speaker Attendees Course Objectives Agenda and Activities Questions?

2. Normal Oral-Motor and Swallowing Development • Structures Involved in Normal Eating & their Functions - A review of Normal Swallowing • Normal Oral-Motor and Swallowing Development Anatomy-Lateral View Superior Endoscopic View

3. Normal and Abnormal Infant Reflexes • Oral • Hand-to-mouth • Limiting Patterns • Motor • Connection between Motor and Oral-Motor Development “the results of motor development point to similar data between supine, prone, seated and standing positions; for the oral motor skills (during feeding/ breastfeeding, using spoon, cup and chewing). A similarity was observed in the acquisition of motor abilities related to the lips, tongue and jaw in each of the feeding situations. There was an association between motor and oral-motor skills; the results indicate that motor development (motor skills) occurred prior to the development of the oral skills from the 5th to 24 months and that the skills related to the jaw when using a cup and spoon occurred prior to the development of the skills related to the lips and tongue” (p. 117) Research: Telles & Macedo, 2008

4. Motor Development Milestones (WHO Multicentre Growth Reference Study Group, 2006) Oral-Motor Development Milestones (Guerra & Vaughn, 1994) • Tongue tip elevates for swallow • Cup drinking skills begin developing • Lip closure with liquids • Coordinated suck-swallow breath • Lips clean spoon • Swallow becoming independent of preceding suck • Lower lip becomes active in spooning • Most infantile reflexes integrated • Strong, rhythmical suck • Opens mouth in anticipation of nipple • Suck-swallow pattern • Tongue cups nipple • Infantile reflexes predominate • Responds to nipple by touch, not sight • Sucking pattern is inefficient and often uncoordinated Age in months 0 3 6 9 12 18

5. The Development of Biting and Chewing Skills (Evans-Morris, 1999) • Let’s review normal feeding development in order to recognize developmental level of feeding skills 1st- The Development of Biting • Early Biting • Phasic bite & release pattern • Hold & break pattern • Sustaining the bite • Biting through hard foods 2nd- The Evolution of Chewing Skills • Early chewing (phasic bite-release) • Voluntary bite-release pattern ~ 6 mos. • It’s an early munch • Tongue flattens and spreads in the mouth as the jaw moves up & down • This pattern mixes with an earlier in-out suckle pattern

6. Next, increased voluntary control. The child stops & starts munching at will. • Tongue has some ability to move laterally without the jaw also moving to the side. • Earlier, this was a reflexive pattern called the transverse tongue reflex; now it’s voluntary. • Next, Early diagonal movements • ~6-9 months, when food is placed between the biting surface of the gums, the jaw moves slightly toward the side and downward in a diagonal movement as the tongue shifts to find the food.

7. ~ 1 year old • Child can transfer food to either side when presented in the center • Reverts to in & out movements when the transfer is challenging • Begin transferring from center to side, side to center, center to the other side • ~ 15 months, jaw movements are smooth & well coordinated – tongue is developing some independence • Development of rotary jaw movement pattern continues • ~2 - 3 years (usually, closer to 3), the child can transfer food from one side to the other • The tongue now moves independent of the jaw • Jaw movements are graded • A circular, rotary chewing pattern is fully developed • Lips close with chewing & swallowing, tongue & jaw move in synchrony • Cheeks tense to prevent pooling

8. Dysphagia in Infants: Select Motor and Sensory Aspects Select Issues with Physiological State Select Issues with Respiratory Involvement • Hypotonic to hypertonic -easily fatigued • Abnormal sensory awareness -physiologically stressed • Motor organization may be poor or transient -anatomical/physiological issues • Reflexes may not be intact or strong; abnormal reflexes may be present • Poorly organized states of alertness • Difficult state transitions • Not easily consoled • Doesn’t organize well • Optimal states for feeding (quiet, focused, alert) may be very brief • Postural issues may result in decreased muscular integrity to support airway • May have trouble maintaining airway with feeding -RDS • Reduced bolus control, trouble latching on -tracheomalasia • Regulation of airway open and closing may be poorly timed -Chronic lung disease or • May have transient tachypnea of newborn (TTN) BPD • Micro fluid aspiration -Tracheostomy • Congenital heart problems/abnormalities -Apnea • Sequelae of difficult delivery (perinatal depression) • Increased work of breathing, poor endurance • Qualitative issues that may involve respiratory function such as noisy swallows, noisy suck, coughing, choking, color changes, A’s & B’s…more

9. Select Oral-Motor Issues Select Gastrointestinal Issues • Ineffective and/or uncoordinated suck - • Uncoordinated S-S-B • Difficulty latching on • Impaired NNS or NS • Decreased O-M strength, coordination, range of motion • More… • T-E fistula • Poor esophageal motility, physiological and/or structural problems with the • esophagus or gut • GERD – Lack of effective management may result in: • Failure to thrive (FTT), slow growth, weight loss • Respiratory difficulties - Aspiration of stomach contents can lead to apnea or asthma-like symptoms. • Esophagitis • Poor sleep states, irritable baby • Anemia - Caused by bleeding in esophagus or stomach or due to nutritional deficiencies secondary to inadequate intake. • Pain and/or nausea • Linked to development of oral aversion/hypersensitivities • Over time may lead to behavioral feeding problems

10. These Problems Can Result In: • Poor feedings • Stress in family • Poor/limited intake • Poor growth • Weight loss or poor weight gain • Nutritional concerns • Abnormal responses • Problems protecting airway, aspiration • Additional health problems • Abnormal parent/child (caregiver) interaction • Delayed development • More… • AND- • Delay infants’ discharge from NICU

11. Management of Dysphagia in the NICU • Feeding success is often included in hospital discharge criteria • Establishment of evidence-based NICU feeding policies and procedures may impact infants’ feeding success • Earlier, safe discharge • Helps to preserve important hospital and medical resources for those infants and • families who need them the most • May allow infants to be cared for at home • Saves individuals and hospitals money

12. Evidence-based Practice in the NICU Although the evidence-base in this area of study is limited, it is important to determine what established evidence-base exists to inform NICU feeding policies and practices. This information is useful for helping SLPs and other medical personnel as they develop recommendations for evidence-based feeding policies and practices. Related Research (Bartels & Bailey, 2008) Completed a literature search to find evidence-based feeding policies and practices in neonatal intensive care units (NICUs) and created a list of evidence-supported practices using: Cochrane Library Reviews Medline, Pub-Med, ComDisDome, Cinahl Databases Consulted the American Speech-Language-Hearing Association practice documents Roles of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Position Statement (2004) and Roles of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Technical Report (2004) In order to add to /confirm list of evidence-based practices

13. Methods • Obtained hospital NICU feeding policies and protocols posted on hospital websites and/or called and requested written feeding policies from hospitals with Level II or III NICUs Phone call requests were made to hospitals with known Level III and II NICUs Google and Yahoo searches conducted Search terms included ‘children’s hospital, feeding policies, feeding protocols, neonatal intensive care unit, feeding premature infants, dysphagia, feeding policies, nursery feeding policies’ and combinations of these terms • Document analysis methods were used to compare each written policy/protocol list to created matrix of evidence-based NICU feeding policies and practices Although many more attempts were made… A total of 4 hospital feeding policies and protocols were obtained from: • Level II NICU in 200-399 bed hospital in Midwestern United States • Level III NICU in 399+ bed hospital, North Eastern United States • Level II and III NICU in 200+ bed Children’s Hospital in Southern United States • Level II and III NICU in 399+ bed hospital in Australia

14. Summary of Evidence-Based Practices and Select Supporting References Non-nutritive Suck Stimulation Aucott, Donohue, Atkins, & Allen, 2002 Hafstrom & Kjellmer, 2000 Miller & Kang, 2007 Narayanan, Mehta, Choudhury, & Jain, 1991 Neiva & Leone, 2007 Nyqvist, Sjoden, & Ewald, 1999 Pinelli & Symington, 2001 Pinelli, Symington, & Ciliska, 2002 Spatz, 2004 Oral Stimulation Gaebler & Hanzlik, 1996 Fucile, Gisel, & Lau, 1996 Boiron, Nobrega, Roux, Henrot, & Saliba, 2007 Kangaroo Care Conde-Agudelo, Diaz-Rossello, & Belizan, 2003 (Cochrane Review-*ES) Dodd, 2005 Feldman & Eidelman, 2003 Ludington-Hoe, Anderson, Swinth, Thompson, & Hadeed, 2004 Moore, Anderson, & Bergman, 2007 (Cochrane Review-*ES) Swinth, Anderson, & Hadeed, 2003 (*ES-Evidence Supports)

15. Nipple Flow Rate Consideration or External Pacing to Control Flow Lau, Sheena, Shulman, & Schanler, 1997 Law-Morstatt, Judd, Snyder, Baier, & Dhanireddy, 2003 Lemons & Lemons, 1996 Vandenberg, 1990 External oral/jaw support Boiron, Nobrega, Roux, Henrot, & Saliba, 2007 Einarsson-Backes, Price, Glass, & Hayes, 1994 Hill, Kurkowski, & Garcia, 2000 Feeding Schedules Ad-lib/Demand Adibe, Nichol, Lim, & Mattei, 2007 Pridham, Kosorok, Greer, Kayata, Bhattacharaya, & Grunwald, 2001 Crosson & Pickler, 2004 Tosh & McGuire, 2008 (Cochrane Review-*IE) Semi-Demand or Complimentary McCain, Gartside, Greenberg, & Lott, 2001 (*IE-insufficient evidence concluded)

16. Plan for Transition from Enteral Feeding to Oral Feeding Collins, Makrides, & McPhee, 2008 (Cochrane Review, IE) Evans & Thureen, 2001 Lemons, 2001 Lemons & Lemons, 1996 McCain, 2003 Premji, Paes, Jacobson, & Chessell, 2002 Family-Centered Care Bauchner, 1996 Browne & Talmi, 2005 Shield, Pratt, Davis, & Hunter, 2007 (Cochrane Review, IE) Neurodevelopmental Care Approach Als, 1986 Als & Gilkerson, 1995 Als, Lawhon, Brown, Gibes, Duffy, McAmulty, & Blickman, 1986 Aucott, Donohue, Atkins, & Allen, 2002 Shaker & Woida, 2007

17. Benefits Specific to Breastfeeding For Mother • Decreased risk of breast cancer (~25%) • Lower risk of uterine and ovarian cancer due to less estrogen • Less risk of osteoporosis (non-breastfeeding women: 4 times higher incidence) • Child spacing – delayed resumption of ovulation • Promotes postpartum weight loss • Cost of formula feeding: $1200/year • Reduced healthcare costs • Reduced employee absenteeism • Attachment parenting Known Benefits to Babies • Improved immunities • Enhanced developmental and neurocognitive outcome • Greater enteral feeding tolerance, faster progression to full enteral feedings • Enhanced retinal maturation & visual maturity • Greater physiological stability during breastfeeding than bottle-feeding • Support for Breast or Bottle Feeding • Bier, Ferguson, Anderson, Solomon, Voltas, Oh, & Vohr, 1993 • Callen & Pinelli, 2005 • Dollberg, Lahav, & Mimouni, 2001 • Howe, Sheu, Hinojosa, Lin, & Holzman, 2007 • Limpvanuspong, Patrachai, Suthutvoravut, & O-Prasertsawat, 2007 • Rodriguez, Miracle, & Meier, 2005 • Schanler, Schulman, & Lau, 1999 • Schanler, Schulman, Lau, Smith, & Heitkemper, 1999 • Sheppard & Fletcher, 2007 • Singh, Sachdev, Nagpal, Bajaj, & Dubey, 2005 • Spatz, 2004 • Thomas, 2000

18. FINDINGS

19. Dysphagia in Children: Part I

20. COMMON SYMPTOMS OF SWALLOWING PROBLEMS IN CHILDREN • Coughing, Gagging, “Wet” Voice Quality, Choking (!) • Difficulty chewing or moving food around in mouth • Drooling, or food loss at the lips • Residue in mouth after meals or between bites • Weight issues (*usually weight loss, chronically low-weight) • Frequent upper respiratory infections/pneumonias • Extreme preferences for consistency, temperature, taste • Sensory Issues • Fussiness at meals, or food refusals • Breathing and/or color changes during or following eating • Recurrent/chronic fevers or spiking a temp. associated with eating • Wheezing or stridor associated with eating • History of vomiting and/or documented gastro-esophageal reflux

21. Classifying Eating/Swallowing Problems • Motor-based Problems • Sensory-based Problems • Behaviorally-based Problems • Maladaptive mealtime behaviors • Issues of decreased independent functioning with or w/o limited opportunities for development of self-determination skills • * Combinations • Limiting Patterns • Frequent Causes and Associated Characteristics Etiologies of Feeding Problems

22. Oral-Motor and Oral-Sensory Skill Deficits Involve deficiencies in oral-motor awareness and associated movements/necessaryadjustments of tension of the oral structures (i.e., lips, tongue, jaw, cheeks) necessary for preparation, transport, and safe and efficient swallowing of a variety of food consistencies

23. Underlying deficits in feeding skills result in a variety of symptoms related to the area of dysfunction: For example, motor and sensory deficits associated with lips & cheeks- Lips that don’t close or are retracted Lips that aren’t active in spooning and/or chewing Lips that are pursed Lips that don’t maintain closure with swallowing Residue in cheek cavities, cheeks that don’t “help” with bolus control or chewing

24. Examples of Oral-Preparatory Phase Problems Reduced tongue coordination = decreased control of the bolus, slow and/or increased effort to prepare it Reduced tone in the cheeks = Reduced lip closure = Reduced tongue range of motion and/or delayed tongue movement patterns = Reduced/absent lateral tongue movements = Reduced/absent rotary jaw movement = Reduced jaw closure and/or limited opening= Abnormal reflexes interfere (tonic bite, hyper-gag, rooting, startle, etc)= Reduced sensory awareness or hypersensitivities= Dental and/or structural abnormalities that limit functional abilities

25. Examples of Oral Phase Problems • Reduced tongue control (decreased ability to form a bolus and control its movement from front to back of mouth) = can result in premature spillover to pharynx … • Reduced/absent lip closure = • Reduced sensory awareness or hypersensitivities = • Dental and/or structural abnormalities that limit functional abilities • Reduced tone in the cheeks = • Tongue thrust pattern = Common Problems within the Oral Phase of Swallowing

26. Delayed (common) or absent (less common) swallow response = • Reduced closure of the velum = • Reduced tongue base retraction to contact pharyngeal wall = • Reduced contraction of the pharyngeal constrictor muscles = • Reduced coordination of pharyngeal phase with the airway closure of the larynx = • Reduced laryngeal elevation and/or closure = Examples of Pharyngeal Phase Problems

27. Pharyngeal phase problems can result in: Penetration- foods or liquids that extend into the laryngeal vestibule but are swallowed ‘in time’ so that they do not progress beyond the false vocal folds or Aspiration-foods/liquids that fall to the true vocal folds and farther into the airway Absent/delayed & weak/productive cough reflex

28. Most Common in children: Gastroesophageal Reflux! • Less common: • Lax UES • Tracheo-esophageal fistula • Decreased esophageal peristalsis Common Problems within thE Esophageal Phase of Swallowing

29. Deficits in Chewing Skills Development • Children are different than adults in that they don’t typically lose skills they’ve had, but they go through normal developmental patterns slower and/or they “freeze” in their development of skills due to their physical limitations and associated limiting patterns. • Abnormal reflexes can/do interfere with development!

30. End of Part I