Rita L. Bailey, ED.d ., CCC-SLP, BRS-S

1. Management of Dysphagia: Practical Strategies for Infants through School-age Children Rita L. Bailey, ED.d., CCC-SLP, BRS-S Board Recognized Specialist in Swallowing and Swallowing Disorders Associate Professor Department of Communication Sciences and Disorders Illinois State University

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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. ~ 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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)

17. 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

18. 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

19. FINDINGS

20. Dysphagia in Children: Part I

21. COMMON SYMPTOMS OF SWALLOWING PROBLEMS IN CHILDREN • Dysphagia • 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. 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!

31. Oral-Sensory Differences • Oral-sensory awareness • Hyposensitivities • Tend to like strong flavors (spicy, sweet, sour, etc) • Usually require increased stimulation to respond in a more normal fashion (i.e., firm pressure to tongue body with spooning helps initiate tongue cupping bolus and raising tip to alveolar ridge) • React negatively to light touch • Hypersensitivities • Tend to like bland flavors • React negatively to flavor and consistency changes • Gag easily • Aversive to touch in/around the mouth and face • May also be hypersensitive to touch of the hands, arms, etc.

32. End of Part I