The Toddler with Down Syndrome: a perspective on feeding skills Down Syndrome Educational Symposium Series 2012

Arwen Jackson, MA, CCC-SLP Jacklyn Kammerer, MS, OTR

Who are we?

Arwen Jackson, MS, CCC-SLP is a speech-language pathologist who has extensive training and specializes in feeding and swallowing within outpatient therapy services as well as several multidisciplinary clinics at Childrens Hospital Colorado. Arwen also has interest in children with complex medical diagnoses including children with Down Syndrome, tracheostomy and ventilator dependence, allergies, and voice disorders. Jacklyn Kammerer, MS, OTR is an occupational therapist who has extensive training and specializes in feeding and swallowing within outpatient therapy services as well as several multidisciplinary clinics at Childrens Hospital Colorado. Jacklyn also has interest in children with sensory processing disorders, complex airway and gastrointestinal issues (Aerodigestive program), and infant development.

Financial disclosure
We have no relevant financial relationships with any commercial interests. Arwen Jackson, MA, CCC-SLP Jacklyn Kammerer, MS, OTR

Learning Objectives
Review typical feeding development Understand atypical patterns common in children with DS Understand and familiarize with various food textures Review medical diagnoses that can impact feeding Discuss therapeutic perspectives to support feeding and mealtimes with a child with DS

Eating is a Learned Behavior

Anatomy + Physiology + Experience Need repetitive, consistent, & positive association with mealtimes to learn to eat

BRIEF REMINDER Normal Development to Support Successful Feeding 9-12 months of age
Motor Skills Skilled dissociation with hands one to stabilize and one to play Engaging in independent finger feeding Development of pincer grasp Active release Bringing loaded spoon to mouth Oral Motor Skills Increased disassociation of oral structures Tongue lateralization to move foods side to side Rotary chewing patterns - diagonal jaw movements Controlled bite on soft foods Sensory Progressions Lots of sensory play with foods To explore the taste, texture, temperature, smell, etc. Food Textures Liquids for continued nutrition Purees of varying thickness and texture Meltable solids Soft solids Some mashed and coarsely chopped table foods
7

Normal Development to Support Successful Feeding 12-24 months of age

Motor Skills Refinement of self feeding More precise grasp and release Orienting spoon to scoop and bring to mouth Independent cup drinking Force and grasp accommodation to weight of object Improved overall balance and coordination Transition from high chair to booster chair Oral Motor Skills Refinement of diagonal jaw movements as more challenging foods are presented Able to drink from open cup without choking consecutive swallows Biting through hard cookie with sustained bite Speech-Language Development Uses single words with two word combinations by 24 months Able to request AND refuse food items Steady increase in vocabulary Understands and uses no Texture Progressions Liquids from sippy cup, straw, and beginning to use an open cup (transition away from breast and bottle) Purees, meltables, soft solids, and coarsely chopped table foods Avoid highly chokable foods raw vegetables, meats, nuts, small round foods

Normal Development to Support Successful Feeding 24-36 months of age

Motor Skills Increased balance and core stability Sitting at table no adaptations needed Continued refinement of fine motor skills Independent self-feeding with utensils Oral Motor Skills Refined jaw movements Diagonal and rotary movements Use of tongue to clean lips Speech-Language Development Able to use and respond to simple sentences Noted increase in verbal refusal behaviors Food Textures Wide variety of table foods and liquids Able to manage foods which are mixed in texture Continue to avoid chokable foods, especially raw vegetables, fruits, and nuts

Transitioning from a bottle to a cup

Exposure to cups in late infancy/early toddler years Consideration of your childs unique feeding needs
Stage of development versus chronological age Oral motor control Oral sensory preference Childs tolerance of change/transition

How might you explore your options?

Place the cup on tray for exploration Remember the value of modeling cup drinking
Parents and/or siblings Other peer groups (preschool, play group, etc)

Play with cups during bath time or sand box play

10

A few examples because

..everybody sips differently!

11

Normal Development to Support Successful Feeding 3-4 years of age

Motor Skills Independent self-feeding Food Textures Modifications still required for foods with high texture Continue to avoid chokable foods, especially raw vegetables, fruits, and nuts Child is able to understand what is edible/inedible

12

Gagging as a Protective Mechanism

Does the food being presented match developmental level AND oral motor abilities of the child?

PUREES
These foods offered by spoon, may vary in consistency from smooth, thin, and runny to lumpy, thick, or stiff.
Any table foods that are blenderized Grain Group Hot cereal (rice cereal, oatmeal, cream of wheat, malt-omeal) Vegetable Group Baby foods (sweet potatoes, squash, peas, beans) Mashed potatoes or mashed sweet potatoes Spaghetti sauce (marinara or alfredo) Fruit Group Baby foods (applesauce, peaches, pears) Berry sauces Applesauce Mashed banana Milk Group Yogurt Soft cheese spreads Sorbet and sherbet (considered a thin liquid with respect to swallow function) Soft cheese spreads Milk/Fat Pudding or custard Ice Cream, frozen yogurt (considered a thin liquid with respect to swallow function) Meat Group Refried beans Hummus Peanut butter (not recommended the first year due to potential for allergies) Fats and Sweets Cream cheese and flavored cream cheese Ketchup Barbecue Sauce Gravy Jelly, jam Chocolate sauce, butterscotch, or caramel sauce Mashed avocado

____________________________________________________________
Author: N. Creskoff OTR Approved by the Patient Family Education Committee January 2011 2010 The Childrens Hospital, Aurora, CO
14

MELTABLE SOLIDS
These foods which melt or soften readily with saliva and then break apart easily with gumming, mashing, or some chewing. Grain Group Pirates Booty Puffed Rice/Corn Snacks (Veggie Booty, White Cheddar) Gerber wheels Dehydrated veggie sticks Graham crackers Wafer cookies Grain/Fat Group Butter cookies Butter crackers Crushed cookies, cookie crumbs Fruit Group Fruit Booty Fats and Sweets Cheetos Butter cookies Butter crackers Graham crackers Chocolate Mini marshmallows Cotton candy Ice cream cone Wafer cookies Crushed cookies, cookie crumbs

15

Soft Solids, Mechanical Soft Solids

These foods can be mashed and then swallowed, or break apart easily in the mouth without the need to chew. Grain Group Soft breads Soft, well-cooked pasta such as Ramen noodles Well cooked rice (may be more difficult for some children to manage) Pancakes, french toast, or waffles (softened with butter and syrup fats and sweets). Grain/Fat Muffin, cake Fruit and cereal bars Soft cookies such as Fig Newtons Vegetable Group Soft, well-cooked vegetables such as those found in soups (carrots, potatoes, squash) Fruit Group Soft fruits (especially canned fruits such as mandarin oranges, pears, kiwi, bananas, and thinly sliced watermelons) Milk Group Thinly sliced cheese Meat Group Scrambled eggs (should not be given before 9 months) May be more difficult for some children to manage without chewing. Meat sticks or Vienna sausages Cooked legumes / beans Ground meat or tender meats, fish, or poultry

____________________________________________________________
Author: N. Creskoff OTR Approved by the Patient Family Education Committee January 2011 2010 The Childrens Hospital, Aurora, CO

16

SOLIDS
These foods which require some manipulation and breakdown via chewing prior to safely swallowing. Consider variety from semi-soft to crunchy to chewy, with increasing requirement for thorough chewing. Combined Pizza Sandwiches (grilled cheese) Grain Group Pasta, macaroni and cheese Dry cereal, such as Cheerios Crackers Pretzels Bagels, crusty breads Vegetable Group Raw vegetables such as cucumber, celery, carrots, green beans Salad Fruit Group Fruits (apple slices, strawberries, melon, pineapple) Dried fruit, raisins Milk Group Cubed cheese Meat Group Deli meat Chicken, chicken nuggets Hamburger Steak Various other meats, including sausage and bacon Beef jerkey Fish sticks Hard boiled eggs Fats and Sweets Cookies Chips Licorice Carmel or taffy Olives

17

MIXED TEXTURES
These foods which contain more than one food texture, and require the most mature oral motor skills to manage. Vegetable and Meat Groups Casseroles Soups with vegetables, pasta, rice, meat Selected Stage 3 Baby foods Fruit and Milk Groups Yogurt with fruit pieces

18

19

Food lab
Exploring food textures What does your mouth do to manage different food textures?
THINK ABOUT YOUR
lips tongue jaw/teeth cheeks

Puree Meltable solid Soft Solid Solid

20

A closer look at feeding difficulties...

More than what meets the eye, feeding is impacted by several aspects:
Oral motor skills Oral sensory development Motor control and muscle tone Sensory Processing Family context for feeding their child Other health issues

21

Atypical Development of Oral Motor Skills Abnormal Oral Motor Patterns

Tongue thrust Forceful protrusion of the tongue Tongue retraction Pulling back of tongue has thick bunched look Jaw thrust Sudden strong downward movement Jaw retraction Pulling back of jaw difficult to open mouth fully Tonic bite Forceful, tense bite often difficult to relax Lip retraction Pulling back of corners of lips resulting in horizontal line over mouth Always smiling Lip pursing Attempts to counteract lip retraction result in lips being closed in puckered fashion Tremor Rapid, small movements usually during purposeful activity Fasciculation Non-rhythmical, unorganized contractions of muscle fibers across surface

22

Atypical Development of Motor Skills

Abnormal muscle tone Can affect positioning for successful oral feeding High tone - spasticity Low tone flaccidity, floppy Fluctuating tone athetoid, ataxic Fine motor/Gross motor skills delays Can impact development of self feeding skills Diagnosis specific delays

23

Atypical Development of Sensory Processing Skills

Types of sensory dysfunction that can influence typical feeding development: Oral hypersensitivity Oral hyposensitivity Global sensory processing challenges

24

Oral Hypersensitivity
Clinical Signs Difficulty advancing food textures Reduced acceptance of tastes, temperatures and smells Aversive/exaggerated response to touch in and around the mouth Hyperactive gag response Aversion to teeth brushing Lack of age-appropriate oral exploration of hands/toys Treatment Blendarize table foods gradually thicken Avoid mixing food consistencies Meltable or soft mechanical solids are often more easily accepted foods Change only one sensory variable at a time Make gradual changes in taste/texture Work to normalize sensory response with desensitizing activities

25

Oral Hyposensitivity
Clinical Signs Slow registration of food in mouth Poor awareness of food on face/lips Overstuffs mouth May result in gagging or choking Pockets food in mouth Swallows food without adequately preparing the bolus to swallow May result in gagging or choking Drooling Preference for strong tastes Treatment Oral alerting activities Variety of textures of foods Variety of food temperatures Increase flavor of foods with spices/sauces Manipulate foods into safe proportions bite sized pieces
26

A child with Down syndrome can present with a feeding and/or swallowing difficulty
Feeding/Swallowing Swallowing Chronic poor growth Coughing or choking while eating or immediately after eating Compromised nutritional status History of chronic pulmonary difficulties Food refusal/picky eating which may include diagnosis of Decreased variety and volume of oral aspiration pneumonia intake Chronic oxygen requirement Choking, gagging, coughing and Vocal cord dysfunction vomiting while eating Weight gain is difficult and thought to be Inability to chew/swallow secondary to oral motor or pharyngeal Delayed attainment of self-feeding skills dysfunction Inability to maintain oral skills when tube Difficulty initiating a swallow fed Difficulty transitions from tube to oral feeding Behavioral or learned feeding problems

27

Common medical diagnoses and/or structural differences in children with DS

Cardiac Diagnoses that could impact fatigue Hypotonia (low tone) Tracheomalacia Laryngomalacia Subglottic Stenosis Dysphagia Late dental eruption Gastrointestinal Constipation Celiac Reflux
28

Other Atypical Behaviors Common in Children with DS

Orally seeking
Intense chewing on unsafe or odd items

Atypical biting patterns

Biting only with molars Avoiding front of mouth other than drinking or with purees

Reliance on pureed food textures, jarred baby foods, or home blenderized foods Reliance on caregivers for feeding purees due to less efficient but functional fine motor grasping patterns

29

A few things to keep in mind to help encourage positive mealtime experiences..

30

Consider your childs communication level during mealtime

Look at non-verbal communication such as eye gaze and facial expression Food choices
Present food item Augmentative and Alternative Communication
Device Picture Exchange Communication System (PECS) Real pictures of common foods

Sequence and routine for mealtime

Verbal Visual

31

Non-Verbal Strategies to Encourage Eating

NON-VERBAL COMMUNICATION: This form of communication is important because we often give messages without using words. Consider the following during mealtimes: YOUR Position YOUR Facial Expressions YOUR Body Language Observe and Wait Imitation Allow for Equal Turn Taking Make Your Face Match Your Words Decrease Anxiety

32

Verbal Strategies to Encourage Eating

VERBAL COMMUNICATION: What comes out of your mouth at the table is just an important as what goes into it! Language can be a powerful tool to guide, encourage, and positively reinforce food interaction and eating.
Consider the following: Direct Attention Pay Attention to All Aspects of the Meal and All Family Members Provide Appropriate Praise Teach the Basic Rule and Structure of Mealtimes Talk About Your Mouth and What You Do With It Describe Food Properties Provide Reassurance Offer Choices Avoid Questions and Commands; Provide Encouragement and Offer Suggestions for Food Interaction Keep Language Simple and Repetitive

____________________________________________________________
Author: N. Creskoff OTR Approved by the Patient Family Education Committee January 2011 2010 The Childrens Hospital, Aurora, CO

33

Consider the importance of postural stability during feeding

Children need postural stability for distal mobility. What does that mean for a child with Down syndrome and how does that affect feeding?
Support for comfortable and safe positioning for bottle feeding
Impact on swallow function Impact on developmental skills to bring hands to bottle Multiple systems coordinating together for successful feeding experience Impact on tube feedings

Support for a child in the highchair so they are able to easily reach baby purees and spoon to grasp, touch, explore, learn!
Highchair designs vary significantly Adding rolled towels may provide lateral (side) support so that baby can easily stay seated in the highchair without falling to either side or leaning on the tray for support Postural support will allow for more controlled oral movements
34

Food for Thought

Think about your child with Down syndrome.
Are foods too challenging or just right for your child? Think about the environment during feedings, is it chaotic? Music? Television? Bright lights? Others eating? Is feeding with your child fun and social? Is your child positioned in the BEST way to support feeding?

35