Pediatric Dysphagia CSD 625

Management of Swallowing & Feeding Problems

Objectives

Feeding Prerequisites & Readiness

Pre-term feeders

Structurally-Based Pediatric Dysphagia Neurologically-Based Pediatric Dysphagia

 4,000,000 live births each year 250,000 premature (before 37 wks gestation)

75,000 6 weeks (or more) premature

FT but SGA: +2 SD below mean weight for age Preterm & SGA classified:
LBW <1500 grams VLBW <1000 grams ELBW <800 grams

 Retinopathy of Prematurity (ROP)

Infant Respiratory Distress Syndrome (IRDS) Bronchopulmonary Dysplasia (BPD)

GER
FTT

Prerequisites & Readiness

When are premature infants ready to feed?

Medically stable
Postural control Respiration is stable (even, rhythmic, O2 sat 95%) Appropriate state before feeding

Demonstrates rhythmic NNS

Not ready for bottle/breast before 32 wks Ideally start around 33-34 wks

Prerequisites & Readiness

What can we do?
With medical clearance, establish feeding schedule (what is developmentally appropriate)
Educate feeders how to monitor physical parameters before, during, and after feeding Reduce oral aversion to feeding Use oral stim to increase suckling Establish NNS prior to oral feeding Behavioral management- reinforce pleasurable exp.

Prerequisites & Readiness

What can we do? (contd)

Alter the environment Establish optimal infant state (alert/calm cues)
swaddling

Watch for signs of infant stress

Organize infant for oral feedings

Establish optimal position (flexion, head-neck-trunk support)

Prerequisites & Readiness

What can we do? (contd)

Alter the nipple External pacing Loosen diaper Do not force bottle Consider alternating between tube & oral feeding Monitor infants daily schedule

Structural Anomalies

Cleft Lip Cleft Palate Cleft Lip & Palate

Any anatomical deviation can impact feeding/swallowing process but a different anatomy does not always indicate a feeding/swallowing disorder.

 Cleft Lip Breastfeeding Bottle feeding

 Cleft Palate + Lip Breastfeeding

Compression only

Bottle feeding

 Nipples
Stiffness/pliability Size Shape Opening

 Lambs Nipple

 Ross Cleft Nurser

 Mead Johnson

 Orthodontic Nipple

 Haberman Feeder

 Pigeon Nipple

 Obturator

 Heart Defects Chiari Malformation Crouzon syndrome

Mobius sequence

 Freeman-Sheldon syndrome
Pierre-Robin sequence Treacher Collins syndrome Tracheoesophageal Fistula (TEF)

Laryngeal Cleft

Neurologically-Based Pediatric Dysphagia

Cerebral Palsy
Nonprogressive, motor function or posture disorder Onset in childhood Prenatal (fall, car accident, dietary issues, metabolic disorders, infection or toxins) Perinatal (during delivery, long labor, child stuck in birth canal, hypoxic injury to child, turned the wrong way, umbilical cord wrapped around childs neck, mother pelvic competency)

Post natal (CP vs TBI) Neurological damage Associated factors Mental retardation Hearing or processing Dental Vision Orthopedic Psychological Seizures Fractures and pain management Growth failures: height and weight problems
UCPA Statistics- incidence 1/250 live births

Differential Profiles of CP
Spastic

Most predominant form of CP (50-60% of cases) Frontal damage; premotor & motor cortex Problems with balance within muscle groups (agonist/antagonist) Flexion at wrists, knees, fingers, elbows Shoulders & hips adducted Aquinas- walks on tip toes Postural Tx: position at 90o angles to break tone Medical tx: medications, surgery

Profiles of CP (contd)
Flaccid
10% of CP cases rag doll/noodle; frog legs when supine Tx: seating system tilted back, but still at 90o; adductor bars/support for knees

Athetoid
20% of CP cases Dyskinesia present because of extrapyramidal involvement, but calm when sleeping Fluctuating tone; often co-occurs with intellectual impairment Tx: very difficult

Profiles of CP (contd)
Ataxic
~10% of CP cases Decreased proprioception Wide-based gait; rigid movements Decreased integration of motor programs Usually a fair to even good prognosis

Mixed
10-15% of CP cases Used when child has CP, but does not fit nicely into any other category

Drooling
AKA
Hypersalivation

Sialorrhea
Ptyalism Posterior drooling

Estimates range as high as 37% of CP children will have this problem

Drooling Sequelae

Physical: facial chapping, dental carries, infection risk heightened

Social and psychological implications Watch hydration status during management

Drooling Management

Positioning: trunk stabilized, head alignment Behavior Mod./Oral-motor treatment approaches

Biofeedback

Pharmacology (e.g., antihistamines) Surgery (e.g., salivary gland resection) Dental visits

Other Considerations

Poor head, trunk control

Flexion 90-90-90 Adaptive seat Chin tuck position

Poor head control, tongue thrust

Slightly reclined position Use (rolled) towels, blankets to support

The End