The Speaker
Attendees
Course Objectives
Agenda and Activities
Questions?
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
Normal and Abnormal Infant Reflexes
•Oral
•Hand-to-mouth
•Limiting Patterns
•Motor
•Connection between Motor and Oral-Motor
Development
Research: Telles & Macedo, 2008
“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)
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 suckswallow 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
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
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.
~ 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
Dysphagia in Infants: Select Motor and Sensory Aspects
•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
Select Issues with Physiological State
•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
Select Issues with Respiratory Involvement
•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
Select Oral-Motor 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…
Select Gastrointestinal Issues
•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
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
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
Evidence-based Practice
in the NICU
Although the evidence-base in
this area of study is limited, it
is important to determine
what established evidencebase 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 evidencesupported practices using:
Cochrane Library Reviews
Medline, Pub-Med, ComDisDome, Cinahl
Databases
Consulted the American SpeechLanguage-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
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 evidencebased NICU feeding policies
and practices
Although many more attempts were made…
A total of 4 hospital
feeding policies and
protocols were obtained
from:
1. Level II NICU in 200399 bed hospital in
Midwestern United
States
2. Level III NICU in 399+
bed hospital, North
Eastern United States
3. Level II and III NICU in
200+ bed Children’s
Hospital in Southern
United States
4. Level II and III NICU in
399+ bed hospital in
Australia
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)
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)
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
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 (nonbreastfeeding 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
FINDINGS
Care Concepts Stated or Implied in
Policies and Procedures
Level III NICU in
399+ bed hospital,
North Eastern
United States
Level II NICU in
200-399 bed
hospital in
Midwestern
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
Neurodevelopmental Approach
Non-nutritive suck stimulation
Kangaroo Care
+
+
+
Oral Stimulation
+
Nipple Flow Rate or External Pacing
to Control Flow
+
Support for Breast and Bottle Feeding
+
Feeding Schedule Decisions Addressed
+
+
+
+
Identified Plan for Transition from
Enteral to Oral Feeding
External oral/jaw support
+
Family Centered Care
Total:
7
8
5
3
DYSPHAGIA IN CHILDREN: PART I
COMMON SYMPTOMS OF SWALLOWING PROBLEMS IN CHILDREN
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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
ETIOL
OGIES
OF
FEEDI
NG
PROBL
EMS
•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
Oral-Motor and Oral-Sensory Skill
Deficits
Involve deficiencies in oral-motor
awareness and associated
movements/necessary adjustments 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
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 &
cheeksLips 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
Examples of OralPreparatory 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
COMMO
N
PROBLE
MS
WITHIN
THE
ORAL
PHASE
OF
SWALLO
WING
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 =
•
Examples of Pharyngeal Phase Problems
•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 =
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
•Most Common in children:
Gastroesophageal Reflux!
•Less common:
•Lax UES
•Tracheo-esophageal fistula
•Decreased esophageal peristalsis
COMMON PROBLEMS WITHIN THE ESOPHAGEAL PHASE OF SWALLOWING
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!
END OF PART I