Pediatric dysphagia
June 13, 2014
Stability is provided positionally (structures are
very close and large amounts of fat)
 Tongue fills entire oral cavity – touching cheeks,
hard, and soft palate
 Tongue tip sticks out past the alveolar ridge and
touches the lower lip
 Fat pads in the cheeks help support oral and
pharyngeal function
 Soft palate is large, uvula close to the tip of
epiglottis
 Faucial pillars touch the epiglottis
 Hyoid and larynx very close together, near the
mandible and much higher in the neck
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Anatomy and physiology
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Base of tongue and larynx
◦ Descend during the first 4 years of life
◦ By 4 years the base of tongue has descended far
enough that it forms the anterior wall of the
oropharynx
◦ Changes continue during childhood and accelerate
during puberty
Sucking pads disappear between 4 to 6 months of life
Infants tongue fills its mouth and sits more anteriorly
than an adults
Mandible is smaller, makes the tongue look oversized
Tongue, soft palate, pharynx and larynx are higher in
the neck
◦ Facilitates to coordinate nasal breathing during the
swallow
Anatomy and physiology
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Obligatory nose breathers because of
their anatomy
Swallow coincides with cessation of
breathing (1 sec)
Most infants begin with a suck(le) –
swallow – breathe pattern (1:1:1 ratio)
May change to 2:1:1 ratio towards the
end of a feed
Establish and maintain a rhythmic pattern
Coordination between sucking,
swallowing and breathing
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Oral prep phase
◦ When sucking occurs in infants
◦ Longer in children who are eating solid foods that
have to be chewed
◦ Manipulates food or liquid in the mouth to form a
bolus
◦ Lips close around the nipple or cup so no liquid is
lost
◦ Liquid is moved around the mouth to form a bolus
◦ Bolus is held between the tongue and hard palate
◦ Soft palate is pulled forward against the base of the
tongue to keep the bolus from falling into the
pharynx
◦ The airway is open and nose breathing continues
Four phases of swallow
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Oral voluntary phase
◦ Begins as soon as the child moves the bolus
posteriorly
◦ Ends when the bolus leaves the oral cavity
◦ Less than one second for an infant with normal
development
◦ Tongue is elevated toward the soft palate
◦ Tongue presses against roof of the mouth in a
peristaltic motion to squeeze food or liquid
backward
◦ The bolus leaves the mouth
Four phases of swallow
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Pharyngeal phase
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Begins with the initiation of the pharyngeal swallow
True vocal folds close - arytenoids come together
The false vocal folds close
The hyoid and the larynx are pulled up and forward
Epiglottis is pushed down to deflect the bolus to
either side and to move it posteriorly away from the
airway
◦ Bolus propelled through the pharynx by pressure
created by base of tongue, movement of the upper
esophageal sphincter (caused by lifting the larynx)
◦ In the pharynx the bolus divides, half moves
through the pyriform sinus on each side of the
pharynx
◦ Rejoins right above the level of the upper
esophageal sphincter
Four phases of swallow
Esophageal phase – persistent peristaltic
wave moves bolus through the esophagus
into the stomach
 Wave associated with each pharyngeal
swallow
 May be delayed or observed after 4 or
more swallows
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Four phases of swallow
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Infants start with a suckle
Sometime between 6-9 months it changes to a suck
Engage in nutritive and non-nutritive suckle
Nutritive suckle
◦ Continuous burst which changes to intermittent bursts
◦ Bursts become shorter with longer pauses as feeding
proceeds
◦ One suck per second
◦ Swallow 1:1 ratio
◦ Suck more often than swallowing towards end of the
feeding (2:1 ratio)
Non-nutritive suckle
◦ More repetitive
◦ On a pacifier—more repetitive bc. nothing to swallow
◦ 6 sucks per second, 6-8 sucks per swallow
Suckling/sucking
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In a suckle
◦ Lips close around a nipple and turn outwards (inner part
of the lips touch the nipple)
◦ Both positive and negative pressure used to expel milk
◦ Positive pressure occurs when fluid is compressed,
squeezed or pushed out of the nipple (squeezing
toothpaste out of the tube)
◦ Negative pressure similar to suction action (using a
syringe to draw out liquid)
◦ Tongue, lower lip, mandible and hyoid move together
◦ Move down and forward and then up and back
◦ Downward movement causes negative pressure
◦ Up and back movement causes positive pressure
◦ Occurs 2 times per second
Suckling/suck
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In a suck:
◦ The front of the tongue pushes against the
nipple and causes positive pressure
◦ Back of the tongue lowers which increases the
volume of the oral cavity
◦ Causes negative pressure and suction
◦ Negative pressure more important especially
during breast feeding
Suckling/suck
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Reflexes and responses to protect the airway
Reflexes are triggered from receptors in the
nose, nasopharynx, upper airway and lungs
Triggered by chemical receptors (responds to
chemicals such as water, milk or secretions,
acid, etc) or mechanical receptors (touch and
pressure)
Any time the infant has a pause in respiration
because of these receptors it is called apnea
Protective to shut the airway and close larynx
If it continues causes hypoxia and
bradycardia
Response to stimuli
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rooting
suckling
sucking
swallowing
tongue thrusting
biting
gagging
palmomental
Primitive reflexes
Feeding and swallowing
impairments
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Infant who fails to suckle feed or who suckles or
swallows poorly demonstrates problems of
feeding readiness, illness or injury
More concerned about the infant who continues
to have feeding failure
Causes lie in developmental history of the
mouth, pharynx and representation of these
areas in the brain
Abnormalities of mouth and pharynx and/or of
the brain
Sharing of function between mouth/pharynx and
the brain
Feeding and swallowing
impairments
Sensory input from the mouth and the
pharynx stimulate the development of
various areas in the brain which further
refine the oral and pharyngeal movements
 Hypoplasia of the tongue may achieve a
suckle with compensatory functions of the
pharyngeal constrictor wall, palatine folds
 Children with cleft palate may compensate
by use of the tongue, and constrictors
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Premature infants
Gestational period is less than 36 weeks
 Negatively affect their growth and
development
 Not capable of oral feeding due to
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poorly organized sucking bursts
Disorganized jaw and tongue movements
Immature lungs
Intolerant of apneic periods during swallowing
Other circulatory or neurological immaturity
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Maternal anxiety because infants are
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Less interactive
Less responsive
Fussier with less positive affect
Fewer vocalizations during feeding and play
Chronic illnesses and significantly higher level of
care giving
Ultrasound show swallowing amniotic fluid as
early as 13 weeks
Suck, swallow and breath coordination
develops after 34 weeks gestation
Oral prematurity – lack of sucking pads
(fattieness of cheeks)
Premature infants
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Birth weight
◦ An extremely low birth weight (ELBW) infant is
defined as one with a birth weight of less than
1000g (2lb, 3oz)
◦ Most extremely low birth weight infants are
also the youngest of premature newborns,
usually born at 27 weeks' gestational age or
younger
◦ Infants born at less than 1500g are defined as
having very low birth weight (VLBW)
Premature infants
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Birth weight
◦ Low birth weight infants are < 2500g
◦ Infants whose weight is appropriate for their
gestational ages are termed appropriate for
gestational age (AGA).
◦ Infants who are heavier than expected are
large for gestational age (LGA)
◦ Those smaller than expected are considered
small for gestational age (SGA) and are also
usually found to be intrauterine growth
restricted (IUGR) prior to birth.
Premature infants
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Intercranial hemorrhage
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Necrotizing enterocolitis
◦ ½ to 1/3 infants weighing less than 1500 gms
◦ Results in visual deficits, gross motor disorders,
speech delays and swallowing disorders
◦ Location and extent of hemorrhage
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Excessive gas
Mucosal injury in the esophagus
Perforated bowel
Short gut syndrome due to surgery
Feeding intolerance abdominal distention, gastric
retention of feedings
◦ Total NPO, bowel rest, antibiotics and surgery
Premature infants
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Infant respiratory distress syndrome
◦ Insufficient amounts of surfactant
◦ 70% of infants younger than 28 weeks develop IRDS
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Bronchopulmonary dysplasia
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Seen in infants with positive pressure ventilation
Increased respiratory rates
Decreased pulmonary compliance
Impaired gas exchange and respiratory fatigue
Infants under 1000 grams develop BPD (50-85%)
Treated with oxygen, steroids, and diuretics
Feeding difficulties due to inability to regulate breathing
and swallowing, decreased endurance and orally
defensive
◦ Pace the infant, frequent breaks, burp frequently and
increase the amount of oxygen
Premature infants
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Congenital heart disease
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Deficits in cardiovascular system
Results in abnormal blow flow
Increased heart rates and blood pressure
Compensate for inability to pump enough blood
Increased oxygen demands during feeding
Use more external support
Provide frequent breaks
Higher caloric formula
High flow nipple
Proceed with caution not to overwhelm with too
much formula
Prematurity
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Ventricular septal defect (hole between the
right and left ventricles)
Narrowing of the pulmonary outflow tract
(the valve and artery that connect the heart
with the lungs)
Overriding aorta (the artery that carries
oxygen-rich blood to the body) that is shifted
over the right ventricle and ventricular septal
defect, instead of coming out only from the
left ventricle
A thickened muscular wall of the right
ventricle (right ventricular hypertrophy)
Tetralogy of Falot
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Contents of the stomach (acid) returning to the
esophagus
 Lower esophageal sphincter does not work
properly
 Increase in intra-abdominal pressure above the
pressure of the LES
 During normal activities of crying, coughing,
moving and defecating
 Gastrostomy tubes develop significant GERD
within 6-12 months
 Symptoms include:
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Projectile vomiting
Cough, choke, or gag
Abnormal posturing (arching back)
Exhibit irritability
Gastroesophageal reflux disease
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Respiratory complications
Esophageal/gastroenterologic complications
Failure to thrive
Diagnosis
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Barium swallow
PH Probe
Upper endoscopy
Scintigraphy
 Nuclear medicine
 Positron emission tomography
GERD
GERD
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Management
◦ Behavioral
 Position at 30 degree upright or on an incline
 Thickened feedings
 Smaller more frequent feedings
 Fasting before bed
◦ Medical
 Inhibits nocturnal acid secretions
◦ Tagamet
◦ Zantac
◦ Pepcid
◦ Axid
 Increases amplitude of peristaltic contractions
◦ Reglan
 Surgical
◦ Nissen fundoplication- sphincter sewn tightly shut so
that it’s a one way valve downward—they would
never be able to vomit
Inability to absorb nutrients
Occurs after resection of the small
intestine
 Caused by
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Multiple intestinal atresias
Intestinal malrotation
Necrotizing enterocolitis
Abdominal wall defects
Nutrition via central line
Anti-motility drugs (Imodine or Lomotil)
Short bowel syndrome
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Cerebral palsy
◦ Occurring prior to or at birth or soon after
◦ Spastic cerebral palsy – excessive muscle tension,
abnormal postures and movements, exaggerated gag
reflex
◦ Infant unable to hold the nipple because of
increased muscle tone and an arched posture
◦ Once the nipple is in place, the infant may gag and
unrhythmical
◦ Delayed swallow – at risk for aspiration
◦ GERD makes ingestion of food painful
◦ 25% of older children have dysphagia
◦ Bite reflexes, drooling, poor trunk control, coughing or
choking during meals
Cerebral palsy
With dysphagia stay in hospitals twice as
long
 Nutritional needs during coma
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◦ Decorticate or decerebrate posturing need 20%
higher basal energy
◦ 1½ times greater caloric intake for the healing
process
◦ Dysphagia similar to those of adults however,
differences include physiological differences,
cognitive and behavioral issues, social impact
on the family
◦ Start feeding at Rancho level III
Head injury
◦ Impulsive, taking large bites, failing to chew
and swallow before taking another bite
◦ GERD
◦ Treatment suggestions
 Upright posturing
 Reduce oral hypersensitivity
 Absent swallow reflex
 Bite reflex
 Used a rubber coated spoon
Head injury
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Pervasive developmental disorder and autism
◦ Social withdrawal, communication deficits, and
repetitive stereotypic behaviors
◦ Hypersensitivity to light, sound, pain, smell & touch
◦ Social withdrawal affects oral phase
◦ Impaired body posture and tone interferes with
positioning for feeding
◦ Hypersensitivity to smell cause infants to recoil
from food
◦ Hypersensitivity to touch and taste may interfere
with the oral phase
◦ Lick, smell or attempt to eat nonfoods (pica)
Autism spectrum disorder
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Spina bifida
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Spinal column malformation
Lack of closure of the neural tube
Vertebrae do not completely fuse
Limited sensation and motor control difficulties
May experience difficulty in all phases due to
limited sensation
◦ Pharyngeal and esophageal stages of swallow
affected by the cranial nerve damage
◦ Suck and intake of food disturbed due to
sensory impairment and dyspraxia (difficulty
coordinating movements)
Spina bifida
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Fetal alcohol syndrome
Airway feeding problems
◦ Choanal stenosis – atresia
◦ CHARGE – coloboma, heart disease, atresia of the
choanae, retarded growth and development
◦ Genital hypoplasia and ear anomalies
◦ Pierre Robin sequelae
 Glossoptosis
 Inward palatal arches
 Lateral pharyngeal wall hypotonia
◦ Tracheo-esophageal fistulae or atresia
 Repair may cause tracheomalacia
◦ Laryngeal anomalies
◦ Pyloric stenosis
Fetal alcohol syndrome
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Moebius syndrome
◦ Damage to the cranial nerves
◦ Weakness of the face, mandible, lips, and
tongue
◦ Difficulty closing lips
◦ Food and liquid dribbles out of the mouth
Moebius syndrome
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Cognitive impairment and developmental
delay
◦ Motor coordination and delay interfere with
self-feeding and oral phase of swallowing
◦ Communication disorders cause difficulty in
expressing preferences
◦ Down syndrome and Prader-Willi syndrome
Pediatric dysphagia
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HIV/AIDS
◦ White blood cells, the brain, and other parts of
the body are affected
◦ Transmitted in utero and/or through breast milk
◦ 45% have serious feeding problems
◦ Static encephalopathy – developmental delay,
microcephaly, seizure, non-progressive
◦ Progressive encephalopathy – neurological
deterioration due to direct brain infection
◦ Oral herpes, cognitive, language, and attention
deficit disorders
◦ Odynophagia – pain while swallowing due to
damage of the esophagus, crying after a couple
of swallows
HIV/AIDS
◦ Malnutrition – affects other systems in the body
and puts them at risk for aspiration, increased
fatigue during eating, slow feeders with poor
sucking, chewing and bolus formation and food
aversion to textures
◦ Effects of AIDS drugs caused nausea, vomiting,
increased reflux and decreased appetite
◦ Treatment
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Analgesic 20 minutes before a meal
Increase flow of oxygen
Medicine in pudding or other flavorful foods
Smooth cold foods
Avoid strong flavor and acid foods
HIV/AIDS
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Failure to thrive
◦ Consistently below the third percentile for age or is
less than 80% of the ideal weight for age
◦ Organic, non-organic and mixed etiology
◦ Organic factors include
 Endocrine deficiencies
 Chronic diseases
 Enzymatic defects
 Genetic anomalies
 Oral motor dysfunctions
◦ Non-organic factors include
 Poor mother infant interaction
 Psycho social issues
 Environmental deprivation
 Child abuse
 Poor feeding practices
Failure to thrive
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Cleft palate
Cleft lip
Submucous cleft
Surgical repair
Positioning
Nipple burping
Type of bottle
Frequency of feeding
Craniofacial anomalies
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bottle/breast
birth – 6 months
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cup drinking
7 – 12 months (about
1 month after spoon
feeding begins)
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straw drinking
36 months
Normal development of feeding
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Spoon feeding
4-6 months
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Munching/chewing
6-7 months
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Controlled, sustained
biting
12 + months
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Rotary chewing
12-15+ months
Normal development of feeding
Normal development of feeding
Normal development of feeding
Screening to determine if an individual is at risk
Silent aspiration (lack of cough when food or
liquid enters the airway)
 Complete assessment as part of a team
 Determine appropriate intervention
 Failure to thrive
 Monitor for weight gain and development
 Non-instrumental Clinical Evaluation (NICE)
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◦ Breathing and physical coordination
◦ Ability to form a seal and suck using nutritive and nonnutritive sucking
◦ Caregivers counseled and further evaluation scheduled if
necessary
Evaluation for dysphagia
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Refer when
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Case history
Clinical assessment
◦ Difficulties observed relating to feeding and ingestion of
food or liquid
◦ At risk for aspirating food or liquid
◦ Does not receive adequate nourishment
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Caregiver and environmental factors
Cognitive and communicative functioning
Head and body posture
Oral-motor mechanism
Laryngeal function
Swallowing mechanism
Dysphagia evaluation
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Current status
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Social history
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Medical history
◦ Medical diagnosis
◦ Present concerns
◦ Reason for referral
◦ Family, parent/caregiver relationship, Siblings
◦ Home and feeding environment
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Neonatal/birth history
Pregnancy and delivery history
Apgar scores
Perinatal complications
Anesthesia during birth
Respiratory, ventilatory support
Current medications
Past surgeries
Case history
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Medical history contd.
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Feeding and swallow history
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Genetic and neurological evaluation
Lab reports
Ear infections
Sleep patterns
Current interventions
Allergies
Motor and speech and language development
Personality
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Feeding develop
Tube feeding history
Weight gain history
Reflux/emesis during and after meals
Aversive behaviors
Case history
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behavior/state/sensory integration
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Stage
Stage
Stage
Stage
Stage
Stage
Stage
1:
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deep sleep
light sleep
drowsy semi dozing
quiet alert
active alert
alert agitated
crying
Evaluation
◦ Tolerance for feeding
 State-related: staring, panicked or hyperalert,
silent crying, dozing, and startle
 Motor-related: facial grimacing, twitching,
hyperextension of the trunk, arms, hands or legs
 Autonomic mild: gasp, sigh, sneeze, sweating,
hiccup, tremor, startle, and strain
 Autonomic severe: coughing, gagging, reflux, skin
color change, respiratory pausing, irregular
respiration
Evaluation
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General postural control/tone
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Respiratory function/endurance
◦ Assess muscle tone/posture/movement abnormalities
◦ Evaluate head/neck/trunk alignment
◦ Disassociation of head/neck from shoulder girdle (head
support)
◦ Note abnormal compensatory behaviors
◦ Respiratory patterns at rest and during activity
◦ Respiratory patterns
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Belly breathers
Gulp breathers
Ribcage flaring
Sternum depression
Reverse breathing
Irregular shallow
◦ apnea
Evaluation
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Oral motor/cranial nerve evaluation
◦ Oral primitive reflexes
◦ Oral structure and function
 Lips
◦ Observe lips at rest and note symmetry
◦ Observe bilabial closure
◦ Maintain lip closure for 5 seconds
◦ Upper and lower lip for strength increased, decreased or
normal
◦ Anatomical deviations
◦ Symmetry and range of motion
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Lip opening and closing independent from the jaw
Lip rounding
Lip spreading
Lip resistance
Abnormal movement patterns, retractions,
Evaluation
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Jaw
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Size of jaw
Position of jaw (protrusion, retraction, clenched)
Symmetry and degree of jaw opening
Side to side movement, in and out movement
Strength
Abnormal movements (jaw thrusting)
Malocclusions
 Neutrocclusion: class I molars properly aligned
 Distocclusion: class II mandibular molars are too far posterior in relation
to maxillary molars
 Mesiocclusion: class III mandibular molars are too far anterior in relation
to maxillary molars
◦ Dental bite
 Open bite: upper and lower incisors and possibly canines do not meet
 Overbite: the upper incisors overlap the lower incisors with significant
gap between them
 Overjet: the upper incisors project in front of the lower incisors creating a
space
 Cross bite: maxillary and mandibular teeth are not vertically aligned
Evaluation
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Oral motor structures and function
◦ Tongue
 Size micro or macroglossia
 Movement abnormalities
◦ Fasciculations
◦ Tremors
◦ Protruded or retracted
◦ Contour – flat, thick, or bunched
◦ Increased or decreased tone
◦ Lingual deviances – scarring, short frenulum, bifid tip
◦ Observe protrusion, retraction and lateralization
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independent of the jaw
Tongue tip and back elevation
Tongue cupping
Lingual strength by pressing against cheeks on either side
Abnormal movement
Evaluation
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Swallow and feeding evaluation
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Assess the oral/preparatory phase
Make inferences about the pharyngeal stage
Suspect problems with later refer for videoflouroscopy
Bottle feeding
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Evaluate nutritive vs. non nutritive swallow
Type of bottle, type of fluid, flow or nipple
Note position
Suckle initiation
Strength of tongue seal (0-6 months)
Strength of lip seal (6 months up)
Suckle vs. sucking
Mandibular excursion
Suckle/swallow ratio at beginning vs. end of feeding
Length of burst cycle
Length of feeding (endurance)
Evaluation
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Cup drinking
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Lip/cheek movements
Tongue movements
Jaw stability
Biting cup
Loss of material
Straw drinking
◦ Lip/tongue/cheek movements
◦ Vary viscosity of liquids (control volume)
Evaluation
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Spoon feeding
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Biting/chewing soft solid foods
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Anticipatory open mouth
Jaw gradation
Lip/tongue/cheek movement
Clean spoon? How?
◦ Anterior munching patterns
 Straight up and down jaw movement
 Diagonal munch food moves side to side
◦ Mature rotary chewing pattern (later)
 Bite/grind
 Open mouth or lip closure
 Lip/tongue/cheek/jaw movements
Evaluation
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Biting/chewing hard solids
◦ Tongue lateralization
 Midline to side
 Side to midline to side
 Side to side
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Cervical auscultation
◦ Pediatric stethoscope is placed near the larynx and
the sounds of swallowing/respiration are observed
 Start listening to normal respiration before introducing
food
 Listen to cycles of sucking/swallowing/breathing
 Listen for timing of the swallow response
 Observe change in respiratory sound after the swallow
Evaluation
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Instrumentation
◦ Modified barium swallow study
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Videoflouroscopy
Food coated with barium is ingested
Head and body in different positions
Views recorded for later analysis
Real-time visualization of the swallow process
Determine whether the individual should feed orally or not
◦ Fiber-optic endoscopic evaluation of swallowing
 Following topical anesthetic insert a flexible fiber-optic
laryngoscope through the patient’s nose and down into
the pharynx
 Cough, hold his breath, swallow different textures of food
(dyed for visualization)
 Oral and esophageal phase not visible
Evaluation for dysphagia
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Videoflouroscopic swallow study
◦ Responsibilities of the feeding specialist
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Positioning of the infant/child
Assembling the feeding equipment
Instructing the parents who act as feeders during the study
Assuming the role of the feeder
Working with radiologist to obtain an optimum view
Helping infant/child to maintain midline head position
Evaluating stages of swallow
Making suggestions for intervention and compensatory strategies
◦ Responsibilities of the radiologist
 Reviewing the films
 Diagnosing anatomical abnormalities
 Assessing adequacy of airway protection and swallowing
parameters in conjunction with feeding specialist
 Screening esophageal phase
 Reviewing video tape with feeding specialist to discuss objective
findings
◦ Time 2-3 mins because of hazardous radiation
Evaluation
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Videoflouroscopic swallow study
◦ Getting started
 Be sure the child is hungry
 Make feeding as familiar and natural as possible
(familiar utensils)
 Parent/primary caregiver should feed the child
 Use simultaneous audio and video recordings to
document techniques/flow rates
 Universal precautions
◦ Positioning
 Premature infants use small seat (Tumbleform with
appropriate support for head/neck/trunk at a 45
degrees)
 For full term infants use larger seats or special seats
such as a MAMA chair (multiple application, multiple
articulation)
Evaluation
◦ Materials
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Several nipples and bottles
Poor feeders need to increase the flow rate
Slow rate – 3.6ml/minute
Fast rate – 16.2 ml/minute
Have glucose, formula or breast milk that is not mixed
with barium to continue with feeding between
evaluations
Hardest to the easiest consistencies of food
Various cups
Straw
Spoons (one shallow bowl)
Syringe
Pacifier
Evaluation
Evaluation
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Videoflouroscopic swallow study
◦ Procedure
 Presentations
◦ For infants start with NNS
◦ Introduce nipple feedings using regular or preemie
nipple with regular flow rate
◦ Older children liquids may be presented via a spoon (2
ml)
◦ Increase quantity and texture and vary the utensils
◦ For infants with NPO
 Start with easiest consistencies
 Establish NNS
 Introduce familiar bottle feeding and compare NS and
NNS
 With older children begin with spoon feedings
 Instruct the parents/caregivers to feed the infant the
same way as they do at home
Evaluation
◦ Interpretations/recommendations
 Infants trigger at the vallecula by tongue
pressing the posterior pharyngeal wall
 Tongue back/down movement is more
posterior than in older children
 Some infants may experience ventricular
penetration during the initial suckle burst
 This penetration will clear after the first
few swallows if normal
Evaluation
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Videoflouroscopic swallow study
◦ Oral phase
 Suckling from a nipple
◦ Latching on to nipple with a tight lip or
tongue seal
◦ Initiates suckling
◦ Rhythmical suckling 1-2 sucks per
swallow/breath
◦ Stripping the nipple
◦ Nipple compression
◦ Posterior nipple placement
Evaluation
 Removing food from a spoon
◦ Mouth opening
◦ Closure around spoon
◦ Lip assistance to remove food
◦ Masticating (or munching) or mashing
between gums or tongue and hard palate
◦ Manipulate the food from side to side to
form a bolus
◦ Holding the food in midline on the dorsum
of the tongue in preparation for the swallow
◦ Utensil use – spoon, fork, cup etc.
Evaluation

Videoflouroscopic swallow study
◦ Oral stage
 Posterior transit of the bolus
 Oral transit time from the first posterior
movement until the bolus reaches the head of the
ramus of the mandible
 Lingual peristalsis with hard and soft palate
 Soft palate simultaneously with the triggering of
the swallow response
Evaluation
◦ Pharyngeal stage
 Begins with elicitation of swallow response and
ends with bolus passing the CP segment
 Laryngeal elevation and anterior movement
 Epiglottic excursion
 Pharyngeal contraction, no residue
 CP dilation
◦ Esophageal phase
 Primary peristalsis
 Secondary peristalsis
Evaluation
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Feeding environment
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Minimize auditory and visual distractions
Light not too bright or too dark
Noise reduced, music encouraged
Caregiver should be relaxed and unhurried
Respond to client signals regarding feeding speed,
food choices, and quantity
◦ Communication strategies developed
◦ Utensils for feeding must be appropriate
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Slow-flow nipple
Teflon coated spoon
Shallow bowled spoon
Cutout cups
Dysphagia treatment
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Body positioning
◦ Body posture and stability
◦ Upright 90 degree hip angle, symmetrical
position with postural support to provide
stability
◦ Head and neck secure to prevent extraneous
movements
◦ Chin tuck
◦ Head rotation
Dysphagia treatment
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Modification of foods and beverages
Dysphagia treatment
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Oral motor exercises and swallowing
techniques
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Range of motion of the tongue exercises
Lip strengthening exercises
Cheek strengthening exercises
Jaw exercises
 Bubble blowing
 Straw sucking
Dysphagia treatment
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Vital stimulation
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Different pediatric placements
Dysphagia treatment