SPHSC 543
FEBRUARY 12-19, 2010
 Questions?
TRANSITIONAL FEEDING
 Begins at 4-6 months in normal infants
…
Primarily related to CNS and anatomic changes
…
Allows new patterns of food manipulation
 Eruption of teeth is the most notable change
…
Mandibular before maxillary
…
Girls before boys
 20 teeth by second year, 32 by adult
TRANSITIONAL
 Teeth as sensory receptors versus motor purposes
 Molars important for crushing and grinding food
 Tongue movements are basic to food manipulation
…
Anterior-posterior (AP) movement
…
Lateral movement
TRANSITION FROM LIQUIDS
 Smooth solids – homogeneous or with fine
granular bits
…
Mashed by tongue gestures at midline
 Semifirm solids – soft but holds together
…
Tongue moves laterally and tongue/jaw make
vertical motions
…
A prelude to molar chewing
 Solids – require more mature mastication
…
Vertical movements become associated with
alternating lateral motions
…
Fully matures between 3-6 years
TRANSITIONS
 Solid foods characterized by:
…
Handles lumps and textures with ground or
mashed foods
…
Coarsely chopped foods cooked ground meats,
lunch meats, soft cooked chicken/fish
…
Coarsely chopped table foods, most meats, many
raw vegetables/fruits.
 Brain development from sensory input related to
feeding extending to midbrain, cerebellum,
thalamus and cerebral cortex
 With maturity, children begin to evaluate their
food and you start to see food preferences.
TASTE AND SMELL
 Important roles in feeding
 Experience
 Preference
 “Supertasters”
CESSATION OF NIPPLE-FEEDING
 Multi-factorial
…
Age, culture, maternal desire, lifestyle
 Need appropriate CNS development and
coordination to manage cup drinking

…
Open cup
…
Sippy cup
Prolonged nipple-feeding and dental caries
OVERALL DEVELOPMENT
 Take away information:
 Changing feeding experiences are just a portion of
a more general evolution of the developing child
 Sensory and motor skills improve and the child
acquires food preferences.
METHODS OF FEEDING DELIVERY
 Oral includes bottle, breast, cup, straw, fingers,
utensil
 Orogastric
 Nasogastric
…
Short term usage
 Gastrostomy
…
Longer term
 Continuous or bolus

But wait….new information is afoot.
 Duodenum or jejunum
FEEDING DELIVERY METHODS
 Parenteral
…
For severe GI disorders that prevent use of the GI
tract
…
Peripheral vein access
…
Central venous catheter
CLINICAL FEEDING EVALUATION
 Observation is the key component of the clinical
feeding evaluation
…
Eyes
…
Ears
…
Hands
 Need to understand the normal functions and how
they interact
…
Interaction of reflexes
…
Developmental changes
…
Respiration
…
Gastrointestinal
…
Etc.
CLINICAL FEEDING EVALUATION
 Consider the ‘whole’ infant
 Gather information from all sources
 Plan the feeding observation
…
Equipment
… Food textures
…
Physiologic monitors
…
Naturalistic and/or elicited
CLINICAL FEEDING EVALUATION
 Structured feeding history
…
Parent description of the problem – allows them to
be in control for the first part of the interview
…
State/behavior – of infant
…
Schedule – basic nutritional intake and amount of
time spent feeding each day
…
Method of feeding – helps determine a ‘typical’
feeding
…
Feeding problems observed by parent – alerts the
clinician for what to look for
TREATMENT EXPLORATION – HINT FOR
FINAL EXAM
 Develop hypotheses
 Synthesize information
…
What is the child’s level of function?
…
What factors interfere with feeding function?
… How well does the child’s feeding performance
“match” the caregiver concerns or expectations?
…
Is additional information necessary?
…
Are there treatment techniques available that
appear to improve oral feeding function?
KEY AREAS
 Physiologic control
 Motoric control
 Behavior and state
 Response to tactile input
 Oral-motor control
 Sucking, swallowing and breathing
 General observations
CLINICAL FEEDING EVALUATION

From Wolf & Glass, 1992
 From Wolf & Glass, 1992
CLINICAL FEEDING EVALUATION

An infant’s responses to the environment can indicate
how stressful the baby finds the environment and how
well she is able to adapt
 Response to the environment is manifested
through behaviors in any of the following systems:
… Autonomic or physiologic

…
Motoric
…
State
…
Attention
What is happening during the feeding at the time of the
stress cue?
AUTONOMIC/PHYSIOLOGIC
 Heart rate
…
Initial and post-feeding
…
Highest/lowest values
…
Abrupt changes
 Respiratory rate
…
Pre/post-feeding
… Highest, lowest, trends
…
Returns to baseline
BREATHING
 Quality of respiration
 Parameters: respiratory effort, changes in
respiratory pattern, sound of respirations.
 Work of breathing
 Endurance
AUTONOMIC/PHYSIOLOGIC
 Oxygen saturations
…
Amount of o2 in blood and avail for exchange at
tissue level
…
Generally expressed as a percentage of 100
 Color
…
Face, neck, mouth (circumoral)
…
Eyes (circumorbital).
…
Pale
…
Blue/purple
…
Red or ruddy
AUTONOMIC STRESS CUES
 From Wolf & Glass, 1992
MOTORIC
 Overall neuromotor control
…
Disorganized
…
Tone
 Muscle tone
… At rest
…
Change with activity
…
Quality of movement
…
Tonal variations versus movement disorder
MOTORIC
 Reflexes
…
Primitive
…
Integration
…
extinguish
 Posture
…
Development of antigravity postural control
…
Feeding position

Motor

Response to environment

Knowledge of feeder
MOTORIC STRESS CUES
 From Wolf & Glass, 1992
FEEDING POSITION
 Normally feeding babies – adaptable
 Even slight feeding problems might need help for
optimal feeding.
 Overall body posture reflects slight flexion
 Trunk is neutrally aligned and well supported in
a semi-reclined position, with orientation of the
head and extremities about the midline.
 Using proper positioning during feeding not only
affects respiratory mechanism, oral-motor control
and swallowing control, but it may also assist in
the development of early head/neck postural
responses.
STATE
 States of alertness
…
State 1 – deep sleep
…
State 2 – light sleep
…
State 3 – drowsy or semi-dozing
… State 4 – quiet alert
…
State 5 – active alert
…
State 6 – crying
STATE
 Not one optimal state for every baby
 FT (full term) – should have clear differentiation
between states
 Preemies – may seem more disorganized and lack
clarity of state
 Older babies – spend more time awake/alert and
have clearer/more predictable state changes
STATE-RELATED STRESS CUES
 From Wolf & Glass, 1991
STATE
 Is state or state control interfering with feeding?
 How does parent respond or support baby?
 What is the baby’s state throughout the feeding?
 Factors interfering with state control (immaturity
or neurological impairment) may require
prolonged need for state-related intervention.
TACTILE INPUT
 Tactually elicited reflexes present at birth allow the
infant to seek out and obtain nutrition safely.
 Ability to accept touch to the cheeks, lips, gums and
tongue is a prerequisite for feedings and the infant’s
survival.
 Expression of oral reflexes varied depending on a
number of factors.
 Must adapt to the tactile components of the tools
used in feeding
TACTILE INPUT
 Face
…
Cheeks to lips to gums to tongue
…
Head, trunk, extremities
 Input –graded
… firm and smooth (pressure from fingers or toy) to
…
soft and smooth (stuffed animal or soft finger
touch) to
…
prickly or unusual (rubber hedgehog toy).
… Same with sold foods
…
move from smooth/pureed to chunky (baby
food/cottage cheese) to crunchy (crackers)
DEGREE/PERSISTENCE OF RESPONSE
 Absent responses
 Hyposensitive
 Hypersensitive and Aversive
…
Immaturity
…
Chronic illness
… Experience
…
Neurologic impairment
ORAL MOTOR – TONGUE
 Resting position
…
Soft, thin, flat, moderately rounded tip
 Size
…
Relative to oral cavity
 Deviations
…
Tongue-tip elevation
…
Humped/bunched/retracted
 Tone
…
Clonus
…
Fasiculations
…
Asymmetric
JAW
 Resting position
…
Stable platform for tongue, lips, cheeks
 Size
…
Micrognathic
… Retrognathic
 Deviations
…
Asymmetrical or lateral
 Range of motion
…
Poorly graded
…
Clenching, biting
LIPS/CHEEKS
 Resting position
…
Soft, symmetrical
…
Well-defined
 Fat or sucking pads
… Positional stability
 Deviations
…
Tight, pulled back
…
Pursed or floppy
 Tone
…
Hypotonia
PALATE
 Shape
…
Intact
…
Smooth contour
…
Roughly approximates shape of tongue
… Narrow, grooved, arched or flat
 Clefting
…
Interferes with ability to achieve negative intraoral
pressure for suction
 Asymmetry
SUCKING-SWALLOWINGBREATHING
 Evaluate the integrity of each as well as their
coordination/organization
 Rhythmicity – hallmark of normal sucking
 Suction
 Nutritive VS Non-nutritive
 Coughing/choking
 Oral secretions
 Noisy breathing
 Nasal regurgitation
 Frequency of respiratory infections
GENERAL OBSERVATIONS

Method of feeding

Bottle/nipple used

Length of feeding, amount taken

Reason for ending the feeding

Spitting/emesis

Parent-child interaction
RED FLAGS
 Prolonged feeding time
 Limited volume
 Uncoordinated SSB
 Coughing, choking, sputtering with feeds
 Recurrent respiratory problems
 Persistent drooling
 Slow weight gain/FTT
 Food aversion/sensitivity
 Problems transitioning to next diet level
 Poor oral motor skills
DIAGNOSTIC TESTS/PROCEDURES
 Basic understanding of common tests regardless
of professional practice setting.
 Strengths/limitations
 Implications of results
 Integrate data into clinical feeding observation
 Is additional information needed?
 Most developed for adults; lack of normative data
with children (manometry, FEES, scintigraphy)
PHYSIOLOGICAL MONITORING
 Heart rate, respiratory rate, oxygen saturation
 Cardiorespiratory monitor
…
Numerical and visual display of heartbeat and
respiration
…
Averaged over a given period of time (e.g., 10 secs
…
Strengths – quick approximation of infant’s status.
…
Movement artifact /not always accurate
PHYSIOLOGICAL MONITORING
 Oximetry –
…
Oxygen saturation of capillary blood flow through
an external sensor.
…
Expressed as a percentage of 100.
…

Normal infant -- sats above 95%

Below 90% generally indicate some degree of
hypoxia.
Baseline, changes in response to work/handling,
effectiveness of O2 treatment
PHYSIOLOGICAL MONITORING
 Strengths –
…
Easy to transport, non-invasive
…
Ongoing, instantaneous info
…
More reliable index than observation
 Limitations –
…
Very sensitive to movement
…
Natural pigment of baby
…
Ambient light/infrared heating sources
PHYSIOLOGICAL MONITORING
 Pneumogram –
…
Two-channel study based on chest wall excursion
and heart rate
…
Computerized –multichannel recording of
parameters such as heart rate, RR, O2 sats, nasal
airflow, esophageal pressures
…
Gives exact values rather than averaged values so
subtle changes in parameters are identified.
PHYSIOLOGICAL MONITORS
 Polysomnogram – “Sleep study”
…
Multichannel recording of respiration, airflow,
chest and diaphragm movement, oxygen and
carbon dioxide levels, heart rate and esophageal
pressures
… EEG recordings for length of two complete sleep
cycles
…
Measures the greatest number of variables
…
Differentiates between central and obstructive
apnea, apnea secondary to seizures, obstructive
apnea due to GER or airway collapse
…
Limitations – specialized sleep lab, expertise
GASTROINTESTINAL
 Technetium scan (AKA GE scintigraphy or a milk
scan)
…
Small amount of radionuclide isotope is added to
the feeding
…
Images are made every 30 seconds over a one hour
period after the feeding looking for material in the
esophagus.
…
Number/height of reflux episodes calculated and
compared with standards
…
Gastric emptying computed by measuring the
percentage of food remaining within the stomach
after on hour.
GASTROINTESTINAL
 Strength
…
Info on several important parameters of GER:

Acidity/alkaline reflux
…
Unlikely to miss reflux events
…
Height of reflux in esophagus
…
Contribution of delayed gastric emptying
…
Radioactive tracer not absorbed and total radiation
exposure is low
 Criticized
…
Overly sensitive to reflux
…
High false positive rate
GASTROESOPHAGEAL
 Barium swallow (AKA esophogram or upper GI)
…
Evaluates structure and function of esophagus and
stomach
…
Ba delivered either orally or NG tube
…
Fluoroscopy – real-time events observed
…
Still photos taken for later review
…
Esophageal motility can be evaluated
…
Presence of spontaneous reflux or attempt to elicit by
giving pressure to abdomen
…
Rad exposure is proportional to time of exposure, but
generally brief
…
Not sensitive enough to GER, may detect aspiration
UGI
 From Wolf & Glass, 1992
GASTROINTESTINAL
 pH probe –GER
…
Sensor inserted through nose to an area just above
LES to continuously measure acidity of esophagus
…
At least a 24 hour hospital stay
…
Record kept at beside of baby’s activities for later
correlation with changes in pH.
 Data is recorded on the total number of episodes
of pH <4.0, total time with pH<4.0, number of
episodes greater than 5 mins, and longest episode
of pH<4.0. Typically, episodes of pH<4.0 must last
longer than 10 secs to be recorded.
GASTROINTESTINAL
 pH probe –GER
…
Sensor inserted through nose to an area just above
LES to continuously measure acidity of esophagus
…
At least a 24 hour hospital stay
…
Record kept at beside of baby’s activities for later
correlation with changes in pH.
 Data is recorded on the total number of episodes
of pH <4.0, total time with pH<4.0, number of
episodes greater than 5 mins, and longest episode
of pH<4.0. Typically, episodes of pH<4.0 must last
longer than 10 secs to be recorded
GASTROESOPHAGEAL
 Data generates a reflux score
 ‘Gold standard’ for evaluation of GER
AIRWAY/GASTROINTESTINAL
 Pediatric Endoscopy
…
Esophagoscopy/esophageal manometry,
laryngoscopy, bronchoscopy
 Rigid or flexible tube
 Directly observes structures within the body
 Obtain tissue via biosy or aspiration
 Treatment
 Advances in fiberoptics permitted flexible
endoscopes that can be used with even extremely
small infants
VIDEOFLUOROSCOPIC
SWALLOWING STUDY (VFSS)
 VFSS aka MBS
…
Specifically designed to assess the pharyngeal
swallow
…
Normal feeding situation is simulated but may
need to use ‘tricks’
…
Purpose –document aspiration, reason for
aspiration and the point at which it occurs
…
Assess possible therapeutic interventions
…
Positioning can be customized
VFSS
 From Wolf & Glass, 1992
CFE LIMITATIONS
 Info not readily obtained at bedside:
…
VP function
…
Laryngeal elevation and closure
…
Pharyngeal motility, transit time
… Pooling of secretions and contrast in valleculae and
pyriform
…
Number of swallows to clear material
…
Presence and timing of aspiration in relation to the
swallow.
…
Bolus movement through UES and esophagus
VFSS
 SLP/MD
…
Observations relating to timing of swallow
…
Coordination in oral/pharyngeal phase
…
Phary peristalsis
… Pooled material prior to swallow or residue after
…
Esophageal transit time
…
Aspiration before, during, after swallow
VFSS
 Seating/postioning –
…
Support of trunk, neck and head
…
Semireclining angle of approx 45 degrees.
…
Tumbleform chair
… Child’s own seating system
…
Most wheelchairs don’t fit; some have removable
parts
…
Height of seat in relation to floor
VFSS
 Need careful guidelines for appropriate
…
Radiologic risks to infant versus the yield of info
from the test
…
How will information be used?
 Personnel involved varies –
…
OT, SLP, MD, tech
…
Regardless, should have expertise in infant and
skill in interpreting images
 Parent participation
VFSS
 Emergency back up equip and personnel as
needed
 Flexible enough protocol to address each baby’s
needs
 Endurance
VFSS -- FEEDING TECHNIQUE
 Multiple variables
…
Nipple, syringe, nipple alternating with pacifier to
look at NNS and NS, spoon, cup, straw, liquid
thickness, solids
 Bolus type, amount, texture, temperature, timing
can be varied
 Risk of aspiration kept at minimum
 Caregivers provide samples of food

…
Regularly given
…
Causing trouble
…
Introduction
Lateral view -- most important and most information
VFSS
 AP view—
…
Documenting asymmetry/pooling
…
Head positions

Therapeutic changes

Flexed, extended, turned, etc.
 Neurologically impaired
…
Better at handling homogeneous consistency
VFSS
 Alternate feeding methods with plans for oral-motor
stimulation
 Repeat studies:
…
Significant change in medical or neurological status
…
Recurrence of previous symptoms
…
Previous documentation of silent aspiration
…
Tx program changes are indicated for diet textures or
compensation techniques
 Improved oral-motor function in profoundly
neurologically impaired children have not shown to
be directly correlated with improved pharyngeal
transit time.
VFSS -- LIMITATIONS
 Lack of standardization –
…
Positioning
…
Amount and order of presentation
…
Therapeutic modifications
… Overly sensitive
VFSS VS CLINICAL FEEDING
EVALUATION (CFE)
 Benefits of CFE first –
…
Establish baseline behaviors to compare with
feeding during VFSS.
…
Feeding during VFSS is often not representative
 Paradoxical performance

Has significant feeding d/o but swallows Ba without
difficulty
 Pre-determine types/textures of foods, order of
presentation, optimal positioning, equipment
needed
 Able to formulate and test treatment strategies
VFSS
 Confirms need for VFSS
…
Radiation exposure
 Signs during CFE
…
Coughing/choking
… Noisy, wet respirations
…
Subtle signs –unexplained respiratory infection or
illness, difficulty managing oral secretions.
 Aspiration can be silent
…
Logemann reports 40% of adult patients who asp
during VFSS not identified during bedside
VFSS
 Pay particular attention to medical history,
parent descript of feeding, subtle indicators of
potential swallow dysfunction
 Generalizability of feeding sample has been
questioned
… Relatively brief sampling
…
Ba may alter baby’s swallowing response
 Not intended to identify GER as objective, but can
be seen