Download Assessment of Feeding and Swallowing Problems

Feeding and Swallowing
Problems in the Child with
Special Needs
Joan Surfus, OTR/L, SWC
Amy Lynch, MS, OTR/L
Misericordia University
This presentation is made possible, in part, by the
support of the American people through the United
States Agency for International Development (USAID).
The content of this presentation is the sole responsibility
of the author(s) and does not necessarily reflect the
views of USAID or the United States Government.
The opinions and views expressed by the authors in this
document do not necessarily reflect the views and
opinions of KPMG.
Why Is Feeding Important?
Physiological Needs for
Feeding/Eating:
• Sustained nutrition ensures:
• promoting growth
• ensuring energy
• organ system function
• Decreased nutrition can yield:
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hair changes
skin problems
organ malfunction
Decreased energy for activity
participation
Feeding/Eating: Participation in Life
• Skills to promote independent
feeding enable participation in:
• Social functions
• Cultural events
• Relationship building
• Lack of independence in age
typical feeding and eating can
be extremely isolating,
impacting the self esteem of
the individual, the caregiver,
and others in the environment
What is a Feeding Problem??
The inability to consume by mouth,
either in quantity or quality, nutrition
which is developmentally appropriate for
that child.
Implications of Feeding Problems
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Failure to thrive/malnutrition
Nutrient deficiencies
Dependence upon supplemental feeding
Low-self esteem
Low energy for participation in activity
Avoidance of meal
Social isolation for child and family unit
Caregiver and family stress
Assessment of Feeding and
Swallowing Problems
• An interview with the primary caregiver(s)
regarding what and how the child is
eating and drinking is very important.
• Medical information (i.e. frequent
respiratory illnesses, history of poor
weight gain etc.) is also important before
direct contact is made with the child.
Assessment of Feeding and
Swallowing Problems
Based on the information obtained
one or both of the following
assessments are done:
• Videofluoroscopic Swallow Assessment
(VSA) also know as a Modified Barium
Swallow Study
• Informal Swallow Assessment
How Do we Eat?
Dysphagia
• = abnormal swallowing
• May be associated with
aspiration, which is the
passage of food or liquid
into the trachea or lungs
• To address dysphagia,
need understanding of
normal swallow
Stages of Swallowing
Stages of Swallowing:
Oral Preparation
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Voluntary control
Recognition of food/liquid “bolus”
being placed in the mouth
“Chewing” of the bolus in a
cohesive and rotary lateral
manner
Lips seal to control bolus
movement
time for oral preparation stage
varies on consistency
Starts with placement of food in
mouth
Ends when food is formed into a
bolus
Stages of Swallowing: Oral Phase
• Voluntary control
• Amount of time 1-3
seconds
• Starts when tongue lifts up
against alvelor ridge and
begins posterior movement
of the bolus (e.g. front of
mouth to back of mouth)
• Ends with trigger of
pharyngeal swallow at
anterior faucial arches
Stages of Deglutition:
Pharyngeal Phase
• Involuntary control
• Amount of time 1-3
seconds
• As tongue propels bolus to
back of mouth
• Sensory receptors in the
oropharynx and the tongue
itself are stimulated
sending information to
brain about swallowing
Stages of Swallowing:
Pharyngeal Phase (continued)
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Starts with trigger of swallow
at anterior faucial arches
(“bolus head”) reaches the
anterior faucial arches.
Must be effectively
coordinated and have
adequate timing
Ends with opening/relaxation
of the cricopharyngeal
sphincter
****You MUST protect your
airway during this phase****
Stages of Swallowing:
Esophageal Phase
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Involuntary control
Amount of time 8-20 seconds
Starts with contraction of
cricopharyngeus muscle
(UES--upper esophageal
sphincter)
Ends with food entering the
stomach at the LES--lower
esophageal sphincter
Motility of the bolus is
accomplished via the
peristaltic wave
Swallowing Problems
Occur When…
• Inability to maintain adequate nutrition
• Inability to maintain adequate hydration
• Risk of Penetration
• Risk of Aspiration
Videofluoroscopic Swallow
Assessment
• A formal assessment of swallow under
fluoroscopy
• Oral, pharyngeal and esophageal
phases of swallow with different food
and liquid consistencies can be
evaluated.
Videofluoroscopic Swallow
Assessment
The study allows the radiologist and clinician to
• observe the food or liquid as it progresses through all
the stages of swallow.
• identify the presence or absence of penetration
and/or aspiration of food or liquid into the airway
• identify whether silent aspiration is occurring
• determine which strategies may be implemented to
eliminate the risk of aspiration
Example of Adult
Videofluoroscopy
Example of Adult Lateral View –
Videofluoroscopy
Example of Adult AnteriorPosterior View – Videofluoroscopy
Example of Pediatric
Videofluoroscopy
Example of Aspiration
on Videofluoroscopy
Types of Swallowing
Evaluations/Diagnostic Procedures
Videoendoscopy/Flexible Fiberoptic
Endoscopy (FEES/FEEST) (continued)
• Provides direct view of anatomy and has been
shown to detect aspiration and penetration
• “White out” occurs during swallow so unable to
determine what occurs at exact time of swallow
• No radiation exposure
Example of FEES/FEEST
Example of FEES/FEEST
with Food
Clinical Signs & Symptoms
• When you do not have a VideoFluroscopy
• Screening for “high risk” factors
• Often another discipline will identify the
“presence or absence” of symptoms and
make the referral for a clinical bedside
evaluation or diagnostic procedure
conducted by the swallowing therapist
. Medical
Diagnosis Linked To
Feeding Problems
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GER
Constipation
Malabsorption
Esophagitis
Slow Gastric Emptying
Allergies
Celiac Disease
Presence of bacteria, such
as H-pylori, c-diff, etc.
• Gastro-intestinal
obstruction or malrotation
• Metabolic disease
• Bowel disease (such as
Hirshprungs)
• Other organ problems (renal,
liver, etc)
• Metabolic Disorders
• Tracheomalacia
• Respiratory Illness or
Compromise
• Structural Anomalies (cleft,
TEF, etc)
• Trach/Vent
Clinical Signs & Symptoms
of Problems in Feeding
Symptoms
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Poor Oral Feeding
Loss of weight or inability to gain weight
Coughing or choking before, during or after a meal
Weak, ineffective cough
Gargly/gurgly wet sounding voice after swallowing
Residue/pocketing in oral cavity or oral seepage or drooling
Copious secretions/difficulty managing secretions
Oral motor weakness
Difficulty controlling food/chewing
Fullness around sternum/increased time to eat
Clinical Signs & Symptoms
Signs
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History of aspiration pneumonia
Patient complains of swallowing difficulty
Avoidance of certain food consistencies
Food catching in the throat
Takes longer than 10 seconds to swallow a bolus
Decreased appetite/weight loss
Low grade fever (of unknown etiology)
Temperature spikes (especially at night)
Acoustic changes in the lung fields
Chest X-ray findings (RLL infiltrate)
Significant cognitive or visual impairment
Poor cardiopulmonary status/physical endurance
Final Definitions you can use
with Dysphagia
Identification of swallowing “risk factors”
may lead to:
• Aspiration: The entry of liquid or food into
the lower airway, e.g. below the true vocal
folds
• Penetration: The entry of liquid or food into
the laryngeal vestibule but not below the
level of the true vocal folds
Most children with dysphagia are
SILENT aspirators
Medical Diagnosis
Associated with
Swallowing Problems
Infancy and Toddler Years
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Prematurity
Tracheo-Esophogeal Fistula
Mechonium Aspiration
Tracheomalacia
Craniofacial Issues
PVL/ IVH
Tetrology of Fallot/ Cardio-Respiratory problems
SMA/ Neuromuscular Dystrophies
Mitochondrial Disorders
Cystic Fibrosis
GER
Failure to thrive
Down syndrome
Cerebral palsy
School Age and Adolescent Years
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Cerebral Palsy
Down syndrome
Spina bifida
Head Trauma
Oncology Diagnosis – s/p chemotherapy or
radiation or tumor resection
• Psychogenic Dwarfism
• Anorexia/Bulemia
Adult Years with Developmental
Disabilities: Our “Kids” Grow Up!
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Advancing motor involvement
Aging process occurs earlier & at faster rate
Nutritional issues; dehydration; constipation
Strokes
Arthritis
Hypertension
Endocrine Disorders
Dementia
Case Study 1
Group Activity
Starting to Assess Structures
in Feeding:
• Mouth
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Lips
Teeth/Jaw
Cheek
Tongue
• Respiratory
• Positioning
Group Activity:
Introducing Positioning