Assessment of NS includes evaluation of the following: The infant's communication behaviors during feeding can be used as cues to guide dynamic assessment. the impact of feeding and swallowing impairments on. In addition to determining the type of treatment that is optimal for the child with feeding and swallowing problems, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. Neonatal Network, 16, 43–47. Feeding provides children and caregivers with opportunities for communication and social experience that form the basis for future interactions (Lefton-Greif, 2008). Feeding difficulties in craniofacial microsomia: A systematic review. Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. Shaker, C. S. (2013b, February 1). If the child has not eaten by mouth (NPO), the clinician allows a period of time for the child to develop the ability to accept and swallow a bolus. Koudstaal, M. J. Pediatric Dysphagia: Etiologies, Diagnosis, and Management is a comprehensive professional reference on the topic of pediatric feeding and swallowing disorders. Comprehensive coverage addresses the full spectrum of dysphagia to strengthen the care provider’s clinical evaluation and diagnostic decision-making skills. International classification of functioning, disability and health. Behavioral interventions include such techniques as antecedent manipulation, shaping, prompting, modeling, stimulus fading, and differential reinforcement of alternate behavior, as well as implementation of basic mealtime principles (e.g., scheduled mealtimes in a neutral atmosphere with no food rewards). (1998). Pacing—moderating the rate of intake by controlling or titrating the rate of presentation of food or liquid and the time between bites or swallows. (2013). Treatment for dysphagia can come in a number of forms, depending on the specifics of each individual case. socio-emotional factors (e.g., parent–child interactions at mealtimes). § 1400 (2004). Serving as an integral member of an interdisciplinary feeding and swallowing team. The U.S. Food and Drug Administration (FDA) has cautioned consumers about the use of commercial, gum-based thickeners for infants from birth to 1 year of age, especially when the product is used to thicken breast milk. the child's familiar and preferred utensils, if appropriate. Functional assessment of muscles and structures used in swallowing, including assessment of symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement. The goal of a system-supported process is to develop procedures that are consistent throughout a school district. Maneuvers are strategies used to change the timing or strength of movements of swallowing (Logemann, 2000). (2000). Diet modifications incorporate individual and family preferences, to the extent feasible. Consult with families regarding safety of medical treatments, such as swallowing medication in liquid or pill form, which may be contraindicated by the disorder. Imaging tests may also be done to evaluate your child’s mouth, throat and esophagus. Albany, NY: Singular Publishing. In all cases, the SLP must have an accurate understanding of the physiologic mechanism driving the symptomatic feeding problems seen in this population. During an instrumental assessment of swallowing, the clinician may use information from cardiac, respiratory, and oxygen-saturation monitors to monitor any changes to physiologic or behavioral condition. Although feeding, swallowing and dysphagia are not specifically mentioned in IDEA, the U.S. Department of Education acknowledges that chronic health conditions could make a student eligible for special education and related services if the disorder interferes with the student's strength, vitality, or alertness and limits the student's ability to access the educational curriculum. Endoscopy. Additional members can include the school psychologist, social worker, and cafeteria staff. Feeding strategies include pacing and cue-based feeding. Impression of airway adequacy and coordination of respiration and swallowing. (1999). Treatment of your child’s GERD may include: #1 Ranked Children's Hospital by U. S. News & World Report, remaining upright for at least an hour after eating, medications to decrease stomach acid production, medications to help food move through the digestive tract faster, an operation to help keep food and acid in the stomach (fundoplication). § 701 (1973). Neonatal Network, 32, 404–408. Coughing and/or choking during or after swallowing. Treatments can range from behavioral therapy and medications to surgery. The appropriateness of the treatment format often depends on the child's age, the type and severity of the feeding or swallowing problem, and the service delivery setting. Speaker Disclosures: SLPs treating preterm and medically fragile infants must be well versed in typical infant behavior and development so that they can recognize and interpret changes in behavior that provide cues that signal well-being or stress during feeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 25, 771–776. Other benefits of KMC include temperature regulation, promotion of breastfeeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability. (2017). Therefore, childhood swallowing difficulties must be diagnosed accurately and … Becker, A. E. (2015). Jacques, D. C. (2013). 4. 308 Racebrook Rd. Your child is given a liquid containing barium to drink and a series of x-rays are taken. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5. Methods Program Development The telepractice program presented herein is part of a dedicated Dysphagia Research Clinic (DRC) housed No single posture will provide improvement to all individuals, and, in fact, postural changes differ between infants and older children. MCN: The American Journal of Maternal/Child Nursing, 41, 230–236. Anatomical and physiological differences include the following: Chewing matures as the child develops (see e.g., Gisel, 1988; Le Révérend, Edelson, & Loret, 2014; Wilson, & Green, 2009). Newman, L. A., Keckley, C., Petersen, M. C., & Hamner, A. Walsh, B. T. (2014). Some maneuvers require following multistep directions and may not be appropriate for young children and/or older children with cognitive impairments. Behavioral state activity during nipple feedings for preterm infants. ... Orange Pediatric Therapy. Anatomical, functional, physiological and behavioural aspects of the development of mastication in early childhood. Treatment of Pediatric Swallowing Disorders ***** DISCLAIMER The information in these notes were developed from the three primary sources cited below. The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. Disorders associated with pediatric swallowing issues. See the Service Delivery section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives. Format refers to the structure of the treatment session (e.g., group and/or individual). B. Gisel, E. G., Applegate-Ferrante, T., Benson, J., & Bosma, J. F. (1996). Cue-based feeding in the NICU: Using the infant's communication as a guide. Imaging studies, such as chest radiographs and computed tomography of the chest, are not specifically used for diagnosis of aspiration, but can show evidence of damage suggestive of aspiration, and can also be useful in determining the extent of lung injury from chronic aspiration. These therapists can give your child exercises to help make swallowing more effective, or suggest techniques for feeding that may help improve swallowing problems. In addition to the SLP, team members may include. Evaluating Recovery From Dysphagia. Intraoral prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize the intraoral cavity by providing compensation or physical support for children with congenital abnormalities (e.g., cleft palate) or damage to the oropharyngeal mechanism. See ASHA's resources on dysphagia teams, interprofessional education/interprofessional practice [IPE/IPP], and person- and family-centered care. Observation of head–neck control, posture, oral and pharyngeal reflexes, and involuntary movements and responses in the context of the child's developmental level. Questions to ask when developing an appropriate treatment plan within the ICF framework include: Consider the child's pulmonary status, nutritional status, overall medical condition, mobility, swallowing abilities and cognition, in addition to the child's swallowing function and how these factors affect feeding efficiency and safety. Awareness of the prevalence of pediatric dysphagia in today's population and the signs and symptoms of this condition aids in its treatment. Our Pediatric Dysphagia treatment service manage children with speech and language delays, Speech Apraxia, Swallowing problems, Poor Oro-motor skills, Stutter/Stammer etc. The SLP who specializes in feeding and swallowing disorders typically leads the professional care team in the clinical or educational setting. Pediatrics, 135, e1467-e1474. The ASHA Leader, 18, 42–47. . (. Treatment for dysphagia depends on the cause of the condition. If the dysphagia is severe, another source of nutrition and hydration, such as a feeding tube, may be needed. Provider refers to the person providing treatment (e.g., SLP, occupational therapist, or other feeding specialist). de Vries, I. In many NICUs, it is a unilateral decision on the part of the neonatologist; in others, the SLP, neonatologist, and nursing staff share observations during their assessments of readiness for oral feedings. Students must be healthy (e.g., free from aspiration pneumonia or other illnesses related to malnutrition or dehydration) to maximize their attendance at school. Feeding is the process involving any aspect of eating or drinking, including gathering and preparing food and liquid for intake, sucking or chewing, and swallowing (Arvedson & Brodsky, 2002). Management of swallowing and feeding disorders in schools. Feeding disorders can be characterized by one or more of the following behaviors: Swallowing disorders (dysphagia) can occur in one or more of the four phases of swallowing and can result in aspiration—the passage of food, liquid, or saliva into the trachea—and retrograde flow of food into the nasal cavity. Your doctor will likely perform a physical examination and may use a variety of tests to determine the cause of your swallowing problem.Tests may include: 1. Keep in mind that infants and young children with feeding and swallowing disorders, as well as some older children with concomitant intellectual disabilities, often need intervention techniques that do not require them to follow simple verbal or nonverbal instructions. You drink a barium solution that coats your esophagus, allowing it to show up better on X-rays. How can the child's functional abilities be maximized? Considering culture as it pertains to food choices, perception of disabilities, and beliefs about intervention (Davis-McFarland, 2008). Modifications to positioning are made as needed and are documented as part of the assessment findings. Students must be safe while eating in school, including having access to appropriate personnel, food, and procedures to minimize risks for choking and for aspiration while eating. Clinicians will discuss this with the medical team in order to determine options, including temporary removal of the feeding tube and/or use of another means of swallowing assessment. . Similar to treatment for infants in the NICU, treatment for toddlers and older children takes a number of factors into consideration, including the following: Management of students with feeding and swallowing disorders in the schools addresses the impact of the disorder on the student's educational performance and promotes the student's safe swallow in order to avoid choking and/or aspiration pneumonia. Scope of practice in speech-language pathology [Scope of Practice]. Oral–motor treatments are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b). Evaluation and treatment of swallowing disorders. Appropriate roles for SLPs include the following: Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children. Feeding protocols include those that consider infant cues (i.e., responsive feeding) and those that are based on a schedule (i.e., scheduled feeding). SLPs should be aware of these cautions and consult as appropriate with their facility to develop guidelines for using thickened liquids with infants. Protocols for determining readiness for oral feeding and specific criteria for initiating feeding vary across facilities. Brian B. Shulman, vice president for professional practices in speech-language pathology, served as the monitoring officer. This test uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of your child’s digestive tract. See figures below. The family's customs and traditions around mealtimes and food should be respected and explored. They may also change the type of cup or bottle your child is eating or drinking from. Assessment of developmentally appropriate secretion management, which might include frequency and adequacy of spontaneous dry swallowing and ability to swallow voluntarily. The infant's ability to turn the head and open the mouth (rooting) when stimulated on the lips or cheeks and to accept a pacifier into the mouth. Treatment depends on the cause. She consults to organizations worldwide to create and train for treatment. changes in normal heart rate (bradycardia or tachycardia); skin color change such as turning blue around the lips, nose and fingers/toes (cyanosis); temporary cessation of breathing (apnea); frequent stopping due to uncoordinated suck-swallow-breathe pattern; and. Foods given during the assessment should be consistent with the child's current level of chewing skills. Discuss key elements of a multidisciplinary and tiered framework for pediatric feeding and swallowing Functional assessment of swallowing ability, including but not limited to typical developmental skills and task components—suckling and sucking in infants, mastication in older children, oral containment, and manipulation and transfer of the bolus. A prospective, longitudinal study of feeding skills in a cohort of babies with cleft conditions. Infants are obligate nasal breathers, and compromised breathing may result from the placement of a fiberoptic endoscope in one nostril when a nasogastric tube is in place in the other nostril. Families may have strong beliefs about the medicinal value of some foods or liquids. complex medical conditions (e.g., heart disease, pulmonary disease, gastroesophageal reflux disease [GERD], delayed gastric emptying); developmental disability (i.e., disability with onset before the age of 22 that warrants lifelong or extended medical, therapeutic, and/or residential supports and is attributable to a mental or physical impairment or a combination of mental and physical impairments); factors affecting neuromuscular coordination (e.g., prematurity, low birth weight, hypotonia, hypertonia); genetic syndromes (e.g., Down syndrome, Pierre Robin Sequence, Prader–Willi, Rett syndrome, Treacher Collins syndrome, 22q11 deletion); medication side effects (e.g., lethargy, decreased appetite); neurological disorders (e.g., cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, muscle weakness in face and neck); sensory issues as a primary cause or secondary to limited food availability in early development (e.g., in children adopted from institutionalized care; Beckett et al., 2002, Johnson & Dole, 1999); structural abnormalities (e.g., cleft lip and/or palate and other craniofacial abnormalities, laryngomalacia, tracheoesophageal fistula, esophageal atresia, choanal atresia); behavioral factors (e.g., food refusal); and. Careful pulmonary monitoring during a modified barium swallow is essential to help determine the child's endurance over a typical mealtime. San Antonio, TX: Communication Skill Builders. Experts in pediatric dysphagia have reported on the basic elements of a clinical assessment. Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors. Determining the appropriate procedure to use depends on what needs to be visualized and which procedure will be best tolerated by the child. Treatment for Dysphagia. Disability and Rehabilitation, 30, 1131–1138. The SLP providing and facilitating oral experiences with NNS must take great care to ensure that the experiences are positive and do not elicit stress or other negative consequences. Anatomic differences between adults and children and why they are significant. NS skills are assessed during breastfeeding and bottle feeding, if both modes are going to be used. This presentation will provide a review of 2 case studies to demonstrate the nuance of evaluation and treatment of complex patients with pediatric dysphagia. Once the infant begins eating pureed food, each swallow is discrete, and the oral and pharyngeal phases are similar to those of an adult (although with less elevation of the larynx). Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., . The clinician provides families and caregivers with information about dysphagia, the purpose for the study, the test procedures, and the test environment. Gisel, E. G. (1988). Anxiety may be reduced by using distraction (e.g., videos), allowing the child to sit on the parent's or caregiver's lap (for FEES procedures), and decreasing the number of observers in the room. Francis, Krishnaswami, & McPheeters, 2015; Webb, Hao, & Hong, 2013); the identification of additional disorders that may have an impact on feeding and swallowing; a determination of the optimal feeding method; an assessment of duration of mealtime experience, including the need for supplemental oxygen; an assessment of issues related to fatigue and volume limitations; an assessment of the effectiveness of parent/caregiver and infant interactions for feeding and communication; and. Treatment. The physician can watch what happens as your child swallows the fluid, and note any problems that may occur in the throat, esophagus or stomach. Multiple radiographic studies are used to diagnose aspiration and dysphagia in children. Typical modifications may include thickening thin liquids, softening, cutting/chopping, or pureeing solid foods. Eddy, K. T., Thomas, J. J., Hastings, E., Edkins, K., Lamont, E., Nevins, C. M., . [5] Arvedson J. Consider tube feeding schedule, type of pump, rate, calories, and so forth. For procedures that involve presentation of a solid and/or liquid bolus, the clinician instructs the family to schedule meals and snacks so that the child will be hungry and more likely to accept foods as needed for the study. Infants and Young Children, 8, 58–64. being familiar with and using information from diagnostic procedures performed by different medical specialists that yield information about swallowing function—these procedures include manofluorography, cervical auscultation, scintigraphy (which in the pediatric population may also be referred to as radionuclide milk scanning), pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy. Feeding and eating disorders [DSM-5 Selections]. Infants under 6 months of age typically require head, neck, and trunk support. Medical, surgical, and nutritional considerations are important components in treatment planning. 5. Key points about dysphagia in children. In the NICU, the SLP plays a critical role, supporting parents and other caregivers to understand and respond accordingly to the infant's communication during feeding. The incidence of feeding and swallowing disorders refers to the number of new cases identified in a specified time period. The odds of having a feeding problem increase by 5 times in children with autism spectrum disorder (ASD) compared with children who do not have ASD (Sharp et al., 2013). Pediatric dysphagia is a clinical problem that crosses disciplines. Providing prevention information to families of children at risk for pediatric feeding and swallowing disorders as well as to individuals working with those at risk. Other Maneuvers and Techniques. A team approach is necessary for appropriately diagnosing and managing pediatric feeding and swallowing disorders, as the severity and complexity of these disorder vary widely in this population (McComish et al., 2016). ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Pediatric Dysphagia page: In addition, ASHA thanks the members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU); Special Interest Division 13, Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training; and the Working Group on Dysphagia in Schools, whose work was foundational to the development of this content. Such beliefs and holistic healing practices may not be consistent with recommendations made and may be contraindicated. In these cases, intervention might consist of changes in the environment or indirect treatment approaches for improving safety and efficiency of feeding. A child who struggles to prepare (chew) food or liquid in their mouth and swallow it may have a feeding disorder. Concurrent medical issues may affect this timeline. The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 211,000 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students. With this support, swallowing efficiency and function may be improved. These tests can include: Video swallow study. Participating in decisions regarding the appropriateness of instrumental evaluation procedures and follow-up. ... Orange Pediatric Therapy. It’s that time of year again- back to school and back to frequent testing for school age children. Decisions regarding the initiation of oral feeding will be based on recommendations from the medical and therapeutic team with input from the parent and caregivers. International Journal of Rehabilitation Research, 33, 218–224. A. Treatment depends on the cause. Breathing difficulties when feeding that might be signaled by. See ASHA's resources on interprofessional education/interprofessional practice (IPE/IPP) and collaboration and teaming for guidance on successful collaborative service delivery across settings. assessment of pediatric oropharyngeal dysphagia If you suspect that your child may have a problem with bottle/cup drinking, eating, or swallowing, contact your pediatrician, who will refer you to a speech-language pathologist specializing in feeding and swallowing disorders. SLPs should have extensive knowledge of embryology, pre-natal and perinatal development, and medical issues common to the preterm and medically fragile newborn as well as knowledge of typical early infant development. Otolaryngologic clinics of North America. Dysphagia in pediatrics involves feeding (accepting and preparing food orally), and swallowing (transporting food from the mouth to the stomach). An estimated 116,000 newborn infants are discharged from short-stay hospitals with a diagnosis of feeding problems, according to the. Precautions, accommodations, and adaptations must be considered and implemented as students transition to post-secondary settings. 3. Observation of the child eating or being fed by a family member or caregiver using foods from the home and typically used utensils as well as utensils that the child may reject or that may be challenging. Students must be adequately nourished and hydrated so that they can attend to and fully access the school curriculum. San Diego, CA: Plural. Therapy techniques that are used to assist with bolus management can be developed to help children be more successful eaters. The SLP or radiology technician typically prepares and presents the barium items, whereas the radiologist records the swallow for visualization and analysis. Pediatric Pulmonology, 41, 1040–1048. If a natural feeding process (e.g., position, caregiver involvement, and use of familiar foods) cannot be achieved, the results may not represent typical swallow function, and the study may need to be terminated, with results interpreted with caution. Taking only small amounts of food, overpacking the mouth, and/or pocketing foods. feeding and swallowing problems that persist into adulthood, including the risk for choking, malnutrition, or undernutrition. For children who have been NPO for an extended period of time, it is important to consult with the physician to determine when to begin oral feeding. Arvedson, J. C., & Brodsky, L. (2002). Dysphagia in pediatric populations can result in multiple adverse health outcomes. World Health Organization. If your child also has symptoms of GERD along with dysphagia, treating this condition may produce improvements in your child’s ability to swallow. Setting Tertiary care pediatric otolaryngology practice.. Know the conditions predisposing to dysphagia and aspiration in children. Nutricion Hospitalaria, 29, 32–37. Signs & symptoms of dysphagia Early identification and treatment (Tx) may help avoid adverse medical complications such as under nutrition or respiratory infection. The SLP also teaches parents and other caregivers to provide positive oral experiences and to recognize and interpret the infant's cues during NNS. Lefton-Greif, M. A., McGrattan, K. E., Carson, K. A., Pinto, J. M., Wright, J. M., & Martin-Harris, B. physician (e.g., pediatrician, neonatologist, otolaryngologist, gastroenterologist); Case history, based on a comprehensive review of medical/ clinical records, as well as interviews with the family and other health care professionals. Available from www.asha.org/policy/. Small tissue samples, called biopsies, can also be taken to look for problems. See the Assessment section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives. The NICU is considered an advanced practice area, and inexperienced SLPs should be aware of the risks of working in this setting. Feeding and Swallowing. Additional medical and rehabilitation specialists may be included, depending on the type of facility, the professional expertise needed, and the specific population being served. How is Pediatric Dysphagia (Swallowing Disorder) treated? McComish, C., Brackett, K., Kelly, M., Hall, C., Wallace, S., & Powell, V. (2016). Clinical Oral Investigations, 18, 1507–1515. Consider how long it takes to eat a meal, fear of eating, pleasure obtained from eating, social interactions while eating, and so on (Huckabee & Pelletier, 1999). The Rehabilitation Act of 1973, Section 504. The hyoid bone and larynx are positioned higher than in adults, and the larynx elevates less than in adults during the pharyngeal phase of the swallow. Feeding and gastrointestinal problems in children with cerebral palsy. Available from www.asha.org/policy/. Interpreting the complex information collected during these assessments and forming a treatment plan that is functional during the home program can be challenging. Members of the Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training included Caryn Easterling, Maureen Lefton-Greif, Paula Sullivan, Nancy Swigert, and Janet Brown (ASHA staff liaison). Arvedson, J. C., & Lefton-Greif, M. A. Surgery for Chronic Aspiration. use of intervention probes to identify strategies that might improve function. Francis D. O., Krishnaswami S., & McPheeters M. (2015). . The infant's oral structures and functions, including palatal integrity, jaw movement, and tongue movements for cupping and compression. aspiration pneumonia and/or compromised pulmonary status; gastrointestinal complications such as motility disorders, constipation, and diarrhea; poor weight gain velocity and/or undernutrition; rumination disorder (unintentional and reflexive regurgitation of undigested food that may involve re-chewing and re-swallowing of the food); ongoing need for enteral (gastrointestinal) or parenteral (intravenous) nutrition; psychosocial effects on the child and his or her family; and. Collaboration with outside medical professionals is indicated when medical clearance is needed for an assessment and/or intervention for a student who. Strategies that slow the feeding rate may allow for more time between swallows to clear the bolus and may support more timely breaths. 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