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Feeding & Swallowing Disorders inToddlers

ASHA Online ConferenceBirth to Three: Working Together to Serve Children and TheirFamilies 1


Memorie M. Gosa, PhD, CCC-SLP, BCS-S

[email protected]

Disclosures

• Financial

– Employee of The University of Alabama, Druid City Hospital,Le Bonheur Children’s Hospital

– Grant funding from ASHFoundation New Investigator Grant

– Financial compensation from ASHA for this presentation

• Nonfinancial

– Chairperson of the American Board of Swallowing andSwallowing Disorders

• No conflicts of interest to disclose



Learning Objectives

You will be able to:

• Name the seven evaluation areas for clinical feedingassessment in toddlers

• Describe the intervention options available to treat feedingand swallowing disorders in toddlers

Typical Feeding/Swallowing DevelopmentTypical Feeding/Swallowing Development

Evaluation Areas for Clinical AssessmentEvaluation Areas for Clinical Assessment

Treatment Options & Evidence to SupportTreatment Options & Evidence to Support

Presentation Road Map



Feeding & Swallowing Development

Feeding Progression



Pediatric Swallowing Anatomy

Pediatric Swallowing Physiology

• Obligate nasal breathers

• Absence of oral preparatory phase – continuous with oraltransit

• Pharyngeal swallows are more frequent

• Less hyolaryngeal excursion

• Commonly trigger swallow at valleculae

• Residue in valleculae is common

(Newman, 2001)



Swallowing Physiology Differences

Infants

• Volume per swallow: 0.2 ml(+/- 0.11 ml)

• 300 sucking & swallowingmotions to drink 1 ounce

Older Children/Adults

• Volume per swallow 20 ml-25 ml

(Morris & Klein, 2000)

Nipple Feeding

• Alterations of:

– Compression (+pressure)

– Expression (-pressure)Suction: Creation of negativeintraoral pressure

– Together, these draw milkinside the oral cavity



Airway Protection

• Airway protection accomplished by:

– Elevation of larynx under base of tongue

– Anterior movement of the arytenoids toward the base of theepiglottis

– ??Epiglottic deflection??

(Thach, 2001, 2007; Crompton et al., 2008; Rommel, 2002)

Airway Protection, Cough

• Cough reflex

– Newborn, poorly developed

– More common to have period of apnea, then swallow, possiblecough after swallow

(Thach, 2007)



Sucking, Swallowing, & Breathing

• Suckle-swallow-breathe

– Suckle and swallow 1:1

– 10-30 times before taking a breath and continuing

– More likely, suckle*swallow*breathe ratio is 1:1:1

– After bolus leaves the pharynx, air flows in (through) the noseand is followed by next S:S:B sequence

(Wilson et al., 1981; Gewolb et al., 2001)

Transition to Sucking and Spoon Feeding:4–6 Months of Age



Transition to Chewing: 7–9 Months of Age

Transition to Regular Diet: 9–12 Months of Age



Refinement of Oral Skills: 12–24 Months of Age

Behavioral Development

Sensorimotor

Birth–2

Preoperational

2–7

(Dodrill, 2016)



Evaluation Areas for Clinical Assessment

Clinical FeedingAssessment

1. History/CurrentFunctioning Status

2. Parent/Child Interactions3. Child Feeding Behaviors4. Oral Mechanism Exam5. Feeding Skill Assessment6. Sensory Assessment7. Nutrition/Growth

(Arvedson, 2008; Dodrill &Gosa, 2015; Piazza, 2004)



History & Current Functioning

• Birth history

• Medical history– Neurologic Hx

– Cardiac Hx

– Respiratory/airway Hx

– GI Hx

– Renal Hx

– Craniofacial Hx

– Hemolytic Hx

• Feeding history

• Allergies/intolerances

• Medications

• Weight/height growth charts

http://www.asha.org/Practice-Portal/Templates/

Parent/Child Interactions

Antecedent (Caregiver)

Verbal/Physical

Behavior (Child)

Verbal/Physical/Escape/Withdrawal

Consequence (Caregiver)

Verbal/Physical/Escape/Withdraw

(Marshall et al., 2014)



Child’s Feeding Behaviors

• Behavioral Pediatric Feeding Assessment Scale (BPFAS)

– Valid tool for identifying childhood feeding difficulties

– High reliability and specificity

– Parent questionnaire

– Typically developing children display few undesirablefeeding behaviors & few behaviors are perceived asproblems by parents

– Children with a large number of feeding problems on thisparent-reported measure need further multidisciplinaryevaluation

(Crist & Napier-Phillips, 2001)

Oral Mech Exam

• Oral anatomy– Lips, palate, tongue, jaw, teeth, cheeks

– Structures are complete, symmetrical, appropriate size, tone,range of motion

• Oral reflexes– Adaptive reflexes, protective reflexes

• Oral motor control– Assess with non-nutritive & (when possible) nutritive tasks to

determine function of oral structures

• Oral sensory processing– Assess response to touch in and around oral cavity, response to

various sensory-diverse foods

– Typical, hypersensitive, or hyposensitive



Quality of Feeding Skill Assessments

• Three basic elements of quality for an assessment

– Reliability: Measure of assessment’sconsistency

– Validity: Measure of an assessment’susefulness

– Standardization: Provides a mean (average)and standard deviation (spread) of assessmentscores

Available Feeding Skill Assessments



Infant Feeding Skill Assessments

• 11 tools identified

• Early Feeding Skills (EFS): Assessment has most supportivepsychometric development and testing for assessment ofbottle- and breastfeeding in preterm infants through 52 weeksPMA & full-term infants with significant feeding difficulties

• Bristol Breastfeeding Assessment Tool (BBAT): Has the mostpsychometric support for assessment of breastfeeding inhealthy, full-term infants with minor feeding difficulties

Pediatric Feeding Skill Assessments

• 30 tools identified– 11 caregiver, 18 clinician, 1 caregiver or clinician

• Schedule for Oral Motor Assessment (SOMA)– Observation, infants and children 0–2 years old– Scales: Puree, semi-solid, solid, cracker, bottle, trainer cup, and cup– Mixed response scoring options– 15–20 minutes– Formal training required

• Dysphagia Disorder Survey (DDS)– Observation, children w/ DD 2–21 years old– Scales: Related factors (7), feeding/swallowing competency (8)– Binary scoring– 10–15 minutes– Formal training required



Typical Outcomes Documented FromNonstandardized Feeding Skill Assessments

Volume ofIntake

Duration ofFeeding

Fussing/Refusal During

Feeding

PhysiologicMeasures

Stage of OralMotor

Development

Signs ofPossible

Aspiration

Sensory Assessment

• Sensory Profile

– Dunn (2002)

– Published assessment

– Standardized, reliable

– Used in several published studies

– Parent completed

– OTs assist with interpretation



Sensory Assessment, Sensory Profile

• Infant/Toddler Sensory Profile

– Assessment covers 6 sections• General Processing, Auditory Processing, Visual Processing,

Tactile Processing, Vestibular Processing, and Oral SensoryProcessing

– Results are grouped into 4 quadrants• The quadrant scores reflect the child's responsiveness to

sensory experiences, and are based on Dunn's Model ofSensory Processing

• Sensation Seeking and Low Registration indicate different high-threshold responses

• Sensory Sensitivity and Sensation Avoiding reflect different low-threshold responses

Nutrition & Growth

• 24-hour diet recall

– Amount of intake

– Type of intake

– Texture of intake

– Frequency of feeds

– Duration of feeds

– Dietitian for advice regarding nutrient, energy, and fluid needs

• Anthropometric measurement

– Height and weight measured using standardized method

– Computation of BMI

– Plotting on growth chart



Treatment Options & Evidence to Support

Multidisciplinary Management

Speech-Language

Pathologist

Speech-Language

Pathologist

DieticianDietician

PCPPCP

OT,PT,

Teacher

OT,PT,

Teacher

GI,Pulmonology,

Psychology

GI,Pulmonology,

Psychology

Social WorkerSocial Worker

PedsDysphagiaTreatment



SuccessfulFeeding

SuccessfulFeeding

MedicalManagement

MedicalManagement

NutritionNutrition

SkillSkill

EnvironmentEnvironment

BehaviorBehavior

Management Considerations

• Oral motor interventions (OMI) include exercises andactivities designed to influence the actions of the tongue, lips,soft palate, jaws, larynx, and/or respiratory muscles forimproved strength, tone, range of motion, or coordinationduring feeding/swallowing and include traditional muscleexercises (active or passive), stretching, and/or sensorystimulation to the articulators and related structures

Treatment: Motor/Skill, Definition

(Gosa & Dodrill, 2017)



Treatment: Motor/Skill, Examples

(Gosa & Dodrill, 2017)

Treatment: Motor/Skill, Goals

• Goals of oral motor or oral sensory motor interventionsinclude

– Assisting an individual in reaching their maximal functionalcapacity for feeding/swallowing/speech

• Target areas include:

– Oral structures (lips, tongue, cheeks, jaw, palate)

– Specific feeding skill (lip closure, jaw opening/closing, tonguelateralization)

– Neck, chest, posture, respiration



Treatment: Motor/Skill, Evidence

Treatment: Motor/Skill, Evidence (Cont’d)



Treatment: Behavioral Interventions

Medical Skill Behavioral

(Rommel et al., 2003)

Treatment: Behavioral Interventions, ABC

• Antecedent

– Prompt: Verbal, visual, tactile

• Behavior

– Desirable vs. undesirable

• Consequence

– Reinforcement – increases the likelihood of a behaviorhappening again

– Punishment – decreases the likelihood of a behavior happeningagain



Treatment: Behavioral Approaches, OC

• Operant Conditioning (OC) Therapy Approach

– Goal is to change behaviors related to eating

– Typically incorporates information on general parenting skills

Treatment: Behavioral Approaches, SD

• Systematic Desensitization (SD) Therapy Approach

– Goal is to improve willingness to interact with food

– Also incorporates information on general parenting skills

https://theoriesinpsychologyf10.wikispaces.com/file/view/Desensitization.gif/177474605/Desensitization.gif



Treatment: Behavioral Approaches, Evidence

What is the effect of behavioral-based interventions (includingapproaches that incorporate techniques with elements fromoperant conditioning, systematic desensitization, etc. …) onfunctional oral feeding outcomes in children?

• 37 studies

• 919 pooled participants, 86% were between 2 and 7 yearsold

• 70% were small sample size (N of 1–13), 30% had samplesizes of 24–490

Treatment: Comparison of Behavioral Approaches

• Determine whether OC or SD intervention results ingreater improvements in dietary variety/intake andgreater reductions in difficult mealtime behaviors

• Children, 2-6 years w/ ASD or NMC randomized toreceive 10 OC or SD sessions at 1x/week or for 1week




Treatment: Comparison of OC & SD

• In OC group:

• Trend toward greater increase in total number of foodsconsumed & total number of unprocessed fruits andvegetables

• In SD group:

• Trend toward greater reduction of difficult mealtimebehaviors


Treatment: Mixed Modality Approaches, Evidence

What is the effect of applying mixed modality interventions onfunctional oral feeding outcomes in children?



Treatment: Mixed Modality Approaches, Evidence(Cont’d)

• 23 of the 61 studies

• 395 pooled participants; majority of studies featured smallsample sizes (less than 10 participants)

• 95% of participants were between 2 and 10 years of age

• Mixed diagnostic population that included Down syndrome,ASD, Goldenhar syndrome, Rett syndrome, CP, rubellasyndrome, & feeding complications due to major organsystem impairments

• Included: Behavioral & OMI; behavioral & sensoryinterventions; behavioral, OMI, & sensory

(Gosa et al., 2017)

Treatment: Evidence Conclusions

• From this EBSR, clinicians recognize the importance ofbehavioral therapy techniques for remediating feedingdisorders (60/61 articles)

• Lack of evidence to support the singular use of OMI

• Moderate amounts of published evidence to support the useof behavioral interventions (37/61 articles) and the use ofmixed method interventions (23/61 articles)

• Various levels of evidence available to support the use ofbehavioral (32/37, 86% were found to be phase one research)and combined treatment options (all phase one research)

(Gosa et al., 2017)



Go Do

• Consider how your facility performs pediatric clinical feedingassessments:

– Are you using clinically validated instruments?

– Is there a standardized approach to the assessment?

– What types of treatment are being offered?

– How is training provided within your facility?

• Considering your answers to the above questions, evaluatewhat (if any) changes should be implemented to improve thestandard of care for toddlers with feeding and swallowingissues

• Collaborate with multidisciplinary partners to implementquality improvement changes within your facility

Feeding & Swallowing Disorders in Toddlers, by Memorie Gosa

ASHA Online Conference Birth to Three: Working Together to Serve Children and Their Families

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Feeding & Swallowing Disorders in Toddlers, by Memorie Gosa

ASHA Online Conference Birth to Three: Working Together to Serve Children and Their Families

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