Family Based Management Family Based Management of Dysphagia in Pediatric of Dysphagia in Pediatric

PatientsPatientsNiki Carder M.A., CCC-SLPNiki Carder M.A., CCC-SLP

Decrease stressDecrease stress

• Place emphasis in decreasing the child’s Place emphasis in decreasing the child’s stress signals while facilitating the child stress signals while facilitating the child in his attempts to interact with his in his attempts to interact with his environment. environment.

• The child is an The child is an active participant active participant in his own in his own development. Let’s not do therapy “to” development. Let’s not do therapy “to” the child.the child.

• Reduce the ways the child’s fragileReduce the ways the child’s fragile resources are challenged during care…resources are challenged during care…ventilation ability, engaged learning ventilation ability, engaged learning opportunities, and muscular endurance.opportunities, and muscular endurance.

Increase Fun!!Increase Fun!!

Typical developmental challenges:Typical developmental challenges:

1. hunger1. hunger

2. fatigue2. fatigue

3. boredom3. boredom

4. separation anxiety4. separation anxiety

Increase Fun!!Increase Fun!!

Challenges for kids with developmental delays:Challenges for kids with developmental delays:

1. Oxygen deprivation1. Oxygen deprivation

2. Cardiac fatigue2. Cardiac fatigue

3. Chronic pain3. Chronic pain

4. Procedure anxiety4. Procedure anxiety

5. Sensory dysfunction5. Sensory dysfunction

We need to work TWICE as hard at having fun!We need to work TWICE as hard at having fun!

Let’s EvaluateLet’s Evaluate

Family FriendlyFamily Friendly

1.1. Just TALK to the parents…we are Just TALK to the parents…we are communication specialists!communication specialists!

2.2. Use the floor whenever possible. It’s Use the floor whenever possible. It’s harder for the parents to separate from harder for the parents to separate from you there. (bean bags, pillows, stools, etc.)you there. (bean bags, pillows, stools, etc.)

3.3. Build language into the dysphagia session. Build language into the dysphagia session. (nursery rhymes, a picture book, finger (nursery rhymes, a picture book, finger plays)plays)

4.4. End with the parent doing something End with the parent doing something successful with the child.successful with the child.

HistoryHistory

• Day time routineDay time routine• MedicationsMedications• Previous illnessesPrevious illnesses

– Bronchopulmonary Dysplasia (5,000 – Bronchopulmonary Dysplasia (5,000 – 10,000/yr)10,000/yr)

– Necrotizing Enterocolitis (20%-40% die)Necrotizing Enterocolitis (20%-40% die)– Intraventricular HemorrhageIntraventricular Hemorrhage– Gastroesophageal RefluxGastroesophageal Reflux– Neonatal Abstinence SyndromeNeonatal Abstinence Syndrome– Congenital heart defectCongenital heart defect

Persistence of primitive Persistence of primitive reflexesreflexes

• Major diagnostic indicator of long-Major diagnostic indicator of long-term problemterm problem– Tonic biteTonic bite– RootingRooting– Asymmetric tonic neck (ATNR)Asymmetric tonic neck (ATNR)– RightingRighting– Moro – startle reflex (4 to 5 months old)Moro – startle reflex (4 to 5 months old)– LandauLandau

Assess…treat…assess…Assess…treat…assess…treat…treat…

STATE and SUPPORT SYSTEMSTATE and SUPPORT SYSTEM• Drowsy, alert, calm, active, asleepDrowsy, alert, calm, active, asleep• Unaware, agitated?Unaware, agitated?• Hypertonic? Hypotonic?Hypertonic? Hypotonic?• Head control? Sitter? Roller? Head control? Sitter? Roller?

Crawler? Walker? Crawler? Walker? • Try to duplicate a typical feeding Try to duplicate a typical feeding

experience.experience.

Respiratory systemRespiratory system

• Need before/after measurements of Need before/after measurements of W.O.B.W.O.B.

• Respiratory rate Respiratory rate – Infants: 30-80bpmInfants: 30-80bpm– 3 year old: 20-30 bpm3 year old: 20-30 bpm– 10 year old: 17-22bpm10 year old: 17-22bpm

• Supplementary O2 needs, delivery methodSupplementary O2 needs, delivery method– Nasal cannulaNasal cannula– High flow nasal cannulaHigh flow nasal cannula– Tracheostomy (with/without PMSV)Tracheostomy (with/without PMSV)– Ventilator supportVentilator support

PositioningPositioning

• Feet on stable surfaceFeet on stable surface• Head/neck/trunk alignmentHead/neck/trunk alignment• Decrease elevated shouldersDecrease elevated shoulders• Hands toward midlineHands toward midline• Slight chin tuckSlight chin tuck• Chair, lap, bean bag, tumbleform, Chair, lap, bean bag, tumbleform,

sidelyingsidelying• If GER, remain at 35-45 mins after If GER, remain at 35-45 mins after

feedingfeeding

Set the stage for successSet the stage for success

• After assessing the sensory system, choose After assessing the sensory system, choose alerting or calming foods depending on the alerting or calming foods depending on the sensation need and muscular ability.sensation need and muscular ability.

• Provide sensory information, then show the Provide sensory information, then show the child how to do something functional with child how to do something functional with it.it.

• A pleasurable feeding experience is always A pleasurable feeding experience is always the GOAL.the GOAL.

Bolus characteristic, Bolus characteristic, consider…consider…

• SizeSize• ConsistencyConsistency• Placement within Placement within

oral cavityoral cavity• Rate of Rate of

presentationpresentation• Moldability and Moldability and

flow of materialflow of material

• Increase viscosity Increase viscosity to increase sensory to increase sensory awareness.awareness.

• Decrease viscosity Decrease viscosity if poor pharyngeal if poor pharyngeal motilitymotility

• Increase bolus size Increase bolus size if poor sensory if poor sensory awareness, but awareness, but consider aspiration consider aspiration risk.risk.

UtensilsUtensils

CUPSCUPS– Nosey cups – Clear cups– Spouted– Straw…short/long– Sip-tip (for

muscular prob.)– Open rim

SPOONSSPOONS- flat bowlflat bowl- Coated Coated - Beckman “E-Z” Beckman “E-Z”

spoonspoon- Self feeder spoonSelf feeder spoon

Hypo-sensitiveHypo-sensitive

• Swinging, jumping, Swinging, jumping, topsy-turvytopsy-turvy

• Consider joint Consider joint compressionscompressions

• Brisk, firm touchBrisk, firm touch• IcingIcing• VibrationVibration• Electrical StimulationElectrical Stimulation• Vital StimulationVital Stimulation

Pre-feeding Pre-feeding InterventionsInterventions

Start with a clean mouth!!!Start with a clean mouth!!!• ROMROM• Quick stretch Quick stretch • Icy teether / cheeseclothIcy teether / cheesecloth• Pacifier Pacifier • Cold coated spoonCold coated spoon• Cold drinkCold drink• Crunchy foodCrunchy food• Sour, Tangy, SpicySour, Tangy, Spicy

Hyper-sensitiveHyper-sensitive

• Increase flexionIncrease flexion• Soft music/ singingSoft music/ singing• Slow, firm touchSlow, firm touch• Consider joint Consider joint

compressions and compressions and massagemassage

• Warm surfacesWarm surfaces• In order to learn, keep In order to learn, keep

calm, alert statecalm, alert state

Pre-Feeding Pre-Feeding InterventionsInterventions

Start with a clean mouth!!!Start with a clean mouth!!!• ROMROM• SLOW stretch SLOW stretch • Deep pressure at touchDeep pressure at touch• Warm cloth to T.M.J.Warm cloth to T.M.J.• Pacifier or spoon playPacifier or spoon play• Chewing Chewing • Thickened drink through Thickened drink through

strawstraw

Aversion strategiesAversion strategies(consider Dr. Kay Toomey (consider Dr. Kay Toomey

seminar)seminar)• Familiar tastes changed by one Familiar tastes changed by one

modalitymodality• Introduce changes slowlyIntroduce changes slowly• I.e., graham cracker crumbs, grated I.e., graham cracker crumbs, grated

carrotscarrots• Peer influence is idealPeer influence is ideal• Use carefully guided heirarchyUse carefully guided heirarchy• Parental participation is crucial for Parental participation is crucial for

carry-overcarry-over

Aspiration riskAspiration riskDon’t be afraid to stopDon’t be afraid to stop

Request more information (possibly M.B.S.) if:Request more information (possibly M.B.S.) if:• Decreased functional feeding movements after p.o. Decreased functional feeding movements after p.o.

initiationinitiation• Increased congestion: nasal or pharyngealIncreased congestion: nasal or pharyngeal• Stridor with or without cervical auscultation Stridor with or without cervical auscultation • Color change: mottled, pale, dusky, cyanoticColor change: mottled, pale, dusky, cyanotic• Watery eyes, flaring hands/arms/legs. Watery eyes, flaring hands/arms/legs. • Decreased eye contact or interest after p.o. initiationDecreased eye contact or interest after p.o. initiation• Arching Arching • Repeated swallow attemptsRepeated swallow attempts• Oral residueOral residue• GaggingGagging• Coughing with swallow or delayed coughCoughing with swallow or delayed cough