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A feeding disorder is identified when a child is unable or refuses to eat or drink a sufficient quantity or variety of food to maintain proper nutrition.

It is important to distinguish between a feeding problem that is the result of an inability to eat versus one that is the result of refusal. A child who is refusing to eat is believed to have learned the behaviors that allow him/her to avoid or attempt to control the feeding situation, and the problem is therefore said to be non-organic.  A child who is physically unable to eat, on the other hand, may be suffering from neuromuscular, skeletal or metabolic abnormalities.  These problems are said to be organic and therefore require the attention of a physician to appropriately address and treat the medically related difficulties.

Feeding skill: stages and timing


skills 0-3m 3-6m 7-11m 12-24m

Feeding (motor) Texture (sensory) Speech Fine motor

sucks Liquid Coos Fingers

Sucks/bites Munches Purees Babbles Reaches Turns/sits Chopped Syllables Transfers Stands

Chews Table Words Releases Walks


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Gross motor Lifts head

Appropriate food provided Food introduced into the oral cavity

Suck or mastication prepare bolus Bolus passes into the pharynx

 Respiration ceases  Elevation of the larynx , glottic closure  Opening of upper esophageal sphincter  Pharyngeal peristalsis with clearance of the pharynx  Respiration resumes

Esophageal peristalsis Opening of lower esophageal sphincter

Receptive relaxation allows storage of the food into the stomach Titurbation and controlled emptying of nutrients into the small intestine Intestinal digestion and absorption of nutrients.

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Major Diagnostic Categories Associated with Feeding and Swallowing Disorders in Infants and Children
Neurologic

Encephalopathies (e.g., cerebral palsy, perinatal asphyxia)

Traumatic brain injury Neoplasms Mental retardation Developmental delay Anatomic and Structural

Congenital (e.g., tracheoesophageal fistula, cleft palate)

Acquired
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Genetic

Chromosomal (e.g., Down syndrome)

Syndromic (e.g., Pierre Robin sequence, Treacher Collins syndrome) Inborn errors of metabolism Secondary to Systemic Illness

Respiratory (e.g., chronic lung disease, bronch b y opulmonary dysplasia). Gastrointestinal (e.g., GI dysmotility, constipation) Congenital cardiac anomalies

Psychosocial and Behavioral Oral deprivation Secondary to Resolved Medical Condition Iatrogenic
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Dysphagia and feeding problems are classified according to which phase of swallowing is affected. Oral motor dysfunction in children is seen most commonly in those with neurodevelopment disorders . These children will exhibit poor lingual and labial coordination. This will result in loss of food and a poor seal for sucking or removing food from a spoon.
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These children may also have difficulty with coordination of sucking, swallowing and breathing. Children with pharyngeal dysphagia may demonstrate the symptoms of oral dysphagia, along with coughing, gagging and choking with foods and liquids. However, the signs of pharyngeal dysphagia may be subtle. In this situation, the children may suffer from recurrent upper respiratory infections or have a history of pneumonia. The most common signs and symptoms of feeding disorders and dysphagia are coughing or choking while eating, or the sensation of food sticking in the throat or chest.
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25% in normally developing children 0-1 year. 50% of hospitalised infants for FTT 80% neurologically impaired

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A child with a feeding disorder may experience one or more of the following:

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Weight for age consistently below the 3rd or 5th percentile Progressive decrease in weight to below the 3rd or 5th percentile Weight crosses more than two major percentiles downward. Weight < 80% of ideal weight for height. Decrease in expected rate of growth based on the child's previously defined growth curve, irrespective of whether below the 3rd percentile

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Weight for height or height for age falls below the 10th percentile Child experiences three consecutive months of weight loss Child is diagnosed with dehydration or malnutrition, which results in emergency treatment Child has NG tube with no increase in the percent of calories obtained via oral feeding for 3 consecutive months

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Patient Demographics: Mean Age: 3 years (39 months) Gender: 68% male, 32% female Developmental level:
53% Developmental Delays 47% Typical Cognitive Development

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Patient Demographics
Medical Diagnosis Autism Developmental Delay Cerebral Palsy Prematurity Oral Motor Dysfunction GERD FTT Other-Medical No Diagnosis Mean Percentage 10% 53% 7% 30% 29% 58% 59% 60% 5%

Slow feedings characterized by long meal time.Typically longer than 30-40 minutes. Change in feeding patterns or new problems with feeding. Breathing interruptions or stoppage during feeding. Gurgly/wet vocal quality before and after swallows. Unable to coordinate sucking and swallowing. Significant drooling or oral weakness observed. History of recurrent pneumonia .
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Irritability or behavior problems during meals. Unexplained food refusal . Sleepiness during feedings. Failure to gain weight over 2-3 months. Diagnosis of a disorder associated with feeding and swallowing difficulties. Does not achieve age appropriate feeding behaviors  Not spoon feeding by 9 months  Not chewing table food by 18 months  Not cup drinking by 24 months

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Feeding Disorders

 Etiologies
Medical Oral Motor sensory Behavioral
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PREMATURITY

REFLUX DISEASE

Swallowing and feeding disorders in children and infants are complex and may have multiple causes. Underlying medical conditions that may cause dysphagia may include, but are not limited to (Palmer, 2000; Rudolph and Link, 2002):

Neurological disorders
intracranial hemorrhage

myasthenia gravis cerebral palsy meningitis encephalopathy

Disorders affecting suck-swallow-breathing coordination


choanal atresia

cardiac disease bronchopulmonary dysplasia


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tachypnea

Connective tissue disease


polymyositis muscular dystrophy

Iatrogenic causes
surgical resection radiation fibrosis medications

Anatomic or congenital abnormalities


cleft lip and/or palate

abnormalities of the tongue .


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Structural lesions
thyromegaly

cervical hyperostosis congenital web Zenkers diverticulum ingestion of caustic material neoplasm

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Weak suck Choking or gagging during meals Tongue thrusting or inability to lateralize the
tongue Wet vocal sounds during or after meals Preferences for smooth or creamy textures

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Common Oral-Motor Feeding Difficulties Associated with Down Syndrome

Weak lip seal on nipple (fluid loss)


Tongue protrusion/thrust
Delayed chewing (secondary to delayed dentition and or prolonged tongue thrust)
Difficulty with texture transition
Difficulty with thin liquids (increased fluid loss and coughing) 33

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Nutritional Risk Factors for Children with Developmental Disabilities


Oral-Motor Feeding Difficulties

Discoordination of suck swallow Structural abnormalities (cleft lip/palate; dentition) Poor oral containment (food/fluid loss) Tone abnormalities (hypo/hypertonic) Altered oral sensory response (hypo/hyperresponsive) Delayed oral motor skill development 35 Aspiration

Oral-Motor Weaknesses
Difficulty with oral strength and coordination required for eating.

Open Mouth Posture Frequent drooling Unable to bite through foods Weak chewing Poor bolus formation Unable to close lips on spoon

Poor lip movement (cant pucker / spread) Tongue Thrusting Retracted tongue Poor tongue lateralization Coughing / Choking during meals
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Where do they come from?


Prematurity Chronic illness Multiple medical interventions/medications Underlying neuro issues

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Sensory Integration Dysfunction


The sensory system consists of: Proprioception body awareness Vestibular balance Tactile touch Gustatory taste Olfactory smell Vision Auditory hearing The CNS receives all of these types of input, interprets them, and organizes a response Sensory Integration Dysfunction occurs when the brain does not efficiently process sensory stimuli coming from the body or the environment.

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Sensory Impact on Feeding


Children with tactile hypersensitivity are averse to smooth, wet, slimy textures on their hands, face, body and/or in their mouth. Children with tactile hyposensitivity have reduced sensations of foods in the oral cavity and thus pocket or lose control of them which can lead to gagging or choking. Upper body strength and coordination supports and is required for mouth strength and coordination.
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Oral motor weaknesses lead children to experience eating as difficult and/or scary and thus children do not develop a sense of trust that they are capable of handling food. Sensory dysfunction leads children to experience eating as scary when the child is presented with aversive textures.

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Children with oral-motor weaknesses are most capable of eating smooth, pureed textures (pudding, yogurt, apple sauce) and are less able to eat crunchy or solid foods. However, children with sensory dysfunction are highly averse to smooth foods and are most comfortable with crunchy or solid foods. Most children with feeding problems have both oral motor weaknesses and sensory deficits.
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Avoidance of eating is initially an adaptive behavior as it allows the child to avoid an activity that is painful, difficult, scary and potentially dangerous. Poor oral control and/or sensory aversion may lead to gagging which reinforces fear and promotes further refusal. The child will use a variety of behaviors to avoid placement of food into his/her mouth. Parents often accidentally reward avoidance behaviors by responding with positive attention (playing, smiling, bargaining) or by removing the food.

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Pushing food away Throwing food Turning away Crying Saying No! Refusing to open mouth Expelling foods from mouth Gagging/Vomiting
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Steps for Diagnosis and Treatment of Pediatric Feeding and Swallowing Problems

Define problem feeding and swallowing Identify etiology(ies) Determine appropriate diagnostic tests Plan approach to patient/family Teach about problem, implement treatment Monitor progress Evaluate progress (outcomes focused)
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Evaluation of dysphagia and feeding disorders


Performing a history and physical
Objectives of the history should include: Identifying the anatomic region involved and obtaining clues to the etiology of the condition. This may include information regarding the onset, duration and severity, presence of regurgitation, the perceived level of obstruction and presence of pain or hoarseness, and presence of other disorders.
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During the physical examination:


The patient should be observed during the act of swallowing. A clinical dysphagia evaluation is usually completed by a speech-language pathologist.

The examination will include assessment of posture, positioning, patient motivation, oral structure and function, efficiency of oral intake and clinical signs of safety. In infants, the oral-motor assessment includes evaluation of reflexive rooting and non-nutritive sucking (Darrow and Harley, 1998). Infants and children may require additional assessments, since growth, development, and changes in medical condition may affect the swallowing process. 48

Diagnostic testing that may be employed includes


 Esophagoscopy: This test may be used to rule out neoplasm,
particularly in patients who complain of thoracic dysphagia or odynophagia.

 Esophageal manometry and pH probe studies: These tests may be used when a motility disorder or gastric esophageal reflux disease is suspected.  Electromyography: This test is indicated in patients with motor unit disorder such as polymyositis, myasthenia gravis, or amyotrophic lateral sclerosis  Fibroptic endoscopic examination of swallowing (FEES): This test is performed with a transnasal laryngoscope to assess pharyngeal swallowing.  This test may be helpful when a VFSS (videofluorographic swallowing study) is not feasible  Ultrasound imaging: This testing has been used to a limited extent on infants to assess the oral phase of swallowing. The technique is limited to infants, since teeth will interfere with the sound signal. This method will permit studying of infants during breast-feeding, since contrast media is not required. 49

Videofluorographic swallowing study


Is the gold standard for evaluating the mechanism of swallowing. VFSS is also referred to as modified barium swallow. During this study, the patient will eat and drink foods mixed with barium while radiographic images are observed on a video monitor and recorded on videotape. This test is ideally performed jointly by a physician and a speechlanguage pathologist. The study will demonstrate anatomic structures, the motions of these structures, and passage of the food through the oral cavity, pharynx and esophagus .
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Videofluorographic swallowing study


This test may also be used to test the effectiveness of compensatory maneuvers that are used to improve swallowing. This test cannot be performed on infants and children who are unable to swallow. In addition, infants and children with oral aversion and some feeding disorders may not ingest a sufficient amount of barium to provide a meaningful study.

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Interdisciplinary Approach
 Interdisciplinary team evaluation:
Medicine Rule out physical causes of feeding
problem Nutrition Evaluate adequacy of current intake Social Work Evaluate family stressors Speech/Occupational Therapy Evaluate oral motor status and safety Psychology Assess contribution of environmental factors
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the causes of many of the disorders resulting in feeding disorders or dysphagia may not be amenable to pharmacological therapy or surgery as a result of behavioral contributors to impairment. In these cases, a referral to a professional, such as a speech pathologist, or feeding clinic is appropriate. A child may continue with signs and symptoms of a feeding disorder even after correction of an underlying abnormality due to a learned aversion to feeding. In these cases, behavior therapy may be considered.
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Prerequisites for oral feeding attempts for infants and young children include

Cardiopulmonary stability Alert , calm state In young infants, demonstration of rooting responses and adequate non-nutritive sucking Appetite or observable interest in eating

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Feeding therapy for infants and children may include the following strategies
Position and posture changes: Trunk and head control are closely related to development of oral-motor skills. In particular, children with cerebral palsy and accompanying motor deficits frequently have poor head control and poor trunk stability. Position changes need to be monitored closely for adjustments over time.

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Feeding therapy for infants and children may include the following strategies
Changes in food and liquid attributes: These attributes may include, but are not limited to: volume, consistency, temperature and taste. Oral-motor and swallow therapies: These procedures are focused on developmental stages with goals to increase the range of textures children can handle in their diets. Oral-motor treatment can include direct exercises of the oral mechanism.

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Feeding therapy for infants and children may include the following strategies
Pacing of feedings: Pacing is a technique that regulates the time interval between bites or swallows. This may minimize the risk of aspiration. Some children may need a longer time to swallow. Changing of utensils: The food bolus size can be controlled through spoons of different shapes and sizes. Occupational therapists may recommend adaptive equipment and utensils. Esophageal phase swallow disorders are generally not amenable to oral-motor and swallow therapy. Positioning changes, changes in food characteristics and timing may make a difference.
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Feeding therapy for infants and children may include the following strategies
Specialized feeding techniques that are used for feeding infants with cleft lip and/or palate have been developed to overcome the lack of negative pressure developed during sucking; these strategies may include:
cross-cutting fissured nipples

squeezing a soft bottle to help with the flow of milk pumping breast to deliver breast milk via bottle
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When a patient is unable to achieve adequate alimentation and hydration by mouth, enteral feedings through a nasogastric tube or a percutaneous endoscopic gastrostomy may be necessary.

The presence of a feeding tube is not a contraindication of therapy. Removal of the feeding tube may be a goal of therapy.

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Tips to prevent feeding problems from developing or persisting


 Present a wide range of foods before the child reaches 15 to 18
months of age

 Present preferred as well as non-preferred foods  Stick to a consistent schedule; keep meals, naptime, and bedtime
at same times daily

 Make healthy foods readily available and unhealthy foods less


available

 Model healthy eating behaviors and discuss good eating habits


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Tips to prevent feeding problems from developing or persisting


 Teach your child to communicate about his/her hunger by relating
food to appetite eaten)

 Reinforce good mealtime behaviors (avoid praising amount of food  DO NOT reinforce inappropriate behavior with toys or attention  Try to maintain enough time and energy for meals  Develop a few simple rules and follow them, dont start what you
cant finish
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