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An Interdisciplinary Approach to Assessment and Treatment of Pediatric Feeding DisordersSPECIALIZED DISCIPLINE’S CONTRIBUTIONS TO AN EVIDENCE BASED APPROACH TO EVALUATION AND TREATMENT: SPEECH THERAPY

LISA HACKER, MA, CCC-SLP

ASHLEY PURDUM, MA CCC-SLP

Infants- They are Not just tiny adults!

• Oral space in newborn is small• Lower jaw in newborn is small & retracted• Sucking pads present• Lips/cheeks

• Not active until 3-4 months

• Tongue takes up more space• Infant tongue has restricted movement• Newborns are obligate nose breathers• Epiglottis and soft palate are in approximation in the newborn as a

protective mechanism• Larynx is higher in the newborn pharynx eliminating the need for

coordinated laryngeal closure to protect the airway• Eustachian tubes of the infant lie horizontal, with a more vertical angle in

the adult

Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management. Cengage Learning.

Zimmerman, B. Y. (2009). Pediatric Feeding and Dysphagia Newsletter.

Anatomic Location Infant Older Child

Oral Cavity Tongue fills mouth Mouth is larger, tongue rests on floor of mouth

Edentulous Dentulous

Tongue rests between lips and sits against palate Tongue rests behind teeth and is not against palate

Cheeks have sucking pads Buccinators are muscles for chewing only

Relatively smaller mandible Mandibular-maxillary relations relatively normal

Pharynx No definite/distinct oropharynx Elongated pharynx, so distinct oropharynx exists

Larynx 1/3 adult size

Narrow, vertical epiglottis Flat, wide epiglottis

Infants- They are Not just tiny adults!


Structures and Functions4-6 months

◦ Oral cavity enlarges; as tongue gains more space, it gains neurological control

◦ Pharynx elongates◦ Epiglottis and soft palate no longer approximate

◦ Sucking reflex integrates

3-5 years◦ Adult-like swallow by developmental age of 5

◦ 3 levels of airway protection


Logemann, J. A., & Logemann, J. A. (1983). Evaluation and treatment of

swallowing disorders.

Development of Suck:Swallow:Breathe (SSB) coordination

Age SSB coordination

1 month 2+ sucks, stop to breathe/swallow

3 months 20+ sucks before visible pauses to breathe. Swallow follows each suck

6 months Long sequences of sucking at breast/bottle; from cup- attempts continuous sucks, but uncoordinated (bolus loss). If bolus is too large, cough/choke

9 months Continued incoordination; usually 3 swallows to breathe

12 months Cup drinking- swallow follows drink with no pause; coughs/chokes if bolus is too fast or large

15 months Pattern is well coordinated; rare to cough/choke

Neurological Development


Phases of the Swallow• 1. Oral Prepatory Phase (voluntary)

• 2. Oral Phase (voluntary)

• 3 . Pharyngeal Phase (voluntary and involuntary)

• 4. Esophageal Phase (involuntary)

Logemann, J. A., & Logemann, J. A. (1983). Evaluation and treatment of swallowing disorders.

Begins with the intake of food into mouth and the formation of a bolus

◦ in infant, this is minimal, such as latching

◦ In infant, requires a feeder

Varies with textures of foods introduced

◦ The more chewing, the longer the phase typically, liquids are held in mouth for <2 seconds

Lip closure is vital to avoid anterior loss

Soft palate is lowered, resting against tongue base

ORAL PREPATORY PHASE

ORAL PHASEBolus transport- ends when bolus head reaches anterior faucial arches (takes approx. 1 second)

Sensory and motor systems of tongue must be intact for flawless oral phase

Time should not vary with textures; normally takes <1 sec to complete this phase

Precise timing of pharyngeal trigger is undetermined; anterior tonsillar pillars, base of tongue, vallecula or pyriform


Pharyngeal PhasePotential for aspiration is most critical in this stage

This phase begins with:

Voluntary production of a swallow, and

Soft palate elevation to close nasopharynx

Specific Sequence:1) Velopharyngeal closure

2) Elevation and anterior movement of the hyoid and larynx

3) Closure of larynx- true vocal fold closure-false vocal fold closure- aryepiglottic closure-retroversion of epiglottis

4) Cricopharyngeal Opening; passage into esophagus through UES

5) Tongue base and Pharyngeal wall action

6) Contraction in Pharyngeal Constrictors


Demonstration

https://www.youtube.com/watch?v=YQm5RCz9Pxc

ESOPHAGEAL PHASE

• Slower• Consists of automatic peristaltic wave, which carries the bolus to the stomach• 3 zones

1. Upper (from UES down 6-8cm) composed of striated muscle2. Middle (where striated muscles meets smooth muscle)3. Lower (the final 4cm before the lower esophageal sphincter (LES) composed of smooth muscle

• Esophageal Phase moves 3-4 cm/second


PHASES OF THE SWALLOW

Roya Shahidi, Ph.D, CCC-SLP & Joel Herskowitz, M.D. http://www.swallowsafely.com/chapter-2-excerpt/

Etiologies

Etiologies of Feeding DisordersOrganic

◦ Neurological

◦ Gastrointestinal

◦ Structural Abnormalities

◦ Cardiorespiratory

◦ Aspiration

Non-organic◦ Behavioral

◦ Environmental


OrganicGastrointestinal

◦ Reflux

◦ Motility issues

◦ Food allergies/sensitivities

◦ Atypical bowel movements◦ Constipation, runny stools, discoloration

◦ GI etiologies can cause a response in the child that is interpreted as behavioral


◦ Pierre Robin

◦ Cleft lip/palate

◦ Macroglossia/microglossia

◦ Esophageal stenosis

◦ Tracheoesophageal Fistula

◦ Atresia

◦ Hypertrophic pyloric stenosis

◦ Thickening / narrowing of distal stomach

◦ Decreased passage for food

◦ Projectile vomiting

Common Structural Anomalies


Organic Cardiorespiratory

◦ Congenital heart diseases

◦ Heart malformations account for 25% of all congenital deficiencies

◦ Cause increase in fatigue resulting in cyanosis and anoxia

◦ Respiratory problems which directly effect feeding/swallowing

◦ Risk of oral aversion due to negative experiences/decreased oral feeding-pleasurable experiences are vital!

Neurological

◦ Cerebral Palsy, Chiari malformation, Trisomy 21, encephalopathy

◦ CNS congenital malformations common in 3/1000 births

◦ Spina bifida

◦ Anancephaly (absence of major part of brain)

◦ Malformations of ventricular system – hydocephalus / cerebral palsy

Aspiration

◦ Can be secondary to any of the above organic etiologies

◦ Thickening (more to come……..)


Normally occurs at least 1X/day in infants <3 months

Decreases at 8-12 months

S/S: gagging, projectile vomiting, arching, head turning, irritability, inconsolable crying and feeding aversion

Common Treatments:

◦ Positional: upright 30-60 minutes, elevated mattress in bed, Right side lying to empty stomach, pacifier, diet changes for mom and baby

◦ Mechanical: slow rate, decrease volume

◦ Medicinal: Reglan, Zantac, etc

◦ Surgical: Fundoplication

Rate of gastric emptying affects likelihood of GER – a delay in emptying allows more time for reflux

Nature of material

◦ Volume

◦ Physical state or viscosity

◦ Content – breast milk empties faster than cows milk

Gastroesophageal Reflux (GER)


Non-Organic“Nonorganic feeding disorders are a condition in which children show incorrect feeding behaviors such as selective intake, fear of feeding, low food intake or even food refusal, without underlying organic disease” (Kerzner, 2015)

Behavioral ◦ Can result from primary physiological etiology

◦ Trigger event that leads to anticipatory gagging

◦ Sensory deficit◦ Commonly seen in children on the autism spectrum

Environmental◦ Harmful feeding

◦ Forceful in nature

◦ Foster care

◦ Cultural differences

Kerzner, B., Milano, K., MacLean, W. C., Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach

to classifying and managing feeding difficulties. Pediatrics, 135(2), 344-353.

Rybak, A. (2015). Organic and nonorganic feeding disorders. Annals of Nutrition and Metabolism,

66(Suppl. 5), 16-22.

• Children with special health needs at high risk • Organic:

• Chronic disease• Genetic anomalies

• Non organic:• Poor mother infant interaction• Psychosocial issues• Environmental deprivation• Child abuse

• Acute vs Chronic (chronic= both L and wt is low for age/adjusted age) Acute- wt decreased in % but L is stable

• Appropriate diet for age-remember ADJUSTED age!• Special formulas• Nutrition for toddler years in children with motor delay- they don’t need as many calories

because they are not getting as much physical activity

Failure to Thrive (FTT)

Evaluation

Coughing while eating or drinkingChronic cough, congestion, or history of poor pulmonary healthDisruptive and stressful mealtimesDistraction to increase intakeExcessive droolingFailure to advance texturesFailure to grow over 2-3 monthsFood refusal lasting, 1 monthFrequent reflux / emesisLack of appropriate independent feedingMechanical feeding difficultiesNeurological impairmentsPremature birthProlonged breast or bottle-feedingProlonged mealtimesSuspected caregiver neglectWeight/height below the 5th percentile

Reasons for Referral

Kerzner, B., Milano, K., MacLean, W. C., Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach

to classifying and managing feeding difficulties. Pediatrics, 135(2), 344-353.

EvaluationPurpose

◦ Diagnose

◦ Identify ◦ Which phase(s) of the swallow are impacted?

◦ Contributing factors◦ Referral


AssessmentCase History

◦ Medical/developmental history

Oral Mechanism Exam◦ Be playful!

◦ Don’t lose child’s trust

Observe mealtime◦ Child or caregiver feeding

◦ Positioning

◦ Textures/consistencies offered/accepted◦ Child’s response? Caregiver’s response?

Strategies

Recommendations

Nutritive Suck (NS) – bottle or breast

Main purpose is to obtain nutrition

Child-caregiver bonding

Non-nutritive Suck (NNS) pacifier

Calming, state regulating

NNS is 2x faster than NS

NNS = 2 per second

NS = 1 per second

NS and NNS occur in rhythmic, organized sequences called “bursts”

NUTRITIVE VS NON-NUTRITIVE SUCK


NNS burst = 6-8 sucks, then pause to swallow

Breathing is interrupted to swallow

As child ages, NNS bursts increase

20-30 cycles of suck-swallow-breathe, followed by a pause of about 5 seconds of “catch-up breaths”

Type of nipple and rate of flow influence the cycle

Most often 1:1:1, increasing to 2:1:1 at end of feeding

Most important to develop and maintain a rhythmic pattern.

NUTRITIVE VS NON-NUTRITIVE SUCK


Specific things to look for:• State prior to, during, and after feed• Position• Liquid offered (volume, type, method)• NNS• Bottle/nipple system• Anticipation/Root• Latch• Anterior loss• SSB• Tongue/jaw position• Sucking• Pacing• Swallowing• Respiratory status• Cough/choke/gag• Vocal quality• Stats

• Semi-solids/Solids• Position• Routine• Anticipation• Tongue/jaw position• Lips• Anterior loss

Common Caregiver Errors:- Removing nipple out of mouth to pace- Shaking nipple to try to stimulate-Pacing-Nipple/bottle system-Schedule

INFANT FEEDING OBSERVATION


Specific things to look for:• State prior to, during, and after feed• Caregiver interaction• Position• Ability to feed self• Knowledge of routine • Type of cup/utensils used• Anterior loss• Tongue/jaw position• Swallowing• Respiratory status• Cough/choke/gag• Vocal quality• Refusal patterns• Reaction to praise• Volume consumed/time

Common Caregiver Errors:- Offering developmentally inappropriate textures/solids- Schedule- Grazing- Force feeding

SOLID FEEDING OBSERVATION


SENSORY & MOTOR DISORDERS EVALUATIONSensory Disorder Motor Disorder

Demonstrates nipple confusion with breast-feeding and bottle-feeding Inefficient suck with breast and bottle

Inability to differentiate different tastes in a bottle despite an intact suck Differentiates taste in a bottle

Manages liquids better than solid foods Oral motor inefficiency or incoordination is noted with all textures

Able to sort food out in a mixed texture Swallows food whole when offered mixed textures

Holds food under tongue or in cheek and avoids swallowing Unable to hold and manipulate bolus on tongue; food falls out of mouth or into cheeks

Vomiting only certain textures Vomiting is not texture specific

Gags when food approaches or touches lip Gags after food is moved through oral cavity

Hypersensitive gag with solids; normal liquid swallow Gags with liquids and solids after swallow is triggered

Tolerates own fingers in mouth, does not accept someone else’s fingers Tolerates others’ fingers in mouth

Does not mouth toys Accepts teething toys but is unable to bite them or maintain them in the mouth

Refuses tooth brushing Accepts tooth brushing

Palmer, M. M., & Heyman, M. B. (1993). Assessment and treatment of sensory-versus

motor-based feeding problems in very young children. Infants & Young Children, 6(2),

67-73.

HAVE YOU EVER SEEN A BABY “EAT” FOR THE FIRST TIME?

• Oral exploration• Readiness cues• Posture/positioning• OK from pediatrician• Expect that they will not immediately accept!• Keep calm when they gag/choke• Encouragement• Don’t end on their note!

-Small amounts of food/liquid at first-May try chewable if child appears ready-Use foods that are easier to gum/dissolve

Abnormal Behaviors:- Tonic bite- clamps down, no release—keep fingers OUT until you know and NEVER use plastic utensils- Tongue thrust- normal can be present until 5-6 years of age- Tongue retraction- held in posterior oral cavity at rest- Lip retraction- difficult to remove bolus from utensil, cup drink and straw drinking are difficult- Pocketing/pooling/drooling- Delay in any phase of the swallow- Cough/choke- Wet vocal quality- Increased RR- >1 swallow/bolus

OLDER CHILD FEEDING OBSERVATION

InterpretationConsider:

◦ Safety

◦ Nutrition/hydration

◦ Weight gain

◦ Severity

◦ Impact on child, caregiver, and family

◦ Response to interventions during assessment

◦ Differential diagnosis◦ Immature vs abnormal patterns

◦ Oral sensory vs oral motor

◦ Sensory vs behavioral vs sensory-behavioral

Oral AversionTouch

◦ Face, lips, gums/teeth, tongue

◦ Pressure then movement

Oral Exploration

◦ Infants: teethers, hands, rattles

◦ Children: Nuk brush, toothbrush, Z-Vibe, real foods

Sensory vs Sensory Motor

◦ Gagging

◦ Touch/smell/sound

◦ Taste/pressure/movement

Exploring FoodPlay with food

◦ Get messy!

*Activities to come later!

The Seven Senses (Fernando & Potock, 2015)

◦ Vestibular

◦ Proprioceptive

◦ Visual

◦ Tactile

◦ Auditory

◦ Olfactory

◦ Gustatory

Levels of difficulty

◦ Smell, touch, taste

◦ Steps to Eating

Oral Aversion

Toomey, K. A., & Ross, E. S. (2011). SOS approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(3), 82-87.

Reflux IndicatorsImmediate

◦ Hiccups

◦ Drooling

◦ Increased mucus/phlegm

◦ Bad breath

◦ Gagging

◦ Excessive swallowing

◦ Head hyperextension

◦ Foamy secretions

◦ Crying with liquid intake/needs to be held

BECKMAN

Long Term◦ Only accepts liquids

◦ Eats small amounts

◦ Morning coughing/phlegm

◦ Sleep difficulties

◦ Mealtime refusal

◦ Poor weight gain, despite calorie intake

◦ Hand mouthing

◦ Sandifer’s Syndrome

◦ Increased incidence of thrush

◦ Coffee ground emesis

◦ Otitis media

Reflux Indicators

BECKMAN

Instrumental Assessment

Most Common:

MBS (Modified Barium Swallow)FEES (Flexible Endoscopic Evaluation of Swallow)

Consider appropriate referrals (GI, ENT, Pulmonology, etc)

INSTRUMENTAL EVALUATION OF THE SWALLOW


INSTRUMENTAL EVALUATION

Category Symptoms/Signs

During Feeding Coughing, gagging, excessive drooling, increased congestion, wet vocal quality, irritability, food refusal, lack of alertness or lethargy mealtimes lasting more than 30 minutes

Pulmonary Status Frequent or recurrent pneumonia recurrent upper respiratory infections, chronic lung changes, infiltrates on a chest x-ray

General health & GI Frequent or recurrent low-grade fevers, poor weight gain or weight loss, emesis, reflux, possible hoarseness

Neurologic Oral-motor incoordination or weakness, reduced oral sensation

Structural Suspected tracheoesophageal fistula, vocal fold paralysis or paresis


ExamplesAdult

https://www.youtube.com/watch?v=uxHUUgLeNzk

Baby◦ normal

https://www.youtube.com/watch?v=3Ql8GrGzP5A

Abnormal

https://www.youtube.com/watch?v=nWyIleFuGqY

Child – Abnormal

https://www.youtube.com/watch?v=K7MV2C-MVZE

https://www.youtube.com/watch?v=uxHUUgLeNzk

https://www.youtube.com/watch?v=3Ql8GrGzP5A

https://www.youtube.com/watch?v=nWyIleFuGqY

https://www.youtube.com/watch?v=K7MV2C-MVZE

Thickening

Thickening Future research is needed for infant use

◦ Impact on the developing gut

Controversy over how to thicken in the infant and pediatric populations

Simply Thick◦ Developed in 2001

◦ Was considered the latest and greatest food thickener

◦ Contains Xanthan gum

◦ In 2011, FDA issued warning for use with infant’s due to high incidence of necrotizing enterocolitis (NEC)

◦ Currently, it’s “NOT intended for use with preterm or infants under 12 months of age. Or children under the age of 12 years with a history of NEC.” (SimplyThick)

ThickeningGelmix

◦ Relatively new organic thickener

◦ Tasteless, odorless, and smooth

◦ Thickens breastmilk

◦ Free of common allergens

◦ 3 ingredients◦ Organic Tapioca Maltodextrin

◦ Organic Carob Bean Gum

◦ Calcium Carbonate

◦ Not for use in infant under 42 weeks GA or less than 6 pounds

◦ To use:◦ Liquid must be warm

◦ Wait 5 minutes to reach desired consistency

◦ Thickens over time

GELMIX

ThickeningRice cereal

◦ Is known to cause constipation

◦ Clogs the nipple if not pulverized

◦ Quickly breaks down in breastmilk

◦ In April 2016, FDA recommended limiting rice cereal due to inorganic arsenic exposure◦ Developmental impact

Baby oatmeal◦ Breaks down in breastmilk

◦ Mixes more smoothly than rice cereal

◦ Can cause constipation

Puree food◦ Baby food

◦ Applesauce

Positioning

Stability is the foundation for function and movement.

Different stages of development afford different levels of stability

As neurological control develops, the need for stability provided by the sucking pad decreases. Sucking pads are gone by 6-8 months of age.

-Increased range of open/close of jaw-increased cheek and lip mobility-This decreases need for deep central groove of tongue, allows for a new means of bolus propulsion

The angle of the infant pharynx is a gentle curve. Adults airway is 90

Infant Tone & Positioning


Important for bonding experience

Should promote:-good eye contact-close physical contact-safe/functional feeding

Ideal: Semi-reclined, neutral head and neck, flexion at hips and knees. (Disclaimer: infants who fatigue easily should not be held this way!)

Consider adaptations: angled bottle, various pillows (ie boppy) to assist

Infant Positioning


Infant Positioning

Cross Over- different than cradle because you don’t support head with crook of arm, but rather, your other arm.Best for: small babies, infants who have trouble latching

Football- tuck baby under arm on same side; use c-holdBest for: c-section moms, small babies, babies with latching difficulty, twins.

Side-lying- lying on side (either facing in or out, in preferred for bonding and caregiver’s awareness)Best for: labial spillage, poor motility

Older child/side lying position


Central Alignment-Neutral head flexion-Neck elongated-Shoulder girdle stable and depressed-Trunk elongated-Pelvis stable and symmetrical in neutral position-Hips at 90-Feet in neutral with slight dorsiflexion

Stability is the foundation for function and movement!


TREATMENT

Medical• These patients often warrant diagnostic testing• Close collaboration with all healthcare providers of what they can handle• Close communication with team when they are handling increased PO• Frequent weight checks• Risk of oral aversion

Facilitation Techniques:• Positioning• Nipple Selection: Firmness/Flow• No evidence that increasing rate is safer or promotes cardiorespiratory stability• Slower flow: more opportunities to breathe

• Endurance• Safety

Compensatory Strategies: • External pacing• Organization with non-nutritive item• Cheek/chin support if appropriate

Feeds should not exceed 30 minutes!Never alter a nipple. It is considered medical equipment. Remember, feeding is the hardest job a baby has to do. They fatigue easily from this hard task.


Management of Feeding & Swallowing Problems: Nipple Selection

Flow Basics:• Ultra Preemie• Preemie• Slow• Medium• Fast• Variable• X Cut• Y Cut

Shaker, C., Woida, W., & Marie, A. (2007). An evidence-based approach to nipple feeding in a level III NICU: nurse autonomy, developmental care, and teamwork. Neonatal Network, 26(2), 77-83.

Find the one that makes them happy!


• Firmer/Harder: Avent/Playtex Use for patients with low tone

• Not Firm: Dr. Brown’s Use with weak babies (i.e. cardiac)

• Watch for what nipple is doing. Do you see it collapsing? Listen for pop! If so, go firmer.

• Avoid excessive tightening of the nipple ring

• The best nipple will make the most contact with the tongue

• X/Y Nipples only need compression


Positioning◦ Supine

◦ Prone

◦ Elevated side lying (Shaker, 2017)

◦ Less gravitational impacts

◦ A-P rib cage movement

◦ Movement of bolus towards pharynx

◦ Passive dripping from nipple

◦ Improved latch, less air intake

◦ More breathing opportunities

◦ Less effortful mandibular movement

◦ Increase subglottic pressure?

◦ Upright

Co-regulated pacing◦ Imposes breathing breaks

◦ Longer endurance

◦ Safety

Swaddling◦ Postural stability


Cup/Straw drinkingCup

◦ Consider diameter

◦ “Lift up, set down, stay dry” (Fernando & Potock, 2015)◦ Lift up, cup to lips, sip, set down, stay dry

◦ Final step, place on tummy

Straw◦ Promotes a mature swallow pattern

◦ Start with purees vs thin liquids

◦ Diameter◦ Smaller = less taste

SpoonsSmall, flat bowl

◦ Encourages lip closure and suction

Remove horizontally◦ Avoid scraping food off onto roof of mouth/gums

◦ Encourages forward tongue protrusion

Lateral positioning◦ Promotes upper lip movement

During self feeding:◦ Use a thick, shorter spoon

◦ Grasp close to spoon bowl◦ Better control when guiding to mouth

SpoonsFor children with a bite reflex

◦ Avoid plastic spoons

◦ Metal spoons◦ Coated or covered to avoid breaking teeth

Tonic bite reflex◦ Occurs following stimulation to gums/teeth

◦ Attempt to remove item only increases the reflex

Positioning is key!◦ Consult OT/PT

ChewingInvolves lips, tongue, cheeks, and jaw

Begins with oral exploration during infancy

Vertical chewing pattern◦ Non-food to real food

◦ Chewy tubes

◦ Place directly onto biting surface (“dinosaur teeth”)

◦ Work towards 20 rhythmical chews on each side◦ Fatigue?

Rotary chew◦ Alternate sides every 3-5 chews

Environmental Issues• Failure to Thrive• Social Work referrals• Documentation

• Examples:• Structure, structure, structure!• Poor nutritional choices (i.e. juice, extra water in formula, etc)• Inappropriate expectations


Sensory• Pleasurable experiences: Start ASAP!• Texture specific• Brand specific• Color specific• The “jump” from stage 1 to stage 2• Recipes/food journals• Tolerates, interacts, smells, touch, tastes, eats• Maintain expectation/control….end on a positive• Never let them refuse to get out of eating


Psychosocial Challenges/Behavioral• Can be a control issue• Can stem from abuse/neglect• Can accompany several other fears/anxieties• Psychologist should be involved

• Behavioral charts• Ignore negative/praise positive• Food journals• Group therapy can be helpful

Toomey, K. A., & Ross, E. S. (2011). SOS approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(3), 82-87.


Group Therapy• Comprised of 3-4 kids, each with similar goals and ages• ST and OT • Weekly

Ideology:• Peer mentoring• Decreased anxiety• Feedback from peers• Social skills• Provides a sense of belonging for child and parents

Benefits:• Desire to model to “show off” to peers• Encouragement• Appropriate table manners• Parental support system

Parent Feedback:• “My son gets the chance to see he’s not the only one who struggles.”• “This group has greatly reduced anxiety about foods and made trying new foods fun!’

Drawbacks:• Feeding off of negative behaviors

*Should be done in conjunction with individual treatment, not intended to replace!

Dowden, P. et al. (2006). Survey of SLP caseloads in Washington State schools: Implications and strategies for actions. Language, Speech , and Hearing Services in Schools. 37(2): 104-117.

Group TherapyPreparation:

• Develop a catalog of ideas• One therapist each session plans and leads group

Format:• 1 theme-based game/activity at beginning to decrease anxiety• Theme-based book• Theme-based meal• Language Activity• Gross of Fine motor activity• Discussion of experiences• Home program


Group Therapy ExampleBook: The Very Hungry Caterpillar

Game: Match the colored circles to your caterpillar

Table Time: Same routine each time. • Find placemat• Get washcloth• Wipe face (warm/cold)• Family style serving• All Done bucket

Foods: watermelon, cheese, pickles, cake, ice cream, salami, *Make sure to have preferred and non-preferred items*Present one at a time and offer “all done” bucket

Language Task: Categorize sweet/salty/soft/crunchy

Gross Motor: Wiggle like a caterpillar down the hallway

Discuss: Vote on favorite foods

Home Program: select x2 non-preferred food items to offer child daily; food journal


Kids should, in fact, play with their food!• Play food• Hot/cold washcloths• Pudding Car Wash• Broccoli Basketball• Flying plate game• Handprint animal pictures• Painting• Throwing• Mixing• Car wash• Tug-of-war• Blowing• Kiss• Hot/cold washcloths

Children learn about their environment through oral exploration

Adaptive Equipment

ADAPTIVE EQUIPMENT

HabermanFeeder

Pigeon Nipple

Supplemental Nursing System

Dr. Brown’s Specialty Feeder

Adaptive Equipment

Adaptive Equipment

Adaptive Equipment

Feeding Tubes

Feeding tubesWhy does the child have a feeding tube?

◦ Nasogastric tube◦ short term

◦ Gastrostomy tube◦ long term

Is the child safe to take anything orally?◦ If so, encourage caregiver to do so

NPO◦ Pleasure feeds, if medically safe and appropriate

◦ Oral exploration of toys for positive oral experience

◦ Oral care◦ Decrease risk for aspiration of oral bacteria

Feeding Tubes

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=y7QmiKYMsk_4fM&tbnid=eulI1lLoGrl7bM:&ved=0CAUQjRw&url=http://blog.mldfoundation.org/2013/04/changing-a-g-tube-gastric-feeding-tube/&ei=qCSGU8iiO4eLqAbmtIDIAg&bvm=bv.67720277,d.b2k&psig=AFQjCNH5WYp7UgbV3Hix8D8AIK6BftAEig&ust=1401386521385249

Transitioning from tube to oral feeds

The longer a child goes without oral feeds, the more severe the feeding problem will become.◦ Smoother transition if oral feeds are introduced by the developmental age of 6 months (Blackman &

Nelson, 1987).

Prerequisites:◦ The child is medically stable

◦ The child can safely swallow

◦ The child can tolerate bolus feeds

American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report.

Transitioning (continued)

Continuous to bolus feeds◦ 3 meals, 2 snacks

◦ Allows child to anticipate upcoming feeds

Ideally, eliminate nighttime continuous feeds

Collaboration with Registered Dietician◦ Adjustment in tube feedings

◦ Ensure child is continuing to meet nutritional needs

Removing the feeding tube◦ After 6 months with no use

◦ Or child maintains nutrition and hydration during an illness.

American Speech-Language-Hearing Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report.

Additional SourcesBeckman, Debra A. Beckman Oral Motor Assessment and Intervention. Maitland: Beckman & Associates, n.d. Print.

Fernando, Nimali, and Melanie Potock. Raising a Healthy, Happy Eater: A Parent's Handbook-- a Stage-by-stage Guide to Setting Your Child on the Path to Adventurous Eating. New York, NY: Experiment, LLC, 2015. Print.

"Gelmix Formula & Breast Milk Thickener - Nature's Healthier Thickening Option." Gelmix Formula & Breast Milk Thickener. N.p., n.d. Web. 16 Oct. 2016.

Kerzner, B., K. Milano, W. C. Maclean, G. Berall, S. Stuart, and I. Chatoor. "A Practical Approach to Classifying and Managing Feeding Difficulties." Pediatrics 135.2 (2015): 344-53. Web

"Lowsky, Debra C. "Teaching the Concept of Biting and Chewing." ARK Therapeutic. N.p., n.d. Web. 25 July 2017.

Pediatric Dysphagia: Assessment." American Speech-Language-Hearing Association. ASHA, n.d. Web. 24 July 2017.

Rybak, Anna. "Organic and Nonorganic Feeding Disorders." Annals of Nutrition and Metabolism Ann Nutr Metab 66.5 (2015): 16-22. Web.

Shaker, Catherine, and Theresa Gager. "Pediatric Swallowing and Feeding: The Essentials." N.p.: n.p., n.d. Print.

Shaker, Catherine. "Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part II: Interventions to Promote Neuroprotection and Safety." Seminars in Speech and Language 38.02 (2017): 106-15. Web.

Swigert, Nancy B. The Source for Pediatric Dysphagia. East Moline, IL: LinguiSystems, 1998. Print. "Warning for Infant Use." Warning for Infant Use. N.p., n.d. Web. 16 Oct. 2016.

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