BACKGROUND

Estimated prevalence of feeding disorders in the United States ranges from 25% to 45% in typically developing children and from 33% to 80% in children with developmental delays, per summaries of investigations reporting these figures (Burklow, Phelps, Schultz, McConnell & Rudolph, 1998, Linscheid, 2006).

A healthy preterm baby may rely on oral feeding as early as 34 weeks. Aspiration places an infant at risk for aspiration pneumonia. Any abnormalities in the swallow appear to occur after multiple swallows. Most infants who aspirate do not show signs, such as a cough, indicating silent aspiration. There is a need for normative data to develop a better understanding of typical oral motor development for feeding (Delany and Arvedson, 2008).

Deficits in tongue strength have direct implication on the oral phase of the swallow and therefore effect the pharyngeal phase of the swallow as well. A quantitative measure of tongue strength in infants has the potential to aid in the assessment and treatment of pediatric dysphagia (Porter & Short, 2009).

Nicosia, Roecker, Carnes, Doyle, Dengel, and Robbins (2000) noted multiple-peaked swallows in their study where the first peak had a higher pressure than the second lower pressure after the bolus had left the oral cavity. Furthermore, this was observed in all participants for the liquid bolus. Nicosia (2000) described how the first peak pressure was to propel the bolus into the pharynx and the second lower pressure peak was after the bolus had exited the oral cavity.

HYPOTHESES

There will be a difference in the peak pressure when you compare the infants diagnosed with dysphagia and those with a typical swallow.

Normative data will be provided for infants ranging in age from 0-6 months.

1Zacharias, E., 1Seikel, J. A., 1Sorensen, D., 1Hardy, A., 1Flipsen, P., & 2Devine, N.1Communication Sciences & Disorders, and Education of the Deaf, Idaho State University

2Department of Physical and Occupational Therapy, Idaho State University

PROCEDURE

The participants caregivers were administered a questionnaire to evaluate the birth history, developmental growth and any complications with sucking or swallowing the infant may have had since birth.

The Cradle Side Swallow Assessment was used to evaluate the infants’ feeding abilities.

The IOPI was utilized to obtain three peak pressures in kPa while the infant was swallowing or sucking on the bulb.

The IOPI was connected to digital recorder to collect real time data while the infant was sucking on the bulb. The infant was administered 1mL of breast milk or formula to elicit a nutritive suck.The following data was abstracted :

Jitter percentage was defined as the average period difference between the consecutive cycles divided by the average period multiplied by 100 (Horii, 1982). Jitter percentage was obtained for the sucking interval and the suck- swallow interval for each of the trials that the participants underwent.

The sucking interval consisted of time between consecutive sucks, and did not include a swallow.

Suck-swallow interval was the time between successive swallow events.

Descriptive analysis (mean, standard deviation, and minimum and maximum values) were computed for each trial performed for both groups. Mean peak pressure and percentage of sucking jitter were computed by gestational age in one month increments.

This graph depicts a non nutritive suck from male who had a gestational age of 53 weeks. Five second graph with a 5 Hz low pass filter. Note the swallow followed by the sucking burst and then proceeded by another swallow.

This graph depicts a non nutritive suck from a male diagnosed with Noonan Syndrome who had a gestational age of 58 weeks. Five second graph with a 5 Hz low pass. Note the proximity of the waves that gets further apart as time increased.

This was the first data collected from this participant. His subsequent graph indicated a slower sucking rhythm, which was detected using a 4 Hz low pass filter. And by his third graph, he stopped sucking for a portion of the data.

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Participant 14 infants with a typical swallow. 3 infants with dysphagia

• 2 were diagnosed with dysphagia secondary to reflux

and 1 diagnosed after the study with Noonan Syndrome. Infants were both breast and bottle fed. Ranged in gestational age from 42-63 weeks. Nutritive and non-nutritive sucking data was collected.

Experimental Design Single subject design

Independent variable: swallowing abilities

(typical swallow or diagnosed with dysphagia) Dependent variables: Peak pressure during a swallow,

suck sequence, and suck-swallow sequence. Control Variables: labial strength.

Instrumentation IOPI Northwest Model 2.1 by IOPI™ Northwest Co., LLC,

Carnation, WA, was used to measure swallow pressure

and collect real time data of suck and suck-swallow sequence. Sony ICD-UX200Fdigital recorder. Cradle Side Feeding Evaluation 1mL plastic pipette Parent Questionnaire



This graph depicts a non nutritive suck from a male infant with untreated reflux who had a gestational age of 54 weeks. Five second graph with a 5 Hz low pass filter. Note the number of consecutive swallows with the limited sucking intervals.

Compare the above graph to the graph below of the same infant, but it depicts a nutritive suck. Notice the similarities in the limited amount of sucking bursts along with the irregularity of the sucking rhythm.

DISCUSSION

This study found no difference in tongue strength between infants with a typical swallow and those diagnosed with dysphagia and dysphagia secondary to reflux. Mean data for infants with a typical swallow was 23.46 kPa, while infants diagnosed with dysphagia had a mean of 20.22 kPa, respectively. While no difference was found in tongue strength between the groups form this study, analysis of the data is cautioned due to the limited number of participants of infants diagnosed with dysphagia.

It was hypothesized that a difference would emerge between infants with a typical swallow and those diagnosed with dysphagia with a larger number of participants and a wider array of impairments. This is based on the fact that participant 6 had peak pressures that were on average 10 kPa less than the mean peak pressure from infants with a typical swallow. This is approximately half of the peak pressure of the infants with a typical swallow. Based on the peak pressure from this participant, if the sample were larger and included participants who varied more in severity, then a significant difference could appear between the two groups.

Findings revealed that there was no difference in the organization between infants diagnosed with dysphagia and infants with a typical swallow. This finding is cautioned due to the limited number of participants in the dysphagia group. It is the hypothesis that a larger number of participants combined with more participants who had more severe impairments would reveal a difference in the sucking organization. This is based on the finding that participant 6, who had severe dysphagia, in three different trials was found to become less organized on all of the trails. This indicates that there could be a difference noted and that the level of impairment does play a difference in the infant being able to organize their suck.

Findings revealed that there is no difference in the sucking regularity between infants diagnosed with dysphagia and those with a typical swallow. The mean sucking jitter, which looks at the variability between the sucking intervals, indicated that both groups were around the same sucking jitter of 24.9%.

ConclusionWhile there was no significant difference noted in the peak pressures

generated between the two groups, there is evidence that indicates if the sample size was larger and the degree of involvement reflected what is typically seen in the population, than there may be a significant difference noted between the two groups.

The Effectiveness of the Iowa Oral Performance Instrument (IOPI) to Differentiate Infants Diagnosed with Dysphagia

METHODS

RESULTS

References

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Table 1Descriptive Analysis for Peak Pressure

n Min SD Mean Median Max

Infants with a Typical Swallow

14 16 kPa 4.64 23.46 kPa 24 kPa 31 kPa

Infants with dysphagia

3 12 kPa 6.59 20.22 kPa 20 kPa 30 kPa

Note. SD= Standard Deviation. Min= Minimum Value. Max=Maximum Value. n = number of participants.

Non Nutritive Suck in an Infant with a Typical Swallow

Non Nutritive Suck in an Infant Diagnosed with Noonan Syndrome

Non Nutritive Suck for an Infant with Reflux Symptoms that was Untreated

Burklow, K. A., Phelps, A. N., Schultz, J. R., McConnell, K., & Rudolph, C. (1998). Classifying Complex Pediatric Feeding Disorders. Journal of Pediatric Gastroenterology and Nutrition, 27, 143–147.

Delaney, A.L., & Arvedson, J.C. (2008) Development of Swallowing and Feeding: Prenatal Through First Year of Life. Developmental Disabilities Research Reviews 14.2, 105-117.

Linscheid, T. R. (2006). Behavioral Treatments for Pediatric Feeding Disorders. Behavioral Modification, 30(1), 6–23.

Nicosia, M., Hind, J., Roecker, E., Carnes, M., Doyle, J., Dengel, G., & Robbins, J. (2000). Age Effects on the Temporal Evolution of Isometric and Swallowing Pressure. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55.11, M634-M640.

Porter, Nancy L. & Short, Robert. (2009) Maximal Tongue Strengths in Typically Developing Children and Adolescence. Dysphagia, 24, 391-397.