Indiana ISHA Update in Pediatric Dysphagia-The Growing ... ISHA... · Disorder is managed with non-oral feeding for supplemental or total nourishment. Related nutritional, hydration

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UpdateinPediatricDysphagia:

TheGrowingYears

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DonnaEdwards,M.A.CCC-SLP,BCS-S,OSLHA-F,ASHA-F

Disclosure:NonfinancialRelationshipASHA2018DysphagiaTopicCommitteeMemberASHASIG13EditorialCommittee(PastEditor2012-2015)SpecialtyBoardonSwallowingandSwallowingDisordersMentorCommitteeChair;ApplicationsCommitteeMember;(2011-current)OSLHAPastPresident(2016-2018);RepresentativetoGovernmentalAffairsCoalitionASHAGovernmentRelationsPublicPolicyBoardMember(2015-2018)Financial:HonorariumandsalaryreceivedfromBaldwinWallaceUniversity

April2018ISHAIndianaDonnaEdwards,MACCC-SLP,BCS-S.ASHA-F

Objectives

Ê  Theparticipantwillbeabletostatefourrecentresearchresourcessupportingtreatmentandevaluationofdysphagiainchildrenandyoungadults.

Ê  Theparticipantwillbeabletodelineatebetweentypicalandatypicalfeedingandswallowingdevelopmentinchildrenandyoungadults.

Ê  Theparticipantwillbeabletodescribefouravenuestopromoteadvocacyeffortstosupportchildrenandfamiliesdealingwithdysphagia.


Historically

Complexinterplayofphysiological,socialandbehavioralfactors

Ê  Structuralabnormalities,neurologicalconditions,cardiorespiratorycomplications,metabolicdysfunction,behavioralissues

Ê  Similarbehavioralfeedingpatternsoccurinhealthyyoungchildren,butatahigherfrequencyinchildrenwithafeedingdisorderÊ  Slowfeeders:longerthan30minutesÊ  Significantassociationbetweenpickyeatingpattern,lengthofmealtimeandoral

motordysfunctionÊ  Difficulttransitionbetweenmeals,settings,feeders,foods,etc…Ê  Thetermpickyeater,acommonpatternfortoddlers,isexacerbatedtothelevelof

narrowedfoodselectionoftenwithinsufficientnecessarynutrients

(CristandNapier-Phillips2001,Jungetal2016,Reauetal1996)


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CriticalThinking:OurChargeforFunctionalOutcomes

Ê  Adeptatdiagnosing,treatingandre-assessingfeedingandswallowingdisordersandrecognizethattreatmentvariesinrelationtoindividualpatientneed

Ê  Ultimategoalistoincreaseoralintakewiththepurposeofhelpingeachpatientmeethisorhernutritionalneedsinthesafest,mosteffectivewaypossibleacrosssettings

Ê  Analyzingthefeedingdisordersanddysphagiainassociationwithourevergrowingunderstandingofsensorysystems,psychosocial,psychobehavioralandmotoraspectsoffoodandliquidconsumptioninlightofthefamilyandsocialdynamic


Functionalsingleswallow


Thinliquids

SipperCuppresentation

ReducedAirwayProtection


AspirationDuringtheSwallow StasisorResidue


Highriskof

aspirationpost

swallow ReducedpharyngealpressureReducedlaryngealexcursion/anteriormovementThickerisnotalwaysbetter

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CervicalFlexion


OralandPharyngealDysphagia

Adolescent-OralDysphagia


ImmatureVerticalChewingPattern

DysphagiaManagementStagingScale(DMSS)


Ê DMSS

Quicktestfordysphagia,unsafeeatingbehaviorsanddelayeddevelopmentofeatingskillsthathasbeenstandardizedonover800people,includingchildrenandadults,withdevelopmentaldisabilities.Itcanbeadministeredinaslittleas10minutes.TheDDSisappropriateforuseforages,2-yearsthroughadulthood.TheDDSisataskanalysistoolthatdescribesthecharacteristicsofthedisorderandprovidesrawandstandardizedscoresthatarenumericalmeasuresofseverity.Thescorespermittest-re-testcomparisons,andcomparisonsbetweenindividualsandbetweengroupsofindividuals.TheDMSSisafive-levelscaleforratingseverityofinvolvementforfeedingandswallowingdisorderbasedonmanagementneedsandhealthrelatedoutcomes.ItisusedinconjunctionwiththeDDS.

J.J.Sheppardetal./ResearchinDevelopmentalDisabilities35(2014)929–942


DysphagiaManagementStagingScaleordinallevels.LevelofSwallowingandfeedingdisorder Definition

Level1.Nodisorder

Nosignsorsymptomsofswallowingandfeedingdisorderinoralpreparation,oral-pharyngealoresophagealstagesofswallowing.Swallowingcapabilitiesarefunctionalforallbolustypes.Nosymptomsofrelatedunsafeoranorecticbehaviors.Maybedependentforeating.

Level2.Milddisorder

Swallowingandfeedingdisorderandunsafeoranorecticbehaviorscanbemanagedwithasinglestrategytype:adaptiveutensils,dietrestrictions,seating,adaptivefeeding/swallowingstrategiesormedications.Personmaintainssatisfactoryhealthwithreferencetonutrition,hydrationandrespiratoryfunction.

Level3.Moderatedisorder

Swallowingandfeedingdisorderandunsafeoranorecticbehaviorscanbemanagedwithacombinationoftwoormorestrategytypesincludingadaptiveutensils,dietrestrictions,seating,adaptivefeeding/swallowingstrategiesand/ormedications.Personmaintainssatisfactoryhealthwithreferencetonutrition,hydrationandrespiratoryfunction.

Level4.Severedisorder

Managementofswallowingandfeedingdisorderandunsafeoranorecticbehaviorsincludesacombinationoftwoormorestrategytypesincludingadaptiveutensils,dietrestrictions,seating,adaptivefeeding/swallowingstrategiesand/ormedications.Relatednutritional,hydrationorrespiratoryproblemspersistinspiteofthemanagementprogram.

Level5.Profounddisorder

Disorderismanagedwithnon-oralfeedingforsupplementalortotalnourishment.Relatednutritional,hydrationand/orrespiratoryproblemsmaypersistorconditionmaybesatisfactory.

J.J.Sheppardetal./ResearchinDevelopmentalDisabilities35(2014)929–942

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Thisiswork!Whatdoyousee?Notice:

Reducedenduranceandcoordinationwithrepetitivechewing

Recruitmentofothermuscles/movementsformaladaptivecompensatoryefforts

head

periorbital

procerus

nasalis

mentalis

salivamanagement

shallownasolabialfolds

pale

horizontaljawslideApril2018ISHAIndianaDonnaEdwards,MACCC-SLP,BCS-S.ASHA-F

HowDoWeApplyResearchToPractice?


EBP

HenowRunstowatchcookingshows!

Keypoints:BelgiumStudy(120children)

●Pulmonaryproblemsplayanimportantroleinthemorbidityandmortalityofchildrenwithneurocognitiveimpairment

●Impactmaybeunder-recognizedbycaregiversanddoctors.

●Medicalliteraturepaysrelativelylittleattentiontothistopic.

●Thediagnosticandtherapeuticapproachshouldbemultidisciplinary.

April2018ISHAIndianaDonnaEdwards,MACCC-SLP,BCS-S.ASHA-FProesmans,December2016

Keypoints:BelgiumStudy

●Childrenwithneurocognitiveimpairmentoftenpresentwithchronicorrecurrentrespiratoryproblems.

●Therespiratoryproblemshaveanimportantimpactonqualityoflifeandlifeexpectancy.

●Theunderlyingcausesaremultiple:riskofaspiration,insufficientcough,upperairwayobstructionandprogressivekyphoscoliosis.

●Thereisoftenacomplexinterplaybetweentheseknownriskfactors.

●Thediagnosticandtherapeuticapproachshouldbemultidisciplinary.

April2018ISHAIndianaDonnaEdwards,MACCC-SLP,BCS-S.ASHA-FProesmans,December2016

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Risk factors for respiratory illness in children with disability.

Marijke Proesmans Breathe 2016;12:e97-e103

©2016 by European Respiratory Society

reflux

Obstructivesleepapnea


PosturalStabilityMovementPrinciples

o  Mature,organizedmobilitydevelopsfromstability

o  Movementdevelopsproximaltodistal

o  Grossmotorcontrolprecedesfinemotorcontrol

o  Facilitationofmaximalindependentfunctionisthelongtermgoal

(Redstone,West2004;Verheydenetal.2004)


Whatdoweknow?Kyphoscoliosis


ChildrenwithCP,andotherneurologicalproblems,arepronetodevelopmusculoskeletaldeformities.Mayresultin:•  lossofselectivemotorcontrol•  anincreaseinunderlyingmuscletone/muscleimbalancewhichcanleadtoabnormal

deformingforcesactingontheimmatureskeleton

•  mechanicaldisadvantageoftherespiratorymuscles•  decreasechestwallcompliance•  Ifpresentintheyoungchildmaylimitlunggrowth.•  Inchildrenandadultswithsevereneurologicalimpairment,kyphoscoliosisisoneof

themajorfactorspredictingincreasedend-tidalcarbondioxide,ameasureofrespiratoryventilator

•  Occasionally,severekyphoscoliosiscanleadtoairwaycompressionbythedisplacedspine.

PrimaryRole:RehabilitativeExercises

Ê  EffectchangeinthephysiologiccomponentsofswallowingÊ  StrengthÊ  DurationÊ  Timingofmovement

(Robbins,et.al.2008)

Ê  RetrainingtheneuromuscularsystemstobringaboutneuroplasticityÊ  Theabilityofthebrainandnervoussystemtochange

Ê  StructurallyÊ  Functionally

Ê  Pushinganymuscularsysteminanintenseandpersistentwaywillbringaboutchangesinneuralinnervationandpatternsofmovement

(Langmore&Pisegna2015)


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Neuroplasticity

Transference:Othermotorunitscanlearntoparticipateinthetask(perhapsbyincreasingoverallstrength)oreventakeoverthetask(i.e.non-damagedadjacentcorticalareasorrecruitmentofnon-damagedareas)astransferenceoccurs(Burkheadetal.,2007;Robbinsetal.,2008).

Ø Synkinesisorrecruitmentofneckmusculature


PrinciplesofExercise

Useitorloseit:failuretouseaswallowresultsindegradationoftheswallowingmusculatureanddiminishedinnervationØ  deconditioningaftersurgery/Dependenton

alternatesource/tubefeeders.Useitandimproveit:trainingdrivesplasticity.Ø  patientsshouldpurposefullyswallowmore

oftentoimproveswallowing.(musclememory)

Specificity,swallowingrecruitsspecificmotorunits;trainingthattaskwillreinforcethemotorunitsandtheinvolvedneuronalpathways(Clark,2003;ClarkandShelton,2011;Robbinsetal.,2008).(efficiency)


Principlesofexercise:Neuroplasticity

Ê  Intensityunderliesanyswallowingexerciseprogram.

Ê  “engaginginexercisethatisnotintenseenoughtopushthesystembeyondthelevelofactivitytowhichitisaccustomedwillnotresultinadaptation.”

Ê  Theswallowingexercisemustexceedusuallevelsofactivityandperformedforanadequatedurationtohaveaneffect(Burkheadetal.,2007,p.255).


Placementonthemolartableusesthebitereflextoenhancerepetitivechewingpracticetofurtherpromoteskilldevelopment

Non-swallowingexercises:Shakerheadliftacombinationofanisometricandisokineticexercise,hasbeenshowntohavefavorablelong-termeffectsbyimprovingthestrengthofthesuprahyoidmusclesovertime,andenduranceforincreasingtheopeningoftheupperesophagealsphincterinpatientswithdysphagia(Shakeretal.,1997,2002).

TonguestrengtheningMultiplestudieshaveinvestigatedtonguestrengtheningovertimeinavarietyofpatientpopulations

Ê  Exercisingthetonguehasgreatpotential,yettheevidenceforbenefithasnotyetbeenshown.



SlightlystickysalivaDifficultygradingjawmovementsStabilizingtonguewithlipsandjawSocialissues

Non-swallowingexercises:LeeSilvermanvoicetreatment(LSVT)

Ê  Improvevocalintensity(LeeSilvermanVoiceTreatmentprogram;Scott,S.,&Caird,F.L.,1983)

Ê  TreatmentphilosophiescanbeextendedtootherpopulationswithsmallmovementsbeyondALS.

Ê  Retrainsensoryperception,establishnewassociationbetweeneffortandnormalmovement(makeitbigger)

Ê  RelationtoPrinciplesofneuroplasticityÊ  oForced/Effortfuluse

oIntensivepracticeoRepetitionoComplexity/Challenging

oFeedback/motivation

Expiratorymusclestrengthtraining(EMST)(Troche,Okun,Rosenbek,Musson,Fernandez,Rodriguez,etal.,2010)

Ê  Exhalingquicklyandforcefullyintoamouthpiecethatisattachedtoaone-wayvalve,blockingtheflowofairuntilthepatientproducessufficientexpiratorypressure.Ê  Itismeanttostrengthentheexpiratoryandsub-mentalmusclesbyincreasingthephysiologicload.


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SwallowingExercises:

Ê  Masako.Thismaneuverinvolvesswallowingwhileprotrudingthetonguebeyondthelipsandholdingitbetweenone’steeth.Incompletecontactbetweentheposteriorpharyngealwallandthebaseofthetongue

Ê  McNeilldysphagiatreatmentprotocol.Thisisarelativelynewprograminwhichswallowing“hard”isthesinglefocus.ThisexerciseappearssimilartotheEffortfulSwallow.Reportedly,bolussizesandvolumesareincreasedindifficultyandthepatientisencouragedtoswallowfasterandharder.

Ê  Mendelsohn.Well-knownswallowmaneuvertotargetlaryngealexcursion.Itisoftentaughtwithsomeformofbiofeedbacktohelpthepatientperformitcorrectly.

Ê  Thesuper-supraglotticswallow.Thismaneuverinvolvesapersonholdingatightbreath,swallowingwhilekeepingtheairwaytightlyclosed,thenimmediatelycoughingaftertheswallow.Ê  immediateeffectsonlaryngealandhyoidexcursionÊ  Nostudiesinvestigatedthelong-termeffectorcarryover



OtherClinicalConsiderations

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Ê  Lungdiseaserelatedtochronicpulmonaryaspirationisamajorcauseofdeathinneurologicallyimpairedchildren(Piccione,McPhail,Fenchel,Brody,&Boesch,2012).

Ê  Thebestclinicalcoursemayappeartobeanon-oralfeedingplantoprotectachild’slungs.Ê  Wedon’twanttooverlookthe

importanceoforalexperiencesonthechild’sabilitytodevelopappropriateoralmotorandswallowfunction.

Ê  Werealizethelackofopportunitythroughoutcriticaldevelopmentalperiodscanimpairacquisitionofappropriateoralmotorandswallowfunction

(Arvedson,2008;Kelly,Huckabee,Jones,&Frampton,2007).


‘Tobalanceallfactors,aclinicianshouldadvocateafeedingplanthatallowsfor:

v  greatestamountofexposuretooraltrials

v  lowestamountofaspirationrisk

Closemonitoringoforaldevelopmentandlunghealthmustbeongoingforchildrenatriskforchronicaspiration

Whatshouldwedoclinically?

(Simon&Collins.2013)


BehavioralAssessment

Identifycomponentsofthefeeding

problem

Determineifthefamily'sgoalsareappropriateandachievable

Medicalrecordreview

Caregiver-completed

questionnaires

Clinicalinterview

Clarifyfamily's

treatmentobjectives

Observationofthechildwhilebeing

fed

Silverman2015

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BehavioralManagementStrategy

PickaReward

Immediatereinforcementafterthegoalisreached

Transientreinforcer

Overtimetransitiontorandomreinforcement

Earngametimeorspecialevent

ExtinguishingStrategies

Ignorefussing

Presentfooduntilaccepted

Modifychallenge

Onceaccepted-provide30secondbreak


TrackProgress

(Silverman2015)

BehavioralReinforcement


Behavior RewardingStimulusProvided FutureBehavior

Explorenewfood Lackofgagresponse/emesis Increasedexploration

Acceptsrequestedbitechallengeofnewfood

Thatfoodisputawayforsession Increasedacceptanceoffoodandchallenges

Toleratespresenceofnewfoodnearselforonplate

Notaskedtoexploreoreat Increasedacceptanceofnon-preferredfoods

Behavior RewardingStimulusProvided FutureBehavior

Touch/taste/eatnewfood Parentorclinicianpraiseperformance

Increasedexplorationofnewfood

Portioncontrol/reducebitesize Limitedvolumechewedeasier Increasedacceptanceofbites

Abletoeatschoollunchwithpeers

Reducedseparationfrompeers;

PositiveReinforcement

NegativeReinforcement


IncorporatingFamilyandCulturalIssuesintoaSchoolSwallowingandFeedingProgram


•  Whatdoyouthinkresultedintheswallowing/feedingproblem?•  Haveotherfamilymembershadthesameorsimilarconditions?

•  Howwouldyoudescribefamilymealtimes/communitymeals/schoolmeals?•  Whathaveyoudonetotrytoimprovetheswallowing/feedingproblem?•  Haveyousoughtadviceortreatment?•  Whatgoalsdoyouhaverelatedtotheswallowing/feedingproblem?•  Whatresultsareyouhopingtoachieveintherapy?•  Whowouldyouliketobeapartofthisprocess(i.e.,family,friends,

interpreters)?•  Doyouagreewiththediagnosisandrecommendations?(CalgaryHealthRegion,2005)modified

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HelptheParentFeelSuccessful:Optimizecarryovertohome(s)Reducemealtimestress

Offerachievable,simpletasks

Graduallytransitionskillswithmostreadilyacceptedfoodsinsessiontohome

Worktowardfamily/childgoals

Explorefoodsgroceryshopping,preparingmeal,cleaningup

Helpplanfoodstobringtotherapy

Goalsforsamefamilymeal


“Schoolsaretherightplaceforahealthystart”-CDC

Ê  Enhancingandimprovingacademicperformance

Ê  Recognizingthecloserelationshipbetweenhealthandeducation

Ê  Skippingbreakfast,minimalintakeofspecificfoods,nutrientdeficitsandinsufficientfoodintake=Ê  LowergradesÊ  HigherratesofabsenteeismÊ  InabilitytofocusÊ  Graderepetition

Ê  “Needtofosterhealthandwell-beingwithintheeducationalenvironmentforallstudents”CDC(2010)April2018ISHAIndianaDonnaEdwards,MACCC-SLP,BCS-S.ASHA-F

GoalsandCoreConcepts

Incorporatetreatmentgoalsintoschoolrelatedcoreconcepts

Ê  Dependingontheage,gradelevelandskilllevel:

Ê  Compare/contrastmultiplefruitswithclassmates,caregivers,siblings(appearance,touch,taste,mashable?,etc.)Ê  Completesentencegenerationwithsubject+verbagreement

(spoken,written)Ê  Writeaparagraph/drawimageÊ  “Whquestions”Ê  Writeastoryusingvocabularyrelatedwords(crunchy,shape,..)Ê  Howtoprepareadish/sandwichusingappropriatesequence


ASHA2012SchoolSurvey

0102030405060708090100

studentsdysphagia

preschoolers day/residential

autism

SLPserve

FeedingProb

Selectivefeeder

TypicallyDev


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•  Takeatriptotheschoollibrarytoselectfoodrelated/cookingbook.

•  Sharebookswithparent/caregiverasaroutinepartoflife.

•  Namesomefoods/recipeingredientsinabook.

•  Talkaboutfoodpreparation/vocationalroles/inbooks.

•  Listenattentivelytostories.(restaurant/shopping)

•  Beginpayingattentiontospecificprintsuchasthefirstlettersoftheirnames.

•  Makeacollage/trace/drawpicturesoffoods

•  Trace/copyfoodwords/foodshapedletters(o=cerealring)

•  Asktohelpprepare/servefoodsathome


Individualvsclassroomactivities

•  Clearthetable/helpwithgrocerylistpreparation/shopping

•  Exploretouching,smellingandtalkingaboutfoods.(grid)

•  Understandthatfood/liquidsprovidefuelforthebody/growth/nutrition

•  Identifyfamiliarfoodsfromhome/restaurants

•  Participateinfoodrelatedgames.(makearainbowplate)

•  Identifysomesmells/tastesanddescribe

•  Attemptwritingamenu/planclassparty/celebration


DiagnosisupdateDSM-IV

Childmustbeundertheageof6atthetimeofonset

Poororalintakeorinabilitytomaintainahealthyweightforatleast1monththatcannotbeassociatedwithamedicalcondition

Difficultparent-childrelationship

DSM-5

Avoidant/RestrictiveFoodIntakeDisorder(ARFID)hasreplacedFeedingDisorderofInfancyandEarlyChildhood(Atriskfor…)

Persistentdisturbanceineatingleadingtosignificantclinicalconsequences

Weightloss

Inadequategrowth

Nutritionaldeficiency

Dependenceontubefeedingornutritionalsupplementstosustainadequateintake

Impairedpsychosocialfunctioning(unabletoeatwithothers)

Ê  Bryant-Waugh2013


Strategiestoincorporate

Ê  ‘Studentsmustdevelopskillsforeatingefficientlyduringmealsandsnackssotheycancompleteeatinganddrinkingactivitieswiththeirpeerssafelyandinatimelymanner

Ê  Modifieddiet

Ê  Extendedtimeformealssnackormealwithpeers

Ê  Limitingdistractions

Ê  Useofadaptedutensils

Ê  Equipmentforproperpositioning

Ê  Partialtototalassistwithintake

Ê  Needsofstudentsmaychangeasenvironments,socialsituations,theneedforindependenceandadvancingnutritionalneedsevolve

Mabry-Price(2014)


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ParentalPerception


Theliteraturesupports:

Ø  Anassociationbetweenparents'anxietyandreportingfeedingproblems

Ø  Caregiversfrequentexpressionofinadequacyandfrustration

Ø  Theimportanceofamultifactorialapproachtounderstandingchildhoodfeedingdifficulties.

Furtherresearchneeded:NeuralcontroloffeedingandbreathingcoordinationinfulltermandprematureinfantsThickeningagentsandtheireffectonthepediatricandelderlygeriatricgastrointestinaltractEffectofaspirationonthedevelopingpulmonarysystemEffectofaspirationonthedevelopingsensorysystem


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Indiana ISHA Update in Pediatric Dysphagia-The Growing ... ISHA... · Disorder is managed with non-oral feeding for supplemental or total nourishment. Related nutritional, hydration