Paediatric Feeding (disability) group, EBP Extravaganza (2009) Intervention to promote chewing skills in children Paediatric Feeding (Disability) Group

Paediatric Feeding (disability) group, EBP Extravaganza (2009)

Intervention to promote chewing skills in children

Paediatric Feeding (Disability) Group

http://epicself.com/wpcontent/uploads/2009/02/chewing.jpg


To start: Completed 2008 CAT

Clinical question: In Children with Cerebral Palsy (Spastic Quadriplegia),

what is the evidence that upright positioning in midline is safest for eating and drinking?

Reasoning for question: General recommendations to clients with swallowing

difficulties aim to position clients at the default position of 90-90-90 posture (upright at 90 degrees in the wheelchair as much as possible)


The clinical bottom line.

A 20 to 30 degree reclined position with neck flexion (chin tucked) is the safest positioning for feeding a child with tetraplegia and dystonia.

Chin tuck is a useful technique to improve closure of the airways. The tilting down of the epiglottis seems to be facilitated and this gives some protection to the laryngeal vestibule even if the vestibule is not completely closed.


Continued (positioning CAT)

Reclined (Tilted?) 30 degree position has evidence that it is the better than upright 90 degree position for most children with cerebral palsy (aged 1-10 years).

Positioning is highly individualised for a child with cerebral palsy so this may not work for everyone.

Most importantly head and trunk alignment has the biggest impact on feeding skills for a child with cerebral palsy.


Search for a new clinical question:

Anecdotally, Speech pathologists working with clients in the disability population can often encounter clients who bite non-nutritive objects and also having feeding difficulties.

Is there evidence that these items can assist develop chewing skills for these children?

The group sought to look at the evidence for using non-nutritive objects to develop chewing skills in children


Chewy Tubes

Chewy tubes are a popular product used by the disability population. They are promoted as being able to do the following:

“Chewy Tubes are an innovative oral motor tool designed to develop biting and chewing skills.” (http://www.chewytubes.com/)

They are described as being suitable for the following disability populations: Autism, Down Syndrome and Cerebral Palsy

http://mealtimenotions.com/ProductsTools/362007all_three_chewy_tubesSMALLER.jpg


The question formed

P: Population- In children who have eating and drinking difficulty.

I: Intervention- will non-nutritive objects such as chewy tubes

C: Comparison- N/A

O: Outcome- improve chewing skills.


Searching the evidence

We’ve searched from:

ERIC SpeechBITEGoogle Scholar PsychInfoMedlinePubMEDOVIDCINAHLPEDro

http://www.theequitykicker.com/wp-content/uploads/2009/03/searchmagnifyingglass.jpg


Search terms….

Chewy Tube, theratube, non-nutritive, chewing, disability, feeding difficulty, oro-motor dysfunction, food texture, bite


Clinical bottom line

We do not tend to recommend the use of non-nutritive objects to develop chewing skills if the clients are orally fed.

May be a more appropriate item for meeting sensory needs only; not developing specific feeding skills (Scheerer, 1992)


Difficulty in researching/ question

Too specific in choice of intervention type to investigate (Chewy tubes/ non-nutritive chewing)

Basis of feeding difficulty not clear in clinical question (? Sensory based, neuro-muscular, oral structures)

No preliminary search (this may have saved the group long aimless searching).


Development of a new question

The search for a new question is to be based on the current clinical practice of clinicians working with clients with eating and drinking difficulties.

…What are the current clinical practices that could lend themselves to a new CAT?


Current Clinical Practice

ADHC Hurstville has a lunch club with main objective is to address specific feeding issues such as starting solids and moving to the next texture.

The clients who attend have a range of disabilities: Down Syndrome, Autism, Global Delay, Cerebral Palsy.


Current Recommendations and Rationale for develop chewing skills

RECOMMENDATION

For client to hold and experience with hard munchable food where no bits come off e.g. chunky carrot stick

RATIONALE

To encourage chewing practice without requiring to swallow


Current Recommendations and Rationales for develop chewing skills

RECOMMENDATION

Eat bite and dissolve foods, meltable hard solids e.g. milk balls, cheese bacon balls.

Placing the food to the side of the teeth

RATIONALE

Encourage client to feel and experience different textures and position by placing on one side of the mouth on the molars or the gums



RECOMMENDATION Client is starting to bite

bread so introduce other firm things like cooked vegetables, arrow root biscuits (progressively moving towards crunchy foods).

RATIONALE Extending a new

skill/generalising. Desensitising to different textures.



RECOMMENDATION Client only eating

sandwiches at preschool, introduce this food at home.

Introduce other foods similar to toast eg: english muffins, crumpets, hard ends of cake.

RATIONALE Extend food to other

environments.

Generalising textures to extend range of foods consumed.



RECOMMENDATION Use a left handed

angled spoon.

Develop biting skills with placement at side using cruskits and arrow root biscuits.

RATIONALE Enable client to achieve

appropriate hand grip to feed more easily and independently.

Encourage lateral chewing motion, strengthen, desensitising.



RECOMMENDATION Client is overfilling. Cut

food into 2cm pieces.

RATIONALE Reduce ability to

overstuff, supervise, possibly supplement oral sensory seeking with something else if that is the reason for overstuffing.


Summary of recommendations as potential clinical questions:

Pt./Problem Intervention Comparison

Outcome

Autism

Down syndrome

Oro-motor difficulties

Eating/drinking difficulties

Developmental delay

Positive reinforcement, side placement, chewing training, texture fading

Develop chewing, Encourage lateral chewing, strengthen, desensitise, improve bite, chewing generalisation, increase food variety


In 2010,

We will have access to ADHC library during our meeting time so that we can decide on the topic that has research evidence.

We will continue to monitor the outcomes of clients who need to develop their chewing skills and the rate of success from each of our recommendations with GAS goals

WATCH THIS SPACE!!


Where to from now….

Next year, our meetings will be at ADHC Hurstville

390 Forest Road Hurstville Ph 9701 6000 Please contact Nitha Thomson:

[email protected]

Ph: 9297 6000 if you are interested


References

Dawes,M.,Badenoch,D and Goddard, O. Informed Clinical Practice. Centre for Evidence-Based medicine, Univ of Oxford,Nov 2000

Giselle EG, Tessler MJ, Laplerre G, Seidman E, Drouin E, & Fillon G (2003) Feeding management of children with severe cerebral palsy and eating impairment: an exploratory study. Physical and Occupational Therapy in Pediatrics 23(2): 19-44

Hulme JB, Shaver J, Acher S, Mullette L, & Eggert C (1987) Effects of adaptive seating devices on the eating and drinking of children with multiple handicaps. American Journal of Occupational Therapy 41(2):81-9

Larnert G, & Ekberg O (1995) Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. Acta Paediatr Jun;84(6):689-92

Scheerer, C.R, (1992), Perspectives on an Oral Motor Activity: The use of Rubber Tubing as a “Chewy”, The American Journal of Occupational therapy, Volume 46 (4), pp 344-352

http://www.autism-pdd.net/testdump/test5659.htm

Documents

Paediatric Feeding (disability) group, EBP Extravaganza (2009) Intervention to promote chewing skills in children Paediatric Feeding (Disability) Group