Pediatric Feeding Disorder: Diagnosis & Management...2/19/20 1 Pediatric Feeding Disorder: Diagnosis & Management Presented to the 50th Annual Mid-South Conference on Communicative

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PediatricFeedingDisorder:Diagnosis&Management

Presentedtothe50thAnnualMid-SouthConferenceonCommunicativeDisorders

Memphis,TN*March6,2020

MemorieM.Gosa,PhD,CCC-SLP,BCS-SPediatricSpeech-LanguagePathologist,AssociateProfessor

[email protected]

Definitionofpediatricfeedingdisorder(PFD)anditsrelationshiptopediatricdysphagia2:00–2:15

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Imagefrom:https://nouvelles.umontreal.ca/en/article/2017/12/14/eating-together-as-a-family-helps-children-feel-better/

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•  Anydisruptiontotheswallowsequencethatresultsincompromisetothesafety,efficiency,and/oradequacyofnutritionalintake.

Dodrill&Gosa(2015).Pediatricdysphagia:Physiology,assessment,andmanagement.AnnNutrMetab,66(5),

24-31.

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Dysphagia

•  Dysphagiaexistsif:– Feedingproblemsinterferewithairwayprotection– Compromiseadequatenutrition/hydration–  (Peds)Compromiseenjoymentforeitherparentorchild

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Dysphagia

•  Pediatricdysphagiaisdistinctasaskill-baseddisorder

Dodrill&Gosa(2015).Pediatricdysphagia:Physiology,assessment,andmanagement.AnnNutrMetab,66(5),

24-31.

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VariableIncidence&Prevalence

•  25%-45%oftypicallydevelopingchildren(Arvedson,2008;Bernard-Bonnin,2006;Brackett,Arvedson,&Manno,2006;Burklow,Phelps,Schultz,McConnell,&Rudolph,1998;Lefton-Greif,2008;Linscheid,2006;Manikam&Perman,2000;Rudolph&Link,2002)

•  30%-80%forchildrenwithdevelopmentaldisorders(Arvedson,2008;Brackett,Arvedson,&Manno,2006;Lefton-Greif,2008;Manikam&Perman,2000)

•  3%-10%ofchildrenhavesevereconsequences-Higherprevalence(10%-49%)inchildrenwithhistoryofprematurity,medicalillnessand(26%-90%)physicaldisabilities(Manikam&Perman,2000)

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PediatricFeedingDisorder(PFD)

•  PFD=impairedoralintakethatisnotage-appropriate,andisassociatedwithmedical,nutritional,feedingskill,and/orpsychosocialdysfunction.

Goday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P., Cohen, S. S., Delaney, A. L., Feuling, M. B., Noel, R. J., Gisel, E., Kenzer, A., Kessler, D. B., Kraus de Camargo, O., Browne, J., … Phalen, J. A. (2019). Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. Journal of pediatric gastroenterology and nutrition, 68(1), 124-129.

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•  Classifiedintoacute(<3months’duration)•  Chronic(>3months’duration)Goday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P., Cohen, S. S., Delaney, A. L., Feuling, M. B., Noel, R. J., Gisel, E., Kenzer, A., Kessler, D. B., Kraus de Camargo, O., Browne, J., … Phalen, J. A. (2019). Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. Journal of pediatric gastroenterology and nutrition, 68(1), 124-129.

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•  Impairedoralintakereferstotheinabilitytoconsumesufficientfoodandliquidstomeetnutritionalandhydrationrequirements

•  Toeliminatetransientfeedingproblemsresultingfromacuteillness–impairedoralintakemustbepresentdailyforatleast2weeks


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•  InternationalClassificationofFunctioning(ICF)framework-disabilityresultswhenimpairmentsinteractwithpersonalenvironmentalfactorstoresultinactivitylimitationsorparticipationrestrictions

•  PFDsresultindisabilityGoday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P., Cohen, S. S., Delaney, A. L., Feuling, M. B., Noel, R. J., Gisel, E., Kenzer, A., Kessler, D. B., Kraus de Camargo, O., Browne, J., … Phalen, J. A. (2019). Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. Journal of pediatric gastroenterology and nutrition, 68(1), 124-129.

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PediatricDysphagia&PFD

•  AllchildrenwithpediatricdysphagiacanbeclassifiedashavingPFD

•  AchildcanhavePFDintheabsenceofpediatricdysphagia


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DETERMININGMEANINGFULCLINICALINSTRUMENTSFORDIAGNOSINGPFD

2:15–2:45

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HowDoWeKnowWhat’sNormalandWhat’sAbnormal??

PediatricDysphagia&PFD

RedFlagsforDysphagia:AdultvsPediatric

•  Adults•  RecurrentPneumonia•  HeadandNeckCancer•  Anoxia•  ProgressiveNeurologicDisease•  AnteriorCervicalSpinalFusion•  WeightLoss•  DietModifications•  BrainstemStroke•  GuillainBarre•  LaryngealTrauma•  Intubation•  Ongoingrespiratoryproblems

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RedFlagsforDysphagia:AdultvsPediatric

•  Adults•  RecurrentPneumonia•  HeadandNeckCancer•  Anoxia•  ProgressiveNeurologic

Disease•  AnteriorCervicalSpinal

Fusion•  WeightLoss•  DietModifications•  BrainstemStroke•  GuillainBarre•  LaryngealTrauma•  Intubation•  Ongoingrespiratory

problems

•  Pediatrics•  Issuesaffectingappetite•  MetabolicDisease•  Sensorydefects•  Craniofacialanomalies•  Congenitalconditionsoftrachea/larynx•  AbnormalitiesofesophagusorlowerGItract

•  S:S:BCoordinationDifficulty•  NeuromuscularDisorders•  Mucosalinfections/InflammatoryDisorders

•  Historyofprematurity

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ClinicalSignsofPediatricDysphagia

•  Varyfromchildtochild•  Dependentuponageandtypeofunderlyingdisorder

•  Responsetoaspirationisagedependent•  Coordinationofswallowingmechanismimproveswithage,protectivereflexes– Apneainneonates–  Coughinolderchildren– Desensitizationfromfrequentaspiration/neurologicimpairment

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•  Arvedsonetal.,1994– Poorpredictivevaluesforaspiration:coughing,choking,orrespiratorydistress

– 94%aresilentaspirators•  Perlman(1990)

– Nothavingoneorallclinicalsignsdoesnotsuggestthatpatientisasafefeeder

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•  Knowledgeofunderlyingdiagnosisisimportantbutvigilanceiskey!

•  BPD,asthma,andcysticfibrosisoftenhaveGERandareathigherriskforrespiratorycomplicationsofdysphagia

•  Differencesbetweeninfantsandchildren:– Apneaandbradycardiamorecommonthancough,congestion,wheezing,bronchitis,atelectasis,&pneumonia

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BedsideAssessments/EvaluationforPediatricDysphagia

Hasorderbeenreceived?Bywhom?

ChartReviewDiscussionwithotherprofessionals

Meetpatient

Cognition/LanguagePosition

PulmonaryVoice

MedicalEquipment

SensorimotorExamination/OralMechanism/Cranialnerveexam

IntroducingLiquids/FoodsObservations

Instrumentation:VFSS/FEES(ifneeded)

Recs

This process typically takes 15 minutes to 60 minutes

Impressions

AssessmentforPFD

•  FourdomainsunderliePFD1.  MedicalFactors2.  NutritionalFactors3.  FeedingSkillFactors4.  PsychosocialFactors

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AssessmentforPFD:MedicalFactors

•  Impairedstructure/functionoftheGI,cardiorespiratory,andneurologicalsystemsarefrequentlyassociatedwithdysphagiaandcanresultindysfunctioninfeeding

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MedicalCausesofPFDDisordersofAppetite

MetabolicDiseases

SensoryDefects

ConditionedDysphagia

AnatomicAbnormalities

oftheOropharynx,

Larynx,Trachea,&Esophagus

DisordersaffectingSucking-

Swallowing-Breathing

Disordersaffecting

Neuromuscular

CoordinationofSwallowing

MucosalInfections&InflammatoryDisorders

RudolphCD&LinkDT(2002)FeedingDisordersinInfantsandChildren.PediatricGastroenterology&Nutrition,49(1),97-112.

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AssessmentforPFD:NutritionalFactors

•  Restrictedquality,quantity,and/orvarietyofbeveragesandfoodsconsumed,placechildrenatriskofmalnutrition,overnutrition,micronutrientdeficiency,toxicity,anddehydration

•  Restricteddietarydiversity,includingexclusionofentirefoodgroups(fruits/vegetables)canresultinmicronutrientdeficiencydespiteadequatemacronutrientintake

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AssessmentforPFD:FeedingSkillFactors

•  Impairmentinoralsensoryfunctioninginhibits/limitsacceptanceandtoleranceofliquidsandfoodtexturesexpectedforage

•  Impairmentinoralmotorfunctioninglimitsboluscontrol,manipulation,and/ortransitofliquidsandsolids

•  Impairmentinpharyngealsensorimotorfunctioningcaninhibitairwayprotectionandefficientswallowing(sensory);pharyngealmovementsevidencedbyreducedstrengthandcoordinationofpharyngealconstrictors,velarandlaryngealelevation,andvocalfoldclosure(motor)

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God

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. S.,

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AssessmentofPFD:FeedingSkillFactors

•  Achild’sfeedingskillsmustbesafe,ageappropriate,andefficient.DysfunctioninanyoftheaforementionedareasconstitutesPFD– Unsafeoralfeeding-choking,aspiration,andadversecardiorespiratoryevents

– Delayedfeedingskills-childwhoisunabletoconsumeage-appropriateliquidandfoodtextures

–  Inefficientoralfeeding-prolongedmealtimeduration(>30m)orinadequateoralintake

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God

ay, P

. S.,

Huh

, S. Y

., Si

lver

man

, A.,

Luke

ns, C

. T.,

Dod

rill,

P., C

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, S. S

., D

elan

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. L.,

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., N

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, E.,

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, D. B

., K

raus

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argo

, O.,

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… P

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AssessmentofPFD:PsychosocialFactors

•  Factorswithinthechild,caregiver,andthefeedingenvironmentcanadverselyaffectfeedingdevelopmentandcancontributetoandmaintainPFD

•  Characterizedasdevelopmental,social,and/orenvironmentalfactors,andmental/behavioralhealthproblems

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•  Developmentalfactors–delaysinmotorskills,language,socialization,andcognitionoftenresultinamismatchbetweenthefeedingabilityofthechildandthefeedingexpectationsofcaregivers

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•  Socialfactors–caregiver-childinteractionsandculturalexpectationswithinafeedingcanimpactachild’sbehavior

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•  Environmentalfactors–distractingfeedingenvironmentorresortingtofeedingonlyattimeswhenachildisasleepcanpreventcaregiversfromprovidingappropriateresponsestomealtimebehaviorandcanleadtoaccidentalreinforcementofproblematicmealtimebehavior

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•  Mental/behavioralhealthproblems-child,caregiver,ordyadproblemscanimpactfeedingbehavior– Child-mooddisorders,anxiety,etc…canincreaseratesofdisruptivebehavior

– Caregiver-stresscanaltermealtimeinteractions– Dyad-factorsactbi-directionally

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•  Generallymanifestasoneofthefollowing:–  Learnedfeedingaversions–  Stressanddistressexpressedasnegativeemotionsordisengagementfrommealtimes

– Disruptivebehaviorthatisincompatiblewitheating–  Pickyeating(eatingalimitedvarietyoffoodsorunwillingnesstotrynewfoods)

– Grazing(consumingsmallamountsoffoodorfluidthroughouttheday)

– Useofinappropriatestrategiestoimprovechildnutritionalstatus

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ClinicalFeedingAssessment 1.  History/Current

FunctioningStatus*2.  Parent/Child

Interactions3.  ChildFeedingBehaviors4.  OralMechanismExam*5.  Feedingskillassessment*6.  Instrumentation(if

necessary)*7.  SensoryAssessment8.  Nutrition/Growth

Piazza,2004;Arvedson,2008;Dodrill&Gosa,2015

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History&CurrentFunctioning•  BirthHistory•  MedicalHistory:

–  NeurologicHx–  CardiacHx–  Respiratory/AirwayHx–  GIHx–  RenalHx–  CraniofacialHx–  HemolyticHx

•  FeedingHistory•  Allergies/Intolerances•  Medications•  Weight/HeightGrowthChartshttp://www.asha.org/Practice-Portal/Templates/

FeedingHistory

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Parent/ChildInteractions

Antecedent(Caregiver)Verbal/Physical

Behavior(Child)Verbal/Physical/Escape/Withdrawal

Consequence(Caregiver)Verbal/Physical/Escape/Withdraw

Marshall,J.,Raatz,M.,Ward,E.,&Dodrill,P.(2014).Feedingbehavioursintypicallydevelopingchildrenandchildrenwithfeedingdifficulties.InDysphagia(Vol.29,No.6,pp.762-762).SpringerNewYorkLLC.

Child’sFeedingBehaviors

BehavioralPediatricFeedingAssessmentScale(BPFAS)•  Validtoolforidentifyingchildhoodfeedingdifficulties•  Highreliabilityandspecificity•  Parentquestionnaire•  Typicallydevelopingchildrendisplayfewundesirablefeedingbehaviors&fewbehaviorsareperceivedasproblemsbyparents

•  Childrenwithalargenumberoffeedingproblemsonthisparentreportedmeasureneedfurthermultidisciplinaryevaluation

Crist,W.,&Napier-Phillips,A.(2001).Mealtimebehaviorsofyoungchildren:acomparisonofnormativeandclinicaldata.JournalofDevelopmental&BehavioralPediatrics,22(5),279-286.

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OralMechExam•  Oralanatomy

–  Lips,palate,tongue,jaw,teeth,cheeks–  Structuresarecomplete,symmetrical,appropriatesize,tone,rangeofmotion

•  Oralreflexes– Adaptivereflexes,Protectivereflexes

•  Oralmotorcontrol– Assesswithnon-nutritive&(whenpossible)nutritivetaskstodeterminefunctionoforalstructures

•  Oralsensoryprocessing– Assessresponsetotouchinandaroundoralcavity;responsetovarioussensorydiversefoods

–  Typical,hypersensitive,orhyposensitive

OralReflexes Oral Reflex Present Extinct

Cough ??? Permanent

Gag 18 weeks GA Permanent

Swallow 14 weeks GA Permanent

Transverse Tongue

28 weeks GA Permanent

Phasic Bite 28 weeks GA

9-12 months

Tongue Protrusion

Birth

4-6 months

Santmyer 34 weeks GA

1-2 years

Palmomental Birth

3-4 months

Rooting 32 weeks GA

3-6 months

Suckle 17 weeks GA

3-4 months

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CranialNerveAssessmentNerve Symptoms

V- Trigeminal Reduced mandibular movements

VII- Facial Facial asymmetry, reduced facial movements, weak lip closure

X- Vagus VF paralysis, weak cry, hypernasality, nasal regurgitation

XII- Hypoglossal Reduced tongue movements, poor suck

QualityofFeedingSkillAssessmentsThreebasicelementsofqualityforanassessment

– Reliability:measureofassessment’sconsistency

– Validity:measureofanassessment’susefulness

– Standardization:providesamean(average)andstandarddeviation(spread)ofassessmentscores

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AvailableFeedingSkillAssessments

InfantFeedingSkillAssessments

•  11toolsidentified•  EarlyFeedingSkills(EFS)Assessmenthasmostsupportivepsychometricdevelopmentandtestingforassessmentofbottleandbreastfeedinginpreterminfantthrough52weeksPMA&full-terminfantwithsignificantfeedingdifficulties

•  BristolBreastfeedingAssessmentTool(BBAT)hasthemostpsychometricsupportforassessmentofbreastfeedinginhealthy,full-terminfantswithminorfeedingdifficulties

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PediatricFeedingSkillAssessments

•  30toolsidentified–  11Caregiver,18Clinician,1CaregiverorClinician

•  ScheduleforOralMotorAssessment(SOMA)–  Observation,Infantsandchildren0–2years–  Scales:Puree,semi-solid,solid,cracker,bottle,trainercup,andcup–  Mixedresponsescoringoptions–  15-20minutes–  Formaltrainingrequired

•  DysphagiaDisorderSurvey(DDS)–  Observation,Childrenw/DD2-21years–  Scales:Relatedfactors(7),Feeding/swallowingcompetency(8)–  BinaryScoring–  10–15minutes–  Formaltrainingrequired

EmergingPediatricFeedingSkillAssessments

•  AdaptedPre-FeedingSkillsChecklist(APFSC)

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APFSCSpecificAim1b:DeterminetherelationshipoftheAPFSCtotheclinicaloralmotorassessment•  First,itwasfoundthatoverall,19oftheparticipants(86.36%)hada

typicaloralmotorassessment,whilethreeparticipants(13.64%)hadanatypicaloralmotorassessment.

•  Next,ontheAPFSC,thereweresixparticipants(27.27%)whoscored

perfectly(ascoreof10).Theminimumscoreonthistestisa0,butnoparticipantsinthisstudyscoredeither0orone.TheaveragescoreontheAPFSCinthissamplewas7.95(SD=2.42).

•  AMann-Whitneytestindicatedthattherewerenosignificantdifferences

intheoverallscoreontheAPFSCforthosewhoscorednormallyontheclinicaloralmotorassessment(meanrank=11.32)ascomparedtothosewhoscoredabnormallyontheclinicaloralmotorassessment(meanrank=12.67),U=32.00,p=.787.

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APFSC•  Amongtheparticipantsinthisstudy,73%(n=16)werefoundtohaveanoralfeedingskilldeficitinatleastoneareaofevaluation(drinking,spoon-feeding,and/orchewing).Incontrast,only14%(n=3)wereidentifiedashavinganyatypicalfindingsonthegeneralclinicaloralmotorassessment.Thisfindingsuggeststhatthegeneralclinicaloralmotorassessmentaloneisnotsufficienttoidentifyspecific,skill-baseddeficitsrelatedtodrinking,spoon-feeding,andchewing.

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APFSC

APFSCisameasureoffeedingskillcompetency,andwasshowntohave:1)  Goodtestretestreliability(ĸ=.536,

p<.0001)2)  Verygoodinter-raterreliability(ĸ=.711,

p<.0001)3)  Excellentintraraterreliability(ĸ=.884,

p<.001).

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TypicalOutcomesDocumentedfromNon-StandardizedFeedingSkill

Assessments

VolumeofIntake

DurationofFeeding

Fussing/Refusalduring

Feeding

PhysiologicMeasures

StageofOralMotor

Development

SignsofPossibleAspiration

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SensoryAssessment

•  SensoryProfile– Dunn(2002)– Publishedassessment– Standardized,reliable– Usedinseveralpublishedstudies– Parentcompleted

– OTsassistwithinterpretation

SensoryAssessment,SensoryProfile

•  Infant/ToddlerSensoryProfile–  Assessmentcovers6sections

•  GeneralProcessing,AuditoryProcessing,VisualProcessing,TactileProcessing,VestibularProcessing,andOralSensoryProcessing

–  Resultsaregroupedinto4quadrants•  Thequadrantscoresreflectthechild'sresponsivenesstosensoryexperiences,andarebasedonDunn'sModelofSensoryProcessing.

•  SensationSeekingandLowRegistrationindicatedifferenthighthresholdresponses

•  SensorySensitivityandSensationAvoidingreflectdifferentlowthresholdresponses

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Nutrition&Growth•  Dietitianforadviceregardingnutrient,energy,andfluidneeds

•  24HourDietRecall–  Amountofintake–  Typeofintake–  Textureofintake–  Frequencyoffeeds–  Durationoffeeds

•  AnthropometricMeasurement–  Heightandweightmeasuredusingstandardizedmethod–  ComputationofBMI–  Plottingongrowthchart

INSTRUMENTALASSESSMENTFORDIAGNOSINGPFD

2:45–3:15

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http://www.sheknows.com/parenting/articles/967863/bloomberg-aims-to-up-nycs-breastfeeding-rates

http://www.childanddevelopment.com/tag/time/

http://www.mom365.com/toddler/posts/2012/mar/10-ways-to-inspire-your-picky-toddler-to-eat.aspx

Esophageal Manometry (Esophageal Motility Study, Esophageal Function Study)

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Pros Cons

• Assess esophageal peristalsis during a swallow & passive tension of the LES

• Not useful in medical management of GERD or lesions of the esophagus

• Allows direct observation of the CP muscle

• Usually combined with videofluroscopy to visually identify placement of transducers

• Useful to locate upper and lower esophageal sphincters for pH monitoring

• Invasive & may not be tolerated by those who are tactily defensive; may require sedation

Esophageal Manometry (Esophageal Motility Study, Esophageal Function

Study)

Esophageal pH Monitoring (Esophageal Probe)

http://www.giforkids.com/?a=Procedures&b=pH%20Probe%20Study

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Pros Cons

• Recording device is portable and can be used with active infants and children

• Long (24 hours) procedure

Esophageal pH Monitoring (Esophageal Probe)

Scintigraphy (Milk Scan or Technetium Scan)

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Pros Cons • Detects GER where pH probe might miss it b/c of nonacidic consistency of refluxed material

• Long procedure (1-2 hours)

• Radioactive material is used

Scintigraphy (Milk Scan or Technetium Scan)

Upper Gastrointestinal Series (Barium Esophagram, Barium Swallow Test)

http://www.mountnittany.org/articles/healthsheets/7415 http://www.chop.edu/img/radiology/upper-gi-series.html

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Pros Cons •  Common test, readily available • Radiation exposure

• High false negative rate for reflux

•  Good for evaluation of esophageal anatomy and motility disorders

• Does not provide lasting record of swallowing dynamics

Upper Gastrointestinal Series (Barium Esophagram, Barium Swallow Test)

Ultrasoundography

http://www.ijaweb.org/article.asp?issn=0019-5049;year=2011;volume=55;issue=5;spage=456;epage=462;aulast=Kundra

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Pros Cons • Images may be sagittal, coronal, & transverse by rotating transducer • Images in multiple planes in real time: May be frozen for immediate inspection, digitized and enlarged for further examination of fine details, or stored on videotape for later inspection

• Cannot directly determine whether aspiration has occurred; imaging field is not big enough for direct visualization of mouth, pharynx, and esophagus simultaneously

• No barium; any amount or type of solid or liquid food can be imaged • Evaluate sensory motor stimulation techniques & study sucking patterns of preterm infants

• Soft areas behind larynx & hyoid not imaged

• Noninvasive à allows for soft tissue structures to be imaged that can’t be clearly defined by VFSS; no radiation

• Quality and interpretation depend on operator

• Visualizes motion of tongue and floor of mouth • Portable

• US does not pass through bone

Ultrasoundography

HISTORYOFFEESFEES

Adult

Langmore, Schatz, Olsen

(1988,1991)

Bastian (1991, 1993)

Langmore (2001)

Pediatric

Willging (1995, 2000)

Willging, Miller, Hogan, Rudolph

(1996)

Hartnick, Miller, Willging (2000)

Reynolds,J.,Carroll,S.,Sturdivant,C.,Ikuta,L.,&Zukowsky,K.(2016).FiberopticEndoscopicEvaluationofSwallowing.AdvancesinNeonatalCare,16(1),37-43.Suterwala,M.S.,Reynolds,J.,Carroll,S.,Sturdivant,C.,&Armstrong,E.S.(2017).Usingfiberopticendoscopicevaluationofswallowingtodetectlaryngealpenetrationandaspirationininfantsintheneonatalintensivecareunit.JournalofPerinatology,37(4),404-408.

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Thestudycanbeperformedsafelyinchildrenasyoungasprematureinfants&inadults.(Willging&Thompson,2005)

Hartnick,Hartley,Miller,&Willging(2000)

•  643FEESon568patients•  3daysto21years(M=2.5years)

Leder&Karas(2000) •  30patients•  11daysto20years(M=10.3yrs)

daSilva,LubiancaNeto,&Santoro(2010)

•  30patients•  10.5mosto37.3mos(M=25.8

mos)

Leder,Baker,&Goodman(2010)

•  14patients•  3mosto14mos(M=8.5mos)

Sitton,etal.(2011) •  79patients•  12daysto170mos(M=26mos)

Beer,Hartlieb,Müller,Granel,&Staudt(2014)

•  30patients•  10mosto17years(M=5years)

Ahmed-Abdelhamid&Sarwat(2016)

•  64patients/controls•  2mosto168mos(M=41-49mos)

FEESSAFETY:PEDIATRICS&INFANTSReynolds,J.,Carroll,S.,Sturdivant,C.,Ikuta,L.,&

Zukow

sky,K.(2016).FiberopticEndoscopicEvaluationofSw

allowing.AdvancesinN

eonatalCare,16(1),37-43.Suterw

ala,M.S.,Reynolds,J.,Carroll,S.,Sturdivant,

C.,&Arm

strong,E.S.(2017).Usingfiberoptic

endoscopicevaluationofswallow

ingtodetectlaryngealpenetrationandaspirationininfantsintheneonatalintensivecareunit.JournalofPerinatology,37(4),404-408.

NEONATAL&INFANTFEESADVANTAGES•  No barium •  No radiation•  Bedside evaluation•  3-D, HD view of

structures•  No time constraints•  Family centered•  Real-time evaluation of

interventions•  Simulates true feeding

environment •  Safe evaluation of

bottle feeding & breastfeeding

DISADVANTAGES•  Possible discomfort to

patient •  Specialized training

needed•  Unable to assess oral/

esophageal phases of swallowing

•  Chain Swallows in infants can be difficult to interpret

•  White out during the swallow causing inability to view entire swallow sequence

•  Equipment costReynolds,J.,Carroll,S.,Sturdivant,C.,Ikuta,L.,&Zukowsky,K.(2016).FiberopticEndoscopicEvaluationofSwallowing.AdvancesinNeonatalCare,16(1),37-43.Suterwala,M.S.,Reynolds,J.,Carroll,S.,Sturdivant,C.,&Armstrong,E.S.(2017).Usingfiberopticendoscopicevaluationofswallowingtodetectlaryngealpenetrationandaspirationininfantsintheneonatalintensivecareunit.JournalofPerinatology,37(4),404-408.

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NEONATAL&INFANTFEESCRITERIAINDICATIONS CONTRAINDICATIONS

Age/Maturity(37weeks+)andautonomicallystable

Autonomicinstabilityatrest

Signs/Symptomsofswallowingdysfunctionduringclinicalfeedingevaluation&treatment(bottleand/orbreastfeeding)

Anatomicconsiderations:NasalobstructionChoanalatresia

Stridor/Stertor Considerstateregulation

Airwayabnormalitysuspected

Difficultyweaningrespiratorysupport

Assessreadinessfororalfeedings/secretionmanagement

Allcompensatorystrategieshavebeenattempted(positioning,equipment-slowflownipple,pacing,etc)

Reynolds,J.,Carroll,S.,Sturdivant,C.,Ikuta,L.,&Zukow

sky,K.(2016).FiberopticEndoscopicEvaluationofSw

allowing.AdvancesinN

eonatalCare,16(1),37-43.Suterw

ala,M.S.,Reynolds,J.,Carroll,S.,Sturdivant,C.,&

Armstrong,E.S.(2017).

Usingfiberopticendoscopicevaluationofsw

allowingtodetectlaryngeal

penetrationandaspirationininfantsintheneonatalintensivecareunit.JournalofPerinatology,37(4),404-408.

FEES:INFANTS IN THE NICU

Suterwala,Reynolds,Carroll,Sturdivant,Armstrong(2017)StudyParticipants:•  25infantsinpatientatBaylorUniversity

MedicalCenterNICU•  Meangestationalageforadmissionto

study39.9weeks(37-49weeks)

StudyCriteria:•  Bedsideclinicalevaluationsuggested

aspiration;Medicallystable•  Nobilateralcleftlip/palate

StudyDesign:•  FEES/VFSSVFSS/FEES

BreastfeedingFEES•  Vitalsignswithin10minutesbefore

scopingandwithin5minutesafterexam

•  Protocolincludedvaryingthenippletypeandconsistencybasedonpenetration/aspirationfindings

Results:•  FEESwassafeinthispopulationof

infants:Noadverseevents•  80%reliabilityamongst2ratersfor

identificationofpenetration/aspiration

Vetter-Leracyetal(2018)AimsoftheStudy:•  Determine#ofprematureinfantswithdesaturationsduringfeeding

duetoaspirationusingFEES•  RelateclinicalfactorsandFEESfindingstoaspiration•  Describetypeandefficiencyofsuggestedtreatments

Methods:•  Retrospectivereviewof62prematureinfants•  MedianPMA40weeks•  UnderwentFEESforpersistentdesaturationduringfeeding(after>36

weeksPMA)•  Comparedrecordingsofdesaturationsduringfeedings7daysbefore

andaftertheFEES

Results:•  44oftheinfants(71%)-penetrationand/oraspirationwasidentified.•  Norelationwasfoundtodemographicorclinicaldata•  Accumulationofsalivaandresiduespostswallowingwererelatedto

aspiration(P<0.01)•  UseofathickenerreducedaspirationduringFEESon77%oftheinfants•  9.1%ofinfantsrequiredgastrostomytube

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VFSS

•  Kramer,S.andEicher,P.(1993).Theevaluationofpediatricfeedingabnormalities.Dysphagia,8(3),215-224.–  “Whenfacedwithachildwithdysphagia,thediagnosticevaluationincludinghistory,physicalanddevelopmentalexam,andfeedingobservation,followedbyappropriatediagnostictestsformsthebasisforunderstandingthepathophysiologyandtheanticipateddevelopmentalprogression.”

Logemann,1986andLinden,1989

VFSS

•  Goalsofinstrumentation:– Definenatureandphysiologyoftheimpairedswallow

– Stresssystemtorecreatepresentingcomplaint/Fatiguetesting(Newman2000)

– FindcompensationsandadaptationsthatWORKtodeterminetreatmentplan

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SwallowFunctionChangesoverTime

•  Bolussizemeanforinfants: .2ml•  Volumeconsumedperfeed: 120ml(4oz)•  Swallowsperfeed: 600swallows

•  Ifwecapture20swallowsduringMBS,we’veonlyevaluated3%offeedingwith30secondsoffluorotime

•  Ifwecapture40swallowsduringMBS,we’veonlyevaluated7%offeedingwith1minuteoffluorotime

SafetyConsiderationsofMBS/VFSSinInfants

•  Nostandardprotocol•  Radiationexposure

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AmericanCollegeofRadiology– Positiononradiationdoseinpediatricpatients,“ALARA”

•  AsLowAsReasonablyAchievable– Radiationshouldconsistofandnotexceedtheamountneededfordiagnosticaccuracy

SafetyConsiderationsofMBS/VFSSininfants

•  EffectiveDose–  RelativerisktohumansandisdefinedbytheInternationalCommissiononRadiationProtection(ICRP);Calculatedbymultiplyingequivalentdose(expressesthebiologicalimpactofradiationinhumans)bythetissueweightfactorforthespecificorgan;measuredinsievert(Sv)unit

•  ScreeningTime•  DoseAreaProduct

–  Totalradiationenergydeliveredtothepatient;absorbeddosemultipliedbytheareairradiated,expressedingray-centimeterssquared(Gy-cm2)

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ReducingRadiationDose

•  NewerequipmentuseslowerX-raydoses– Continuousfluoroscopy– Pulsedfluoroscopy

•  Bodypartsnotbeingimagedshouldbeshielded

•  OnlyuseX-raytestswhenneeded

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https://www.youtube.com/watch?feature=player_detailpage&v=6qbisjJNt-E

SafetyConsiderationsofMBS/VFSSinInfants:PulsedFluoroscopyforMBS

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Mercado-DeaneMG,BurtonEM,HarlowSA,etal(2001)Swallowingdysfunctionininfantslessthan1yearofage.PediatrRadiol31:423–428

RecentResearch:Aim

•  Examinetheimpactofpulserate(30pps,andsimulated15&7.5pps)onreliableidentificationofairwaycompromiseeventsduringinfantModifiedBariumSwallowStudies(MBS)

Gosa,M.M.(2015).Determiningtheeffectivepulserateforaccurateinterpretationofairwaycompromiseduringinfantmodifiedbariumswallowstudies;OralResearchPresentationattheAnnualAmericanSpeech-LanguageandHearingAssociationConference;Denver,CO

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RecentResearch:Methods

•  RetrospectiveanalysisofinfantMBSstudiesatplaybackratesof30,15,and7.5framespersecond(fps)

•  RateairwaycompromiseeventsforeachplaybacktimewiththePenetrationAspirationScale(PAS)(Rosenbek,Robbins,Roecker,Coyle,&Woods,1996)


RecentResearchMethods:SubjectSelection

•  MBSstudiesfrom2008•  20infants(birthtofourmonthsofage)•  Recordedat30fps•  LeBonheurChildren’sHospital•  ClinicalimpressionwasModerate-Severe

Dysphagia•  1swallowfromeachsubjectextractedthat

illustratedreportedairwaycompromiseevent(s)–  Penetration14/20(70%)–  Aspiration6/20(30%)

•  Allsubjectsde-identifiedandcodedalphabeticallyforproject

Gosa,M.M

.(2015).Determiningtheeffectivepulserateforaccurateinterpretation

ofairwaycom

promiseduringinfantm

odifiedbariumsw

allowstudies;O

ralResearchPresentationattheAnnualAm

ericanSpeech-LanguageandHearingAssociationConference;Denver,CO

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RecentResearchMethods:VideoManipulation

•  30fpsrecordingsweredown-sampledtoboth15and7.5fps– Deletedframesfromthe30fpsrecordings– Replacedthemwithcopiesoftheprecedingframestoimitatereducedpulserate

– AdobeAfterEffects•  Randomlysequencedforreview


RecentResearchMethods:SwallowRating

•  PASdescribesthedegreeofairwaycompromiseduringeachswallowateachoftheframerates

•  Reliableforratingairwaycompromiseeventsininfantsandchildren(Gosa,2011)


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APenetration-AspirationScaleRosenbek,Robbins,Roecker,Coyle,&

Woods(1996)

Dysphagia11:93-98

Score Description

1 Materialdoesnotentertheairway

2 Materialenterstheairway,remainsabovethevocalfolds&isejectedfromtheairway

3 Materialenterstheairway,remainsabovethevocalfolds&isNOTejectedfromtheairway

4 Materialenterstheairway,contactsthevocalfolds&isejectedfromtheairway

5 Materialenterstheairway,contactsthevocalfolds&isNOTejectedfromtheairway

6 Materialenterstheairway,passesbelowthevocalfolds&isejectedintothelarynxoroutoftheairway

7 Materialenterstheairway,passesbelowthevocalfolds&isNOTejectedfromthetracheadespiteeffort

8 Materialenterstheairway,passesbelowthevocalfolds&Noeffortismadetoeject

RecentResearchMethods:RaterTraining

•  Twostudentraters•  TrainingonuseofPASbeforeparticipatinginthisproject

•  Highpercentagreementwitheachotherandanexpertrater(greaterthan95%)


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RecentResearchMethods:RatingofVideos

•  Reviewed20videoclipsat30fps,15fps,and7.5fps

•  Randomlyordered•  Ratedeachswallowon8pointPASforeachplaybackmode

•  Primaryraterreviewedthewholefile– Waited@leasttwoweeks,primaryraterreviewed20%oforiginalfileagain

•  Secondaryraterreviewed20%oforiginalfile– Waited@leasttwoweeks,secondaryraterreviewedpartialfileagain

Gosa,M.M

.(2015).Determiningtheeffectivepulserateforaccurate

interpretationofairwaycom


odifiedbariumsw

allow

studies;OralResearchPresentationattheAnnualAm


RecentResearchSubjects•  60%Male•  40%Female•  MeanAge8.1weeks•  Rangeinage1wto16w


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RecentResearchSubjects

Characteristic Percentage Number(20)

Prematurity 45% 9

Respiratory 55% 11

Cardiac 35% 7

Gastrointestinal 30% 6

Syndrome/Cranio 10% 2

Neuro 30% 6

Other 85% 17


RecentResearchResults:Reliability

•  PrimaryRater:InterRaterReliability–  r=0.939,n=12,p=.000

•  SecondaryRaterInterRaterReliability–  r=0.802,n=12,p=.002

•  IntraRaterReliability–  r=0.963,n=12,p=.000


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RecentResearchResults:DifferencesinPASScores

BetweenFrameRatesCondition %ofNormal %ofPenetration %ofAspiration

30 0%(0/0) 70%(14/20) 30%(6/20)

15 5%(1/20) 70%(14/20) 25%(5/20)

7.5 15%(3/20) 70%(14/20) 15%(3/20)


30fpsv15fps•  Achi-squaretestwasperformedandarelationshipwasfoundbetweenPASvaluesassignedwhenswallowswereviewedat30fpsand15fps– X2(9,N=20)=32.70,p<.001


BetweenFrameRates


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30fpsv15fps


BetweenFrameRates

Condition %ofNormal %ofPenetration %ofAspiration

30 0%(0/0) 70%(14/20) 30%(6/20)

15 5%(1/20) 70%(14/20) 25%(5/20)

CategoryChanges•  1PenetrationtoNormal•  1AspirationtoPenetration

Gosa,M.M




odifiedbariumsw

allow



30fpsv7.5fps•  Achi-squaretestwasperformedandarelationshipwasfoundbetweenPASvaluesassignedwhenswallowswereviewedat30fpsand7.5fps– X2(9,N=20)=21.19,p=.001


BetweenFrameRates


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30fpsv7.5fps


BetweenFrameRates


30 0%(0/0) 70%(14/20) 30%(6/20)

7.5 15%(3/20) 70%(14/20) 15%(3/20)

CategoryChanges•  3Penetrationtonormal•  3AspirationtoPenetration

Gosa,M.M




odifiedbarium

swallow



15fpsv7.5fps•  Achi-squaretestwasperformedandarelationshipwasfoundbetweenPASvaluesassignedwhenswallowswereviewedat15fpsand7.5fps– X2(9,N=20)=28.31,p=.001


BetweenFrameRates


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15fpsv7.5fps


BetweenFrameRates


15 5%(1/20) 70%(14/20) 25%(5/20)

7.5 15%(3/20) 70%(14/20) 15%(3/20)

CategoryChanges•  2Penetrationtonormal•  2AspirationtoPenetration

Gosa,M.M




odifiedbarium

swallow



Discussion

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RecentResearch:Discussion

•  Researchfromadultstudiesthatreporteddifferencesinjudgmentsofswallowingimpairmentfounddifferencesinratingsbetween30andsimulated15pps– Differencesin6physiologicalcomponents:initiationofpharyngealswallow,anteriorhyoidexcursion,epiglotticmovement,pharyngealcontraction,PEsegmentopening,andtonguebaseretraction

FeaturesofMBS/VFSSinInfants•  Suck&OralTransitTime•  PharyngealTransitTime•  NumberofSucksperSwallow•  TongueMovement•  Collection•  NasopharyngealReflux•  MaterialintheSupraglotticSpace•  ResidueinthePharynx•  HesitationintheCervicalEsophagus

Newmanetal.,1991

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FeaturesofMBS/VFSSinInfants

•  SucksperSwallow– Ameasureofjawexcursionperpharyngealswallow

•  Suck&OralTransitTime•  Beginwithmandibleinupwardexcursiontowardsthenippleandendonlastframematerialinthevalleculaebeforeitwaspropelledintopyriformsinuses

•  PharyngealTransitTime–  Beginonfirstframewherematerialappearedtothrustintothepyriformsinusesandendwhenmaterialreachedcervicalesophagus

Newmanetal.,1991

FeaturesofMBS/VFSSinInfants•  Collectionoffluidbeforeinitiationoftransit

– Forcedchoiceparadigmintermsofanatomiclocationfromananteriortoposteriorposition

•  TongueMovement•  Forcedchoiceparadigmoffivepossibilities(Stripping)

•  NasopharyngealBackflow(9.5%)Newmanetal.,1991

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FeaturesofMBS/VFSSinInfants

•  MaterialinSupraglotticSpace(0)•  ResidueinthePharynx(61.9%)

– Materialremainingaftercompletionoftheswallowinvalleculaeandpyriformsinuses

•  HesitationintheCervicalEsophagus(62%)– Determinationdefinedasalackofmovementofthebariumsuspensionseenontwoconsecutiveframes

Newmanetal.,1991

ReliabilityofFeaturesofMBS/VFSSinInfants

•  Highreliabilitybetweentworaters(ICC)•  Excellentreliabilityforsuckandoraltransit•  Acceptablereliabilityforpharyngealtransittimemeasures

Videofluoroscopyprovidesareliablemeansforanalyzingtheinfantswallow

Newmanetal.,1991

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AdditionalMeasuresforMBS/VFSSINInfants

InitiationofvelarmovementDurationofcricopharyngealopeningDurationofpharyngealconstrictionTimetolaryngealclosureDurationoflaryngealclosureBoluspositionatinitiationoflaryngealclosureEpiglottictiltingPen-AspScale

Gosa,M.M.,Suiter,D.M.,&Kahane,J.C.(2015).ReliabilityforIdentificationofaSelectSetofTemporalandPhysiologicFeaturesofInfantSwallows.Dysphagia,1-8.

AdditionalMeasuresforMBS/VFSSINInfants

Oralandpharyngealmeasuresallfoundtoreachacceptablelevelsofreliability

•  Whichofthesemeasuresmattersclinically?•  Howdotheseandothermeasuresrelatetooutcomesininfantsandchildren?

Gosa,M.M.,Suiter,D.M.,&Kahane,J.C.(2015).ReliabilityforIdentificationofaSelectSetofTemporalandPhysiologicFeaturesofInfantSwallows.Dysphagia,1-8.

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ProtocolConsiderationsMcGrattan,K.E.,McGhee,H.C.,McKelvey,K.L.,Clemmens,C.S.,Hill,E.G.,DeToma,A.,...&Martin-Harris,B.(2020).Capturinginfantswallowimpairmentonvideofluoroscopy:timingmatters.Pediatricradiology,50(2),199-206.•  Identifythestabilityoforopharyngealswallowphysiologyand

protectionthroughtheVFSSexam•  Proposesfluoroscopicvisualizationof5thinliquidswallowsat

fourtimepoints:00:00,00:30,01:30,&02:30withnoattemptstoprovidecompensatoryinterventionsorremovebottlefromoralcavity

•  Analysistodeterminenumberofsucksperswallow,oralboluscontainmentbeforetheswallow,boluslocationatinitiationoftheswallow,timingofinitiationofpharyngealswallow,andbolusairwayentry

EffectiveTreatmentStrategiesforManagingPFD3:15–3:45

112

Imagefromhttps://dysphagiacafe.com/2017/10/06/pediatric-dysphagia-assessment-evaluating-clinical-tools/

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SuccessfulFeeding

MedicalManagement

Nutrition

Skill

Environment

Behavior

OralSensoryMotorTherapy

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•  Oralmotorinterventionsincludeexercisesandactivitiesdesignedtoinfluencetheactionsofthetongue,lips,softpalate,jaws,larynx,and/orrespiratorymusclesforimprovedstrength,tone,rangeofmotion,orcoordinationduringfeeding/swallowingandincludetraditionalmuscleexercises(activeorpassive),stretching,and/orsensorystimulationtothearticulatorsandrelatedstructures

Treatment:Motor/Skill

Treatment:Motor/Skill

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•  Oral-Phaseinterventionsimpactonfunctionalfeedingability,drooling,swallowingphysiology,andpulmonaryhealthinpopulationsotherthanpreterminfants.

•  16studiesincluded–nonereportedonpulmonaryhealthoutcomes

•  Studiespublishedbefore2008

Treatment:Motor/SkillforPediatricPopulations

Arvedson,J.,Clark,H.,Lazarus,C.,Schooling,T.,&Frymark,T.(2010a).Theeffectsoforal-motorexercisesonswallowinginchildren:anevidence-basedsystematicreview.DevelopmentalMedicine&ChildNeurology,52(11),1000–1013.doi:10.1111/j.1469-8749.2010.03707.x

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•  Clinicalquestion1:whatistheeffectofOMEonswallowingphysiologyoutcomesinchildren?– 8studiesaddressedthisquestion– 3-effectsofanintra-oralstimulatingplate– 3-impactofatonguethrusttreatmentorlip&tongueexercises

– 2-useoforal,perioral,andfacialstimulation



•  Clinicalquestion1:whatistheeffectofOMEonswallowingphysiologyoutcomesinchildren?–  3-effectsofanintra-oralstimulatingplateonswallowingphysiologyoutcomesinchildrenwithCP

•  Largepositiveimpactonchewing,smallerimpactonswallowingandmouthclearing

•  1yearfollow-upnochangesnotedbythegroupthatcontinuedtowearthedevice

•  Conclusions-during1yearfollow-upprevioustreatmentgainsweremaintained&maturationalonewasequallyaseffectiveasthetreatment



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•  Clinicalquestion1:whatistheeffectofOMEonswallowingphysiologyoutcomesinchildren?–  3-impactofatonguethrusttreatmentorlip&tongueexercises–  Noneofthestudiesprovideeffectsizes–  OME+artictxmadegreatergainsthanthosereceivingartictxalone

ona3pointtongue-thrustseverityscale–  Tonguethrusttxgroupperformedsignificantlybetterthanano-tx

groupona3pointtonguethrustseverityscale5yearsaftertx–  ChildrencompletingtheFaceFormertxprogramhadsignificantly

greaterimprovementinswallowingpatternsthanthosereceivingtraditionalmyofunctionaltx



•  Clinicalquestion1:whatistheeffectofOMEonswallowingphysiologyoutcomesinchildren?–  2-useoforal,perioral,andfacialstimulation–  Bothusedsinglesubjectdesigns,andonlyoneprovidedstatisticalanalysis

–  Subjectsforeachstudywereclassifiedashavingmultipledisabilities

–  Significantreductionintonguethrustingwithsolidfoodsandsemi-solidfoodsduringtreatment

–  2-weekreturntobaselinetreatment,significantincreaseintonguethrustingwithsolidfoodsbutnotwithsemi-solidfoods



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•  Clinicalquestion3:whatistheeffectofOMEonfunctionalswallowingoutcomesinchildren?

•  6studies–  4-effectsofanintra-oralstimulatingplatein58participantswithspasticCPranginginagefrom4y5m–15y5m

–  2-effectsoforalstimulation&neuromuscularfacilitationproceduresonweightgaininyoungpeoplewithseveretoprofoundmentaldisabilityandneuromotordisability



•  Clinicalquestion3:whatistheeffectofOMEonfunctionalswallowingoutcomesinchildren?–  4-effectsofanintra-oralstimulatingplatein58participantswithspasticCPranginginagefrom4y5m–15y5m

•  3studiesusedsinglesubjectdesignwithtreatmentfor12monthsandfoundnodifferenceinweightgain

•  1studylookedatlongtermimpactofOMEwiththedeviceoveranadditional1yearperiodcomparedwiththosewhodidnotwearthedeviceforanadditionalyearandfoundnosignificanteffectonweightorgrowth



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•  Clinicalquestion4:whatistheeffectofOMEondroolingmanagementinchildren?–  5totalstudiesaddressedthisquestion

•  3-useoforalstimandfacilitationinchildrenandyoungadultswithCP(onewithstatisticalanalysis)

•  1-useofchincupinterventionandOMEclassesinchildrenandadolescentswithCP(nostatisticalanalysis)

•  1-useoforalstimulatingplatesinchildrenwithDownsyndrome



•  Clinicalquestion4:whatistheeffectofOMEondroolingmanagementinchildren?– 1-useoforalstimulatingplatesinchildrenwithDownsyndrome

– NegligibleeffectcomparedwithOMEaloneonparentalperceptionofdaytimedrooling

– Smalleffectonnighttimedrooling



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•  Clinicalquestion4:whatistheeffectofOMEondroolingmanagementinchildren?– 3-useoforalstimandfacilitationinchildrenandyoungadultswithCP

•  Onlyoneprovidedstatisticalanalysis-butdidnotreporteffectsizes

•  OMEhadsignificanteffectonpre/postsalivabibweightforoneparticipantbutnottheother



•  Conclusions•  InsufficientevidencetodeterminetheeffectsofOMEonchildrenwithoralsensorimotordeficitsandswallowingproblems

•  Welldesignedstudiesareneededtoprovideevidencethatcanbeincorporatedintothetreatmentparadigm



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Butsurelyinthelast10yearsbetterresearchhasbeenpublishedonthis

topic…

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•  Thisevidencebasedsystematicreview(EBSR)examinedthepublishedevidencefortheuseofcommonstrategiesusedbycliniciansacrossdisciplinestotreatpediatricswallowingandfeedingproblems.

1.  Whatistheeffectoforalmotorinterventionsonfunctionaloralfeedingoutcomesinchildren?

*Functionalfeedingoutcomes=feedingbehaviors,volumeoforalintake,varietyoforalintake,daystoweantubefeeding,weightgain,and/orgrowth


Gosa,M.M.,Carden,H.T.,Jacks,C.C.,Threadgill,A.Y.,&Sidlovsky,T.C.(2017).Evidencetosupporttreatmentoptionsforchildrenwithswallowingandfeedingdisorders:Asystematicreview.Journalofpediatricrehabilitationmedicine,10(2),107-136.


•  1ofthe61studies•  20participantsinthisexperimental,randomizedcontrol

trialstudyhadprofoundintellectualdisabilityorneuromusculardisorders,livedinaresidentialcarefacility

•  Oralmotorprogramthatincludedmanualintervention,directguidance,stretches,pressure,andoraldesensitizationadministered30–40minutesdaily,fivetimesaweekfornineweeksfortheexperimentalgroup(n=10)



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•  Analysisofthenineexperimentalsubjectsthathadpreandposttreatmentoralmotorfunctiontestingrevealednosignificantchangefollowingtreatment.

•  Statisticalanalysisofthefullsample(n=20)revealednosignificantdifferenceinbodyweightgainsbetweentheexperimentalandthecontrolgroupatdischarge



ORALSENSORIMOTORTHERAPY

•  Features essential to the success of OSM therapy include:

–  Individualized program – Graded tasks – Direct/ hands on –  Involve repetitive practice – Often intensive/ short-term – Only forms part of an overall therapy plan –  Skills worked on during OSM therapy must be

necessary /relevant to functional activities important to the individual’s life

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ThickenedLiquids

Imagefrom:https://cdn-sg.theasianparent.com/wp-content/uploads/2013/08/shutterstock_116855842.jpg

THICKENEDFLUIDSTheuseofthickenedfluidsisroutinelyrecommendedfortwomainpediatricpopulations:

�  (a)childrenwithoral-pharyngealdysphagia�  (b)childrenwhodisplayregurgitation

Itisimportantthatthickenedfluidsarepreparedcorrectly.

�  Ifthickenedfluidsaretoothin,theymaynotassistinmanagingtheunderlyingproblem(i.e.aspirationduringswallowingand/orreflux)

�  Ifthickenedfluidsaretoothick,theymaycauseadditionalproblems(e.g.increasedworkofbreathing,reducedintakeduetofatigue)

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THICKENEDFLUIDSBottlefeedprovidesinfantswithbothnutritionandhydrationBottle-fedinfantsshouldbeabletosuckthefeedthroughanippleonabottlein20-30minutes,inordertomeettheirnutritionalandfluidrequirementswithoutexpendingexcessenergy

�  Ifabottle-fedinfantrequiresthickenedfluids,theymayneedtobeswitchedtoafasterflowingnippletoaccommodatethethickerfluid.

ThickenedFluidsPediatricsLiterature

Gosa,Schooling,&Coleman,(2011).Thickenedliquidsasatreatmentforchildrenwithdysphagiaandassociatedadverseeffects:Asystematicreview.ICAN:Infant,Child,&AdolescentNutrition.Publishedonline5May2011.•  ClinicalQuestion1:Forchildrenwithadiagnosisofdysphagia,whatisthe

effectofthickenedliquidsonswallowingphysiology(eg,aspiration,feedingefficiency),oralfeedingdevelopment,weightgainandgrowth,hydration,orpulmonaryhealth(eg,aspirationpneumonia,wheezing)?

•  ClinicalQuestion2:Isthereanincreasedoccurrenceofadverseeffects

(ie,NEC,gutadhesion,bowelobstruction,diarrhea,constipation,weightloss,failuretothrive,dehydration,aspiration,&cough)associatedwiththeuseofthickenedliquidsorcertainthickeningagentsinchildrenwithorwithoutdysphagia?

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ThickenedFluidsPediatricsLiteratureClinical Question 1: Summary

•  6 of the 22 identified studies •  The 6 studies investigated swallowing physiology or oral

feeding outcomes & 1 study also examined pulmonary health

•  Elimination of laryngeal or tracheal penetration (n=5) •  Elimination of laryngeal penetration in 71% (22/31) •  Half of the participants (60/121) from 5 studies

reported elimination of aspiration w/ the use of thickened liquids

•  Elimination of nasopharyngeal reflux (n=2) •  Improved initiation or resolution of delayed swallow in

20% (2/10)


•  16oftheidentified22studies•  757participantstotalinthe16studies(ssranged18-104)•  Adverseeffectsexaminedinthesestudiesincludedweightloss,

cough,aspiration,constipation,&diarrhea

•  8studiesexaminedweightstatus;overallthickenedformulahadnoeffectorpositiveeffectonweightgain

•  8studiesexaminedcough;mixedresultswithsomereportingresolutionofcough&somereportingnochangeincoughing

•  1studyexaminedaspiration;noinstancesofaspirationundereitherthickenedornon-thickenedfeedingcondition

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•  3studiesexaminedconstipation;nosignificantdifferencesinconstipationratewerereported

•  2studiesexamineddiarrhea;comparedtostandardformula,ricestarch-thickenedformulahadnoeffectontheincidenceofdiarrheaamongstudyparticipants

•  Complicationrate:overallrateofadverseeventsor

unspecifiedcomplicationswereexamined&allofthe16investigationsindicatedthatnoinfantexperiencedanycomplicationduringthestudyperiod

ThickenedFluidsPediatricsLiterature

•  AsystematicreviewbySteeleandcolleagues(2015)investigatingtheinfluenceofliquidconsistencymodificationonswallowingphysiologyandfunctionfoundthatthickerliquidsreducetheriskoflaryngealpenetrationandaspiration,butalsoincreasetheriskofpost-swallowresidueinthepharynx.

Steele,C.M.,Alsanei,W.A.,Ayanikalath,S.,Barbon,C.E.,Chen,J.,Cichero,J.A.,...&Wang,H.(2014).Theinfluenceoffoodtextureandliquidconsistencymodificationonswallowingphysiologyandfunction:Asystematicreview.Dysphagia,30(1),2-26.

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AlternativetoThickenedFluids

•  Iftheinfant/childhasdifficultycoordinatingbreathingandswallowing– Theywilltrytocontrolliquidflow

•  Iftheycannotcontrolliquidflow– Attempttoprotectairway,apnea– Unsuccessfulinprotectingairway,aspiration

•  Iftheycannotcontrolliquidflow-feedermaybeabletocontrolliquidflow

03/06/20 143

AlternativetoThickenedFluids

•  Feedermayassistwithcontrolofliquidflow:– Modificationtoutensil– Changeposition(side-lying)–  Introductionofafeedingstrategy

03/06/20 144

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ALTERNATIVEINTERVENTIONS•  Avacuum-freebottlehasbeenreportedtoimprove

physiologicalstabilityduringfeeds(Fucileetal,2009)•  Ithasalsobeenreportedtoreducetransitiontimeto

exclusiveoralfeeding,thoughfromexistingliteratureitdoesnotappeartoaffectGAatattainmentofexclusiveoralfeeding(36.3+/-1.5daysGAvs.36.8+/-2.0,P=0.425)

•  Theuseofslowflowingbottlenipplesoverfasterflowingnipplesalsoappearstoimprovephysiologicalstabilityduringfeeds(Changetal,2007;Mathewetal,1991)

•  However,itisnotclearwhateffecttheyhaveonGAatattainmentofexclusiveoralfeeding

BOTTLENIPPLEFLOWRATE

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BOTTLENIPPLEFLOWRATE

ALTERNATIVEINTERVENTIONS•  Externallypacedfeedingisassociatedwith

improvedphysiologicalstabilityduringfeeding(LawMorstattetal,2003)

•  Side-lyingpositionisassociatedwithimprovedphysiologicalstabilityduringfeedingandincreasedvolumetakeninafeed(Parketal,2014;Dawsonetal,2013)

•  Externallypacedfeeding+side-lyingposition(CoReg)isassociatedwithimprovedphysiologicalstabilityduringfeeding(Thoyreetal,2013)

However,existingliteraturehasnotevaluatedtheimpactoftheseapproachesonGAatattainmentofexclusiveoralfeeding

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SOFFIMODEL•  Startwithstandardnewbornbottle

nippleandholdtheinfantinastandardfeedingposition(i.e.traditionalcradlehold)

•  Ifneeded(i.e.iftheinfantshowsanychangeinphysiologicalstabilityorengagement),implementthefollowingcompensationsinthefollowingorder:–  Slowerflowingbottlenipple–  Side-lyingpositioning–  Externalpacing

(Rossetal,2011;Philbinetal,2011)

SOFFIMODEL•  SOFFImodelaimstomaintainphysiological

stabilityandengagementduringfeeds•  Post-SOFFIinfantsborn<37weeksGA

achievedfulloralfeedingsinsignificantlyfewerdaysthanpre-SOFFIinfants(Horneretal,2014).

•  However,isnotfullyclearifitaffectedGAatattainmentofexclusiveoralfeeding…

•  Atfollow-up,parentsofpost-SOFFIinfantsreportedsignificantlyfewerfeedingproblemsoverall,lessarching,lessvomiting,andfewerinfantsseeingfeedingspecialists(Horneretal,2014)

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BehavioralFeedingManagement

09/21/18 151

KEYINDICATORSOFFEEDINGDIFFICULTIES

•  Limitedrangeoftextures–  Oftenrelianceon‘easytoeatfoods’–  Puree,dissolvablevs.lumpy,mechanical

•  Limitedrangeoffoods–  <30foods–  <10proteins,<10fruit/veg,<10starches

•  Prolongedmealtimeduration–  >30minsatmealtimes,>2hrsadayspenttryingtofeedchild

•  Battles/problematicbehavioratmealtimes•  Familystressrelatedtothechild’seatingpatterns

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BEHAVIORALFEEDING•  Promote a positive feeding relationship

between caregiver and child –  Where possible, step back from causes of any

unpleasant interactions –  Create opportunities for pleasant interactions –  Establish familiarity and comfort around food

and feeding environment –  Provide pleasurable oral stimulation

•  Determine feeding readiness –  Gut –  Swallowing –  Breathing

BEHAVIORALFEEDING•  Normalize feeding

–  Graded oral sensory tasks during feeding –  Graded oral motor tasks during feeding

•  Initiate a behavioral feeding plan

–  Set goals –  Follow routine –  Provide clear instructions –  Reward desirable feeding behaviors –  Do not reward undesirable feeding behaviors –  Be consistent

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BEHAVIORALFEEDING•  ‘ABC’

•  Antecedent –  Prompt: Verbal, visual, tactile, modelling

•  Behavior –  Desirable vs undesirable

•  Consequence –  Reinforcement – done to increase the likelihood of a

behaviour occurring again –  Punishment – done to decrease the likelihood of a

behaviour occurring again

BehavioralApproaches

•  DifferentialAttention(withorwithoutshaping)–  Positiveattentionforappropriatefeedingbehaviorandignoringinappropriatebehavior

•  Contingentreinforcement–  Praiseforthetargetresponse&ignoringallotherresponses

•  Punishment– Attemptingtoreduceoreliminateunwantedbehaviors

Kerwin,M.E.(1999).Empiricallysupportedtreatmentsinpediatricpsychology:severefeedingproblems.JournalofPediatricPsychology,24(3),193-214.

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•  Positivereinforcement–  Praiseafteranappropriatefeedingresponseregardlessof

whetheritoccurredindependently,afteraverbalprompt,orafteramodeledresponse

•  Manualguidanceoftheappropriatefeedingresponse(s)–  Physically,verbally,ormanuallydirecting

•  3-stepguidedcompliance–  Hierarchyofinstructionandprompting:1)Providing

verbalinstruction;2)ifnoresponseafteraspecificamountoftime,modelingw/theverbalinstruction,&3)ifstillnoresponse,manualguidance


BehavioralApproaches•  Extinction

–  Removingthereinforcerofaresponse

•  Foodrefusalcanbenegativelyreinforcedbyremovingthespoonafterrefusal,therebyincreasingtheprobabilityoffoodrefusal

•  Extinctionprocedurewouldrequirethatthespoonremain

atthechild’slipsuntilitisacceptedintothemouth

•  Increasedacceptanceandvolumeconsumedin10–130sessions

•  Behaviorlikelytoworsenbeforeitimproves•  Canbecombinedwithpositivereinforcement


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BehavioralExamples

09/21/18 159

https://www.youtube.com/watch?v=_R-FyBJV77w

BehavioralExamples

160

Verbalno,escapesfromchairRedirectionisprovidedPushesoverherchairEscapepreventionVerbalpraise

https://www.youtube.com/watch?v=_R-FyBJV77w

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•  Systematicdesensitizationtherapy–  Focusonimprovingwillingnesstointeractwithfood–  Mayalsoincorporateinformationongeneral

parentingskills–  Generallyaimedatclinicalpopulations

•  Generallyruninhospital-basedfeedingclinics•  Usuallyrunbytherapists•  E.g.SOSApproachtoFeeding

https://theoriesinpsychologyf10.wikispaces.com/file/view/Desensitization.gif/177474605/Desensitization.gif

Operantconditioning–  Feederdetermineshowmuchiseaten

Goals:–  Improvedvolumestaken

–  Reducednumberofrefusalbehaviors

Systematicdesensitization

–  Childdetermineshowmuchiseaten

Goals:–  Increasedwillingnesstotryfoods

–  Increasedrangeoffoodstolerated

ComparingPrograms

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BEHAVIORALFEEDING•  Set realistic, step-wise goals

•  Provide positive reinforcement – Reward desirable behaviour –  Provide reinforcement immediately –  Provide specific feedback with reinforcement –  Be consistent in rewarding

¨  Ignore undesired behaviour (when safe to do so)

BEHAVIORALFEEDING•  Gradually fade the prompt

•  Gradually thin the reinforcement –  Increase the number of times the desired task

has to be performed before a reward is given –  e.g. once then reward, then 2x, 3x etc,

before the reward

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BEHAVIORALFEEDING•  Shaping/ chaining

– Gradually increase the demands of the task:

•  Smell a new food, then lick a new food, then taste a new food

•  Hold a piece of new food in the mouth, then spit it out

•  Bite a piece of new food, then spit it out •  Bite a piece of new food, hold it in the mouth, then

spit it out •  Bite a piece of new food, move it to the side of the

mouth, then spit it out •  Chew a piece of new food, then spit it out •  Chew and swallow a piece of new food •  Increase the amount of time that the food has to

stay in the mouth (Count out loud to encourage the task to seem like a competition)

•  3.Whatistheeffectofbehavioral-basedinterventions(includingapproachesthatincorporatetechniqueswithelementsfromoperantconditioning,systematicdesensitization,etc....)onfunctionaloralfeedingoutcomesinchildren?

•  37studies•  919pooledparticipants,86%werebetween2and7yearsold

•  70%weresmallsamplesize(Nof1-13),30%hadsamplesizesfrom24–490

Treatment:Behavioral


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•  11/37studies•  Escapeextinction(behavioraltechniqueusedto

treatbehaviorsthataremaintainedbyescapingoravoiding;removingthepossibilityofescapingfromthechallengingstimulus)

•  Reinforcement(theuseofanystimuluswhichshouldincreasetheprobabilityofadesiredresponse,canbepositiveornegative)

•  Singlesubject&smallcohortdesigns•  Impactonacceptance,intake,andpresenceof

undesirablebehaviorsatmealtimes

Treatment:BehavioralPositiveReinforcement&Extinction


•  Escapeextinctionwith–  differentialreinforcementincreasedoralintake&mouthclean(n=3)

–  orwithoutreinforcementincreasedmouthcleananddecreasedundesirablemealtimebehaviors(n=5)

–  representationofexpelledbitesincreasedacceptanceofnon-preferredfoods(n=3)

–  attentionextinctioncombinationdecreasedinappropriatemealtimebehaviorsandincreasedfoodacceptance(n=4)

–  Chinprompt&representationofexpulsionperbitedecreasedratesofexpulsionandincreasedvolumeofintake(n=4)

–  meal&tasteprobingresultedinincreaseinthevolumeandvarietyoffoodsanddecreaseinundesirablemealtimebehaviorsmaintainedforupto1monthposttreatment(n=3)



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•  Positivereinforcementwith–  non-contingentreinforcementandextinctionofdisruptivebehaviordecreased

undesirablefeedingbehaviorandincreasedvolumeoffoodeaten(n=3)–  negativereinforcement,self-feeding,parenteducation,structuredmealtimes

andrepeatedpresentationofnovelfoodsresultedinimprovementsinvarietyandvolumeoforalintake,reductionofundesirablebehaviors,improvedparent-childinteractionsduringmealtimes,&increasesinbothheightandweight(n=1)

–  escapeextinction,&caregivertrainingforincreasedmastication,mouthclean,andacceptance

–  escapeextinction,&caregivertrainingwithmixedresults–2hadincreasedself-feedingbehaviorand1hadnoimprovement

–  peermodelingforincreasedvolumeandvarietyofacceptedfoods,significantweightgainwith1participantweaningtubefeedingbytwomonths’posttreatment



•  11/37studies•  Shaping-behaviortrainingthatusesdifferentialreinforcementofsuccessiveapproximationsofthedesiredbehavior

•  Fading-initialpromptingtoperformbehaviorisgraduallywithdrawn,ensuringthechilddoesnotbecomedependentonthestimulus

•  Impactonfoodrefusal&discontinuationoftubefeeding

Treatment:BehavioralStimulusShaping&Fading


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•  Shaping&fading–  Generalizationoforalacceptanceinacaseserieswithdiscontinuationoftubefeeding

–  IncreasesinoralintakewiththereductionofG-tubefeedingsandadditionoforalfeedingmeals

–  Increasesinacceptanceofbitesanddecreasednumberofdisruptiveresponses

–  Withvisualcueing&positivereinforcementresultedintubeweaningandfulloralfeedingwith2poundweightgain

–  Withpositivereinforcement,escapeextinction,andfloodingresultedinmajorityincreaseinsomeaspectoforalintake(n=86ex-preterm)



•  Shaping&fading–  Withescapeextinctionresultedinimprovingacceptance,mouthclean,anddecreasinginappropriatebehaviorsduringmealtime

–  WithescapeextinctionandbiterepresentationandNukbrushresultedinincreasedmouthcleanandacceptanceanddecreasedpacking&expulsionsperbite

–  Withnon-contingentaccessresultedinsignificantimprovementsinfoodvariety,consumption,andappropriatemealtimebehaviors

–  Withbehavioralprinciplesinteaching,parenteducation,&concurrentpresentationsofpreferredfoodswithtargetfoodsresultedinincreasedheight,weight,&BMI



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•  13/37studies•  Focusedonparenteducation&involvementincombinationwithbehavioralstrategies(primarily:reinforcement,escapeextinction,&fading)

•  Approximately½reportedoncasestudies•  Positivereportedimpactonallfunctionaloralfeedingoutcomes

Treatment:BehavioralCaregiverInvolvement&Education


*DeterminewhetherOCorSysDinterventionresultsingreaterimprovementsindietaryvariety/intakeandgreaterreductionsindifficultmealtimebehaviors*Children,2-6yearsw/ASDorNMCàrandomizedtoreceive10OCorSysDsessionsat1x/weekorfor1week

Treatment:BehavioralComparisonofOperantConditioning

&SystematicDesensitizationGosa,M.M.,Carden,H.T.,Jacks,C.C.,Threadgill,A.Y.,&Sidlovsky,T.C.(2017).Evidencetosupporttreatmentoptionsforchildrenwithswallowingandfeedingdisorders:Asystematicreview.Journalofpediatricrehabilitationmedicine,10(2),107-136.Marshall,J.,Path,B.S.,&Hill,R.J.JPGNJournalofPediatricGastroenterologyandNutritionPublishAheadofPrint.

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•  DifferencesbetweenOC&SysD•  InOCgroup:•  Trendtowardsgreaterincreaseintotalnumberoffoodsconsumed&totalnumberofunprocessedfruitsandvegetables

•  InSysDGroup•  Trendtowardsgreaterreductionofdifficultmealtimebehaviors



•  DifferencesbetweenASD&NMC•  InASDgroup:•  Greaterimprovementinoveralldietaryquality

•  InNMCgroup:•  Slightlybetterimprovementtodietaryvariety(totalproteins)



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DifferencesbetweenIntensive&Weekly•  Inweeklyarm:•  Greaterreductionsindifficultmealtimebehaviors

•  Greaterreductionsinnumberofproblembehaviorsoutsideofmealtime



Treatment:MixedModality

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5.Whatistheeffectofapplyingmixedmodalityinterventionsonfunctionaloralfeedingoutcomesinchildren?•  23ofthe61studies•  395pooledparticipants;majorityofstudiesfeaturedsmall

samplesizes(lessthan10participants)•  95%ofparticipantswerebetween2-10yearsofage•  MixeddiagnosticpopulationthatincludedDownsyndrome,

ASD,Goldenharsyndrome,Rettsyndrome,CP,rubellasyndrome,&feedingcomplicationsduetomajororgansystemimpairments

Treatment:MixedModalityGosa,M.M.,Carden,H.T.,Jacks,C.C.,Threadgill,A.Y.,&Sidlovsky,T.C.(2017).Evidencetosupporttreatmentoptionsforchildrenwithswallowingandfeedingdisorders:Asystematicreview.Journalofpediatricrehabilitationmedicine,10(2),107-136.

•  Behavioral&OMI•  12/23,withpooledparticipants=30•  Allstudiesutilizedcasestudyorsinglesubjectdesigns•  Resultedin:

–  G-tubefeedingsweresignificantlyreducedoreliminatedwithsignificantreductionoreliminationofundesirablemealtimebehaviorsandanoverallincreaseindesirableparentbehavior

–  Reducedratesofexpulsionsandincreasedmouthcleans–  Improvedvariety,texture,andvolumeoffoodeaten–  Decreasedpacking,increasedoralcoordination&

participationinmealtimes


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•  Behavioral&SensoryIntervention•  4/23•  Sensorytechniquesincluded:light,rockingmotion,

sensoryplay,andindividualizedsensorydiets•  Resultedin:

–  Increasedacceptanceofsolidfoods–  Increasedacceptanceofnon-preferredfoods&caloriesconsumed,decreaseinundesirablebehaviors

–  Caregiversatisfaction


•  Behavioral&OMI&SensoryInterventions•  5/23,Multidisciplinaryapproach•  Resultedin:

–  Increasedacceptanceofnon-preferredfoods&caloriesconsumed,decreaseinundesirablebehaviors

–  Weaningfromtubefeedings–  Increaseinlingualrangeofmotionanddurationofmealtimes

–  Weaningofhighcaloriesupplementuseandweightgain–  Caregiversatisfaction


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•  Resultsdemonstratedpositiveoutcomesacrossallprimaryoutcomesmeasured,regardlessofrandomization,intensityorgroup

•  Thissuggeststhat,overall,interventiondeliveredbyexperiencedtherapiststoastandardizedprotocoliseffectiveinincreasingdietaryqualityandvariety,anddecreasingdifficultbehaviorsatmealtimes.

•  Furtherresearchisrequiredinexaminingothercohortsofchildrenwithfeedingdifficulties,andexploringoutcomesafterlongerperiodspostintervention



•  LackofevidencetosupportthesingularuseofOMIorSensoryBasedInterventions

•  Moderateamountsofpublishedevidencetosupporttheuseofbehavioralinterventions(37/61articles)andtheuseofmixedmethodinterventions(23/61articles)

•  Variouslevelsofevidenceavailabletosupporttheuseofbehavioral(32/27,86%werefoundtobephaseoneresearch)andcombinedtreatmentoptions(allphaseoneresearch)

ConclusionsGosa,M.M.,Carden,H.T.,Jacks,C.C.,Threadgill,A.Y.,&Sidlovsky,T.C.(2017).Evidencetosupporttreatmentoptionsforchildrenwithswallowingandfeedingdisorders:Asystematicreview.Journalofpediatricrehabilitationmedicine,10(2),107-136.

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•  ClinicalutilityoffindingsaboutOMIandMixedModalitylimitedduetotheprimarilydescriptivenatureoftheevidence

•  Moderateamountofpublished,phaseoneevidenceonmixedmethodinterventionsdoescallforfurtherinvestigationofthesestrategieswithgreaterscientificrigortoestablishthefulldimensionsofthetherapeuticeffectandultimatelydeterminetheinternalandexternalvalidityofthesetreatmentoptionsasaninitialtherapeuticeffecthasbeenestablished


•  FromthisEBSR,cliniciansrecognizetheimportanceofbehavioraltherapytechniquesforremediatingfeedingdisorders(60/61articles)

•  Cliniciansmustbetrainedintheappropriateapplicationofthevariousbehavioraltherapytechniques

•  5/60articleswereRCTandmetcriteriaofphaseIVevidence


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SUMMARY&[email protected]

Summary

•  Listonevalidatedmeasureforclinicalassessmentofpediatricfeedingdisorder– DDS– SOMA– APFSC– EFS– BristolBreastFeedingAssessmentTool– BPFAS

03/06/20 188

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Summary

•  Definethepsychometricpropertyofvalidity.– Validityreferstothesoundnessofmeasuresusedinclinicaltrialsandoutcomesresearchtodemonstratethattheymeasurewhattheyaredesignedtomeasure.

03/06/20 189

Summary

•  Describetheefficacyofbehavioralinterventionsfortheremediationofpediatricfeedingdisorders– Moderateamountsofpublishedevidencetosupporttheuseofbehavioralinterventions(37/61articles)andtheuseofmixedmethodinterventions(23/61articles)

– Variouslevelsofevidenceavailabletosupporttheuseofbehavioral(32/27,86%werefoundtobephaseoneresearch)andcombinedtreatmentoptions(allphaseoneresearch)

–  Efficacyestablished

03/06/20 190

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SUMMARY&[email protected]

Received JuFrom the �

of WiscyGrowthogy andPediatricand Swadelphia,Women’SwallowPennsylvthe #FeeWisconsogy, andyyDeparResearchMontreaResourcePediatricAZ, theHamiltoMedicinAurora,Health S

REVIEW ARTICLE: NUTRITION

124

Pediatric Feeding Disorder—Consensus Definition and

Conceptual Framework�Praveen S. Goday, yzSusanna Y. Huh, �Alan Silverman, §Colleen T. Lukens, jjPamela Dodrill,

�Sherri S. Cohen, �Amy L. Delaney, #Mary B. Feuling, ��Richard J. Noel, yyErika Gisel,zzAmy Kenzer, §§Daniel B. Kessler, jjjjOlaf Kraus de Camargo, ��Joy Browne, and ##James A. Phalen

ABSTRACT

What Is Known

� Pediatric feedindefinition.

� Previous diagnodisorder fromdiscipline.

What Is New

� A unifying diagder’’, using thenization InternaDisability, and H

� This term unifiskill, and/or psfeeding disorde

� Theproposeddiof common, preclinical practice,

ly 6, 2018; accepted September 27, 2018.Feeding, Swallowing and Nutrition Center, Children’s Hospitalonsin, Medical College of Wisconsin, Milwaukee, WI, theand Nutrition Program, Division of Gastroenterology, Hepatol-Nutrition, Boston Children’s Hospital, the zDepartment of

s, Harvard Medical School, Boston, MA, the §Pediatric Feedingllowing Center, The Children’s Hospital of Philadelphia, Phila-PA, the jjFeeding and Developmental Therapy Team, Brigham &s Hospital NICU, Boston, MA, the �Pediatric Feeding anding Center, Perelman School of Medicine at the University ofania, The Children’s Hospital of Philadelphia, Philadelphia, PA,ding, Swallowing and Nutrition Center, Children’s Hospital ofin, Milwaukee, WI, the ��Pediatric Gastroenterology, Hepatol-Nutrition, Duke University Medical Center, Durham, NC, the

tment of Pediatrics and CanChild Centre for Childhood DisabilityMcGill University, School of Physical & Occupational Therapy,

l, Quebec, Canada, the zzSouthwest Autism Research &Center, Phoenix, AZ, the §§Developmental and Behavioral

s, University of Arizona College of Medicine-Phoenix, Phoenix,jjjjRon Joyce Children’s Health Centre, McMaster University,

n, Ontario, Canada, the ��University of Colorado School ofe, Anschutz Medical Campus, Fielding Graduate University,CO, and the ##Developmental-Behavioral Pediatrics Universityystem, Uniformed Services University, San Antonio, TX.

Address correspondence aCNSC, Pediatric Gasof Wisconsin, 8701(e-mail: pgoday@mcw

Supplemental digital conteappear in the printed teHTML text of this arti

Funding Source: This artiBank to Feeding MatterPhoenix, AZ on March

Dr Goday serves as consuMonitoring Board for Sno financial relationshi

Copyright # 2017 The Auton behalf of the Europpatology, and NutritioGastroenterology, Heparticle distributed undeNon Commercial-No Dis permissible to downcited. The work cannotwithout permission fro

DOI: 10.1097/MPG.00000

JPGN

g disorders lack a universally accepted

stic paradigms have defined feedingthe perspective of a single medical

nostic term, ‘‘Pediatric Feeding Disor-framework of the World Health Orga-tional Classification of Functioning,ealth is proposed.

es the medical, nutritional, feedingychosocial concerns associated withrs.agnosticcriteriashouldpromotetheusecise, terminology necessary to advanceresearch, and health care policy.

Pediatric feeding disorders (PFDs) lack a universally accepted definition.

Feeding disorders require comprehensive assessment and treatment of 4

closely related, complementary domains (medical, psychosocial, and feed-

ing skill-based systems and associated nutritional complications). Previous

diagnostic paradigms have, however, typically defined feeding disorders

using the lens of a single professional discipline and fail to characterize

associated functional limitations that are critical to plan appropriate inter-

ventions and improve quality of life. Using the framework of the World

Health Organization International Classification of Functioning, Disability,

and Health, a unifying diagnostic term is proposed: ‘‘Pediatric Feeding

Disorder’’ (PFD), defined as impaired oral intake that is not age-appropriate,

and is associated with medical, nutritional, feeding skill, and/or psychosocial

dysfunction. By incorporating associated functional limitations, the pro-

posed diagnostic criteria for PFD should enable practitioners and researchers

to better characterize the needs of heterogeneous patient populations,

facilitate inclusion of all relevant disciplines in treatment planning, and

promote the use of common, precise, terminology necessary to advance

clinical practice, research, and health-care policy.

Key Words: dysphagia, failure to thrive, feeding disorder

(JPGN 2019;68: 124–129)

eeding is a complex process that requires interaction of thecentral and peripheral nervous systems, oropharyngeal mech-
F
anism, cardiopulmonary system, and gastrointestinal (GI) tract withsupport from craniofacial structures and the musculoskeletal

system. This coordinated interaction requires acquisition and mas-tery of skills appropriate for a child’s physiology and developmen-tal stage. In children, feeding occurs in the context of the caregiver-child dyad. A disruption in any of these systems places a child at risk

nd reprint requests to Praveen S. Goday, MBBS,troenterology and Nutrition, Medical CollegeWatertown Plank Rd, Milwaukee, WI 53226.edu).nt is available for this article. Direct URL citationsxt, and links to the digital files are provided in thecle on the journal’s Web site (www.jpgn.org).cle was possible through a grant from Comericas, Inc. to enable a consensus meeting to be held in4 and 5, 2016.

ltant to Nutricia and serves on a Data Safety andhire Pharmaceuticals. The remaining authors haveps relevant to this article to disclose.hor(s). Published by Wolters Kluwer Health, Inc.ean Society for Pediatric Gastroenterology, He-

n and the North American Society for Pediatricatology, and Nutrition. This is an open accessr the terms of the Creative Commons Attribution-erivatives License 4.0 (CCBY-NC-ND), where itload and share the work provided it is properly

be changed in any way or used commerciallym the journal.00000002188

� Volume 68, Number 1, January 2019

mailto:[email protected]

http://www.jpgn.org/

http://dx.doi.org/10.1097/MPG.0000000000002188

TABLE 1. Proposed diagnostic criteria for pediatric feeding disorder

A. A disturbance in oral intake of nutrients, inappropriate for age, lasting at

least 2 weeks and associated with 1 or more of the following:

1. Medical dysfunction, as evidenced by any of the following�:

a. Cardiorespiratory compromise during oral feeding

b. Aspiration or recurrent aspiration pneumonitis

2. Nutritional dysfunction, as evidenced by any of the followingy:

a. Malnutrition

b. Specific nutrient deficiency or significantly restricted intake of one or

more nutrients resulting from decreased dietary diversity

c. Reliance on enteral feeds or oral supplements to sustain nutrition and/

or hydration

3. Feeding skill dysfunction, as evidenced by any of the followingz:

a. Need for texture modification of liquid or food

b. Use of modified feeding position or equipment

c. Use of modified feeding strategies

4. Psychosocial dysfunction, as evidenced by any of the following§:

a. Active or passive avoidance behaviors by child when feeding or

being fed

b. Inappropriate caregiver management of child’s feeding and/or

nutrition needs

c. Disruption of social functioning within a feeding context

d. Disruption of caregiver-child relationship associated with feeding

B. Absence of the cognitive processes consistent with eating disorders and

pattern of oral intake is not due to a lack of food or congruent with cultural

norms.

The following International Classification of Functioning, Disability andHealth (ICF) categories apply to each of the criteria above and can be used todescribe the functional profile of affected patients.�

Medical dysfunction: impaired functions of the cardiovascular andrespiratory systems.yNutritional dysfunction: any impaired body functions and structures,

JPGN � Volume 68, Number 1, January 2019 Pediatric Feeding Disorder

for a feeding disorder and associated complications (1,2). Often,more than 1 system is disrupted, contributing to the developmentand persistence of pediatric feeding disorders (PFDs) (3). Hence,effective assessment and treatment of PFDs require the involvementof multiple disciplines. The lack of a universally accepted definitionhas, however, hindered collaborative care.

Despite inherent multiple underlying mechanisms and needfor multidisciplinary care, the diagnosis of feeding disorders hasbeen approached unilaterally, with each discipline suggesting itsown approach. These unilateral paradigms typically do not capturethe complexity of feeding disorders. The American Speech-Lan-guage-Hearing Association defines pediatric dysphagia in terms ofimpaired oral, pharyngeal, and/or esophageal phases of swallowing(4). The Diagnostic and Statistical Manual of Mental Disorders, 5thEdition diagnosis of Avoidant/Restrictive Food Intake Disorderincorporates nutritional complications and acknowledges that feed-ing disorders are common in certain medical conditions; however, itrequires that severity of the eating disturbance exceeds that associ-ated with the condition and specifically excludes children whoseprimary challenge is a skill deficit (5,6).

Historically, feeding disorders were defined using anorganic/nonorganic dichotomy. The International Statistical Clas-sification of Diseases and Related Health Problems, 10th Revision(ICD-10) diagnostic codes for PFDs either requires the absence oforganic disease (F98.2: Other feeding disorders of infancy andchildhood) or uses the nonspecific, poorly defined R63.3: Feedingdifficulties (7). Existing diagnostic codes are clearly inadequate todescribe the multiple factors involved in a feeding disorder (8).

In this article, use of the International Classification ofFunctioning, Disability, and Health (ICF) framework to define aunifying diagnostic term, ‘‘pediatric feeding disorder’’ (PFD) isproposed. The World Health Organization ICF framework definesfunctioning as an umbrella term referring to all body functions,activities, and participation, and defines disability as an umbrellaterm covering impairment (a problem in body function or structure),activity limitation (difficulty encountered in executing a task oraction), and participation restriction (problem experienced ininvolvement in life situations). The ICF framework complementsthe ICD-10 (9), and emphasizes a holistic understanding of thephysiologic and functional impact of PFD, including the impairedmechanisms, environmental barriers, and facilitators and, mostimportantly, the impact on participation in daily family and com-munity life. The proposed diagnostic criteria in this article resultfrom deliberations among a panel of experts well versed in the careof children with feeding disorders. The diagnostic criteria werederived from a combination of evidence, when available, andexpert opinion.

Since the publication of the World Health Organization ICF,there is increasing recognition that diagnoses do not necessarilypredict function, and that assessment of functional limitations iscritical to planning appropriate interventions to improve quality oflife (10). PFDs can profoundly impact a child’s physical, social,emotional, and/or cognitive function, and increase caregiver stress(3). A classification system describing the effects of a PFD onfunction would enable practitioners and researchers to better char-acterize the needs of heterogeneous patient populations, facilitateinclusion of all relevant disciplines in treatment, and allow thehealth care team to use a common, precise terminology necessary toadvance clinical practice and research (10).

environmental factors (products and substances for personal consumption).zFeeding skill dysfunction: limitations in activities/participation related to

eating.§Psychosocial dysfunction: limitations in activities/participation related

to interpersonal interactions and relationships.

PEDIATRIC FEEDING DISORDER: DEFINITIONPFD is defined as impaired oral intake that is not age-

appropriate, and is associated with medical, nutritional, feedingskill, and/or psychosocial dysfunction. The proposed diagnostic

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criteria are shown in Table 1. PFD can be classified into acute (<3months’ duration) and chronic (�3 months’ duration) (11).

The proposed reference standard for oral intake is age-appropriate feeding: the progressive acquisition of feeding skillsenabling progression from breast or bottle feeding to self-feeding avariety of age-appropriate table foods. Children with developmentaldelays may have feeding skills appropriate for their level ofdevelopment but not their age; hence, these children will have adiagnosis of PFD.

In the proposed definition, impaired oral intake refers to theinability to consume sufficient food and liquids to meet nutritionaland hydration requirements. The definition excludes the inability totake medications or atypical, unpalatable foods. To eliminatetransient feeding problems resulting from acute illness, impairedoral intake must be present daily for at least 2 weeks.

To distinguish between PFD and eating disorders (eg,anorexia nervosa), PFD should be diagnosed only in the absenceof body image disturbances. Although pica and rumination can beassociated with PFD, their presence alone does not constitute PFD(12).

According to the ICF framework, disability results whenimpairments interact with personal and environmental factors toresult in activity limitations or participation restriction. PFD resultsin disability (13). For example, impaired ability to eat leads toparticipation restrictions or modifications in childcare, school, andother environments that involve mealtime interactions. In later life,

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PFD can impair attainment of social relationships and employment(9). Because the definition of disability is dependent on environ-mental factors (the physical, social, and attitudinal environment inwhich people live and conduct their lives), culturally specificfeeding behaviors in the absence of dysfunction do not qualifyas PFD.

Four important domains underlie PFD: medical, nutritional,feeding skills, and psychosocial. Because of interplay between thesedomains, impairment in one can lead to dysfunction in any of theothers. The result is PFD. Disability resulting from interactionsamong health conditions, personal factors, and environmentalfactors are discussed below.

MEDICAL FACTORSImpaired structure/function of the GI, cardiorespiratory, and

neurological systems are frequently associated with dysphagia thatresults in dysfunction in 1 or more feeding domains, and PFD.(Supplementary Table 1, Supplemental Digital Content, http://links.lww.com/MPG/B507) The impairments related to medicalconditions give rise to dysfunction through several mechanisms.

Upper GI tract dysfunction is associated with PFD, arisingprimarily from a GI anomaly or disease, or secondarily fromrespiratory or airway pathology. Oropharyngeal and laryngealanomalies can impair the mechanics of normal feeding. Inflamma-tory diseases of the upper GI tract may also impair normal feeding.Although there is insufficient documented evidence to support astrong association between gastroesophageal reflux disease andPFD, the link between PFD and eosinophilic esophagitis is betterestablished (14). Motility and functional GI disease also may impairfeeding including children with repaired esophageal atresia (15),post-fundoplication (16), and feeding volume intolerance indepen-dent of gastroparesis in medically complex children.

Diseases of the airway and lungs are the other components of‘‘aerodigestive disease’’ and can also result in PFD, particularly inyoung children with chronic tachypnea, where the suck-swallow-breathe coordination is particularly challenging. Chronic lungdisease of prematurity often causes tachypnea and dyspnea thataffect swallowing and feeding skill acquisition (17). Aspirationresulting from PFD can manifest as lower respiratory tractinfections (eg, pneumonia), but is more commonly identified viafluoroscopy based on subtle respiratory signs/symptoms and/orother clinical manifestations (eg, feeding refusal in infancy).

Children with congenital heart disease may require pro-longed hospitalization with critical care interventions that can delayand subvert the acquisition of feeding skills. Cardiac surgerycan result in recurrent laryngeal nerve injury with left vocalfold paralysis and impaired airway protection. Chronic hypoxiaand possible vagal injury may play a role in feeding intolerance andvomiting in these children (18).

Children with neurologic impairments are at increased riskfor PFD, particularly as they grow and reach points where nutri-tional needs exceed their feeding skills (19). Generally, childrenwith more severe motor and cognitive delays have greater feedingimpairment (20). Neurogenic dysphagia is common during infancybut may present later secondary to cerebral palsy, leading tomorbidity and mortality from chronic aspiration (21).

Neurodevelopmental disorders, specifically autism spectrumdisorder, are also associated with PFD (22). Finally, some childrenwho consume inadequate calories for normal growth may have adisorder of appetite signaling mechanisms causing PFD.

NUTRITIONAL FACTORSMany children with PFD have a restricted quality, quantity,

and/or variety of beverages and foods consumed, placing them at

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risk of malnutrition, overnutrition, micronutrient deficiency ortoxicity, and dehydration (Supplementary Table 2, SupplementalDigital Content, http://links.lww.com/MPG/B507). Malnutrition isdefined as intake of nutrients insufficient to meet nutritionalrequirements, resulting in ‘‘cumulative deficits of energy, proteinor micronutrients’’ that may adversely impact growth, develop-ment, and health (23). Malnutrition affects 25% to 50% of childrenwith PFD (24,25) and is most prevalent among those with chronicdisease or neurodevelopmental disorders (26).

The restricted dietary diversity common in PFD can haveother adverse nutritional consequences. Exclusion of entire foodgroups, such as fruits and vegetables, can result in micronutrientdeficiency despite adequate macronutrient intake (27–30). Chil-dren with excessive intake of specific foods, beverages, or dietarysupplements can experience micronutrient excess or, rarely, toxicity(22). Excessive energy intake, especially in the setting of lowerenergy requirements, can result in obesity (31).

FEEDING SKILL FACTORSAltered feeding experiences due to illness, injury, or devel-

opmental delay may lead to impairment of feeding skills. Neuro-developmental delay inhibiting feeding may become evident anytime in the first few years of life, during periods of change inoropharyngeal anatomy and neuromuscular coordination, texturetransitions, and transitions in feeding/drinking utensils (32,33).Specific impairments in oral and pharyngeal sensory-motor func-tioning may also inhibit feeding skills. In addition, altered oralexperiences from physical injury, deficits in neurologic functioning(34), abnormal oral structure or function (35), and/or adverse orlimited feeding experience (36–39) can cause feeding skillsimpairment (Supplementary Table 3, Supplemental Digital Con-tent, http://links.lww.com/MPG/B507).

Impairment in oral sensory functioning inhibits/limits accep-tance and tolerance of liquids and food textures expected for age; itmay be associated with specific characteristics of liquids and foodtextures such as the flavor, temperature, bolus size, viscosity,texture, or appearance (40,41). Under-response or hyposensitivityis generally characterized by lack of awareness of food within themouth, limited bolus formation, loss of food from the mouth,increased bolus size, and gagging or refusal of liquids and foodtextures that provide inadequate sensory input. These childrencharacteristically seek increased bolus size or exaggerated flavors,temperatures, and textures. Over-response or hypersensitivity isgenerally characterized by gagging with specific textures or bolussize, excessive chewing, and limited variety of intake. Thesechildren characteristically seek bland flavors, finely grained tex-tures, small bolus sizes, and room-temperature foods.

Impairment in oral motor functioning limits bolus control,manipulation, and/or transit of liquids and solids; it can be charac-terized by inefficient intake, messy eating, poor control of liquidsand foods, slow or ineffective bolus formation and propulsion,gagging during bolus formation, and postswallowing residue (42).

Although the clinician can evaluate the oral phases visually,evaluation of pharyngeal structures and their function requiresinstrumental assessment using a modified barium swallow orfiberoptic endoscopic evaluation of swallowing (37,38,43).Impairment in pharyngeal sensation inhibits airway protectionand efficient swallowing; it is often associated with poorly timedand coordinated swallowing during pharyngeal transit, poor aware-ness of bolus location, presence of pharyngeal residue post-swal-low, and silent aspiration. Clinical characteristics of sensoryimpairment can include gulping or audible swallows, too manyor too few swallows per bolus, wet vocalization, and no attempts toclear residue after swallowing (44,45).

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Impairment in pharyngeal motor functioning inhibits pha-ryngeal movements. It may be evidenced by reduction in strengthand coordination of pharyngeal constrictors, velar and laryngealelevation, and vocal fold closure. Symptoms can include multipleeffortful swallows per bolus, throat clearing, pharyngonasal flow,chronic nasal congestion, inability to clear residue, and poorairway protection.

Skill-based Dysfunction

To be fully functional, a child’s feeding skills must be safe,age appropriate, and efficient. Dysfunction in any of these areasconstitutes PFD.

Unsafe oral feeding may present as choking, aspiration,adverse cardiorespiratory events (eg, apnea, bradycardia) duringoral feeds, or other adverse mealtime events (eg, gagging, vomiting,fatigue, refusal) (46,47).

Delayed feeding skills may present as a child who is unable toconsume age-appropriate liquid and food textures. The child mayrequire food/fluid to be modified from its original form (eg,blending solids into a puree) or may rely on a natural variant(eg, a naturally smooth food) that is not age appropriate. Thesechildren may have deficits in use of feeding utensils and devices orself-feeding skills. They may require special feeding equipment,positioning, or feeding strategies (32,33).

Inefficient oral feeding may present as prolonged mealtimeduration (ie,>30 minutes) or inadequate oral intake. These childrenmay require modified textures, special feeding equipment or strat-egies, or nutritional supplementation (32,33).

PSYCHOSOCIAL FACTORSFactors within the child, caregiver, and the feeding environ-

ment (psychosocial impairments) can adversely affect feedingdevelopment and ultimately contribute to and maintain PFD(48,49). Problem feeding behaviors are the resultant dysfunctionand are often among the first concerns that caregivers expressregarding feeding their child (50).

Psychosocial Impairments

Psychosocial factors in the child and/or caregiver can con-tribute to feeding dysfunction (51) and are characterized as Devel-opmental Factors, Mental and Behavioral Health Problems, SocialFactors, or Environmental Factors (Supplementary Table 4,Supplemental Digital Content, http://links.lww.com/MPG/B507)(48,49). Although problems in any of these domains can lead tofeeding dysfunction, most commonly PFD results from an inter-action among any or all 4 domains (6,52).

Developmental factors resulting in delays of motor skills,language, socialization, and cognition can contribute to the devel-opment of PFD. These delays often result in a mismatch betweenthe feeding abilities of the child and the feeding expectations ofadult caregivers who are responsible for feeding the child. Forexample, if a caregiver’s expectations of what a child should eatare not congruent with what a child can eat due to delays in skilldevelopment, this incongruence can contribute to aversive feedingexperiences resulting in a PFD, particularly if the caregiver persistsin attempting to feed the child in a chronologically age-typicalmanner (53).

Mental and behavioral health problems in the child, care-giver, or dyad can adversely influence feeding behavior (54). In achild, dysregulated temperament, mood disorders, anxiety, or dis-ordered thinking can increase rates of disruptive feeding behavior(55). In a caregiver, stress and/or other mental health factors can

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alter mealtime interactions (56). These factors may impact how thecaregiver approaches the feeding situation, resulting in over- orundercontrolling parenting practices. These factors act bidirection-ally within the child-caregiver dyad (51).

Social influences including caregiver-child interactions andcultural expectations within a mealtime context can impact a child’sbehavior at mealtimes. For example, a caregiver’s strategies forgeneral management of problem behavior may not be effective inmanaging mealtime-specific behavior problems. Caregivers maymisinterpret a child’s hunger and satiety cues, interrupting thedevelopment of positive learning about eating. Finally, a care-giver’s cultural beliefs about feeding and nutrition may not beconsistent with expectations of others (eg, American Academyof Pediatrics guidelines, expectations of teachers and healthcareproviders), which may affect how the caregiver feeds the child andhow the child responds.

Environmental factors can contribute to the development ofPFD. During meals, a distracting feeding environment (eg, use oftelevision or other electronic devices) or resorting to feeding only attimes when a child is asleep, may prevent caregivers from providingappropriate responses to mealtime behavior or can lead to theinadvertent reinforcement of problematic mealtime behavior bywell-intentioned caregivers (eg, replacing refused foods with highlypreferred foods, attending to crying) (57). An inconsistent mealtimeschedule can adversely affect appetite and subsequently mealtimebehavior (53). Unavailability of food resources can affect how andwhat a caregiver feeds their child, which can subsequently affect thechild’s feeding behavior.

Psychosocial Dysfunction

PFD can develop as a result of the impairments describedabove and generally manifests as one of the following (49):

Learned feeding aversions result when a child repeatedlyexperiences physical or emotional pain or discomfort during feed-ings. Over time, the child develops strategies to avoid the aversivefeeding situations. When these strategies succeed, the behaviors andlearned aversion are strengthened (48).

Stress and distress in the child and/or caregiver are expressedas negative emotions or as disengagement from meals (3,56).

Disruptive behavior that is incompatible with eating. Thesebehaviors can be active (eg, pushing food away, elopement, aggres-sion toward the caregiver) or passive (eg, refusal to self-feed).

Food overselectivity (picky eating) is defined as eating alimited variety of foods or unwillingness to try new foods, despitethe ability to eat a broader diet (58).

Failure to advance to age-appropriate diet despite adequateskill (54).

Grazing is defined as consuming small amounts of food orfluid throughout the day. It causes a false sense of satiety and oftenleads to reduced intake (59).

Caregiver use of inappropriate strategies to improve childnutritional status (59). Some compensatory strategies are func-tional, but maladaptive. Instead of improving nutritional status,maladaptive compensatory strategies can perpetuate or worsenmalnutrition and other manifestations of feeding dysfunction.Examples include offering only preferred foods, feeding a childthat has the skills to self-feed, forced feeding, or giving fluid viainfant bottle outside of the recommended age for bottle feeding.

CONCLUSIONSThese proposed diagnostic criteria for PFD use a conceptual

framework that goes beyond disease-oriented or unilateral diagnos-tic paradigms, defining PFD as restricted oral intake that is not age

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appropriate and leads to dysfunction in at least one of 4 closelyrelated, complementary domains. Adoption of this definition byhealthcare professionals from all disciplines will establish a com-mon terminology that could have widespread impact on clinicalpractice, education, research, and advocacy.

These criteria aim to create a platform for change to ensureinfants and children with PFD receive the best care possible and thatthe families receive the broadest community support available. Thisframework supports advocacy by family and professional organiza-tions, and promotion of increased training opportunities, to ensurethat children with PFD have access to all specialists needed foroptimal management. Although not all children have impairment inall 4 domains, initial evaluation of each domain is strongly recom-mended because the same presenting symptoms and signs can yielddistinct, complementary domain-specific recommendations neededfor successful treatment to promote optimal function (60). Optimalcare of children with PFD requires a team approach (SupplementaryTable 5, Supplemental Digital Content, http://links.lww.com/MPG/B507), but many patients are unable to access evaluations in all 4domains, due to lack of insurance coverage or lack of availablespecialists in their geographic location.

By promoting usage of a consistent, comprehensive, inter-disciplinary terminology that encompasses both physiologicimpairment and function, this definition has the potential tofacilitate interdisciplinary collaboration; promote educational cur-ricula to train practitioners; promote research investigating bestpractices; and allow comparison of outcomes between studies andclinical programs. This, in turn, may lead to recognition of specificdiagnostic subtypes with treatment or prognostic implications.Additional systems-oriented advantages include the ability topartner with policymakers so that PFD is a qualifying diagnosisfor early intervention services under part C of the Individuals withDisabilities Education Act; and stimulate changes to the ICD-10codes and insurance coverage policies to allow for improvedreimbursement and coverage of infants and children for rehabili-tative services.

Acknowledgments: The authors wish to thank the followingindividuals without whom this article would not have been possible:Joan Arvedson, PhD, Colin Rudolph, MD, PhD, Kay A. Toomey,PhD, and Shannon Goldwater and Chris Linn of Feeding Matters.

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P e d i a t r i c F e e d i n g H i s t o r y a n d C l i n i c a l A s s e s s m e n t T e m p l a t e ( L i q u i d , P u r e e d , S o l i d ) |

Templates are consensus-based and provided as a resource for members of the American Speech- Language-Hearing Association (ASHA). Information included in these templates does not represent official ASHA policy.

1

A. Preliminary Information Reason for referral: _________________________________________________________________ Chronological age (Adjusted age): ________________________________________________ Primary caregiver: __________________________________________________________________ Informant for evaluation: ___________________________________________________________ Primary language: __________________ Interpreter Family concerns ____________________________________________________________________ Barriers to learning: ___________________________________________________________

B. Background Information B1. Summary Medical team (physicians, dentists, etc): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Ancillary care team (nursing, therapists, etc): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Previous Hospitalizations: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Previous Surgeries: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Medications: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies/Intolerances: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Cultural preferences relevant to feeding: __________________________________________________________________________________________________________________________________________________________________________________________



2

B2. Birth History Complications during pregnancy: _____________________________________ Delivery:

Vaginal Cesarean-‐section: (reason) _________________________ Single Birth Multiple Birth: (define) ________________________

Complications during delivery: _______________________________________ Term Preterm: _______________(weeks/days) NICU: (describe) _______________________________________________ Birth weight: ___________ APGAR Scores: _____ @ 1m, _____ @ 5 m, _____ @ 10 m

B3. Congenital malformations, deformations, and chromosomal abnormalities Details including treatment: ________________________________________________________ _________________________________________________________________________________________

B4. Conditions/Disorders/Diseases of the nervous system

Details including treatment: ________________________________________________________ _________________________________________________________________________________________

B5. Conditions/Disorders/Diseases of the circulatory system


B6. Conditions/Disorders/Diseases of the respiratory system


B7. Conditions/Disorders/Diseases of the digestive system


B8. Conditions/Disorders/Diseases of the musculoskeletal system and

connective tissue Details including treatment: ________________________________________________________ _________________________________________________________________________________________

B9. Neoplasms

Details including location of neoplasm & treatment: _____________________________ _________________________________________________________________________________________

B10. Mental, behavioral, and neurodevelopmental disorders




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B11. Injury, poisoning and other consequences of external causes Details including treatment: ________________________________________________________ _________________________________________________________________________________________

B12. Hearing impairment: _____________________________________________________________

B13. Visual impairment: _______________________________________________________________

B14. Diagnostic procedures completed (dates & results)

MBS/VFSS: _____________________________________________________________________ FEES: ____________________________________________________________________________ pH/Impedance probe: _________________________________________________________ Upper GI: _______________________________________________________________________ Gastric emptying/Milk Scan: __________________________________________________ Other: ___________________________________________________________________________

B15. Swallowing/Feeding & Nutrition History Breastfeeding:

Bottle feeding:

Spoon from caregiver:

Fingers (self):

No spill cup:

Straw:

Utensils (self):

Open cup:

Alternate feeding methods (tube feeding, parenteral nutrition, etc…)



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Historically, child consumes adequate amount and variety of: Comment if No

Liquids Yes No

Fruits Yes No

Vegetables Yes No

Grains Yes No

Dairy Yes No

Meats Yes No

History of: Dehydration Poor Weight Gain Coughing/choking during or after eating/drinking Gagging/vomiting during or after eating/drinking Wet vocal quality during or after eating/drinking Problematic behaviors during or after eating/drinking Details: _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



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C. Evaluation Information Number of meals/snacks offered each day: _________________________________ Average length of meal/snack times: _______________________________________ Routine for meal/snack times: ________________________________________________ Typical position for feeding: ________________________________________________________ Fed by: Self Others: _______________________________________________ Sensory preferences: ________________________________________________________ Modifications to food or fluid: ______________________________________________ Use of additives or supplements: __________________________________________

Before assessment: State: _______________________________________ Respiratory Rate: ___________________ Oxygen saturation: _______________________ Pain Assessment: ___________________ Assessment Oral Motor/Peripheral All structures observed Yes No

List structures not observed: _______________________________________________ All structures within expected limits for age, sex, race: Yes No

Details if no: _________________________________________________________________ Movement patterns, tone, and reflexes are appropriate for age Yes No

Details if no: _________________________________________________________________ Non-‐Nutritive Suckling/Sucking: Not applicable Adequate Impaired Describe: _____________________________________________________________________________ Oral sensory response Functional Signs of hypersensitivity Signs of hyposensitivity Describe: _____________________________________________________________________________ Adequate secretion management: Yes No Describe if no: _______________________________________________________________________ Phonation: Functional Impaired Not applicable (i.e. trach) Describe if impaired: ________________________________________________________________ Signs of stress during assessment: Yes No Describe if yes: ________________________________________________________________



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Oral Feeding Position(s) during feeding: _________________________________________________________ Pureed foods trialed: ___________________________________________________________ Fed by: Self Caregiver Clinician Spoon feeding skills were appropriate for age: Yes No Details if no: _________________________________________________________________ Compensatory strategies trialed: __________________________________________ Results of compensatory strategies: _______________________________________ Solid foods trialed: ___________________________________________________________ Fed by: Self Caregiver Clinician Biting/chewing skills were appropriate for age: Yes No Details if no: _________________________________________________________________ Compensatory strategies trialed: __________________________________________ Results of compensatory strategies: _______________________________________

Liquids trialed: _________________________________________________________________ Fed by: Self Caregiver Clinician Drank from: Lidded cup Straw Open cup

Bottle Other: _____________________________________ Drinking skills were appropriate for age: Yes No Details if no: _________________________________________________________________ Compensatory strategies trialed: __________________________________________ Results of compensatory strategies: _______________________________________ Concern for pharyngeal phase dysfunction: _________________________________ Concern for esophageal phase dysfunction: _________________________________ Disruptive feeding behavior: ______________________________________________ Oral sensory response:

Functional Signs of hypersensitivity Signs of hyposensitivity Comments: ___________________________________________________________________ After assessment: State: _______________________________________ Respiratory Rate: ___________________ Oxygen saturation: _______________________ Pain Assessment: ___________________ Other observations: _________________________________________________________________

D. Clinical Summary

(Patient name) is a (age) (gender) that presents with (functional/dysfunctional) oral feeding skills characterized by _______________. Prognosis for safe oral intake: Good Fair Poor Prognosis for adequate oral intake: Good Fair Poor Strengths: ____________________________________________________________________________ Concerns: ____________________________________________________________________________



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Diagnosis/ICD10: Dysphagia, unspecified R13.10

Dysphagia, oral phase R13.11 Dysphagia, oropharyngeal phase R13.12 Other: ____________________________________________________________________________

Recommendations: Continue oral feeding, no modifications

Continue oral feeding with the following modifications: ___________________ ________________________________________________________________________________

Instrumental evaluation of swallow function MBS/VFSS FEES Other: ________________________ Feeding therapy (see plan of care) Refer to Registered dietitian Gastroenterologist Pulmonologist Developmental pediatrician Other: ___________________________________________________________ Additional recommendations: _________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Plan of care: Speech therapy intervention (is/ is not) recommended for (number of times/

week) for (time of session, such as 30 minutes) as tolerated for at least (number of weeks/months). Interventions include but are not limited to the following: _________________________________________________________________________________________ Long term goals: _____________________________________________________________________ _________________________________________________________________________________________ Short term goals: ____________________________________________________________________ _________________________________________________________________________________________ Education provided to family regarding results, recommendations, and

plan. Barriers to learning: ___________________________________________________________ Family demonstrated understanding of results, recommendations, and

plan. Reinforcement needed: ________________________________________________________

Oral Motor Skills Checklist For oral skills consolidated >24 months

Food/skill area Skill Skill met?

Y/N 1. Open cup drinking OR

No liquid loss during drinking or when cup is removed from the lips

Uses up-‐down jaw pattern with cup held between the lips for consecutive sips (score 0 if no consecutive sips)

Not biting on cup for stabilization Total (≤2=FAIL) /3

1. Pop-‐top bottle/straw drinking

Sequences 3 suck-‐swallows without pause Swallowing follows sucking with no pause, and no coughing/choking is observed

No liquid is lost during sucking Total (≤2=FAIL) /3

2. Pureed food No tongue protrusion beyond incisors during swallowing

No loss of food observed Tongue and lip movement are independent of jaw movement when clearing the spoon (score 0 if not actively using upper lip to clear, if biting on spoon, or if spoon needs to be flipped to clear)

Total (≤2=FAIL) /3 3. Chewable/ crunchy food

No tongue protrusion beyond incisors during swallowing

Tongue lateralization observed for chewing (score 0 if using fingers to assist)

Minimal loss of food/no mess observed Takes an adequately sized bite without associated head/hand movement and with appropriate jaw grading for chosen food (score 0 if ‘munching’ or overstuffing mouth)

Total (≤3=FAIL) /4 Overall Total

(cup drinking OR pop-‐top scores) /10 0 areas failed=WNL; 1 area failed=mild delay; ≥2 areas failed=moderate delay

Adapted from Morris, S. E. & Klein, M. D. (2000) Pre-‐Feeding Skills: A Comprehensive Resource for Mealtime Development, Therapy Skill Builders, United States of America.

Dodrill and Marshall (2016)

Documents

Pediatric Feeding Disorder: Diagnosis & Management...2/19/20 1 Pediatric Feeding Disorder: Diagnosis & Management Presented to the 50th Annual Mid-South Conference on Communicative