The Basics of Feeding:A Workshop in Pediatric Dysphagia
Part III
Stacy Antoniadis, MA, MPH, CCC/SLP
Lisa McCarty, MS, CCC/SLP
Julie McCollum Daly,BS, OTR/L
Cindy Straub, BS
Medical Problems Associated With Feeding - By Symptoms
• Fatigue
• Food refusal
• Apnea during feeding
• Difficult transitions
• Spillage and drooling
• Head tilting
• Poor weight gain
Symptom with Etiologies: Fatigue
• Cardiac• BPD• Chronic diseases
– leukemia– cystic fibrosis
• Neuromuscular disease– muscle weakness, cerebral palsy– spinal cord injury, spina bifida
Symptom with Etiologies: Food Refusal
• Chronic– Gastro-Esophageal (GE) Reflux
– Allergies• milk and food intolerances
– Hypersensitivity
– Pain
Symptom with Etiologies: Food Refusal
• Acute– Oral lesions
– Otitis media
– Pharyngitis
– Medications
Symptom with Etiologies: Apnea During Feeding
• Prematurity
• Aspiration/penetration
• Cardiac/respiratory insufficiency
Symptom with Etiologies: Difficult Transitions
• Developmental delay
• Hypersensitivity/sensory integration disorder
• Autism
• Dysphagia
Symptom with Etiologies: Spillage and Drooling
• Hypotonia
• Hypertonia
• Oral motor apraxia
• Cleft lip/palate
• Micrognathia
• Developmental delay
• Abnormal swallow
Symptom with Etiologies: Head Tilting
• Back tilt– poor oral motor control– abnormal swallow– impaired visual field or eye control
• Forward tilt– poor head control– abnormal swallow
• To one side tilt– asymetric neurologic problem
• facial palsy, torticolis
Symptom with Etiologies: Poor Weight Gain
• Inadequate diet, diluted formulas
• Poor appetite• Slow feeding• Spilled food• Hidden infections• Cystic Fibrosis
• Cardiac insufficiency• Renal insufficiency• Malabsorption• Genetic• Hormonal deficits• Psychological/
relationship problems
Gastroesophageal Reflux (GER)
• Symptoms– food refusal, posturing, vomiting, regurgitation, pain,
irritability during feeding• Diagnostic tests for GER
– pH probe– endoscopy– barium swallow (cookie swallow, modified barium
swallow)– - milk scan– - esophageal manometry
Observing GE Reflux
• Note the timing of the swallowing bursts.
• Note what happens when facilitation is offered.
• Note how the reflux is triggered.
Gastroesophageal Reflux (GER)
• Treatment– Medical
• drugs• positioning• feeding therapy
– Surgical• fundoplication• pyloroplasty• tube insertion (NG, J, gastrostomy)
Nutrition and the Child With Developmental Disabilities
• Big concern is MALNUTRITION
– Three types:• marasmus• kwashiorkor• marasmic kwashiorkor
Nutrition Research on Children with Developmental
Disabilities
• Cincinatti University Affiliated Program study (n=83 children with DD)– most were under/over weight and had
feeding disorder– some had nutrient deficiency– other problems: unusual food habits,
metabolic disorders
Nutrition Research on Children with Developmental
Disabilities
• Norwegian study– growth stunting in children with
feeding problems, lack of appetite, food aversions
Components to Nutritional Assessment
• Anthropometry
• Biochemical indices
• Clinical indices
• Drug/Nutrient interactions
• Dietary indices
Factors Influencing Caloric Intake
• Activity level
• Body composition
• Monitoring
Pathogenesis of Malnutrition
• Reduced nutrient intake
• Increased nutrient requirements
• Impaired nutrient absorption
Suggested Criteria for Referral
• Height or weight below the 10th or greater than 90th percentile
• Cross over >2 growth channels
• Mechanical feeding difficulties
• Unusual food habits
• Inherited metabolic disorders
The goal of a nutrition program is to establish
adequate intake for growth and energy.
Next Steps After Identification
• Involve team and family
• Consider ethnic dietary practices
• Consider income level of family
• Review of child’s illnesses/medications
• ADA’s guidelines for disability areas
• Adjust nutrition plan to meet family needs
Feeding Safety Practices
Texture
• Definition
• Oral motor patterns
• Problems and options
Consistency
• Definition
• Safety issues
Temperature
• Serving/holding temperature
• Sensitivity to hot and cold food
• Safety issues
Positioning for Feeding
• Check for position
• Head at midline
• Position of person presenting food
• Continue to recheck body and head position
• Alternate positioning during meals
Mealtime
• Position and head alignment
• Presentation of food
• Meal time problems– hyperextension, tongue thrust, vocalization
• When to offer food
• Checklist for food refusal
• Dangerous practices
Fluids
• Offering fluids– every 3-4 bites– do not hold to the end of meal
• Thickening liquids– rice cereal, Thick-It, etc
• Dangerous practices
• Handouts for parents