Pediatric D ysphagia Treatm ent: The How & W hy - The ...

Pediatric Dysphagia Treatment:

The How &

Why

Presented to The 20thAnnual Loretta G.

Brown Sym

posium at the

Mem

orieM

. Gosa, PhD, CCC-SLP, BCS-SPediatric Speech-Language Pathologist, Assistant Professor

mem

[email protected]

Review of Feeding and sw

allowing problem

s in pediatric populations8:15 -9:45

09/21/182

Image from

: https://nouvelles.umontreal.ca/en/article/2017/12/14/eating-together-as-a-fam

ily-helps-children-feel-better/

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http://www.craftsy.com/blog/2013/08/childs-face-mastering-proportions/ http://www.new-vis.com/fym/papers/p-feed10.htm

Developmental vs Acquired Dysphagia

• Relearning vs. basic acquisition of skills• Critical/Sensitive periods for learning• Cognitive skills for applying strategies

Early Nutrition for Growth & Long-Term Development

http://secondinnocence.blogspot.com/2008_10_01_archive.html

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Children vs Adults: Feeding Skills• Early suckling– Oral phase is reflexive– Intake is single consistency (fluid)– Plane of movement in uni-directional– Brainstem mediated – Central pattern generator

• Later transition to solids– Oral phase is volitional– Intake is of variable consistency– Plane of movement in multi-directional– Greater cortical input is required

Sensory Integration

• Hyposensitive• Hypersensitive

• Stimulation– Tactile– Thermal– Chemo

Sensory Integration

• Hyposensitive– High threshold for

registering sensory input

– Reduced response to stimuli

– Actively seeks extra stimulation

http://noahsdad.com/first-tim-tam-balance-parenting/

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Sensory Integration

• Hypersensitive– Low threshold for registering sensory input– Increased response to stimulus–May actively avoid stimulation

http://www.dailymail.co.uk/news/article-2085776/Moment-baby-tries-lemon-time--love-hate-time.html

Food Aversion

– Behavioral response to stimulus–May persist beyond initial sensory integration

problem

http://thetherapeuticresourcesblog.blogspot.com/2011/08/picky-eater-or-sensory-food-aversion.html

Learning to EatSynchrony of systems

Gut maturation

Oral anatomy

Neurology

Posture

Behaviour

Milk> solid foods

Small oral cavity> large

Reflexes> voluntary skills

Requiring support> independent

Passive> independent

• “Dysphagia is a swallowing disorder characterized by difficulty in oral preparation for the swallow or in moving material from the mouth to the stomach. Subsumed in this definition are problems in positioning food in the mouth and in the oral manipulation preceding the swallow including suckling, sucking, and mastication.”

ASHA, 1987, p. 57

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Dysphagia

• Dysphagia exists if:– Feeding problems interfere with airway protection– Compromise adequate nutrition/hydration– (Peds) Compromise enjoyment for either parent

or child

Variable Incidence & Prevalence

• 25% - 45% of typically developing children (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% for children with developmental disorders (Arvedson, 2008; Brackett, Arvedson, & Manno, 2006; Lefton-Greif, 2008; Manikam & Perman, 2000)

• 3%-10% of children have severe consequences-Higher prevalence (10%-49%) in children with history of prematurity, medical illness and (26%-90%) physical disabilities (Manikam & Perman, 2000)

Consequences of Pediatric Dysphagia

1) Malnutrition-Managed successfully with supplemental nutrition

2) Aspiration with resulting respiratory compromise-Management is more complex-Airway problems may result from dysphagia but airway problems might also create dysphagia

Consequences of Pediatric Dysphagia

• Texture of food/fluid aspirated linked to respiratory outcomes

• Taniguchi and Moyer, 1994: – Pureed consistencies 9x increase in risk of

developing pneumonia– Thickened liquids, second greatest risk of

developing pneumonia– Thin liquids, not statistically significant increase in

risk for developing pneumonia

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Causes of Pediatric Feeding Problems Disorders

of Appetite

Metabolic Diseases

Sensory Defects

Conditioned

Dysphagia

Anatomic Abnormalities of the Orophary

nx, Larynx,

Trachea, &

Esophagus

Disorders affecting Sucking-

Swallowing-

Breathing

Disorders affecting

Neuromuscular

Coordination of

Swallowing

Mucosal Infections

& Inflamma

tory Disorders

Rudolph CD & Link DT (2002) Feeding Disorders in Infants and Children. Pediatric Gastroenterology & Nutrition, 49(1), 97-112.

Clinical Signs

• Arvedson et al., 1994– Poor predictive values for aspiration: choke,

respiratory problems, concern for aspiration, and dependence on others for feeding

– 94% are silent aspirators• Perlman (1990)– Not having one or all clinical signs does not

suggest that patient is a safe feeder

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Clinical Signs• Vary from child to child• Dependent upon age and type of underlying

disorder• Response to aspiration is age dependent• Coordination of swallowing mechanism improves

with age, protective reflexes– Cough in older children– Apnea in neonates– Desensitization from frequent aspiration/neurologic

impairment

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Clinical Signs

• Knowledge of underlying diagnosis is important but vigilance is key!

• BPD, asthma, and cystic fibrosis often have GER and are at higher risk for respiratory complications of dysphagia

• Differences between infants and children:– Apnea and bradycardia more common than

cough, congestion, wheezing, bronchitis, atelectasis, & pneumonia

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Oral Impairment• Lack of energy/endurance• Significant amount of oral residue• Excessive drooling• Prolonged mealtimes• Excessive gagging on secretions• Lip retraction/limited upper lip movement• Poor labial seal/anterior spillage• Jaw thrust/clench/retraction/instability/tonic or phasic bite

reflex• Reduced buccal tone/sensory awareness• Poor bolus formation/transport• Difficult initiation of swallow• Multiple swallows to clear oral cavity

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Pharyngeal Impairment• Nasopharyngeal backflow• Slowed initiation of swallow• Multiple swallows to clear single bolus• Piecemeal deglutition• Hyper/Hypo active gag• Aspiration before/during/after swallow• Most commonly aspirate on liquids• Absent or reduced cough reflex• Cricopharyngeal dysmotility

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Red Flags: Adult vs Pediatric Red Flags

• Adults• Recurrent Pneumonia• Head and Neck Cancer• Anoxia• Progressive Neurologic Disease• Anterior Cervical Spinal Fusion• Weight Loss• Diet Modifications• Brainstem Stroke• Guillain Barre• Laryngeal Trauma• Intubation• Ongoing respiratory problems

• Pediatrics• Issues affecting appetite• Metabolic Disease• Sensory defects• Craniofacial anomalies• Congenital conditions of

trachea/larynx• Abnormalities of esophagus

or lower GI tract• S:S:B Coordination Difficulty• Neuromuscular Disorders• Mucosal

infections/Inflammatory Disorders

• History of prematurity

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Prematurity

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Prematurity

1. Difficult S:S:B coordination2. Poor endurance due to respiratory problems3. Reduced strength/control of oral structures4. Poor state modulation/alertness5. Reduced control of oral-motor activities6. Oral hypersensitivity

Wolf & Glass, 1992

Intraventricular Hemorrhage– 40% in infants born prior

to 32 weeks (Volpe, 1997)– May lead to long-term

neurological impairment & decreased survival rate

– May impact on oral & pharyngeal functioning dependent on site of bleed and resulting neuropathology (hydrocephalus, etc…). (Ward & Beechy, 2003)

Necrotizing Enterocolitis (NEC)– GI disease, pathology unknown– Bowel injury in the neonate due

to pathogenic organism, enteral feedings and bowel compromise

– Symptoms range from mild feeding intolerance and abdominal distention to bowel perforation & additional system involvement

– Complicates nutritional support, creates LONG TERM feeding problems(Ward & Beechy, 2003)

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Bronchopulmonary Dysplasia– Chronic lung disease– Secondary to infant respiratory

distress syndrome, barotrauma from positive pressure ventilation, oxygen toxicity, & respiratory infection

– 23-31 weeks gestation at greatest risk– Lung function improves during

childhood– Significant impact on growth, 30-67%

have growth failure in months following discharge

(Ward & Beechy, 2003; Vohr et al,. 1982; Kurzner et al., 1988)

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Bronchopulmonary Dysplasia• Physiologically based feeding

problems & problems of mother-infant interaction– Poor sucking patterns, aspiration

during feeding (Pridham et al., 1989)

– Failure to develop anticipated suck/swallow rhythms at 32-40 weeks (Gewolb et al., 2001)

– Feeding interactions may be compromised

– Mothers report more depression & anxiety (Singer et al., 1996)

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Congenital Heart Disease• Congenital Heart Disease– Higher risk for FTT/growth failure (Hofner et al., 2000)– 3 main categories

1. Acyanotic2. Cyanotic3. Obstructive heart defects

– Presence of hypoxia & pulmonary hypertension are predicting factors for feeding problems in this population

– Physiological problems & infant-mother feeding problems (Varan et al., 1999)

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Congenital Neurologic Disorders

• Dysphagia common among children with CND and DD

• Both groups have predisposition to oral-motor dysfunction and GERD (Gisel et al., 2003)

• DD characteristically show food refusal, food selectivity by type or texture, oral-motor delay and dysphagia (any problem with swallowing) (Field et al., 1993)

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Cerebral Palsy (CP) and Feeding/Swallowing

• 75% of patients with CP have some sign/symptom of dysphagia

• Malnutrition, dehydration, and respiratory complications can result from dysphagia

• Assessment of their feeding/swallowing abilities is an important part of their overall care

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CP and Feeding/Swallowing• 45-50% of patients with CP are undernourished• Respiratory complications and pneumonia-- 90%

of deaths in patients with severe CP are caused by pneumonia

• Feeding/Swallowing difficulties due to:– Poor oral motor control– Poor pharyngeal movements– Persistence of primitive reflexes– Delayed gastric emptying– Abnormal posturing– Poor head control– Poor trunk stability

CP and Feeding/Swallowing• Poor growth seen in CP is frequently due to malnutrition• Pharyngeal dysphagia puts children with CP at risk for

multiple episodes of aspiration/pneumonia• GERD may also be associated with aspiration and

esophagitis• This combined with delayed gastric emptying may all

contribute to reduced oral intake

CP and Feeding/Swallowing• Chronic constipation present in 74% of patients– Secondary to prolonged transit at level of proximal

segments of the colon

• GERD present in more than 90% of children with CP– Also had prolonged gastric emptying

– Abnormal esophageal motility

• Oral motor dysfunction in children with CP is more than 90%-- with 1/3 of those presenting with severe OMD

• Results in:– Abnormal formation of bolus

– Defects in propulsion of bolus

CP and Feeding/Swallowing

• Feeding/Swallowing Functional Influences– Oral Issues– Pharyngeal Issues– Gastrointestinal Issues– Respiratory/Airway Issues

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Aerodigestive Tract Anomalies

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Nasopharynx Oropharynx Larynx Pharynx Trachea/Esophagus

Micellaneous

Choanal atresia

Nasal cysts

Tumors

Deviated

septum

Midface

hypoplasia

Cleft lip

Mandibular

hypoplasia

Adenotonsillar

hyperplasia

Epiglottitis

Penetrating

trauma

Tumor

Cyst

Laryngeal

Subglottic

stenosis

Laryngom

alacia

Vfpara.

Laryngeal

cleft

Laryngeal

web

Pharyng.

Paralysis

Pharyngit.

Peritonsill

ar absces

Retrophar

yngeal

abcess

TEF/Eso Atre

Esophageal

Mass

Mechanical

obstruction

LES/UES dysf.

Esophagitis

Esophageal

compression

NMJun

Disease

Muscular

disorders

Neoplastic

causes

Traumatic

Injury

Foreign body

ingestion

Nasopharynx

• Obstruct the nasal cavity- most impact on infants

• Bilateral/partial obstruction & stenosis• Stridor, labored breathing• Strained breathing increases during oral

feeding- disrupting coordination of breathing and swallowing

(Arvedson & Lefton-Greif, 1998) (Brodsky, 1997)

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Oropharynx

• Cleft lip & palate–Most commonly occurring craniofacial anomalies– Palate=inability to generate adequate intraoral

pressure for sucking– Lip=may effect ability to produce intraoral

pressure due to lip seal inadequacy– Pierre Robin sequence most commonly presents

with a U-shaped cleft palate(Kosko et al., 1998)

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Larynx

• Laryngomalacia–Most common cause of stridor, respiratory

distress, and airway obstruction in infants– High pitched inspiratory stridor during feeding

and/or crying– Commonly occurs with GERD– Typically resolves within first year of life

(Brodsky, 1997)

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Larynx

• Vocal fold paralysis– Frequently leads to aspiration– Second most common congenital anomaly – Unilateral, bilateral, congenital, or acquired– Functional voicing but inspiratory stridor– Unilateral paralysis: aspiration & hoarseness– Bilateral paralysis: inspiratory or biphasic stridor;

worsens with feeding– Spontaneous recovery or tracheostomy

(Kosko et al., 1998) & (Friedman et al., 2001)

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Larynx• Posterior laryngeal cleft– Rare congenital anomalies– Failure of posterior cricoid lamina to fuse– Association between laryngeal cleft and TEF

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Trachea and Esophagus• Tracheosophageal fistula/Esophageal atresia

– Most common congenital aerodigestive tract anomalies– Surgical repair– May exist separately, frequently seen togetherTEF:– Communication between trachea and esophagus allow

food/fluid to pass directly to lungs– Congenital or acquired– Coughing, choking, cyanosis, and hyperreactive airway-

recurrent aspiration pneumonia(Brodsky and Volk, 1993)

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Trachea and Esophagus• Tracheostomy– Surgical opening running from neck through to

trachea– Typically placed between 2-3 cervical vertebrae– May inhibit laryngeal excursion– Granulation tissue accumulation is common– Chronic bronchitis, wheezing, congestion, and

recurrent bacterial tracheitis should raise concern about chronic recurrent aspiration

– Aspiration is common complication(Loughlin and Lefton-Greif, 1994) & (Brodsky, 1997)

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GERD• 2 main causes:

1. Failure of normal means of preventing reflux2. Failure of means to clear occurring refluxo Infants: LES, esophageal peristalsis, and anatomy of esophagus

matures with ageo Infants with normal development of LES can maintain

pressure, preventing reflux between swallowso Infants with GERD, transient relaxation of LES between

swallows (seconds-minutes), most significant etiology of GERD in children

(Kawahara el al., 1997) (Putnam, 1997)

GERD• Two hallmark clinical symptoms

(Carr et al., 2000) (Carr and Brodsky, 1999)Respiratory Feeding

Stridor *Frequent vomiting during & after feeding

Wheeze *Growth Faltering

Cough *Choking/gagging

Nasal Congestion Drooling

Hoarseness Irritability with feeding

Aspiration Wet burps

Reflux central apnea Back arching

Reflux-induced laryngospasm

Reflux bronchospasm

GERD

• Treatment– Pharmacological: medicines either neutralize acid or

prevent acid production– Nonpharmacological: Upright positioning, thickened

feeds– Surgical: Nissen fundoplication

(Sullivan, 1997) (Putnam, 1997) (Orenstein, 1983)

GERD• Feeding Problems

– Prolonged presence of refluxed material in esophagus leads to inflammation of mucosa & bleeding

– Pain associated with esophagus leads to food refusal (Pain association with Feeding)

– Reduced oral intake Failure to thrive– Irritability, arching, grimacing, head turning, physical refusal,

and gagging/wretching– Reports of globus/food stuck in throat- result of non-specific

disruptions in esophageal peristalsis– Chronic inflammation may lead to thickening & development

of a fibrous stricture: food impaction &/or vomiting (Putnam, 1997) (Cucchiara et al., 1990) (Hyman 1994)

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GERD• Oral Phase

– Food refusal– Reduced self-feeding and readiness behaviors for solids– Oral hypersensitivity– Immature lip, tongue and jaw control– Food loss, poor lip closure/bolus containment– Difficulty with puree/semisolid foods– Delayed oral transit

• Pharyngeal Phase– Silent aspiration– Delayed pharyngeal transit times

(Mathisen et al., 1999)

Behavioral Feeding Problems

• Can arise as part of a number of other

comorbidities

• High prevalence (up to 85%)

• Reduced oral intake, poor/reduced weight

gain, malnutrition, FTT Effecting

neurological and physical development

• Disruptions in feeding routine impacts

intellectual, social and emotional growth of

the child AND overall family functioning

(Chatoor et al., 1988) (Palmer et al., 1975)

Behavioral Feeding ProblemsCommon clinical signs of behavioral feeding problems:

– Frowning/falling asleep, expressions of resistance/fear of accepting foods or liquids

– Panic in response to feeding utensil approaching

– Head turning– Hiding face– Struggling to avoid being fed– Gradual/sudden onset of

“difficult” mealtime behaviors

– Selective food refusal/food resistance

– Reduced appetite/lack of oral intake

– Failure to accept age-appropriate foods

– Excessive adaptations– Sudden refusal to

eat/drink– Sudden loss of appetite– Gradual change in eating

habits/patterns

Behavioral Feeding Problems• Causes

– Complex, multifactorial– Organic: physiological abnormalities, neuromuscular conditions,

allergies and acute infections, & various syndromes– Defining feature: medical/organic causes ruled out as being

significant enough to explain problems persistence– Non-organic environmental factors

• Two main etiologies1) Delayed development, lack of oral experience,failure to move into transitional period of feeding atnormal, developmentally appropriate time2) Psychological issues: negative patterns of mother-child

interaction and/or behavioral mismanagement

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Behavioral Feeding Problems• Lack of oral experience/developmental delay– Critical period for taste: 4-6 m– Critical period for texture advancement: 6-7 m– Late development results in inadequate mastication for

chewing = aversive gagging or choking, further refusal– Populations at risk: prolonged NG feedings, children with

severe medical illness/prolonged hospitalization– Combination of oral restrictions and aversive oral

stimulation during developmentally critical periods promotes dysfunctional feeding abilities

(Skuse, 1993) (Morris, 1989) (Willging 2000)

Behavioral Feeding Problems• Psychosocial Factors– Successful feeding relies heavily on both child’s

OM skills and parent’s skill in interpreting child’s needs

– Failure of caregiver to understand child’s needs and their own role during feeding process often leads to AVERSIVE FEEDING PRACTICES & subsequent behavioral feeding problems

– Reaches beyond physical growth and into child’s cognitive and linguistic competence & attachment to major caregivers

(Arvedson, 1997)

9:45 –10:00

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Motor, Sensory, &

Behavioral Approaches to Feeding10:00 –

11:30

09/21/181

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Multidisciplinary Management

Speech Language

Pathologist

Dietician

PCP

OTPT

Teacher

GIPulmonology

Social Worker

PedsDysphagia

Dysphagia TreatmentWhy treat Dysphagia?

• To facilitate safe oral feeding needed to sustain appropriate health and nutrition

Or• To transition patients to oral feedings as

appropriate

Successful Feeding

Medical Management

Nutrition

Skill

Environment

Behavior

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Oral Sensory Motor Therapy

ORAL SENSORIMOTOR THERAPY• Oral sensorimotor therapy is a broad term,

encompassing many different therapy techniques aimed at improving the function of the structures involved in the skills of eating (and speaking)

• SLPs are taught the basic principles of OSM therapy as part of their training

• However, a range of new OSM therapy texts, equipment resources, and therapy programs become available each year

ORAL SENSORIMOTOR THERAPY

o Acquired knowledge and judgement are required to: o Set therapy goals

o Determine which specific OSM techniques to use to achieve goals

o Implement the OSM techniques

o Measure relevant outcomes

o Modify therapy techniques, as necessary, in order to achieve goals


• Aims of OSM therapy

– Main aim • To achieve an individual’s maximal functional

capacity for feeding and speech

– Target areas • Oral structures (lips, tongue, cheeks, jaw,

palate)

• Neck, chest, posture, respiration

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• Goals of OSM therapy– Depending on the individual, goal may be to

achieve:• Skills appropriate to age • Skills appropriate to level of development / physical

capacity

– At different times during therapy specific goals may be to:• Acquire new skills• Develop existing skills• ‘Normalize’ skills the individual already

demonstrates


• Individual goals for OSM therapy

• Increased/decreased oral sensitivity to touch/ taste/ temperature

• Increased awareness of oral structures and movements

• Appropriate levels of arousal/ preparation for oral-motor tasks

• Co-ordinated oral movement sequences


• Individual goals for OSM therapy• Increased/ decreased oral muscle tone

• Increased/ decreased range of movement of oral structures

• Increased oral muscle strength

• Increased rate of movement of oral structures

• Increased precision of oral movements

• Facilitating appropriate oral reflexes, integrating/ inhibiting any abnormal oral reflexes

• Establishing functional oral movement patterns by guiding/ facilitating oral movements


• Specific goals for OSM therapy - Feeding– Decreased oral hypersensitivity/ increased oral

awareness– Increased oral self-exploration – Improved oral skills for feeding

(sucking/ chewing/ biting) – Safe swallowing – Improved saliva control – Assist in the transition from non-oral to oral feeding– Improve mealtime participation

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• Specific OSM therapy techniques often involve:

– Utilizing equipment (purpose-specific or adapting non-specific equipment)

– Using taught strategies

– Cueing (tactile/ visual/ auditory)

– Games to make the task more appealing to children

ORAL SENSORIMOTOR THERAPY• 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

Thickened Liquids

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

THICKENED FLUIDSThe use of thickened fluids is routinely recommended for two main pediatric populations:

� (a) children with oral-pharyngeal dysphagia

� (b) children who display regurgitation

It is important that thickened fluids are prepared correctly.

� If thickened fluids are too thin, they may not assist in managing the underlying problem (i.e. aspiration during swallowing and/or reflux)

� If thickened fluids are too thick, they may cause additional problems (e.g. increased work of breathing, reduced intake due to fatigue)

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THICKENED FLUIDSBottle feed provides infants with both nutrition and hydrationBottle-fed infants should be able to suck the feed through a nipple on a bottle in 20-30 minutes, in order to meet their nutritional and fluid requirements without expending excess energy

� If a bottle-fed infant requires thickened fluids, they may need to be switched to a faster flowing nipple to accommodate the thicker fluid.

THICKENED FLUIDSThickened bottle feeds are generally served heated, but will cool over the duration of a feed, and will likely get thicker. If the feed is re-heated, it may get thinner

Be aware that an infant with dysphagia who shows no clinical signs of aspiration with one type of thickened fluid may not manage another thickened fluid in the same way.

� Clinicians recommending thickened fluids need to be aware of potential variation in the viscosity or thickness of thickened fluids, as infants may be consuming liquids more or less viscous than assumed. Check that the recipe being used makes the correct thickness.

� Caregivers should be alert to clinical signs of fatigue and/or aspiration demonstrated during feeding (e.g. coughing, wet vocalizations, increased work of breathing), as this may indicate the thickness of the feed needs to be adjusted.

THICKENED FLUIDS

Expected measurements for thickened fluids

of different degrees of thickness are listed

below.

Thickened fluids Radius (mean) Radius (range) Reference

Pudding thick 2.2 cm 1.50- 2.89 cm QHealth (2006)

Honey thick 3.2 cm 2.90- 3.89 cm QHealth (2006)

Nectar thick 4.2 cm 3.90- 5.00 cm QHealth (2006)

Infant formula 9.7 cm Dodrill et al (2007, 2008)

THICKENING AGENTSThickening agents used for children with dysphagia should be labelled as suitable for use with patients with dysphagia. In addition, the packaging should contain clear instructions on how much thickening agent is required to prepare fluids that are consistent with the levels set out in the National Standards and/or to thicken bottle feeds.

In addition to speech pathology staff, dietetic, pharmacy, and medical staff should be involved in deciding which types of thickening agents are suitable for use with children.

Be aware that some thickening agents may contain allergens. Take particular care if a child has an allergy/ intolerance to corn, wheat, or gluten, or if they have eosinophilic esophagitis.

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THICKENING AGENTSBe aware that most suppliers of thickening agents do not recommend the use of their products with infants prior to term age (i.e. premature babies), or if the child has certain types of gut pathology, as some kinds of thickening agent may not be digested by the premature/ pathological gut, and may possibly cause gut complications.

Many suppliers of xanthan gum do not recommend the use of their product with children under 1-2 years of age (Simply Thick & Thicken Up Clear)

THICKENING AGENTSSimply Thick Xanthan gum, citric acid and potassium sorbateThick & Easy (Hormel) Modified maize starch, maltodextrinResource ThickenUp (Nestle) Modified maize starchResource ThickenUp Clear (Nestle)

Maltodextrin, xanthan gum, potassium chloride (may contain traces of milk)

GelMix Maltodextrin, Organic Carob Bean Gum, Calcium Lactate

Rice Cereal (Gerber) Rice flour, tri- and di-calcium phosphate, soybean oil, soy lecithin, mixed tocopherols, electrolytic iron sulphate, alpha tocopherylacetate (vitamin A), pyridoxine hydrochloride (vitamin B6), thiamin mononitrate (vitamin B1), folic acid (vitamin B9), cyanocobalamin(vitamin B12)

Enfamil AR Rice starch, maltodextrinSimilac Sensitive for Spit Up Rice starch

RICE CEREAL

Can separate to thin fluid and solid mass

Can block teat

Increases energy content of feed

Contains potential allergens

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Behavioral Feeding Management

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Medical Skill Behavioral

Rommel, N., De Meyer, A. M., Feenstra, L., & Veereman-Wauters, G. (2003). The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. Journal of pediatric gastroenterology and nutrition, 37(1), 75-84.

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Classification System

700 children age 10 and under seen by a multi-disciplinary feeding clinic

• Medical: 86% • Oropharyngeal dysfunction: 61% • Behavioral: 18%

Rommel, N., De Meyer, A. M., Feenstra, L., & Veereman-Wauters, G. (2003). The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. Journal of pediatric gastroenterology and nutrition, 37(1), 75-84.

Romm

el, N., De Meyer, A. M

., Feenstra, L., & Veerem

an-Wauters, G. (2003). The com

plexity of feeding problem

s in 700 infants and young children presenting to a tertiary care institution. Journal of pediatric gastroenterology and nutrition, 37(1), 75-84.

Feeding problems that can result from GI Issues

• Inappropriate mealtime behaviors• Refusal to self feed• Food selectivity • Inability to advance texture• Food refusal• Oral motor dysfunction/immaturity• Dysphagia/Aspiration• Frequent vomitingKerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: severe feeding problems. Journal of Pediatric Psychology, 24(3), 193-214.

Food Neophobia

• Reluctance to eat and/or avoidance of new foods

• Peaks between 2-6 years of age

Dovey, Staples, Gibson, & Halford (2008). Food neophobia and picky/fussy eating in children: A review. Appetite, 50: 181-193.

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KEY INDICATORS OF FEEDING DIFFICULTIES• Limited range of textures – Often reliance on ‘easy to eat foods’– Puree, dissolvable vs. lumpy, mechanical

• Limited range of foods– < 30 foods– <10 proteins, <10 fruit/ veg, <10 starches

• Prolonged mealtime duration– >30 mins at mealtimes, >2hrs a day spent trying to feed

child• Battles/ problematic behavior at mealtimes• Family stress related to the child’s eating patterns

BEHAVIORAL FEEDING• 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

BEHAVIORAL FEEDING• 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

BEHAVIORAL FEEDING• ‘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

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Behavioral Approaches• Operant conditioning therapy

– Focus on changing behaviors related to eating– May also incorporate information on general parenting skills– Generally aimed at clinical populations

• Generally run in hospital-based feeding clinics• Usually run by therapists• E.g. Kennedy Kreiger, Medical College Wisconsin

Behavioral Approaches

• Differential Attention (with or without shaping)

– Positive attention for appropriate feeding behavior

and ignoring inappropriate behavior

• Contingent reinforcement

– Praise for the target response & ignoring all other

responses

• Punishment

– Attempting to reduce or eliminate unwanted

behaviors Kerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: severe feeding problems. Journal of Pediatric Psychology, 24(3), 193-214.


• Positive reinforcement– Praise after an appropriate feeding response regardless of

whether it occurred independently, after a verbal prompt, or after a modeled response

• Manual guidance of the appropriate feeding response(s)– Physically, verbally, or manually directing

• 3-step guided compliance– Hierarchy of instruction and prompting: 1) Providing

verbal instruction; 2) if no response after a specific amount of time, modeling w/ the verbal instruction, & 3) if still no response, manual guidance

Kerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: severe feeding problems. Journal of Pediatric Psychology, 24(3), 193-214.

Behavioral Approaches• Extinction

– Removing the reinforcer of a response

• Food refusal can be negatively reinforced by removing the spoon after refusal, thereby increasing the probability of food refusal

• Extinction procedure would require that the spoon remain at the child’s lips until it is accepted in to the mouth

• Increased acceptance and volume consumed in 10 – 130 sessions

• Behavior likely to worsen before it improves• Can be combined with positive reinforcement

Kerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: severe feeding problems. Journal of Pediatric Psychology, 24(3), 193-214.

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• Systematic desensitization therapy– Focus on improving willingness to interact with food– May also incorporate information on general

parenting skills– Generally aimed at clinical populations

• Generally run in hospital-based feeding clinics• Usually run by therapists• E.g. SOS Approach to Feeding

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

Operant conditioning– Feeder determines

how much is eaten

Goals:– Improved volumes

taken– Reduced number of

refusal behaviors

Systematic desensitization

– Child determines how much is eaten

Goals:– Increased willingness

to try foods – Increased range of

foods tolerated

Comparing Programs

SOS APPROACH TO FEEDING

– Dr Kay Toomey and colleagues– Formal training is required to use this

approach

– Multi-disciplinary– Systematic desensitization – graded

hierarchies and games for learning and to minimise anxiety

– Social modelling – family, other children– Family focused – parent education– Family meals vs. therapy meals

FACTORS TO CONSIDER•Child’s health•Family issues•Service delivery issues

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12

BEHAVIORAL FEEDING• 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)

BEHAVIORAL FEEDING• 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

BEHAVIORAL FEEDING• 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)

Lunch on your own

11:30 –12:45

09/21/1850

Practice scenarios for Motor, Sensory, and Behavioral

Approaches to Feeding & Sw

allowing Problem

s12:45 –

2:15

09/21/181

9/17/18

1

Four Case Scenarios• Please divide into groups of 5-6• Review and then select a case scenario from the

following 4 options• For Cases 1-3, considering the treatment options

reviewed this morning, document how you would address the feeding/swallowing issues for each individual case

• For Case 4- please use the provided thickeners and tools to determine the appropriate ratio of thickener to formula for this family

• We will review each case and have input from each group after ~30 minutes of discussion

09/21/18 2

Case 1: 2 y.o., 17p-syndrome with hypotonia, developmental delay, visual

impairment, and dysphagia• G-tube @ 1 month

secondary to difficulty eating

• H/o vocal stridor, severe GERD with copious vomiting and coughing during G-tube feedings until 1 year of age

• Viral pneumonia 3 months before evaluation- otherwise good respiratory health

09/21/18 3

• Satisfactory growth• MBS @ 5m revealed

laryngeal penetration with thin liquids but no aspiration. Subsequent initiation of transition to oral feedings began using pureed foods

• At this eval: Student taking pureed, baby foods (fruits & veggies)– two times daily in 1-2 oz portionsSheppard, J.J. (1997).Pediatric Dysphagia and Related Medical, Behavioral, and

Developmental Issues. In B.C. Sonies (Ed), Dysphagia: A Continuum of Care (p. 67). Gaithersburg, Maryland: Aspen Publishers, Inc.

9/17/18

2

Case 1- 2 y.o., 17p-syndrome with hypotonia, developmental delay, visual

impairment, and dysphagia• Smith-Magenis syndrome is a developmental disorder that affects many parts of the body. The

major features of this condition include mild to moderate intellectual disability, delayed speech and language skills, distinctive facial features, sleep disturbances, and behavioral problems.Most people with Smith-Magenis syndrome have a broad, square-shaped face with deep-set eyes, full cheeks, and a prominent lower jaw. The middle of the face and the bridge of the nose often appear flattened. The mouth tends to turn downward with a full, outward-curving upper lip. These facial differences can be subtle in early childhood, but they usually become more distinctive in later childhood and adulthood. Dental abnormalities are also common in affected individuals.Disruptedsleep patterns are characteristic of Smith-Magenis syndrome, typically beginning early in life. Affected people may be very sleepy during the day, but have trouble falling asleep and awaken several times each night.People with Smith-Magenis syndrome have affectionate, engaging personalities, but most also have behavioral problems. These include frequent temper tantrums and outbursts, aggression, anxiety, impulsiveness, and difficulty paying attention. Self-injury, including biting, hitting, head banging, and skin picking, is very common. Repetitive self-hugging is a behavioral trait that may be unique to Smith-Magenis syndrome. People with this condition also compulsively lick their fingers and flip pages of books and magazines (a behavior known as "lick and flip").Other signs and symptoms of Smith-Magenis syndrome include short stature, abnormal curvature of the spine (scoliosis), reduced sensitivity to pain and temperature, and a hoarse voice. Some people with this disorder have ear abnormalities that lead to hearing loss. Affected individuals may have eye abnormalities that cause nearsightedness (myopia) and other vision problems. Although less common, heart and kidney defects also have been reported in people with Smith-Magenis syndrome.

09/21/18 4

Case 1- 2 y.o., 17p-syndrome with hypotonia, developmental delay, visual impairment, and dysphagia• Clinical findings:

– Piecemeal swallowing of spooned boluses

– Poorly coordinated breathing & swallowing while eating pureed foods

– Increased respiratory rate after a few tastes, then refusal to continue accepting boluses

– Slightly wet breath sounds after bolus swallows

– Apparent anxiety during bolus swallowing and during NN mouthing tasks

Modified Barium Swallow:– Safe bolus swallows on puree

and thin liquid– No evidence of laryngeal

penetration or tracheal aspiration

– Bolus size was restricted by piecemeal delivery of the bolus into the pharynx

– Swallows became less organized as feeding progressed

Nutritional Evaluation:– Heavier than desired weight

for height

Sheppard, J.J. (1997).Pediatric Dysphagia and Related Medical, Behavioral, and Developmental Issues. In B.C. Sonies (Ed), Dysphagia: A Continuum of Care (p. 67). Gaithersburg, Maryland: Aspen Publishers, Inc.

9/17/18

3

Case 1- 2 y.o., 17p-syndrome with hypotonia, developmental delay, visual impairment, and dysphagia

• Clinical impression is dysphagia with impairment of oral preparation, oral initiation, and pharyngeal phases of swallowing. Contributing causes are:1) Traumatically conditioned effects of GERD2) Inadequate amount of practice for acquisition of the skills

needed for oral feeding


http://graceriddell.com/

9/17/18

4

Case 2

• 4y, 3m with diagnoses of – Static encephalopathy with microcephaly– Cerebral palsy spastic quadriplegia– Profound cognitive impairment– Alternating exotropia– Scoliosis– Seizure disorder– Dysphagia


Case 2: 4y, 3m: Microcephaly, CP spastic quadriplegia

• Hip adductor release surgery

• Selective posterior rhizotomy

• Tegretol and Depakote for seizure management, continues to have modified

complex partial seizures many times each day

• Asthma triggered by URI and takes Ventolin orally PRN for wheezing

• Multiple episodes of pneumonia- most recent episode 1 year ago

• Senokot and glycerine suppositories for constipation

• Reglan on a trial basis- family found it to be helpful. Discontinued b/c of concern

about side effects

• Weight for height is below 5th percentile

• Current diet is pureed table foods by spoon and liquids by cup– fed in another

person’s lap or in feeder seat

• Meal times are prolonged at 30-60 minutes

• Sounds congested during feedings

• Limited oral intake and crying after eating

• Referred for assessment secondary to coughing and gagging associated with eating

• Mother requests that recommendations focus on improving oral feeding

• Patient has G-tube, family attempting to wean from G-tube. Patient hasn’t used G-

tube in ~6 months

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9/17/18

5

Case 2: 4y, 3m: Microcephaly, CP spastic quadriplegia• Clinical findings:

– Special chair and assistance needed to stabilize head-neck and thorax in sitting position during feeding– Small mandible and marked distoclusion (Malocclusion of the teeth in which those of the lower jaw

are in distal relation to the upper teeth– Pooled oral secretions in mouth and oropharynx– Reduced mouth opening and tongue blocking– Slow oral transit – Multiple swallows to clear each bolus– Congested breath sounds during and after each feedingDietician:– 861 calories/day– 50% of daily needsMBS:– Poor posterior containment of the bolus before swallow initiation– Spillover to pyriform sinuses before the swallow and residue in the valleculae and pyriform

sinuses after the swallow– Multiple swallows used to clear each bolus from the phayrnx– With pureed bolus, large laryngeal penetration & tracheal aspiration after the swallow– With liquid, laryngeal penetration with trace tracheal aspiration after the swallow

• Diminished pharyngeal contraction and ineffectual on all swallows• No coughing or gagging• Chest X-ray revealed barium in the left lower lobe bronchi



Clinical Impressions• Severe dysphagia with involvement in oral

preparatory, oral initiation, and pharyngeal phases of swallow

• Severe malnutrition• Reactive Airway Disease• Contributing causes include

– Static encephalopathy– CP– Break through seizures– Oral and thoracic skeletal deformations


9/17/18

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Case 3- 11 month old infant with reflux and dysphagia

• 11 month old infant, born at term following uncomplicated delivery

• Significant reflux and ongoing unresolved respiratory issues

• Upper GI documented reflux • Modified barium swallow shows aspiration

with thin liquids, improved with slightly thick consistency

09/21/18 13

9/17/18

7

Case 3- 11 month old infant with reflux and dysphagia

• Referred to your clinic to determine appropriate thickening recommendations

• Determine if any of the provided formulas are the Slightly Thick consistency at rest with IDDSI Flow Test

• Use the provided thickening agents to determine the appropriate recipe for each formula provided- confirm with the IDDSI Flow Test

09/21/18 14

Case 3- IDDSI Flow Test

Copyright 2017 - Used with permission from IDDSI

9/17/18

8

Case Study #4: Cory• 2-year old boy with a normal birth• 6 weeks: began projectile vomiting during breast

feeding, was given medication, and the problem was resolved

• 6 months: refused introduction of baby foods, but still breastfeeding well

• 9 months: growth was slowing down and vomiting increased again

• 11 months: hospitalized for growth faltering and diagnosed with �behavioral feeding aversion�, placed on a gastronomy tube

• Now, parents want him enrolled in intensive behavioral feeding program to wean off the tube feeding

JusticeC

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unication Sciences and Disorders: An Introduction

Copyright ©

2006 by Pearson Education, Inc.U

pper Saddle River, N

ew Jersey 07458

All rights reserved.

Case Study 4- Cory

• What type of behavioral approach will you take?

• What will your goals be?• What else do you need to know? Whom else

might need to be involved?• What specific strategies might work well for

Cory?

09/21/18 17

Review of Case Scenarios

1:15 –2:15

09/21/1818

Break 2:15 –

2:30

09/21/1819

Review of the Evidence

2:30 –4:00

09/21/181

9/17/18

1

• Oral motor interventions include exercises and activities designed to influence the actions of the tongue, lips, soft palate, jaws, larynx, and/or respiratory muscles for improved strength, tone, range of motion, or coordination during feeding/swallowing and include traditional muscle exercises (active or passive), stretching, and/or sensory stimulation to the articulators and related structures

Treatment: Motor/Skill

Treatment: Motor/Skill

9/17/18

2

• Oral- Phase interventions impact on functional feeding ability, drooling, swallowing physiology, and pulmonary health in populations other than preterm infants.

• 16 studies included– none reported on pulmonary health outcomes

• Studies published before 2008

Treatment: Motor/Skill for Pediatric Populations

Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010a). The effects of oral-motor exerciseson swallowing in children: an evidence-based systematic review. Developmental Medicine & Child Neurology,52(11), 1000–1013. doi:10.1111/j.1469-8749.2010.03707.x

9/17/18

3

• Clinical question 1: what is the effect of OME on swallowing physiology outcomes in children?– 8 studies addressed this question

– 3- effects of an intra-oral stimulating plate

– 3- impact of a tongue thrust treatment or lip & tongue exercises

– 2- use of oral, perioral, and facial stimulation



• Clinical question 1: what is the effect of OME on swallowing physiology outcomes in children?– 3- effects of an intra-oral stimulating plate on

swallowing physiology outcomes in children with CP• Large positive impact on chewing, smaller impact on

swallowing and mouth clearing• 1 year follow-up no changes noted by the group that

continued to wear the device• Conclusions- during 1 year follow-up previous treatment

gains were maintained & maturation alone was equally as effective as the treatment



9/17/18

4

• Clinical question 1: what is the effect of OME on swallowing physiology outcomes in children?– 3- impact of a tongue thrust treatment or lip & tongue exercises– None of the studies provide effect sizes– OME+ artic tx made greater gains than those receiving artic tx alone

on a 3 point tongue-thrust severity scale– Tongue thrust tx group performed significantly better than a no-tx

group on a 3 point tongue thrust severity scale 5 years after tx– Children completing the Face Former tx program had significantly

greater improvement in swallowing patterns than those receiving traditional myofunctional tx



• Clinical question 1: what is the effect of OME on swallowing physiology outcomes in children?– 2- use of oral, perioral, and facial stimulation – Both used single subject designs, and only one provided

statistical analysis– Subjects for each study were classified as having multiple

disabilities– Significant reduction in tongue thrusting with solid foods

and semi-solid foods during treatment– 2-week return to baseline treatment, significant increase

in tongue thrusting with solid foods but not with semi-solid foods



9/17/18

5

• Clinical question 3: what is the effect of OME on functional swallowing outcomes in children?

• 6 studies– 4- effects of an intra-oral stimulating plate in 58

participants with spastic CP ranging in age from 4y 5m – 15y 5m

– 2- effects of oral stimulation & neuromuscular facilitation procedures on weight gain in young people with severe to profound mental disability and neuromotor disability



• Clinical question 3: what is the effect of OME on

functional swallowing outcomes in children?

– 4- effects of an intra-oral stimulating plate in 58

participants with spastic CP ranging in age from 4y

5m – 15y 5m

• 3 studies used single subject design with treatment for 12

months and found no difference in weight gain

• 1 study looked at long term impact of OME with the device

over an additional 1 year period compared with those who

did not wear the device for an additional year and found

no significant effect on weight or growth

Treatment: Motor/Skill for Pediatric

Populations

Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010a). The effects of oral-motor exercises

on swallowing in children: an evidence-based systematic review. Developmental Medicine & Child Neurology,

52(11), 1000–1013. doi:10.1111/j.1469-8749.2010.03707.x

9/17/18

6

• Clinical question 4: what is the effect of OME on drooling management in children?– 5 total studies addressed this question

• 3- use of oral stim and facilitation in children and young adults with CP (one with statistical analysis)

• 1- use of chin cup intervention and OME classes in children and adolescents with CP (no statistical analysis)

• 1- use of oral stimulating plates in children with Down syndrome



• Clinical question 4: what is the effect of OME on drooling management in children?– 1- use of oral stimulating plates in children

with Down syndrome– Negligible effect compared with OME alone

on parental perception of daytime drooling– Small effect on night time drooling



9/17/18

7

• Clinical question 4: what is the effect of OME on drooling management in children?– 3- use of oral stim and facilitation in children

and young adults with CP• Only one provided statistical analysis- but did not

report effect sizes• OME had significant effect on pre/post saliva bib

weight for one participant but not the other



• Conclusions• Insufficient evidence to determine the

effects of OME on children with oral sensorimotor deficits and swallowing problems

• Well designed studies are needed to provide evidence that can be incorporated into the treatment paradigm



9/17/18

8

But surely in the last 10 years better research has been published on this

topic…

9/17/18

9

• This evidence based systematic review (EBSR) examined the published evidence for the use of common strategies used by clinicians across disciplines to treat pediatric swallowing and feeding problems.

1. What is the effect of oral motor interventions on functional oral feeding outcomes in children?

*Functional feeding outcomes = feeding behaviors, volume of oral intake, variety of oral intake, days to wean tube feeding, weight gain, and/or growth


Gosa, M. M., Carden, H. T., Jacks, C. C., Threadgill, A. Y., & Sidlovsky, T. C. (2017). Evidence to support treatment options for children with swallowing and feeding disorders: A systematic review. Journal of pediatric rehabilitation medicine, 10(2), 107-136.


• 1 of the 61 studies • 20 participants in this experimental, randomized control trial

study had profound intellectual disability or neuromuscular disorders, lived in a residential care facility

• Oral motor program that included manual intervention, direct guidance, stretches, pressure, and oral desensitization administered 30–40 minutes daily, five times a week for nine weeks for the experimental group (n=10)



9/17/18

10


• Analysis of the nine experimental subjects that had pre and post treatment oral motor function testing revealed no significant change following treatment.

• Statistical analysis of the full sample (n =20) revealed no significant difference in body weight gains between the experimental and the control group at discharge



Thickened FluidsPediatrics Literature

Gosa, Schooling, & Coleman, (2011). Thickened liquids as a treatment for children with dysphagia and associated adverse effects: A systematic review. ICAN: Infant, Child, & Adolescent Nutrition. Published online 5 May 2011.

• Clinical Question 1: For children with a diagnosis of dysphagia, what is the effect of thickened liquids on swallowing physiology (eg, aspiration, feeding efficiency), oral feeding development, weight gain and growth, hydration, or pulmonary health (eg, aspiration pneumonia, wheezing)?

• Clinical Question 2: Is there an increased occurrence of adverse effects (ie, NEC, gut adhesion, bowel obstruction, diarrhea, constipation, weight loss, failure to thrive, dehydration, aspiration, & cough) associated with the use of thickened liquids or certain thickening agents in children with or without dysphagia?

9/17/18

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Thickened FluidsPediatrics LiteratureClinical 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)


• 16 of the identified 22 studies• 757 participants total in the 16 studies (ss ranged 18-104)• Adverse effects examined in these studies included weight loss,

cough, aspiration, constipation, & diarrhea

• 8 studies examined weight status; overall thickened formula had no effect or positive effect on weight gain

• 8 studies examined cough; mixed results with some reporting resolution of cough & some reporting no change in coughing

• 1 study examined aspiration; no instances of aspiration under either thickened or non-thickened feeding condition

9/17/18

12


• 3 studies examined constipation; no significant differences in constipation rate were reported

• 2 studies examined diarrhea; compared to standard formula, rice starch-thickened formula had no effect on the incidence of diarrhea among study participants

• Complication rate: overall rate of adverse events or unspecified complications were examined & all of the 16 investigations indicated that no infant experienced any complication during the study period

Thickened Fluids

Pediatrics Literature

• A systematic review by Steele and colleagues

(2015) investigating the influence of liquid

consistency modification on swallowing

physiology and function found that thicker

liquids reduce the risk of laryngeal penetration

and aspiration, but also increase the risk of

post-swallow residue in the pharynx. Steele, C. M., Alsanei, W. A., Ayanikalath, S., Barbon, C. E., Chen, J., Cichero, J. A., ... & Wang, H. (2014). The influence of food

texture and liquid consistency modification on swallowing physiology and function: A systematic review. Dysphagia, 30(1), 2-26.

9/17/18

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Treatment :Sensory

2. What is the effect of sensory-based interventions (exercises and activities that are designed to promote sensory integration such as using a brushing or vibration protocol, a weighted vest, or deep pressure in the joints) on functional oral feeding outcomes in children

• None of the 61 articles included examined only sensory-based interventions.

Treatment: Sensory


9/17/18

14

• 3. What is the effect of behavioral-based interventions (including approaches that incorporate techniques with elements from operant conditioning, systematic desensitization, etc.. . . ) on functional oral feeding outcomes in children?

• 37 studies• 919 pooled participants, 86% were between 2

and 7 years old• 70% were small sample size (N of 1-13), 30% had

sample sizes from 24 – 490

Treatment: Behavioral


• 11/37 studies• Escape extinction (behavioral technique used to

treat behaviors that are maintained by escaping or avoiding; removing the possibility of escaping from the challenging stimulus)

• Reinforcement (the use of any stimulus which should increase the probability of a desired response, can be positive or negative)

• Single subject & small cohort designs• Impact on acceptance, intake, and presence of

undesirable behaviors at mealtimes

Treatment: Behavioral Positive Reinforcement & Extinction


9/17/18

15

• Escape extinction with – differential reinforcement increased oral intake & mouth clean

(n=3)– or without reinforcement increased mouth clean and decreased

undesirable mealtime behaviors (n=5)– representation of expelled bites increased acceptance of non-

preferred foods (n=3)– attention extinction combination decreased inappropriate

mealtime behaviors and increased food acceptance (n=4)– Chin prompt & representation of expulsion per bite decreased

rates of expulsion and increased volume of intake (n=4)– meal & taste probing resulted in increase in the volume and

variety of foods and decrease in undesirable mealtime behaviors maintained for up to 1 month post treatment (n=3)



• Positive reinforcement with– non-contingent reinforcement and extinction of disruptive behavior decreased

undesirable feeding behavior and increased volume of food eaten (n=3)– negative reinforcement, self-feeding, parent education, structured mealtimes

and repeated presentation of novel foods resulted in improvements in variety and volume of oral intake, reduction of undesirable behaviors, improved parent-child interactions during mealtimes, & increases in both height and weight (n=1)

– escape extinction, & caregiver training for increased mastication, mouth clean, and acceptance

– escape extinction, & caregiver training with mixed results– 2 had increased self-feeding behavior and 1 had no improvement

– peer modeling for increased volume and variety of accepted foods, significant weight gain with 1 participant weaning tube feeding by two months’ post treatment



9/17/18

16

• 11/37 studies• Shaping- behavior training that uses differential

reinforcement of successive approximations of the desired behavior

• Fading- initial prompting to perform behavior is gradually withdrawn, ensuring the child does not become dependent on the stimulus

• Impact on food refusal & discontinuation of tube feeding

Treatment: Behavioral Stimulus Shaping & Fading


• Shaping & fading – Generalization of oral acceptance in a case series with

discontinuation of tube feeding– Increases in oral intake with the reduction of G-tube

feedings and addition of oral feeding meals – Increases in acceptance of bites and decreased number

of disruptive responses– With visual cueing & positive reinforcement resulted in

tube weaning and full oral feeding with 2 pound weight gain

– With positive reinforcement, escape extinction, and flooding resulted in majority increase in some aspect of oral intake (n=86 ex-preterm)



9/17/18

17

• Shaping & fading – With escape extinction resulted in improving acceptance,

mouth clean, and decreasing inappropriate behaviors during mealtime

– With escape extinction and bite representation and Nukbrush resulted in increased mouth clean and acceptance and decreased packing & expulsions per bite

– With non-contingent access resulted in significant improvements in food variety, consumption, and appropriate mealtime behaviors

– With behavioral principles in teaching, parent education, & concurrent presentations of preferred foods with target foods resulted in increased height, weight, & BMI



• 13/37 studies• Focused on parent education & involvement

in combination with behavioral strategies (primarily: reinforcement, escape extinction, & fading)

• Approximately ½ reported on case studies• Positive reported impact on all functional

oral feeding outcomes

Treatment: Behavioral Caregiver Involvement & Education


9/17/18

18

* Determine whether OC or SysD intervention results in greater improvements in dietary variety/intake and greater reductions in difficult mealtime behaviors* Children, 2-6 years w/ ASD or NMC à randomized to receive 10 OC or SysD sessions at 1x/week or for 1 week

Treatment: Behavioral Comparison of Operant Conditioning

& Systematic Desensitization Gosa, M. M., Carden, H. T., Jacks, C. C., Threadgill, A. Y., & Sidlovsky, T. C. (2017). Evidence to support treatment options for children with swallowing and feeding disorders: A systematic review. Journal of pediatric rehabilitation medicine, 10(2), 107-136.Marshall, J., Path, B. S., & Hill, R. J. JPGN Journal of Pediatric Gastroenterology and Nutrition Publish Ahead of Print.

• Differences between OC & SysD• In OC group:• Trend towards greater increase in total number of

foods consumed & total number of unprocessed fruits and vegetables

• In SysD Group• Trend towards greater reduction of difficult mealtime

behaviors



9/17/18

19

• Differences between ASD & NMC• In ASD group:• Greater improvement in overall dietary quality

• In NMC group:• Slightly better improvement to dietary variety

(total proteins)



Differences between Intensive & Weekly • In weekly arm:• Greater reductions in difficult mealtime

behaviors• Greater reductions in number of problem

behaviors outside of mealtime



9/17/18

20

Treatment :Mixed Modality

• 5. What is the effect of applying mixed modality

interventions on functional oral feeding outcomes in

children?

• 23 of the 61 studies

• 395 pooled participants; majority of studies featured small

sample sizes (less than 10 participants)

• 95% of participants were between 2-10 years of age

• Mixed diagnostic population that included Down syndrome,

ASD, Goldenhar syndrome, Rett syndrome, CP, rubella

syndrome, & feeding complications due to major organ

system impairments

Treatment: Mixed Modality

Gosa, M. M., Carden, H. T., Jacks, C. C., Threadgill, A. Y., & Sidlovsky, T. C. (2017). Evidence to support treatment

options for children with swallowing and feeding disorders: A systematic review. Journal of pediatric rehabilitation medicine, 10(2), 107-136.

9/17/18

21

• Behavioral & OMI• 12/23, with pooled participants = 30• All studies utilized case study or single subject designs• Resulted in:

– G-tube feedings were significantly reduced or eliminated with significant reduction or elimination of undesirable mealtime behaviors and an overall increase in desirable parent behavior

– Reduced rates of expulsions and increased mouth cleans– Improved variety, texture, and volume of food eaten – Decreased packing, increased oral coordination &

participation in mealtimes



• Behavioral & Sensory Intervention• 4/23• Sensory techniques included: light, rocking motion,

sensory play, and individualized sensory diets• Resulted in:

– Increased acceptance of solid foods– Increased acceptance of non-preferred foods & calories

consumed, decrease in undesirable behaviors– Caregiver satisfaction



9/17/18

22

• Behavioral & OMI & Sensory Interventions• 5/23, Multidisciplinary approach• Resulted in:

– Increased acceptance of non-preferred foods & calories consumed, decrease in undesirable behaviors

– Weaning from tube feedings– Increase in lingual range of motion and duration of meal

times– Weaning of high calorie supplement use and weight gain– Caregiver satisfaction



• Results demonstrated positive outcomes across all primary outcomes measured, regardless of randomization, intensity or group

• This suggests that, overall, intervention delivered by experienced therapists to a standardized protocol is effective in increasing dietary quality and variety, and decreasing difficult behaviors at mealtimes.

• Further research is required in examining other cohorts of children with feeding difficulties, and exploring outcomes after longer periods post intervention



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• Lack of evidence to support the singular use of OMI or Sensory Based Interventions

• Moderate amounts of published evidence to support the use of behavioral interventions (37/61 articles) and the use of mixed method interventions (23/61 articles)

• Various levels of evidence available to support the use of behavioral (32/27, 86% were found to be phase one research) and combined treatment options (all phase one research)

Conclusions


• Clinical utility of findings about OMI and Mixed

Modality limited due to the primarily descriptive

nature of the evidence

• Moderate amount of published, phase one

evidence on mixed method interventions does

call for further investigation of these strategies

with greater scientific rigor to establish the full

dimensions of the therapeutic effect and

ultimately determine the internal and external

validity of these treatment options as an initial

therapeutic effect has been established

Conclusions

Gosa, M. M., Carden, H. T., Jacks, C. C., Threadgill, A. Y., & Sidlovsky, T. C. (2017). Evidence to support treatment

options for children with swallowing and feeding disorders: A systematic review. Journal of pediatric rehabilitation medicine, 10(2), 107-136.

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• From this EBSR, clinicians recognize the importance of behavioral therapy techniques for remediating feeding disorders (60/61 articles)

• Clinicians must be trained in the appropriate application of the various behavioral therapy techniques

• 5/60 articles were RCT and met criteria of phase IV evidence

Conclusions


http://www.asha.org/members/ebp/EBSRs/

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http://www.asha.org/members/ebp/EBSRs/

50

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Framing the Question: PICOPopulation Intervention Comparison Outcome

Pediatric Patients

(0-18 yoa)

Thickened Fluids Regular (Thin)

Fluids

Swallowing

Function/Develop

ment, Nutrition, &

Pulmonary Health

Pediatric Patients

(0-18 yoa)

Thickened Fluids Regular (Thin)

Fluids

Constipation,

Diarrhea, NEC,

etc…

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Clinical Question 1: For children with a diagnosis of dysphagia, what is the

effect of thickened liquids on swallowing physiology (eg, aspiration, feeding

efficiency), oral feeding development, weight gain and growth, hydration, or

pulmonary health (eg, aspiration pneumonia, wheezing)?

Clinical Question 2: Is there an increased occurrence of adverse effects (ie, NEC,

gut adhesion, bowel obstruction, diarrhea, constipation, weight loss, failure to

thrive, dehydration, aspiration, & cough) associated with the use of thickened

liquids or certain thickening agents in children with or without dysphagia?

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Finding the Evidence: ASHA’s Evidence Maps (www.ncepmaps.org)

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55


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Finding the EvidenceStudy Types Description What Can They Tell Us?

Systematic Review Assessment & evaluation of research attempting to address a focused question using methods designed to minimize biasWhen a systematic review pools data across studies to provide a quantitative estimate of overall treatment effect- it’s called a meta-analysis

Effectiveness of interventions

RandomizedControlled Trials

Experiment that randomizes individuals to receive or not receive an intervention & then follows up to determine the effect of the intervention


Quasi-experimental designs

Naturally occurring control groups who are not receiving the intervention or are receiving a different intervention- matched on key characteristics with those receiving the intervention


Evaluation studies with non-experimental designs

Interventions are evaluated but without pre-intervention matching of groups or with no comparison groups. No way to determine if the intervention is responsible for any change in outcome


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Finding the Evidence

Study Types Description What Can They Tell Us?

Case-controlstudies

Subjects with problem are matched with controls w/o the problem. Exposure of two groups to possible causes is compared

Risk Factors

Cohort studies Collect information longitudinally at intervals; often from birth into adulthood

Associations btwn early development & experiences, and later outcomes

Population Surveys Sample of the population asked to provide responses to questions on subject of interest

Prevalence of problems

QualitativeResearch

Concerned with the meanings people give to their experiences and how they make sense of the world

About social processes and what matters to people, how these vary in different circumstances, and why

Practice Guidelines Consist of systematically developed statements to assist practitioners and service users in making decisions about services. Should be based on high quality research.

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Finding the Evidence:Hierarchy of Levels of Evidence

Level DescriptionIa Well designed meta-analysis of >1 RCTIb Well designed RCTIIa Well designed controlled study without randomizationIIb Well-designed quasi-experimental studyIII Well-designed non-experimental studies (case studies)IV Expert committee report, consensus conference, clinical

experience of respected authorities

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• Medline: Best place to start for health care studies

• Largest online bibliographic database of health care studies

• Cites over 12 million articles • Articles from 4,000 peer reviewed journals

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Cumulative Index to Nursing and Allied Health (CINAHL)

• More likely to contain studies with negative findings

• European database; studies in all languages

“Grey” Literature

• Not published in peer-reviewed literature

• Technical reports, conference proceedings, testimony

and other unpublished evidence

• Typically requires conversation with content experts,

relevant professional groups/organizations, and

internet search engines

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Finding the Evidence: Key Words & Controlled Vocabulary

• Key words: describe the characteristics of a subject you are reviewing – Looking for the word(s) in the title and/or abstract of the article – Key word searching helpful when looking for a new drug or a

new procedure that has not been introduced into the controlled vocabulary of the database

• Controlled vocabulary: organized list of approved terms or key words that indexers of the journal or set of journals used to describe the same journal articles– Controlled vocabulary using the terms that indexers used when

they indexed the articles– MEDLINE/PubMed MESH- medical subject headings– MESH heading for cancer is controlled vocabulary term

neoplasms

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Finding the Evidence:Controlled Vocabulary in Abstracts

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Finding the Evidence:Snowballing Technique

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Goal: use references in the appears or books you have read to gather more references

Build a list of references until you begin to see the same references over and over again

You own the literature when you read a few sentences about a study cited by an author and you know the article before you see the reference

Assessing the Evidence• Relevance of the article/review to your specific clinical question

• Who wrote & published the article/review– Some are produced by advocacy groups or payors– To what extent would they be affected by positive or negative

findings?

• Level of evidence and study quality– Establishment of a hierarchy of study designs based on the ability of

the design to protect against bias (no one universally accepted hierarchy)

– Assessment of the extent to which a study was designed and implemented appropriately (no universally accepted set of criteria) http://www.sign.ac.uk/guidelines/fulltext/50/annexc.html

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Making Decisions• Synthesize clinical expertise/experience, patient’s

perspective, and available scientific evidence• EB clinical guidelines may have already been developed on

topics related to your question; do you follow them?1) How relevant are the guidelines to your specific clinical

question(s)?2) To what extent are the clinical practice guidelines truly

evidence-based?a) The methodology by which evidence was identified and evaluated should be

transparentb) Appraisal of Guidelines Research and Evaluation II (AGREE II)- evaluates the

process of practice guideline development and the quality of reporting

3) Who wrote and published the guideline?

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Making Decisions

• When guidelines do not meet expectations or do not exist, clinicians must rely on the evidence they identified and assessed to make clinical decisions

• Other factors will come into play- patient preference, cost effectiveness, potential harm, availability

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QUESTIONSMEM

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