The Source® for Pediatric Dysphagia-Second Edition Ages: Birth-18Grades: Birth-Adult Updated and expanded evaluation tools and goals help organize your treatment. Exercise. Atypical eating and drinking behaviors can develop in association with dysphagia, aspiration, or a choking event. Feeding and Swallowing. . Imaging tests may also be done to evaluate your child’s mouth, throat and esophagus. Pediatric Dysphagia Pediatric Dysphagia Overview; Symptoms and Diagnosis; Treatments; Definition. This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA. They also provide information about the infant's physiologic stability, which underlies the coordination of breathing and swallowing, and they guide the caregiver to intervene to support safe feeding. Pediatric Dysphagia. Prevalence of feeding disorders in children with cleft palate only: A retrospective study. Scope of practice in speech-language pathology [Scope of Practice]. Oral–motor treatments range from passive (e.g., tapping, stroking, and vibration) to active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). San Diego, CA: Plural. Methods Program Development The telepractice program presented herein is part of a dedicated Dysphagia Research Clinic (DRC) housed Functional assessment of swallowing ability, including but not limited to typical developmental skills and task components—suckling and sucking in infants, mastication in older children, oral containment, and manipulation and transfer of the bolus. If your child has chronic dysphagia or dysphagia caused by a health condition, speech or occupational therapy may help. Non-nutritive sucking (NNS) involves allowing an infant to suck without taking milk, either at the breast (after milk has been expressed) or with the use of a pacifier. Non-nutritive sucking (NNS)—sucking for comfort without fluid release (e.g., with a pacifier, finger, or recently emptied breast)—does not determine readiness to orally feed, but it is helpful for assessment. Loss of food/liquid from the mouth when eating. A. Prior to the instrumental evaluation, clinicians are encouraged to collaborate with the medical team regarding feeding schedules that will maximize feeding readiness during the evaluation. In turn, the caregiver can use these cues to optimize feeding by responding to the infant's needs in a dynamic fashion at any given moment (Shaker, 2013b). Comprehensive coverage addresses the full spectrum of dysphagia to strengthen the care provider’s clinical evaluation and diagnostic decision-making skills. Treatment includes rewarding positive behaviors and decreasing the negative behaviors We want to increase acceptance of foods Aversive behaviors that should be addressed include: food stuffing or holding, spitting food out, food selectivity or refusal, tantrums or crying, refusal of the high chair, blocking, grimacing, and intentional Abstract. Feeding strategies include pacing and cue-based feeding. B. A clinical evaluation of swallowing and feeding is the first step in determining the presence or absence of a swallowing disorder. Other benefits of KMC include temperature regulation, promotion of breastfeeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability. School-based SLPs do not require a doctor's order to perform a clinical evaluation of feeding and swallowing or to implement intervention programs. Language, Speech, and Hearing Services in Schools, 39, 199–213. Disability and Rehabilitation, 30, 1131–1138. School-based services typically include a referral process, a screening and evaluation, and the development of a feeding and swallowing intervention plan. Periodic assessment and monitoring of significant changes are necessary to ensure ongoing swallow safety and adequate nutrition throughout adulthood. McComish, C., Brackett, K., Kelly, M., Hall, C., Wallace, S., & Powell, V. (2016). Frequent congestion, particularly after meals. They are seated upright or in the position that you feed them in at home. Normal swallowing mechanism for infants. Lefton-Greif, M. (2008). Treatment depends on the cause. Swallowing is commonly divided into the following four phases: Feeding disorders are problems with a range of eating activities that may or may not include problems with swallowing. Treatment of your child’s GERD may include: #1 Ranked Children's Hospital by U. S. News & World Report, remaining upright for at least an hour after eating, medications to decrease stomach acid production, medications to help food move through the digestive tract faster, an operation to help keep food and acid in the stomach (fundoplication). Medical, surgical, and nutritional considerations are important components in treatment planning. Structural assessment of the face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa. Treatments can range from behavioral therapy and medications to surgery. (2006). Feeding is the process involving any aspect of eating or drinking, including gathering and preparing food and liquid for intake, sucking or chewing, and swallowing (Arvedson & Brodsky, 2002). As the child matures, the intraoral space increases as the mandible grows down and forward, and the oral cavity elongates in the vertical dimension. (2016b). Rates increase with greater severity of cognitive impairment and decline in gross motor function (Benfer et al., 2014; Calis et al., 2008; Erkin, Culha, Sumru, & Gulsen, 2010). Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved functional feeding skills. In addition to determining the type of treatment that is optimal for the child with feeding and swallowing problems, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. A series of moving picture x-rays are taken to evaluate what happens as your child swallows the liquid. (2013). Assessment of consistency of skills across the feeding opportunity to rule out any negative impact of fatigue on feeding/swallowing safety. Anxiety may be reduced by using distraction (e.g., videos), allowing the child to sit on the parent's or caregiver's lap (for FEES procedures), and decreasing the number of observers in the room. feeding and swallowing problems that persist into adulthood, including the risk for choking, malnutrition, or undernutrition. The Rehabilitation Act of 1973, Section 504. Your child is given small amounts of a liquid that contains barium (a chalky liquid used to coat the inside of organs so that they will show up on an x-ray) to drink with a bottle, spoon, or cup or spoon-fed a solid food containing barium. SLPs should have extensive knowledge of embryology, pre-natal and perinatal development, and medical issues common to the preterm and medically fragile newborn as well as knowledge of typical early infant development. The infant's strength of compression and suction. Sensory stimulation may be needed for children with reduced responses, overactive responses, or limited opportunities for sensory experiences. Positioning for VFSS depends on the size of the child and his or her medical condition (Arvedson & Lefton-Greif, 1998; Gisel, Applegate-Ferrante, Benson, & Bosma, 1996). U.S. Food and Drug Administration. American Speech-Language-Hearing Association. Consider tube feeding schedule, type of pump, rate, calories, and so forth. 308 Racebrook Rd. Postural and positioning techniques involve adjusting the child's posture or position during feeding. https://www.childrenshospital.org/.../d/dysphagia/diagnosis-and-treatment Does the child have the potential to improve swallowing function with direct treatment? Determining the appropriate procedure to use depends on what needs to be visualized and which procedure will be best tolerated by the child. It’s that time of year again- back to school and back to frequent testing for school age children. Appropriate roles for SLPs include the following: Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children. Anatomic differences between adults and children and why they are significant. If the dysphagia is severe, another source of nutrition and hydration, such as a feeding tube, may be needed. Part IV includes an introduction to the concept of evidence-based practice and the application of evidence-based strategies in the management of dysphagia. World Health Organization. Clinicians working in the NICU need to be aware of the multidisciplinary nature of this practice area, the variables that influence infant feeding, and process for developing appropriate treatment plans in this setting. However, there are times when the SLP needs to contact the student's primary care physician or other health care provider—either through the family or directly, with the family's permission. Refusing foods of certain textures or types. Cases of ARFID are reported to have a greater likelihood in males and children with gastrointestinal symptoms, a history of vomiting/choking, and a comorbid medical condition (Fisher et al., 2014). A speech-language pathologist will evaluate your child’s dysphagia and suggest or provide therapy to: Develop strength, range of motion, and coordination of the lips, tongue, cheeks, and jaw muscles for eating and drinking Pediatric feeding assessments and interventions. The team (a) works together to inform the evaluation process, (b) contributes to the development and implementation of the individualized education program (IEP) for safe swallow, and (c) oversees the day-to-day implementation of the IEP strategies to keep the student safe from aspiration while in school. Dysphagia and the accompanying pulmonary aspiration are frequently unrecognized by pediatricians and caregivers as a cause of chronic respiratory symptoms such as recurrent wheezing, recurrent pneumonias, chronic cough, stridor, and brief resolved unexplained events (formerly known as acute life-threatening events). Alternative feeding does not preclude the need for feeding-related treatment. A child with dysphagia may develop anxiety about eating or drinking. Koudstaal, M. J. Infants and Young Children, 8, 58–64. (2014). If you suspect your child might have pediatric dysphagia, it is important to receive an assessment from a qualified speech-language pathologist (SLP) as soon as possible. Tests are meant to measure skills or knowledge in a particular area. See Person-Centered focus on Function: Pediatric Feeding and Swallowing for examples of assessment data consistent with ICF. Benfer, K. A., Weir, K. A., Bell, K. L., Ware, R .S., Davies, P. S. W., & Boyd, R. N. (2014). Journal of Adolescent Health, 55, 49–52. A referral to the appropriate medical professional should be made when anatomical or physiological abnormalities are found during the clinical evaluation. Protocols for determining readiness for oral feeding and specific criteria for initiating feeding vary across facilities. The key to successful management of dysphagia is correctly identifying the cause. International classification of functioning, disability and health. Wilson, E. M., & Green, J. R. (2009). (2010). American Speech-Language-Hearing Association. Although feeding, swallowing and dysphagia are not specifically mentioned in IDEA, the U.S. Department of Education acknowledges that chronic health conditions could make a student eligible for special education and related services if the disorder interferes with the student's strength, vitality, or alertness and limits the student's ability to access the educational curriculum. Feeding difficulties in craniofacial microsomia: A systematic review. Cue-based feeding—relies on cues from the infant, such as lack of active sucking, passivity, pushing the nipple away, or a weak suck. Journal of Clinical Gastroenterology, 30, 34–46. Your speech-language pathologist (SLP) will work with you and other specialists to determine the treatment plan that is right for your child. Early Human Development, 85, 303–311. Advocating for families and individuals with feeding and swallowing disorders at the local, state, and national levels. Manikam, R., & Perman, J. In their role as communication specialists, SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infant's communication signals. See Homer (2016) for in-depth information related to feeding and swallowing services in the schools. ... Clinical management of dysphagia in adults and children. Journal of Developmental and Behavioral Pediatrics, 23, 297–303. Hyattsville, MD: National Center for Health Statistics. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5. Brian B. Shulman, vice president for professional practices in speech-language pathology, served as the monitoring officer. See FDA consumer cautions (U. S. Food and Drug Administration, 2017). 29 U.S.C. SLPs need to be sensitive to family values and beliefs regarding bottle feeding and breastfeeding; they consult with parents and collaborate with nurses, lactation consultants, and other medical professionals to help identify parent preferences. Feeding and gastrointestinal problems in children with cerebral palsy. Therapy techniques that are used to assist with bolus management can be developed to help children be more successful eaters. changes in normal heart rate (bradycardia or tachycardia); skin color change such as turning blue around the lips, nose and fingers/toes (cyanosis); temporary cessation of breathing (apnea); frequent stopping due to uncoordinated suck-swallow-breathe pattern; and. Students must be healthy (e.g., free from aspiration pneumonia or other illnesses related to malnutrition or dehydration) to maximize their attendance at school. Dave, what are we talking about today? Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 2000-2002 and 2003-2005, respectively). A risk assessment for choking and an assessment of nutritional status should be considered as part of a routine examination for adults with disabilities, particularly those with a history of feeding and swallowing problems. 1998; 31(3): 453-476. Taking only small amounts of food, overpacking the mouth, and/or pocketing foods. Positioning for infants and children for videofluoroscopic swallowing function studies. Recent research efforts are reviewed which contribute data necessary for development of evidence-based evaluation and management methods. Questions to ask when developing an appropriate treatment plan within the ICF framework include: Consider the child's pulmonary status, nutritional status, overall medical condition, mobility, swallowing abilities and cognition, in addition to the child's swallowing function and how these factors affect feeding efficiency and safety. review of any past diagnostic test results; review of current programs and treatments; assessment of current skills and limitations at home and in other day settings; assessment of willingness to accept liquids and a variety of foods in multiple food groups; consideration of ARFID concerns, such as dependence on diet supplements to meet nutrition needs; evaluation of independence and need for supervision and assistance; and. Decisions are made based on the child's needs, his or her family's views and preferences, and the setting where services are provided. Students must be adequately nourished and hydrated so that they can attend to and fully access the school curriculum. of providing dysphagia treatment via telepractice in this pediatric patient; secondarily, we aimed to examine whether this treatment program was effective for this child. SLPs conduct assessments in a manner that is sensitive and responsive to the family's cultural background, beliefs, and preferences for treatment. Treatment selection will depend on the child's age, cognitive and physical abilities, and specific swallowing and feeding problems. See the Pediatric Feeding and Swallowing Disorders Evidence Map for summaries of the available research on this topic. Eddy, K. T., Thomas, J. J., Hastings, E., Edkins, K., Lamont, E., Nevins, C. M., . Assessment of overall physical, social, behavioral, and communicative development. Clinical Oral Investigations, 18, 1507–1515. You may need: Esophageal dilation —making the esophagus wider where it narrows Surgery—to treat GERD or take out something that is blocking the path; Dietary changes such as: Not eating foods that cause problems; Eating softer or pureed foods; Using a feeding tube if needed Intraoral prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize the intraoral cavity by providing compensation or physical support for children with congenital abnormalities (e.g., cleft palate) or damage to the oropharyngeal mechanism. • Its chronic course and frequent progression to subepithelial fibrosis leading to strictures and narrow-caliber esophagus indicate the need for treatment. Becker, A. E. (2015). Serving as an integral member of an interdisciplinary feeding and swallowing team. Objective To determine the effectiveness of tonsillectomy for the treatment of dysphagia related to tonsillar hypertrophy.. Design Prospective cohort study.. 3 Feeding therapy, performed by an experienced SLP, is often the first … Language, Speech, and Hearing Services in Schools, 31, 50–55. Please enable it in order to use the full functionality of our website. use of intervention probes to identify strategies that might improve function. Earn an Advanced Certificate in Pediatric Dysphagia online at New York Medical College. Black, L. I., Vahratian, A., & Hoffman, H. J. It is used as a treatment option to encourage eventual oral intake. The long-term consequences of feeding and swallowing disorders can include. Research on various oral sensory disorders and … In addition, an ASHA treatment efficacy report on pediatric feeding and swallowing disorders is available on the ASHA Web site (search “pediatric dysphagia” on the ASHA Web site). Difficulty managing secretions (including non-teething-related drooling of saliva). This article provides a review of symptoms, etiologies, and resources available regarding management of this condition to help the primary care physician and the families … Infants cannot verbally describe their symptoms, and children with reduced communication skills may not be able to adequately do so—clinicians must rely on a thorough case history; data from monitoring devices (e.g., in the neonatal intensive care unit (NICU); and nonverbal forms of communication (e.g., behavioral cues signaling feeding or swallowing problems). Pediatric Dysphagia Treatment How to treat your child ranges on the severity of their Pediatric Dysphagia. Gisel, E. G. (1988). The recommended citation for this Practice Portal page is: American Speech-Language-Hearing Association (n.d). She consults to organizations worldwide to create and train for treatment. When conducting an instrumental evaluation, consider the following: Procedures take place in a child-friendly environment with toys, visual distracters, rewards, and a familiar caregiver, if possible and when appropriate. We evaluate and treat children of all ages from preterm infants to teenagers. Reading the feeding. Coughing and/or choking during or after swallowing. You will be asked questions about how your child eats and any problems you notice during feeding. Taking longer to finish meals or snacks (longer than 30 minutes). When assessing feeding and swallowing disorders in the pediatric population, clinicians consider the following factors: As infants and children grow and develop, the absolute and relative size and shape of oral and pharyngeal structures change. Keep in mind that infants and young children with feeding and swallowing disorders, as well as some older children with concomitant intellectual disabilities, often need intervention techniques that do not require them to follow simple verbal or nonverbal instructions. In addition to the clinical evaluation of infants noted above, breastfeeding assessment typically includes evaluation of the, For an example, see Community management of uncomplicated acute malnutrition in infants < 6 months of age (C-MAMI; 2015) [PDF], The assessment of bottle-feeding includes evaluation of the, The assessment of spoon-feeding includes evaluation of optimal spoon type and the infant's ability to, In addition to the areas of assessment noted above, the evaluation for toddlers (ages 1–3 years) and pre-school/school-age children (ages 3–21 years) may include. Cue-based feeding in the NICU: Using the infant's communication as a guide. The clinical evaluation of infants typically includes. participating in decisions regarding the appropriateness of these procedures; conducting the VFSS and FEES/FEESST instrumental procedures; interpreting and applying data from instrumental evaluations to (a) determine the severity and nature of the swallowing disorder and the child's potential for safe oral feeding and (b) formulate feeding and swallowing treatment plans, including recommendations for optimal feeding techniques; and. If the child has not eaten by mouth (NPO), the clinician allows a period of time for the child to develop the ability to accept and swallow a bolus. 2 nd Edition. They will be lying down on their back for this test. Diagnosing pediatric oral and pharyngeal swallowing disorders (dysphagia). This test uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of your child’s digestive tract. Collaboration with outside medical professionals is indicated when medical clearance is needed for an assessment and/or intervention for a student who. Pediatrics, 135, e1467-e1474. NNS patterns can typically be evaluated with skilled observation and without the use of instrumental assessment. The infant's ability to turn the head and open the mouth (rooting) when stimulated on the lips or cheeks and to accept a pacifier into the mouth. International adoptions: Implications for early intervention. Observation of head–neck control, posture, oral and pharyngeal reflexes, and involuntary movements and responses in the context of the child's developmental level. Assessment of NS includes evaluation of the following: The infant's communication behaviors during feeding can be used as cues to guide dynamic assessment. This article provides an overview of dysphagia in children, as well as common causes of childhood swallowing difficulties, populations at risk for pediatric dysphagia, techniques used to assess swallowing in pediatric patients, and the current treatment options available for infants and children with dysphagia. Retrieved from https://www.cdc.gov/nchs/data/nhds/8newsborns/2010new8_numbersick.pdf. Johnson, D. E., & Dole, K. (1999). Part III focuses on the management of pediatric dysphagia, covering a wide range of treatment strategies and interventions for children with various categories of feeding disorders. Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Diet modifications should consider the nutritional needs of the child in order to avoid undernutrition and malnutrition. infant's current state, including respiratory rate and heart rate; infant's behavior (e.g., positive rooting, willingness to suckle at breast); infant's position (e.g., well supported, tucked against mother's body); infant's ability to latch onto the breast; efficiency and coordination of infant's suck/swallow/breathe pattern; mother's behavior (e.g., comfort with breastfeeding, confidence handling infant, awareness of infant's cues during feeding). Moreno Villares, J. M. (2014). A prospective, longitudinal study of feeding skills in a cohort of babies with cleft conditions. Oral sensitivity: It involves providing therapy to reduce the oral sensitivity. When the quality of feeding takes priority over the quantity ingested, feeding skill develops pleasurably and at the infant's own pace. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, education, administration, and research. A team approach is necessary for appropriately diagnosing and managing pediatric feeding and swallowing disorders, as the severity and complexity of these disorder vary widely in this population (McComish et al., 2016). Learning Objectives. Treatment of Pediatric Swallowing Disorders ***** DISCLAIMER The information in these notes were developed from the three primary sources cited below. SLPs play a significant role in the management of students with swallowing and feeding problems within school settings. Instrumental evaluation can also help to determine if swallow safety can be improved by modifying food textures, liquid consistencies, or positioning. Swallowing is a complex process during which saliva, liquids, and foods are transported from the mouth into the stomach while keeping the airway protected. Other Maneuvers and Techniques. Rehabilitation Act of 1973, Section 504. . Dosage depends on individual factors, including the child's medical status, nutritional needs, and readiness for oral intake. These therapists can give your child exercises to help make swallowing more effective, or suggest techniques for feeding that may help improve swallowing problems. Observation of the child eating or being fed by a family member or caregiver using foods from the home and typically used utensils as well as utensils that the child may reject or that may be challenging. Jennifer has presented on pediatric feeding disorders at state and regional conferences as well as with several online webinars. No single posture will provide improvement to all individuals, and, in fact, postural changes differ between infants and older children. Behaviors can include changes in the following: Readiness for oral feeding in the preterm or acutely ill full-term infant is associated with (a) the infant's ability to come into and maintain awake states and to coordinate breathing with sucking and swallowing (McCain, 1997) and (b) the presence or absence of apnea. Members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit included Justine J. Sheppard (chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio).