Postural Control Evaluation with oral or non-oral enteral feeding Types of Feeding Tubes Orogastric (OG) Nasogastric (NG) Duodenal (ND) Gastrostomy (GT) Jejunostomy (JT or GJT ...

Joan C. Arvedson, Ph.D.

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Management of Infants & Children with Feeding & Swallowing Disorders

SAC Conference, May 4, 2018Joan C. Arvedson, PhD, CCC-SLP, BCS-S, ASHA Honors & Fellow

[email protected] & [email protected]

Postural Control EvaluationMuscle tone (hypotonia or hypertonia)Central alignment relates directly to oral

sensorimotor systemPresence of primitive reflexesLevel of physical activitySelf oral stimulation

Use of eye contact, head turning, & touch

Principles of ManagementWhole child approachTotal oral feeding is not always the goalNutrition & respiratory status criticalGER managed optimallyChanges in management needed

with gains or regression


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Management Recommendations

Direct & indirect approaches for oral sensorimotor function

Types of abnormal sensory responses need to be considered

Oral sensorimotor treatment for anatomic structure problems

Intervention Based on Developmental Skill LevelsOverall gross & fine motor skill levelsCognitive, language, communicationAdjusted age for first year or two in

case of prematurityImportant that all involved with a child

understand & respect the child

Intervention Factors

Cognitive statusPosture, movement, motor skillsMuscle toneMedicationsReflexesCranial nerve findingsDysmorphology diagnosis


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Ongoing Monitoringfor Potential Changes

Airway statusGI tract disease (e.g., GER)Clinical ongoing assessment

Postural/positional observationsCaregiver/child interactionsOral sensorimotor feeding statusObservation of respiration

Intervention forDysfunctional SwallowingDietary changesPosition & postureBolus placement in mouthTiming between bolus presentationsThermal sensitization - caution for

infants & young children

Bolus Formation (Oral-Motor Focus for Function of Structures)

JawLipsCheeksTonguePalate


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Oral Phase Management

PositioningSensory aspectsPresentationTextureMovement patterns

Pharyngeal Phase Management

Indirect oral sensorimotor treatment(e.g., improve tongue base propulsion)

Position changes

Textures changes

Nutrition Support

Boost calories in a variety of waysSpecial formulas or foodsCut back calories/volume

Close monitoring with tube feeds Infants with cardiac conditions along

with neurologic problems may be fluid restricted


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Positioning & SeatingCritical as underpinning to oral

sensorimotor considerationsAdaptations may be needed with

HypotoniaHypertoniaGrowthRegression

Therapeutic Techniques: Pros & Cons for Discussion

ThickenersOral sensorimotor therapyElectrical stimulationEscape extinction (part of ABA)

Thickening: QuestionsWhat effect might thickened feeds have on

the GI tract?Young infants may face ↑ risk of life-

threatening condition (NEC)Simply Thick banned by FDA for infants

Some companies now marketing for ages 3 years & above


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Thickeners: QuestionsWhat happens to timing & coordination with

prolonged use of thickened liquid when no practice is given to work toward thinner liquidThickened fluids & water absorption in rats &

humans (adults) – no evidence that absorption rate of water from the gut was different (Sharpe et al, 2007, Dysphagia)

International Dysphagia Diet Standardisation Initiative (IDDS)Working committee working to standardize

terminology related to texture modificationTrends with thicker liquidsReduce risk of penetration-aspiration Increase risk of post-swallow residue in

pharynxFood texture: properties of hardness,

cohesiveness & slipperiness are relevant

IDDSI Processes10 international researchers collaborated to

review articles: started 10,147 screened for relevance; 488 met inclusion criteria

36 articles contained specific info re oral processing or swallow behaviors for at least 2 liquid consistencies or food textures

Steele, CM et al Dysphagia 2015


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CP: Risks with Thin Liquids

Cochrane review – no studies found to support or refute water for children with cerebral palsy (Weir & Chang, 2005)

Are there safe thin liquids if intermittent minimal aspiration occurs? If so, what conditions?

How can practice/experience be provided?

Oral-Motor Exercises

Evidence in literature: very limited with mixed quality of reportsArvedson et al 2010: 16 studies of variable

quality Insufficient evidence to determine effectsWell-designed studies are needed

Oral-Motor ExercisesLikely sensory involved as wellWork only on bolus formation & bolus transit

– hoping to facilitate pharyngeal functionFarther off task they go, the greater difficulty

to bring around to desired functionMust be pleasurable & not stressfulHow much time to spend on OM vs use of

food or liquid leading to functional feeding?


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Electrical StimulationElectrodes placed on surface of skin – not

adjacent to muscles involved in swallowingGoal: Increase speed of pharyngeal initiation

of swallow and improve strength of pharyngeal contractorsOne report: no more effective than usual

care for primary dysphagia in childrenChristiaanse et al, 2011, Pediatr Pulmonol.

Escape Extinction

Reports in psychology literatureUsually part of ABA therapy especially for

children with autismNonremoval of spoon is typical focus to

increase acceptance & mouth cleanUsed with positive reinforcement often

Escape Extinction: QuestionsNon-psychologists carry out?Is non-removal of the spoon really negative

reinforcement?Could this approach ever be perceived as

“forced” feeding?Can negative reinforcement ever be

considered positive to the child?For what types of children, is this useful?


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Management with Feeding Tubes

Considerations for Initiating Tube FeedingIncapacity or limited ability to eat & drinkInability to meet nutrition needs by oral

feeding alone (>75% calorie needs even with high calorie supplements)Inability to maintain adequate hydrationLengthy feeding timesHigh risk for aspiration – Impaired swallowDisordered gastrointestinal systeme.g., Gottrand & Sullivan (2010)

Long Term Tube Feeding?Beyond 4-6 weeks, gastrostomy tube

should be considered (ESPGHAN Committee on Nutrition)PEG routine for all ages, including neonates

weighing as little as 2.5 kgGtube – replaced by button once site

healed, some endoscopic 1-step button procedures now available


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Goals of Tube FeedingAlleviate undernutrition in chronic conditionsMaintain or improve nutrition statusMinimize GI signs & symptomsImprove/maintain quality of life for child &

caregiversEasier administration of fluids & medicationMore time for education & rehabilitation

Management with Feeding TubesEnteral route: through digestive tractParenteral route: bypass digestive tract

Total Parenteral Nutrition (TPN) or hyperalimentation

Peripheral intravenous or central arterial lines

Conjunction with oral or non-oral enteral feeding

Types of Feeding Tubes

Orogastric (OG)Nasogastric (NG)Duodenal (ND)Gastrostomy (GT)Jejunostomy (JT or GJT)


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Nutrition Support for Tube FeedingAdjust formula as needed for

GrowthMedical needsFamily needs

Adjust schedule to optimize interest in & ability for oral feeding (bolus vs continuous)Maintain feeding therapy – encourage PO

Formulas for Tube FeedingsCommercial formulasSpecialized formulas with food allergies or

sensitivitiesBlenderized tube feedingsKetogenic diets with intractable seizure

disorderOthers?

Bolus Feeding with Gastrostomy

Upright positionPump or gravity delivery, air removedFormula at room temperatureFeeding time minimum of about 20

minutes to no more than 30 minutesOral stimulation during feeding (or prior)Tubing flushed after feedings or meds


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Contributing Factors to WeaningProlonged experiences with invasive oral

proceduresInability to regulate self hunger/satietyMissing out on critical or sensitive period of

oral exploration & exposure (6-12 months)Oral aversions leading to continued

dependence on supplemental feeding tube

Transitioning Off Tube FeedingsEstablish patient’s medical & nutrition

stabilityAdjust TF schedule: bolus vs night dripDecrease TF in 10-25% increments to

stimulate hungerMonitor weight on regular basis

Transitioning Off Tube FeedingsEstablish regular schedule for oral feeding

Use appropriate textures of foodUse high calorie diet as neededMonitor fluid intake & provide free water

by tube as neededUse supplements as needed

Communicate feeding plan with all team members


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Criteria: Discontinue Tube Feeding

Patient able to take >75% of estimated calorie need orally & maintain weight

May be able to discontinue calories by TF before discontinuing all water by TF

Consider removal of feeding tube when child has maintained weight, hydration, & adequate oral intake for > 2 months & during period of illness

Who is a Picky Eater?

Child with limited or decreased Dietary varietyQuantity of food

Generalized resistance to foods

Normal or Picky?Toddlers – 2nd year of life

Decrease in growth velocityRelative tapering off in appetite

Parents’ expectations often challengedNatural progression in growth & feeding

can be misinterpreted by caregiversLeads to impression of picky eating


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Fundamental Principles for Eating

Children eat best when parentsdo their part in feedingprovide children with appropriate support

for their developmental age avoid putting pressure on feeding

Fundamental Principles for Eating

Health care providersmust be careful about setting

expectations for how much children should eat

need to be aware that caloric densities may need manipulation under guidance of dietitians with physician monitoring

Food RulesScheduling

Meal times < 30 min + planned snacks Nothing between meals (except water)

Environment Neutral atmosphere - no forced feeding No game playing; no reward with food

Procedures Solids first; self-feeding encouraged Meal over if food is thrown in anger Clean up only at end of meal


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Picky vs Non-Picky EatersPicky eaters: Less varietyToddlers perceived as picky by mothers

Lower dietary variety & diversityNutrient intake & growth parameters

not significantly different

Picky Eaters: Children with Special Health Care NeedsPrevious negative experiences

Medical interventionsPhysical condition that made eating

scary, painful, or dangerousDesire to avoid eating may continue

after physical condition is corrected

Treatment StrategiesMedical (e.g., GER/aspiration management)Nutrition (e.g., calorie boosters, fortifying

foods, cap on juices, multivitamin/mineral supplement, fiber & fluid considerations)Educational opportunities (for parent & child)

Role play for selected parents Nutrition classes & snack time sessions


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Meal Time StrategiesConsistent meal & snack time schedules

Average child:1/3 of calories from snacksFor child who consistently rejects certain

foods, provide nutritious alternativesReintroduce previously rejected foodsIncrease exposure to new food

Meal Time StrategiesAlteration of food & liquid

TemperatureTasteTexture or consistency

Use appropriate serving size: SmallMaterial must be appropriate for oral

sensorimotor skill levels

Guide for Parents:Building Foundation of Understanding

Typical development around growth & development

Challenges that children may bring to tableWays parent find themselves stuck in

unpleasant & counterproductive feeding patterns

Rowell & McGlothlin 2015


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STEPS: Supportive Treatment of Eating in PartnershipS

Decrease stress, anxiety, & power strugglesEstablish a routineEnjoy pleasant family mealsBuild skills in “what” and “how” to feedStrengthen & support oral motor & sensory skillsUnderstand progress in short & long term –different for every child & family

Rowell & McGlothlin 2015

Behavioral InterventionsDivision of responsibility: parent & child

Adults are responsible for what food is presented to eat & manner in which it is presented

Children are responsible for whether they eat & how much they eat

Behavioral InterventionsEmpower parents with clear guidelines

Focus on aspects under controlUnderscore that you can’t force

another person to eatSet time limits for meals & snacks


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Behavioral Intervention Strategies

Feeding structureManipulation of hungerContingency managementShaping Parent training

Feeding StructureManipulation of factors known to increase

desirable behaviors & reduce problem behaviorsAll meals at the tableChild securely seated in appropriate chairConsistent meal & snack time scheduleMeal free from distractions

Manipulation of HungerPromotion of hunger to ↑ motivation at

mealtime - ↑ range & volume of foods & beverages consumedElimination of grazing ↓ supplemental feedingsAllow child to “fail” a meal to experience

natural consequences of increased hungerUse of appetite stimulants


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Videos Demonstrating Strategiesfor Discussion: What Else?

What Else?What about sensory approaches (SOS)?Do children who play in food readily end of

putting that food into the mouth?What other functional approaches can we

use to facilitate improved oral skills along with hunger for children?

Other ideas? How do we measure outcomes?

Intervention SummaryAirway & nutrition highest prioritiesOften cannot depend on clinic observations

alone with suspicion of pharyngeal problem Effort expenditure must be consideredDevelopmental skill levels criticalFunctional techniques/processes


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Summary

Children with neurologically based feeding and swallowing problems are COMPLEX

Feeding/swallowing status changes over timeRealistic goals are critical & must be

established with parents & professionals working closely together with mutual respect & coordination/collaboration

Postural Control Evaluation with oral or non-oral enteral feeding Types of Feeding Tubes Orogastric (OG) Nasogastric (NG) Duodenal (ND) Gastrostomy (GT) Jejunostomy (JT or GJT ...

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