Training for feeding

Training for Feeding

Presented by: Dr.Shilpa Prajapati

CONTENTS• DEFINITION

• ANATOMY OF ORAL STRUCTURE

• PHYSIOLOGY OF ORAL STRUCTURE

• WHAT IS ORAL DYSFUNCTION?

• CAUSES OF ORAL DYSFUNCTION

• SYMPTOMS OF ORAL DYSFUNCTION

• EVALUATION

• TREATMENT

• TRAINING FOR FEEDING IN PREMATURE INFANTS

• REFERENCES

FEEDING: DEFINITION

• Feeding can be defined as placement of food in the mouth, manipulation of food in oral cavity prior to initiation of swallow, including mastication and oral stage of swallow when the bolus is propelled backward by the tongue.

ANATOMY OF ORAL STRUCTURE

Oral Phase of Swallowing

Food is held within the mouth A bolus is formed in the central portion of the tongue

At same time, the base of the tongue and the soft palate close the oral cavity to prevent food spilling into the open larynx and trachea.

Tongue pushes bolus posteriorly toward the pharynx with an anterior-to-posterior tongue elevation.

As the bolus enters the pharynx the actual swallow or pharyngeal reflex is triggered.

B

Oral Preparatory phase Oral phase

Pharyngeal Phase

This phase is a reflex action. The bolus passes through the pharynx quickly and then enters the esophagus.This takes place in less than a second.

The initiation of this process starts when the bolus passes the anterior faucial arch and reaches the posterior pharyngeal wall. Elevation of the soft palate prevents material from entering the nasal cavity.

This stage is followed by the pharyngeal constrictor muscles pushing the bolus further into the pharynx, toward the cricopharyngeal sphincter. The larynx prevents material from entering the trachea by respectively closing the true vocal cords. Contraction of the lower pharyngeal constrictor is followed by relaxation of the cricopharyngeal muscle, allowing the bolus to pass into the esophagus.

Esophageal Phase

WHAT IS ORAL DYSFUNCTION?• Children with hypersensitive oral dysfunction may be very

picky eaters and may possibly one eat one type of food.

• Many children with oral dysfunction may resist eating solid foods and may gag when trying to eat foods with a lot of texture.

• They may also prefer bland food and dislike using toothpaste.

• In addition, they may also have a fear of choking.

• Those with hyposensitive oral dysfunction may put all kinds of food and nonfood items in their mouths. In addition, they may chew on their clothing or fingers. They may also prefer flavorful food.

CAUSES OF ORAL DYSFUNCTION• Some of the conditions:

o Cerebrovascular accident(CVA),

o Head injury ,

o Brain tumor,

o Anoxia,

o Guillain-Barre syndrome,

o Parkinson disease,

o Quadriplegia.

SYMPTOMS OF ORAL

DYSFUNCTION• Symptoms reported by patient (check all that apply):

o Drooling

o Coughing

o Choking

o Difficulty swallowing:• Solids• Liquids

o Pain on swallowing

o Weight loss

o History of aspiration or pneumonia

EVALUATION

• Mental status:o Alert or oriented o Direction following

• Physical status(symmetry, control, tone):o Head controlo Trunk controlo Endurance o Respiratory

o Suctioning required o Tracheostomy

EVALUATION • Outer oral status:

o Facial expression o Jaw movement o Lip movement o Sensationo Abnormal reflexes

• Inner oral status(symmetry, control ,tone) :o Dentition o Tongue

• Appearance • Tone• Movement

o Protrusion o Lateralizationo “ ng”-”ga”

EVALUATION

• Soft palate/Gag reflex

• Cough (reflexive / voluntary)

• Swallowo Spontaneouso Voluntaryo Laryngeal movement• Tongue• Elevation

EVALUATION

• Food managemento Pureeo Mechanical softo Chopped/groundo Regular dieto Liquids• Thick • Semi thick• Thin

TREATMENT: GOALS

1. To improve motor control at each stage of swallow through normalization of tone and the facilitation of quality movement

2. To maintain an adequate nutritional intake

3. To prevent aspiration

4. To re-establish oral eating to the safest , optimum level.

5. To facilitate appropriate positioning during eating

PRINCIPLES OF FEEDING

1. Patient is looking at and reaching for foodo Visual field o Normal hand to mouth movement patterns o As much control of the situation-adjustmento Patient’s intake is monitored –avoid too much food in

to the mouth.o To monitor for sign of aspirationo Assesse voice quality upon completion of the swallow

2. After completing the feeding process, the patient should remain in an upright position for 15-30 min to reduce the risk of reflexing

DURING ORAL FEEDING

• Patient must:

1) Be alert,

2) Be able to maintain adequate maintain trunk and head positioning with assistance,

3) Have a beginning tongue control,

4) Manage secretion with a minimal drooling and

5) Have a reflexive cough

DIET SELECTION

• Food chosen should

1) Be uniform in consistency and texture,

2) Provide sufficient density and volume,

3) Remain cohesive,

4) Provide pleasant test and temperature and

5) Be easily removed and suctioning when necessary

DIET PROGRESSION• Stage – I food level( pureed form):

1) best for a patients with little or no jaw control, moderate or delayed swallow.

2) Pureed food move more slowly, allowing time for the swallow response to trigger.

3) It helps to increase the oral intake and patient should be advanced to the next level as soon as possible.

• Stage – II food level( mechanical soft / cohesive):1) Best for a patients with a beginning rotatory chew, enough tongue

control with assistance to propel food back toward the pharynx, and a minimal delayed swallow.

2) Reduce the risk of aspiration and start of the swallow response as the back of the tongue elevates toward the hard palate,

3) Patient improve tongue control.

DIET PROGRESSION

• Stage – III food level(chopped / ground food):

1) This stage require chewing, controlled bolus formation, and a fair swallow.

2) This food group offers a wider variety of consistencies

3) Patient should progress to a regular diet

• When a patient is ready to progress to next diet level the therapist can adjust the meal by requesting one or two item from the higher group, enabling assessment at new level

Treatment - Oral preparatory stageStructure

Symptoms Problem Pre-feeding technique

Feeding technique

Trunk

Leaning to one side

Hips sliding forward out of chair

↓trunk tone, Ataxia ,↑trunk tone, Poor body awareness

↑tone in hip extensors

Facilitate trunk strength Exercises : patient clasp hands, lean down, touch food Arm raise to 90’ shoulder flection moves arm turning side 2 side

Provide firm sitting surface

Assist patient to hold correct position as a head control, provide perceptual boundary ,lateral trunk support

Adjust positioning so that patient lean slightly forward

Head Inability to hold head in mid line

Inability to move head

↓toneWeakness

↑tone ,Poor ROM

Facilitate strength through neck & head flexion ,extension lat.flex

Tone reduction of head shoulder and trunk

Assist with head control

As above

Treatment: Oral preparatory

stageStru.

Sympt. Problem Pre-feeding technique Feeding technique

UE Spillage of food from utensil

Inability to self-feed

↓tone Apraxia↓ co-ordination

↑toneAbnormal movt. pattern

Facilitate tone through weight bearing , taping muscle belly

Reduce proximal tone from scapula mobilization weight bearing

Guide correct movement pattern : consider adoptive equipment

See above

Face

Drooling , food spillage from mouth

↓lip control , poor sensation, apraxia

↓sensation

Place weight blade between patient’s lipsAsk patient to hold trunk blade while therapist tries to pull it out.Vibrate lips with electric tooth brush Lip exercises 2-3 times daily ,Blow bubble in to glass of liquid

Use side hand grip for head control , the therapist assist lip close & jaw closerUse straw when drinking liquid Place food to unimpaired side.Use cold food / liquid

Special Straw- Drinking Techniques

Treatment: Oral preparatory

stageStruct.

Symptoms Problem Pre-feeding technique

Feeding technique

Tongue

Pocketing of food in cheeks.Poor bolus formation

Retracted tongue

↓sensation Poor tongue control

Increased tone,Retracted jaw

Tongue exercise

Tongue ROM , wrap tip of tongue , gently pull tongue forward, side to side and up downVibrate tongue back & side ways to decrease tone & facilitate protrusion Normalize neck tone & jaw tone

Avoid crumbly foods Stroke patient outside cheek where pocketing occur with index finger back and up towards patient’s ear.

Reduce tone as needed during meal

Treatment: oral stageStruct.

Symptoms Problem Pre-feeding technique

Feeding technique

Tongue

slow oral transit,Inability to make a “ng-ga” sound

Tongue retraction

Slow oral transit timeInability to channel food back toward pharynx

Poor anterior to posterior movements. :↓tone,Poor sensation, ↑tone

Inability to form central groove in tongue,Apraxia

Practice “ng-ga” soundsAs above

Grasping tongue wrapped in gauze, pull forward to front teeth; stock firmly down middle of edge of tongue blade

Tuck chin toward chest.Avoid crumbly food.Use warm vs. hot/cold food.

As above

Treatment: oral stageStruct.

Symptoms Problem

Pre-feeding technique

Feeding technique

Tongue

Repetitive movt. Of tongue; food is pushed out front of mouth

Food falls off tongue into cheeks or food remain on tongue without patient awareness.

Tongue thrust

Poor sensation

Facilitate tongue retraction to bring tongue back into normal position; vibrate on either side of the frenulum, with a finger.Increase jaw control; teach isolated tongue movement.

Ice tongue; ice in gauze to prevent from slipping into the pharynx; brush tongue with a tooth brush to stimulate receptors.

Correct positioning.Place food away from midline of tongue toward back of mouth.Provide pressure to back of tongue with a spoon after food placement

Use food with a high density.Alternate presentation of foods- cold, hot during meal.

Treatment: oral stageStruct.

Symptoms

Problem Pre-feeding technique Feeding technique

Tongue

Slaw oral transmit time; food remains on hard palate; coughing before swallow

Slow oral transit time.Food remain on back of tongue

Poor tongue elevation; decrease tone

Decrease tone,↑ tone,↓ LOAWeakness

Ask patient to practice k,g,n,d,t sounds.Lightly touch tongue blade or soft tooth-brush to roof of mouth at back of tongue, instruct patient to press tongue, resist movt with brush. Vibrate tongue at below chin; provide quick stretch by pushing down on base of tongue.

Tone reduction: vibrate base of tongue, wrapped tongue by wet gauze pull tongue forward.

Give correct position with finger under chin with base of tongue, move finger upward and forward to facilitate elevation.

Adjust correct position to ↓ tone.Reduce tone by giving rest during exercise.

Treatment: oral stage

Structure

Symptoms Problem Pre-feeding technique

Feeding technique

Tongue Coughing before swallow; retracted tongue.

↓ sensation Grasping base of tongue under chin between two fingers move it back and forth to ↓ tone.

With finger under chin at a base of tongue, move finger.

Treatment: pharyngeal stageStructure

Symptoms Problem

Pre-feeding technique Feeding technique

Soft palate

Tight voice; nasal regurgitationAir felt through nose.↓ tone, nasal speech

Delayed swallow

Inadequate soft palate movt; ↓ tone, rigidity, ↑ tone

↓ triggering of response

Facilitate normal head and neck positionHave patient tuck chin into therapist cupped hand and applies resistance afterwards patient says “ah”Speed and height of uvula, elevation should ↑ followed by thermal application.

Thermal application repeat up to ten times a day

Facilitate normal positioning Patient have tuck chin slightly to ↓ rate of food entering into pharynx

Alternate presentation start with cold substances followed by hot.

Treatment: pharyngeal stage

Struct.

Symptoms Problem Pre-feeding tech

Feeding technique

Hyoid Delayed elevation of hyoid bone,Poor tongue elevation,Tongue retraction

Delayed swallowIncomplete swallowAbnormal tongue tone; poor ROM

↑ tongue humping as elevation of tongue and hyoid stimulates triggering of responseTone reduction

Place index finger under chin and facilitate tongue elevation

Pharynx

Coughing after swallow

Coting of pharynx seen on videofluroscopy,Gurgly(hoarse) voice

↓ pharyngeal movement,Penetration into laryngeal vestibule

Unilateral pharyngeal movements.

None Alternate presentation of stage II & stage III foods. Tilt head to stronger side.If patient with law tone, patient use compensatory technique: patient turn head toward affected side during swallow to prevent pooling in affected pyriform sinuses.

Treatment: pharyngeal stage

Structure

Symptoms

Problem Pre-feeding technique

Feeding technique

Larynx

Coughing, chocking after swallow

Noisy swallow

↓ laryngeal elevation;↓ tone,Weakness

↑ tone,Rigidity,Uncoordinated swallow

Quick ice up sides of larynx; ask patient to swallow.Vibrate laryngeal musculature from under chin

ROM—side to side, back and forth.Using ice chipped or pack in wash cloth and place around larynx for 5 minutes

Teach to clear throat immediately after swallow.Use effortful swallow.

Placing finger and thumb along both side of larynx, assist with upward elevation before swallow.

Treatment: pharyngeal stage

Structure

Symptoms

Problem Pre-feeding technique

Feeding technique

Trachea

Continuous coughing during, before and after

Aspiration – if before: poor tongue control, if during delayed swallow, if after : ↓ pharyngeal movement.

Blocked airway

Teach to produce voluntary cough :ask to take deep breath followed by cough, therapist uses palm of hand to push downward on the sternum.

none

Encourage patient to keep coughing; facilitate reflexive cough.Push downward on sternum when patient breath out.Suction patient if problem increase.

Push into patient sternal notch to assist with cough.Seek medical assistance

Due to insufficient closure of the larynx in delayed swallow

Oral cavity doesn’t close well in

preparatory phase due to poor tongue

control

When larynx opens,

↓ pharyngeal movt,

bolus enters into trachea

Esophageal Phase

Peristaltic muscle action pushes food through esophagus to stomach OR

aspiration occurs

Treatment : Esophageal stage

Structure

Symptoms Problem Pre-feeding technique

Feeding technique

Esophagus

Frequent regurgitation of food or liquid and coughing or choking after swallow;Material collecting in a side pocket in a esophagus.

Inability to pass through the pharynx or esophagus

Esophageal diverticulum

Partial or total obstruction of the pharynx or esophagus

Requires a medical diagnosis; problem can be seen through traditional barium x-ray study.Surgical correction is needed

Report symptoms to medical staff.(therapist cannot treat)

TRAINING FOR FEEDING IN

PREMATURE INFANTS

• Therapeutic positioning and handling are used to enhance development of normal oral-motor skills.

• Placing the infant in an upright position with the neck elongated is encourage.

• Hyper-flexion of the neck must be avoided because occlusion of the airway must be result.

• The infant’s respiration, heart rate and color should be monitored constantly, when first attempting oral feeding.

Positions for Facilitating Suck

Facilitating Suck• The position in which a baby is held during feeding, can

influence a baby’s ability to suck.

• Holding babies in the proper position not only helps them relax and better control their shoulders, trunks, and hips, but also helps them control their jaws, cheeks, lips, tongue movements, & overall smoothness of swallowing.

• Proper positioning can affect the baby’s strength, organization, and energy for sucking, increasing the time of efficiently sucks on the nipple

• In the chin tuck sets up the neck & jaw muscles for the strongest sucking

Shoulders & Trunk

Shoulders & Trunk• Ideally, the baby’s arms should be forward, with hands

resting on or near the bottle. The position in which the baby’s shoulders are drawn back in a tight or retracted position can lead to tension in the shoulders, neck, jaw, and throat. Swallowing is more difficult, and the baby has to work harder. The harder the baby has to work, the less formula or breast milk will be consumed.

• When trying to improve baby’s shoulder and arm position, remember that some babies cannot handle both arms forward at first. They may need to start with one arm and over time progress to both arms. Gradually, your baby may comfortably rest both hands on the bottle or may hold your hands while you are holding the bottle

Hips

Tongue Lateralization• Tongue lateralization is necessary for placing food over the teeth and

keeping it there during the whole chewing process. Without good sideways tongue movement, food falls off the teeth and isn’t well-chewed.

• You can use the NUK brush with the child, or let the child use it while you supervise. But a child should NEVER be left alone with the brush because choking can occur.

• Infa-Dent Finger Toothbrush

Choosing a nipple and Cup

• Developmental Skills• Size• Shape & Design• Safety• Lid Cover• Handles• Weight• Training System

References Pediatric physical therapy, 3rd edition, by:

Jan Stephen Tecklin

Occupational therapy, 4th edition, by: Lorraine Williams Pedretti

Starting again, by: Patricia M. Davies

•THANK YOU