Clinical Evaluation of Dysphagia in School-Aged Children

1. Clinical Evaluation of Dysphagia in School-Aged Children Kelly Dailey Hall, Ph.D. CCC/SLP Pediatric Speech & Language Services, Inc. Greensboro, NC kdhall2@uncg.edu

2. Swallowing/Feeding Disorders is educationally relevant • Students must be safe while eating at school • Students must be adequately nourished/hydrated so they can attend fully to access the curriculum • Students must be healthy to maximize attendance at school • Students must develop skills for eating efficiently during meals/snack time so they can complete these activities with their peers safely and in a timely manner

3. SLPs do not need a medical prescription or medical approval to perform clinical evaluations or implement intervention services • We do have the responsibility to determine whether the student’s medical condition warrants medical clearance for clinical procedures. Roles of speech-Language Pathologists in Swallowing and Feeding Disorders, ASHA 2001a, b

4. Preschool/Elementary • identifying students with swallowing and feeding problems; • determining the strategies to maintain the student's health and safety while eating/drinking in the school setting; • facilitating developmental gains in swallowing and feeding skills

5. Middle/High School • improving the efficiency of the student's swallowing and feeding behaviors; • generalizing swallowing and feeding skills for varied social purposes in a variety of settings. • responding to and minimizing regression

6. Incidence of Pediatric Dysphagia • 25% in all children • 80% in children with developmental disabilities • Occur with greater prevalence in children with physical disabilities, medical illness and prematurity (Manikam & Perman 2000) Summarized in Oct. 2006 Brackett, Arvedson & Manno in SID #13 newsletter

7. Where did it start? • Child who experience pain, nausea, fatigue associated with eating may develop refusal/aversive behaviors • Inadequate opportunities to develop/practice skills (i.e. tongue lateralization, chewing, swallowing) • Inadequate experience as an oral feeder reduces the probability that the child can or will eat in the future. Piazza (2008)

8. Types of Feeding Problems 1. Food Refusal Refusal to eat all or most foods so the extent that the child fails to meet his/her nutritional needs 2. Selectivity Eating a narrow range of food that is nutritionally inappropriate Refusal to eat food textures that are developmentally appropriate 3. Oral Motor Problems Difficulty with mastication, lip closure, tongue mvts 4. Pharyngeal dysphagia Aspiration

9. The Big Question? Is the student at risk for aspiration? Yes? Then you need to establish strategies for oral intake that minimizes the risk. • Most appropriate diet consistencies (e.g.thickening liquids) • Manuevers (e.g. chin tuck, double swallow) • Increase timing of swallow response • Increase strength of pharyngeal contractions No? Then you need normalize feeding behavior.

10. What Are Parents/Teachers Reporting? • prolonged and/or stressful mealtimes • coughing and throat clearing when eating and drinking or from accumulation of saliva • wet breath sounds and/or gurgly voice quality associated with swallowing • spillage of food and liquid from the mouth • drooling • food remaining in mouth (pocketing) after swallowing • swallowing solid food without chewing • inability to drink from a cup • multiple swallows per bite of food or sip of liquid • effortful swallowing • gagging or vomiting associated with eating and drinking.

11. What Do You Find Out After Probing Further? • Food refusal-turns away, spits out food. • Extreme food selectivity-eats only a few foods or kinds of food. • Gastrostomy tube dependence • Accepts little or no food by mouth. • Behavioral problems related to mealtime crying, gagging, vomiting, throwing food. • Poor hydration/fluid intake-doesn't drink enough fluids • Poor intake of food leading to failure to thrive • Significant respiratory • Oral-motor problem-tactile defensiveness, gagging • Delay in the development of self-feeding skills. • Consistently missing 2 or more food groups • Feeding habits differ significantly from family/peers and affect social life (e.g. can’t go to birthday parties)

12. Potential Students on Our Caseloads • Group 1 • History of feeding/swallowing disorder with concomitant medical disorder • Previous VFSS and swallowing therapy by and SLP and/or OT • 70% of children whose pediatric feeding/swallowing issues are not resolved by age 3 will have persistent feeding difficulties 4 to 6 years later (that puts them on your caseload in the schools) Piazza (2008)

13. Group 1 • History of: • GER • Prematurity • Short Bowel Syndrome • Autism • Developmental Delay • Prolonged tube feeding

14. Group 2 • No previous feeding/swallowing intervention • History of “picky” eater • May or may not have a significant medical history

15. Need to determine the etiology: • Behavioral • Sensory • Physiological • Combinations

16. Sensory Issues • Where do they come from? • Prematurity • Chronic illness • Multiple medical interventions/medications • Underlying neuro issues • Diagnosis with SI as a component • Unpleasant oral-tactile experiences • Delayed introduction of oral feeds • GI issues

17. BehavioralIssues • Where do they come from? • Bad habits/desperation • Poor limit setting • Lack of mealtime structure and routine • Passive eating with distractions • Inconsistent expectations re: eating

18. SensoryIssues - Presentation • Often avoids whole foods or texture groups • Difficulty tolerating sensory input – sight/smell/touch/taste • Eats the same regardless of people/place • Overstuffs oral cavity/takes tiny bites • Stores food “for later” • Gags as a sensory response • Excessive drooling

19. Behavioral Issues - Presentation • Rarely selective avoidance • Eats better for certain people/places • Gags to get attention • Rarely underlying neuro or medical issue

20. Other factors to consider • Adipsia • the absence of thirst or the desire to drink • Dysphagia can be a real or imagined difficulty in swallowing • phagophobia

21. Kasese-Hara (2002) research suggest that children with FTT lack the normal responses to hunger and satiety cues to regulate food intake. • Childen with feeding problems can be minimally or completely unaffected by hunger cues

22. Clinical Assessment of Feeding and Swallowing • History/Background • Oral Mechanism/CN exam • Swallowing Exam

23. Visual Evaluation of Structures • Lips • Teeth - dental status, dentures • Oral mucosa • Tongue • Palate, faucial arches • Neck (larynx)

24. Visual Evaluation of Structures • Relative size and symmetry • Abnormalities • scarring • atrophy • asymmetry • resting movement (fasciculation)

25. CN V (Trigeminal – Mandibular Branch

26. Lips (CN VII) • retraction • rounding • Closure

27. Tongue (CN XII) • elevation (ant.) • lateralization • protrusion • retraction • elevation (post)

28. VP port (CN V,IX, X) • elevation • retraction • lateral wall mvt • posterior wall mvt

29. CN IX (Glossopharyngeal) • Look at your neighbor saying “ah, ah, ah”

30. Laryngeal Exam (CN X) • cough • voice quality • dry swallow (cervical auscultation)

31. Swallow Exam • Listen (cervical auscultation)to respiratory sounds at the level of the thyroid cartilage • Dry swallow (with CA) • Introduce 1iquids, small amount, via straw or spoon (with CA) • Continue with thick liquids, pudding, and soft solids

32. Feel for laryngeal elevation and posterior tongue mvt. • Check for timing of the swallow response

33. What are we looking for? • lip closure • tongue mvt • laryngeal elevation/hyoid elevation • timing of swallow response • Residue • Signs/symptoms of aspiration

34. What does CA tell us? Cervical auscultation during oral intake of ________________ revealed changes in the respiratory sounds following the swallow which may be indicative of aspiration.

35. Intervention • Facilitative • Facilitate recovery to “normal” • Compensatory • Compensate for a disordered system

36. Compensatory • Positioning • Utensils • Maneuvers Most students who require compensatory strategies will have these strategies identified on their MBSS. We implement a program to be sure that the child is using these strategies to reduce aspiration risk.

37. Compensatory/Manuevers Chin Tuck Supraglottic Swallow Mendelsohn Maneuver Effortful Swallow

38. Facilitative 1. Oral Motor Exercises Lingual strengthening • Sensory stimulation to increase awareness • Increasing ROM 2. Development of Normal Feeding Skills

39. Food Chaining • A systematic, child specific, home-based treatment program • Builds on successful eating experiences • One part of a comprehensive treatment program • Foods are used as desensitization • tools in treatment

40. Foods are selected based on the • child’s preferences, this reduces • the risk of refusals • Currently accepted foods, rejected foods and previously accepted foods are analyzed for patterns in taste / texture / consistency • New food items are introduced that are very similar to foods /liquids in the core diet. • Chains can be simple or extremely complex.

41. Food Chaining helps the Therapist to determine: • Core Diet: Foods child eats on a regular basis, consistently accepted. • Patterns of Intake: Grazing, excessive liquid intake, food jags, refusals. • Consistency of Intake: With parent, in the home, extended family, at a restaurant, at school, with peers—is there any difference?

42. Goal food items are selected that have similar features (taste texture temperature) to those in the child’s core diet (consistently accepted foods) • What Food to Select Next: Rating scales (1-10) are used weekly to: measure reaction to new foods, measure change in preferences over time to help select next targeted food items.

43. How to Implement the Program: • Parent implements the program at home under direction of the team. Feeding therapy continues at school. • Flavor Mapping involves analyzing the child’s preferences. Are there patterns between favorite foods? Does the child seek strong or more bland flavor of food? What is the most common texture of food.

44. Transitional Foods involves using favorite foods between bites of new food to encourage the child and help mask after taste of a new food item. • Flavor Masking involves finding flavors that can be used on a variety of newer food items. Masking allows the child to experience a known accepted taste paired with the new food item. Masks are then faded as the child tolerates the targeted food items. (Example: Ranch Dressing).

45. What is sensory integration? • Sensory pertains to our senses: • Hearing, sight, smell, touch, taste, and perception of motion/movement and gravity • Integration refers to the process of unifying and allowing the brain to use the information that the senses gather and take into the body

46. Sensory-Based Feeding ProblemsNon-nutritive Stimulation Protocol • Oral stimulation of the lips, teeth/gums, cheeks, tongue, and palate with Nuk brush • Develop tooth brushing protocol for therapy and home • Introduce mild tastes on finger, cloths, and brushes as tolerated

47. Sensory-Based Feeding Problems • Visual • Olfactory • Tactile • Gustatory

48. Food ExperiencesVisual • Non-mealtime visual experience • Object-based, picture-based system • Establish comfort level with food proximity • Work on tolerating food on the table, on the child’s plate, etc.

49. Food ExperiencesOlfactory • Introduce mild smells • Establish comfort with proximity to smells • Handling directly • Presenting on another object • Increase intensity of smells • Scented therapy tools

50. Food ExperiencesTactile • Water play/Sensory bean bags • Painting with food • Food activities (i.e., flower pots, boats, gingerbread houses) • Cooking activities • Pizza, muffins, waffles, fruit salad, soup