Twin Functions: How Feeding and Speech are Intertwined

1. Twin Functions: How Feeding and Speech are Intertwined By Brandi Watts, M.S, CCC-SLP Children’s Hospital of Richmond Feeding Program

2. Objectives • State developmental milestones and how different system integrate functions-Feeding, Speech/Language, Gross Motor and Cognition • State how delays in one developmental area can negatively effect function in other areas • List types of complications and how they impact feeding and speech

3. Milestones Handout References: Feeding and Physical Motor info: Morris and Klein (2000) Speech and Language info: The Rosetti Infant-Toddler Language Scale (Rosetti, 1990) Cognitive info: Hawaii Early Learning Profile (HELP) Checklist (1984-1994) & Developmental milestones: A guide for parents Powell, J. and Smith, C.A. (1994).

4. Developmental Milestones: 0-3 months

5. Developmental Milestones: 3-6 months

6. Developmental Milestones: 6-9 months

7. Developmental Milestones: 9-12 months

8. Developmental Milestones: 12-18 months

9. Developmental Milestones: 18-24 months

10. Developmental Milestones: 24-30 months

11. Developmental Milestones:30-36 months

12. Examples of Causes for Feeding or Speech Delays • Neurological/Mechanical-cleft palate, tracheostomy, ankyloglossia, cerebral palsy, apraxia, low tone, gross motor delays, autism • Medical-Recurrent ear infections, thrush, teething, enlarged tonsils/adenoids, frequent emesis caused by reflux or slow gastric emptying, severe food allergies, even constipation! • Environmental-Parents unaware of typical development with expectation too high or to low, parents who have difficulty reading their child’s physical cues, lack of appropriate stimulation to encourage skills development during the appropriate developmental window

13. Neurological and Mechanical Complications for Speech and Feeding • Cleft palate-Nasal regurgitation, intelligibility • Tracheostomy-Sensory Motor complications • Ankyloglossia-”Tongue-tie” • Cerebral palsy-Anterior tongue thrust • Apraxia-Motor Planning for Volitional movement • Low tone-Open Mouth Posture • Gross motor delays-Body Pyramid of Stability • Examples of Syndromes/Conditions: Cerebral palsy, Down’s Syndrome, Russell Silver Syndrome, Prematurity

16. Medical Complications for Speech and Feeding Respiratory issues-BPD, Laryngomalasia Recurrent ear infections Thrush/Teething Enlarged tonsils/adenoids Frequent emesis caused by gastrointestinal complication i.e. reflux or slow gastric emptying Severe food allergies-Eosinaphilic Esophagitis Constipation Cancer, Metabolic issues

19. Respiratory “No food or drug will ever do for you what a fresh supply of oxygen will.” Tony Robbins • Bronchopulmonary dysplasia (BPD)  Chronic lung disease (CLD) • Laryngotracheobronchomalacia

20. Bronchopulmonary Dysplasia • Commonly seen in premature infants (more than 10 weeks early) who require O2 therapy • Characterized by mild, moderate, and severe • Dependent upon how much supplemental O2 is required and for how long • Diagnosed by: • Chest X-ray • May show areas of inflammation or other issues such as a collapsed lung • Blood tests • r/o infection • Echocardiogram • r/o cardiac etiology

21. Laryngotracheobronchomalacia • “Softening of the Airway” • Three areas where we commonly see this • Larynx • Trachea • Bronchi • With laryngomalacia, expect to hear inspiratory stridor. Expiratory stridor/wheezing heard with tracheo- and bronchomalacia. • Generally, infants outgrow this around 2 years of age • However, may require surgery if severe • Diagnosed with flexible endoscopy and/or bronchoscopy

22. Laryngotracheobronchomalacia Strong relationship between tracheomalacia, laryngomalacia and GERD • Thought to be related to high negative intrapleural and abdominal pressures which in turn, affects the lower esophageal sphincter (LES). • Best practice is for reflux management (positioning, diet modification, medication) in these children to avoid complications related to GER Bibi, H., Khvolis, E., Shoseyov, D., Ohaly, M., Dor, D., London, D., & Ater, D. (2001). The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia. Chest,119(2), 409-413. Retrieved March 6, 2015, from http://journal.publications.chestnet.org/data/Journals/CHEST/21958/409.pdf

23. Gastrointestinal • Reflux • Constipation • Motility • Pain Sensation • Short Gut http://www.webmd.com/children/childs-digestive-system

24. GERD • Reflux, or gastroesophageal reflux (GER), occurs when the contents of the stomach pass back up through the Lower Esophageal Sphincter (LES) into the esophagus.

25. Causes of Reflux • Weak or non functioning Lower Esophageal Sphincter (LES) • Increased Production of Stomach Acid • Low Trunk Tone • High Trunk Tone • Allergies • Slow Gastric Emptying • Constipation

26. Signs of Reflux • Vomiting • Nasal flaring or reddening of the nose • Watering eyes • Increased respiration • Excessive swallowing • Increased congestion • Coughing • Inconsistent feeding behaviors • Difficulty sleeping or going down to sleep • Breakfast is more difficult • Fussiness • Volume limiting • Excessive drinking • Arching • Posturing

27. Evaluation of Reflux • Clinical evaluation and observation is your best tool for diagnosis. • Upper GI • Remember, this is only a moment in time in a situation that is vastly different from normal feeding • Often treated without having an Upper GI

28. Treatment of Reflux • Postural changes • Upright after meals, elevate bed • Thickening liquids • Dietary changes • Decrease allergens or acidic foods • Decreasing volume and increasing number of meals • Medications • Acid reducers • Acid reducers neutralize acid already present in the stomach • Example: Zantac • Protein pump inhibitor (PPI) • Stops the stomach from producing the acid • Example: Prevacid • Nissen Fundoplication • Surgical procedure where the top of the stomach is wrapped around the LES to prevent reflux.

29. Constipation • Never underestimate the importance of daily bowel movements!! • Food goes in, it has to come out or the system backs up. • Kids can still go daily and get impacted. • Texture and consistency should be like oatmeal

30. BRISTOL STOOL CHART

31. Constipation: Diagnosis Largely based on history: • Straining and flushing of the face while attempting bowel movement • Hard and dry bowel movements • No bowel movements at all for several days • Abdominal cramps and pain • Nausea and/or vomiting • Weight loss • Traces of stool in the underwear (indicative of a backup in the rectum)

32. Constipation: Medical Treatment • Common Medications: • Miralax • Milk of Magnesia • Senna • Enemas and Suppositories

33. GI Motility Issues • Motility issues can be seen at any point in the GI tract from the lips to the colon • Depending on where the motility issue is will change the name of the dysfunction • Esophageal • Slow gastric emptying

34. Slow Gastric Emptying • Definition • Also called gastroparesis. Food moves too slowly through the intestinal tract or becomes static at certain points. • Know the anatomy of the GI tract! • At the bottom of the stomach is the pyloris sphincter. • The pyloris keeps stomach contents from entering the small intestine before it has been broken down and mixed with acid.

35. GI Tract Anatomy • The pyloris empties into the small intestine which is comprised of three sections: the duodenum, the jejunum and the ileum. • The sections of the small intestines are important to know when assessing G-tube kids • Most kids have tubes that empty directly into the stomach • If absorption or reflux is an issue, will often have tubes that enter through the stomach and extend into the duodenum, jejunum or ileum.

36. GI Tract Anatomy • Often kids who are on continuous feedings will have G-J tubes. • After the ileum is another valve that prevents bacteria laden contents in the colon from going backward. • Lastly is the colon.

37. Clinical Indicators of SGE • Volume limiting • Vomiting hours after meals are consumed • Sour smelling emesis • Inconsistent feeding performance from meal to meal or day to day (emptying is a non-linear process) • Meals are often more difficult as the day progresses

38. SGE Treatment: Medical Periactin • An antihistamine • Side effects might increase emptying speed as well as hunger signals • Only side effect is temporary drowsiness which fades over about a month • If you don’t take a break from Periactin, then the beneficial side effects fade • Periactin can lower the threshold for seizures.

39. SGE Treatment: Medical Erythromycin • Old school antibiotic used in lower doses than when used as an antibiotic • You don’t have to worry about making kids antibiotic resistant because most bacteria these days aren’t impacted by it • Because it isn’t used widely as an antibiotic any more, it’s often hard to get a pharmacy to compound it. Erythromycin works to speed emptying because it aggravates the GI mucosa • Stomach aches are often a side effect.

40. SGE Treatment: Compensatory • Meal schedules • More numerous meals of smaller volumes. • Changes in formula to include elemental formulas

41. Food Allergies Definition: • The body’s immune response to a food that the body views as foreign. Therapist is often the first to catch and refer to Allergist • Most common food allergies include: • peanut, milk, soy, corn, wheat, egg

42. Signs of Allergies to Foods • Hives • Eczema • Diarrhea • Dumping • Respiratory issues such as wheezing • Fatigue • Upper respiratory congestion • Vomiting • Reflux • Watering or itchy eyes • Coughing

43. Food Allergies: Evaluation • Skin Prick Test • RAST testing • Elimination diet • Only one able to diagnose food intolerances The Skin prick test and RAST testing both at risk for false positive and false negative results

44. Special Note on Severe Food Allergies Eosiniphilic Esophagitis • Usually seen in conjunction with gastritis (overall GI inflammation) • The body produces eosinaphils (clumps of white blood cells) in the esophagus causing tearing, striations and severe pain • Treated with elimination diet and oral steroids such as Pulmicort. You can have EoE even if you only have environmental allergies • Use of Hypoallergenic formulas such as Elecare and EO28

46. Environmental Impacts on Feeding and Speech • Parents not aware of developmental norms-example-prematurity • Parents unable to read child’s cues accurately-chewing skills and stage 3 foods • No stimulation or stimulation introduced outside of the developmental window

47. Environmental • How is the home equipped? • Highchairs • Constant activity level in the home • Adequate food supply • Utensils available: spoons, bottles, etc. • How many people reside in the home? • Family meals v. Eating on the go? • Preschool? Baby sitter? • Siblings present? • Pets? • Distraction v. No distraction?

48. How to Treat?? • Identify the underlying causes by asking clarifying, open ended questions • Refer to the appropriate medical professionals if mechanical, neurological or medical issues are suspected. Professions can include: Pediatrician, Otolaryngologist, Gastroenterologist, Developmental Pediatrician, Immunology • Refer to Occupational Therapist, Physical Therapist, Speech-Language Pathologist, Audiologist, Psychologist for a whole body approach • Parent education

49. What does this mean in the classroom? • Special seating • Decreasing distraction by moving student to a different part of the room, less students at the table • 1 to1 assistance • Use of motivators • Food rotation • Prize incentives • Keeping food logs for the family • Collaboration with SLP or OT • Referral for services