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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 Swallowing/Feeding Disorders is educationally relevant Students must be safe while eating at school

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clinical evaluation of dysphagia in school aged children

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

swallowing feeding disorders is educationally relevant
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
slide3
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

preschool elementary
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
middle high school
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
incidence of pediatric dysphagia
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

where did it start
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)

types of feeding problems
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

the big question
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.

what are parents teachers reporting
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.
what do you find out after probing further
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)
potential students on our caseloads
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)

group 1
Group 1
  • History of:
    • GER
    • Prematurity
    • Short Bowel Syndrome
    • Autism
    • Developmental Delay
    • Prolonged tube feeding
group 2
Group 2
  • No previous feeding/swallowing intervention
  • History of “picky” eater
  • May or may not have a significant medical history
need to determine the etiology
Need to determine the etiology:
  • Behavioral
  • Sensory
  • Physiological
  • Combinations
sensory issues
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
behavioral issues
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
sensory issues presentation
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
behavioral issues presentation
Behavioral Issues - Presentation
  • Rarely selective avoidance
  • Eats better for certain people/places
  • Gags to get attention
  • Rarely underlying neuro or medical issue
other factors to consider
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
slide21
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
clinical assessment of feeding and swallowing
Clinical Assessment of Feeding and Swallowing
  • History/Background
  • Oral Mechanism/CN exam
  • Swallowing Exam
visual evaluation of structures
Visual Evaluation of Structures
  • Lips
  • Teeth - dental status, dentures
  • Oral mucosa
  • Tongue
  • Palate, faucial arches
  • Neck (larynx)
visual evaluation of structures24
Visual Evaluation of Structures
  • Relative size and symmetry
  • Abnormalities
    • scarring
    • atrophy
    • asymmetry
    • resting movement (fasciculation)
lips cn vii
Lips (CN VII)
  • retraction
  • rounding
  • Closure
tongue cn xii
Tongue (CN XII)
  • elevation (ant.)
  • lateralization
  • protrusion
  • retraction
  • elevation (post)
vp port cn v ix x
VP port (CN V,IX, X)
  • elevation
  • retraction
  • lateral wall mvt
  • posterior wall mvt
cn ix glossopharyngeal
CN IX (Glossopharyngeal)
  • Look at your neighbor saying “ah, ah, ah”
laryngeal exam cn x
Laryngeal Exam (CN X)
  • cough
  • voice quality
  • dry swallow (cervical auscultation)
swallow exam
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
slide32
Feel for laryngeal elevation and posterior tongue mvt.
  • Check for timing of the swallow response
what are we looking for
What are we looking for?
  • lip closure
  • tongue mvt
  • laryngeal elevation/hyoid elevation
  • timing of swallow response
  • Residue
  • Signs/symptoms of aspiration
what does ca tell us
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.

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

compensatory manuevers
Compensatory/Manuevers

Chin Tuck

Supraglottic Swallow

Mendelsohn Maneuver

Effortful Swallow

facilitative
Facilitative

1. Oral Motor Exercises Lingual strengthening

  • Sensory stimulation to increase awareness
  • Increasing ROM

2. Development of Normal Feeding Skills

food chaining
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
slide40
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.
food chaining helps the therapist to determine
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?
slide42
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.

how to implement the program
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.
slide44
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).
what is sensory integration
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
sensory based feeding problems non nutritive stimulation protocol
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
sensory based feeding problems
Sensory-Based Feeding Problems
  • Visual
  • Olfactory
  • Tactile
  • Gustatory
food experiences visual
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.
food experiences olfactory
Food ExperiencesOlfactory
  • Introduce mild smells
  • Establish comfort with proximity to smells
    • Handling directly
    • Presenting on another object
  • Increase intensity of smells
  • Scented therapy tools
food experiences tactile
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
food experiences gustatory
Food ExperiencesGustatory
  • Hierarchical Approach (Toomey, 2000)

1. Kissing

2. Licking

3. Bite and remove

4. Bite, chew and spit

5. Bite, chew, swallow

6. Consider taste, temperature, texture

7. Structure movement through hierarchy with an “all done” bowl

treatment of poor hunger satiety
Treatment of Poor Hunger/Satiety
  • Guidelines for following normal mealtime schedule including 3 meals and 2-3 snacks daily
  • Pair tube feedings in high-chair/booster seat with or immediately after the oral feeding
  • Medication may aid in stimulating hunger
management of behaviorally based feeding problems
Management of Behaviorally-Based Feeding Problems
  • Rule-out medical, motor, or sensory involvement
  • Parent education
  • Promote ownership in older child
  • Referral to behavior specialist and/or psychologist/psychiatrist
use of reinforcement as a part of feeding therapy
Use of Reinforcement as a Part of Feeding Therapy
  • Use reinforcers to develop new skills
  • Age appropriate reinforcers including puppets, books, peg boards, card games
  • Natural reinforcers should be used at home
  • Homework sticker charts
slide55
Some Activities to Increase Oral Stimulation

Young children with feeding and swallowing issues related to a sensory disorder may benefit from stimulation activities that can be done at home by a caregiver at home or in a child care setting. Always consult with a speech-language pathologist or occupational therapist before embarking on a program to affect oral defensiveness.

Gentle massage with a NUK brush

Gentle massage with a small finger toothbrush brush

Offer a strong piece of sterile rubber tubing to practice biting and increase jaw strength

Offer foods of different textures: pretzels, crackers, puddings, jell-o, ice cream, mashed potatoes, etc.

Offer drinks of different temperatures and composition

Offer gentle vibrating toys for facial massage or oral exploration

Gentle facial massage with different textures of cloth

slide56
Increase appropriate feeding behaviors.
  • Decrease inappropriate behaviors.
  • Motivate the child to demonstrate an existing behavior more frequently.
food rules for arvedson 1998
Food Rules for (Arvedson, 1998)
  • Maintain regular mealtimes
  • Meals last no longer than 30 minutes
  • No grazing.
  • Neutral feeding atmosphere
  • No game playing
slide58
Solids come first
  • Liquids come last
  • Remove food after 15 minutes if s/he is throwing it, playing with it or not eating it.
  • Don’t wipe the child’s hands or mouth until the meal is finished.
getting started
Getting Started

1. Allow the child to watch others eat.

2. Experience smells, tastes, and play with food.

3. Mealtime should be fun/social.

slide60
Get MD approval to begin bolus feedings for exclusively tube fed children.
  • Oral motor therapy should be separate from mealtime.
remember
Remember…
  • The goal of all feeding therapy is a pleasurable experience associated with food. You must first determine if the problem is a motivation vs skill deficit.