Alison Spurr August 2014

1. Alison Spurr August 2014 Feeding Development

2. Overview of Presentation • Prevalence and Importance of Early Identification • Development of Feeding • Reflexes • Anatomy • Development for first 2 years • Feeding Evaluation Check list • Red Flags for further referral • Management of feeding difficulties • Case studies

3. Prevalence of feeding difficulties • A wide variety of studies suggest 20% of children struggle with some type of feeding and/or growth problem during the first 5 years of life • 5-10% of infants and young children have significant feeding/growth problems • These are the children that we need to identify early and refer for early intervention

4. Importance of identifying problem feeders Dubois et. al (2007) Picky eaters were more likely to have a Body mass Index below the 10th percentile at 4.5 years of age compared to the children who were never reported as being picky eaters at any one point in time. Motion, S., Northstone, K, Edmond, A. (2001)The children who had persistent feeding difficulties went on to have significant delays in motor, language and behaviour milestones at 18months and 30 months of age

5. AUTISM DIAGNOSIS • Identified as picky eaters long before referral for diagnosis of ASD • Later introduction of solids • Described as “slow feeders” at 6 months • From 15-54 months of age, consistently reported as “difficult to feed” • From 15-54 months of age, consistently reported as “very choosy” • From 15 months, had a significantly less varied diet, which became increasingly more difficult than controls • By 24 months, are more likely to have a different diet from their family than controls Edmond et.al. (2010)

6. Feeding Problems Cycle Poor Feeding Feed Aversion Poor weight Gain Deviant Parent-child bonding Increase in parental stress Deviant parent behaviours eg. Force feeding Decreased reading of child’s cues

7. Feeding Development From Birth

8. Babies are born with the skills to feed • Reflexes • automatic instinctive reactions in response to a stimulus • Anatomy • Anatomy of the newborn differs from adult

9. Infant Reflexes

10. Swallowing Anatomy Infant Adult

11. Anatomy of the New born • Oral space is filled by the tongue – which is in full contact with the gums, as well as the hard and soft palate • Buccal pads support sucking by providing stability • Soft palate and epiglottis are in contact (obligatory nose breathers) • Suction is created with tongue cupping and jaw movement, creating negative pressure

12. Swallowing

13. Normal Swallow & Anatomy LNORMAL.MOV xnormal.MOV

14. Non-Nutritive Sucking No liquid flowing (other than own secretions) →swallowing rate is low & the respiratory rate remains at baseline levels. Sucking rate may be rapid as there is limited interruption for swallowing. NNS = 2 sucks/ second. 6-8 sucks/ swallow/ breath. Infants' should be exposed to a variety of oral input for NNS (own fingers/hands, dummy, adult finger, teats, safe mouthing toys). NNS at the breast for infants transitioning to oral/ BF.

15. Nutritive Sucking Apnoeic periods (‘deglutition apnoea’) occurring in association with swallows. Rhythmic sucking, swallowing. Jaw movements & breathing are usually co-ordinated in a 1:1 relationship. NS = 1suck/ second 1-2 sucks/ swallow/ breath Initial continuous sucking burst lasting up to 60-80 seconds, followed by intermittent sucking (sucking bursts & pauses) over the feed. Duration of sucking bursts gradually decrease while length of pauses increase. End of feed = only 2-3 sucks per burst with 4-5 second pause.

16. Development of feeding Birth to 6 months. Suckle feeding. Liquid from breast or bottle 6 months: ‘first solids’ or purees In addition to breast/bottle feeding Approx. 8 months: increased texture Lumpy mashed and minced textures Chewable solids usually for mouthing and oral exploration

17. Development of feeding 10 months: introduce new foods for biting and chewing 12 months: eating harder chewable solids By 24 months: most children consuming adult-like diet (variety of textures)

18. FEEDING DIFFICULTIES FEEDING (this is just the tip of the iceberg) All organs- respiratory, GI tract, cardiac All muscles- fine/gross motor, posture, GI All Senses- sensory experience Learning – early experiences, capacity to learn Development Nutritional status Environment – reflection of the problem, not the cause

19. Swallowing Difficulties • A swallowing disorder or dysphagia, occurs when there is a problem with the normal ability to swallow food and or liquids. • Causes • oral and facial structure abnormalities, • neurological and/or • developmental difficulties

20. Swallowing Disorders • LDURING.MOV • XASDUR.MOV

21. Swallowing Disorders • Severity • mild (addressed with modifications) • Severe - food and fluid cannot be taken orally and the individual must be fed enterally either temporarily, partially or permanently.  • Swallowing difficulties can pose significant dangers as food or fluid may enter the lungs rather than the stomach.

22. Swallowing Disorders • Swallowing difficulties can occur at any stage of the swallowing process. • Oral stage: Issues with strength, movement, coordination and sensation of the oral musculature may cause difficulties with bolus collection, containment, manipulation and transit. • Pharyngeal Stage: difficulties with triggering swallow reflex; poor or absent cough reflex. Issues with bolus transit resulting in pooling and or residue; refluxing into nasal passageways or penetration and aspiration into the airway.

23. Swallowing Disorders • Oesophageal Stage: Problems with bolus transit; residue; reflux; narrowing or pocketing of the bolus. • Medical specialists (eg gastroenterologist, ENT, respiratory physician and or paediatrician etc) need to be consulted for specialised investigation and/or treatment. As difficulties can be due to a variety of reasons, these need to be carefully investigated.

24. Red Flags • Weight loss and/or failure to thrive • Lengthy feed times (longer than 30-40mins) • Refusal to eat or drink. • Poor ability to manage own secretions • Recurrent chest infections • Recurrent cough • Difficulties coping with certain types of food/liquids

25. Red Flags • Coughing, spluttering, gagging at mealtimes • Difficulty coordinating sucking swallowing and breathing • Wet, gurgly vocalisations during or immediately after swallowing or at mealtimes. • Nasal regurgitation or frequent sneezing during a meal. • Reflux and vomiting. • Weak cough or inability to cough.

26. Red Flags • Multiple swallows to clear food and fluid • Discomfort swallowing whilst eating or drinking. • Delayed or slow swallow trigger. • Sweating, pallor or glassy eyes during meals. • Desaturation levels during oral feeds. • Increased heart rate during feeds. • Sudden onset of feeding difficulties

27. Check list for sucking • Suck Evaluation Check list – see separate hand out • NB: For use in 0-3 months only

28. Common Feeding Problems in Babies Poor suck swallow breathe coordination Reduced endurance Oral aversion and oral hypersensitivity Structural – Cleft palate - Tongue Tie

29. Management Principles • Depends on: • The anatomic or physiological dysfunction • Child’s prognosis • Child’s developmental stage • Child’s cognitive status and new learning skills • Child’s level of independence/physical status • Family resources (physical, financial, emotional)

30. Tongue Retraction Postural support – provide flexed position & stable support. Modifying tone of tongue- mvmts proximal to distal (lateral gum ridge → on top of tongue) with finger in a midline position. Shaking, jiggling, tapping & stroking the tongue may be useful movements. Longer nipple – that is firm with a round cross section to provide greater contact on the tongue (↑ proprioceptive input) & promote more effective movements during sucking. BF – if adequate contact between tongue & breast still cannot be achieved, use of a nipple shield may be considered to create a longer ‘nipple’.

31. Lack of Central Grooving of the Tongue Proprioceptive input – Downward pressure to the midline of the tongue provides feedback re: proper position in the mouth and encourages central grooving. Slight stroking forward combined with downward pressure may help initiate appropriate sucking patterns. Can be applied with a finger prior to feeding or with the teat during feeding (firm straight nipple with round cross section). BF – breast nipple may be too soft to provide sensory input needed during feeding. May consider nipple shield if appropriate sucking pattern elicited on finger or teat, but not on breast (with caution).

32. Excessive Tongue-Tip Elevation Postural support – stable feeding position to reduce neck extension. Increase flexion in body. Facilitation of tongue movements – quick swiping or vibration to the tip of the tongue will help bring it down. Assist with mouth opening – stimulation to the lips & slight downward pressure on the jaw to encourage greater jaw opening → tongue tip ↓ for easier nipple/ teat placement

33. Tongue Protrusion Postural support – bring head into a slightly flexed position & provide stable support to the head. Building tone in the tongue – firm tapping to the midline of the tongue, moving from the tip toward the base may help bring the tongue further into the mouth. Facilitating appropriate tongue movements – tongue protrusion results in a compression pattern dominating sucking. Techniques to facilitate normal tongue movement i.e central grooving to increase negative pressure suction → efficient feeding (finger & firm straight teat with round cross section. Not broad, flat → compression) Facilitating lip activity – Use of cheek support with thumb & index finger to facilitate better lip seal.

34. Reduced Spontaneous Mouth Opening Prepare the infant’s state – arousal techniques to alert the baby. Elicit the rooting reflex. Assist mouth opening – gentle downward pressure & traction to the jaw (chin) may help open the mouth. Useful in eliciting the wide mouth opening necessary for BF. Inhibit jaw clenching – vibration to mouth or hold the mandible between thumb & index finger & provide extremely small-range, low amplitude, side-to-side mvmt of the jaw. Pressure to the gums – firmly stroking outer portion. Start at midline of gums stroke towards back → Upper & Lower gums R & L

35. Weak Suck Facilitating a stronger sucking pattern – provide maximal stability for optimal positioning, using firm cheek & jaw support. A smaller bottle may make it easier for the feeder to place fingers to provide 3 points of stability. Slight traction on the teat/ nipple by gently pulling may also promote stronger sucking. Increase the flow of liquid – to allow the infant to get a larger bolus in response to a weak suck (i.e. fast flow teat). Many babies with a weak suck can co-ordinate swallowing & breathing with a larger bolus. However must be done with caution (may be too large → coughing/ choking).

36. Reduced Lip Seal Focus on underlying problem – i.e. Facial weakness/ hypotonia, excessive jaw excursion or tongue protrusion. External support – support to cheeks & lips to help increase lip approximation around the teat/ nipple.

37. Reduced Cheek Stability Increase facial tone – tapping, vibration, quick stretch (during a sucking pause of greater than 2 seconds). External support – Cheek & jaw support.

38. Prolonged Sucking – Feeding-induced Apnoea Long sucking bursts without interspersing breaths at appropriate intervals → oxygen desaturation&bradycardia. Difficulty ‘pacing’ sucking & swallowing with breathing. Often strong, rapid sucking & may have difficulty initiating breathing, even after the nipple/ teat has been removed from the mouth. More pronounced at the beginning of the feed. More common in premature babies → related to maturation. Mx: External pacing – feeder assists infant in appropriately interspersing breaths during sucking bursts (count 3-5 breaths). Decrease the rate of flow – thicker liquid or slow-flow teat → time to organise the swallow/ breath pattern. Youtube: Paced Feedings

39. Disorganised Suck • Duration of sucking bursts & pauses may vary considerably. • Uneven pattern of breathing and swallowing within the sucking burst. • Coughing & choking are frequently noted. • Possible causes – general neurologic disorganisation, mild respiratory problems, or a nipple flow rate that is incompatible with the infant’s sucking. Mx: • Assisting with external organisation – e.g.wrapping, ↓ distractions. • Acknowledging respiratory problems. • External pacing. • Reducing the flow rate - ↑ rhythmic coordination (thicker liquid, slower-flow teat.

40. Coordination of Suck, Swallow, Breathing • Feed when baby best able to organise self • - timing, wrapping, rocking • Express before feed • Use external pacing • Variable flow teat • Thicken the feed • Consider respiratory support

41. Poor Initiation of Sucking Focus on underlying problems – poor state & organisational abilities, oral tactile hypersensitivity or neurologically based (hypertonia/ hypotonia). Controlling excessive rooting – provide firm stabilisation & control of the head through positioning (↓ head shaking from side to side). Stabilise front of the head with jaw control & cheek support if needed. Place teat firmly on the midline of infant’s tongue with slight downward pressure to give central point of stabilisation. Assist with mouth closure – jaw support. Facilitating appropriate tongue movements

42. Excessive Jaw Movement Postural support – jaw support with 3rd/ 4th finger to the mandible to allow adult to grade range of movement. Increased neck flexion – head in strong neck flexion. The chin should be close to the chest, with the chest then providing pressure and helping to grade jaw movement. May need to use an angled bottle → always monitor infant’s respiratory pattern. Neuromotor preparation – for jaw thrusting (hypertonicity) → reduce overall body muscle tone (support from Physio or OT). Facilitating appropriate tongue movements

43. Short Sucking Bursts • Infant takes only 1-3 sucks in a burst before pausing for multiple breaths. • Pauses are too frequent & too long compared to the length of the sucking bursts. • Swallowing &/ or respiratory difficulties may lead to this pattern. • Adaptive responses from infant – limiting the no. of sequential boluses → swallowing problem. -frequent pauses to ‘catch up’(self-pacing) → respiratory problem. Mx: • Swallowing-related incoordination – VFSS ax. • Respiratory-related incoordination – provide respiratory support.