Sphsc 543 march 5 & 12, 2010

Sphsc 543march 5 & 12, 2010 • Questions?

treatment • Assessment will have identified if there is a problem and what the problem is. • Any treatment plan must meet three criteria: should be safe should strive to maintain optimal nutrition should be farsighted

treatment • What the child needs to bring to the treatment process: • Functioning GI system • Stable pulmonary system • Developmentally appropriate oral sensorimotor and feeding skills • Look at relationships between oral and respiratory systems, and child’s learning and communication strategies.

Treatment • What influences tone/movement patterns? • Look at limiting movement patterns and look for automatic reflexes that can be elicited to promote normal patterns of movement. • Family dynamics • Important in evaluation and treatment planning

Basic principles • Facilitate normal patterns of movement and normalize ability to accept/integrate input – visual, auditory, vestibular, taste and temperature • Include treatment into typical ADLs of childhood • Mealtime • Toothbrushing • Bathing • Dressing • Play • Remember: The ultimate goal may not be achieving full oral feeding • Success may include whole or part nutrition by non-oral means

treatment • Can be direct • Oral “exercises” • Non-nutritive oral stimulation (NNOS) • Therapeutic tastes • Can be indirect • Alterations in • Environment • Positioning • Seating • Communication signals • Food consistency

Terminiology • Feeding Therapy • Implies primary goal is oral feeding • Oral Sensorimotor Treatment • Primary goal is coordinated movements of the mouth, respiratory and phonatory systems for communication and oral feeding • Focus is on the ‘total’ child

Treatment VS management • Treatment • Goal is to improve a problem or condition underlying feeding dysfunction • Management • Underlying cause of problem cannot be modified by treatment techniques at this time • Address symptomatology to maintain health and nutrition • “Buy time” until the underlying problem changes through maturation or medical improvement

Options for treatment/management • Medical techniques • Medications, O2, NGT • Surgical techniques • Repair of anatomical anomalies • G Tube placement • Modification of feeding situation • State • Posture and position • Swallowing • Oral-motor control • Coordination of SSB • Tactile responses

Getting ready • Prepare the infant • State, tone and movement, tactile responses • Prepare the environment • Visual stimuli • Noise • Temperature • Prepare the feeder

state • Feeding possible in drowsy/semi-dozing, quiet alert and active alert states • Hypersensitive, easily disorganized –drowsy versus active/alert state • Sleepy –very alert • Look at patterns of states, transitions between states, and stability of state • May need to modify environment during feeding

state • Tactile • Alerting effect • Often combined with movement • Temperatures • Cooler • Change clothes/diaper • Unbundle • Cool washcloth

arousal • From sleepy/semi-drowsy to calm, alert • Variable, not predictable, not rhythmic • Movement • Can have a strong alerting effect • Picking up baby, being in an upright position • Rocking from side-to-side • Auditory • pitch, tone, rhythm, quiet to louder, lively music

calming • Irritable, crying, hyperstimulated, disorganized, easily startled • Containment and rhythmicity are key • Tactile • Firm, deep pressure and containment • Swaddling • Physical containment • Tonic, disorganized • Frequent, firm proprioceptive and deep pressure contact

calming • Swaddling continued • Arms together in midline, hips flexed, head covered • Use well-flexed, vertical position • Use body – posture and firmness of holding • Infant massage • Movement • Rhythmic, constant, predictable • Try different rhythms • Bouncing, rocking when swaddled

calming • Auditory • Decreasing auditory input • White noise, rhythmic, repetitive music • Minimal speech • Tone, posture, position • Balance between flexor and extensor • Movements should be smooth and well modulated • Alignment of head, neck and trunk are crucial

Optimal feeding position • Overall flexion • Orientation of head and extremities about the midline • Shoulders symmetric and forward • Arms flexed and toward body midline • Hips flexed from 45-90 degrees

Seating/positioning • Look at shoulder girdle, trunk, hips/pelvis, sitting base, stability of feet, eye contact/control, head control and spinal mobility • Soft chair (bean bag) or foam/towel between shoulders – retraction • Vest attached to chair, foam/towels on table – protraction • Hold shoulders down • May need trunk supports/pads • Rolled towels under knees – posterior pelvic tilt • Lumbar spine – anterior pelvic tilt • Seat depth, width, angle

Seating/positioning • Sitting base – wider (pommel) more stable; hip adductor to bring knees together • Foot rest, towels, blankets, books • Eye control/contact – supine – no demands for head control. • Feeder should be at eye level • Head/spine – must look at hips, pelvis, trunks and shoulder girdle first. Slight recline, head rest, chin tuck • Abdomen – build muscle tone and control. Improve breathing and postural adjustments during mealtimes

Seating/positioning • Freedom of movement – spinal movement and changes movement around body axis

Feeding positions • En face • Maximal head control is possible, harder to provide trunk support • Supine in lap • Hard to control side-to-side head movement • Hands free tube feeders, pacifier for NNS • Can be inclined • Sidelying on lap • Trunk straight and well supported • Helps retracted tongue come forward

Feeding positions • Head in greater flexion • Facilitate sucking and lip seal • Compensate for poor laryngeal elevation • Head in slight extension • Assists breathing

Swallowing • Depends on where the problem is: • Poor organization of bolus in oral phase • Delayed swallow reflex initiation • Abnormal pharyngeal phase • Incoordination of pharyngeal/esophageal peristalsis

Improve bolus formation • Problem with tongue control • Provide single bolus then pause to allow organization • Small boluses (0.1-0.5 cc, 1 Tbsp to 2 oz) • Allows establishment of suck • Thicken liquid • Moves slower, easier for tongue to maintain bolus

Delayed swallow reflex initiation • Thermal stimulation • Triggers faster swallow reflex in adults • Refrigerator-chilled liquids or semisolids • May diminish over subsequent swallows • If non-orally fed – may suck on frozen pacifier • Thicken liquid/pureed foods • Improving laryngeal closure • Forward head flexion/chin tuck • Angled bottle, cut out cup, straw

Aspiration during swallow • Usually caused by reduced or insufficient laryngeal elevation/closure and part of the bolus seeps under epiglottis into airway • Treatment techniques aimed at improving laryngeal elevation and changing viscosity of bolus to minimize seep • Strong forward head flexion or chin tuck – changes relative position of larynx so needs less elevation • Use cut out cup or straw to assist in maintaining neck flexion; use angled bottle • Thickening feedings – moves slower so more time to elevate

Aspiration after the swallow • Usually secondary to residue • Decreased pharyngeal peristalsis • Dysfunction of the CP muscle • Inadequate pressure gradients • Noisy, wet-sounding breathing that is worse following feeding • Modify food texture • Encourage “dry” swallows • Palatal trainer

Decision-making and aspiration • Degree of swallowing dysfunction • Amount of aspiration • Response to treatment • Underlying pulmonary status • Tracheostomy • Therapeutic feeds • Full PO with modifications

GER • Non-oral restriction decreases GER but may still have…. • Ascending aspiration • Need to increase/maintain oral skills • Provide therapeutic feeds

Oral-motor control • Hypotonia – poor stability and abnormal control • Need to ‘wake up’ or ‘alert’ CNS • Tapping • Vibration • Quick stretch • Masseter and buccinator muscles • Lips/tongue

Oral-motor control • Hypertonia – abnormal movement and may lead to abnormal alignment • Neurological insult or abnormality, stress • Preparatory movements • Handling • Body alignment • Firm pressure • Shaking/vibrating • Tongue retraction • Environmental management

tongue • Neck extension – functionally pulls tongue into retracted position • May be hypertonic or passively retracted • May be actively seeking point of stability (micrognathia) • Postural support – improve head/neck alignment • Handling – normalize tone, neck/shoulders • Modify tone in tongue • Finger in midline • Shaking, jiggling, tapping, stroking, vibrating • Longer nipple

tongue • Bunched, humped, retracted, hypotonic • Lacks central groove • Get tongue forward • Downward pressure to midline • Stroking forward with downward pressure • Firm straight nipple with cross-cut

Tongue • Tongue-tip elevation – pressed against hard palate, distal to alveolar ridge • Common in preemies – may be a means of stabilization • Postural support • Preparatory handling • Quick swiping or vibration • Downward pressure • Assist with mouth opening • Stimulation to lips • Downward pressure on jaw

tongue • Protrusion – sits on lower lip below nipple and interferes with lip seal • Hypotonia/weakness/increased tone • Neck extension • Postural support – neutral or slightly flexed • Preparatory handling to reduce tone • Sensory input – firm tapping • Firm, downward pressure to midline • Firm straight nipple • Facilitate lip activity

Poor mouth opening • Poor arousal • Neurologic insult • Prepare state • Elicit rooting reflex • Assist mouth opening – gentle downward pressure • Inhibit jaw clenching – vibration, very small-range, low amplitude side-to-side movement • Touch/pressure to gums

Weak suck • Ineffective feeding • Overall weakness, medical/nutritional compromise, immaturity, myopathies, respiratory/endurance • Provide oral stability – optimal positioning, firm cheek/jaw support, traction on nipple • Increasing flow rate (with caution)

Jaw movement • Excessive – no stable base for tongue, lip seal may be compromised • Develop stable base for jaw, slightly tucked chin position, develop neck flexor musculature • Preemies – often have jaw instability. Poor developed tone/bulk in oral-facial mm, minimal active neck flexion, neck hyperextension common • Neurologically-based hypertonicity – poorly balanced control between opening and closing mm. May lead to strong downward thrust of jaw • Neck hyperextension – could be immature development of neck flexion, abmormal mm tone or stress

Abnormal tongue movement • Attempts to use marked jaw depression to create negative pressure suction • Postural support – neck/head alignment key. Don’t allow neck hyperextension. Head in neutral or slight flexion will provide additional positional stability to jaw. • External support – firm pressure under jaw. Keep pressure distal and under mandible, proximally will be under base of tongue could interfere with sucking.

Abnormal tongue • Increased neck flexion – if doesn’t respond well to external support, bring head into strong neck flexion. Help grade jaw movement. Continually monitor respiratory status. • Handling techniques to reduce overall mm tone • May need to target tongue

Lip seal • Negative pressure reduced or broken intermittently • Smacking/kissing, excessive fluid loss • Low tone, weakness – preemies or conditions • Excessive jaw movements

Abnormal tongue movements • Strong protrusion – treat tongue • Treat underlying problems first– facial weakness/hypotonia, excessive jaw movement • External support – cheeks/lips and jaw support, too.

cheeks • Hypotonia/weakness, diminished fat pads • Poor stability leads to poor lip seal. Excessive jaw excursion may result • Increase facial tone • Cheek/jaw support

Poor initiation of sucking • Crying, fussing, ‘tuning out’ – baby hungry and will become increasingly frustrated • May root excessively and unable to inhibit – turns head wildly from side-to-side • Extreme mouth opening and unable to close • Tongue protrusion/lapping pattern may be attempt as sucking • Hypersensitive response or poorly developed sucking patttern • Poor state/organizational abilities – overly hungry

Poor initiation • Treat underlying problems – if poor state/organization treat those underlying conditions • Preparatory handling • Stabilize front of head with jaw control as needed • Place nipple firmly at midline, cheek support as needed –for central reference point • Assist with mouth closure – firm jaw control to assist with closure, grading of mouth open, vibration to relax tension and assist with closure • Facilitate appropriate tongue movement

Coordination of ssb • Prolonged sucking – feeding induced apnea • Having difficulty ‘pacing’ SS and B • Strong, rapid sucking with difficulty initiating breathing even when nipple removed • More common in preemies • External pacing • Be sure baby can initiate breathing • May have better regulation later in feeding • Decrease rate of flow – thicker liquid, slower flow – to allow time to organize

Coordination of ssb • Short sucking bursts • 1-3 sucks in a burst before pausing for multiple breaths • Pauses too frequent/long compared to sucking bursts • May be adaptive response • VFSS • Look at respiratory status • Endurance

Sphsc 543 march 5 & 12, 2010