Feeding skills of premature infants will be consistent with neurodevelopmental level rather than chronological age or adjusted age. In these articles, we hear from both sides on the controversial use of neuromuscular electrical stimulation (e-stim) in dysphagia treatment. This might involve decisions about whether the individual can safely eat an oral diet that meets nutritional needs, whether that diet needs to be modified in any way, and whether the individual needs compensatory strategies to eat the diet. McCain, G. C. (1997). Journal of Early Intervention, 40(4), 335346. Modifications to positioning are made as needed and are documented as part of the assessment findings. Responsive feedingLike cue-based feeding, responsive feeding focuses on the caregiver-and-child dynamic. Group I received neuromuscular electric stimulation sessions on the neck one hour daily for 12 weeks. Anxiety may be reduced by using distractions (e.g., videos), allowing the child to sit on the parents or the caregivers lap (for FEES procedures), and decreasing the number of observers in the room. See ASHAs Scope of Practice in Speech-Language Pathology (ASHA, 2016b). Protocols for determining readiness for oral feeding and specific criteria for initiating feeding vary across facilities. 0000037200 00000 n If certain practices are contraindicated, the clinician can work with the family to determine alternatives that allow the child to safely participate as fully as possible. an assessment of oral structures and function during intake; an assessment to determine the developmental level of feeding skills; an assessment of issues related to fatigue and access to nutrition and hydration during school; a determination of duration of mealtime experiences, including the ability to eat within the schools mealtime schedule; an assessment of response to intake, including the ability to manipulate and propel the bolus, coughing, choking, or pocketing foods; an assessment of adaptive equipment for eating and positioning by an OT and a PT; and. The aim of this study was to investigate the immediate effects of TTS on the timing of swallow in a cohort of people . Transition times to oral feeding in premature infants with and without apnea. Diet modifications should consider the nutritional needs of the child to avoid undernutrition and malnutrition. These studies are a team effort and may include the radiologist, radiology technician, and SLP. Infants cannot verbally describe their symptoms, and children with reduced communication skills may not be able to adequately do so. ; American Psychiatric Association, 2016), ARFID is an eating or a feeding disturbance (e.g., apparent lack of interest in eating or in food, avoidance based on the sensory characteristics of food, concern about aversive consequences of eating), as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: SLPs may screen or make referrals for ARFID but do not diagnose this disorder. Dosage depends on individual factors, including the childs medical status, nutritional needs, and readiness for oral intake. The Journal of Pediatrics, 161(2), 354356. Pacingmoderating the rate of intake by controlling or titrating the rate of presentation of food or liquid and the time between bites or swallows. Late onset necrotizing enterocolitis in infants following use of a xanthan gum-containing thickening agent. The infants ability to maintain a stable physiological state (e.g., oxygen saturation, heart rate, respiratory rate) during NNS. Can the child receive adequate nutrition and hydration by mouth alone, given length of time to eat, efficiency, and fatigue factors? (1998). We recorded neuromagnetic responses to tactile stimulation of . Information from the referral, parent interview/case history, and clinical evaluation of the student is used to develop IEP goals and objectives for improved feeding and swallowing, if appropriate. According to IDEA, students with disabilities may receive school health and nursing as related services to address safe mealtimes regardless of their special education classification. School districts that participate in the U.S. Department of Agriculture Food and Nutrition Service Program in the schools, known as the National School Lunch Program, must follow regulations [see 7 C.F.R. https://www.asha.org/policy/, Arvedson, J. C. (2008). https://www.cdc.gov/nchs/products/databriefs/db205.htm, Brackett, K., Arvedson, J. C., & Manno, C. J. Chewing cycles in 2- to 8-year-old normal children: A developmental profile. 0000075777 00000 n appropriate positioning of the student for a safe swallow; specialized equipment indicated for positioning, as needed; environmental modifications to minimize distractions; adapted utensils for mealtimes (e.g., low flow cup, curved spoon/fork); recommended diet consistency, including food and liquid preparation/modification; sensory modifications, including temperature, taste, or texture; food presentation techniques, including wait time and amount; the level of assistance required for eating and drinking; and/or, Maureen A. Lefton-Greif, MA, PhD, CCC-SLP, Panayiota A. Senekkis-Florent, PhD, CCC-SLP. Neuropsychiatric Disease and Treatment, 12, 213218. As the child matures, the intraoral space increases as the mandible grows down and forward, and the oral cavity elongates in the vertical dimension. It is used as a treatment option to encourage eventual oral intake. Consult with families regarding safety of medical treatments, such as swallowing medication in liquid or pill form, which may be contraindicated by the disorder. (1998). They were divided into two equal groups according to the rehabilitation programs they received. Instrumental evaluation is completed in a medical setting. Strategies that slow the feeding rate may allow for more time between swallows to clear the bolus and may support more timely breaths. In all cases, the SLP must have an accurate understanding of the physiologic mechanism behind the feeding problems seen in this population. 0000089331 00000 n Infants under 6 months of age typically require head, neck, and trunk support. ASHA is strongly committed to evidence-based practice and urges members to consider the best available evidence before utilizing any product or technique. The TSTP (tactile, taste and temperature stimuli) or the CSTP (NMES and tactile, taste and temperature stimuli) was administered by one speech language pathologist with > 20 years' training in dysphagia management. For infants, pacing can be accomplished by limiting the number of consecutive sucks. Accommodating children with disabilities in the school meal programs: Guidance for school food service professionals. Cue-based feedingrelies on cues from the infant, such as lack of active sucking, passivity, pushing the nipple away, or a weak suck. 0000023632 00000 n The effects of TTS on swallowing have not yet been investigated in IPD. The evaluation process begins with a referral to a team of professionals within the school district who are trained in the identification and treatment of feeding and swallowing disorders. Early introduction of oral feeding in preterm infants. Congenital abnormalities and/or chronic conditions can affect feeding and swallowing function. Careful pulmonary monitoring during a modified barium swallow is essential to help determine the childs endurance over a typical mealtime. Please see Clinical Evaluation: Schools section below for further details. 0000009195 00000 n How can the childs functional abilities be maximized? Oralmotor treatments are intended to influence the physiologic underpinnings of the oropharyngeal mechanism to improve its functions. Code of ethics [Ethics]. https://doi.org/10.1016/j.jadohealth.2013.11.013, Francis, D. O., Krishnaswami, S., & McPheeters, M. (2015). Developmental Medicine & Child Neurology, 50(8), 625630. Cultural, religious, and individual beliefs about food and eating practices may affect an individuals comfort level or willingness to participate in the assessment. The school-based feeding and swallowing team consists of parents and professionals within the school as well as professionals outside the school (e.g., physicians, dietitians, and psychologists). The pharyngeal muscles are stimulated through neural pathways. Concurrent medical issues may affect this timeline. https://www.cdc.gov/nchs/data/nhds/8newsborns/2010new8_numbersick.pdf [PDF], National Eating Disorders Association. Consider the childs pulmonary status, nutritional status, overall medical condition, mobility, swallowing abilities, and cognition, in addition to the childs swallowing function and how these factors affect feeding efficiency and safety. NS skills are assessed during breastfeeding and bottle-feeding if both modes are going to be used. Appropriate referrals to medical professionals should be made when anatomical or physiological abnormalities are found during the clinical evaluation. Please see the Treatment section of ASHAs Practice Portal page on Adult Dysphagia for further information. https://doi.org/10.1002/ppul.20488, Lefton-Greif, M. A., McGrattan, K. E., Carson, K. A., Pinto, J. M., Wright, J. M., & Martin-Harris, B. breathing difficulties when feeding, which might be signaled by. Family and cultural issues in a school swallowing and feeding program. Other signs to monitor include color changes, nasal flaring, and suck/swallow/breathe patterns. Pediatric Videofluroscopic Swallow Studies: A Professional Manual With Caregiver Guidelines. (Justus-Liebig University, protocol number 149/16 . For more information, see also Accommodating Children With Disabilities in the School Meal Programs: Guidance for School Food Service Professionals [PDF] (U.S. Department of Agriculture, 2017). Arvedson, J. C., & Brodsky, L. (2002). Silent aspiration is estimated at 41% of children with laryngeal cleft, 41%49% of children with laryngomalacia, and 54% of children with unilateral vocal fold paralysis (Jaffal et al., 2020; Velayutham et al., 2018). The process of identifying the feeding and swallowing needs of students includes a review of the referral, interviews with the family/caregiver and teacher, and an observation of students during snack time or mealtime. When treatment incorporates accommodations, modifications, and supports in everyday settings, SLPs often provide training and education in how to use strategies to facilitate safe swallowing. Neonatal Network, 16(5), 4347. https://doi.org/10.1111/dmcn.14316, Thacker, A., Abdelnoor, A., Anderson, C., White, S., & Hollins, S. (2008). TTS should be combined with other swallowing exercises or alternated between such exercises. Oropharyngeal dysphagia in preschool children with cerebral palsy: Oral phase impairments. Additional components of the evaluation include. 0000063512 00000 n Swallowing is a complex process during which saliva, liquids, and foods are transported from the mouth into the stomach while keeping the airway protected. The ASHA Leader, 18(2), 4247. 0000016965 00000 n Speech-language pathologists (SLPs) should be aware of these precautions and consult, as appropriate, with their facility to develop guidelines for using thickened liquids with infants. Children are positioned as they are typically fed at home and in a manner that avoids spontaneous or reflex movements that could interfere with the safety of the examination. 0000075738 00000 n https://doi.org/10.1097/NMC.0000000000000252, Meal Requirements for Lunches and Requirements for Afterschool Snacks, 7 C.F.R. See the Pediatric Feeding and Swallowing Evidence Map for summaries of the available research on this topic. has had a recent choking incident and has required emergency care, is suspected of having aspirated food or liquid into the lungs, and/or. Instrumental assessments can help provide specific information about anatomy and physiology otherwise not accessible by noninstrumental evaluation. For procedures that involve presentation of a solid and/or liquid bolus, the clinician instructs the family to schedule meals and snacks so that the child will be hungry and more likely to accept foods as needed for the study. The prevalence of pediatric voice and swallowing problems in the United States. It is important to consult with the physician to determine when to begin oral feeding for children who have been NPO for an extended time frame. 205]. https://doi.org/10.1016/j.pedneo.2017.04.003, Speyer, R., Cordier, R., Kim, J.-H., Cocks, N., Michou, E., & Wilkes-Gillan, S. (2019). The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. Dosage refers to the frequency, intensity, and duration of service. Please visit ASHAs Pediatric Feeding and Swallowing Evidence Map for further information. A population of cold-responding fibers with response properties similar to those innervating primate skin were determined to be mediating the thermal evoked response to skin cooling in man. 0000018888 00000 n 0000061360 00000 n Silent aspiration: Who is at risk? Nutricin Hospitalaria, 29(Suppl. Members of the Working Group on Dysphagia in Schools included Emily M. Homer (chair), Sheryl C. Amaral, Joan C. Arvedson, Randy M. Kurjan, Cynthia R. O'Donoghue, Justine Joan Sheppard, and Janet E. Brown (ASHA liaison). support safe and adequate nutrition and hydration; determine the optimum feeding methods and techniques to maximize swallowing safety and feeding efficiency; collaborate with family to incorporate dietary preferences; attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eating meals with peers in the preschool, mealtime with the family); minimize the risk of pulmonary complications; prevent future feeding issues with positive feeding-related experiences to the extent possible, given the childs medical situation. Additional Resources Prevalence of feeding problems in young children with and without autism spectrum disorder: A chart review study. TTS is used in patients with neurogenic dysphagia particularly associated with sensory deficits. The odds of having a feeding problem increase by 25 times in children with autism spectrum disorder compared with children who do not have autism spectrum disorder (Seiverling et al., 2018; Sharp et al., 2013). Behavioral interventions include such techniques as antecedent manipulation, shaping, prompting, modeling, stimulus fading, and differential reinforcement of alternate behavior, as well as implementation of basic mealtime principles (e.g., scheduled mealtimes in a neutral atmosphere with no food rewards). The infants ability to use both compression (positive pressure of the jaw and tongue on the pacifier) and suction (negative pressure created with tongue cupping and jaw movement). Pediatrics, 108(6), e106. SLPs develop and typically lead the school-based feeding and swallowing team. (2016b). (Note: Lip closure is not required for infant feeding because the tongue typically seals the anterior opening of the oral cavity.). Members of the team include, but are not limited to, the following: If the school team determines that a medical assessment, such as a videofluoroscopic swallowing study (VFSS), flexible endoscopic evaluation of swallowing (FEES), sometimes also called fiber-optic endoscopic evaluation of swallowing, or other medical assessment, is required during the students program, the team works with the family to seek medical consultation or referral. thermal stimulation and swallow maneuvers for treatment of the patients with dysphagia. The space between the tongue and the palate increases, and the larynx and the hyoid bone lower, elongating and enlarging the pharynx (Logemann, 1998). An estimated 116,000 newborn infants are discharged from short-stay hospitals with a diagnosis of feeding problems, according to the. https://www.ada.gov/regs2016/504_nprm.html, Reid, J., Kilpatrick, N., & Reilly, S. (2006). Cases of ARFID are reported to have a greater likelihood in males and children with gastrointestinal symptoms, a history of vomiting/choking, and a comorbid medical condition (Fisher et al., 2014). See, for example, Manikam and Perman (2000). Nursing for Womens Health, 24(3), 202209. Yet, thermal feedback is important for material discrimination and has been used to convey . identify any parental or student concerns or stress regarding mealtimes. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed. Little is known about the possible mechanisms by which this interventional therapy may work. Key criteria to determine readiness for oral feeding include. This requires a working knowledge of breastfeeding strategies to facilitate safe and efficient swallowing and optimal nutrition. Geyer, L. A., McGowan, J. S. (1995). SLPs do not diagnose or treat eating disorders such as bulimia, anorexia, and avoidant/restrictive food intake disorder; in the cases where these disorders are suspected, the SLP should refer to the appropriate behavioral health professional. Prevalence refers to the number of children who are living with feeding and swallowing problems in a given time period. The long-term consequences of feeding and swallowing disorders can include. https://doi.org/10.1177/1053815118789396, Shaker, C. S. (2013a). https://doi.org/10.1007/s10803-013-1771-5, Simpson, C., Schanler, R. J., & Lau, C. (2002). Responsive feeders attempt to understand and read a childs cues for both hunger and satiety and respect those communication signals in infants, toddlers, and older children. 0000090013 00000 n National Health Interview Survey. Periodic assessment and monitoring of significant changes are necessary to ensure ongoing swallow safety and adequate nutrition throughout adulthood. International Classification of Functioning, Disability and Health. https://www.asha.org/policy/, American Speech-Language-Hearing Association. Celia Hooper, vice president for professional practices in speech-language pathology (20032005), served as monitoring vice president. clear food from the spoon with their top lip, move food from the spoon to the back of their mouth, and. Students who do not qualify for IDEA services and have swallowing and feeding disorders may receive services through the Rehabilitation Act of 1973, Section 504, under the provision that it substantially limits one or more of lifes major activities. Thermal tactile stimulation also, known as thermal application is one type of therapy used for the treatment of swallowing disorders. They also discuss the evaluation process and gather information about the childs medical and health history as well as their eating habits and typical diet at home. https://doi.org/10.1016/j.pmr.2008.05.007, Lefton-Greif, M. A., Carroll, J. L., & Loughlin, G. M. (2006). has a complex medical condition and experiences a significant change in status. 0000089512 00000 n Swallowing function and medical diagnoses in infants suspected of dysphagia. behavioral factors, including, but not limited to. Feeding protocols include those that consider infant cues (i.e., responsive feeding) and those that are based on a schedule (i.e., scheduled feeding). overall physical, social, behavioral, and communicative development, structures of the face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa, functional use of muscles and structures used in swallowing, including, headneck control, posture, oral and pharyngeal reflexes, and involuntary movements and responses in the context of the childs developmental level, observation of the child eating or being fed by a family member, caregiver, or classroom staff member using foods from the home and oral abilities (e.g., lip closure) related to, utensils that the child may reject or find challenging, functional swallowing ability, including, but not limited to, typical developmental skills and task components, such as, manipulation and transfer of the bolus, and, the ability to eat within the time allotted at school. 0000055191 00000 n Pediatrics, 110(3), 517522. A non-instrumental assessment of NNS includes an evaluation of the following: The clinician can determine the appropriateness of NS following an NNS assessment. Thermal tactile oral stimulation (TTOS) is an established method to treat patients with neurogenic dysphagia especially if caused by sensory deficits. The roles of the SLP in the instrumental evaluation of swallowing and feeding disorders include. Diet modifications consist of altering the viscosity, texture, temperature, portion size, or taste of a food or liquid to facilitate safety and ease of swallowing. Pediatric dysphagia. The SLP also teaches parents and other caregivers to provide positive oral experiences and to recognize and interpret the infants cues during NNS. consideration of the infants ability to obtain sufficient nutrition/hydration across settings (e.g., hospital, home, day care setting). Students with recurrent pneumonia may miss numerous school days, which has a direct impact on their ability to access the educational curriculum. Therapeutic learning is the motor learning process in which target behavior is achieved by utilizing activity-dependent elements and the assistive system. Prevalence rates of oral dysphagia in children with craniofacial disorders are estimated to be 33%83% (Caron et al., 2015; de Vries et al., 2014; Reid et al., 2006). Recommended practices follow a collaborative process that involves an interdisciplinary team, including the child, family, caregivers, and other related professionals. Sometimes a light transient headache and a feeling of fatigue is reported, although it is not clear whether these are caused by the stimulation or participation in the experiment . (Figure 4) Thermal stimulationuse a damp towel that has been cooled in a refrigerator for at least five minutes. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed. The clinical evaluation typically begins with a case history based on a comprehensive review of medical/clinical records and interviews with the family and health care professionals. Therefore, management of dysphagia may require input of multiple specialists serving on an interprofessional team. infants current state, including the respiratory rate and heart rate; infants behavior (willingness to accept nipple); caregivers behavior while feeding the infant; nipple type and form of nutrition (breast milk or formula); length of time the infant takes for one feeding; and, infants response to attempted interventions, such as, a different bottle to control air intake, and. Dysphagia, 33(1), 7682. Postural changes differ between infants and older children. Maneuvers are strategies used to change the timing or strength of movements of swallowing (Logemann, 2000). 0000017901 00000 n 0000018447 00000 n an assessment of behaviors that relate to the childs response to food. 128 48 J Rehabil Med 2009; 41: 174-178 Correspondence address: Kil-Byung Lim, Department of Reha- It is believed They may include the following: Underlying etiologies associated with pediatric feeding and swallowing disorders include. The participants in the experimental group underwent five consecutive sessions of tactile-thermal stimulation for 30 minutes each time. (Practice Portal). (2012). NNS involves allowing an infant to suck without taking milk, either at the breast (after milk has been expressed) or with the use of a pacifier. https://doi.org/10.1044/0161-1461.3101.50, Mandich, M. B., Ritchie, S. K., & Mullett, M. (1996). determine whether the child will need tube feeding for a short or an extended period of time. 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