Typical Feeding Development

Question 1

What is the role of the SLP?

Answer 1

• specialists in communication/swallowing
• swallowing: dysphagia and mealtime management
  Paediatric feeding/swallowing management:
• oral phase (sucking, biting, chewing)
• pharyngeal phase (swallowing)
• coordination of suck, swallow and breathe
• communication: pre-verbal, infant cues, non-verbal
• counselling: providing sensitive explanations to families
• advocacy: liasion with the medical team, timely referrals

Question 2

List the child, parent and staff focused services the SP provides

Answer 2

Child:
- assessment
- treatment
- consultation
Parent:
- training in reading and responding to infant cues
- training in feeding techniques
Staff:
- providing education
- providing input into multi-disciplinary team

Question 3

What factors contribute to being able to feed/eat?

Answer 3

• normal anatomy
• normal oral reflexes
• intact cranial nerves
• physiologic control
• state control
• secure attachment/communication
• postural control
• intact sensory system

Question 4

List features of the normal anatomy of the mouth/pharynx of newborns

Answer 4

• Soft palate - in approximation with epiglottis as a protective mechanism
• Tongue - appears to fill oral cavity, restricting movement to a forward-backward suckling motion
• Cheeks - sucking pads present which assist with stability for suckling (support tongue)
• Breathing - preferential nasal breathers because of approximation of soft palate and epiglottis
• Lower jaw - small and slightly retracted
• Hyoid - made of cartilage rather than bone
• Larynx - higher in the neck than in adults, which reduces the need for sophisticated closure to protect the airway during swallowing

Question 5

What are oral reflexes?

Answer 5

• Infants are born with reflexes that facilitate survival → diminish as more mature skills emerge
• Reflexes are brainstem-mediated
• Progression of early reflexes can give important information regarding neurological development

Question 6

What are the two types of oral reflexes?

Answer 6

• adaptive: facilitate getting food into the mouth and to the stomach
• protective: prevent foreign material from entering the airway

Question 7

List the adaptive reflexes, including their purposes

Answer 7

Rooting reflex

Touch to cheek or mouth results in head turn towards the source of the stimulus
Purpose is to:
Suckling
- Develops before sucking
- Involves forward-backward movement of tongue

Sucking
- Develops around 6 months
- Involves up-down movement of the tongue

Purpose:
- positive pressure pushes fluid out of nipple
- negative pressure draws fluid out of the nipple

Question 8

Discuss nutritive and non-nutritive sucking

Answer 8

• Important to be able to observe the difference between nutritive and non-nutritive sucking, especially for breastfeeding assessment
• Be aware that infants can use non-nutritive sucking at times to stimulate let-down reflex so you may see a combination of both types during a feed (but should be nutritive > non-nutritive)

Question 9

Discuss the purpose, rhythm, rate, suck: swallow ratio and jaw movement of nutritive sucking

Answer 9

Purpose: obtain nourishment
Rhythm: initial continuous suck-burst, moving to intermittent suck bursts with pauses becoming longer over the course of feeding
Rate: one suck/second
Suck: swallow ratio: young infant 1:1 - older infant 2:1 or 3:1
Jaw movement: deep and slow

Question 10

Discuss the purpose, rhythm, rate, suck: swallow ratio and jaw movement of non-nutritive sucking

Answer 10

Purpose: state regulation
Rhythm: repetitive pattern of bursts and pauses; stable number of sucks per burst and duration of pauses
Rate: two sucks/second
Suck: swallow ration: very high, 6:1 to 8:1
-Jaw movement: shallow and quick

Question 11

List the protective reflexes

Answer 11

• gag
• cough
• tongue protrusion
• transverse tongue (lateralisation)
• phasic bite

Question 12

Discuss the gag reflex in terms of its: stimulus, response, purpose and when it diminishes

Answer 12

Stimulus: touch to posterior 1/3 of tongue
Response: contraction of palate and pharynx
Purpose: expels foreign material from the pharynx
Diminishes: persists into adulthood but becomes less sensitive

Question 13

Discuss the cough reflex in terms of its: stimulus, response, purpose and when it diminishes

Answer 13

Stimulus: foreign material entering airway
Response: epiglottis and vocal folds close and open again rapidly as air is pushed out of the lungs
Purpose: expel foreign material from airway
Diminishes: persists into adulthood

Question 14

Discuss the tongue protrusion reflex in terms of its: stimulus, response, purpose and when it diminishes

Answer 14

Stimulus: touch anterior tongue
Response: tongue moves anteriorly and protrudes outside mouth
Purpose: pushes food out of the infants mouth when they are not mature enough to cope with it
Diminishes: 4-6 months

Question 15

Discuss the tongue lateralisationreflex in terms of its: stimulus, response, purpose and when it diminishes

Answer 15

Stimulus: touch to lateral surface of tongue
Response: tongue moves towards stimulus
Purpose: pushes food to side of mouth in primitive chewing attempt -> integrates into more refined movement for chewing
Diminishes: 6-9 months

Question 16

Discuss the phasic bite reflex in terms of its: stimulus, response, purpose and when it diminishes

Answer 16

Stimulus: pressure on gums
Responses: rhythmic opening and closing of jaw
Purpose: keeps material out of an infant’s mouth when they are not mature enough to manage it -> integrates into more sophisticated chewing
Diminishes: 9-12 months

Question 17

What is a laryngeal chemoreflex?

Answer 17

• Young babies are more likely to experience apnoea (cessation of breathing) than overtly coughing in response to aspiration

This occurs due to the laryngeal chemoreflex:
- Vocal folds close for a prolonged period in response to presence of foreign material
- Presumably to protect the lungs

• Emerges during the third trimester and resolves within the first few months of life

Question 18

Discuss the general role of the cranial nerves in the control of sucking, swallowing, and breathing - list the CNs involved also

Answer 18

• functions overlap, but very important to have an understanding of normal function with respect to feeding and swallowing
• Trigeminal
• Facial
• Glossopharyngeal
• Vagus
• Hypoglossal

Question 19

Discuss the role of the Trigeminal Nerve in swallowing, and list some assessment tasks and potential deficits

Answer 19

Controls the muscles of biting and chewing, and provides sensation to the face

Assessment tasks:
- jaw opening to resistance
- jaw lateralisation
- sensation to face

Potential deficits:
- poor mastication and bolus formation
- poor bolus awareness
- reduced hyolaryngeal elevation
- impaired supraglottic closure
- decreased opening of upper oesophageal sphincter

Question 20

Discuss the role of the Facial Nerve in swallowing, and list some assessment tasks and potential deficits

Answer 20

Controls the muscles of the face, submandibular and sublingual glands and provides sense of taste to anterior 2/3 of tongue

Assessment tasks:
- facial symmetry at rest and in movement (e.g. closing eyes, wrinkling brow, blowing a kiss)
- taste response

Potential deficits:
- paralysis of facial muscles
- poor lip strength
- impaired taste/salivation

Question 21

Discuss the role of the Glossopharyngeal Nerve in swallowing, and list some assessment tasks and potential deficits

Answer 21

Responsible for sensation to the tongue, pharynx and soft palate, and sense of taste to posterior 1/3 tongue

Assessment tasks:
- Not able to be assessed clinically
- Gag reflex (*high risk of false positive; not recommended in clinical assessment)

Potential deficits:
- Reduced pharyngeal motility → post swallow residue
- Reduced supraglottic compression
- Decreased base of tongue to posterior pharyngeal wall movement
- Weak cough reflex and diminished gag reflex

Question 22

Discuss the role of the Vagus Nerve in swallowing, and list some assessment tasks and potential deficits

Answer 22

Controls sensation of the larynx, base of tongue, pharynx, palate and their muscles

Assessment tasks:
- Vocal quality
- Volitional cough
- Swallow initiation
- Velopharyngeal closure (soft palate movement – velar elevation)

Potential deficits:
- Reduced velopharyngeal closure → hyper nasality & nasal regurgitation
- Diminished capacity for laryngeal adduction
- Decreased effectiveness of cough on aspiration
- Impaired opening of upper oesophageal sphincter

Question 23

Discuss the role of the Hypoglossal Nerve in swallowing, and list some assessment tasks and potential deficits

Answer 23

Controls muscles of the tongue

Assessment tasks:
- Lingual movement: superior, lateral, protrusion, retraction

Impact on feeding:
- Poor bolus manipulation, preparation and propulsion
- Decreased base of tongue to posterior pharyngeal wall approximation

Question 23

Why is physiological control important?

All include some signs a child is not coping

Answer 23

Basis for feeding management

If not physiologically stable:
- may not be ready for oral feeding
- may not have stamina for full volumes
- may be a safety risk

Signs a child might not be coping:
- frequent coughing/choking
- changes in vocal quality/breathing
- sweating
- breathing very quickly or holding breath
- increased breathing effort (e.g. nasal flaring, tracheal tug)
- watery eyes
- cyanosis

Question 24

What is respiratory distress?

Answer 24

Difficulty breathing - child not getting enough oxygen

Child’s body may attempt to compensate for lack of oxygen by:
- increasing respiratory rate
- nasal flaring
- recessions (tracheal tug, substernal or subcostal recessions)
- may hear signs of effort such as stridor or grunting
- precursor to respiratory failure

Question 25

What is state control?

Answer 25

= the level of alertness and environmental interaction patterns present in a child at a given point

State is modulated by stimulation:
- internal: hunger, pain, temperature
- external: noise, light, handling

Question 26

List the state levels, and a description of each

Answer 26

1. Deep/quiet sleep
   - infant is asleep and has a regular respiratory pattern
2. Light sleep
   - eyes are closed, although rapid eye movements may be seen beneath the eyelids. There is some low-level motor activity present
3. Drowsy/semi-dozing
   - eyes are open but heavy-lidded/fluttering. movements are generally smooth with mild startles
4. Quiet alert
   - infant is strongly focused on a stimulus. There is minimal movement
5. Active alert
   - there is considerable movement. The infant often responds to stimuli with more movement. Brief ‘fussy’ periods may be observed
6. Crying
   - the infant is crying intensely, and may be difficult to console

Question 27

Make a comment about role of attachment on feeding

Answer 27

Successful feeding is reciprocal process -> relies on caregiver’s ability to interpret cues, and child’s ability to provide consistent messages

Question 28

At ages 0-3 months, 2-6 months and 6-36 months, list infant development and parent behaviours typically seen

Answer 28

0-3 months:
(infant development) - homeostasis
(parent behaviours) - calm and organise the infant, respond to the infant’s cues

2-6 months:
(infant development) - attachment (achieving a positive state of affective engagement/purposeful movements for communication)
(parent behaviours) - reciprocate interactions, engage with the child, modulate arousal

6-36 months:
(infant development) - separation individuation
(parent behaviours) - provide the child with opportunities to explore, support drive for autonomy but welcome back when required, provide structure and set limits

Question 29

What are infant cues?

Answer 29

The ways that infants communicate their needs with caregivers
- infants are born with the ability to respond in a predictable and organised way (consistent response from the parent reinforces behaviour)
- may be in response to external or internal stimuli
- engagement vs. disengagement cues
- subtle vs. overt cues

Question 30

List some baby feeding cues

Answer 30

Early cues- ‘I’m hungry’:
- stirring
- mouth opening
- turning head
- seeking/rooting

Mid cues - ‘I’m really hungry’:
- stretching
- increasing physical movement
- hand to mouth

Late cues - ‘calm me, then feed me’:
- crying
- agitated body movements
- colour turning red

Question 31

List some engagement cues

Answer 31

• bright and alert
• mouthing fingers
• eye contact
• smiling
• smooth movements
• hands reaching out

Question 32

List some disengagement cues

Answer 32

• gaze aversion
• lip compression
• yawning
• hiccups
• eyes shut
• splayed fingers
• dull looking face/eyes
• back arching
• crying/fussing
• lateral head shake
• turning head away
• pulling/pushing away
• vomiting

Question 33

What is postural control?

Answer 33

• essential for effective and safe oral feeding
• Positioning of the feet, legs, and pelvis influences the trunk, which influences control of the head, and structures involved in feeding and swallowing
• Develops from proximal to distal parts of the body
• In an infant, the parent provides external postural support
• Child develops ability to control their own posture as they grow

The essential components of postural stability include:
- Neutral head position
- Pelvic stability, with child’s hips symmetrical in a neutral position
- Hips, knees and ankles at 90 degrees flexion

Question 34

Contrast flexion and extension in infant feeding

Answer 34

Positioning is often described in terms of flexion and extension:
- Flexion is used to describe movement towards the midline

• Extension is used to describe movement away from the midline
• In utero, infants are naturally in a position of flexion
• Slightly flexed (rather than extended) positioning will support oral feeding

The infant’s head and neck position should be carefully assessed:
- Excessive extension can impair airway protection
- Excessive flexion may place the infant at increased risk of airway collapse or apnoea

Question 35

For a hypo-responsive baby, compare the ‘active’ and ‘passive’ responses

Answer 35

Active:
- excessive dummy use
- put everything in their mouth
- seeking out strong flavours/crunchy foods

Passive:
- poor lip seal
- may be very messy
- may pocket foods

Question 36

For a hyper-responsive baby, compare the ‘active’ and ‘passive’ responses

Answer 36

Active:
- creaming/crying when approached with bottle or food
- gagging/vomiting
- extra fussy with teat type, textures, flavours, etc.
- running away from table

Passive:
- stopping feed early without apparent reason
- disengagement cues like limited eye contact
- shutting down during the meal/falling asleep during feeding

Question 37

What is oral aversion?

Answer 37

• Behavioural response to stimulus → learnt behaviour
• May persist beyond initial sensory integration problems
  e.g.,
• A child who cries and arches their back in response to the bottle being prepared, even though they are no longer experiencing pain with eating
• A child who becomes hysterical with the process of being strapped into their high chair

Question 38

How do we develop feeding?

Answer 38

Feeding is a developmental skill:
- begins as a reflexive action and gradually becomes a learned behaviour
- in neonates and young infants, all phases are involuntary
- as infants mature, the oral phase becomes volitional
- feeding skills develop along a continuum and alongside skills in other developmental domains

Question 39

Provide information about a 0-4 month old infants’ feeding behaviours

Answer 39

Liquids/foods - breastmilk or formula only
Oral motor skills: suckle
Developmental skills: head control required

Sucking, swallowing and breathing

• All complex tasks
• Infant must be able to coordinate all of these in order to feed effectively
• Problems in any one task may present a problem to the whole mechanism
• Sucking and swallowing reflexes emerge separately early in utero
• Coordination of these does not emerge until late in the third trimester (close to 36 weeks) with neurological maturation
• Poor coordination may be an indicator of neurological immaturity or neurological impairment
• A brief respiratory pause occurs during swallowing as the airway closes
• If flow rate increases, swallowing rate increases, and the number of respiratory pauses increases
• Flow rate that is too fast can worsen suck-swallow-breath coordination, and place the child at risk of harm

Question 40

Provide information about a 4-6 month olds’ feeding behaviours

Answer 40

Liquids/foods - predominately breastmilk/formula; beginner purees may be introduced
Oral motor skills - suckle matures into suck pattern; tongue protrusion reflex diminishes as child improves oral control for purees
Developmental skills - begin to develop balance for sitting; can bring hands to midline

NHMRC guidelines recommend commencing around 6 months; but not before 4 months

Signs of readiness for first foods:
- Good head control
- Mouths hands and toys independently
- Able to sit in an upright position with support either on the lap or in a suitable high chair
- Tongue thrust/protrusion reflex has diminished
- Opens mouth when food is offered
- Enjoys watching others eat
- “Signs of developmental readiness are a better indicator than age”

Question 41

Provide information about a 6-9 month olds’ feeding behaviours

Answer 41

Liquids/foods: predominately breastmilk/formula/ having mostly meals of smooth purees; introduction of soft finger foods; introduction of lumpy purees

Oral motor skills: may be introduced to cup - still suckles/sucks; tongue protrusion no longer observed; uses up-down biting (phasic) and chewing pattern; some integration of tongue lateralisation occurring; may gag at times with lumps and soft solids

Developmental skills: develop independent sitting; hand to mouth play is observed ++; child begins to assist with spoon and explore finger feeding ; pincer grasp begins to develop

Question 42

Discuss the development of tongue lateralisation from 0-24 months, including a description at each stage

Answer 42

<6 months:
- absent
- use of sucking or suckling pattern if solid food placed in centre of the mouth

6 months:
- emerging
- tongue moves up and down in a ‘munching’ pattern with no lateralisation when solid foods are placed in the centre of the mouth. Sucking may alternate with munching. May demonstrate some lateralisation if the food is placed between the biting surfaces of the gums.

9 months:
- emerging
- lateral movements occur with ease when the food is placed on the side of the mouth. Infant begins to transfer food from the centre of the tongue to the side.

12 months:
- developed
- can transfer food from either side of the mouth to both sides of the mouth

24 months:
- well-developed
- can transfer food from either side of the mouth to the other side without pausing in the centre

24+ months:
- well-developed
- can transfer rapidly and skilfully across the midline

Question 43

What are the types of biting? Include the direction and type of movement

Answer 43

Phasic bite:

• up-down
• rhythmic bite-release pattern of jaw opening and closing stimulated by touch to the teeth or gums

Unsustained bite:

• upward movement followed by rapid or irregular opening
• closing of teeth on food followed by a hesitation and a new attempt to bite through the food. Biting through the food in a smoothly graded fashion does not occur.

Graded bite:

• upward, controlled movement followed by easy opening for chewing
• the teeth close on the food and bite through it gradually. This is followed by easy release for chewing

Question 44

List the types of chewing skills

Answer 44

• munching with stereotypical vertical chew
• munching with non-stereotypical vertical chew
• diagonal rotary chew
• circular rotary chew

Question 45

What are ‘hard munchables’ and why are they used?

Answer 45

• Hard stick-shaped foods (roughly size of thick crayon) or teething toys
• Used to develop chewing skills only and should not be bitten
  through or swallowed.
• Close supervision required by adult

Question 46

What are the types of food developments?

Answer 46

1. smooth purees
2. lumpy puree
3. soft finger foods
4. chopped table foods

Question 47

What are the 9-12 month olds’ feeding behaviours?

Answer 47

Liquids/foods - still having some breastmilk/formulas; managing lumpy purees and a range of soft chewable finger foods

Oral motor skills - able to drink from a cup independently; still predominately up-down jaw movements but beginning to improve precision and speed; able to lateralise foods for chewing most of the time

Developmental skills - able to finger feed and pincer grasp becomes more refined; begins to grasp spoon with whole hand

Question 48

What are dissolvables?

Answer 48

• foods that ‘melt in the mouth’

Question 49

What are a 12-18 month olds’ feeding behaviours?

Answer 49

Liquids/foods - eating predominately solid foods ; managing a range of finger foods and chopped table foods, including easily chewed meats

Oral motor skills - uses a controlled, sustained bite on soft foods but may revert to sucking/phasic bite on harder foods; competent at tongue lateralisation; diagonal jaw movements emerge and become more refined

Developmental skills; increased independence for feeding

Question 50

What are an 18-24 month olds’ feeding behaviours?

Answer 50

Liquids/foods - fed unsupported at the family table; can have liquids and coarsely chopped table foods, including most meats and many raw vegetables

Oral-motor skills - may still bite edge of cup for stabilisation but cup drinking refined by 2 years; uses a controlled and sustained bite on hard foods but may have some associated food or body movements; uses appropriate jaw grading for solids; uses mostly diagonal jaw movements for chewing but begins to use more circular rotary movements by 2 years

Question 51

What are a 2-3 year olds’ feeding behaviours?

Answer 51

Liquids/foods - can eat most family foods with continued avoidance or modification of high choking risk foods

Oral-motor skills - adequate jaw grading and bite strength with dissociation of head and body movements

Developmental skills - can be involved in simple meal preparation; can self-feed independently

Question 52

What is most consistently found in children’s eating habits?

Answer 52

• Eight-month-olds are really not eating much in the way of solid food yet (<5% of total intake)
• Most babies are eating food with “tiny lumps” by around nine months of age
• Children master chewy foods by around two years of age, but are still working on lots of other textures, like combination textures, food with skin, and tough meat up to and beyond three years of age
• Wide range of “normal”
• Red flag not whether babies are “eating lumps” → frequency of consuming different textures and in what volume, acknowledging that shifts towards solids>liquids should be starting to happen by about 12 months of age

Question 53

What are high risk choking foods?

Answer 53

Choking risk is highest in the first 12 months of life and decreases steadily until 5 years of age

• Nuts and seeds e.g. peanuts, pumpkin seeds, cashews
  - Do not give whole or chopped
  nuts to children under the age of 5
  - Offer nut or seed butter thinly
  spread
• Raw carrot, apple, pear and celery
  
  • Offer cooked or finely grated
  • Remove skin from apple and pear
• Whole grapes, cherry tomatoes or strawberries
  - Halve or quarter (lengthways) or
  - finely chop
• Popcorn
  - Not recommended for children
  - under 3
• Sausages (including cheerios, saveloys and frankfurts) whole or in small circles
  - Remove skin and cut into quarters
  - or halves (lengthways)
• Fruits with stones, large seeds or pips e.g. peaches, cherries
  - Remove stones, large seeds or
  pips
• Marshmallows, chewing/bubble gum and round chocolates and lollies e.g.,
  Fantales
  - Not recommended for children
  under 5

Question 54

What is the Baby Led Weaning approach?

Answer 54

• Baby-Led Weaning is an alternative method of infant feeding which is becoming increasingly popular
• Baby-led weaning recommends no spoon feeding until the child can
  independently feed themselves with a spoon, and instead offers children finger foods to let them learn to self-feed

Signs of readiness for baby-lead weaning are:
* Sitting independently
* Grasping toys and bringing to mouth independently
* Interested in chewing fingers, toys etc.
* Interested in family foods

Question 55

What is a typical infant intake?

Answer 55

• Breastmilk or cow’s milk based infant formula until around 6 months age
• Introduction of iron-rich solids from around 6 months of age
  - Iron fortified rice cereal
  - Pureed red meats – lamb and beef
  - Cooked tofu
  - Cooked and pureed lentils and
  legumes
• Continue breast milk or infant formula until 12 months
• Can introduce any foods in any order after consistently consuming daily iron containing foods

Question 56

What are the NHMRC Infant feeding guidelines?

Answer 56

• initially start solids once per day after milk feed
• once taking a few tablespoons consistently once per day, increase to two meals per day
• ideally taking three solid meals by 8-9 months
• introduce morning and afternoon snacks around 10 months
• offer foods before fluids around 10 months
• Transition onto cows milk as a drink after 12 months provided eating range of foods from food groups (max intake of 600ml/d)

Question 57

What interrupts typical feeding development?

Answer 57

• Medical
• Developmental
• Environmental

Question 58

What medical factors interrupt feeding?

Answer 58

• Medical factors commonly contribute to the development of feeding difficulties
• Feeding difficulties in infants can reflect an underlying medical condition
• SP can be a helpful advocate
• Intervention usually not effective while a medical condition is contributing to feeding difficulties (unless the condition is stable)

Medical conditions may be either:
- Congenital, i.e., present at birth
- Acquired, i.e., occurring after birth

Medical conditions may also be:
- Acute
- Chronic static (stable)
- Chronic progressive (degenerative)
- Additionally, early experiences (e.g., illness, hospitalisation) may cause disruption to feeding development

Question 59

What is a systems based approach? List the relevant systems to know

Answer 59

• As an SLP, you are not expected to know about every medical condition and how it might impact on feeding → this is not feasible!
• Additionally, not every medical condition will affect feeding in exactly the same way, so assessment still needs to be individualised
• General knowledge about systems is helpful, to guide assessment, clinical reasoning and intervention planning

Systems:
- GI
- respiratory
- cardiovascular
- neurological
- orofacial
- metabolic

Question 60

Neurological system relationship with eating

Answer 60

Perhaps the most important system as impairment can have so many impacts across other systems

• Oral, pharyngeal and oesophageal phases of swallowing are complex sensory-motor sequences, comprising voluntary and involuntary components

Communication is required between:
- Cranial nerves
- Upper cervical nerves
- Swallowing centres (or central pattern generators) in the brainstem and cerebellum
- Modulation by the cerebral cortex

Question 61

Common neurological conditions

Answer 61

Congenital:
- Neurodevelopmental e.g., Down Syndrome
- Neurodegenerative e.g., Spinal Muscular Atrophy (SMA)
- Brain malformations e.g., Chiari malformation
- Seizure disorders (can also be acquired)

Acquired:
- Hypoxic-ischaemic encephalopathy (HIE) – results from oxygen deprivation impacting cerebral circulation (common in neonates)
- Intraventricular haemmorhage (IVH) – bleeding in or around the ventricles of the brain (common in preterm infants); higher grades more likely to lead to long-term brain injury or CP

Question 62

How does neurological damage impact on feeding?

Answer 62

• Oral, pharyngeal and oesophageal dysphagia may be present resulting from neurological damage
• Altered consciousness can negatively impact on a child’s ability to protect their airway
• Medication used to treat symptoms may cause fluctuating alertness or loss of muscle tone
• Lethargy can reduce endurance for the work of feeding or limit opportunities across the day to feed
• Irritability can be common and may result in challenges with cue reading and/ or feed refusal
• Physiological demands of a condition (e.g. high tone, seizures, trauma recovery) may result in increased energy expenditure
• Altered muscle tone may increase the frequency of reflux, which can result in loss of feeds/ feed refusal

Question 63

Motor disorders

Answer 63

• Many types of movement disorders
• Children have unwanted movements or trouble moving in the way they intend
• Can include impaired voluntary movements, dysfunction of posture, abnormal involuntary movements or presence of normal movements at unintended times (Singer et al.,2016)

Two major types:
- Hyperkinetic: abnormal, repetitive movements
- Hypokinetic: lack of movement

• Spasticity and weakness are other forms of motor dysfunction

Question 64

The impact of muscle tone

Answer 64

• Muscle tone is a feature of movement that may be affected by or an early sign of a neurological impairment
• Normal muscle tone allows us to remain stable at rest but move when required
• Mediated by the central nervous system (not a feature of the muscle itself)
• Muscle tone may be normal, high, low or mixed
• Wide range of normal

Question 65

Explain hypotonia (very low muscle tone)

Answer 65

• Children appear floppy or listless
• Open mouth posture is common
• May have poor oral-pharyngeal coordination
• Require ++ postural support
• Sometimes require more oral-sensory feedback (e.g., wide neck bottle, cold fluids)

Examples of conditions where hypotonia is common:
- Prader Willi syndrome
- Spinal Muscular Atrophy (SMA)
- Down Syndrome

Question 66

Explain hypertonia (very high muscle tone)

Answer 66

• Commonly push into extension (rather than flexion)
• Extension can occur with body as well as orally (e.g., lip retraction)
• Can be difficult to position for feeds
• Can fatigue very quickly
• May have increased energy requirements

Examples of conditions where hypertonia is common:
- Brain injury/ stroke
- Cerebral palsy

Question 67

Respiratory system relationship with eating

Answer 67

• Shared anatomy for breathing and eating mean that the structures need to work in synchrony
• Our body will make breathing its first priority → if an infant is unable to breathe well, they will not prioritise eating
• May be a congenital condition (e.g. bronchopulmonary dysplasia; congenital diaphragmatic hernia) or child may be acutely unwell (e.g. influenza; bronchiolitis)
• Some anatomic/ structural problems may have an impact on the respiratory system (e.g., choanal atresia; tracheoesophageal fistula)

Question 68

How does the impaired respiratory system impact feeding?

Answer 68

• Poor suck swallow breath coordination due to increased work of breathing
• Audible noise during feeding (e.g., stridor)
• Limited efficiency of feeds due to fatigue
• Colour changes with feeding
• Frequent respiratory illnesses/ aspiration pneumonia -
• Increased vomiting/ reflux (due to downward pressure of diaphragm on stomach caused by effortful breathing)

Question 69

Cardiovascular system relationship with eating

Answer 69

• Heart is a pump that circulates deoxygenated blood to the lungs, and oxygenated blood to the rest of the body
• Poor function of the respiratory system may impact the cardiovascular system and vice versa
• Most common birth defect (1:100)
• Not all cardiac anomalies are symptomatic
• Some require one or more surgeries
• May affect resting heart rate and oxygen saturations
• CHD conditions may occur in isolation or also comma

Question 70

How does the impaired cardiovascular system impact feeding?

Answer 70

Poor endurance for feeding:
- Affects ability to take full feeds
- May not wake for feeds
- May present with weak suck (due to fatigue rather than neurological issues)
- May become uncoordinated as feed continues

Poor appetite:
- Gastrointestinal system may be impacted
- Frequent reflux/ vomiting
- Can develop aversion

Growth challenges:
- May require more calories to grow adequately

Often have different acceptable saturations/ heart rate

Question 71

Gastrointestinal system relationship with eating

Answer 71

Well functioning GI system is important for a functional feeder – from the mouth to the trunk

Differences in any part of this can impact on intake

Some common conditions include:
- Gastroesophageal reflux
- Food intolerances (typically a digestive system response rather than allergies which is an immune system response)*
- Oesophageal atresia
- Malabsorption disorders
- Constipation

Question 72

How does an impaired GIT impact feeding?

Answer 72

• Unable to take sufficient volumes/ lose volumes due to vomiting/ need to replace calories
• May require tube feeding to support intake (often continuous)
• Feed refusal due to nausea or pain with feeding
• Delayed feeding skills due to lack of experience
• May require special formulas → often have an unpleasant taste

Question 73

Metabolic system relationship with eating

Answer 73

Metabolism = chemical reaction that changes food to energy
Involves two types of activities
- Anabolism → building up body tissues/ stores, growth of new cells
- Catabolism → breaking down body tissues/ stores to get more fuel (e.g., heating the body, allowing muscles to contract and move)

Common metabolic conditions include:
- Diabetes
- Galactosemia – affects how the body processes galactose
- Phenylketonuria (PKU)
- Some conditions are treatable (e.g., PKU) and children can lead a normal life; some conditions are degenerative

Question 74

How does an impaired metabolic system impact feeding?

Answer 74

• Need specialised formulas to prevent/ slow metabolic decompensation → often unpleasant taste
• Often have growth failure prior to diagnosis; may have ongoing growth issues
• Breastfeeding may not be possible in some infants (e.g., galactosemia)
• Some conditions result in neurodevelopmental delays
• May require tube feeding
• Some medications may cause GI discomfort
• May not tolerate thickener
• May not be able to tolerate fasting (or periods of food refusal)

Question 75

Orofacial system relationship with eating

Answer 75

Referring to structural abnormalities of the face and upper airway

Examples of congenital anomalies include:
- Cleft lip/ palate*
- Craniofacial anomalies
- Tracheoesophageal fistula
- Choanal atresia

Examples of acquired anomalies:
- Vocal cord palsy
- Subglottic stenosis
- Tumours

Cleft palate - child unable to generate negative intraoral pressure

TOF - food and liquid may enter airway through hole

Choanal atresia - infant unable to feed for long periods due to nasal blockage

Question 76

Explain tongue tie

Answer 76

Restricted movement of the tongue causing functional limitations, accompanied by a visually restricted lingual frenum

Controversial area – lots of variability in definition agreement

“Increasing” prevalence
~4-11% in newborns (Hogan, 2005)
420% treatment increase in Australia between 2006 and 2016 (Kapoor et al., 2018)

Lingual frenulum itself is a complex structure that changes with movement. Proposed that it is made up of:
- Oral mucosa
- Underlying floor of mouth fascia
- Genioglossus muscle is drawn up into the midline fold with elevation/ retraction in some individuals
- Branches of lingual nerve are located superficially on the underside of the tongue

Tongue tie (ankyloglossia):
- Diagnosis should not be made on appearance alone (consider structure and function)
- Non-surgical management can be an effective first line treatment
- Surgical management should be considered after non-surgical management has failed
- Multidisciplinary assessment and management is vital

Posterior tongue tie:
- The term ‘posterior tongue tie’ was first introduced in 2004 through an opinion piece
- The existence of posterior tongue tie remains controversial
- Posterior tongue ties are argued to be submucosal and are therefore much more difficult to see
- It is argued that “anterior tongue ties” always have a posterior component behind them, and failure to release the posterior collagen fibers results in ongoing dysfunction
- Improvements in tongue mobility and breastfeeding have been found after release
- The ADA Consensus Statement (2020) states there is a lack of evidence to support the diagnosis of ‘posterior tongue tie’ and that use of this term can result in a normal lingual frenulum being classified as abnormal. They recommend that the term ‘posterior tongue tie’ should not be used as a medical diagnosis.

Always consider the impact of restriction on function, and work closely with your MDT

Question 77

What is the impact of a tongue tie on feeding?

Answer 77

In infants:
- Tongue tie has been argued to interfere with a baby’s ability to suckle efficiently at the breast
- This may lead to nipple pain and trauma, poor breastmilk intake and a decrease in milk supply over time
- Where there are no feeding problems, a visible frenulum may be considered a normal variant and this procedure may not be required

Question 78

What developmental and psychosocial factors contribute to feeding development

Answer 78

Developmental factors:
- Oral motor delay/ disorder: may arise due to developmental delay or lack of experience
- Sensory processing disorder

Psychosocial factors:
- Breakdown in communication between the parent and child
- Parent provides, child decides
- May be a result of:
- Environmental issues: not
providing the right types of foods;
not providing boundaries around
behaviour; abuse/ neglect
- Problematic attachment
- Parent mental illness