Guest: Pediatric feeding swallowing disorders

Question 1

prenatal development

Answer 1

• Taste buds 6-7wk
• Swallowing 11-14wk
• Non-nutritive (NNS) sucking 18-24wk
• Nutritive sucking (NS) 33-36wk
• Functional taste sensation 14-18wk
• Functional olfaction ~24wk
• Coordinated sucking and breathing 38-40wk

Question 2

postnatal development

Answer 2

Swallowing
* dependent on digestive, respiratory and sensory functions
* Not only anatomical overlap
* Reflexes involved in swallowing are used in both digestive and respiratory functions: Chemoreceptors, Mechanoreceptors, Thermoreceptors, Nocioreceptors

Sucking
* a brainstem reflex that persists for first 1-3 months and then matures
* NS starts with bursts of sucking then bursts of breathing
* Matures to bursts of 20-30 sucks-swallows with breaths (1:1:1; 2:1:1)
* Matures with increased volume per suck
* Not just dependent on gestational age

Question 3

What are some clues to feeding ability?

Answer 3

• alertness (should not be falling asleep)
• breathing (should be consistent chest rise)

Question 4

Infany feeding skills

Answer 4

• suction (oral)
• expression (oral): Jaw, lips, tongue (elevates to cause vacuum seal)
• Movement of fluid bolus: Tongue
• Pharyngeal: Pharynx constricts, palate elevates, epiglottis closes, vocal cords close UES relaxes then contracts
• Esophageal

Question 5

Clues to diagnosis in infant feeding skills

Answer 5

• Oral phase poor suck, pocketing, spillage and drooling; sensory responses like gag and vomiting on early presentation
• Pharyngeal phase cough, gag, nasopharyngeal regurgitation, aspiration… & speech delay
• Esophageal phase as above (discordant upper esophageal relaxation) and regurgitation/vomiting

Question 6

risk factors for feeding skills

Answer 6

Functional
* Prematurity
* Neurological or neuromuscular disease
* Cardio-respiratory disease

Structural
* Oro-facial-laryngeal
* Tracheoesophageal fistula (TEF)

Environmental
* negative/depriving experiences (especially oral)
* lack of love

Question 7

Advantages and challenges of breastfeeding

Answer 7

Advantages
* NNS / oral stimulation - 27 weeks GA
* learning NS - 33-33 weeks (often start 29 weeks)
* Requires less sucks per burst (bottle fed babies have to continuously suck as continuous flow of milk)
* Helps feeding maturation & cognitive development

Challenges
* Flow of milk depends on skill; esp suction pressure
* Feeding studies in preterm focus on bottle feeding

Question 8

Feeding as a learned behaviour

Answer 8

first 6 months are critical time for learning
* Dependent on maturation and stimulation
* Animal science ‘imprinting’ (eg. maternal deprivation during suckling period in many speicies can cause feeding difficulties)
* Delayed introduction of solids can lead to food refusal, vomiting, failure to chew
* Esophageal atresia without sham feeds may never establish oral feeding

Question 9

What is PFD?

Answer 9

Pediatric feeding disorder
* Defined as impaired oral intake lasting at least 2 weeks that is not age appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction (in the absence of body image disturbances)
* Acute: 2 weeks to 3 months
* Chronic: 3 months or more

Question 10

What is PFD associated with?

Answer 10

• medical dysfunction
• nutritional dysfunction
• feeding skill dysfunction
• psychosocial dysfunction

Question 11

What is ARFID?

Answer 11

Avoidant Restrictive Food Intake Disorder - feeding disturbance
* psychiatric diagnosis in DSM 5
* associated with weight loss/ malnutrition and often dependance on tube feeding and oral nutritional support

Question 12

What is most common cause of PFD?

Answer 12

neurological disorders
* others could be: autism, cardiorespiratory disorders, structural disorders (GI tract, ENT)

Question 13

Aspiration

Answer 13

most feared end outcome typically associated with dysphagia where there is passage of material below vocal cords or penetration passage of material into larynx but above vocal cards
* thick solids is particularly bad if cannot clear
* cystic fibrosis and cerebral palsy are heightened risk
* 25% is silent; need instrumental diagnosis (VFSS, FEES)

Question 14

Normalcy of aspiration

Answer 14

not all aspiration is bad depends (pharyngeal clearance is key):
* general health, mobility, oral & pulmonary health
* frequency, material & depth/clearance

Question 15

Symptoms of dysphagia and aspiration

Answer 15

• Fussy with feeds
• Noisy breathing after feeds
• Turning head away or refusing feeds
• Vomiting
• Arching during feeds
• Coughing, choking, gagging during and after feeds
• Does better with thickened feeds

Question 16

What can dysphagia be misdiagnosed with?

Answer 16

GERD

Question 17

Most common causes of aspiration

Answer 17

• CNS disorder or lesion (aspiration is often seen as end stage for cerebral palsy)
• Vocal cord palsy
• Laryngeal cleft
• Neonatal Swallowing Dysfunction (usually improves over 6 months)

Question 18

Clinical assessment of PFD

Answer 18

• History
• Examination
• Feeding assessment

Question 19

Clinical assessment of PFD
* history

Answer 19

• Prenatal and birth history
• Respiratory
• GI
• Growth & Development
• Feeding history (history of refusal; solids worse than liquids consider structural issue)
• Family history & circumstances around feeding (time involved, who feeds and where, stress)

Question 20

Clinical assessment of PFD
* examination

Answer 20

• Orofacial (chromosomal problems)
• Dentition
• Voice
• Respiratory
• Neurodevelopmental (difficult to assess in first 6 months)
• Nutrition
• Sensitivity to touch (or smell or texture)

Question 21

Clinical assessment of PFD
* feeding assessment

Answer 21

Before - during - after feed
* RR/HR/Sats
* Arousal state
* Motor tone and oromotor function
* Caregiver interactions

Question 22

Instrumental assessment of PFD

Answer 22

VFSS → Assess laryngeal and pharyngeal phase
* Limited assessment of oral phase (clinical exam)
* Limited assessment upper esophageal transit
* Delineates ‘risk’ of aspiration & timing relative to swallow (before-oral, during-phar or after-phar clearance)
* ‘safe’ textures can be determined
* Does not rule out aspiration
* Is not a real meal but artificial situation
* Is not a pass/fail exam
* Detailed but limited in time and real meal
* Normative data for infants insufficient
* Dynamic study but radiation dose limiting
* Challenging behavior limiting (32%)

Question 23

Contraindication to VFSS

Answer 23

Feeding aversions

Question 24

VFSS indications

Answer 24

• Risk for aspiration on history or clinical exam
• Prior aspiration pneumonia (but only 10-20% of those that aspirate & difficult to diagnose)
• Pharyngeal/Laryngeal problem
• Gurgly voice quality/stertor
• In order to manage swallowing problems

Question 25

How to manage pediatric swallowing disorders

Answer 25

• GI role (medical domain)
• Feeding tubes

Question 26

Manageing swallowing disorders through GI

Answer 26

• Identify the multidisciplinary team members (OT/speech, Psychology/Psychiatry, Dentistry)
• Assess nutrition - dietitian
• Assess need for endoscopy
• Assess need for a G tube (Safety, Nutrition)

Question 27

Treatment for aspiration (and GERD)

Answer 27

Thickeners best option

Question 28

Role of feeding tubes

Answer 28

• Impossible, unsafe or inadequate CHRONIC oral intake for nutrition and growth e.g. neurological disorders, craniofacial abnormalities, recurrent aspiration, etc. (Including to improve quality of life in PFD)
• To prevent wasting/malnutrition in high-risk scenarios e.g. CRF, CF, metabolic problems, CHD, SBS, IBD, etc.
• Support unpalatable diet or adherence to critical medications
• Rarely for gastric drainage and decompression

Can greatly improve QoL especially for parents who struggle to feed

Question 29

Use of nasogastric tubes

Answer 29

Short term enteral nutrition support hospital and at home
* May have lower rates of emergency visits compared to G tubes at home (NICU grads)
* Trial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth

Question 30

Risks of Ng tubes

Answer 30

• Safety concerns over nasal tube placement: Trachea and lungs, Brain, Esophagus
• Sleep disturbance for care giver
• Tube dislodgement (child pulls tube out or vomits up)
• Tube entanglement
• Tube blockages/kinking
• ncreased GERD
• Sinusitis
• Interference with normal swallow
• Oral aversion