Overview of Presentation

SLP role in feeding/swallowing disorders

Pediatric Feeding and ●
● Evaluation
Swallowing ●
●
Treatment
Case studies
● Group activity
Michelle Anzures, M.S. CCC-SLP
September 14, 2018

Role of a Speech-Language Pathologist in Feeding Evaluation: Relevant Medical History

Disorders ● Chart Review
● Overall role of SLP when evaluating and treating swallowing disorders : ● Date and time of evaluation
therapy may include exercises to strengthen muscles involved in ● Patient name and date of birth
swallowing, learning new techniques for feeding, and determining which ● Referring physician and referring concerns
foods and liquids are most appropriate for your child and which should be ● Patient accompanied by / additional specialists present
avoided ● Primary language
● Evaluates and treats patients with swallowing difficulties, including
● Pertinent medical history : other diagnoses, surgeries, medications,
direct modifications of physiologic responses and indirect approaches
such as diet modification. allergies, born full term/prematurely
● Previous feeding evaluations/therapy
 Evaluation: Concerns
Evaluation: Parent Interview
● Choking/coughing/gagging on solids/liquids present?
● Decreased oral intake ?
● Current route of nutrition/ current diet
● Lack of weight gain?
● Being followed by any medical specialists: DVBP, ENT, ● Respiratory illness?
neurology, OT, audiology, PT, etc. ● Frequent emesis?
● Mealtime picture in home (i.e., chair, family mealtime, does ● Picky eating?
Transitioning from tube to oral feeds?
family prepare foods, etc.) ●
● Feeding too frequently?
● Cultural considerations ● Hypersensitivity/oral aversion?
● Caregiver goals & concerns ● Combination of any difficulties listed above

Evaluation: Oral Mechanism Examination

Evaluation: Oral Mechanism Examination (cont.)

● Fixed structures: Teeth, Palate (hard/soft), Jaw

● Lips: Should assess strength, range of motion, and coordination

● Secretion management: Consider extent of and quality of secretions

● Non-nutritive suck: Should assess orientation, latch and initiation of non-nutritive suck

● Mucosa: Consider color, moistness, any overt abnormalities

● Respiration: Should consider at baseline, during feeding, and after feeding

● Tongue: Should assess strength, range of motion and coordination

 Evaluation: Food Presentations/Trials
Evaluation: Positioning & Behavior during feeding
● Liquid consistency: Thin liquid texture, ½ Nectar liquid texture, Nectar
liquid, Honey liquid
● Positioning: Should assess in normal feeding positions as well as with any
appropriate modifications during the assessment ● Mode of presentation

● Volume presented/consumed
● Behavioral observations: Should assess their level of attention and
cooperation as well as types of refusals; Consider improvements with ● Presenter
strategies in evaluation

Evaluation: Food Presentations/Trials

● Consistency presented: Evaluation: Feeding/Swallowing Observations
○ Puree solids texture (level 4)
○ Minced & Moist texture (level 5, i.e. Ground solid) Oral Phase
○ Soft solid texture (level 6)
○ Regular/hard solid texture (level 7)
○ Transitional texture (i.e. meltable solid) Pharyngeal Phase

● Mode of presentation Esophageal Phase

● Volume presented/consumed

● Presenter
 Evaluation: Strategies/Interventions Trialed Evaluation: Trialing of Nipples

● None Reduced nipple fill Signs that you may need to change nipple size :
● External pacing provided based on cues External pacing provided every X sucks
● Slower flow nipple Faster flow nipple
● Change in position Single controlled sips ● Milk/formula flooding mouth, increased risk of aspiration and penetration,
Use of flow controlled utensil Verbal cues
●
and/or decreased coordination
● Changes in sensory property of foods Visual cues
● Controlled bite presentation Tactile cues ● Fatigue, collapsed nipples, more sucks per swallow, and/or decreased volume
Limiting amount offered Modifications to diet
●
intake

Evaluation: Nipple Information and Facts Evaluation: Bottle Information and Facts
● Enfamil Standard-Flow Soft Nipple (dark blue) : requires a good suck, good for typically
● Softer nipples are easier to compress; firmer nipples require more pressure developing children
● Commercial nipples are usually silicone, which is more durable than latex ● Enfamil Slow-Flow Soft Nipple (aqua) : premature infants who do not yet have a strong
○ Combined influence of compression and pliability can cause the same nipple to suck
● Enfamil Cross Cut Nipple (yellow): thickened feeds
have different flow rates for different infants
● NUK orthodontic nipple : good for babies demonstrating a “chomping motion,” or those
● Length (back half of tongue applies more compression, so longer nipples end up getting more
showing weak labial seal
squeeze) ● Dr. Brown’s : Reduces gas and emesis; has various flow rates available
● Shape - orthodontic nipples vs more traditional; wider nipples aren’t as easy to be cupped, may ○ Preemie flow
engage more of the masseter muscle, which influences the infant’s suck ○ Level 1 : 0M+
● If you hold the bottle upside down, it will drip faster than if you hold is on an angle, etc. ○ Level 2 : 3M+
● Build up of negative pressure creates a vaccuum; more air exchange = faster flow rate; also why ○ Level 3: 6M+
tightening cap can affect flow rate ○ Level 4: 9M+
○ Y- cut: 9M+ : thickened feeds
 Evaluation: Referrals
Evaluation: Recommendations
Modified barium swallow study
When to recommend for feeding therapy with an SLP: ●
● Gastroenterology
● Nutrition
● Neurology
● Signs of a feeding/swallowing disorder ● Pulmonary
● Not gaining weight ● Occupational therapy
● Otolaryngologist
● Limited foods in diet ● Feeding Team
● Needs thickening assistance ● Intensive feeding program
● Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Aspiration / Penetration
8 point Penetration- Aspiration Scale
● Penetration is defined as “passage of material into the larynx that does not pass below the vocal 1. Material does not enter the airway.
folds. The amount of material, the depth of penetration, and whether all or a portion is 2. Material enters the airway, remains above the vocal folds, and is ejected
subsequently expelled are potentially critical variables.” from the airway.
3. Material enters the airway, remains above the vocal folds, and is not
● Aspiration is defined as “passage of material below the level of the vocal folds, and the amount, the
ejected from the airway
distance the material passes into the trachea, and whether all or a portion has potential clinical
4. Material enters the airway, contacts the vocal cords, and is ejected from
significance
the airway
5. Material enters the airway, contacts the vocal folds, and is not ejected from
the airway
6. Material enters the airway, passes below the vocal folds, and is not ejected
into the larynx or out of the airway
7. Material enters the airway, passes below the vocal folds, and is not ejected
from the trachea despite effort
8. Material enters the airway, passes below the vocal folds, and no effort is
made to eject
Therapy Framework Developing Goals
Considerations:

- Age - Impairment Feeding Goals Reducing mealtime behavior Goals

- Attention level - Family schedule
- Time needed for thickening/education - Other barriers
Chewing Goals Swallowing Goals
Examples:

1x/week, 30 mins, 12 visits Diet Expansion Goals

1x/every other week, 60 mins, 8 visits

Developing Goals Feeding/Swallowing Treatment: Developing Goals

Feeding Goals :
LTG: Patient will safely obtain optimal levels of oral nutrition via the least restrictive an age appropriate Chewing Goals :
diet.
STG: Patient will consume ¼ cup transitional solid texture within 30 minutes given verbal and visual STG: Patient will bite through solid boluses when placed on lateral molars in a position for grinding
cues. to grind and chew food sufficiently before swallowing with 4 or 5 successes on each side for 3/4
consecutive sessions.
LTG: Patient will bite, chew, and safely swallow solid boluses in order to optimize oral intake to meet
nutritional goals using identified caregiver feeding strategies STG: Patient will move food placed between molars on one side to the other side by using lateral
STG: Patient will consume 4oz puree within 30 minutes with timely A/P bolus transport prior to swallow tongue action for 3-4 successes over 3/4 consecutive sessions.
given verbal, visual, and tactile cues.
 Feeding/Swallowing Treatment: Developing Goals Developing Goals
Swallowing Goals :
Reducing Mealtime Behavior Goals/Diet Expansion Goals
STG: Patient will demonstrate 10 swallows in 10 minutes using thermal tactile STG: Patient will move through 2 steps of the food hierarchy with non-preferred foods within one session
given models and verbal praise within a 30 minute session.
stimulation or sour bolus techniques.
STG: Patient will consume goal amount of puree and transitional solid given positive praise and visual
STG: Patient will produce a falsetto /i/ continuously for 10 seconds in order to schedule with limited refusals within 30 minutes.
improve laryngeal elevation

Patient will improve his base of tongue strength by pushing up on a tongue

depressor while producing /k/ in 8/10 trials

Feeding/Swallowing Treatment: Picky Eaters Feeding/Swallowing Treatment: Sensory Approach

● Food Hierarchy - Refer to handout
● Food Scientist - Refer to handout
● Eating around a plate : Collect Food List : Always eaten, Occasionally eaten, Used to eat, Never eaten
● Use divided plate, follow 1, 2, 3 sequence
● Use all preferred foods to teach protocol and reduce anxiety
● Can put 2-3 preferred foods in each section
● Can put same preferred food in each section ● Try finger painting with pudding or whipped cream. Be sure to have a clean, wet cloth nearby and allow him/her to
● Teach rules of even rotation (1 bite from each section of plate) clean hands as needed.
● Alternate difficult food and easy foods ● String fruit loops, dry pasta, cheerios, etc, using string or pipe cleaners.
● Difficult food may first be an occasionally eaten food or a food with a slight change to taste, texture or brand
● If s/he's gagging at the sight of food, you might want to start with object or picture representation of food items, feed
● Gradually progress to a never eaten food
● If unable to actually eat food, reward any attempts to move up food heirarchy
dolls etc.
● Begin with reinforcing each bite of new food, progress to reinforcing following full sequence completion ● Other ideas are to start with food at a distance (say on the kitchen counter while he is in the highchair), then move them
● Reinforcement when using sectional plate may just be getting to eat the next food in the sequence to the opposite end of the table from where s/he is sitting and gradually move them closer and closer until they are on
● Use guided compliance protocol his/her tray to look at. Then you can move to smells, touches, licks, etc
● HOH assist
● Gestural Prompt
● Verbal Cue
● Independent
Feeding/Swallowing Treatment: Oral motor exercises Feeding/Swallowing Treatment : Transitioning from
and home programming the bottle
.
● Tactile input should be provided with a washcloth (towel or terry cloth bib) or NUK brush to cheeks, chin, and lips. Initially
light to moderate pressure should be used, gradually increasing to moderate to firm input. Pressure should be provided Spoon Feeding :
from the ears, and outer and inner eyes towards and through the lips as well as from the bottom of the chin upward ● Use a flat, hard, plastic coated spoon, not metal. Start with small amount—1/8 to ¼ tsp
towards and through the lips. Strokes should be well-graded to provide full muscle elongation. ● Child should open mouth as spoon approaches. Do not force food into child’s mouth.
● Put spoon on tongue at about mid-tongue with slight downward pressure. Lips should close around
● Combine tactile pressure with use of vibratory input (i.e., vibrating toy) or temperature input to cheeks and lips to
maximize oral stimulation. the spoon. Bring spoon out along the tongue, not scraping off roof of mouth.
● If child needs help closing lips, place one finger between lower lip and chin to help guide jaw to
● Provide tactile input to the tongue by providing moderate to firm pressure with small forward strokes to the sides of the close, or press up gently directly under chin bone ( to help stabilize the jaw)
tongue first. As tolerance increases provide pressure straight down in the middle of the tongue in a tapping motion. ● Do not scrape off chin with every bite, just occasionally scraping interrupts the routine. You can
clean off the face at end of meal.
● Provide tactile input to the upper and lower biting surfaces (e.g., molars) with NUK brush or regular toothbrush. Moderate
to firm pressure should be provided downward through the biting surfaces of the lower teeth and upward through the
biting surfaces of the upper teeth.

Feeding/ Swallowing Treatment : Promoting cup Feeding/ Swallowing Treatment : Promoting chewing
drinking
Developmental readiness for introduction of cup : ● Transitioning to mature chewing patterns : you want to look at their biting pattern, if they can move food from
● At least 6 months tongue to chewing surface, if they use a rotary chewing pattern, moves food from one side to the other, moves
● Sit independently food posteriorly
● Able to grasp with two hands
● Promoting chewing : introduce lumpy foods gradually, add finely ground crackers into purées, give foods to bite
● Is interested in playing with cup
through even if child spits it out, allow time between bites to practice skills, introduce strip foods to back of
● Introduce at 6 months but don’t expect wean until closer 12 months
First Steps : molar surface alternating side of presentation from left to right, slowly feed strip foods through back molar with
● Start with an empty light weight cup to play with and explore (training cups with soft spout are preferred as first cups) repetitive bites, assist with biting by gently tapping under the chin
● Model bringing cup to mouth ● Model chewing with open mouth and larger than life motions to show the child what chewing should look like
● Water is a great first liquid to experiment with (sight, sound and feel of it) inside your mouth
● Offer cup during snack time, between feeds ● To begin biting and chewing harder foods, offer vegetables cooked until slightly soft and cut into strips, then
● Begin replacing child’s least favorite feed with cup of breastmilk begin to cook them less each time until your child can chew them without cooking them
● Begin to shorten each breast feeding or
● Use a mirror modeling appropriate chewing pattern
● Skip a breast feeding every 5-7 days
Case Study
Group activities
● 7-week-old- 11-month-old female
● Diagnoses : oropharyngeal dysphagia, hypoxic ischemic encephalopathy, muscle ● Testing food textures/ consistencies using IDDSI
hypotonia
● Goals in Treatment :
● Accept 1oz of formula via bottle with no s/sx of airway compromise
● Accept 1oz of stage 2 purees with no s/sx of airway compromise ● Thickening using syringe test
● Demonstrate readiness for VFSS by consuming 1oz of thins and 1oz of purees
● Tolerate oral motor exercises / stimulation : tolerate lingual stimulation to
promote lateralization, tip and midblade elevation

IDDSI Diet Levels Questions?

References
American Speech-Language-Hearing Association. (2002). Knowledge and Skills Needed by Speech Language Pathologists Providing Services to
Individuals with Swallowing and/or Feeding Disorders. ASHA supplement 22, 81-88.

McCarthy, J., Feeding infants and toddlers, strategies for safe, stress free mealtimes. Mosaic Childhood Project, Inc.

Pados, B.F., Park, J., Thoyre, S.M., Estrem, H., & Nix, W. B. (2015). Milk Flow Rates From Bottle Nipples Used for Feeding Infants Who Are
Hospitalized. American Journal of Speech-Language Pathology, 24(4), 617-679.

Robbins, J., Coyle, J., Rosenbek, J., Roecker, E., & Wood, J. (1999). Differentiation of Normal and Abnormal Airway Protection during Swallowing
Using the Penetration–Aspiration Scale. Dysphagia, 14(4), 228-232.

Ross, E., & Fuhrman, L. (2015). Supporting Oral Feeding Skills Through Bottle Selection. S/G 13 Perspectives on Swallowing and Swallowing
Disorders (Dysphagia), 24(2), 50-57.