Pediatric feeding and swallowing disorders: General assessment and intervention. Neonatal Network, 16(5), 4347. Anxiety and crying may be expected reactions to any instrumental procedure. Nutricin Hospitalaria, 29(Suppl. (2016b). Prevalence of drooling, swallowing, and feeding problems in cerebral palsy across the lifespan: A systematic review and meta-analyses. International Journal of Oral & Maxillofacial Surgery, 44(6), 732737. Brian B. Shulman, vice president for professional practices in speech-language pathology, served as the monitoring officer. https://doi.org/10.1007/s00784-013-1117-x, Eddy, K. T., Thomas, J. J., Hastings, E., Edkins, K., Lamont, E., Nevins, C. M., Patterson, R. M., Murray, H. B., Bryant-Waugh, R., & Becker, A. E. (2015). See ASHAs resource on transitioning youth for information about transition planning. (1998). 0000023632 00000 n 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). Pediatrics, 108(6), e106. Communication disorders and use of intervention services among children aged 317 years: United States, 2012 [NCHS Data Brief No. If the child cannot meet nutritional needs by mouth, what recommendations need to be made concerning supplemental non-oral intake and/or the inclusion of orally fed supplements in the childs diet? Language, Speech, and Hearing Services in Schools, 31(1), 5055. 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). See the Assessment section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. ASHA does not require any additional certifications to perform E-stim and urges members to follow the ASHA Code of Ethics, Principle II, Rule A which states: "Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience" (ASHA, 2016a). chin downtucking the chin down toward the neck; head rotationturning the head to the weak side to protect the airway; upright positioning90 angle at hips and knees, feet on the floor, with supports as needed; head stabilizationsupported so as to present in a chin-neutral position; reclining positionusing pillow support or a reclined infant seat with trunk and head support; and. infants current state, including respiratory rate and heart rate; infants behavior (e.g., positive rooting, willingness to suckle at breast); infants position (e.g., well supported, tucked against the mothers body); infants ability to latch onto the breast; efficiency and coordination of the infants suck/swallow/breathe pattern; mothers behavior (e.g., comfort with breastfeeding, confidence in handling the infant, awareness of the infants cues during feeding). It may also improve the timing of oral feeding initiation (Simpson et al., 2002), increase rates of majority breastmilk enteral feeds compared to those who receive tube feeding of formula alone (Snyder et al., 2017), and allow for earlier attainment of full enteral feedings (Rodriguez & Caplan, 2015). (2018). Protocols for determining readiness for oral feeding and specific criteria for initiating feeding vary across facilities. facilitate the individuals activities and participation by promoting safe, efficient feeding; capitalize on strengths and address weaknesses related to underlying structures and functions that affect feeding and swallowing; modify contextual factors that serve as barriers and enhance those that facilitate successful feeding and swallowing, including the development and use of appropriate feeding methods and techniques; and. This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA. observations of the caregivers behaviors and ability to read the childs cues as they feed the child. It is used as a treatment option to encourage eventual oral intake. . A. C., Breugem, C. C., van der Heul, A. M. B., Eijkemans, M. J. C., Kon, M., & Mink van der Molen, A. https://doi.org/10.1597/05-172, Rodriguez, N. A., & Caplan, M. S. (2015). 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. Swallowing is commonly divided into the following four phases (Arvedson & Brodsky, 2002; Logemann, 1998): Feeding disorders are problems with a range of eating activities that may or may not include problems with swallowing. Instrumental evaluation is conducted following a clinical evaluation when further information is needed to determine the nature of the swallowing disorder. . NNS does not determine readiness to orally feed, but it is helpful for assessment. See the treatment in the school setting section below for further information. https://www.ada.gov/regs2016/504_nprm.html, Reid, J., Kilpatrick, N., & Reilly, S. (2006). Methods: Thirty-six subjects were randomized into experimental and control groups. move their head toward the spoon and then open their mouth. Does the child have the potential to improve swallowing function with direct treatment? Responsive feeding emphasizes communication rather than volume and may be used with infants, toddlers, and older children, unlike cue-based feeding that focuses on infants. In their role as communication specialists, SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infants communication signals. (Practice Portal). Incidence refers to the number of new cases identified in a specified time period. A non-instrumental assessment of NNS includes an evaluation of the following: The clinician can determine the appropriateness of NS following an NNS assessment. https://doi.org/10.1111/j.1552-6909.1996.tb01493.x. Code of ethics [Ethics]. NS skills are assessed during breastfeeding and bottle-feeding if both modes are going to be used. Please see AHSAs resource on state instrumental assessment requirements for further details. Furthermore, as stimulation of the rapidly-adapting skin mechanoreceptors during dynamic touch has been shown to be critical for other previously described intra- and inter-sensory interactions (e.g. Apnea is strongly correlated with longer transition time to full oral feeding (Mandich et al., 1996). Singular. Any loss of stability in physiologic, motoric, or behavioral state from baseline should be taken into consideration at the time of the assessment. (n.d.). hb``b````c` B,@. Feeding skills of premature infants will be consistent with neurodevelopmental level rather than chronological age or adjusted age. Congenital abnormalities and/or chronic conditions can affect feeding and swallowing function. Oralmotor treatments include stimulation toor actions ofthe lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles. Little is known about the possible mechanisms by which this interventional therapy may work. Members of the Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training included Caryn Easterling, Maureen Lefton-Greif, Paula Sullivan, Nancy Swigert, and Janet Brown (ASHA staff liaison). https://doi.org/10.1044/leader.FTRI.18022013.42, Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., Klin, A., Jones, W., & Jaquess, D. L. (2013). 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. The plan includes a protocol for response in the event of a student health emergency (Homer, 2008). 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. Behavioral interventions are based on principles of behavioral modification and focus on increasing appropriate actions or behaviorsincluding increasing complianceand reducing maladaptive behaviors related to feeding. Thermal tactile stimulation also, known as thermal application is one type of therapy used for the treatment of swallowing disorders. https://www.asha.org/policy/, American Speech-Language-Hearing Association. Although thermal tactile oral stimulation is a common method to treat dysphagic patients to improve swallowing movement, little is known about the possible mechanisms. Supportive interventions to facilitate early feeding and/or to promote readiness for feeding include kangaroo mother care (KMC), non-nutritive sucking (NNS), oral administration of maternal milk, feeding protocols, and positioning (e.g., swaddling). 0000089121 00000 n The Journal of Perinatal & Neonatal Nursing, 29(1), 8190. Underlying disease state(s), chronological and developmental age of the child, social and environmental factors, and psychological and behavioral factors also affect treatment recommendations. National Center for Health Statistics. TTS may help to increase stimulation and sensation of the oral cavity by providing a sensory stimulus to the brain. Keep in mind that infants and young children with feeding and swallowing disorders, as well as some older children with concomitant intellectual disabilities, often need intervention techniques that do not require them to follow simple verbal or nonverbal instructions. The clinician allows time for the child to get used to the room, the equipment, and the professionals who will be present for the procedure. touch-pain and thermal-pain, in which touch and thermal stimuli reduce the perception of pain) (Bolanowski et al., 2001, Green and Pope, 2003 . A. The clinical evaluation for infants from birth to 1 year of ageincluding those in the NICUincludes an evaluation of prefeeding skills, an assessment of readiness for oral feeding, an evaluation of breastfeeding and bottle-feeding ability, and observations of caregivers feeding the child. https://doi.org/10.1016/j.nwh.2020.03.007, Rehabilitation Act of 1973, Section 504, 29 U.S.C. different positions (e.g., side feeding). an assessment of current skills and limitations at home and in other day settings. 0000090444 00000 n https://doi.org/10.1542/peds.108.6.e106, Norris, M. L., Spettigue, W. J., & Katzman, D. K. (2016). See ASHAs resources on interprofessional education/interprofessional practice (IPE/IPP) and collaboration and teaming for guidance on successful collaborative service delivery across settings. https://doi.org/10.5014/ajot.42.1.40, Homer, E. (2008). 0000090013 00000 n It is primarily used to treat individuals who have an absent or delayed swallow reflex. National Center for Health Statistics. (2017). Thermal-tactile stimulation (TTS) is a sensory technique whereby stimulation is provided to the anterior faucial pillars to speed up the pharyngeal swallow. https://doi.org/10.2147/NDT.S82538, Pados, B. F., & Fuller, K. (2020). Intraoral appliances are not commonly used. American Psychiatric Association. ; 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. Do these behaviors result in family/caregiver frustration or increased conflict during meals? Oralmotor treatments range from passive (e.g., tapping, stroking, and vibration) to active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). 0000009195 00000 n Best practice indicates establishing open lines of communication with the students physician or other health care providereither through the family or directlywith the familys permission. 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. In addition to determining the type of treatment that is optimal for the child with feeding and swallowing problems, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. 0000063512 00000 n Dycem to prevent plates and cups from sliding. Those section letters and numbers from 2011 are 210.10(g)(1) and can be found at https://www.govinfo.gov/content/pkg/CFR-2011-title7-vol4/pdf/CFR-2011-title7-vol4-sec210-10.pdf. The SLP also teaches parents and other caregivers to provide positive oral experiences and to recognize and interpret the infants cues during NNS. The familys customs and traditions around mealtimes and food should be respected and explored. Setting refers to the location of treatment and varies across the continuum of care (e.g., NICU, intensive care unit, inpatient acute care, outpatient clinic, home, or school). These techniques serve to protect the airway and offer safer transit of food and liquid. 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. The NICU is considered an advanced practice area, and inexperienced SLPs should be aware that additional training and competencies may be necessary. Oropharyngeal dysphagia and cerebral palsy. 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). Anatomical, functional, physiological and behavioural aspects of the development of mastication in early childhood. Key words: swallowing, dysphagia, stroke, neuromuscular elec-trical stimulation. 0000000016 00000 n 0000037200 00000 n KMCskin-to-skin contact between a mother and her newborn infantcan be an important factor in helping the infant achieve readiness for oral feeding, particularly breastfeeding. (1998). As a result, intake is improved (Shaker, 2013a). Tube feeding includes alternative avenues of intake such as via a nasogastric tube, a transpyloric tube (placed in the duodenum or jejunum), or a gastrostomy tube (a gastronomy tube placed in the stomach or a gastronomyjejunostomy tube placed in the jejunum). 2), 3237. Rates increase with greater severity of cognitive impairment and decline in gross motor function (Benfer et al., 2014, 2017; Calis et al., 2008; Erkin et al., 2010; Speyer et al., 2019). 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. SLPs treating preterm and medically fragile infants must be well versed in typical infant behavior and development so that they can recognize and interpret changes in behavior. 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. The Laryngoscope, 128(8), 19521957. Late onset necrotizing enterocolitis in infants following use of a xanthan gum-containing thickening agent. Infants and Young Children, 8(2), 58-64. A significant number of studies that evaluated tactile-pain interactions employed heat to evoke nociceptive responses. https://doi.org/10.1017/S0007114513002699, Lefton-Greif, M. A. The health and well-being of the child is the primary concern in treating pediatric feeding and swallowing disorders. School-based SLPs play a significant role in the management of feeding and swallowing disorders. 701 et seq. The plan should be reviewed annually along with the IEP goals and objectives or as needed if significant changes occur or if it is found to be ineffective. Ongoing staff and family education is essential to student safety. J Rehabil Med 2009; 41: 174-178 Correspondence address: Kil-Byung Lim, Department of Reha- Consistent with the World Health Organizations (WHO) International Classification of Functioning, Disability and Health framework (ASHA, 2016a; WHO, 2001), a comprehensive assessment is conducted to identify and describe. Results There were eight participants, six women and. American Speech-Language-Hearing Association. Available 8:30 a.m.5:00 p.m. https://doi.org/10.1097/JPN.0000000000000082, Seiverling, L., Towle, P., Hendy, H. M., & Pantelides, J. 0000018013 00000 n Feeding and eating disorders: DSM-5 Selections. promote a meaningful and functional mealtime experience for children and families. Using this treatment, clinicians deliver electrical current through electrodes to stimulate peripheral nerves and evoke a muscle contraction. 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. DPNS has been shown to have a large effect on swallow function, quickly improving reflexive cough and improving vocal quality. an assessment of sucking/swallowing problems and a determination of abnormal anatomy and/or physiology that might be associated with these findings (e.g., Francis et al., 2015; Webb et al., 2013); a determination of oral feeding readiness; an assessment of the infants ability to engage in non-nutritive sucking (NNS); developmentally appropriate clinical assessments of feeding and swallowing behavior (nutritive sucking [NS]), as appropriate; an identification of additional disorders that may have an impact on feeding and swallowing; a determination of the optimal feeding method; an assessment of the duration of mealtime experience, including potential effects on oxygenation (SLP may refer to the medical team, as necessary); an assessment of issues related to fatigue and volume limitations; an assessment of the effectiveness of parent/caregiver and infant interactions for feeding and communication; and. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Pediatric Dysphagia page: In addition, ASHA thanks the members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU); Special Interest Division 13, Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training; and the Working Group on Dysphagia in Schools, whose work was foundational to the development of this content. Cue-based feedingrelies on cues from the infant, such as lack of active sucking, passivity, pushing the nipple away, or a weak suck. Pediatric feeding disorders. See ASHAs Scope of Practice in Speech-Language Pathology (ASHA, 2016b). a review of any past diagnostic test results. Arvedson, J. C., & Lefton-Greif, M. A. Other signs to monitor include color changes, nasal flaring, and suck/swallow/breathe patterns. SLPs should be sensitive to family values, beliefs, and access regarding bottle-feeding and breastfeeding and should consult with parents and collaborate with nurses, lactation consultants, and other medical professionals to help identify parent preferences. The prevalence of swallowing dysfunction in children with laryngomalacia: A systematic review. https://www.fns.usda.gov/cn/2017-edition-accommodating-children-disabilities-school-meal-programs, U.S. Food and Drug Administration. Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. Typical feeding practices and positioning should be used during assessment. Oropharyngeal administration of mothers milk to prevent necrotizing enterocolitis in extremely low-birth-weight infants. 0000061484 00000 n Reading the feeding. Thermal-Tactile Stimulation* (TTS) is utilized by speech-language pathologists to treat dysphagia (disorder of swallowing). The school SLP (or case manager) contacts the family to notify them of the school teams concerns. https://doi.org/10.1016/j.ijporl.2013.03.008, Wilson, E. M., & Green, J. R. (2009). Treatment of ankyloglossia and breastfeeding outcomes: A systematic review. 128 48 Therapy for children with swallowing disorders in the educational setting. 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. cal stimulation combined with thermal-tactile stimulation is a better treatment for patients with swallowing disorders af-ter stroke than thermal-tactile stimulation alone. Feeding and swallowing disorders may be considered educationally relevant and part of the school systems responsibility to ensure. Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. Sensory stimulation may be needed for children with reduced responses, overactive responses, or limited opportunities for sensory experiences. The assessment of bottle-feeding includes an evaluation of the, The assessment of spoon-feeding includes an evaluation of the optimal spoon type and the infants ability to, In addition to the areas of assessment noted above, the evaluation for toddlers (ages 13 years) and preschool/school-age children (ages 321 years) may include, Evaluation in the school setting includes children/adults from 3 to 21 years of age. 1400 et seq. (2008). (2015). The ASHA Action Center welcomes questions and requests for information from members and non-members. thermal stimulation and swallow maneuvers for treatment of the patients with dysphagia. 0000090522 00000 n McCain, G. C. (1997). 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). Positioning for the VFSS depends on the size of the child and their medical condition (Arvedson & Lefton-Greif, 1998; Geyer et al., 1995). Prevalence refers to the number of children who are living with feeding and swallowing problems in a given time period. Interdisciplinary feeding team: A medical, motor, behavioral approach to complex pediatric feeding problems. Typical modifications may include thickening thin liquids, softening, cutting/chopping, or pureeing solid foods. Family and cultural issues in a school swallowing and feeding program. 0000016965 00000 n Language, Speech, and Hearing Services in Schools, 39, 199213. A written referral or order from the treating physician is required for instrumental evaluations such as VFSS or FEES. Behavior patterns associated with institutional deprivation: A study of children adopted from Romania. (2016). Administration of small amounts of maternal milk into the oral cavity of enteral tubedependent infants improves breastfeeding rates, growth, and immune-protective factors and reduces sepsis (Pados & Fuller, 2020). The development of jaw motion for mastication. Sensory stimulation techniques vary and may include thermaltactile stimulation (e.g., using an iced lemon glycerin swab) or tactile stimulation (e.g., using a NUK brush) applied to the tongue or around the mouth. 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 . 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. . (Figure 4) Thermal stimulationuse a damp towel that has been cooled in a refrigerator for at least five minutes. https://doi.org/10.1097/NMC.0000000000000252, Meal Requirements for Lunches and Requirements for Afterschool Snacks, 7 C.F.R. Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study. 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. Consumers should use caution regarding the use of commercial, gum-based thickeners for infants of any age (Beal et al., 2012; U.S. Food and Drug Administration, 2017). Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit included Justine J. Sheppard (chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio). Dysphagia, 33(1), 7682. Other benefits of KMC include temperature regulation, promotion of breastfeeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability. World Health Organization. Speech-language pathologists (SLPs) play a central role in the assessment, diagnosis, and treatment of infants and children with swallowing and feeding disorders. https://doi.org/10.1016/j.earlhumdev.2008.12.003. Anatomical and physiological differences include the following: Chewing matures as the child develops (see, e.g., Gisel, 1988; Le Rvrend et al., 2014; Wilson & Green, 2009). clear food from the spoon with their top lip, move food from the spoon to the back of their mouth, and. Most NICUs have begun to move away from volume-driven feeding to cue-based feeding (Shaker, 2013a). These techniques may be used prior to or during the swallow. https://doi.org/10.1080/09638280701461625, U.S. Department of Agriculture. 0000027867 00000 n effect of neuromuscular and thermal tactile stimulation on its rehabilitation. 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). International Journal of Pediatric Otorhinolaryngology, 139, 110464. https://doi.org/10.1016/j.ijporl.2020.110464. Instrumental evaluation can also help determine if swallow safety can be improved by modifying food textures, liquid consistencies, and positioning or implementing strategies. Consider how long it takes to eat a meal, fear of eating, pleasure obtained from eating, social interactions while eating, and so on (Huckabee & Pelletier, 1999). Atypical eating and drinking behaviors can develop in association with dysphagia, aspiration, or a choking event. International adoptions: Implications for early intervention. 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). With this support, swallowing efficiency and function may be improved. 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