As a feeding therapist you often encounter infants and toddlers who have not eaten well, have poor weight gain, and may have even been diagnosed with failure to thrive. Many of these patients have undergone placement of a nasogastric tube or even a gastrostomy tube which the parents have been told is just temporary. It is now your job to decide how to proceed with these children.
Do you start with oral-motor therapy and oral exercises to either normalize oral-motor patterns or alleviate sensory-based oral feeding disorders, or do you jump right into feeding therapy?
Before making a treatment decision on exactly how you will proceed there are at least 10 questions that you will need to answer about the child you will be treating.
1). How does the child manage his own secretions. Does he cough and choke on saliva and require suctioning? Is there a history of aspiration pneumonia? Asthma? Respiratory issues that require medication? Does the child drool with secretions that collect and then spill from the open mouth?
This child most likely has a decreased intra-oral sensory awareness/perception and is unable to feel the material in his mouth. There are several sensory-based exercises that can be implemented to improve intra-oral sensory perception.
2). Is there pooling of secretions, liquid, and/or food in the oro-pharynx before, during, or after the pharyngeal swallow has been triggered?
If material pools in the oro-pharynx prior to the initiation of the pharyngeal swallow, it is an indication of an oral-motor problem. Material pools before the swallow because bolus collection of the material (secretions, liquids, pureed foods, solids) is inadequate. Since the tongue is primarily responsible for the collection and transport of the bolus during the oral phase of swallow this child will require oral-motor therapy to improve bolus collection.
When material pools in the oro-pharynx during the pharyngeal swallow and does not clear with the majority of the bolus, a videofluoroscopic study may be indicated to investigate whether or not this occurs with all consistencies (liquids, pureed foods, solids) or with just one.
Recommendations for a therapeutic diet may then be made following the results of the study.
When material pools after the pharyngeal swallow has occurred it most likely is secondary to a delay in the relaxation of the upper esophageal sphincter. When material pools in the upper esophagus it may cause the child to cough or sputter so it is always important to ask the parent whether the child coughs before or after he swallows?
This feeding therapy program would involve the introduction of different textures in order to assess which are easiest and most difficult for the child to manage. Techniques like taking a sip of liquid after a spoonful or bite of solid or cutting those solids that do not dissolve easily during the oral phase of swallow into smaller pieces may be tried.
3). Is there a difference in the way the child manages liquids, pureed foods, solids?
Some children swallow water without difficulty but are unable to eat foods. Others are able to bite and chew hamburgers but then spit the food out because they cannot swallow. Then there are those children who are able to bite, chew, and eat many foods that dissolve easily in the mouth such as chips, cookies, cereals, but may choke and/or vomit on mashed potatoes. Each of these situations requires a different therapeutic approach and it is up the feeding therapist to decide which approach to take.
Let’s start with the child who is receiving all nutrition by gastrostomy tube because he is unable to eat but drinks water without any problem. This is very clearly an esop0hageal phase problem. A videofluoroscopic study is not needed because, despite this daily intake of water, there is no aspiration or respiratory issue for this child. The treatment would be what I have named, “Incremental Progression” (for more information go to Talk #8, Series 1 course on CEU section of website). This is a gradual thickening of the water that the child drinks daily. Of course, the first step would be to add a flavor to the water that would be tolerated. Select a flavor that also comes in a thin juice such as apple.
The next step is to move to apple juice so that the child is able to drink both apple-flavored water and apple juice. Next, you could add a small amount of applesauce (1/4 teaspoon to 4 oz. of apple juice) and then every three days increase the thickness by ¼ teaspoon until the child is able to swallow the pureed applesauce. This treatment is for the esophageal phase of swallow and with gradually increase the peristaltic wave during swallow so that the child is able to swallow a pureed food consistency.
Now we have a child who loves McDonalds hamburgers and chicken nuggets but is not able to swallow them. He bites and chews and the spits the pieces out into a small cup that goes everywhere with him. His nutrition comes only from liquids and pureed foods. Using “Incremental Progression” again but this time start with pureed food and gradually increase its consistency/thickness for a small portion of the meal. You could also try mixed consistencies, i.e., small pieces of ground beef mixed into mashed potatoes. (for more information on texture transitions see Series 3 on website)
The last situation is the child who “eats everything” or so the parents would have you believe. He drinks liquids, eats pureed foods, and chews solids well. However, this child is not able to manage thick pureed foods that do not fall off the spoon when the spoon is turned upside down (mashed potatoes, guacamole, sweet potatoes, oatmeal, etc.) and will usually gag, choke, or vomit when attempting to eat foods of this consistency. This is because of inadequate lingual function during the oral phase of swallow. The tongue is not able to move this thick and heavy bolus efficiently back to the oro-pharynx for swallow and the bolus just remains on the tongue blade and results in gagging or worse. This child needs tongue exercises to strengthen his ability to collect and transport the bolus. This requires oral-motor exercises and not feeding therapy.
4). Does positioning aid oral feeding in any way?
A gravity-assisted position may be successful for the child with a cleft palate. In this case an upright position may help to prevent or lessen the occurrence of naso-pharyngeal reflux. In the case of a paralyzed vocal cord a child can be fed in side lying with the affected cord above the unaffected one to help with vocal cord closure.
5). What are the prevailing medical conditions?
Before starting a therapeutic feeding program, you will need to know if the child has food allergies or dietary restrictions. Has the child been diagnosed with eosinophilic esophagitis, gastroesophageal reflux, or esophageal dysmotility? Any one of these diagnoses will affect your therapy decisions. (for more information on esophageal dysmotility see Talks 9 &10, Series 1 on website)
6). If the child is fed by tube what is the type, schedule, and duration of the tube feeding?
If the child is on a 24-hour or 12-hour drip feeding and parents are interested in moving toward oral feeding and tube removal then feedings will gradually need to be consolidated and the schedule changed to bolus feedings that more closely approximate oral feeding. If the child is already fed by bolus on a mealtime schedule, then the Palmer Protocol for Sensory-Based Weaning can be introduced. (for more information see Talk #11, Series 1 on website) This feeding therapy program was not designed for children who present with oral-motor difficulties or abnormal oral-motor patterns.
7). Are there abnormal oral-motor patterns and/or oral-facial tone?
Are the oral reflexes (gag, phasic bite, suck, transverse tongue) and mastication present? If a child has never eaten by mouth because of a specific medical diagnosis, it is important to evaluate the oral reflexes, all of which are innervated by the brain stem. I once saw an infant who had been diagnosed with pseudobulbar dysfunction, placed on a gastrostomy tube, and parents were advised not to feed him by mouth. Every three months the MBS was repeated and he aspirated and again parents were told not to feed him orally. When I first evaluated him the transverse tongue reflex was intact and that meant there was hope! After a few months of treatment, the MBS that followed showed no aspiration! This infant went on to become an oral feeder with adequate motor function but decreased pharyngeal sensory perception.
8). Is the child sensitive around the mouth secondary to hyposensitivity or hypersensitivity? Does sensitivity differ from front, back of mouth, tongue, lips?
A child may be defensive around the mouth and present with oral defensiveness if there is an underlying hypersensitivity or hyposensitivity. When there is less sensory awareness with poor sensory perception the child will attempt to protect himself by withdrawing from the stimulus, turning away, gagging, and/or vomiting. When there is oral hyposensitivity the same reaction may occur. It is the task of the feeding therapist to determine the underlying etiology of the sensory defensiveness and treat it accordingly.
9). How motivated is the primary caretaker? What are his/her feeding goals for the child? How much contact do you have with the family?
This child does not belong to you, the feeding therapist and, although you may determine that much progress could be made toward successful oral feeding, it is not your decision alone. On one occasion in our GI clinic at UCSF I saw a 2-year old girl with Down syndrome who was being fed by gastrostomy tube. This little girl could have been successfully weaned off the tube feds onto oral feeding using the Palmer Protocol for Sensory-Based Weaning but the mother said that she was expecting another baby and would not have the time to manage a weaning program. So this little girl remained on her gastrostomy tube feeds. Not always our decision!
10). How long has the child been a non-oral feeder? What is the early medical history and age at which tube feeds were initiated?
Before starting a feeding therapy program it is important to know the length of the time that the child has been on tube feeding and the reason that tube feeding was recommended and initiated. The medical condition that precipitated the placement and initiation of the tube feeding may have since resolved. It is important to communicate with the gastroenterologist who is overseeing the tube feedings.
Just a word of wisdom from experience. When making the transition from drip to bolus feeding don’t say “we are going to decrease the overnight drip” instead try “is it OK if we change the feeding schedule slightly?” This I have learned from experience. Any questions please let me know. I am here to help you to help your infants and children to be successful oral feeders.
Marjorie Meyer Palmer MA, NLP, CCC-SLP, Neonatal / Pediatric Feeding Specialist, Speech-Language Pathologist, Founder / Director NOMAS® International
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