Whats the Big Deal about Feeding? An Interdisciplinary Approach - - PowerPoint PPT Presentation
Whats the Big Deal about Feeding? An Interdisciplinary Approach Towards Improvement DATE: October 13th, 2018 PRESENTED BY: Kristin Mangan, MA, CCCSLP Erin Cochran, MS, OTR/L Sarah Sahl, BS, RD Darren Janzen, PsyD Kevin Senn, MD
DATE: October 13th, 2018 PRESENTED BY: Kristin Mangan, MA, CCC‐SLP Erin Cochran, MS, OTR/L Sarah Sahl, BS, RD Darren Janzen, PsyD Kevin Senn, MD
An Interdisciplinary Approach Towards Improvement
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interdisciplinary clinic
treatment for pediatric feeding difficulties
with feeding through case studies
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sensory systems
nature
these families
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health, sleep, musculoskeletal status
evaluation and interpretation of growth in special populations
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pharyngeal, and laryngeal function, as well as the aerodigestive tract.
practice to include performance, interpretation, and diagnosis of feeding difficulties and various dysphagias through clinical and instrumental evaluations – MBSS/VFSS/Oropharyngeal Swallow Studies – FEES: Fiberoptic Endoscopic Evaluation of Swallowing
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assessment
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the family is functioning (e.g. stress, structure, and coordination)
present: Behavior is often Avoidance-, Access-, and/or Attention-maintained
behavior using Shaping and Fading techniques
barriers and lessen stress
adherence to goals and any achieved success
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team members in as soon as a month (ex. NG tube management) and as long as a year (ex. Medically stable with minimal changes)
monitoring, ensure appropriate feeding-related referrals (ex. MBSS, FEES, ENT, GI, etc)
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CDRC Pediatric Feeding & Swallowing Disorders Clinic: Who We Serve
gastrointestinal (ex. Reflux, EoE), structural etiologies (ex. Cleft lip & palate), and congenital syndromes (ex. Down Syndrome)
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strategies they have already tried
siblings? Many generations?)
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– Only about half of Americans regularly sit down to family meals. – Forty percent of parents in one study prepared separate meals for their grade school-aged children (Fulkerson et al. 2008).
– Carried on chromosome 4 = some are more taste sensitive.
increase the risk for feeding problems.
– This leads to hospitalization for dehydration and malnutrition in select children.
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My child doesn’t eat enough. My child is dependent on formula and/or tube feedings. My child coughs and chokes when eating/drinking. My child only eats certain foods or certain textures. My child doesn’t self-feed. My child doesn’t indicate hunger. Understand: Parent perception of “normal” vs. “abnormal” Decide: What to prioritize with parents Target: Balance short-term vs. long term goals
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not eat that food, but after 2 weeks may resume eating it again.
Kay Toomey http://sosapproach-conferences.com/wp-content/uploads/2016/06/PickyEaters-VS-Problem-Feeders.pdf
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Kay Toomey http://sosapproach-conferences.com/wp-content/uploads/2016/06/PickyEaters-VS-Problem-Feeders.pdf
eat it.
about certain foods.
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What if I choke… That’s Gross! I’m not hungry. I’ll only eat if you make me what I want…
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Get food to the mouth – increase acceptance Keep food in the mouth – decrease expels Swallow the food – increase mouth clean Increase volume – increase bites, grams Increase variety – number of foods eaten Increase texture – texture eaten, gagging Increase self-feeding – level of prompting
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Kay Toomey, Ph.D http://www.qicreative.com/wp-content/uploads/Steps-To-Eating.pdf
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– Tone, asymmetries, spacing of eyes, – Shape and position of ears, ability to breath through nose
– Size/shape/strength/excursion of jaw, lips, dental status and condition - including shape of teeth, size/shape/tone/strength/range of motion of tongue, labial and lingual frenulum connections, size/shape and movement of palate, presence and viscosity of saliva, evidence of thrush, gag reflex, rooting reflex, bite reflex
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Tongue Tie Classification
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becomes less reflexive
movements; mouth and digestive system getting read for purees
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– Baby can also pick up pieces of food with fist – and begin to pass from hand to hand
movements
consideration of weaning from the bottle or breast to a more mature drinking vessel
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asthma, etc)
following feed
as “one or the other.”
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(food, secretions, and/or gastric contents) incorrectly enter the larynx below the vocal folds into the tracheobronchial tree
material into the laryngeal vestibule followed by a rapid expulsion back into the pharynx during swallowing
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and feeding modifications likely.
steroids, or pulmonary toileting. Mealtime and feeding modifications required.
(hypoxia) or even death. May occur during a seizure, vomiting, or swallowing an unsafe
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larynx, and upper esophagus during all four phases of swallow
time and basic motility
swallowing
factors – Before, during, or after swallow – Texture specificity – Estimated of risk
combined radiation exposure
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the reason for the exam)
changes
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larynx before and after swallow
enhancements
assess an entire meal/feeding
months of age and children > 4 years of age (cognitively)
positions/postures
secretions
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FEES is NOT:
swallowing
either
laryngeal excursion, and UES relaxation
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coughing with liquids and regularly overnight
– RESPIRATORY: hospitalization of RSV in Feb 2017, with persistent coughing and congestion x 3 months; (positive remote familial history
– GI: history of GERD, three separate trials of Zantac (Omeprazole not covered), no meds now, still vomiting and spitting up 5-10 times daily, also currently with diarrhea x 3 days
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– SLEEP: snoring, sleeping best in swing – DEVELOPMENT: Torticollis (getting weekly PT services at
“would scream”). Started on bottles of formula during neonatal
ready-to-feed formula. Purees started early- 4-months- due to weight and GER concerns.
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7 oz per feed. Purees (stage 1 and 2) offered twice per day in Bumbo chair. Eats 2-3 oz of puree at each sitting.
tongue tie (with restricted posterior elevation but adequate tongue tip protrusion)
good anticipatory mouth opening, age appropriate anterior loss, increasing tongue tremor, positive regard for food and eating
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movements and increased cheek retractions, increased tongue fasciculations/ tremor after feeds, increased congestion after feed – MD auscultation of the lungs following the bottle feed notable for "increased work of breathing“ – took a total of 1 oz in 5 minutes – spit up 5 mins after feed
30%ile however weight for age consistent with severe malnutrition; growth velocity is less than expected.”
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tongue tie, continued GERD, failing weight, and torticollis.
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later at 8 months of age – Prior to visit parents shared: congestion had continued, coughing overnight had increased, watery loose stools had persisted x 5 weeks – Chest Xray notable for low lung volumes and mild airway thickening
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– Introduction of crispy dissolvables
– Occurred 1 week after MBSS and MD did not feel lingual frenulum was restrictive
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asymmetrical position of head and neck, and secondary craniofacial asymmetry of structures.
partially innervates swallowing and digestive motility system.
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tongue.
release) including: maternal confidence with BF, maternal nipple pain, and infant reflux symptoms all improved- along with improved milk transfer
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lower airway diseases), halitosis, chronic OM, increased drooling, brassy cough, coughing/choking, sleep disturbances, apnea, laryngospasms, laryngitis, sinusitis, and even life threatening apneic event
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was able to tolerate sitting with his family for meals
improve hunger/satiety, school evaluation for special education services, participation in snack time at school for peer influence
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expanded variety of beverages and new foods he was interested in licking (sauces)
any foods in his repertoire that required chewing
reward based program for increasing table foods and variety, and introducing a no thank you bowl
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Gradual increase to oral eating with removal of g-tube at 7 years 1 month [Recognize that it typically takes children 2-3 years to move through all stages of oral skill development, and therefore, feeding therapy should be a slow process if skills are truly attained]
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play doh, finger paint)
frequent grimacing
development however, at 7 years 3 months, family saw decrease in progress of eating skills and returned to focus on feeding during OT
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specific desires for how his food is prepared, appears difficult for him to swallow at times, and overall behavior is a general concern
and cheese (without pepper added), tortellini (can be many varieties), pretzel goldfish, grapes, olives, cheese pizza, bean and cheese burritos, hot dogs, hummus, tortillas. Refused vegetables and most meats.
unexpected touch.
re-introducing the “steps of eating”, present foods outside of their packaging, Apps for toothbrushing, general sensory processing resources, information regarding Feeding Matters (organization)
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each session
events when food is involved, have designated nights for T to meal plan, and plant a garden/join a CSA/visit farmer's markets to become more engaged with where food comes from
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continue to move forward
progress through Steps of Eating with less stress To summarize: T is an example of a child with a medically based diagnosis necessitating g-tube use, who was able to successfully wean from the g-tube at age 7 with significant support, and lengthy intervention with slow steady progress, from many clinicians and his parents, however, continues with behavioral and sensory based challenges in regards to feeding and eating
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development
feeding
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grew well until around her second month of life when her parents began a sleep training program. She was the couples second child and they were determined to help her sleep better than their first.
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to sleep 12 hours at 2 months". Fed only 4 x at breast in 24 hours. Suspect Mom's milk supply then decreased. -Growth stopped for GC.
menses returned at about 8 weeks pp, move and stress
kneading breasts during feeding
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weight lacking)
screen (missing)
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PARENT/CAREGIVER CONCERN OR REPORT: 1- "how do we get rid if her NGT?"
get the tube out? 2 - why do you think she needed the NGT in the first place? 3- why is whole milk recommended, and is there a suitable alternative?
4- how do we know when she has achieved catch up weight?
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Sometimes pump assisted over one hour. – Mom had cut back on NG volume & night feeds
no chewing or swallow, with some intentional tongue thrusting out
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adverse to drinking
malnutrition- resolved
and TF volume
practices/responsive feeding
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comments and PCP contact
and adequate hydration. Nursing 2-3 times in 24 hours
visits
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share 1 bedroom.
removed),
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1) Desensitize the child to food cues.
2) Encourage, but do not force, the child to eat. 3) Do not allow the child to “graze” during the day. 4) Ignore resistant or oppositional behavior during mealtimes. 5) Praise eating behavior, even for small bites or attempts. 6) Remove toys/attention-getting devices during mealtime. 7) Allow toddlers to take more responsibility in feeding. 8) Encourage the child to eat in the presence of other people who are eating. 9) Follow meals with interesting reinforcers. 10) Preface meals with a calm-down time.
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1) Hunger induction (get 100% of hydration needs, but you want them to
get hungry – Most adults don’t eat because they are hungry, but because it is a habit. After it becomes a habit, then hunger will come.)
2) Escape extinction for refusal (can’t get away until they take a bite) 3) A structured meal and snack schedule (3 meals and 2 snacks) 4) Positive reinforcement for acceptance (toys, positive praise, etc.) 5) Gradually increasing response effort (extremely small at first =
“molecules”)
6) Extinction of inappropriate behavior (ignoring annoying behaviors)
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many children with feeding issues.
to be used forever.
– Continuous schedule with praise or reward every time initially – Fade this to be less and less in time.
want them to do initially.
natural reinforcers (e.g., food)
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– often called “planned ignoring”
– often called “escape prevention”
– “just waiting until he or she cooperates”
– Pick it up and ignore – Shape putting it into a “no thank you” bowl
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situations->thoughts->feelings->actions
High levels of difficulty – start with Mild!
Social, activity, and tangible
home with area to write thoughts down about this food.
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(and why we don’t use this…)
plate (B) containing large bites or pieces of preferred foods, and a drink
eating a bite of new food
eternal optimist
will have a meal again soon.”
diagnosed and she is on stimulant medication
in accepting certain textures
preferred foods
ways to reward her that remain powerful enough...
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with meaningful reinforcement.
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coupled with reinforcement - “We all make choices!”
tablets, and phones are off) with family-style serving
preparation at least once a week
behaviors, rather than inappropriate behaviors
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may impact feeding and growth
medical team visit
treatment in the community under the various systems of EI, private therapy, schools and other medical systems.
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variation common.
feeding
provide intake, but may not move on to the next level for higher textures
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– Excessive sucking, incoordination of feeding, vomiting and loose stools are common
effects, hyperalert babies.
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Infant Older Child/Adolescent Feeding refusal Abdominal pain/heartburn Recurrent vomiting Recurrent vomiting Poor weight gain Dysphagia Irritability Asthma Sleep disturbance Recurrent pneumonia Respiratory symptoms Upper airway symptoms (chronic cough, hoarse voice) Common Presenting Symptoms of GERD in Pediatric Patients
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Meds to reduce acid or increase good peristalsis Positioning Surgery ? probiotics ? Wait it out ? Thickeners Formula Changes Allergen avoidance Essential oils, ionized water, massage, acupuncture
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– Acid reducing PPIs and H2 Blockers might put kids at risk of colonization with
resistant bacteria- (then lower respiratory infections), might alter the internal biome in a negative way and might alter calcium metabolism leading to fractures ( as appears to happen in elderly)
– Prokinetic agents may be cramping, cause sedation, motor side effects or irritability
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in keeping food down – chronic coughs are common and a tsp
been associated with late onset NEC and the risks are not fully worked out.
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time already tried some by family.
powder, dairy free, real foods blended and maternal diet
with position and meds.
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Age distribution
CP 1
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with learning profiles and very likely also has some effect on long term emotional regulation
appetite and energy level to increase consumption
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developmental evaluations can be of variable intensity – but may help guide the treatment options, improve child's comfort and even preserve long term potential for good behavior and nutrition and hopefully alleviate family concerns.
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Albany, NY: Singular Publishing Group.
Challenges among Parents of 8- to 10-Year-Old Children. Journal of the American Dietetic Association, 108, 706- 709.
and lip tie release: A prospective cohort study. Laryngoscope, 127, 1217-1223.
eaters vs problem feeders. [Basic 4-day course] Seattle, WA, Star Institute for Sensory Processing Disorder.
Feeders.pdf
Books:
Cox, Walbert
Extreme Picky Eating –Rowell,
McGlothlin
Not Too Much – Satter Websites:
identify problems.
for Pediatric Feeding Disorder.