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Frequency of swallowing in children
600-1,000 times per day
Frequency of swallowing in adults
up to 2,400 times per day
Greatest elongation of pharynx and downward displacement of larynx occurs during:
- girls 11~15 years
- boys 13~15 years
- boys can have swallowing problems due to dropping/forward movement of larynx during puberty
Prenatal Development (gestational age)
Week 3- CNS system begins to develop
End of week 3- blood circulates to heart.
Week 4-7- four chambers of heart develop.
Week 4- respiratory system begins to develop.
Week 4- mandible develops.
Week 4- primitive gut develops (digestive tract)
Week 5- palate develops (separating oral/nasal cavities) and is complete by week 12 (hard and soft palate fusion).***
Prenatal Development (gestational age) continued
Week 5- arytenoids and epiglottis begin to develop.
Week 5-6- 12 cranial nerves formed
Weeks 6-7- lips and tongue begin to develop.
Week 7- esophagus elongates and reaches final relative length by 7th week.
Week 7- Taste buds present and mature at 12 weeks
Between 3-8 weeks after fertilization, the embryo develops all major systems.
Embryo consists of 3 germ layers (ectoderm, mesoderm, endoderm) from which all tissues and structures of body form.
-reflex elicited by placing nipple in mouth, stroke tongue or touch hard palate.
-Backward and forward tongue movement and up and down jaw movement
-Involves Cranial Nerves V, VII, IX, XII
-Present 18-24 weeks gestation
-Disappears 4-6 months
-reflex elicited by placing nipple in mouth or touching hard palate.
-Up and down movement of tongue with smaller vertical jaw excursion. Jaw moves more independently
-Movement is rhythmical and lip seal around nipple is firmer.
-Infant repeatedly pumps tongue expressing milk from nipple and collecting liquid at faucial arches or typically valleculae.
-Cranial Nerves V, VII, IX, XII
-Present around 6 months of age
-Diminishes 24 months or older**
2 types of sucking:
1) Nutritive- nutrition
2) Nonnutritive- calming, state regulating and pacifies
-Helps medically fragile children (i.e. esp. tube feedings) adapt to new environments, self-stabilize, increase oxygen saturation levels, and increase feeding performance
-twice as fast as nutritive sucking (NNS 2x/sec vs NS 1x/sec) bc they aren't pausing to swallow
4 important factors to consider from birth to 36 months:
-separation of movement
-movement options (all 3)
child's ability to produce rhythmic movement patterns
child's ability to hold body steady.
Important to the development of coordinated and organized movement patterns.
-Examples include sucking pads and physiological flexion (fetal position).
Separation of movement
ability to move one part of the body without moving other parts.
-Vital to feeding and development of speech.
rhythmicity+stability+separation of movement
-Allow infant more than one way to perform a physical activity.
-Allow infant to experiment with different ways of dealing with unfamiliar tasks.
separated into 3 periods
1) Nursing Period (birth-3 mos)
2) Transitional Period (4-6 mos to 1 yr)
3) Modified Adult Period (12-24 mos)
1 year old
Whole cow's milk should not be given until approximately this age. Contains little iron and vitamin C
Physiology of the pediatric swallow
1) Motor development
3) Postural stability*
4) Swallow function
5) Cognitive development
6) GI function (not fully developed until ~1 year)
Development of Postural Stability
Muscle use against gravity in response to shifts in weight through various planes of movement.
phasic movement patterns
change with every move we make
Breathing in infants
Close proximity of tongue, soft palate, pharynx, and larynx facilitates nasal breathing (infants obligate nose breathers)
-Infants can suck and breathe; can't swallow and breathe
Transverse tongue reflex (Cranial Nerve XII)
-stimulated by touch or taste on lateral portion of tongue. Causes tongue to move in direction of stimulus.
-Precursor to tongue lateralization
-Present birth-6 months of age
Phasic bite reflex (Cranial Nerve V)
-rhythmic series of up and down jaw movement produced after tactile stimulation to the teeth or gums.
-Present at birth-6 months.
-Precursor to mastication
airway defense mechanisms
drop in heart rate
the constriction of the airways in the lungs due to the tightening of surrounding smooth muscle, with consequent coughing, wheezing, and shortness of breath
Infant enjoys a variation in color and taste of food as early as 4-6 months. Food variation culturally dependent
-Sweet: preferred by infants, children, and adults.
-Sour: rejected by infant. Becomes a preference in childhood (24 months+)
-Bitter: infants reject or are indifferent to. Children and adults generally reject.
-Salty: infants reject or are indifferent to. Becomes a preference by 4 months.
-Expanding taste preferences
-can be developed
GI system develops based on what you put into it. May be affected by:
-Intestinal muscle function
-Lack of physical activity
-Increased constipation common with low tone children.
Normal reflux a result of:
1) Shorter esophagus
2) Decreased capacity of esophagus
3) Liquid diet
4) Reclined posture for feeding
-50% 0-3 month olds regurgitate 2 or more times a day
-70% 4-6 month olds
-25% 7-9 month olds
-Less than 10% 10-12 month olds
Gastro-Intestinal Functions Barriers to Reflux
-Esophageal volume capacity
-Apnea/Airway Clearance (infants)
-Cough/Airway Clearance (6 mos+)
-Acid Neutralization (saliva swallows)
When assessing infants and children with feeding disorders, it is important to consider the following:
-Oral motor development
-Ability to maintain nutrition and hydration
-Relationship and interaction between caregiver and child.
-Medical and/or neurological problems affecting the child.
Where to begin a clinical assessment
-Begin with thorough case history—including parental concerns.
-Evaluate sensory, motor, and structural components involved in the feeding and swallowing process (sensation, symmetry, tone, elicited movements).
-Observations/assessment of feeding and swallowing
-Recommendations for further diagnostic procedures
Nasogastic (NG) tube
-placed through child's nose into the esophagus with the tip resting in the stomach.
-Physician practices vary (leave in for several days vs. change daily from one nostril to the other or reinserted for each feeding).
- Advantages: provides short term nutritional maintenance, an infant or child can eat by mouth while in place, and may be replaced with gastrostomy if supplemental nutrition required long term.
-Disadvantages: associated with reflux, sinusitis, increased gagging, abnormal sensory input, and aversion to being touched about the face.
-Insertion of tube through nasopharynx prevents closure of velopharynx, which decreases intraoral pressure. This may interfere with sucking and swallowing.
Orogastric (OG) tube
-inserted via mouth through pharynx, esophagus and into the stomach. Almost always removed after each feeding and replaced for the next feeding.
-Advantages: preferred method for young infants (nasal breathers) and provides short-term nutritional maintenance.
-Disadvantages: very difficult for child to eat by mouth, interference function, and presence of foreign body in the pharynx and esophagus.
Percutaneous endoscopic gastrostomy tube (PEG tube)
-placed surgically through abdominal wall directly into the stomach.
-Advantages: beneficial for a child who requires nonoral feedings for extended period (greater than 3 months), can be kept under clothing and child is less likely to pull at it, and there is no tape or aversive stimuli around face.
-Disadvantage: Can be associated with reflux.
Percutaneous endoscopic jejunoscopy (PEJ tube)
-similar to gastrostomy tube but the surgery passes tube through the abdominal wall into the jejunum, which is the beginning of the small intestine past the duodenum.
-Advantage: reduced risk of reflux vs. PEG.
states of alertness
Stage 1: Deep sleep
Stage 2: Light sleep
Stage 3: Drowsy-semi dozing *
Stage 4: Quiet alert *
Stage 5: Active alert
Stage 6: Alert agitated
Stage 7: Crying
optimal stages of alertness for feeding
Stage 3: Drowsy-semi dozing *
Stage 4: Quiet alert *
staring, looking panicked or hyper alert, discharge smiling, silent crying, dozing, and startle.
facial grimacing, twitching, hyperextension of trunk, arms, hands, or legs.
Autonomic (mild) stress
gasp, sigh, sneeze, sweating, hiccup, tremor, startle, and strain.
Autonomic (severe) stress
coughing, gag, reflux, skin color change, respiratory pausing, and irregular respiration.
If child is unable to protect the airway during feedings, then the child is NOT a candidate for oral feedings.
-goal is to observe respiratory patterns before, during, and after feeding to determine if the child can be fed orally.
-Observe respiratory/swallow coordination, unstable until 3 months age.
When evaluating aspects of oral, pharyngeal, and/or laryngeal mechanism, important to consider:
sensation, symmetry & tone, strength, and elicited movements (ROM, coordination, rate)
Eval of face sensation
-Will the child allow touch to the face?
-What is child's response to touch?
-Can the child determine site of touch?
-Can he discriminate textures?
Eval of lip sensation
-Will the child allow touch to lips?
-What is child's response to touch?
-Does the child attempt to wipe the lips when drool or food is present?
-If lips are touched, can he determine the site of the touch?
-Does touching the lips trigger abnormal reflexes (i.e. startle)
-Does touching the lips trigger lip retraction, bite, or pucker?
Eval of lingual sensation
-Is there a hyperactive gag?
-Is a bite reflex elicited?
-Is there tongue retraction?
-Does the child turn away or grimace when tongue is touched?
Eval of palatal sensation
does not need to be addressed formally.
Eval of velopharyngeal sensation
Does child exhibit gag after stimulation to back of the pharynx?
3 major concerns of evaluating oral feed
1. Safe feeding with minimal risk for aspiration.
2. Functional feeding with sufficient caloric intake for weight gain within a reasonable length of time each feed.
3. Pleasurable feeding.
oral intake performance dependent on
2) level of cognition
4) comfort level
Management of GERD
-Decrease volume and increase frequency
-Nothing by mouth 3-4 hours before bed
-Surgery to strengthen tonicity of LES
Management/Treatment of Feeding and Swallowing Disorders in Children
-Primary importance establish adequate and healthy breathing patterns.
-Next priority meeting nutritional needs.
Specific goals for the infant/child diagnosed with dysphagia are based on the result of comprehensive clinical assessment of:
1) Oral motor skills
2) Oral sensory skills
3) Respiratory status
4) Phonatory status
6) Muscle tone
9) Language level
Primary goals of dysphagia therapy are to:
1) Promote adequate nutrition/hydration
2) Develop age appropriate feeding skills
3) Educate, train, and work collaboratively with the individual(s) who are primarily responsible for the development of the child within his/her environment.
help to ensure successful feeding in the presence of the underlying disorders.
promote and/or develop normal feeding skills.
Compensatory Strategy examples
1. Establishing optimal infant state/feeding readiness
2. Organizing the infant for oral feeding/altering the environment
3. Establishing optimum position/posture
4. Altering the consistency, temperature, volume, and taste of food.
5. Changing feeding utensils (equipment adaptations)
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