Pediatric Dysphagia

CSD 625 Developmental Milestones as they relate to Feeding

Objectives
Cognitive Development Gross & Fine Motor Development Oral Motor Skills Sensory Development Taste & Olfactory Milestones Some Myths about Mealtime (scattered
throughout)

Myths about eating interfere with understanding and treating feeding problems.

Myth #1

Eating is the Bodys #1 Priority

Normal Cognitive Development

 Piaget Birth to 24 mos=Sensorimotor

Understanding of the world is based on physical experience Symbiosis with primary caregiver

 Birth:
Vision best at 7+ inches Prefers sharp visual contrasts Turns head to moving objects Prefers human voice Sleeps 20 hours/day Short visual memory Control of eye muscles (2 months) Regular feeding expected Chooses faces over objects

 3-4mos
Searches/localizes for sounds Able to focus visually Visual/oral exploration Visual memory up to 7 seconds Senses unfamiliar places Identifies mom in gathering of people

 6-7 mos
Coordination of vision and grasping objects Oral/tactile exploration Reaches to retrieve objects Starts to search for lost toys Imitates actions Cause/effect of movements (emerging) More interactive

 9-10 mos
Prefers complex toys Recognizes color/form Actions become intentional Depth perception emerges Identifies body parts by pointing

 12-15 mos
Symbolic play emerges Object permanence Uses simple objects (tools) Reaches without looking Following simple instructions Ambulatory

 2 to 5/7 years
pre-operational thinking Pre-logical thinking and magical thinking Connections between events are made based on closeness in time (arent necessarily true)

 5/7-9/11 yrs
Concrete operations Logical thinking Still can not complete reverse operations

 9/11 years and on

Formal operations Abstract thought Can reverse on operation directly in the mind versus needing to act on the world;

Myth # 2

Eating is instinctive

Gross & Fine Motor for Feeding

 2 -3 mos
steady head control achieved

4-6 mos
beginning of hand to mouth play (independent and exploration of objects); increased reaching skills, reaches for spoon when hungry

 6-7 mos
Trunk control sufficient for independent sitting for greater than 3-5 sec Stable head control in sitting (no head bobbing) Transfer toys and food from one hand to the other

 8-10 mos
Trunk rotation and weight shift Beginning to move in and out of positions Voluntary release patterns Uses fingers to rake food toward self Puts finger in mouth to move food and keep it in

 10-12 mos
Independent sitting in a variety of positions Pincer grasp developing Pokes food with index finger Uses finger to self-feed soft chopped foods

 14-16
Efficient finger feeding Practicing utensil use versus effective use for volume Typically co-feeding with a parent

 18-24 mos
Able to pick up, dip, bring foods to mouth Increasing utensil use (not efficient until after 24 mos) Scoops purees with utensil and brings to mouth

Definition of muscle tone

the state of activity or tension on a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. United Medical Language System (MeSH) at the National Library of Medicine A state of partial contraction that is characteristic of normal muscle, is maintained at least in part by a continuous bombardment of motor impulses originating reflexively, and serves to maintain body posture. (Merriam-Websters Medical Dictionary)

Re: postural stability

Children with Low muscle tone may Slouch while sitting Prop when sitting Joint lock/fix Slides out from underneath table/trays Prefer to stand to eat Like to walk around and eat Appear stronger than they are because of joint locking

Myth #3

Eating is easy!

Oral Motor Milestones

 Preterm-Term
Organizing physiological system Maturing coordination of suck/swallow/breathe Development of flexion Maturing muscle tone Maturing motor modulation Organizing state stability and transitions

 Birth-3 mos. (reminder)

Oral space filled by the tongue, full contact with gums, as well as soft and hard palate; Structures are vertically compressed Buccal fat pads support sucking by providing stability

 Birth to 3 mos
Soft palate & epiglottis are in contact (babies are obligate nose breathers likely due to obstruction) Larynx & hyoid cartilage are higher in the neck and closer to the base of the epiglottis Suction is created with tongue cupping and jaw movement to generate negative pressure

 4-6 mos. Changes in Anatomy

Downward-forward growth of mandible Tongue no longer fills oral cavity Breath/bottle nipples no longer automatically compressed inside the mouth Tongue must be active to help achieve compression Tongue lateralization emerges at 6 mos if food is placed on sides of tongue

 4-6 mos
Opens mouth when spoon approaches or touches the lips Initial difficulty moving food back; which is active rather than through changes in pressure Tongue used to move purees to back of the mouth for the swallow

 4-6 mos
Tongue moves back and forth as food is introduced Suckling foods rather than phasic biting Able to keep foods in mouth vs being re-fed Munching pattern may appear near 6 mos

AAP recommendations for the transition to solid foods

Exclusive Breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 mos after birth (Pediatrics, 1997, 100(6), 1037) In the first 6 mos, water, juice and other foods are generally unnecessary for breast fed infants (Pediatrics, 1997, 100(6), 1037) Position re-affirmed (Pediatrics, 2001, 108(5), 1216-1217)

Nutrient adequacy of exclusive breastfeeding for the term infant during the first six mos of life (WHO)
Iron endowment (from mother) meets needs for 6 mos in term infants; Outside source of iron needed to prevent iron deficiency after 6 mos; Zinc is more bio-available in breast milk; Zinc stores need to be replenished by 6 mos
WHO source Nutrient adequacy of exclusive Breastfeeding for the term infant during the first months of life http://whqlibdoc.who.int/publications/9241562110.pdf see also: Zlotkin, S.H. (2002), Iron, Zinc, and Calcium; fundamental nutrients for infants and young children. Pediatric basics, 97, 12-20.

Factors influencing beginning solid foods

Physical readiness (hold heads up, sit by self 3-5 sec) Physiological maturity to digest, metabolize more complex nutritional foods Cognitive and motor development Impact of chronic disease Other social, psychological, cultural, economic considerations
Guthrie, 1997

 7-9 mos
Lip closure supports movement of bolus to pharyngeal area Able to bring top lip down on spoon to remove foods (clear the bowl)

Spoon technique
Use infant feeding spoon (small bowl, long handle) Parent brings spoon straight-on, into the front of the mouth (not sideways) Parent stops spoon when just inside the lips, with spoon tip approximately at the tip of the tongue (or slightly further in, if need to work on tongue cupping) As child closes lips around the spoon, parent draws spoon straight back (no dumping, scraping onto the palate)

 7-9 mos
Consistent tongue lateralization seen when foods presented to sides of tongue; Mature tongue lateralization emerging Active movement of foods from side of mouth to central tongue groove and back

 7-9 mos
Able to transition to slightly more texture (small bumps) With assist, able to break off pieces of meltable foods Chewing (munching) of softer foods

 10-12 mos
Clearing food off of lips emerges Simple tongue protrusion may occur More controlled biting, isolated from body movements Full transfer of foods from sides across midline occurs, without difficulty
*gross motor crossing midline milestones?

 12-15 mos
Chews and swallows firmer foods w/o choking Chews foods that produce juice Able to keep most bites in mouth during chewing

 16-24 mos
Uses tongue to gather shattered pieces Sweeps pieces into a bolus with the tongue Chews bigger pieces of soft table foods Working on chewing foods increasing in texture hardness

 16-24 mos
Working on increasing speed and efficiency Chewing strength improves Better able to manage hard-to-chew foods

% calories from solid foods

4-5 mos 5-6% 7-8 mos 8% 9-11 mos 25% 24 mos 63%
Briefel, Reidy, Kanwe, Jankowski, Hendricks. (2004) Toddlers transition to table foods: impact on nutrient intakes and food practices. Journal of American dietetic association, 104, 538-44. Fox (2006). What are kids eating? FITS data reveals unhealthy trends appearing in toddlers. Pedatric Basics, 112, 2-17.

Myth #4

Eating is a two-step process

Sensory Development

Taste Milestones (Mennella, Julie)

7-8 wks gestation- appearance of specialized taste cells; mature taste cells at 10 wks 12 wks gestation fetal swallowing begins 6 mos gestation- increases in swallowing to sweet taste injected in amniotic fluid; decreased swallowing to bitter taste injected

Taste Milestones (Mennella, Julie)

Newborn has >2500 taste buds dispersed throughout the soft palate, epiglottis, pharynx, larynx Newborns can discriminate between different concentrations of sweet flavors 2 wks old reject bitter tastes 2 mos old reject sour tastes

Taste Milestones (Mennella, Julie)

3 mos can detect flavor differences (eg. increased suckling to new flavors) 4 mos preference for salt taste emerges 1-3 yrs # of taste buds remains constant 8 years same # taste buds as adults but higher density due to smaller tongue size

Flavor facts
Flavor of amniotic fluid reflects flavor of mothers diet
(detected by fetus in the 2nd trimester)

Flavor of mothers diet in the last trimester impacts newborns responses to similar foods after birth
(eg. orients to garlic as newborn if Mother ate regularly in last trimester)

Flavor Facts (contd)

Flavor of mothers milk reflects the mothers diet Breast fed infants are more accepting of solids due to exposure to a variety of flavors 0-6 mos experience with sweetened food does not lead to a generalized heightened preference for sweet tastes in all other foods

Olfactory Milestones

Olfactory Milestones (Mennella)

8 wks gestation primary olfactory receptors present and olfactory bulbs form by 10 wks gestation 24 wks gestation markers of olfactory function are present (olfactory marker protein) 28 wks gestation respond to nasally administered odors (eg. changes in facial responses and movement)

Olfactory Milestones (Mennella)

6 mos gestation nares plugs resolve and airway is then open and continuously bathed in amniotic fluid Newborn prefers smell of mothers unwashed breast Newborn can recognize mother by smell within hours

Dysfunctional sensory modulation patterns

Sensory over-responsivity Sensory under-responsivity/low arousal Sensory under-responsivity/seeker Sensory craving

Examples of smell over-responses

Covering nose Eye watering Turn head away Makes a funny face Coughing/gagging to smells

Examples of Tactile over-responses

Lip splays Grimacing Frequent hand wiping Finger splaying

Examples of Taste over-responses

Gagging Vomiting to tastes Grimacing/lip splays Shudders

Under responder- low arousal

Doesnt react to large noxious smells Cant locate or loses food in mouth Pockets food in mouth Staring into space Humming, rocking, self stimulation Swallows food whole or barely chewed May miss facial expressions

Under responder- seeker

Prefers big and/or complex flavor/tastes Appear to have decreased pain responses Constantly in motion Crashes, climbs everything, may appear aggressive Grinds teeth Seeks spinning Overstuff food into mouth Intense examination of details

Sensory discrimination problems

The child with discrimination issues has difficulties identifying between the specific characteristics within a sense.
Anita Bundy (2002) Sensory Integration; Theory & Practice (2nd ed)

Discrimination and feeding

Problem: the discrimination requirements of feeding change over time as development progresses and as the type of food offered is changed.

Eating
is the

most difficult sensory task that children do

Sensory changes during bottle & breast feeding

Sight-stays the same Sound- stays the same Touch- stays the same Taste- stays the same on formula, different if breast fed Smell- stays the same if formula, different if breast fed Balance-someone else provides Kinesthetic-someone else can provide Proprioception-rhythmical changes

Sensory changes during spoon feeding

Sight-only color changes Sound- stays the same Touch- stays the same Taste-changes within a limited spectrum Smell-changes within a limited spectrum Balance-provides by self, no chewing head shifts Kinesthetic-purees need minimal tracking Proprioception-open and close movements

Sensory changes with textured table foods

Sight- changes with every chew; Sound- changes with every chew; consistency is different Touch- changes with every chew; texture is different Taste- changes with every chew; molecules are broken Smell- changes with every chew; molecules are broken Balance- changes with every chew; head shifts every chew Kinesthetic- changes with every chew; pieces shift around Proprioception- changes with every chew; pressure is different

The End