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Disorder of swallowing which can involve oral and/or pharyngeal difficulties
Dysphagia
A term used to reference the strength, ROM, coordination and endurance of the musculature of the face and mouth that is used for speaking and the oral stage of swallowing
Difficulties with the swallowing structure, musculature, timing and sequence of swallow once bolus leaves oral cavity
Pharyngeal dysphagia
A neurological "dislike", fear, avoidance of sensory input that interferes with functional development of skills or ability to compensate ADLs
Sensory defensiveness
When food/liquid material enters the larynx and is squeezed out either during the swallow or from a cough or throat clear that occurs. The material never falls below the vocal cords.
Laryngeal penetration
Strength, coordination and endurance of muscles from the shoulder girdle to the hips; required for head control
Trunk control
Difficulties with oral sensory acceptance of food, liquids; difficulty with oral containment, oral manipulation, bolus movement and control, oral preparation for the pharyngeal swallow
Oral dysphagia
- Weakness or discoordination in the muscles of the mouth (oral) and/or throat (pharyngeal)
- Often can result in coughing, gagging, and possibly choking during mealtimes
- Aspiration, which can be "silent", can occur and result in frequent illness
- No age limit - can impact a person from birth to geriatric
- Etiology can be neurological, drug exposure, genetic or unknown
- Can morph into a sensory feed disorder, extreme "picky eating", or failure to thrive
Motor based swallowing disorder
When food/liquid material enters the larynx and falls below the true vocal cords and enters the trachea
Aspiration
What are the (2) major anatomy differences between adults and children when it comes to swallowing?
1. Childs tongue is larger compared to their mouth
2. Vocal cords are slanted
- "Picky" versus sensory
- Dysphagia?
- OT and SLP
Sensory processing feeding disorder
- Premature infants (36 weeks or less)
- C-section delivery
- In utero drug exposure
- Jaundice
- Full term infants unable to latch on to the breast or bottle
- Patients on a trach/passey muir speaking valve
- Patients on a feeding tube system of any kind
- GERD
- Diagnosed failure to thrive
- Respiratory issues
- Specific medical diagnosis: CP, cleft palate, down syndrome, CVA, TBI, genetic syndromes
Higher risk for feeding issues
- Coughing or choking during meals or drinking
- Wet vocal quality during or after meals
- Messy eater
- Food/liquid material expelled from the nasal cavity
- Food left in mouth after meal
- Avoids specific foods
- Eats fast at the start of the meal and tires as the meal continues
- Swallows without chewing
- Takes a long time to eat a meal/bottle
- Takes frequent breaks during eating/drinking
- Holds food in the mouth for periods without swallowing
- Difficulty or failure to advance to age appropriate diet
- Chronic sickness including pneumonia, upper respiratory infection, ear infections, asthma, RSV, sinus infection
Clinical signs of dysphagia
- Hypotonia and hypertonia: affects both external and internal musculature
- GI: discomfort, difficulty swallowing
- Feeding tube placement: impact hunger
- Cardiac: reduces endurance and coordination
- Respiratory: can impact and be impacted by swallowing disorders
Medical conditions impacting feeding
- Arching back
- Splayed hands
- Head turn
- May appear hungry but refuse to eat or eat very limited amounts
- Eats only certain foods/textures -- often very specific
- Eats only when distracted
- Gagging during eating or at the sight of certain foods
- Poor tolerance of "mess" on hands, face, or skin
Signs of sensory based feeding disorder
- Bypassing the stomach requires special formula where nutrition is broken down to help aid digestion
- Feedings are continuous at low volume and can run 18-24 hours a day
- More permanent -- has to be in for 30 days at least
Jejunostomy tube (GJ tube)
- Passed through the nose to the stomach
- Placed temporarily to aid in supplementation
- Can be bolus or on a pump
Nasogastric tube (NG tube)
- Passed through the stomach and to the jejunum to decrease reflux and vomiting of feedings due to intolerance
- Require slow volume, continuous feeds
Nasojejunum tube (NJ tube)
Assessment completed in the room or clinic with food and liquids as appropriate to the patients age and level of intake
Clinical dysphagia evaluation
- Can take larger bolus size in short periods of time
- More permanent -- has to be in for 30 days at least
Gastrostomy tube (G-tube)
- Further evaluation with a pediatric video swallow study
- Liquid or food alterations
- Presentation alteration/adaptions
- OT/PT/ST evaluation
- Dietary consultation
- GI consult
- ENT consult
Common recommendations: clinical evaluation
Assessment completed in the radiology suite with food/liquids mixed with barium as contrast
Video swallow study
- Oral motor therapy
- Feeding therapy
- Sensory integration therapy
- PT for trunk/core strengthening
- Diet changes for consistency of food with the goal to progress to age appropriate food/liquids and presentation modality
Treatment options
- Food or liquid alterations
- NPO
- Presentation adaptations/alterations
- OT/PT/ST evaluations
- Dietary consultation
- GI consults
- ENT consult
- Audiological evaluation
Common recommendations: pediatric video swallow study
- Case history/parent interview
- Oral motor examination
- Feeding observations with parent, child and or therapist feeding current diet and alternate consistencies as appropriate
- Screenings for sensory processing skills, fine and gross skills
- Screening for speech, language and play skills
Clinical evaluations for pediatric dysphagia