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A.feeding and swallowing disorder in an infant or child is often a clinical manifestation of an underlying medical disorder (see Table). Treatment, based on the underlying etiology after confirmed diagnosis, is an interdisciplinary process consisting of collaboration among medical staff (usually with a gastroenterologist), nursing, speech-language pathology, physical and occupational therapy, behavioral medicine and dietitians.

For acutely ill patients, the team process is initiated within the hospital setting and continues after discharge. The team suggests therapies and interventions to assist the child with the feeding process, as well as makes referrals to other healthcare professionals as needed, such as allergists, dentist, ear, nose and throat specialists, etc. Therapy goals focus on the feeding process, types of food, prevention of aspiration, the sucking process, helping the child reach developmental milestones and family education.

Suck-Swallow-Breathe
The sucking, swallowing and breathing processes are the cornerstones for infant feeding.1 All three processes are interrelated to achieve optimal feeding patterns. If an infant has a dysfunction in one of the processes, then one or both of the others also will be affected.

Sucking is the rhythmic movements of the infant's mouth and tongue to an object placed in the mouth, such as a nipple, pacifier, hand or object.1 Sucking plays multiple roles in an infant's development. There are many benefits to both types of sucking: Nutritive sucking is for nutrition, and non-nutritive sucking, such as use of a pacifier, provides a calming effect or maintains oral motor movement.

By sucking, an infant releases the milk from the mothers nipple. If an infant does not demonstrate a strong suck, the caregiver can enhance the sucking process by focusing on non-nutritive sucking. This can be done by placing a gloved finger or pacifier in the infant's mouth, pressing firmly 1-2 times per second, 4-5 times, on the middle of the tongue and pausing to see if the infant will suck unassisted. Repeat this procedure as the infant tolerates.2 Non-nutritive sucking is started first in neonates before they start nutritive sucking for feeding.

Swallowing Process
Swallowing consists of three phases: oral, pharyngeal and esophageal.1,3

The oral phase is when food is processed in the mouth and prepared to be passed through the pharynx. This voluntary process is completed through sensory and motor nerves. Sucking makes up this phase in infants, and in older children the process of moving food from the anterior portion of the tongue to the posterior portion occurs.

The pharyngeal phase is the process of passing fluid or solids through the pharynx into the esophagus. Three functions occur during this phase:

  1. closure of the nasal, laryngeal, and oral openings;
  2. opening of the cricopharyngeal sphincter; and
  3. creation of pharyngeal pressure to move the fluid/food from the oral cavity to the esophagus.

Goals of this phase include prevention of aspiration.

The esophageal phase is the last phase of swallowing. Here, peristalsis moves the fluid/food through the esophagus into the stomach. Swallowing dysfunction can be a result of anatomic or neuromuscular abnormalities, functional suppression or paralysis. Aspiration can occur before, during or after the swallowing stage.1

The third component of the suck-swallow-breath sequence is breathing. This refers to the infant/child's ability to coordinate breath patterns during the suck and swallow stages. Optimal positioning of the child's head and trunk can achieve an effective and safe suck-swallow-breath pattern.3 An infant may require a slower flow rate bottle nipple to enhance adequate respirations during the feeding process.

Assessment
Referral to a multidisciplinary feeding disorders team is recommended if a child has any indications of a feeding or swallowing disorder. This can include (but is not limited to):

  • choking or coughing with feeding;
  • poor oral motor control;
  • failure to thrive;
  • muscle tone disorders; or
  • food aversions.

Team members, consisting of a speech-language pathologist (SLP), physical therapist, occupational therapist, dietitian, staff from behavioral medicine, nurses and physicians, will obtain a complete history, including feeding and swallowing history, as well as a physical. The child may have labs drawn to confirm any underlying etiologies, and radiological exams may be ordered.

Interventions
Intervention for a child diagnosed with a feeding and swallowing disorder should encourage successful, developmentally appropriate feeding skills, and promote and maintain optimal nutrition.2

Developing proper body mechanics enhances the feeding process. A child should sit upright in a chair with feet flat on the floor and hips, knees and ankles flexed at a 90-degree angle. If the child has poor head control, the head and trunk need to be supported. The caregiver should sit directly in front of the child to prevent the child from hyperextending the neck.

The caregiver also needs to focus on the type and texture of the food. If the child can chew solid foods, the food should be cut into small pieces and the child taught to chew thoroughly. For children who may aspirate or do not tolerate liquids well, the liquids can be thickened with rice cereal (1 or 2 tsp per fluid oz), yogurt or pudding. Pureed foods also can be provided.

The temperature of the food should stimulate the child's mouth, and cold temperatures help alert the child. Room-temperature food provides the least sensory stimulation and may be easily aspirated.2 Caregivers also may have the child try different flavors such as spicy, sour or tangy food to stimulate feeding.2

Older children who use cups and other utensils for eating and drinking may need to have these items adapted.2 Cups that can be tipped to get the fluid out without causing the child's head to tip backward, such as a cut-out cup, are optimal. The caregiver should use a clear cup to allow for visualization of the child's lips while drinking. Modifications to the spoon may include using a flat-shaped spoon that fits the child's mouth. If the child has hypersensitivity of the mouth, a coated versus metal spoon is better to avoid overstimulation.

Infants
Breastfeeding is always encouraged for infants with feeding disorders. However, if the infant has difficulty latching on and sucking, the mother can express her milk into a bottle with a specialized nipple.

Infants with difficulty tolerating bottles will need some alternatives.2 Focus on the nipple; slower flow rates should be used for infants with respiratory compromise, poor endurance or a weak suck. A faster flow rate nipple should be used for infants who show early fatigue. If the infant also becomes disorganized, a dripless nipple is recommended. Infants with hypotonic tongues need a firmer nipple, and those with a weak suck or early fatigue require a softer nipple. The size of the nipple should be appropriate for the size and shape of the child's mouth. The bottle also can enhance the feeding process; bright-colored bottles with designs provide visual stimulation.

Infants should be held with an overall feeling of flexion of the body; the head should be midline with slight flexion or extension. The infant's shoulders should be symmetrical and forward with the arms flexed and toward the body midline, hips flexed from 45 to 90 degrees. Flexion and extension of the body can be altered based on hypertonicity or hypotonicity. The caregiver should hold the infant in the standard position (on the caregiver's arm), the face-to-face position (the baby held looking at you) or side lying in the bed for the baby who cannot tolerate being held.2

Making adjustments and taking time during the feeding process can achieve optimal nutrition and enhancement of developmental milestones. Be patient and soothing while feeding children; make it a pleasurable experience for the child to look forward to. As the child progresses, continually educate the family and caregivers so transition is as smooth as possible for the child.

Deborah Hill-Rodriguez is the clinical nurse specialist in the specialty medical and surgical units at Miami Childrens Hospital.

References
1. Wolf, L.S., & Glass, R.P. (1992). Feeding and swallowing disorders in infancy: Assessment and management. San Antonio: Therapy Skill Builders.

2. Hall, D.H. (2001). Pediatric dysphagia resource guide. San Diego: Singular Thompson Learning.

3. Siktberg, L.L., & Bantz, D.L. (1999). Management of children with swallowing disorders. Journal of Pediatric Healthcare, 13(5), 223-229.




     

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