The Basics of Feeding: A Workshop in Pediatric Dysphagia. Part I.

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The Basics of FeedingA Workshop in Pediatric
Dysphagia. Part I.

• Stacy Antoniadis, MA, MPH, CCC/SLP
• Lisa McCarty, MS, CCC/SLP
• Julie McCollum Daly,BS, OTR/L
• Cindy Straub, BS

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This workshop is sponsored by Early Intervention
Technical Assistance through the Pennsylvania
Departments of Health, Education and Public
Welfare
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About the Authors
Stacy Antoniadis has been a consultant with Early
Intervention Technical Assistance of Pennsylvania
(EITA) since 1991. She provides technical
assistance and training to provider agencies who
serve Pennsylvanias early intervention (birth to
five) population. She holds the M.A. in Speech
Pathology and M.P.H in Community Health
Education. Ms. Antoniadis had over 14 years of
clinical experience working with infants and
toddlers in a variety of settings before joining
EITA. Currently she is the Chair of the American
Speech-Language Hearing Associations
Communication Disorders Prevention and
Epidemiology Study Group.
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About the Authors
Lisa C. McCarty graduated cum laude with her
Bachelors Degree in Secondary English Education
at Millersville University in Pennsylvania where
she concentrated in linguistics. She received her
Masters Degree in Communication Disorders from
the Pennsylvania State University at University
Park. Lisa is currently a licensed speech
language pathologist in the State of Pennsylvania
and has been employed with the Capital Area
Intermediate Unit as a pre-school speech-language
pathologist since 1994. She has attended and
presented dysphagia training workshops and has
served as a consultant regarding
feeding/swallowing issues. She has attended
workshops by Jerilyn Logemann,Ph.D. and the oral
motor courses presented by Debra Beckman, M.S.
CCC-SLP. She lives in New Cumberland, PA with her
husband, Andrew and daughter,Catherine.
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About the Authors
Julie McCollum Daly, is a licensed Occupational
Therapist. She is a graduate of Thomas Jefferson
University in Pennsylvania. She is currently
employed at Ken-Crest Services in the birth to
three early intervention program and is a member
of the Ken-Crest home and community based feeding
team.
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About the Authors
Cindy Straub has been Developmental Specialist
at Tiny Tot Child Development Center in
Rochester, PA since 1993. She currently provides
early intervention services including feeding to
children with special needs (birth to five) and
their families in their natural environment.
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The Basics of. . .

• swallowing
• typical feeding development and nutrition
• medical conditions contributing to feeding
  problems
• nutritional problems in feeding disorders
• feeding safety practices

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Anatomy and Physiology Related to Pediatric
Feeding Disorders

• Introduction
• Overview of Structures
• -Lips, Teeth, Tongue, Palate, Larynx
• Esophagus, Lungs
• Phases of Swallowing
• -Oral Preparatory Phase, Oral Phase
• Pharyngeal Phase, Esophageal Phase

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Introduction

• People swallow 600-800 times per day
• Purposes Eliminates nasal mucous, saliva and
  food
• Feeding and swallowing (as related to nutrition)
  affect our ability to concentrate and learn

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A Few Definitions

• Feeding Generally considered the act of getting
  the food from the cup, dish or bowl to the mouth
• Swallowing Generally considered the next step.
  After the food gets to the mouth, the swallowing
  process includes preparing the food to be
  swallowed, moving it to the back of the mouth and
  triggering the swallow

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Overview of Structures

• Activity Jot down the body parts crucial for
  swallowing

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Activity Observe Lip Movements

• Part 1 Chew an animal cracker. Watch someone
  else do the same, or watch yourself in the
  mirror.
• Observe What are the lips doing? How are they
  doing it?
• Part 2 Now, take another bite, pretend that the
  lips arent working very well.
• You might notice they are very weak or they dont
  close.

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Lips

• Removes food from spoon, and liquid from cup
• Need adequate ability to move (range of motion)
• Need adequate strength
• Need ability to maintain closure while chewing
  and swallowing

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Teeth

• Need to adequately chew food
• If food is not chewed, choking may occur
• Nutrients may not be adequately broken down and
  used by the body if not properly chewed and
  broken down first (masticated)
• If not cared for can lead to drooling
• Poor jaw alignment may impact feeding

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Tongue

• Needs adequate strength to break down foods,
  transfer foods, and maintain control of foods
• Needs adequate range of motion to clear oral
  cavity
• Needs stamina to maintain strength and agility
  throughout a meal

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Cheeks

• There are many muscle groups in the cheeks
• In feeding they help to control the liquid and
  food in the mouth
• If the cheeks do not work properly, food can fall
  into the lateral sulci (between the outer gums
  and cheek walls) If the tongue is not working
  either, the food and nutrients cannot be retrieved

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Soft Palate

• Elevates at the point of the swallow to prevent
  nasal reflux
• If cleft, there is no prevention for the nose
• Lost food means lost nutrients
• Nasal obstruction may prevent palate from closing
  properly may cause difficulty maintaining a
  closed mouth posture and mean a potential loss
  of food/nutrients

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Larynx

• PROTECTS AIRWAY
• Epiglottis flips over the larynx
• Vocal folds close over the trachea (windpipe)
• Larynx elevates to allow food to pass into the
  esophagus

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Esophagus

• Hollow muscular tube with sphincters at each end
  peristalsis moves that food down
• UES-Upper Esophageal Sphincter muscle that opens
  to the pathway from larynx to stomach
• LES-Lower Esophageal Sphincter muscle that opens
  from the esophagus to the small intestine

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Lungs

• Not important in swallowing itself
• If food is not swallowed properly and gets into
  the trachea and lungs, pneumonia can result
• Aspiration is the action of material penetrating
  the larynx and entering the airway below the true
  vocal folds (Logemann, 1983)
• Aspiration can generally be seen in the right
  lower lobe on an x-ray of the lung

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Aspiration Signs and Symptoms

• Fever spike five minutes after the episode
• Coughing
• Wet voice quality
• Medical history of frequent upper respiratory
  infections / pneumonias
• Weight loss

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Phases of Swallowing

• Oral Preparatory Phase
• Oral Phase
• Pharyngeal Phase
• Esophageal Phase

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Oral Preparatory Phase

• Lip closure
• Cheek tone
• Rotary and lateral jaw movement
• Rotary and lateral tongue movement
• Anterior bulging of the soft palate
• Tongue forms a bolus with the food

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Oral Phase

• Bolus is held between the tongue and palate
• Tongue pushes bolus to the back of the mouth
• Tongue elevates and retracts squeezing the bolus
  along the palate
• If tongue control is poor, food may go into
  pharynx (throat) and be aspirated

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Pharyngeal Phase

• When food reaches anterior faucial pillars, the
  pharyngeal phase is triggered
• Velum (soft palate) closes
• Larynx elevates (epiglottis flips, true and false
  vocal folds slam together)
• Tongue has a major role in triggering the swallow
  

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Practice Feeling for the Swallow

• Use 4 fingers on the neck to feel for the swallow
• Under chin (above the bone)
• Bottom of the bone
• Top and bottom of the thyroid cartilage
• Normally should take 1-2 seconds

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Esophageal Phase

• Begins when the UES opens and the food is
  transferred to the esophagus
• Peristaltic action pushes the food down into the
  stomach
• This phase lasts 8-20 seconds
• Ends when the LES opens and the food is passed
  into the stomach