Intervention to promote chewing skills in children

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Intervention to promote chewing skills in children

• Paediatric Feeding (Disability) Group

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To start Completed 2008 CAT

• Clinical question
• In Children with Cerebral Palsy (Spastic
  Quadriplegia), what is the evidence that upright
  positioning in midline is safest for eating and
  drinking?
• Reasoning for question
• General recommendations to clients with
  swallowing difficulties aim to position clients
  at the default position of 90-90-90 posture
  (upright at 90 degrees in the wheelchair as much
  as possible)

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The clinical bottom line.

• A 20 to 30 degree reclined position with neck
  flexion (chin tucked) is the safest positioning
  for feeding a child with tetraplegia and
  dystonia.
• Chin tuck is a useful technique to improve
  closure of the airways. The tilting down of the
  epiglottis seems to be facilitated and this gives
  some protection to the laryngeal vestibule even
  if the vestibule is not completely closed.

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Continued (positioning CAT)

• Reclined (Tilted?) 30 degree position has
  evidence that it is the better than upright 90
  degree position for most children with cerebral
  palsy (aged 1-10 years).
• Positioning is highly individualised for a child
  with cerebral palsy so this may not work for
  everyone.
• Most importantly head and trunk alignment has the
  biggest impact on feeding skills for a child with
  cerebral palsy.

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Search for a new clinical question

• Anecdotally, Speech pathologists working with
  clients in the disability population can often
  encounter clients who bite non-nutritive objects
  and also having feeding difficulties.
• Is there evidence that these items can assist
  develop chewing skills for these children?
• The group sought to look at the evidence for
  using non-nutritive objects to develop chewing
  skills in children

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Chewy Tubes

• Chewy tubes are a popular product used by the
  disability population. They are promoted as being
  able to do the following
• Chewy Tubes are an innovative oral motor tool
  designed to develop biting and chewing skills.
  (http//www.chewytubes.com/)
• They are described as being suitable for the
  following disability populations Autism, Down
  Syndrome and Cerebral Palsy

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The question formed

• P Population- In children who have eating and
  drinking difficulty.
• I Intervention- will non-nutritive objects such
  as chewy tubes
• C Comparison- N/A
• O Outcome- improve chewing skills.

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Searching the evidence

• Weve searched from
• ERIC SpeechBITE
• Google Scholar PsychInfo
• Medline
• PubMED
• OVID
• CINAHL
• PEDro

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Search terms.

• Chewy Tube, theratube, non-nutritive, chewing,
  disability, feeding difficulty, oro-motor
  dysfunction, food texture, bite

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Clinical bottom line

• We do not tend to recommend the use of
  non-nutritive objects to develop chewing skills
  if the clients are orally fed.
• May be a more appropriate item for meeting
  sensory needs only not developing specific
  feeding skills (Scheerer, 1992)

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Difficulty in researching/ question

• Too specific in choice of intervention type to
  investigate (Chewy tubes/ non-nutritive chewing)
• Basis of feeding difficulty not clear in clinical
  question (? Sensory based, neuro-muscular, oral
  structures)
• No preliminary search (this may have saved the
  group long aimless searching).

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Development of a new question

• The search for a new question is to be based on
  the current clinical practice of clinicians
  working with clients with eating and drinking
  difficulties.
• What are the current clinical practices that
  could lend themselves to a new CAT?

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Current Clinical Practice

• ADHC Hurstville has a lunch club with main
  objective is to address specific feeding issues
  such as starting solids and moving to the next
  texture.
• The clients who attend have a range of
  disabilities Down Syndrome, Autism, Global
  Delay, Cerebral Palsy.

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Current Recommendations and Rationale for develop
chewing skills

• RECOMMENDATION
• For client to hold and experience with hard
  munchable food where no bits come off e.g. chunky
  carrot stick

• RATIONALE
• To encourage chewing practice without requiring
  to swallow

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Current Recommendations and Rationales for
develop chewing skills

• RECOMMENDATION
• Eat bite and dissolve foods, meltable hard solids
  e.g. milk balls, cheese bacon balls.
• Placing the food to the side of the teeth

• RATIONALE
• Encourage client to feel and experience different
  textures and position by placing on one side of
  the mouth on the molars or the gums

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Current Recommendations and Rationales for
develop chewing skills

• RECOMMENDATION
• Client is starting to bite bread so introduce
  other firm things like cooked vegetables, arrow
  root biscuits (progressively moving towards
  crunchy foods).

• RATIONALE
• Extending a new skill/generalising. Desensitising
  to different textures.

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Current Recommendations and Rationales for
develop chewing skills

• RECOMMENDATION
• Client only eating sandwiches at preschool,
  introduce this food at home.
• Introduce other foods similar to toast eg
  english muffins, crumpets, hard ends of cake.

• RATIONALE
• Extend food to other environments.
• Generalising textures to extend range of foods
  consumed.

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Current Recommendations and Rationales for
develop chewing skills

• RATIONALE
• Enable client to achieve appropriate hand grip to
  feed more easily and independently.
• Encourage lateral chewing motion, strengthen,
  desensitising.

• RECOMMENDATION
• Use a left handed angled spoon.
• Develop biting skills with placement at side
  using cruskits and arrow root biscuits.

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Current Recommendations and Rationales for
develop chewing skills

• RECOMMENDATION
• Client is overfilling. Cut food into 2cm pieces.

• RATIONALE
• Reduce ability to overstuff, supervise, possibly
  supplement oral sensory seeking with something
  else if that is the reason for overstuffing.

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Summary of recommendations as potential clinical
questions
Pt./Problem Intervention Comparison Outcome
Autism Down syndrome Oro-motor difficulties Eating/drinking difficulties Developmental delay Positive reinforcement, side placement, chewing training, texture fading Develop chewing, Encourage lateral chewing, strengthen, desensitise, improve bite, chewing generalisation, increase food variety
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In 2010,

• We will have access to ADHC library during our
  meeting time so that we can decide on the topic
  that has research evidence.
• We will continue to monitor the outcomes of
  clients who need to develop their chewing skills
  and the rate of success from each of our
  recommendations with GAS goals
• WATCH THIS SPACE!!

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Where to from now.

• Next year, our meetings will be at ADHC
  Hurstville
• 390 Forest Road Hurstville
• Ph 9701 6000
• Please contact Nitha Thomson nitha.thomson_at_dadhc.
  nsw.gov.au
• Ph 9297 6000 if you are interested

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References

• Dawes,M.,Badenoch,D and Goddard, O. Informed
  Clinical Practice. Centre for Evidence-Based
  medicine, Univ of Oxford,Nov 2000
• Giselle EG, Tessler MJ, Laplerre G, Seidman E,
  Drouin E, Fillon G (2003) Feeding management of
  children with severe cerebral palsy and eating
  impairment an exploratory study. Physical and
  Occupational Therapy in Pediatrics 23(2) 19-44
• Hulme JB, Shaver J, Acher S, Mullette L, Eggert
  C (1987) Effects of adaptive seating devices on
  the eating and drinking of children with multiple
  handicaps. American Journal of Occupational
  Therapy 41(2)81-9
• Larnert G, Ekberg O (1995) Positioning
  improves the oral and pharyngeal swallowing
  function in children with cerebral palsy. Acta
  Paediatr Jun84(6)689-92
• Scheerer, C.R, (1992), Perspectives on an Oral
  Motor Activity The use of Rubber Tubing as a
  Chewy, The American Journal of Occupational
  therapy, Volume 46 (4), pp 344-352
• http//www.autism-pdd.net/testdump/test5659.htm