Paediatric Dysphagia

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Paediatric Dysphagia

• Grizelda Steyn
• Janet Smith Incorporated
• Audiologist Speech Therapist
• St. Augustines Hospital

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Background of Dysphagia

• Feeding problems common in NICU/preterm infants
• Minor feeding problems in normal children 25-30
• 40-70 feeding problems in premature infants and
  infants with chronic illness
• Feeding is very complex process which involve
  mouth, pharynx, larynx and esophagus and sucking
  reflex in infants in the first phase.
• Cornerstones of infant feeding
  suck/swallow/breath
• Sucking reflex initiates swallowing in the infant
  by stimulation of the lips and deeper parts of
  the oral cavity.
• The mandible, maxilla, upper gums, lips, palate
  and cheeks are necessary for compression of the
  nipple and expression of contents

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General Background

• Any defect of lips, tongue, palate, mandible,
  maxilla or cheeks may create problems in the
  first phase of feeding in an infant.
• 3 stages of swallowing disorders oral
  phase,pharyngeal phase and esopharyngeal phase)

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What is Dysphagia?

• Difficulty swallowing
• The inability of food or liquids to pass easily
  from the mouth, into the throat, and down into
  the esophagus to the stomach during the process
  of swallowing.

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What could affect successful feeding in an infant?

• Conditions that impact the neurological system
  developing, respiration and digestion.
• Medications often have side effects that could
  cause nausea, stomach pain and irritation.
• Cardiac patients often lack the endurance to take
  sufficient amount of liquid in a timely manner.

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What about our Premature/NICU infants?

• Difficult delivery
• Aspiration, hypoxia
• Impacts postural control, breathing regulation,
  state of infant, oral and pharyngeal reflexes
• Prolonged ventilation
• Cardiac problems
• Start with limited respiratory reserves
• Difficulty regulating cardio-respiratory function
• Impacts energy, endurance, intake, coordination
  and safety

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Premature/NICU infants

• Congenital anomalies
• Cleft lip- and palate
• Hyperbilirubinemia (Jaundice)
• Impacts alertness, vigor and therefore intake.
• Infant of Diabetic motor( IDM)
• Impact work of breathing and therefore disrupts
  coordination of suck-swallow-breathe sequence.
• Respiratory Distress Syndrome (RDS)
• Compromise the transition to nipple feeding

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Common feeding difficulties in NICU

• Tires before finishing feeding
• Lacks spontaneous mouth opening breathing too
  much effort to be willing to suck.
• Feeding for long periods at a time
• Difficulty coordinating sucking, breathing and
  swallowing
• Gagging during feeding
• Drooling
• Congestion in the chest after drinking
• Coughing or choking when drinking (or very soon
  afterwards)

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Symptoms of Dysphagia

• Tiredness or shortness of breath while eating or
  drinking
• Frequent respiratory infections
• Colour change during feeding, such as becoming
  blue or pale silent aspiration
• Spitting up or vomiting frequently
• Food or liquids coming out of the nose during or
  after a feeding
• Disorganized sucking overall postural
  disorganization and poor sucking rhythm, poor
  tongue stability
• Trouble latching related to breathing, abnormal
  CNS or could be oral-tactile hypersensitivity
• Weight loss

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Important to remember

• The reluctance to suck may be an instinctive
  reaction, a purposeful respond to attempt to
  protect their airway.

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Protocol for Oral feeding

• 34 weeks G.A
• Weight of 1.6kg
• No medical conditions that would interfere with
  feeding
• Respiratory rate 70 breaths per minute
• Effort no change in skin colour
• Able to maintain a wakeful state of 10-15 minutes
• Aspiration none (Swallowing of Oral Secretions?)
• Ability to gag and reflexively protect airway.
• Rhythmic, non-nutritive sucking

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Treatment of Dysphagia

• Goal of treatment plan is safe, independent
  feeding(swallow).
• Changing bottle or teats Premature infant
  bigger teat provide internal stability. (Tongue
  position and mouth size).
• Positioning impacts airway maintenance,
  breathing, safe swallow and organization of
  infant
• Swaddling provides overall postural support and
  containment
• Pacing of feeds
• Flow rate greatest obstacle to safe and
  successful feeding. Increased flow poor
  endurance/weak suck. Reduce flow- poor
  coordination of SSB. Aspiration!!

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Treatment of Dysphagia

• Oral motor Swallowing simulation techniques
• Pacifiers
• Calorically dense formulas (Cardiopulmonary
  disorders)
• NGT
• PEG

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Outcome of our babies in NICU

• Early intervention
• Good prognosis for babies with no severe or
  chronic illness
• Maturation of CNS
• Alternative feeding as part of goal towards
  successful feeding

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Questions or Comments?