Com Dis Chapter 15

Diet restrictions (PKU)

metabolic disorder that has deficient liver enzyme and elevated levels of the amino acid phenylalanine

Dysphagia

A condition in which an individual exhibits an unsafe or inefficient swallowing pattern that undermines the eating or drinking process

Client and Family Perspectives Related to Treatment

Adults with feeding and swallowing problems are under stress and experience a diminished quality of life. Parents of children with feeding and swallowing problems are also under stress. Caring for child Making decisions for child Guilt over problem Finding time away Mealtime is stressful Financial burden

Oral Phase

Bolus moves toward pharynx to trigger swallow Conditions experiencing problems here include: Strokes Progressive neurological diseases Tooth loss Characteristics include: Inability to adequately control the bolus flow Delayed initiation of the bolus movement

Oral Preparatory Phase

Breakdowns at this phase occur when lips, tongue, cheeks, and mandible don't function properly. These include: Problems controlling the ingested materials Difficulty biting or chewing Inefficient oral preparation, requiring increased time to prepare bolus Impaired sensitivity of the tongue, lips, and other oral structures

Traumatic Brain Injury (TBI)

Caused by car accidents, falls, and physical acts of violence One-fourth to three-fourths of individuals with TBI exhibiting dysphagia

Alternative and Supplemental Feeding

Children who are candidates for supplemental or alternative nutrition are those: Who cannot meet 80% of their caloric needs orally Who have not gained weight or who have continuously lost weight for 3 months Whose weight and height ratio is below the 5th percentile Whose feeding time is greater than 5 to 6 hours daily Nasogastric tube Gastrostomy tube Jejunostomy tube

How Is Adult Dysphagia Identified and Treated?

Clinical Swallowing Exam Also called a bedside swallow examination Includes the following: Review current and past medical records Complete a comprehensive client interview Conduct a thorough oral mechanism examination Attempt trial feedings Make feeding recommendations Refer for instrumental assessment of swallowing Refer to other professionals for any specialized testing

Inadequate Feeding and Swallowing

Defining characteristics Inefficiency Overselectivity Refusal Feeding delay Terms Reflux Conditioned dysphagia

Unsafe Feeding and Swallowing

Defining characteristics Results from the dysfunction of or damage to a child's oral-motor system or an inappropriate eating rate Can affect planning, timing, coordination, organization, and sensation. Terms Valleculae Non per os

The Normal Swallow

Deglutition, or swallowing, is neuromuscular act of moving substance from mouth into throat. We swallow approximately 580 times daily. Stages, or phases: Oral preparatory phase The oral phase The pharyngeal phase The esophageal phase

Enteral feeding tube

Directs liquid formula to stomach Typically placed through nose or directly into stomach

Progressive Neurological Disorders

Disorders of the nervous system producing discoordination and weakness of motor skills as well as decreased sensory abilities. Parkinson's Disease Amyotrophic Lateral Sclerosis Dementia

Underlying Pathology Or Cause

Dysphagia is a secondary disorder Most common causes Neurological damage due to a stroke, a brain injury, or a disease Laryngeal damage due to radiation, surgical removal of the larynx, or trauma

Physical Feeding and Swallowing Evaluation

Evaluation of the structures and functions of the child's oral-motor mechanism includes observation of: Lips Tongue Jaw Teeth Hard and soft palates How they work together Examined at rest and during feeding

Causes and Risk Factors

Frequently accompanies some syndromes with these features: Hypotonia Delayed motor development Physical deformities affecting the oral-motor area Downs syndrome Cerebral palsy Cleft palate

Case History

Gathers information on the child's and family's eating and feeding experiences Length of meals Quality of intake Child's progression from breast/bottle to purees and solids History of formulas used and volumes tolerated

Nutrition and Dietary Considerations

Individuals must achieve adequate nutrition to promote healing of and recovery from the underlying disease May require restricted diet or feeding tube

Restorative Techniques

Intended to improve or restore swallow function Examples include Oral and pharyngeal exercises biofeedback

Stroke

Leading cause of disability and even death among adults. Percentage of those developing dysphagia following stroke - 50% or even higher

Causes and Risk Factors of Inadequate Feeding and Swallowing

Low birth weight Prematurity Prenatal drug exposure Diet restrictions (PKU)

Instrumental Dysphagia Examination

Means of providing a more objective and quantifiable measure of swallowing functions Commonly used procedures Fiberoptic Endoscopic Examination (FEES) Ultrasonography- useful in oral phase, but not pharengeal phase Videofluoroscopy- modified curium swallow (MBS) **gold standard yields information of all phases

Severity of dysphagia

Mild - some difficulties with oral preparation and pharyngeal functioning Moderate - some danger of aspiration and penetration Severe - serious risk of aspiration and penetration Profound - unable to swallow safely

The Esophageal Phase

Moves bolus through the esophagus into the stomach. Process starts as bolus passes through the upper esophageal sphincter (UES). Bolus is propelled through the esophagus by an involuntary contraction. Passes through lower esophageal sphincter (LES) into stomach. Esophageal motility is esophageal movement.

Non per os

Nothing by mouth

Head and Neck Cancer Treatments

Often result in oral or pharyngeal stage dysphagia Glossectomy- removal of tongue Laryngectomy Tracheotomy Xerostomia- (reduced saliva production) and edema- (swelling, water retention in tissues) Affects of chemotherapy- nausea, vommiting, or fatigue

Techniques to Improve the Physiology of Feeding and Swallowing

Organic and neurodevelopmental aspects include: Muscle tone Articulator movement and coordination Oral-motor sensitivity Body posture Swallowing disorder treatment focus: Improve coordination of swallow

What Are The Characteristics Of Pediatric Feeding And Swallowing Disorders?

Problems in the oral phase are called feeding problems. Children can have deficits in both feeding and swallowing.

Pharyngeal Phase

Problems when structures don't function as needed to move bolus through pharynx to entrance to esophagus. Occurs in these conditions: Neurological disorders Head and neck cancer ***Characteristics Incomplete palatal elevation Delayed initiation of the pharyngeal swallow reflex Diminished tongue and pharyngeal muscle force to move the bolus through the pharynx Reduced laryngeal elevation and closure Inadequate opening of the cricopharyngeus muscle

The Oral Phase

Purpose is to move bolus to rear of oral cavity for propulsion down throat. Use the tongue and buccal muscles in this process.

The Oral Preparatory Phase

Purpose is to prepare substance to be swallowed. Starts as the food or liquid enters the mouth. Includes containing the material in the oral cavity and preparing the food or liquid into a cohesive ball, or bolus. Soft palate lowers toward tongue to contain bolus and prohibit flow of food into the pharyngeal region. Mastication is integral part of phase.

Comprehensive Assessment

SLP conducts a comprehensive assessment that includes: Case history Physical feeding and swallowing evaluation Observation of mealtime interactions

Phase Affected

SLP is primarily concerned with disorders in the: Oral preparatory phase Oral phase Pharyngeal phase Terms Gastroenterologist Esophageal dysphagia

Compensatory Approaches

Strategies that compensate for a spcific problem Includes the following: Modifications in the way client takes in food Diet modifications

Techniques to Improve the Psychology of Feeding and Swallowing

Targets emphasize: Accepting certain food types or textures Decreasing resistance and fussiness when eating Following a consistent meal schedule Terms Shaping Conditioning and reinforcement Systematic desensitization

Treatment of Adult Dysphagia In Evidence-based Practice

Two types of rehabilitation strategies: Compensatory Approaches Restorative Techniques

Pediatric Feeding Disorders

a child's "persistent failure to eat adequately" for a period of at least 1 month, which results in a significant loss of weight or a failure to gain weight May also demonstrates one or more of the following: Unsafe or inefficient swallowing patterns Growth delay affecting height and/or weight Lack of tolerance of food textures and tastes Poor appetite regulation NICU

Feeding delay

do to developmental delay

Penetration

food or liquid enters larynx, which can cause choking.

Aspiration

food or liquid passes through larynx and into lungs, which can cause pneumonia. Silent aspiration occurs without any signs.

Reflux

gastric acid is regurgitated into the esophagus and even the pharynx resulting in a burning of the esophagus and throat.

Overselectivity

picky about the taste, type, texture, or volume of food they will eat.

Vallecule

the space formed when the epiglottis folds down to cover the trachea during swallowing

Conditioned dysphagia

traumatic event that results in resistance to eating. Chocking, ingestion of poison, or severe allergic reations.

Inefficiency

unable to meet their caloric and nutritional needs

How Are Pediatric Feeding and Swallowing Disorders Identified and Treated?

Early Identification and Referral Child may be referred in the first few days after birth. Pediatricians and parents monitor height and weight. Problems can include: Excessive feeding time Poor weight gain Rigid eating behaviors Discomfort during feeding

Treatment of Pediatric Feeding and Swallowing Disorders in Evidence-Based Practice

Immediate goals are to ensure nutritional needs are met and feeding and swallowing do not endanger child's life. May mean providing alternative or supplemental nutrition via tube feeding. Also focus on improving child's ability to meet nutritional needs and see eating as a pleasant experience.

The Pharyngeal Phase

Purpose is to propel bolus down the throat to entrance to esophagus. Starts at the anterior faucial pillars. Pharyngeal swallow reflex is triggered. Cricopharyngeus muscle, or upper esophageal sphincter, is juncture between pharynx and esophagus. Reflexive cough is protective reflex. Apneic moment is period of not breathing during normal swallow.

What Are the Defining Characteristics of Adult Dysphagia?

These relate to the following: The phase of swallow affected The underlying pathology or cause The severity of the disorder