Treatment section of the Pediatric Dysphagia Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The primary goals of feeding and swallowing intervention for children are to
- safely support adequate nutrition and hydration,
- determine the optimum feeding methods/technique to maximize swallowing safety and feeding efficiency,
- collaborate with family to incorporate dietary preferences,
- attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eat and chew meals with peers in the preschool),
- minimize the risk of pulmonary complications,
- maximize the quality of life,
- prevent future feeding issues with positive feeding/oral experiences as able given medical situation,
- help the child eat and drink efficiently and safely to whatever degree is possible.
The overall health of the child is the primary concern in treatment of pediatric dysphagia. Families may have strong beliefs regarding the medicinal value of some foods or liquids. Such beliefs and holistic healing practices may be contraindicative to recommendations made. The intervention processes and techniques must never jeopardize the child's safety, nutrition and pulmonary status.
Medical, surgical, and nutritional considerations are all important components of a treatment plan. For example, if gastroesophageal reflux is a factor, adequate management is fundamental to other aspects of treatment. Underlying disease state(s), chronological and developmental age of the child, social/environmental arena, and psychological/behavioral factors all affect treatment recommendations.
Treatment needs to address oral-motor function, positioning, seating, muscle tone, and sensory-motor issues. Functional intervention approaches focus as directly as possible on training the specific swallowing or feeding task to minimize inappropriate and maladaptive behaviors. Questions to ask in order to develop an appropriate treatment plan include:
Can the child eat and drink safely? Consider the child's pulmonary status, nutritional status, overall medical condition, mobility, swallowing abilities and cognition, in addition to the child's swallowing function and how these factors impact feeding efficiency/safety.
Can the child receive adequate nutrition and hydration by mouth alone, given length of time to eat, efficiency, and fatigue factors? If the child cannot meet nutritional needs by mouth, what recommendations need to be made concerning supplemental non-oral intake and/or the inclusion in the child's diet of orally fed supplements? Consider tube feeding schedule, type of pump, rate, calories, etc.
How can the child's functional abilities be maximized? This might involve decisions about whether the individual can safely eat an oral diet that meets nutritional needs, whether that diet needs to be modified in any way, or whether the individual needs compensatory strategies in order to eat the diet. Does the child have the potential to improve swallowing function with direct treatment?
How can the child's quality of life be preserved and/or enhanced? Consider how long it takes to eat a meal, fear of eating, pleasure obtained from eating, social interactions while eating, and so on (Huckabee & Pelletier, 1999). The family's customs and traditions around mealtimes and food should be respected and explored.
Are there behavioral and sensory-motor issues that interfere with feeding and swallowing? Do these behaviors result in family/caregiver frustration or increased conflict during meals? Is a sensory-motor based intervention for behavioral issues indicated?
Clinicians must realize that there are inherent differences between adult and infants/young children swallowing and feeding, and that these differences have an impact on treatment. For example
- There are distinct differences in the relationships of anatomic structures and physiology of the swallowing mechanism among infants, young children, and adults that effect swallowing and feeding function.
- Infants and children grow and develop even when they have a chronic condition, which means that swallowing and feeding function may change over time.
Treatment selection will depend on the child's age, cognitive and physical abilities, and specific swallowing and feeding problems. When considering treatment options, keep in mind that infants and young children with swallowing disorders, as well as some older children with concomitant intellectual disabilities, often need intervention techniques that do not require them to follow simple verbal or nonverbal instructions. Intervention might consist of changes in the environment or indirect treatment approaches for improving safety and efficiency of feeding.
Aspects for change that can affect oral and pharyngeal transit include posture and position, timing and pacing, bolus characteristics (e.g., texture, temperature, taste), and sensory input. Depending on the assessment results, intervention may focus on supporting hydration and nutrition, minimizing risk for pulmonary complications, facilitating oral/pharyngeal/respiratory coordination, and modification of behavioral and sensory issues.
Behavioral interventions are based on principles of behavioral modification and typically focus on increasing appropriate actions or behaviors, including increasing compliance, and reducing maladaptive behaviors. Behavioral interventions include such techniques as shaping, prompting, modeling, stimulus fading, antecedent manipulation, alternate behavior, and differential reinforcement, as well as implementation of basic mealtime principles (e.g., scheduled mealtimes in a neutral atmosphere with no food rewards).
Positioning techniques involve adjusting the child's posture or position during feeding. These techniques serve to protect the airway and offer safe transit of food and liquid. No single posture will provide improvement to all patients/clients, and in fact, postural changes differ between infants and older children. However, the general goal is to establish central alignment and stability for safe feeding. Techniques include
- chin down-tucking chin down toward neck,
- chin up-slighty tilting head up,
- head rotation-turning head to the weak side to protect the airway,
- upright positioning-45 degree angle at hips and knees, with supports as needed,
- head stabilization-supported so as to present in chin neutral position,
- cheek and jaw assist,
- reclining position-e.g., using Boppy pillow or reclined infant seat with trunk and head support,
- side-lying positioning for infants.
Diet modifications consist of altering the viscosity, texture, temperature, or taste of a food or liquid to facilitate safety and ease of swallowing. Typical modifications may include thickening thin liquids (e.g., breast milk, formula) or softening, chopping, or pureeing solid foods. Taste or temperature of a food may be altered to provide additional sensory input for swallowing. Dietary modifications incorporate preferences, to the extent feasible. Consult with families regarding safety of medical treatments, such as swallowing vitamin supplements or drinking thin liquids, which may be contraindicated by disorder. Diet modifications should consider the nutritional needs of the child, and a dietitian should be consulted when appropriate.
The USFDA has cautioned consumers about commercial, gum-based thickeners for use with infants from birth to one year of age, especially when thickening breast milk. SLPs should be aware of these cautions and consult as appropriate in their facility to develop guidelines for using thickened liquids with infants. (See
U.S. Food and Drug Administration (FDA) consumer cautions (2011, 2013).
Adaptive feeding equipment or change in feeding utensils may be used to control bolus size or achieve the optimal flow rate of liquids. For infants, the selection of the appropriate type of bottle or nipple may promote the coordination of sucking, swallowing, and respiration during feeding; for older children, spoons of various shapes and sizes can help regulate bolus size and facilitate more effective feeding, particularly in children with oral phase deficits (Arvedson, 1998). Varied nipples and containers should be tried to find optimal rate of flow. Infants may improve efficiency of nipple feedings with a self-pacing system and vacuum-free bottles; individual differences must always be considered, as exceptions to general principles may be needed.
Biofeedback includes instrumental assessments that provide visual feedback to aid in the treatment of feeding or swallowing disorders. Children with sufficient cognitive skills can be taught to interpret the visual information provided by these assessments (e.g., surface electromyography, ultrasound, nasendoscopy) and make physiological changes during the swallowing process.
Maneuvers are specific strategies used to change the timing or strength of particular movements of swallowing (Logemann, 2000). Some maneuvers require following multi-step directions and may not be appropriate for young children and/or older children with cognitive impairments. Examples of maneuvers include
- Effortful swallow-increases posterior tongue base movement to facilitate bolus clearance.
- Masako or tongue hold-tongue is held forward between the teeth while swallowing; this is performed without food or liquid in the mouth to prevent coughing or choking.
- Mendelsohn maneuver-designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway.
- Supraglottic swallow-vocal folds are usually closed by voluntarily holding breath before and during swallow in order to protect the airway.
- Super-supraglottic swallow-effortful breath hold tilts the arytenoid forward which closes the airway entrance before and during the swallow.
Oral-motor treatments include stimulation to or actions of the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles that are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions. Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive (e.g., tapping, stroking, and vibration) to the more active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises).
Pacing and Cue-based Feeding Strategies
The use of pacing for infants or children involves controlling or titrating the rate of presentation of food or liquid and the time between bites or swallows to moderate the rate of intake. Feeding strategies for children may include alternating bites of food with sips of liquid or swallowing 2-3 times per bite or sip. For infants, pacing can be accomplished through limiting the number of consecutive sucks, which limits the bolus size, for example. Strategies that slow the feeding rate or limit the bolus size may allow for more time between swallows to clear the bolus, or support more timely breaths. This may in turn reduce the risk of aspiration and optimize safety during feeding and swallowing.
Most NICUs have begun to move away from volume-driven to cue-based feeding. Rather than setting a goal to empty the bottle, the feeding experience is viewed as a partnership with the infant. Cue-based feeding relies on cues from the infant such as lack of active sucking, passivity, pushing nipple away, or a weak suck that typically indicate the infant is disengaging from feeding. The infant is communicating the need to stop. Preterm infants communicate through their behaviors which should guide the caregiver in understanding thresholds of stress and supporting safety during feeding. The infant's cues provide information regarding physiologic stability, which underlies the coordination of breathing and swallowing. These cues guide the caregiver to intervene to support safety. When the quality of feeding takes priority over the quantity ingested, feeding skill develops pleasurably and at the infant’s own pace. As a result, intake is improved (Shaker, 2013b). The SLP plays a critical role in the NICU supporting parents and other caregivers to understand and contingently respond to the infant's communication during feeding.
Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize the intraoral cavity by providing compensation or physical support for children with congenital abnormalities (e.g., cleft palate) or damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved. Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved functional feeding skills.
Sensory stimulation techniques vary and may include thermal-tactile stimulation (e.g., using iced lemon glycerin swab) or tactile stimulation (e.g., using a NUK brush) applied to the tongue or around the mouth. Children who demonstrate aversive responses to stimulation may need approaches that reduce the level of sensory input initially, with incremental increases as the child indicates tolerance. The opportunity for sensory stimulation may be needed for those with reduced responses, over-active responses or limited opportunities for sensory experiences.
Tube feeding includes alternative avenues of intake (e.g., nasogastric tube [NG], transpyloric tube [placed in the duodenum or jejunum], or gastrostomy [G-tube placed into the stomach or GJ-tube placed into the jejunum]). These approaches may be considered if the child's swallowing safety and efficiency cannot reach a level of adequate function or does not support nutrition and hydration adequately. In these instances, the swallowing and feeding team will consider whether the child will need the alternative source for a short or extended period of time to determine the optimum tube feeding selection to best meet the child's needs. Alternative feeding does not preclude the need for feeding-related treatment.
Clinicians working in the NICU need to be aware of the many variables that influence both infant feeding and the clinician's ability to develop appropriate treatment plans, including the multi-disciplinary nature of the practice area. The NICU is considered an advanced practice area, and inexperienced SLPs should be aware of the risks of working in this setting.
In all cases, the SLP must have an accurate understanding of the physiologic mechanism driving the symptomatic feeding "problems" seen in this population. Understanding the physiologic concern gives the SLP the knowledge to choose appropriate treatment interventions and provide a solid rationale for their use in the NICU.
The SLP is in the unique position of being able to assess the infant's current feeding potential and predict their future feeding performance based on where the infant is along the maturation continuum and the infant's physiologic and state stability as communicated through their response to various oral experiences. SLPs counsel families regarding appropriate feeding techniques to maximize feeding safety, with sensitivity to values and beliefs for breast vs. bottle feeding.
Treatment for infants must take into consideration the importance of communication and readiness.
In all interactions with preterm and medically fragile infants, SLPs are encouraged to hold paramount their role as communication specialists. In the role of communication specialists, SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infant's communication signals. In order to do this, SLPs treating preterm and medically fragile infants are well versed in typical infant behavior and development so that they may recognize and interpret changes in behavior that provide cues as to their well-being or stress while at rest or during activities such as interaction and feeding. Behavior in the infant can be expressed by changes in
- Autonomic system-pattern of respiration (pauses, tachypnea), color changes (red, pale, dusky, mottled), and visceral signs (e.g., spit up, gag, burp).
- Movement-postural alignment (hyperflexed, extended), muscle tone (flaccid, hypertonicity), movement patterns in extremities, trunk, head and face, and level of motor activity.
- State-the range of available states of consciousness (i.e., deep sleep, quiet alert, and crying), the smoothness of transition between them, and the clarity of their expression.
- Attention-the infant's ability to orient and focus on environmental stimuli, such as face, sounds, or objects.
Readiness for oral feeding in the preterm or acutely ill full term infant is associated with the infant's ability to come into and maintain awake states and to coordinate breathing with sucking and swallowing (McCain, 1997), as well as with the presence or absence of apnea. Apnea is strongly correlated with longer transition time to full oral feeding (Mandich, Ritchie, & Mullett, 1996).
Supportive interventions to facilitate early feeding and/or to promote readiness for feeding include kangaroo mother care (KMC), nonnutritive sucking (NNS), and feeding protocols.
Kangaroo Mother Care (KMC)
KMC, skin-to-skin contact between a mother and her newborn infant, can be an important factor in helping the infant achieve readiness for oral feeding, particularly breast-feeding, and earlier discharge from the hospital. Other benefits of KMC include temperature regulation, promotion of breast feeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability.
Non-Nutritive Sucking (NNS) Facilitation
Non-nutritive sucking involves allowing an infant to suck without taking milk, either at the breast (after milk has been expressed) or with the use of a dummy (e.g., pacifier) and is used as a treatment option to eventually encourage oral intake. The SLP providing and facilitating oral experiences with NNS must take great care to ensure that the experiences are positive and do not elicit stress or other negative consequences. The SLP also teaches parents and other caregivers to provide positive oral experiences as appropriate and recognize and interpret the infant's cues during NNS.
Feeding protocols (e.g., ad-lib, demand, semi-demand) provide clear criterion for the initiation and systematic advancement of oral feeding. Protocols may consider a variety of factors including infant readiness, demand for feeding, infant cues, infant stress, or infant development and state.
Management of students with dysphagia in the schools addresses the impact of the disorder on the student's educational performance. Based on the results of a
comprehensive, interdisciplinary dysphagia evaluation, a detailed swallowing and feeding plan is developed and documented on the student's IEP, IHP, or 504 plan, if the student is determined to be eligible for services.
Individual Education Plan (IEP) /504 Plan
An IEP meeting is held, during which the interdisciplinary dysphagia team meets to discuss the student's swallowing and feeding issues. Evaluation results including team recommendations are reviewed and discussed. Goals/objectives and accommodations are written and agreed upon by the team. If the student does not have an existing swallowing and feeding plan, a plan will be created during this meeting.
Swallowing and Feeding Plan
The swallowing and feeding plan includes training, service delivery, and daily management. The plan ensures that the student will receive adequate nutrition efficiently and in the safest manner possible. A plan typically includes recommendations/guidelines on positioning, equipment, diet/food preparation, feeding plan techniques and precautions. Personnel will require adequate education and training related to the swallowing and feeding plan by the SLP. It is important to verify and document the educational training within the plan.
Individual Health Plan (IHP)
The IHP, also called the emergency plan, is drawn up at the IEP conference by the school nurse. The IHP provides information on specific precautions related to the student's dysphagia and is kept in an easily accessible place in the classroom. Classroom personnel are trained on the IHP. The swallowing and feeding plan may be attached to the IHP for additional information on the student's swallowing and feeding safety precautions.
Intervention and Monitoring
SLPs may provide direct intervention to students with swallowing and feeding concerns for oral sensorimotor skills, sensory stimulation, and so on. Other students may need only monitoring of swallowing and feeding status. Services should be recorded in treatment logs (Home, Beauxis, & Fish-Finnigan, 2003).