Infant Toddler Development Training
Module 6, Lesson 2
A swallowing disorder that may cause nutritional risk is called dysphagia. Dysphagia may occur at different stages in the swallowing process. There are three stages to a swallow:
- Oral - the oral phase includes sucking, chewing and moving food or liquid into the throat
- Pharyngeal - the trigger of the swallow reflex occurs during the pharyngeal phase and also includes the compression of food down the throat, while closing off the airway to prevent aspiration or choking
- Esophageal phase - the esophageal stage begins with the upper esophageal sphincter (UES) opening allowing the food to travel down the esophagus. As the food travels down the esophagus, the lower esophageal sphincter (LES) relaxes allowing the food to enter the stomach.
Pediatric dysphagia includes a wide range of etiologies. These include gastroesophageal reflux disease (GERD) and respiratory disorders. In addition, intracranial hemorrhage, traumatic brain injury, prematurity, and structural abnormalities such as cleft palates can lead to dysphagia and subsequent nutritional concerns.
Respiration Patterns with Feeding Concerns
In a clinical evaluation of feeding disorders, respiration patterns are also observed as a potential etiology of feeding difficulties. Continuous nutritive sucking can slow the breathing of healthy infants, but is well tolerated. In infants with respiratory compromise, swallow apnea can cause the infant to become bradycardic and hypoxemic. Those children with upper airway obstruction or other pulmonary complications may require a tracheostomy. Unfortunately, the tracheostomy may intensify the dysphagia due to limited laryngeal elevation required during the pharyngeal phase of a swallow.
Alternative Methods of Food Intake
The physician for a child who experiences chronic dysphagia may advise the family about alterative methods of nutritional intake for the child. Primary support for short-term nutritional maintenance includes orogastric and nasogastic tubes. Nasoduodenal and nasojejunal tubes are usually used when reflux is present or in long-term feeding problems. Supplemental support can be given through the implementation of a gastrostomy tube. One type of gastrostomy tube is called a percutaneous endoscopic gastrostomy (PEG). A PEG tube is inserted into the stomach allowing the child to be freed of any invasion through the mouth and nose. Oral feeding can be administered with a PEG tube. The various types of feeding tubes are defined below:
- orogastric tube is a feeding tube that is inserted into the mouth and through the pharynx, esophagus and into the stomach. This is usually a short term, temporary measure.
- nasogastric tube is a feeding tube that is inserted through one side of the nose into the pharynx, through the esophagus and into the stomach.
- nasoduodenal tube is a feeding tube inserted into the nasal cavity, through the pharynx, esophagus, and stomach and into the duodenum of the small intestine.
- nasojejunal tube is a feeding tube that is inserted into the nasal cavity, through the pharynx, esophagus, and stomach and into the jejunum of the small intestine.
- percutaneous endoscopic gastrostomy (PEG) is a feeding tube that is inserted through the stomach using a simplified surgical procedure. This is sometimes simply referred to as a gastrostomy.
- gastrostomy is the opening in the stomach created surgically for the purpose of feeding. This is usually a permanent opening.
There are various techniques available to medical professionals for evaluating swallowing. Each is comprised of advantages and disadvantages. A selection of an evaluation tool is usually customized to the patient. A fiberoptic endoscopic evaluation of swallowing (FEES) provides detailed information about pharyngeal and laryngeal structures and does not expose the child to radiation. A disadvantage is that it does not assess the oral and esophageal stages of swallowing. FEES is administered through a flexible nasoendoscope which is passed through the nose into the phayrnx, allowing visualization of the structures important for swallowing.
Videofluoroscopic swallow study (VFSS) is another way of assessing swallowing. The child is given different consistencies, easiest to hardest for the child to swallow, and they are mixed with either liquid, paste or powder barium. The VFSS assesses all three stages of swallowing and is recorded onto a videotape or still x-rays. Radiation exposure, although minimal, and lack of portability of the equipment are disadvantages of a VFSS.
A feeding specialist or a speech-language pathologist with specific additional training and experience can implement treatment strategies. As determined by the team, an occupational therapist as a consultant or direct therapist may address sensory issues relating to foods.
Therapy can be divided into teaching compensatory strategies and/or facilitative strategies. Compensatory strategies can include organizing the infant for feeding, altering the environment, establishing optimum positions, changing feeding utensils and alternating food consistencies. Facilitative strategies can include establishing a pace and rhythm to feeding, reducing oral aversions, and intervention for behavioral based feeding disorders. The professional will guide and counsel the caregiver to optimize the child's nutritional intake in the home.
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