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The Infant Spoon:A Real Power Tool in
Pediatric FeedingPeggy Eicher, MD
The Center for Pediatric
Feeding & Swallowing
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Food Selectivity Difficulty advancing texture
Difficulty initiating spoon feeding
Prolonged mealtimes
When is a feeding issue a feeding problem?• Persistence of problem
• Growth/Nutritional Outcomes• Caloric intake
• Vitamins and other important nutrients
• Dietary imbalance
• Associated Problems• Sleep
• Irritability
• Speech
• Cognitive
• Educational/Social CompromiseThis Photo by Unknown Author is licensed under CC BY-NC-ND
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Prevalence of Feeding Problems
30%-80% children with developmental disability
25%-45% children without
developmental disability
Bryany-Waugh R, et al. Int J Eat Disord 2010;43:98-111
3-10% of children experience severe feeding problems
Why so many children at risk?
•A child learns how to eat•Eating is a sequential progression•Like any motor skill, practice is
required to acquire the skill•Anything that limits or prevents
practice can interfere with oral motor skill acquisition
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Overview of Workshop
I. Review normal oral motor ontogeny
II. Overview of risk factors MedicalMotorLearned Patterns
III. How spoon functions as
Identifier
Stimulator
Facilitator
Pathfinder
Swallowing Process
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GROSS MOTOR DEVELOPMENT
Birth 3 mos 6 mos 9 mos 12 mos
Rate of Acquisition = Maturation of
Nervous SystemX Positive Practice
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ORAL MOTOR DEVELOPMENT
Suckle Reflex
Phasic Bite
34 weeks TERM 5-6 months 6-9 months 8-36 months
SUCK /
SWALLOW SUCKLE SUCKING MUNCH CHEW
Conceptual Model
STRUCTURE
MOTORPATTERN
FACTORS
TIME
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Oral Motor Development
Suckle Birth –
4months
Anterior/
posterior
Nipple
feeding
Sucking 4-7
months
Up/down spoon
Munching 7-12
months
Side to
side
cheerios
Chewing 12-18
months
Diagonal finger
foods
Suckling Sucking
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Spoon Feeding Mastery
Adequate mouth opening
Pressure accepted onto tongue
Lips stripping the spoon
Jaw stability and tongue mobility to
facilitate bolus formation and transfer
Who’s ready for spoon feeding?
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Munching Chewing
Conceptual Model
STRUCTURE
MOTORPATTERN
FACTORS
TIME
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RISK FACTORSinterfere with Skill Acquisition
MEDICAL• NEUROLOGICAL• RESPIRATORY• GASTROINTESTINAL
MOTOR• ORAL MOTOR• GROSS MOTOR
LEARNED PATTERNSFAMILY
“swallowing center” in brainstem
input from pharynx heart lungs GI cortex
NEURO CONTROL
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Neurogenic modifiers to the swallowing complex
oFortification of UES barrier• Esophago-UES contractile
response to GER
• Pharyngo-UES contractile reflex
• Laryngo-UES contractile reflex
oClosure of the glottis• Pharyngoglottal adduction reflex• Esophagoglottal closure reflex
» Shaker & Hogan, AJM, 2000
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Medical Influences: Respiratory
• Increased respiratory rate decreases time for swallowing
• Anything that affects breathing has potential to affect eating- congestion, asthma, tonsil, adenoids
• Body position critical
Vallecular space eliminated
Head and Neck Alignment
space enlargedVallecular
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Medical Factors: GI
• Irritation sensitive-reflux, gut flora toxins, allergens, food intolerance
• Pressure/flow sensitive- constipationdelayed gastric empty
GI issues highly prevalent
• 50% of all babies have GER•Up to 80% of children with DD have
GER•Constipation in 29% of all children and
80% of children with DDJadcherla & Shaker, 2001
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GERD Mechanisms for Dysfunction• Irritation
• Acid stimulates chemoreceptors and causes cellular irritation
• Cellular irritation weakens strength and speed of contractile propagation
• Food intolerance?• Reflexive
• Volume stimulates mechanoreceptors• Texture selectivity?
• Neurogenic• Vagally mediated bronchospasm • Vagally mediated posturing?• Food refusal?
The Influence of Pediatric Gastroesophageal Reflux onSwallow Apnea Duration and Respiration Patterns
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Swallow Apnea Duration0.986s
GER influence on respiratory pattern
• Inspiration-Swallow-Inspiration PatternLeast preferred most associate w/ aspiration
• Expiration-Swallow-Expiration PatternMost Preferred
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GER Influence on Tongue• Backward
tension on tongue to retract
• Increased gag
• Influence on oral motor pattern
• Influence on practice
GI Tract Constipation
• Infrequent, hard or effortful stools
• Increase pressure within GI tract
• Impact of Constipation on Growth
Chao et al. Pediatric Research 64: 308-311, 2008
• Influence on gastric emptying Boccia et al. Clin Gastroenter & Hepatology
2008,6:556-560
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What is Constipation• Traditional definition=
less than 1 stool every 3 days
• Functional definition= hard, infrequent or effortful stooling
• For feeding= 1-2 large, mushy, effortless stools each day
• Can’t get more in ‘til you get more out!
Medical Influences: GI/RESP INTERACTION
• Inverse pressure relationship
• Relationship of GI and respiratory infection
• Relationship of GI and congestion
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Optimal Postural Alignment
• Head and neck alignment: ear falls directly above humeral head
• Neutral alignment of spine with natural
• S-shaped curve
• Neutral pelvis
• Hip, knee and ankles at 90 degrees
Neutral Posterior Pelvis Pelvic Tilt
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Forward Head Posture (FHP)• Effects:
Tongue muscle is shortened and stays in a lower, posterior position
Reduced tongue range limits oral motor pattern to a suckle transport pattern
Limited mobility of hyoid bone-risk of aspiration
FHP pulls hyoid superior and posterior
Pharyngeal airway space is reduced
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Vallecular space eliminated
Head and Neck Alignment
space enlargedVallecular
Oral Motor
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Important roles of the spoon
• Indicator – difficulty introducing spoon signals a potential problem
•Stimulator- advancing oral motor pattern
•Facilitator- introducing variety
•Pathfinder- spoon skills translate into open cup skills
Conceptual Model
STRUCTURE
MOTORPATTERN
FACTORS
TIME
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Spoon as INDICATORDifficulty Introducing spoon-won’t open, can’t get on tongue• Look for factors contributing
• RESPIRATORY• Nasal obstruction
• Increased work of breathing
• GI • GER
• Formula intolerance
• Volume limitation
• Constipation
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SPOON as STIMULATOR
Spoon Refusal
STRUCTURE
MOTORPATTERN
FACTORS
TIME
Bottle sole nutrition
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Consequences of spoon refusal
SPOON as STIMULATOR
Difficulty introducing spoon
STRUCTURE
MOTORPATTERN
FACTORS
TIME
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Inadequate tongue stimulation with spoon feedings of puree
Difficulty advancing texture
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Risk inherent to baby led weaning
Difficulty cup drinking
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SPOON as FACILITATOR
Difficulty introducing spoon
STRUCTURE
MOTORPATTERN
FACTORS
TIME
Eating avoiding tongue-selective
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Spoon Histories?
SPOON as THERAPIST
STRUCTURE
MOTORPATTERN
FACTORS
TIME
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Conceptual Model
For YOU as ANTICIPATOR
STRUCTURE
MOTORPATTERN
FACTORS
TIME
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RISK FACTORSinterfere with Skill Acquisition
MEDICAL• NEUROLOGICAL• RESPIRATORY• GASTROINTESTINAL
MOTOR• ORAL MOTOR• GROSS MOTOR
LEARNED PATTERNSFAMILY
Common Feeding Problems•Food refusal
•Bottle dependence
•Failure to advance texture
•Food selectivity
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www.feedingcenter.org
The Center for Pediatric Feeding & Swallowing
Collaborative Full Time Interdisciplinary Team:
PhysicianNurse PractitionerSpeech PathologistApplied Behavioral AnalystPhysical TherapistOccupational TherapistFamily CounselorFeeding SpecialistsFinancial AdministratorChild Care Aides