11/2/18  

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The  Role  of  Speech  and  Occupa5onal  Therapy  in  Breas;eeding  Issues  

Jessica  Gri@ner,  MS,  CCC-­‐SLP  Holly  Schifsky,  OTR/L,  CBIS,  NTMTC,  CNT  

Disclosure  Informa5on  

Speakers:  Jessica  Gri@ner  &  Holly  Schifsky  

• Disclosure  of  Relevant  Financial  Rela2onships– Holly  Schifsky  and  Jessica  Gri@ner  are  both  employeesof  M  Health  Fairview.  

– Jessica  is  an  employee  of  the  University  of  Minnesota.

• Disclosure  of  Off-­‐Label  and/or  inves2ga2ve  Uses– We  will  not  discuss  off  label  use  and/or  inves5ga5onaluse  in  our  presenta5on.  

Objec5ves  

• Discuss  the  development  of  oral  feeding  in  medically  fragile  and  premature  infants  

• Discuss  the  clinical  symptoms  of  aspira5on  in  infants

• Understand  the  types  of  instrumenta5on  u5lizedduring  a  swallow  study  

• Differen5ate  the  feeding  symptoms  of  the  infant  andmake  appropriate  referrals  

• Understand  the  role  of  the  feeding  therapist  and  how  to  make  referrals  

History  of  Infant  Feeding  Support  

• Lacta5on  support  has  been  a  service  for  since  the  beginning  of  5me  

• In  only  the  past  few  decades,  we  are  seeing  an  increased  survival  rate  in  NICU  

• With  the  increased  survival  rates,  we  are  seeing  increased  disability  

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Oral  Feeding  Development   Oral  Motor  

development  and  Feeding  

• Goal  is  for  each  infant  to  demonstrate  weight  gain/growth  and  have  a  posi5ve  feeding  experience.    – Avoid  Oral  Aversion  development  

• Infant  feeding  can  be  a  complex,  challenging,  and  high  risky  ac5vity  as  the  infant  is  learning  to  coordinate  SSB  (suck,  swallow,  breath)  

Complexity  of  Infant  Oral  Feeding  

Coordina5on  of  Suck,  swallow,  breath  

Aerodiges5on  track  is  the  most  complex  

neuromuscular  unit  in  the  body  

Normal  swallow  requires  ac5va5on  of  31  muscles,  6  cranial  nerves,  brain  stem  control,  and  cerebral  cortex  integra5on  

Only  human  behavior  that  has  a  voli5onal  (oral  

phase  preparatory  and  oropharyngeal  phase)  

This  triggers  a  non-­‐voli5onal  (automa5c)  

swallow  Feeding  

• Discuss  with  family  their  preferred  feeding  plan  for  home  discharge  – Breas;eeding  – Bo@le  feeding  – Coordinated  plan  to  reduce  risk  of  over-­‐fa5gue  of  oral  motor  musculature  

– Integra5on  of  Kangaroo  care  and  early  breast  orienta5on  opportuni5es  

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Development  of  oral  motor  

skills  

36-­‐40  weeks  SSB  mature  and  func5onal  

Cough  ini5ated  at  26-­‐27  weeks  and  consistent  at  37-­‐38  weeks  

Gag  response  at  26-­‐27  weeks,  and  consistent  at  32-­‐33  weeks  

Sucking  skills  emerge  at  9  weeks,  peak  at  17  weeks  gesta5on  and  con5nue  “prac5cing”  un5l  29  weeks   • NNS  program  at  28  weeks  gesta5on  

Oral  Motor  Progression  

Oral  Experience      Oral  fixing  pa@erns  • Oral  intuba5on  or  nasal  

intuba5on:  tape  or  Neobar  • Modes  of  ven5la5on  • RAM  canula  vs  mask  CPAP  • Cranial  changes  affec5ng  oral  

anatomy  development  • Oral  feeding  progression  

(greater  than  30  days  of  tube  feeding  has  higher  incidence  of  language  impairment:  Malas,  2017)  

• Reflexive  to  cor5cal  feeding  progression  

• Neurological  and/or  pulmonary  co-­‐morbidi5es  

• GERD  • OG,  NG,  NJ  feeding  plan  • Anklyoglossia  • Posterior  tongue  bunching  

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Feeding  therapist:    Anatomical  changes  secondary  to  medical  interven5ons  

These  can  lead  to  Oral  

Aversion  

Medical  Defini5on  as  used  by  

Interdisciplinary  Feeding  Teams  and  medical  providers  

“Reluctance,  avoidance,  or  fear  of  ea5ng,  drinking,  

or  accep5ng  sensa5on  in  or  around  the  mouth.”  

Symptoms  of  

Emerging  Oral  

Aversion  

•    Hunger  cues  but  refusal  to  swallow  •    NNS  on  pacifier  but  refusal  to  take  

bo@le  or  breast  

•    Pulling  away  from  feeding  source  •    Significant  mouth  closure  when  

offered  oral  a@empts  •    Stress  signs  when  preparing  to  be  fed  

•    Feeding  only  when  asleep  (reflexive  feeders  not  voli5onal  feeders)  

•    Poor  growth  

Considera5ons  for  successful  infant  feeding  

• Considera5ons:  – Anatomical:    frenulum  length,  tone  

of  tongue,  hard/soj  palate  structure  

– O2  needs  – Organiza5on  of  suck  pa@ern  with  

NNS  

– Historical  considera5ons  

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Medically  Complex  Infant:    

Breas;eeding  Posi5oning  

ma@ers  

• Common  breas;eeding  posi5ons  – Cradle  – Cross  Cradle  

– Football  – Side-­‐lying  – Laid-­‐back  

• Motor  considera5ons  of  each  

– Postural  Stability  – Breathing  pa@ern  to  control  

swallow  – Inspiratory  5dal  volume  

– Swallow  stability  

Everything  Ma@ers:    The  Latch      

• Cervical  spine/Mandibular  movement  synergy:  – Neck  extension  and  mouth  open  

– Neck  flexion  and  mouth  closed  • Infant  must  demonstrated  roo5ng  skills  

and  ini5ate  mouth  opening  – Recessed  jaw  

– Posterior  tongue  posi5oning  – Soj  5ssue  changes  to  facial  region  – Palate  presenta5on  

• Chin  contact  with  the  breast,  slight  neck  flexion,  lip  flange  to  make  a  seal  

Tongue  Movement  

• Extrinsics:    4  muscles  that  control  the  POSITION  of  the  tongue  in  the  moral  cavity  

– They  originate  from  the  bone  and  extend  to  the  tongue  

• Genioglossus,  hypoglossus,  styloglossus,  and  palatoglossus  

• Intrinsics:    4  muscles  that  control  the  SHAPE  of  the  tongue  as  it  moves  in  the  mouth  

– They  have  soj  5ssue  inser5ons  • Superior  longitudinal,  inferior  

longitudinal,  Transverse,  Ver5cal   The  Mouth  Reigns  

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Infant  Driven  Feeding  

Assess  Readiness  (hunger  cues)  

• Awake/alert  • Roo5ng  • Sucking  on  fisted  hands  

Assess  Quality  of  feeding  (Breast  or  bo@le  feeding)  

• Coordina5on  • Stability  • Quality  of  feeding   Infant  Driven  Feeding  

Assessment  

Addi5onal  Interven5ons  

for  Breas;eeding  

Medically  Complex  Infants  

• Cervical  Ausculta5on  

• Feeding  team  (lacta5on  specialist  and  feeding  therapist)  co-­‐treatment  sessions  

• Co-­‐regulated  feeding:  matching  mother  flow  with  infant  abili5es  

• Supported  oral  motor  interven5ons  prior  to  latch  and  during  feeding  (as  needed)  

• Posi5on  changes  during  the  feeding  

Addi5onal  Nutri5on  Requirements:    Bo@le  Feeding  

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Feeding  Strategies:    Equipment  

• Vented,  non-­‐vented,  valve  

Bo@le  Selec5on  

• Standard  or  orthodon5c  • Standard  or  wide  base  

Nipple  Shape  

• Intensity  of  silicone  

Integrity  of  Nipple  

Flow  Rate  

Feeding  Strategies:    Feeder  Skill  

Control  Hydrosta5c  pressure  

Pacing  

External  supports  • Chin  support  • Cheek  support  • Mandibular  trac5on  

Posi5on  of  infant  (swaddle?)  • Upright  • Sidelying  

Protec5ng  Breas;eeding  during  

Bo@le  feeding  • Nipple  selec5on:    Slow  flow  nipple,  

match  infant  oral  cavity  size  with  base  of  nipple  

• Posi5oning:    mimic  mother  preferred  posi5on  

• Facilitate  roo5ng  and  ac5ve  latch  to  nipple  

• Ini5ate  bo@le  feeding  with  dry  sucks,  do  not  give  immediate  milk  

• Trac5on  to  bo@le  to  facilitate  mandibular  protrac5on  for  nutri5ve  sucking  pa@erns  

Oral  Feeding  Goals:    Skilled  Feeders  not  Sufficient  Feeders  

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Aspira5on  

Is  Aspira5on  the  Problem?  

• Coughing  or  “choking”  during  feeding  • Infants  not  mee5ng  their  expected  developmental  oral  feeding  goals  for  growth  

• Infants  that  lose  physiological  stability  during  feeding  – Tachypnea  – Labored  or  noisey  breathing  – Color  changes  

• Infants  that  have  significant  nega5ve  behaviors  during  feeding  

• Medical  history  of  pneumonia  or  chronic  respiratory  illnesses  that  are  not  responding  to  conven5onal  interven5on  

Types  of  Aspira5on  

Anterograde  

• Occurs  pre-­‐,  intra-­‐,  and  post-­‐deglu55ve  

Retrograde  

• Ascending  aspira5on  events  in  response  to  GER  

• EERD:    Extraesophageal  Reflux  Disease  

Silent  • Without  any  symptoms  

Assessment  for  Aspira5on  

Video  Fluoroscopy  

X-­‐ray  movie  of  the  infant  while  she  swallows  

“Gold  standard”  

Cervical  Ausculta5on    

Clinician  listens  to  the  swallow  

with  stethoscope  

Can  be  a  powerful  

screening  tool    

FEES  (Fiberop5c  Endoscopic  Evalua5on  

of  Swallow)  

Fiber-­‐op5c  camera  used  to  

watch  oropharynx  

Newer  instrument  for  infant  dysphagia    

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What  happens  during  a  VFSS  • Parent  interview  and  oral  motor  exam  • We  watch  the  baby  drink  a  radiopaque  thin  liquid  (barium)  while  taking  x-­‐ray  images  

• The  radiologist  and  rehab  therapist  will  come  to  agreement  on  whether  aspira5on  occurred  

• The  rehab  therapist  will  make  adjustments  to  how  the  baby  is  fed  to  try  to  stop  the  aspira5on  

Protec5ng  Breast-­‐Feeding  in  VFSS  • Problem:  a  common  way  of  addressing  aspira5on  is  to  use  thickened  liquids;  breast  milk  cannot  be  thickened  • Enezyme  Amalyse  in  breast  milk  breaks  down  the  starch  (rice,  oat,  barley)  within  the  bo@le,  so  does  not  allow  for  a  thicker  viscosity  for  swallow  

• Posi5oning  and  flow  rate  from  nipple  will  be  assessed  to  reduce  the  need  for  a  thicker  viscosity  

VFSS  Results  and  Recommenda5ons  

Avoid  pn

eumon

ia  

Safe  oral  feeding  

Limit  the  use  of  th

ickene

r  

VFSS  follow-­‐up  

Add

ress  th

e  root  problem

 

Rehab  therapy  

Referrals  to  other  specialists  

Dysphagia  op2ons  for  infants  

• Posi5oning  – Side-­‐lying  is  both  naturalis5c  and  can  aid  in  swallow-­‐breath  coordina5on  

• Adjus5ng  flow  rate  – Slower  flow  can  allow  the  epigloss  5me  to  close  

• Are  the  behaviors  the  same/different  between  breast  and  bo@le  – Have  we  looked  at  all  of  the  op5ons  to  support  safety  and  healthy  intake?  

•  Thickening  as  a  last  resort  

Protec5ng  nutri5on  and  lung  health  for  a  fast  recovery  

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Rehab  Services  &  Feeding  Therapy  

• Infant  Feeding  Therapy:    Early  Interven5on  is  Cri5cal  to  Long-­‐Term  Success  

• Two  Goals:    Growth  and  Posi5ve  Experience  

Bodily  Systems  &  Poor  Feeding  in  Infants  

• Head  &  Neck  Structures  – Clej  lip  &  palate  

– Facial  asymmetries  – Ankyloglossia  

– Tracheostomy  &  ENT  surgeries  

• Cardio-­‐respiratory  – Significant  pulmonary  anomalies  – Prematurity-­‐related  lung  disease  

– Cardiac  anomaly  and  related  failure-­‐to-­‐thrive  

Bodily  Systems  &  Poor  Feeding  in  Infants  

• Diges5on,  Absorp5on,  and  Elimina5on  – Poor  GI  mo5lity  &  reflux  

– Complex  medical  history  (including  abdominal  surgeries  

– Any  pharmacological  interven5ons  with  appe5te  side  effects  

– Cons5pa5on  or  diarrhea  – Metabolic  issues  

Bodily  Systems  &  Poor  Feeding  in  Infants  

• Neurogenic  issues  – Acquired  neuromotor  

impairments  • Cerebral  palsy  

• In  utero  stroke  

– Gene5c  neuromotor  impairments  • Down  Syndrome  

• Spinal  muscle  atrophy  

– Iratogenic  neuro  lesions    • Vocal  fold  paralysis  

• Airway  scarring  

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Occupa5onal  Therapy  

• The  prac5ce  of  providing  occupa5on-­‐based  and  ac5vity  of  daily  living  interven5ons  to  infants  with  feeding  delays.    This  pertains  to  all  aspects  of  feeding  and  swallow  experience.  

• U5lize  a  Global  assessment  of  func5on  to  iden5fy  individualized  factors  affec5ng  feeding  

• Specialized  training:  –  developmental  progression  of  

feeding  

–  sensory  experience  

– musculoskeletal  demands    – medical  complexi5es  

associated  with  feeding  delays  

Speech  Therapy  

• SLP  training  includes  intensive  study  of    – Normal  cogni5ve,  behavioral,  and  

motor  development  across  the  lifespan    

– Neuromotor  control  and  impairment  

– The  physics  of  “fluids  in  tubes”  – Respira5on  and  voice  

• Dysphagia  is  a  required  part  of  all  speech  therapy  master’s  programs    – Then  must  pass  an  exam  that  had  a  

designated  number  of  dysphagia  ques5ons  

• Role  in  addressing  infant  feeding  – Aspira5on  &  instrumental  exam  – Oral  motor  – Parent  educa5on  – Feeding-­‐related  communica5on  

I  s5ll  don’t  understand  who  does  what…  

Similari2es  

• Evaluate  and  treat  issues  with  latch  to  bo@le  or  breast  

• Address  issues  with  intake  or  safety  (aspira5on)  

• Work  with  families  to  find  frenotomy  op5ons  

Differences  

• Many  5mes,  differences  come  down  to  individual  clinicians  and  their  training  

• In  general,  an  OT  will  address  sensory  and  trunk  control  

• In  general,  a  speech  therapist  will  address  aspira5on  and  oral  motor  

Take  Home  Message:    

• Op5mally,  an  infant  will  benefit  from  collabora5on  between  mul5ple  specialists  

• In  reality,  it  can  be  difficult  to  find  therapists  who  are  trained  to  address  infant  feeding  issues  

• Different  health  systems  and  even  Early  Interven5on  services  may  provide  different  models  of  support  

Find  an  experienced  therapist  

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How  to  get  an  OP  SLP  referral  

• Ask  during  physician  visit  

• Types  of  exams:  – Clinical  Feeding  Exam  =  Just  SLP  or  OT  

– Feeding  Clinic  Exam  =  SLP,  OT,  die5cian  

– Video  Swallow  Study  

– Pediatric  FEES  – NICU  Follow-­‐up  Clinic  

Resources  

• Help  Me  Grow  (0-­‐3)  – h@p://helpmegrowmn.org/HMG/index.htm  

• American  Academy  of  Pediatricians  “Aged  &  Stages  – www.healthychildren.org  

• American  Occupa5onal  Therapy  Associa5on  – h@ps://www.aota.org    

• American  Speech-­‐Language  Hearing  Associa5on  – h@ps://www.asha.org/public/    

References  • Averdson  J.  Assessment  of  pediatric  dysphagia  and  feeding  disorders:  Clinical  and  

instrumental  approaches.  Dev  Disabil  Res  Rev.  2008;  14:  118-­‐127.    • Clark  L,  Kennedy  G,  Pring  T,  Hird  M.  Improving  bo@le  feeding  in  preterm  infants:  

Inves5ga5ng  the  elevated  sidelying  posi5on.  Infant.  2007;  3(4):  154-­‐158.  • Garber  J.  Oral-­‐motor  func5on  and  feeding  interven5on.  Phys  Occup  Ther  Pediatr.  

2013;  33(1):  111-­‐138.  doi:  10.313109/01942638.2012.750864  • Jackman,  K.    (2013).    Go  with  the  flow.    Choosing  a  feeding  system  for  infants  

in  the  neonatal  intensice  care  unit  and  beyond  based  on  flow  performance.    

Newborn  and  Infant  Nursing  Reviews,  13,  31-­‐14.    • Lau,  C.  Is  there  an  advantage  for  preterm  infants  to  feed  orally  in  an  

upright  or  sidelying  posi5on?  J  Neonatal  Nurs.  2013;  19:28-­‐32.  • Lau,  C.    (2000)    Characteris5cs  of  the  developmental  stages  of  sucking  

in  preterm  infants  during  bo@le  feeding.    Acta  Paediatrica,  89(7),  846-­‐852.  

• Ross,  Erin.    Perspec5ves  on  Swallowing  and  Swallowing  Disorders  (Dysphagia)  Volume  24,  April  2015,  Copyright  ©  2015  American  Speech-­‐Language-­‐Hearing  Associa5on  

• Shaker  CS,  Woida  AM  2007  An  evidence-­‐based  approach  to  nipple  feeding  in  a  level  III  NICU:  nurse  autonomy,  developmental  care,  and  teamwork.  Neonatal  Netw  26:  77-­‐83    

• Costeloe,  K.  L.,  Hennessy,  E.  M.,  Haider,  S.,  Stacey,  F.,  Marlow,  N.,  &  Draper,  E.  S.  (2012).  Short  term  outcomes  ajer  extreme  preterm  birth  in  England:  comparison  of  two  birth  cohorts  in  1995  and  2006  (the  EPICure  studies).  Bmj,  345,  e7976.  

• Lagarde,  M.  L.,  Kamalski,  D.  M.,  &  Van  Den  Engel-­‐Hoek,  L.  E.  N.  I.  E.  (2016).  The  reliability  and  validity  of  cervical  ausculta5on  in  the  diagnosis  of  dysphagia:  A  systema5c  review.  Clinical  rehabilitaJon,  30(2),  199-­‐207.  

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MBC 2018 Workshop

11/2/18  

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Contact  Informa5on  

• Jessica  Gri@ner,  MS,  CCC-­‐SLP  – jgri@n1@fairview.org    

• Holly  Schifsky,  OTR/L,  CBIS,  NTMTC,  CNT  – hschifs1@Fairview.org  

MBC 2018 Workshop