SPHS 543JANUARY 29, 2010

Failure to Thrive (FTT)… Poor weight gain/growth failure… Below 3rd – 5th percentile… No gain for three consecutive months

Often causes overlap… Illness, disorder, feeding difficulty, parent/child

interaction

May impact cognitive development

GASTROESOPHAGEAL REFLUX The return of gastric contents, either food

alone or mixed with stomach acid, into the esophagus.

Reflux is normal!

BARRIERS TO REFLUX

LES – contains gastric contents; pressure differentials

Growth – longer esophagus, more upright, solid foods

Saliva… Acid neutralization… Clears refluxed materials… Polypeptide hormone

Respiratory protective systems… Cough/airway clearance (6 mos +)

GER Delayed gastric emptying

… Strictures… Esophageal spasm leads to odynophagia

Respiratory impact… Increased WOB… Lack of energy = slower digestion… Asthma subgroup

Pressure sensitive… constipation

GER OR GERD? Weight loss or inadequate weight gain (FTT) Persistent irritability Food refusal/selectivity Posture -arching Coughing/choking Pain Apnea Sleep disturbance Recurrent pneumonia

CAUSES OF GERD Food allergies/intolerance

Immature digestive system

Structural

Immature neurological system… Low tone

TREATMENT Non-medical

… Thickening

… Positioning

Feeding frequency

TREATMENT Medication

… Improves gastric motility Metoclopramide Erythromycin

… Lowers gastric acid production Ranitidine hydrochloride

… Proton pump inhibitor Omeprazole, lansoprazole

TREATMENT Surgical

… Fundoplication… Percutaneous endoscopic gastrostomy (PEG)… Jejunostomy feedings

TREATMENT Child/Family

… Food as power

NORMAL DEVELOPMENT AND FEEDING SKILLS

Everything is connected

Gradual disassociation of movements

Tactile senses give way to visual and auditory

Drive toward independence

STABILITY Stability

… Need a stable base from which to develop … movement (mobility) and functional skills

Central to distal

External (positional) stability… Supporting one body part against another… Against an external source… Achieve muscle balance on both sides of a joint

STABILITY Internal (postural) stability

… No reliance on external aid or support… Balance of contraction between agonist and

antagonist muscles

Movement through space

STABILITY Achieves external stability by lying supine

Initial success with a controlled reach

STABILITY Balance of co-contraction of shoulder

… begins to develop internal control

Positional stability of elbow on floor

Weight shifts

MOBILITY Mobility develops from a proximal base of

stability

Affects refined development of distal oral-motor skills… Dependent on neck/shoulder girdle stability… Dependent on trunk/pelvic stability

PROXIMAL AND DISTAL Relative terms

… Head/neck distal to body… Jaw is proximal to distal lips, cheeks, tongue

SEPARATION OF MOVEMENT From gross motor to fine motor

GROSS-TO-FINE PROGRESSION Present in all skill areas Gradually develop isolation of a skill

REFINED ORAL SKILLS

STRAIGHT PLANES OF MOVEMENT TO ROTATION

Straight planes first… Random, undirected… Alternate pulls from extensor or flexor muscles

Then lateral/diagonal planes and rotary skills… Gain stability by balancing extensor/flexor

systems… Graded function… Lateral righting reactions

Tendency toward active movement of extensor muscles of neck and back

Gradual control of counterbalancing flexor muscles… Stability in head control

… Rolling and weight shifting… Diagonal and rotary movements

ORAL-MOTOR SKILLS Parallel feeding and speech development

Develop from straight planes to lateral then rotary… Jaw opens and closes for munching

… Lateral movement as food moves side to side

… Circular rotational movement to grind food

MIDLINE DEVELOPMENT Four midlines in the body

… Vertical… Horizontal… Two diagonals

Develop our sense of midlines through weight shifts over proximal joints

Experience plays a major role

MIDLINE AWARENESS OF MOUTH

“Home base” resting place for the tongue… Newborn – tongue fills oral cavity… Grooved tongue = vertical midline… Tongue tip elevation = horizontal midline… Lateral movement = diagonal/rotational

midline… ‘Center of mouth’ = defined sense of

horizontal, vertical, diagonal oral midlines

REVERSION TO EARLIER PATTERNS

As children acquire a new skill, some of the previously learned control and stability may be lost temporarily

Often seen in the development of oral-motor skills… Softer foods – munching with some tongue

lateralization

… Move to harder foods, may revert to forward-backward tongue pattern before using more controlled tongue lateralization

REVERT TO EARLIER PATTERNS

… May revert to suckle-swallow with introduction of spoon before using lips

… May cough/choke with cup when previously handled bottle well

ECONOMY/EFFICIENCY OF MOVEMENT

When two or more possibilities exist, the choice will be the one requiring the least effort

Rhythmicity and smoothness… Body rhythms… Timing… Coordination