Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4464_Библиотеки_им_академика_М_И_Перельмана.pdf
252 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
FIGURE 11–3. Cranial nerve innervation of swallowing muscles. continues
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 253
FIGURE 11–3. continued
254 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Rooting and sucking
0–4 months
36
Moro
0–3/6 months
Stepping and placing
0–12 months
Palmar grasp
0–6 months
Plantar grasp
0–15 months
Babinski
0–12/24 months
Landau
3–12/24 months
Glabellar
37
Infancy
Touching the mouth or cheek → turn toward object
Once object/nipple is placed in mouth → suckling
Triggering falling sensation → limbs suddenly extend
Upright with feet touching a surface → raise legs as if walking
Pressure to palm of hand → grasp object
Pressure to sole of foot → toes curl
Stroking sole of foot heel to toe → no movement or downward flexion
NB: Feet will fan upward if positive. A positive response is normal in
infants due to neurologic immaturity. In adults this indicates upper
motor neuron pathology.
Suspended prone → head raised, legs flexed
Tapping between eyebrows → eyes blink
NB: This reflex will disappear in adulthood. A positive Glabellar
reflex beyond infancy is suggestive of a movement disorder.
38
Asymmetric tonic neck
0–4/6 months
Symmetric tonic neck
Head turned → arms and legs extend on the same side
This reflex becomes symmetricwhere the shoulders, trunk and pelvis
also rotate.
6–9/11 months
Parachute response
Suspended prone, headfirst toward ground → arms extend to break fall
8/9 months–adulthood
FIGURE 11–4. Primitive reflexes35 test communication pathways of the central nervous system. They are elicited
by stimulating afferent sensory receptors to generate efferent motor responses.
infants will exhibit inadequate coordination of the
suck-swallow-breathe sequence. If infants, who
are reliant on their nose for breathing, have nasal
congestion, it can be challenging for them to per-
form their usual suck-swallow sequence. A perfectly
healthy infant who is successfully breastfeeding may
have a temporary feeding disorder due to an acute
respiratory infection.
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 255
Four-month-old hospitalized with acute
Respiratory Syncyntial Virus (RSV). Madeline
was a healthy term 4-month-old exclusively
breastfeeding with normal growth patterns.
She became febrile, lethargic, fed poorly, had a
productive cough and chest retractions. Upon
hospital admission, she was diagnosed with
bronchiolitis, bilateral pneumonia and was positive for RSV. While her breathing was labored,
oral feeding was complicated. Her mother was
provided with a breast pump to feed the milk via
bottle in a controlled manner so she would not
aspirate due to the complexity of her rapid respiratory rate and fatigue. Some children admitted
with RSV have a temporary nasogastric feeding
tube, and they may also be intubated. Madeline
had deep suctioning via nasal catheter every
3 hours for approximately 48 hours to clear her
bronchial secretions. Madeline resumed breastfeeding once she was weaned from respiratory
support, afebrile, and exhibited improved feeding
stamina.
As children mature, their tongue descends,
altering the mechanics of their pharyngeal swallow.
The airway becomes increasingly vulnerable without the tongue base and palatal barriers. Once food
enters the oral cavity, it must safely break down with
rotary chewing, transport to the posterior tongue,
and initiate a wave of contraction for pharyngeal
transport. While this peristalsis occurs, the laryngeal vestibule tightly closes its 3 layers: aryepiglottic
and false and true vocal folds. The larynx elevates
while closing, inverting the epiglottis and pushing food from the vallecula through the pyriform
sinuses and into the esophagus. Figure 11–5 illustrates the sequential and directional activation of
muscles involved from the moment material enters
the mouth until it reaches the stomach.
Respiratory Coordination for
Pediatric Swallowing
Timing breaths while swallowing is a crucial skill for
airway protection. A normal newborn’s respiratory
rate is 30 to 60 breaths per minute and gradually
lessens with maturation to approximately 17 breaths
per minute in a 12-year-old child.
ing typically occurs during exhalation.
that impair breathing and often implicate dysphagia
include prematurity, laryngomalacia, congenital lung
disease, acquired lung infections, and pulmonary
malformations. The origins of respiratory mistiming
during swallowing may relate to the neurological signal, air hunger, or mechanical ventilation.
39,40
Safe swallow-
41,42
Conditions
256 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
FIGURE 11–5. Stages of swallowing.
The simplest scenario of respiratory coordination during swallowing relates to milk flow.
Ahealthy term baby can breastfeed with a parent
who has no lactation concern and persistently choke
from flow patterns. Sometimes this is due to high
intraoral infant vacuum and/or rapid milk ejection.
Typically, simple modifications such as reclining or
unlatching during the parent’s letdown will improve
their ability to coordinate breathing and swallowing.
A clinician may also encounter a child with an intellectual disability whose respiratory and deglutitory
systems are intact, yet they are often choking due
to impulsive eating patterns.
A more complex scenario is a premature baby
who has required mechanical ventilation since birth.
As babies near 32 weeks’ gestation and are medically stable, oral trials using a pacifier dipped in
breast milk, latching, or bottle-feeds may be initiated. Often these clinician interactions will be once
or twice a day to determine if the infant has sufficient stamina to consume a partial or complete
feed. In the early days, this volume may be as low
as 5 to 45 mL. The remaining intake will typically
be delivered into a nasogastric feeding tube. During
oral trials, they will have monitors assessing heart
rate, respiratory rate, and temperature, which reflect
physiological stability while eating. Understanding
behaviors associated with oral nutrition tolerance is
also vital to successful feeding advancement.
Parents can facilitate improved transition from
enteric to oral feeds with skin-to-skin and
nonnutritive suckling. It can additionally support
their nurturing role and sense of self-worth
during a stressful time as their child is hospitalized.43 There is emerging evidence that low-cost
sensory interventions explored in a recent TASTE
(Taste and Smell to Enhance Nutrition) trial
improve neurodevelopmental outcomes. The
authors found that infants born at less than 29
weeks’ postmenstral age or with a birth weight
less than 1250 grams exhibited significantly
higher head circumference and length when
exposed to the smell and taste of milk.
44
Children with primary respiratory pathology
will require clearance from their pulmonologist and
primary care physicians prior to oral intake. Oral
hygiene, secretion management, pacifiers dipped in
breast milk, and modifications of free water proto-
45
col
are therapeutic tasks prior to drinking and eating. Mechanical ventilation does not preclude oral
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 257
intake, although there is caution surrounding bolus
control and airway protection. When possible, advocating for a speaking valve will equip the child with
the ability to communicate and clear their airway if
material is misdirected into their lungs.
PREMATURITY
Early-term deliveries frequently implicate feeding
and dysphagia symptoms that are managed among
a team of clinical experts including neonatologists,
pulmonologists, nurses, physical therapists, occupational therapists, speech therapists, and lactation consultants. Oral competence and suckling
organization can be promoted when the infant is
not intubated. Kangaroo care
for families to bond with their babies. It is additionally shown to facilitate improved physiological outcomes, including feeding and swallowing.
Sucking becomes increasingly organized around 30
weeks’ postmenstrual age.
ling strength, burst frequency, and duration provide insight on readiness for oral trials. A common
concern among premature infants relates to feeding
stamina. While they may possess suckling skills to
ingest milk safely, they tire before required volumes
are consumed. Successful interventions carefully
trace infant responses (“cue-based feeding”) during
oral feeds, trial strategies related to position and
flow, and await their readiness to advance volume
and frequency of feeds.
lasting effects on feeding performance once they
transition home. For nursing parents, support from
lactation clinicians is important as they transition
from a pump-dependent regimen to direct feeds
with an infant who may be persistently inefficient.
Providing ongoing breast milk requires frequent
and effective milk emptying to sustain lactation. Parents will require guidance to determine how much,
if any, pumping is needed to offer sufficient milk
volumes. Premature babies newly discharged home
will require at least 1 bottle of expressed milk daily
so their intake can be fortified with nutrients they
missed in utero.
52
Some infants born preterm, particularly “micro-preemies,” have numerous comorbidities that may delay when an uncomplicated
46,47
is an opportunity
48,49
Nonnutritive suck-
50,51
The interactions have
early-term baby initiates feedings. It is in the best
interest of the child and family to await physiological stability and positive engagement during oral
intake (Figure 11–6).
Prematurity categorization
Extremely premature — less than 28 weeks
Premature — 28 to 32 weeks
Late preterm — 32 to 37 weeks
Term — 37 to 42 weeks
53
MILK TO SOLIDS
The American Academy of Pediatrics recommends
exclusive breast milk intake until 6 months of age
when iron-rich complementary foods are introduced.
until 2 years or beyond as mutually desired by infant
and mother. Literature now supports early introduction of allergenic foods prior to 11 months of age to
reduce incidence of IgE-mediated reactions in later
life.
tively on breast milk and formula due to oral-motor
dysfunction, reflux, or other aerodigestive problems
impacting suckling and swallowing, a decision may
occur collaboratively among providers to introduce
solids as early as 4 months. Some infants can sustain reasonable growth curves with higher feeding
frequency, changing positions, altering flow rates, or
consolidating calories by fortifying milk with calorie
additives. If infants are born preterm, their gastrointestinal tract is not prepared for solid foods until
their adjusted age nears at least 4 months. They also
may have medical complexity that precludes typical
solid food introduction.
varied diet of meat, poultry, fish, eggs, and vitamin A–
rich fruits and vegetables should be consumed
between 6 and 24 months while continuing to
breastfeed.
to thrive; in particular, vitamin D, iron, and zinc are
important to incorporate into their diet. Before feeding solids, infants should demonstrate readiness.
54
They advise ongoing breast milk intake
55
For children who are struggling to feed effec-
As guided by the World Health Organization, a
56
Infants require vitamins and minerals57
58
258 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
FIGURE 11–6. Objective scales.
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 259
Watch for sitting without support, bringing their
hand to mouth, pincer grasp, mouth opening when
food is offered, and transferring food from the anterior to posterior tongue. While it is not necessary to
present pureed foods, it may be easier for infants to
coordinate smooth textures and reduce choking risk
while their oral-motor skills develop. Once competent with smooth textures, small bites of soft foods
can be presented and self-administered.
Information on vitamins and minerals for vita
minD,
59
iron,60 and zinc can be found by scanning
the accompanying QR codes.
TAKING A CASE HISTORY
Interviewing a family about their child’s feeding and
swallowing concerns is an opportunity to establish
rapport and develop a collaborative partnership
to meet mutually developed goals. Involving children in conversations, when appropriate, helps to
garner perspective and promotes autonomy. Some
families may arrive with thick digital and paper files
of prior dysphagia interventions and relevant medical history. Preparing for a consultation by studying medical records demonstrates commitment to
novel intervention with reasonable goals that are
deemed achievable. In situations where the condition is potentially of a behavioral origin, intently
understanding the progression of symptoms will
ultimately help solve the condition.
If a child had prior feeding and swallowing
therapy, review of former clinical interactions is
advised so novel solutions and exercises are prescribed. When medical records are sparse, request
them for review, and schedule an additional visit to
integrate the results into treatment recommendations. Figure 11–7 is a guide on how to structure
consultations with families. Open-ended questions
create an opportunity for families to tell their story.
Because the answers may lead to additional relevant
questions, it is ideal to avoid strict adherence to a
specific diagnostic rubric. This can also personalize
the appointment and demonstrate to families that a
clinician is open to filtering unique aspects of their
history into interventions.
While getting to know families, there are key
points of the nutritional history to obtain, including
whether the condition is developmental or acquired.
Ask about the birth and feeding practices; there may
be earlier indicators of dysphagia that were not perceived as disordered. An example is an infant who
met growth milestones; however, when probing
about breastfeeding the parents indicated their child
needed to be fed very often due to fatigue. Additionally, the child was unable to sustain the mother’s lactation due to ineffective milk removal, so she needed
to pump and supplement his intake. Some children
might have nursed effectively and when introduced
to solid foods exhibited extreme preferences and
intolerance to texture or taste. This was likely an
early indicator of hypersensitivity or may suggest
muscle weakness inhibiting solid food transport. Figure 11–8 lists historical questions that are typically
relevant when performing a dysphagia evaluation.
Clinical Evaluation
Once the case history is complete, inspect the
mouth, neck, and response to swallowing textures.
During this process, cranial nerves, muscle tone,
and structural integrity will become apparent. Cranial nerves have bilateral representation, and in the
case of complicated histories, there may be right and
left involvement of different nerves. An example of
this is a brainstem tumor, which might invade one
or more nerves on the right and/or left side. Damage to nerves may also occur incidentally in surgery
as the area is carefully navigated to remove tumors.
The bulbar nerves, which were given their name as
they represent the “bulb” of the brain, house essential neurological input for swallowing and speech:
glossopharyngeal (IX), vagus (X), and hypoglossal
(XII). All are in close proximity to one another, so
depending on the source of damage, there may be
more than one affected. Other cranial nerves relevant during a swallowing evaluation include the
trigeminal (V) and facial (VII) nerves. Figure 11–9
provides a schematic of where the nerves exit the
brain, what information they supply, and what to
expect if there is damage. Figure 11–10 is a task list
for children to perform that will reveal if the nerves
are intact.
260 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
● “I had an opportunity to review Aiden’s medical records before your appointment. From
what I understand, a feeding tube was placed when he was 2 years old because of
malnutrition. I see he has worked with another clinic on optimizing oral intake. Would
you tell me more about how I can help?”
● “It is a pleasure to have you visit our clinic. Ingrid’s hospital records were available
prior to the appointment. My inpatient colleagues indicated that she was hospitalized for
heart surgery, and postoperatively she developed lengthy respiratory failure so a
tracheostomy was performed. I see they started offering small amounts of water and
pureed foods by mouth. These appear to be safe based on her recent swallowing study.
I am interested in knowing how she is doing at this point.”
● “Nice to meet you and your family, Taylor. I read about the surgeries you have
undergone this past year for neurofibromatosis. It sounds like your journey has been
extremely challenging. I am here to help you improve your swallowing skills. This may
reduce how often you need to suction your secretions and potentially start to try
popsicles. I want to create therapy goals with you. Tell me about your experience with
swallowing. I may also ask your parents for their perspective if that is ok with you.”
FIGURE 11–7. Openers.
11. PEDIATRIC DYSPHAGIA: ASSESSMENT OF DISORDERS OF SWALLOWING AND FEEDING 261
●Gestational age at delivery
● Difficulty breast- or bottle-feeding
●Hospitalizations or surgeries with intubation
●Any surgery on the head and neck
●Prior tracheostomy or feeding tube
●If current feeding tube, percentage by mouth and by tube
● Aspiration pneumonia
●Pulmonary status
●Results of prior FEES and MBS
●Developmental milestones
●Intellectual delay or difference
●Maintaining weight–growth curve
●Gastroesophageal or laryngopharyngeal reflux
●Aversion to taste or texture
●Family dynamic surrounding dysphagia
FIGURE 11–8. Child and family interview.