Improving Feeding Skills in Children with DS 6 slide handout

1/15/2019

Improving Feeding Skills
in Children with
Down Syndrome

Minnie Bray, M.S., CCC-SLP, BCS-S
Speech Language Pathologist

Board Certified Specialist-Swallowing Disorders

DSG Keys to Success Conference
January 26, 2019

Feeding and Swallowing Skills Think Bottom Up

 Eating is a learned behavior  Medical problems often lead to discomfort
 Acquisition of skills follows a progression associated with eating, which leads to
selective eating or refusals, which leads to
with each new milestone building on skills delayed oral motor development, which leads
of the previous one to difficulty eating, which leads to more
 If there is an interruption in this process, selective eating or refusals, and on and on
a feeding problem may develop
 Dysphagia: difficulty moving food  Very few children have a behavioral feeding
efficiently and safely from the mouth into problem in isolation
the stomach
 Penetration/aspiration are results of the  Help with the underlying problem (bottom)
condition, and not the condition itself while addressing the mouth (top)

Gross Motor Skills and Feeding Gross Motor Skills Cont.

 Positioning is the foundation for feeding  What can parents do?
 How are gross motor skills related to
◦ Tummy time
feeding? ◦ Avoid the “Container Baby Syndrome”
◦ Facilitate positioning for every feeding
◦ Abnormal muscle tone can interfere with body
alignment  Motor therapy facilitates feeding

◦ Lack of trunk support greatly hinders ribcage ◦ Positioning: hips and knees at right angles;
expansion, interfering with respiration and Need good postural alignment when getting
increasing pressure on the stomach and ready to chew
abdominal cavity
◦ Basic exercises for trunk strength and rotation
 Link between gross motor skill (weight shift on exercise ball, log roll, prone on
development and oral motor skill ball, side sitting during play, play games with
development trunk rotation)

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GI Considerations

 Must achieve “gut comfort” before traditional
therapy approaches will be effective

 Vomiting leads to negative feeding
association

 Slow GI motility can increase reflux/vomiting
 Poop matters

◦ Constipation is common in children with Ds
◦ Constipation causes slower GI motility and

reflux/vomiting

 When eating causes pain/discomfort, a
negative association with eating is formed

 Collaboration is ongoing

Ear Nose and Throat Cardiac and Respiratory
Considerations
Considerations
 Consider structural abnormalities
 Narrow airways  Common in infants with Ds
 Chronic congestion impacts respirations  Cardiac issue often leads to increased

and suck-swallow-breathe coordination respiratory rate
 Enlarged adenoids and/or tonsils
 Chronic middle ear fluid ◦ Swallow apnea of 1 second is okay if respiratory
rate is 30 (swallow-breathe-swallow-breathe)

◦ What about a respiratory rate pushing 60?

 “Breathing always wins.”
 Considerations

◦ Eating is a lot of “work” and fatigue leads to
disorganized Suck-Swallow-Breathe” pattern

◦ Fast flow may be more “work” than a slow flow
nipple

◦ Consider pacing techniques
◦ Work with dietician regarding caloric intake

Feeding Therapy Feeding Therapy Cont.

 Includes working with physicians to  Feeding is a reciprocal exchange.
manage medical issues that affect feeding  Look at Family Mealtimes
 Establish scheduled meals/snacks
 Includes motor, sensory, and behavioral
components ◦ Avoid grazing
◦ Water only between meals/snacks
 Disordered feeding in a child is seldom
limited to the child alone; it also is a  Mealtime Responsibilities
family problem
◦ Adults Decide: What is offered, When it is
 Includes working with families so they offered, and Where it is offered
may
◦ Child Decides: What is actually eaten and
◦ Better understand the child’s feeding skills How much is eaten
◦ Help their child to advance skills
◦ Help parents separate their self-esteem with  The “Purpose of Mealtime” goes beyond
nutrition and hydration
their child’s abilities

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Feeding Therapy Cont. Positioning Across the Ages

 Feeding interactions occur multiple times  Positioning is the foundation for feeding
each day and impact attachment  Energy should be on eating, not sitting
interactions

Recommended Not Recommended The Progression of Feeding Skills
For Feeding
 Suckle
 Sucking
 Munching/Midline Mashing
 Vertical Chewing (Tongue Lateralization)
 Rotary Chewing

 The development of chewing takes time
 When a child tires during a feeding, he will

revert backwards in skill
 Balance oral motor skill development with

nutrition/hydration needs

From Bottles to Solids  Avoid “Tip and Scrape”

 There’s no perfect bottle Tip and Scrape:
but choose one Baby is passive.
Accidentally promotes
 Introduce baby foods around six months more forward-backward
 First goal is anticipation tongue movements.
Doesn’t require sucking.

Present a flat spoon and
wait for the baby to clear
the spoon.
Promotes top lip
movement, lip closure,
and sucking.
Baby is active.

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Recommended Not Recommended for The Continuum of Foods
Feeding
 Spoon with narrow,  Liquids
shallow bowl for easy  Spoon with wide,  Purees
clearance deep bowl  Thicker Purees
 Meltables
 Easy to grasp  Soft Table Foods

◦ Soft Cubes
◦ Soft Single Texture Solids
◦ Soft Mixed Texture Solids

 Table Food Requiring More Chewing

Midline Mashing Vertical Chewing/Midline Mashing

Vertical Chewing/Midline Mashing Transition to Cup Drinking

 The transition to cup drinking is closely
linked to the transition to solids

 Suckling and sucking from a bottle or
sippy cup involve a forward-backward
infantile tongue movement contradictory
to tongue lateralization needed for
chewing

 Sippy cups are not recommended. Work
toward the straw and open cup.

 Have patience!
 Be prepared for messes.

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Recommended Cups 1/15/2019

 Honey Bear Straw Cup Recommended Cups Cont.
 Medicine Cups
 Recessed Lid Cup  Cut Out Cup
 Take and Toss
 Infatrainer Cup Straw Cup
 Playtex Coolster
without the valve
 360 cups are okay to
limit spills but not a
great teaching cup

Videofluorscopic Swallow Study Tube Feeding Considerations

(VFSS)  Tube feedings are not a sign of failure!!!
 Hydration/nutrition is the primary feeding goal
 When do we refer for VFSS?  Malnutrition results in weakness and further
 Concerns of swallow safety and penetration/aspiration
based on signs/symptoms and medical history developmental delays. Weakness results in poor
 When we think it would change the feeding routine or feeding skills and a decline in swallow safety.
program

 Considerations
 Health status
 Feeding utensils and consistencies

 Concerns
 Not pass/fail
 NPO

 Repeating the VFSS—Considerations
 Do we expect to see a change from previous results?
 Will results accurately reflect abilities?
 Have we considered radiation exposure?
 What do the parents want?

Feeding is Messy Business References and Resources

It’s a marathon, not a sprint.  As They Grow: Motor Development From Birth to
Six 2nd Edition by Jennifer Jones, Ph.D. BCS-S

 Pediatric Feeding Disorders: Evaluation and
Treatment edited by Kellyl VanDahm, MS, CCC-
SLP

 Prefeeding Skills, 2nd Ed. by Suzanne Evans
Morris, PhD., CCC-SLP and Marsha Dunn Klein,
M. ED., OTR/L

 The Reflux Book: A Parent’s Guide to
Gastroesophageal Reflux by Beth Pulsifer-
Anderson

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