Explanation
In pediatric dysphagia, factors that inhibit children from acquiring necessary functions are insufficient sensorimotor experience, environment factors, and the underlying disorder. We need to obtain information about the medical history and general condition, as well as detailed information about mealtimes, from the children's parents or guardians and their caregivers.
The following are important before intervention is started: understanding the developmental stages reached in eating and swallowing function, by carefully observing eating movements; and getting cooperation from parents and caregivers, and understanding the children's development and environment beyond that needed for eating and swallow function. In clear contrast to adult patients, pediatric patients are still in the process of acquiring eating and swallowing functions, so it's essential to gain cooperation from the adults around them. It's also important that those adults fully understand eating and swallowing for their child. In particular, we want to avoid daily mealtimes becoming just about eating training; mealtimes should also integrate flavor training.
Explanation
We need to take a medical history first, then assess the children's present condition and their oral and related movements. Based on the findings, we can develop a plan for intervention.
Explanation
During the history taking, collect information about the history of the present condition, history of feeding and swallowing conditions, and current eating status from parents and caregivers.
History of eating-related conditions:
Collect the following information: starting and finishing dates of tube feeding, milk feeding, and weaning periods; whether the patients mouthed (or are still mouthing) fingers and/or toys.
Current eating status:
Assess the current eating situation such as whether patients take food orally and need for support to maintain good posture and/or support for eating. Also, collect information on, for example, muscle tone, height, weight, and daily rhythms.
Assessment of present condition:
Assess the presence of hypersensitivity, the ability to breathe through the nose, and the presence of primitive reflexes to determine whether patients are ready to start oral feeding. Also examine the oral structures (eg, occlusion and palate), salivation, and the presence of reflexes (eg, swallowing reflex).
Hypersensitivity: See Slide 5.
Nasal breathing: This can be confirmed by placing a hand mirror or a piece of tissue paper under the nose.
Primitive reflexes (rooting, sucking, and bite reflexes): They should be tested when patients are awake.
Rooting reflex: The reflex is present if the baby turns the head toward the stimulus (eg, tapping the corners of the baby's mouth and lips with your little finger).
Sucking reflex: The reflex is present if the baby sucks your little finger inserted in the mouth, with the tongue cupping the finger.
Bite reflex: The reflex is present if the baby moves the mandible up and down or has continuously mastication movements when you place your finger on the maxillary and mandibular posterior alveolar ridges.
Oral morphology: Examine occlusion (open occlusion, reverse occlusion), height of the palate, narrowness of the dental arch, tooth eruption status, and morphological abnormalities.
Salivation: Assess the volume and timing of salivation.
Reflexes and responses: Check for the presence or absence of the gag reflex, the swallowing reflex, and mouth opening responses.
Examination of hypersensitivity
The pathogenesis and causes of hypersensitivity remain unclear, but one possible major cause is insufficient sensorimotor experiences. Hypersensitivity prevents individuals from reacting adequately to stimuli. Hypersensitivity makes caregiving difficult and also can be a factor preventing functional development.
In patients with hypersensitivity, touch, regardless of who from, triggers increases in muscle tone initially at the location of touch and this then spreads to the whole body. If a similar symptom occurs only when being touched by certain individuals, this is not hypersensitivity but rejection. It's important to distinguish hypersensitivity from rejection.
Confirmation of the presence or absence of hypersensitivity:
It's necessary to identify areas of hypersensitivity, ideally, in the presence of parents or caregivers who have already established a rapport with the pediatric patients. This is because hypersensitivity cannot be easily distinguished from psychological rejection if assessed by medical professionals who are strangers to the patients. The conventional method recommends using the palms of the hands to firmly touch a wide area of the body in the following order (distal to proximal): distal area of the hands, arms, shoulders, neck, face, around the mouth, and then inside the mouth (see left figure). According to the summary of exercises published in the journal of the Japanese Society of Dysphagia Rehabilitation (vol. 18, no.1 (42)), the following order is recommended: trunk, shoulders, neck, face, around the mouth, and then inside the mouth (see right figure). See the Society's homepage for detail of the exercises.
Carefully observe facial expression (eg, crying and grimacing) to identify the area of hypersensitivity. When patients present with symptoms of hypersensitivity, hands should be removed after the patients' movements have stopped but not immediately after symptom onset. Patients with more severe hypersensitivity may go into spasm upon touch stimulation. Hypersensitivity tends to be found in the following areas: face, around the mouth, and inside the mouth (maxilla rather than mandible, anterior teeth rather than molars).
Methods to relieve hypersensitivity:
When hypersensitivity is confirmed, hypersensitivity should, in principle, be relieved before initiating training. Indirect training is usually done before a meal, but relief of hypersensitivity should be done at times unrelated to meals, otherwise children may connect mealtimes with preceding unpleasant experiences of hypersensitivity and start to have a negative image of meals.
In principle, weak stimulation on the sensitive area should be kept for a considerable time without removing your hands. It's important to help patients get used to touch stimulation. Whole hands should be placed firmly on the surface of the patients' skin. The contact surface area should be wide, and the hands should not be moving or rubbing the patient's skin. Even if patients move or try to escape from the discomfort, try not to move your hands to rub their skin or to let them move away. Patients will calm after a while and then hands can be removed slowly. This sequence should be repeated several times.
Examination of oral movements
Lip closure: Assess whether patients can close their lips during rest, feeding, oral processing of food, swallowing, and drinking.
Movement of the corners of the mouth: See Slide 7.
Tongue movement: See Slide 8.
Jaw movement: Assess whether children's jaws are making simply up-down movements or rotary lateral movements, whether children bite down on a spoon, and whether they can control the jaw (whether the mandible is stable and not moving up and down excessively) while taking solids and liquids.
Observe movements during actual eating. Observing the whole eating process is beneficial, and the main areas to be examined are the lips, tongue, and jaws. Be sure to assess mealtime posture because inappropriate posture can increase muscle tone and lead to functional impairment. Assess movements of each area of the body required for eating and swallow function. Also, be sure to note the findings separately for movements associated with assisted feeding and those with self-feeding.
Explanation
Movements of the corners of the mouth during oral processing of food should be classified into the following: virtually no movement; symmetrical pulling (indicating that children are swallowing or crushing food); and asymmetric complex movements (indicating that they are chewing).
Symmetrical pulling: The lips are tightly closed, so they look thin. Both sides of the corners of the mouth are pulled simultaneously.
Asymmetric complex movements: The upper and lower lips are twisted on one side in a coordinated manner. The corner of the mouth on the chewing side is pulled.
Tongue movements
Forward and backward: The tongue mainly moves forward and backward (including sucking movements).
Up and down: The tongue can crush food by elevating and descend
Lateral: The tongue can make lateral movements that is required for mastication.
Presence of tongue protrusion: This should be assessed during rest, feeding, oral processing of food, swallowing, and drinking.
Explanation
The stage of children's feeding and swallow function should be determined based on the findings of the above assessment (also see the previous module: Development and impairment of feeding and swallowing) in order to plan dysphagia treatment that addresses the eating environment, diet, and functional training. Understanding functional development is important when implementing interventions for pediatric dysphagia. Also, the children's eating environment and the relationship between them and their parents should be taken considered in order to develop feasible treatment plans.
Guidance for an adequate eating environment:
- Have brief friendly exchanges and create good eating environment so that entire meal experience can be training.
- Give guidance on how to support patients so that they maintain a stable posture during mealtimes (see Slide 10).
- Select eating utensils that help patients use and acquire functions.
Dietary guidance:
Select food with an appropriate texture either suited to current function or facilitating function. The next grade diet can be tried when patients are about to acquire a new eating function.
Functional exercise:
In a practice sense, patients do functional training with their parents. So, choose training based on the assessment results but also consider the burden on parents and caregivers and their level of understanding. Also, ensure mealtimes should are fun and motivating, with these aspects not becoming secondary to training.
Children should be fully assessed to determine the training they need. For children with multiple disabilities, it may seem logical to do different types of tasks to address the different disabilities, but it's very important to prioritize these based on the children's and parent and caregivers' situation as well as the eating environment.
Indirect training: This includes desensitization therapy, nasal breathing exercises, exercises that facilitate swallowing, and exercises of muscles to facilitate the movements of body parts requiring feeding and swallowing.
Direct training: These include swallowing exercises using different taste stimuli, eating using actual foods, mastication, self-feeding, and drinking.
Mealtime posture
If children have severe conditions and can't maintain a stable posture or have involuntary generalized muscle rigidity, it's important to stabilize them by holding them or placing them on a chair with necessary stabilizers. Here we see the anti-reflex curled up posture where the shoulder, hip, knee, and ankle joints are flexed to relieve rigidity.
Gum rubbing
This facilitates swallowing. Oral sensory function will be improved. It's effective for children who bite down on a spoon. If patients have hyperesthesia of the gum, desensitization should precede gum rubbing.
Procedure: Perform rubbing in each quadrant. Place the index finger between the patient's teeth and gingiva. Move the finger from the center to the back in each hemiarch with the jaws closed. Don't rub the gingiva in a reverse direction.
The video shows the Vangede method. This passive lip exercise to address impaired lip function (eg, incomplete lip closure) is for children who can't follow instructions.
Tongue exercises
The figure shows the extraoral tongue exercise in the Vangede method for impaired tongue function (eg, impaired food crushing and tongue protrusion).
Explanation
Let's look now at feeding assistance with direct training. Hold the spoon at the height of the children's mouth and move it horizontally towards their mouth. Tell the patients what is on the spoon. If they don't voluntarily open their mouth, stimulating the lower lip with a spoon may be effective. When the mouth opens, feeding assistance can be done as follows: 1) place the spoon on the lower lip; 2) if the patients don't close their lips after a while, lower their upper lip manually; and 3) remove the spoon straight back out of the mouth. If they tend to open their mouth too soon, support the jaw until the swallowing process is complete. The purpose of this support is to help the children be able to take food into the anterior part of the oral cavity that senses physical properties and make appropriate movements for the food form. This training should be done as part of the mealtime until both the children and their parents get used to receiving and providing feeding assistance, respectively. Then the time for feeding assistance should be increased gradually. When patients acquire functions, support for these functions should be withdrawn. In this way, the entire mealtime will not be used for training.
Explanation
When pureed food is put in the mouth, it should be swallowed with the jaws closed. The mandible moves up and down throughout the eating-swallowing process, and the tongue is protruding: the child cannot swallow food with the jaws closed.
So, the child cannot acquire the swallowing function when the eating function is still developing.
A lip exercise for lip closure, an extraoral tongue exercise for tongue protrusion, and a feeding exercise to learn all movements without retroflexion of the neck in the eating-swallowing process.
References
- Yoshihiro Kaneko: Eating Function Disorders: Concepts and Rehabilitation, Ishiyaku Pub.
- Masaru Takaku, Yoshiharu Mukai: Eating and Swallowing Rehabilitation for Children, Ishiyaku Pub.
- Yoshihiro Kaneko: Eating, swallowing and respiratory rehabilitation for disabled children, Ishiyaku Pub.
Recommended readings
- Yoshihiro Kaneko: Eating Function Disorders: Concepts and Rehabilitation, Ishiyaku Pub.
- Masaru Takaku, Yoshiharu Mukai: Eating and Swallowing Rehabilitation for Children, Ishiyaku Pub.
- Yoshihiro Kaneko: Eating, swallowing and respiratory rehabilitation for disabled children, Ishiyaku Pub.
- Yoshihiro Kaneko, Takeshi Kikutani: Eating Well: Supporting Understanding Development, Ishiyaku Pub.
- Humio Tamura: Eating Well: Feeding Guidance, Ishiyaku Pub.
- Yoshihiro Kaneko: Development and Disability of Eating Skills: Comprehensive Support from the Child's Perspective, Ishiyaku Pub.
