Management of Feeding and Swallowing Problems in Children
- Management decisions are made in light of the total child with consideration for medical/surgical, nutrition, oral sensorimotor, behavioral, and psychosocial factors. Intervention strategies are focused on primary problem areas of deficit. Evidence-based practice guidelines are needed. Airway stability and adequate nutrition/hydration status are prerequisites for all oral sensorimotor and behavioral approaches to increase the volume of oral feeding or to improve oral skills to expand food textures and to increase efficiency. Initial efforts to improve caloric intake may include increasing caloric density of food, as per the dietitian and physician, along with making adjustments of food textures to improve efficiency and safety of oral feeding. Adequate fluid intake is critical to meet hydration needs and to minimize potential of constipation, which can be a major complicating factor in facilitating hunger, appetite, and interest in feeding.
- Oral sensorimotor intervention involves strategies related to the function of oral structures for bolus formation and oral transit that are under voluntary neurologic control, that is, the jaw, lips, cheeks, tongue, and palate. Techniques vary widely among therapists with little evidence of efficacy, efficiency, and outcomes. Some children appear to improve oral function when foods vary on the basis of texture, tastes, and temperature. Other children show significantly improved oral skills and timing of swallowing with posture and position changes. Frequently used strategies include tapping or stroking the face and using a “Nuk ®” brush or other kinds of stimulation. Parents and therapists report that this kind of stimulation will “wake up the system” and then the child will swallow more quickly and more firmly. However, data are sorely lacking. Goals of specific exercises usually relate to improved strength and coordination, but without defined objective measures of outcomes.
- Professionals and parents do not disagree about the importance of adequate nutrition/hydration. However, there is more likely to be disagreement regarding the need for a gastrostomy tube (GT). It is not unusual for parents to need some time, at least a few weeks or even months, before they agree to a GT. A nasogastric (NG) tube may be used for a few weeks as a test to determine if the child tolerates needed volume of liquid per feeding time without discomfort or emesis. The NG tube feeds also provide an opportunity to monitor weight gain. If nonoral feeds are likely to be required for longer than several weeks, not necessarily for total oral feeding but perhaps just to meet fluid requirements or for medications, a GT should be considered. A feeding gastrostomy tube often relieves stress on the caregivers by allowing freedom from fear of malnutrition. More efficient caloric delivery also frees time for other more pleasurable interactions with the child. Some oral therapy should continue at appropriate levels to ensure the continued experience and maximal development of oral skills over time. Speech-language pathologists can train parents, who can then take advantage of offering tastes during several brief “practice” sessions each day. Duration of each session should be only about 5 to 10 minutes in these circumstances. When a child is on bolus feeds, optimal timing for “pleasurable practice” is likely to be shortly before the start of the tube feeding, providing the child does not show aversive reactions to the tube feedings.
- Data on evidence-based research are needed. All therapeutic approaches have a primary goal for each child to experience healthy, safe, and pleasurable oral feeding, whether the child is a total oral feeder or gets just limited quantities and types of food for practice and pleasure. Pulmonary stability and nutritional well-being are always the primary goals for all infants and children.
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Clinical – Editor in Chief : Dr WIDODO JUDARWANTO, pediatrician
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