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Tuesday, December 24, 2013

GI Issues and Feeding in Children

Step-by-step approach to food tolerance and diet expansion

The condition of a child's GI system has a direct effect on feeding. If the GI system is not functioning efficiently it's going to impact feeding tremendously.
Many of the children with GI system present with:
  • gastroesophageal reflux disease (GERD),
  • constipation due to the limited diets related to food refusal,
  • vitamin and mineral deficit, which in consequences affect the GI tract and put things off balance,
  • eosinophilic esophagitis, an allergy-based esophageal inflammation
  • necrotizing enterocolitis in premature infants - an occurrence when intestines become inflamed or infected. The intestines need to be repaired and reconnected through surgery, causing serious GI complications.
  • negative associations with feeding, e.g. If the child is refluxing and it's causing pain, he associates pain with eating so he stops eating.
It is the same with eosinophilic esophagitis. If the child is constipated and feels bloated and full, he doesn't want to eat and does not have any hunger cycles. The chiled can learn that negative association within a month or two and starts refusing the bottle.
Many of the children treated by speech-language pathologists on the feeding team are tube-dependent. As a result, they are seen by a team consisting of speech pathology, gastroenterology and nutrition. The collaboration of these three specialists is necessary.
The speech-language pathologist requires a constant line of communication with the dietitian because these nutrition decisions are tied so closely to oral intake. Feeding is the only activity that involves all your organs and all of your muscles. Everything goes into feeding, so everything impacts it.
Families of tube-fed children often struggle with the idea that their children will never be hungry enough to eat orally if they remain on the tube. It's a double-edged sword. We can not pull back on the tube just because the child is not eating enough.
Generally, the preference of the treatment team is to put children who are tube-fed on bolus feeds rather than continuous feeds. However, if the child cannot tolerate a bolus feed, the continuous feed will continue.
A fairly normalized mealtime schedule is arranged for children who can tolerate a bolus feed. In an ideal situation the feed would be given by a pump over 20 to 30 minutes because that is a more normalized mealtime that the child would take if they were given everything PO (orally).
The 20-minute feed time presents an ideal opportunity for the speech-language pathologist to put the pump behind the child's chair, where it is out of sight, and begin PO trials. The children learn that something is going in they mouth and they stomach is feeling full, but they don't associate feeling full with the sight of the machine.
Children still can learn proper feeding positioning by sitting in a chair and can sit with their family to establish mealtime traditions and precedents, even if they are not fed orally yet. That can work even if the child is an aspirator. They can still get positive oral stimulation.
Appropriate oral stimulation toys or devices and textured plastic play food should be used to reinforce oral associations with feeding. There would be kids who will point to their tube and say 'hungry' because they know that's how they are fed. Nobody wants that association. Speech-language pathologist wants the child to point to his mouth and say “That.”
In the feeding program SLP uses several activities with an empty spoon and cup before introducing food. If a child can't tolerate an empty spoon in his mouth, most probably he won’t be able to put a spoon with pudding in his mouth.
Even when food finally is introduced, the child may tolerate puree but reject a "wet" texture food, such as green beans or mandarin oranges. Food chaining posits that children are more likely to accept a new food if it is similar in some way-color, shape or texture-to a food they already like. If a child eats Goldfish crackers, for example, clinician may use a fish-shaped cookie cutter to cut slices of cheese to reflect the color scheme. Clinician then introduces the food to the child by discussing its likeness to the previously accepted food.
Another sensory technique used by the team targets the large number of children with GERD who present with sensory processing difficulties caused by the pain they experience while eating. These children are pulling back on a lot of oral stimulation that they would normally be doing, so they're not putting things in their mouths, they're not mouthing on a toy, and they're very sensitive to the texture or temperature of foods. When it's reintroduced, they're hypersensitive.
It is not uncommon for these children to gag or vomit food. With those kids SLP has to work on tolerating the food on the tray.
The clinicians use the Sequential, Oral, Sensory (SOS) Approach to Feeding developed by psychologist Kay Toomey, PhD. Dr. Toomey's approach seeks to lessen the fearfulness of feeding for children by breaking down the process into much smaller steps. There may be 28 to 32 steps before a child takes a bite and swallows. These steps include kissing the food, licking, putting it into the mouth, and spitting it out.
The therapy is pushed as much as the child can tolerate it and until the kid is finally eating the bite.
The step-by-step approach incorporates an "all-done bowl" that allows the clinician to maintain control of the feeding therapy. For example, if a child starts throwing the food, which is very common, instead of saying: No throwing, Stop, the clinician would say, The food stays on the table. If you're done with it, you can clean it up and put it in the bowl. If the child gets distressed about the food does not just throw it off the table. The child has to follow an instruction to complete the task. It allows for a much more efficient, less battle-oriented mealtime, which is something a lot of parents deal with.
Speech-language pathologist on the team also works with the parents on using appropriate, positive language during mealtime to allow them to remain in control. The parents should avoid questions, such as: Will you take a bite? Do you like it? or Will you eat a bite for Mommy? but use positive statements, like: You can take a bite. Mommy wants to see you do it.
During feeding therapy, children must remain seated with appropriate positioning in the chair. They are not permitted to walk around the room and come back to the food when they want it. This reinforces normalized mealtime scheduling and the routine of family interaction at the table.
Infants don't have trunk support yet. When we hold them in a cradled position, they're slumped down and putting a lot of pressure on their abdomen, which causes the reflux to come up a little easier. As they learn to crawl and walk and sit upright, there's not as much pressure on the stomach and as the result half of infants outgrow reflux by 9 months of age.
Children who had reflux as infants need to be monitored for less visible but still present symptoms of GI disturbance. The reflux instead of coming out of the mouth might be coming up and down into the esophagus.
Older children with reflux often present with a chronic cough, hiccups, burping and frequent ear infections. They may only be able to tolerate small feeds but in frequent intervals.
Dental caries also can serve as an indicator for a speech-language pathologist. When a toddler has had a lot of dental work, which can be a red flag because the acid is coming up and eroding tooth enamel.
Recurrent pneumonia is another serious concern and GI problem indicator. Reflux is typically worse at night because we sleep lying down, and by doing so we lose the benefit of gravity. It comes up, spills over into the larynx, and goes into the lungs. The children are getting aspiration pneumonia, but they're aspirating reflux.

Thursday, December 12, 2013

Phonological Processes and Elimination in Typically Developing Child

A concerned parent asked me about the phonological development and processes in typically developing child. In replay I presented him with two tables created by Caroline Bowen. I frequently use the tables for my clients.

“All children make predictable pronunciation errors (not really 'errors' at all, when you stop to think about it) when they are learning to talk like adults. These 'errors' are called phonological processes, or phonological deviations. In Table 2 are the common phonological processes found in children's speech while they are learning the adult sound-system of English.” Caroline Bowen

TABLE 2: Phonological Processes in Typical Speech Development

PHONOLOGICAL PROCESS (Phonological Deviation)
Context sensitive voicing
"Pig" is pronounced as  "big"
"Car" is pronounced as "gar"
A voiceless sound is replaced by a voiced sound. In the examples given, /p/ is replaced by /b/, and /k/ is replaced by /g/. Other examples might include /t/ being replaced by /d/, or /f/ being replaced by /v/.
Word-final devoicing
"Red" is pronounced as "ret"
"Bag" is pronounced as "bak"
A final voiced consonant in a word is replaced by a voiceless consonant. Here, /d/ has been replaced by /t/ and /g/ has been replaced by /k/.
Final consonant deletion
"Home" is pronounced a "hoe"
"Calf" is pronounced as "cah"
The final consonant in the word is omitted. In these examples, /m/ is omitted (or deleted) from "home" and /f/ is omitted from "calf".
Velar fronting
"Kiss" is pronounced as "tiss"
"Give" is pronounced as "div"
"Wing" is pronounced as "win"
A velar consonant, that is a sound that is normally made with the middle of the tongue in contact with the palate towards the back of the mouth, is replaced with consonant produced at the front of the mouth. Hence /k/ is replaced by /t/, /g/ is replaced by /d/, and 'ng' is replaced by /n/.
Palatal fronting
"Ship" is pronounced as "sip"
"Measure" is pronounced as "mezza"
The fricative consonants 'sh' and 'zh' are replaced by fricatives that are made further forward on the palate, towards the front teeth. 'sh'  is replaced by /s/, and 'zh'  is replaced by /z/.
Consonant harmony
"Cupboard" is pronounced as "pubbed"
"dog" is pronounced as "gog"
The pronunciation of the whole word is influenced by the presence of a particular sound in the word. In these examples: (1) the /b/ in "cupboard" causes the /k/ to be replaced /p/, which is the voiceless cognate of /b/, and (2) the /g/ in "dog" causes /d/ to be replaced by /g/.
Weak syllable deletion
Telephone is pronounced as "teffone"
"Tidying" is pronounced as "tying"
Syllables are either stressed or unstressed. In "telephone" and "tidying" the second syllable is "weak" or unstressed. In this phonological process, weak syllables are omitted when the child says the word.
Cluster reduction
"Spider" is pronounced as "pider"
"Ant" is pronounced as "at"
Consonant clusters occur when two or three consonants occur in a sequence in a word. In cluster reduction part of the cluster is omitted. In these examples /s/ has been deleted form "spider" and /n/ from "ant".
Gliding of liquids
"Real" is pronounced as "weal"
"Leg" is pronounced as "yeg"
The liquid consonants /l/ and /r/ are replaced by /w/ or 'y'. In these examples, /r/ in "real" is replaced by /w/, and /l/ in "leg" is replaced by 'y'.
"Funny" is pronounced as "punny"
"Jump" is pronounced as "dump"
A fricative consonant (/f/ /v/ /s/ /z/, 'sh', 'zh', 'th'  or /h/), or an affricate consonant ('ch' or /j/) is replaced by a stop consonant (/p/ /b/ /t/ /d/ /k/ or /g/). In these examples, /f/ in "funny" is replaced by /p/, and  'j'  in "jump" is replaced by /d/.

TABLE 3: Elimination of Phonological Processes
Phonological processes are typically gone by these ages (in years ; months)
Context sensitive voicing
pig = big
Word-final de-voicing
pig = pick
Final consonant deletion
comb = coe
car = tar
ship = sip
Consonant harmony
mine = mime
kittycat = tittytat
Weak syllable deletion
elephant = efant
potato = tato
television =tevision
banana = nana
Cluster reduction
spoon = poon
train = chain
clean = keen
Gliding of liquids
run = one
leg = weg
leg = yeg
Stopping /f/
fish = tish
Stopping /s/
soap = dope
Stopping /v/
very = berry
Stopping /z/
zoo = doo
Stopping 'sh'
shop = dop
Stopping 'j'
jump = dump
Stopping 'ch'
chair = tare
Stopping voiceless 'th'
thing = ting
Stopping voiced 'th'
them = dem

Bowen, C. (1998). Developmental phonological disorders. A practical guide for families and teachers. Melbourne: ACER Press.
Grunwell, P. (1997). Natural phonology. In M. Ball & R. Kent (Eds.), The new phonologies: Developments in clinical linguistics. San Deigo: Singular Publishing Group, Inc.
Check Caroline Bowen’s page  

If Someone prefers more visual version can go to Tracy Brading page to see the chart 
"By the age of ___________, 90% of children have suppressed the phonological process of _________________."

Age 3
AF = Affrication (e.g. "cho" for "show") 
BA = Backing (e.g. "buk" for "bus") 
VC = Voicing Change (e.g. "dief" for "thief")

Age 4
CD = Consonant Deletion (e.g. "bu" for "boot") 
DE = Deaffrication (e.g. "sew" for "chew")

Age 5
FR = Fronting (e.g. "tey" for "key") 
SY = Syllable Deletion (e.g. "mado" for "tomato")

Age 6
AL = Alveolarization (e.g. "tum" for "thumb") 
CR = Cluster Reduction (e.g. "poon" for "spoon") 
CS = Cluster Simplification (e.g. "twa" for "tray") 
GL = Gliding (e.g. "wug" for "rug") 
SD = Stridency Deletion (e.g. "but" for "bus") 
ST = Stopping (e.g. "toup" for "soup") 
VO = Vowelization (e.g. "penco" for "pencil")

Age 8
LA = Labialization (e.g. "fad" for "sad")


Lowe, R.J.  (2000) ALPHA (Assessment Link Between Phonology and Articulation Phonology) Revised Test of Phonology.  (2000)  Mifflinville, PA: ALPHA Speech & Language Resources