“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

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Swallowing Evaluation and Rehabilitation

Check my other post:
Dysphagia - Feeding & Swallowing Disorders in Infants & Children

http://slpzone.blogspot.com/2012/05/feeding-and-swallowing-disorders-in.html    

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

http://slpzone.blogspot.com/2012/04/dysphagia-and-swallowing-therapy-and.html

 

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I refreshed my knowledge about Dysphagia by viewing ASHA webinars:

“Elements of a Comprehensive Clinical Dysphagia Evaluation presented” by Joseph Murray, PhD, CCC-SLP

“Impact of Impaired Antomy and Physiology on Treatment of Dysphagia in Adults” presented by Nancy B. Swigeret, MA CCC-SLP, BCS-S

“Dysphagia Intervention: Planning and Implementation” presented by Nancy B. Swigeret, MA CCC-SLP, BCS-S

“Theoretical Basis of Exercise and Treatment of Dysphagia” Nancy B. Swigeret, MA CCC-SLP, BCS-S

 

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What is normal swallowing?

Normal swallowing consists of a set of physiologic behaviors which result in food, liquid or other substances moving from the mouth to the pharynx and esophagus while protecting and closing the airway to the stomach. Swallowing is an important part of eating and drinking.

What is swallowing dysfunction?

When the process fails and the bolus is aspirated, this is called swallowing dysfunction or dysphagia. Dysphagic patients may have difficulty with any one or more of the anatomic or physiologic components of the oral, pharyngeal or esophageal stages of the swallow.

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What is a role of swallowing evaluation?

Evaluation of the patient with dysphagia should identify the anatomic or physiologic abnormalities characterizing the patient's swallow and include introduction and assessment of the efficacy of treatment strategies.

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What is the primary goal in the management of swallowing disorders?

The primary goal in the management of swallowing disorders is to ensure safe swallowing. For determination of the appropriate rehabilitative approaches, clinicians should consider the assessment of all symptoms and problems causing dysphagia.

What are tree types of management?

The management of swallowing disorders:

• medical management
• surgical approaches
• rehabilitative approaches.

What are the types of treatment?

Treatment may involve:

• compensatory management, such as postural changes or enhancing sensory input
• rehabilitative management, such as active muscle exercise with or without the introduction of food.

Dysphagia - Feeding & Swallowing Disorders in Infants & Children

Children with feeding and swallowing difficulties (also called dysphagia) are at risk for malnutrition, dehydration, and respiratory problems. Infants and children with feeding and swallowing problems are a diverse group, ranging from premature babies to teenagers. Parents are often the first to notice a feeding problem.

Check my other post:

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

http://slpzone.blogspot.com/2012/04/dysphagia-and-swallowing-therapy-and.html

“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

https://slpzone.blogspot.com/2020/05/the-best-practice-for-swallowing-is.html

Causes of feeding and swallowing problems

• Prematurity
• Cerebral palsy
• Autism
• Head and neck abnormalities
• Muscle weakness in the face and neck
• Gastroesophageal reflux
• Multiple medical problems
• Respiratory difficulties
• Medications that may cause lethargy or decreased appetite
• Problems with parent-child interactions at mealtime

Symptoms

Children with feeding and swallowing problems present with a wide variety of symptoms, depending on the nature and cause of their disorder. Typical symptoms include:

• Poor feeding
• Difficulty chewing
• Difficulty drinking from a bottle or cup
• Difficulty breast feeding
• Refusing food or liquid
• Coughing or choking while eating or drinking
• Excessive drooling and food spilling from the mouth
• Liquid leaking out the nose
• Gagging
• Vomiting during meals
• Increased congestion during meals
• Increased fussiness or crying during meals
• Accepting only certain types of food (only pureed foods or only crunchy foods)
• Poor weight gain
• Frequent respiratory infections or pneumonia (may occur when food or liquid is aspirated into the airway, rather than swallowed effectively)

Evaluation and Diagnosis of Feeding and Swallowing Disorders

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your physician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. The pediatrician may refer you and your child to a feeding team or speech-language pathologist who specializes in treating children with feeding and swallowing disorders. The SLP will discuss your concerns and observe your child while they eat. The SLP may also conduct an instrumental assessment of your child's swallowing ability. This involves having your child eat and drink foods and liquids mixed with barium while watching them on an x-ray. This procedure is typically called a modified barium swallow (MBS) and is conducted in a radiology office. Sometimes a different instrumental assessment will be completed, which involves having a lighted scope inserted through the nose so your child's swallow can be observed.

If a feeding team is involved, which may include the speech language pathologist SLP, an occupational therapist OT, a physical therapist PT, a physician or nurse, and a dietitian, your child's posture, self-feeding abilities, medical status, and nutritional intake will also be examined. The team will then make recommendations on how to improve your child's feeding and swallowing.

You can watch 

normal swallow - animation

https://www.youtube.com/watch?v=4FMnXz6o2vI

X-Ray swallow -

http://www.youtube.com/watch?v=PwVreNrTKBw&feature=related

abnormal swallow

https://www.youtube.com/watch?v=mvAKyuI_nUE

Learn about basic of videofluoroscopy of swallowing

http://www.youtube.com/watch?v=-wmt6HlLduY&feature=related

Treatment

Based on the results of the feeding evaluation, the SLP or feeding team may recommend any of the following:

• Medical intervention, as needed
• Direct feeding therapy designed to meet your child's individual needs
• Nutritional changes
• Postural or positioning changes (different seating, etc.)
• Behavior management techniques
• Desensitization to new foods or textures
• Food temperature and texture changes
• Referral to other disciplines, such as psychology or a dentist

If feeding therapy with an SLP is recommended, the focus of intervention may include:

• Strengthening the muscles of the mouth
• Increasing tongue movement
• Improving chewing patterns
• Increasing tolerance of different foods or liquids
• Improving sucking /drinking ability
• Coordinating the suck-swallow-breathe pattern (for infants)
• Altering food textures and liquid viscosity to ensure safe swallowing
• Other interventions depending on your child's specific needs

Swallowing strategies for dysphagia 

A. Compensatory Strategies
- Supraglottic Swallow
- Effortfull Swallow
- Mendelsohn Maneuver
- The Supra-Supraglottic Swallow

B. Postural Techniques
- Head Rotation To Weak Side
- Head Rotation To Strong Side
- Head Back/ Chin Up
- Chin Tuck

Watch video with the swallowing strategies presented by a clinician - 

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

  

Management hints of gastro-oesophageal reflux 

1. Keep your baby upright for at least 30 minutes after a feed. 
2. Use a baby sling; which keeps your child upright, while your hands are free. Avoid baby slumping. 
3. Try elevating the head of the cot/bassinet. 
4.  Consider using a dumm. 
5. Avoid vigorous movements or bouncing a baby. 
6. The best time to lay your baby on the floor is when baby's tummy is empty, i.e. before feeding. 
7. Change nappy before feeding. Take care to elevate baby's head and shoulders. Avoid lifting legs too high. Turn to the side if possible. 
8. Avoid any tight clothing around the waist, such as tight nappies, elastic waistbands. 
9. Avoid overfeeding – if baby vomits, wait until the next feeding rather than feeding your baby again. 
10. If a baby is bottle-fed, it may be worthwhile to try AR (anti-reflux) or hypoallergenic formula.
11.  Offer a spoonful of thickened milk (formula or breastmilk) following the feed. 
12. If breastfeeding, in your diet avoid foods that can aggravate reflux, e.g. citrus, tomato, fatty foods, spicy foods, chocolate and carbonated drinks. 
13. Some reflux children may suffer from food sensitivities, and may need dietary restrictions (or the mother may consider an elimination diet). If you suspect foods may be responsible for your child's condition, it is essential to discuss this with your health care provider. Do not change your or your child's diet before seeking medical advice. 
14. Contact a reflux support organisation for further information and support. The support groups can offer the emotional support you may need.

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

I. Swallowing therapy/treatment

Conventional therapy for dysphagia typically employs

1. Compensatory strategy techniques

·         diet changes

·         head positioning

·         modifying bolus size

2. Specific techniques aimed at improving the coordination and strength of the swallowing muscles

·         thermal stimulation

·         biofeedback

·         mendelssohn maneuver

·         supraglottic swallow

Check my other post:

Dysphagia - Feeding & Swallowing Disorders in Infants & Children

http://slpzone.blogspot.com/2012/05/feeding-and-swallowing-disorders-in.html

“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

https://slpzone.blogspot.com/2020/05/the-best-practice-for-swallowing-is.html

VitalStim Therapy is the use of electrical stimulation for activation of muscles. Research shows that the combination of electrical stimulation and traditional treatment techniques is very effective at restoring swallowing function.

http://www.empi.com/empi_products/detail.aspx?id=222 

II. The standardized diet, consistencies and general guidelines

The American Dietetic Association (ADA), the United States' largest organization of foodand nutrition professionals, in January 2012 officially changed its name to the Academy of Nutrition and Dietetics, developed guidelines for the National Dysphagia diet published in  “The National Dysphagia Diet: Standardization for Optimal Care”

http://webdietitians.org/cps/rde/xchg/ada/hs.xsl/shop_1344_ENU_HTML.htm

The standardized diet consistencies and general guidelines are:

Level I - Dysphagia Pureed

A. Guidelines:

This diet consists of pureed, homogenous, and cohesive foods.

Food should be:

• "Pudding-like"
• No coarse textures, raw fruits or vegetables
• No oatmeal or unprocessed wheat bran stirred into cereals
• Any foods that require bolus formation, controlled manipulation, or mastication are excluded.

NOTE: Smooth chocolate candy (plain) is allowed if thin liquids allowed.

B. Purpose
This diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Close or complete supervision and alternate feeding methods may be required.

Level II - Dysphagia Mechanically Altered

A. Guidelines:
Consists of foods that are:

• Moist, soft-textured, and easily formed into a bolus
• Meats are ground or are minced no larger than onequarter-inch pieces; they are still moist, with some cohesion
• All foods from NDD Level 1 are acceptable at this level.
• Avoid rice, bacon, hard cooked eggs, potato chips/French fries, and fibrous cooked vegetables

B. Purpose
This diet is a transition from the pureed textures to more solid textures. Some chewing ability is required. The textures on this level are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia. Patients should be assessed for tolerance to mixed textures. It is expected that some mixed textures are tolerated on this diet.

Level III - Dysphagia Advanced

A. Guidelines consist of:

• Food of nearly regular textures with the exception of very had, sticky, or crunchy foods.
• Avoid French bread, fresh apples, pears or grapes, and cooked corn.
• Foods still need to be moist and should be in “bite-size” pieces at the oral phase of the swallow.

B. Purpose
This diet is a transition to a regular diet. Adequate dentition and mastication are required. The textures of this diet are appropriate for individuals with mild oral and/or pharyngeal phase dysphagia. Patients should be assessed for tolerance of mixed textures. It is expected that mixed textures are tolerated on this diet.

Liquid Consistency Controversy

Liquid consistencies:

• thin     
• nectar     
• honey
• spoon or pudding thick

With dysphagia patients we use:

3. Pre-thickened liquids or food
4. Instant food & beverage thickeners:

Please watch a video to learn more how to use a thickener.
http://www.dmes.com/p-13369-simplythick-how-to-mix-video.aspx

·         Thick-It manufactured by Milani
http://www.woodburyproducts.com/thickit_powder.htm?gclid=CNrY3_jeoK8CFUbe4Aod7lTamA 

·         Thick & Easy manufactured by Hormel
http://www.healthykin.com/p-358-hormel-thick-easy-instant-food-beverage-thickener.aspx

I also suggest to look into:

“The Dysphagia Cookbook”by Elayne Achilles

http://www.amazon.com/The-Dysphagia-Cookbook-Elayne-Achilles/dp/1581823487 

“Manual of Dysphagia Assessment in Adults” by Joseph Murray
http://www.amazon.com/Manual-Dysphagia-Assessment-Adults-Series/dp/1565938712/ref=sr_1_fkmr0_1?s=books&ie=UTF8&qid=1337705623&sr=1-1-fkmr0