1
Q
Purpose of infant feeding:
7
A
Satisfies hunger
Provides nourishment for growth and development
Provides oral-sensory and oral-motor stimulation
Facilitates state regulation and maintain homeostasis
Provides calming and sense of well-being
Enhances bonding and interactions with caregiver
Serves as foundation for other functions, including speech
2
Q
Anatomy Relevant to Infant Feeding
How is the oral anatomy of an infant different from that of an adult?
A
- Oral anatomy of an infant is smaller and different from that of an adult.
1. Oral cavity is small relative to tongue size.
2. Buccal pads (fat inside cheeks) are large.
3. There are no teeth.
4. Tongue rests anterior to alveolar ridge and contacts lower lip.
5. Temporomandibular joint does not allow much movement of jaw
-Oral anatomy is well suited for suckling (extension-retraction movements of the tongue).
3
Q
Anatomy Relevant to Infant Feeding
How is the pharyngeal anatomy of an infant different from that of an adult?
A
- Pharyngeal anatomy of an infant is also smaller and different from that of an adult.
1. Pharynx is short.
2. Tongue base, soft palate, and pharyngeal walls are in close approximation.
3. Larynx is one-third the size of an adult’s and is high in the hypopharynx.
4. High position of the infant larynx causes the epiglottis to pass superiorly to the free margin of the soft palate and project into the nasopharynx.
4
Q
Anatomy relevant to infant feeding
A
- Pharyngeal anatomy is well suited for the suck-swallow-breathe synchrony.
- Head, chin, neck relationship are ideal for the suck-swallow-breathe synchrony.
5
Q
Physiology Relevant to Infant Feeding
**oral phase-
pharyngeal phase
esophageal phase
A
- Oral phase—nipple compression and generation of negative pressure occur for sucking
- Pharyngeal phase—tongue base, velum, and posterior pharyngeal provide driving force for bolus transfer to esophagus
- Esophageal phase—upper esophageal sphincter opens for bolus transfer to esophagus; lower esophageal sphincter opens to allow bolus entrance into stomach
6
Q
Synchrony of Sucking, Swallowing, and Respiration
- coordination of..
- _____ ratio is…
- decreased…
A
- Coordination of sucking, swallowing, and breathing is crucial to prevent aspiration (entry of material into the airway).
- Suck-swallow-breathe ratio during is generally 1:1:1 or 2:1:1.
- Decreased ventilation during feeding may be a problem for some medically compromised infants.
7
Q
Changes with Growth and Maturation
-Significant oral, pharyngeal, and laryngeal growth takes place in the first... 1. 2. 3. 4. 5.
-
A
- Significant oral, pharyngeal, and laryngeal growth takes place in the first 2 to 3 years of life.
1. Oral cavity becomes larger with mandibular growth.
2. Tongue tip moves back to under alveolar ridge.
3. Teeth erupt.
4. Pharynx elongates.
5. Neuromuscular, particularly oral-motor function matures.
-Growth and maturation lead to changes in feeding and swallowing pattern.
8
Q
Cleft Lip and Alveolus Only
- Infant may have initial problems achieving
- inadequate…
A
- Infant may have initial problems achieving an adequate lip seal on the nipple.
- Inadequate lip seal may cause difficulty generating negative pressure for sucking.
9
Q
Cleft Palate only
- Depends on the …
- Infant may be unable to …
- Infant may be unable to …
- Infant may experience…
A
- Depends on the extent of the cleft
- Infant may be unable to generate negative pressure for suction.
- Infant may be unable to find a hard palatal surface for compression of the nipple.
- Infant may experience nasal regurgitation.
10
Q
Cleft Lip and Palate
- Infant may have all the difficulties noted above, including these:
1. Difficulty achieving…
2. Inability to generate …
3. Inability to find …
4. ___ ___
A
Infant may have all the difficulties noted above, including these:
Difficulty achieving an adequate lip seal on the nipple
Inability to generate negative pressure for suction
Inability to find palatal surface for compression of the nipple
Nasal regurgitation
11
Q
After the Cleft Lip and Palate Repair
- __ ___vary among centers.
- Some discourage …
- Some recommend …
- Some allow ….
A
- Postoperative recommendations vary among centers.
- Some discourage sucking following surgery and may may recommend the use of cup or spoon instead.
- Some recommend supplemental tube feeding for a short time.
- Some allow unrestricted feeding after surgery.
12
Q
Other craniofacial anomalies
Anomalies that can contribute to a feeding or swallowing problem:
11
A
Anomalies that can contribute to a feeding or swallowing problem: Micrognathia (small mandible) Macroglossia (large tongue) Pharyngeal stenosis (narrowing) Vascular anomalies Laryngeal cleft Tracheoesophageal fistula Cortical or cranial nerve involvement Glossoptosis (posterior displacement of the tongue in the pharynx) Midface retrusion Congenital heart or lung disease Choanal atresia
13
Q
Craniofacial conditions
-Conditions that often affect feeding and swallowing include the following:
A
Conditions that often affect feeding and swallowing include the following:
- Pierre Robin sequence
- Moebius syndrome
- Hemifacial microsomia
14
Q
Feeding Methods, Modifications, and Facilitation Techniques
- Most infants with a cleft are…
- Infant’s performance during the …
A
- Most infants with a cleft are able to feed with simple modifications.
- Infant’s performance during the initial feedings determines which feeding method and technique will be best.
SLPs make recommendations, alter feeding
15
Q
Breastfeeding
A
- Breastfeeding trials should be supported.
- With cleft lip, breastfeeding is usually not a problem.
- With cleft palate, it is very challenging due to difficulties with compression and suction.
- Options with cleft palate include:
1. Supplemental nursing (insert tube, pace tube so milk flows)
2. Modified nipples/bottles - Pumping breast milk should always be recommended if breastfeeding is not possible.
16
Q
Modified Nipples
Characteristics to consider when choosing a modified nipple:
A
Characteristics to consider when choosing a modified nipple:
Pliability - (compliancy - correlated to motor system - boiling water to make it softer)
Shape - (traditional, orthodontic)
Length - (reach to soft palate, if only hard palate cleft)
Hole type - (cross cut [doesn’t drip], traditional round)
Hole size - ()
17
Q
Nipples
types
-
-
A
- Orthodontic nipple
- Pigeon nipple (as illustrated here)
- Ross® Premature Nipple
- Standard traditional nipple
18
Q
Specialized Nipple and Bottle Systems
-
-
A
- Mead JohnsonTM Cleft Lip/Palate Nurser
- Ross® Cleft Palate Nurser
- SpecialNeeds Feeder® (formerly the Haberman® Feeder)
- Medela® SoftCup Feeder and Bottle
19
Q
Mead JohnsonTM Cleft Lip/Palate Nursing System
- - - - -
A
- Bottle and nipple unit, but can use any nipple with bottle
- Straight, long, & firm nipple
- Crosscut nipple
- Pliability of bottle allows assistive squeeze to increase flow
- Ability to monitor size of bolus being delivered by squeeze is poor
20
Q
SpecialNeeds Feeder®
- - - - - -
A
- This bottle/nipple unit is relatively expensive.
- It has a straight, moderate length, soft nipple
- It delivers fluid by compression of nipple alone.
- Nipple slit opening allows for adjustment of flow to three rates.
- One-way valve decreases air intake.
- Consider parent’s skills.
21
Q
Medela® SoftCup System
-
A
- Bottle/soft cup unit
- Used for infants that cannot tolerate intraoral placement of nipple
- Allows presentation of liquid in measured amounts
22
Q
Angled neck bottle
A
- Helpful when positioning has to be very upright
- Allows for downward flow of milk without forcing baby to adapt extended head-neck position
23
Q
Pigeon Nipple and Bottle
-Nipple is
-Thinner side is
-
-One-way valve…
-Bottle is…
-Flow rate ….
A
- Nipple is “Y” crosscut, with one thin side and one thicker side.
- Thinner side is for positioning against infant tongue to extract liquid flow with compression.
- The Pigeon nipple is larger (wider).
- One-way valve allows for flow into nipple with no back flow.
- Bottle is pliable to allow for assistive squeezing.
- Flow rate can be adjusted with tightness of collar on bottle.
24
Q
Positioning of Infant
A
- Semi-upright (at least 60º) is best.
1. Facilitates control of jaw, cheek, lip, and tongue movements
2. Allows gravity to assist with swallowing
3. Helps prevent nasal regurgitation
25
Positioning the Nipple
-Place nipple
Place nipple under palatal bone to aid nipple compression.
26
Pacing Intake
- Fluid must be ...
- Feeder should modify pace when there are these signs of stress:
-Fluid must be provided in rhythm with the infant’s sucking compressions.
- Feeder should modify pace when there are signs of stress:
1. Eye widening or changes in facial expression
2. Decreased alertness
3. Avoidance of feeding
4. Coughing or choking
5. Signs of excessive air intake
6. Signs of fatigue
27
Pacing Intake
-Flow can be regulated by:
- Flow can be regulated by:
1. Tilting nipple slightly upwards
2. Partially removing the nipple from the oral cavity
28
Oral Facilitation Strategies
includes __ and __ support.
Includes jaw and cheek support
29
Preventing Excessive Air Intake
-
-
- Increase the frequency of burping.
| - Burp infant at least once every ounce.
30
Managing Nasal Regurgitation
Feeder Should:
-
-
-
Feeder should:
- Allow infant time to cough or sneeze to clear the nasal passage.
- Ensure that the infant is in an upright position.
- Use a slower flow nipple or slow the pace.
31
Consistency of Feeding Method
-Infant should be...
-Infant should be fed in the same position, with the same nipple and bottle, and same technique during each feeding.
32
Use of Feeding Obturators
definition
-Feeding obturator—a prosthetic appliance which can be used in first few months to assist infant with cleft palate in feeding
33
Use of Feeding Obturators
advantages and disadvantages
- Advantages:
1. Keeps the tongue from resting inside the cleft
2. Provides a solid surface so tongue can achieve compression of the nipple against it
-Disadvantages:
1.Expense
2.Need for frequent replacement due to growth
3.Retention issues
Irritation of mucosa
34
Use of Feeding Obturators
- Most craniofacial centers...
- Most infants with cleft...
- Most craniofacial centers no longer use feeding obturators, as they feel they are unnecessary.
- Most infants with cleft feed well with modifications.
35
Oral Hygiene
- Mouths of infants are..
- Infants with clefts have...
- Caregiver should...
- Mouths of infants are essentially self-cleaning.
- Infants with clefts have fluids in cleft area and nose, which can cause infection.
- Caregiver should cleanse the cleft and surrounding areas after feedings with a washcloth, gauze, or Toothette®.
36
Transitioning to a Cup
- Consider when...
- The ... can help with transition.
- Most surgeons recommend ...
- Consider when transitioning to a cup is developmentally appropriate (usually between 6 and 9 months).
- The Medela SoftCup™ feeder can help with transition.
- Most surgeons recommend weaning from bottle prior to palate surgery because nipple in the mouth and sucking could cause breakdown of repair.
37
Introduction of Solid Foods
- Usually begun around ...
- Assist in transition by ...
- ... can cause more frequent __ ___ and disorganized ___.
- Usually begun around 4 to 6 months, with rice cereals and strained foods
- Assist in transition by using appropriate positioning, small boluses, slow pace, alternating with liquid to assist with clearance.
- Rapid spoon-feeding or large spoonfuls can cause more frequent nasal regulation and disorganized swallowing.
38
Assessment and Management of Complex Feeding Problems
-
-
-
- Clinical assessment
- Videofluoroscopic Swallowing Studies (VFSS)
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
39
Clinical Assessment
- Should be performed by ...
- Assesses...
- Determines ...
- Should be performed by a feeding specialist (qualified SLP or OT)
- Assesses infant’s ability to safely feed
- Determines effect of compensatory strategies on feeding performance
40
Videofluoroscopic Swallowing Study (VFSS)
- Also called...
- Performed by a ...
- Allows visualization of ...
- Can observe ...
- Also called modified barium swallow
- Performed by a radiologist and a speech-language pathologist
- Allows visualization of oral, pharyngeal, and esophageal phases of swallowing
- Can observe aspiration, response to aspiration, nasopharyngeal reflux, and effect of compensatory strategies
41
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
- Involves the ...
- Allows assessment of ..
- Provides information ...
- Can clearly view ...
- Disadvantage is ...
- Involves the transnasal passage of an endoscope for viewing of the pharyngeal and laryngeal structures
- Allows assessment of airway protection during swallowing
- Provides information regarding sensory threshold in the pharynx and larynx
- Can clearly view structures and management of secretions
- Disadvantage is temporary loss of view when VP valve closes during the swallow
42
Interdisciplinary Feeding Team Evaluation
-Severe cases should be evaluated by a team of feeding specialists. Who is on the team?
- Severe cases should be evaluated by a team of feeding specialists.
- Feeding team may include the following members:
- Gastroenterologist
- Nutritionist
- Nurse
- Speech-language pathologist
- Occupational therapist
- Behavioral psychologist
- Otolaryngologist
- Pulmonologist
- Consulting radiologist
43
Alternative Feeding Methods for Severe Cases
-
-
- Orogastric or nasogastric (NG) tube—for supplemental feeding
- Gastrostomy (G) tube—for infants with abnormal oral reflexes or poor airway protection while swallowing
44
Summary
Ultimate goals of the feeding method are to provide:
- Adequate nutrition and weight gain
- Pleasurable experiences for infant and caregiver
- Enhancement of bonding process
- Sensorimotor stimulation for normal development
Ultimate goals of the feeding method are to provide:
- Adequate nutrition and weight gain
- Pleasurable experiences for infant and caregiver
- Enhancement of bonding process
- Sensorimotor stimulation for normal development
Cleft Palate
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