Outline: Introduction to Feeding Anatomy and Physiology Development of Feeding Skills Dysphagia Assessment Treatment

2. Outline
Introduction
Anatomy and Physiology
Development of Feeding Skills
Dysphagia in Pediatric Population
Assessment
Treatment

4. ADL
Feeding

5. Feeding
process of setting up, arranging and bringing of
food from the plate or cup to the mouth
Eating
Swallowing

6. SSB synchrony
Must be rhythmically synchronized so that infant
can receive adequate nutrition from mother’s
breast or nipple of a bottle
Allows individuals to breathe while
simultaneously and unconsciously sucking in
and swallowing food, drink, and saliva

7. Feeding Problems
Medical conditions
Developmental disabilities
Oral motor dysfunction
Behavioral problems

8. Feeding Problems
Clinical findings may include food
refusal/selectivity, vomiting, swallowing
difficulty, prolonged mealtimes, poor weight gain
and failure to thrive.

10. Oral Structures
• Intact = pre-requisite for normal eating and
drinking

11. Newborn
Small oral cavity filled
with fat pads inside the
cheeks and tongue.
Can feed safely in
inclined position

12. Infant
neck elongates and the
configuration of the oral
and throat structure
changes
Oral cavity becomes
larger and more
open, tongue becomes
thinner and more
muscular, and the cheeks
lose much of their fatty
padding

13. < 1 year
Hyoid epiglottis, and larynx descend, creating a
space between these structures and the base of
the tongue.
The hyoid and larynx become more mobile
during swallowing, elevating with each swallow.

14. Functions of Oral
Structures in Feeding
Oral cavity =
Contains the food
during drinking and
chewing and
provides for initial
mastication before
swallowing

15. Pharynx
Funnels food into
the esophagus
and allows food
and air to share
space

16. Larynx
Valve to the
trachea that
closes during
swallowing

17. Trachea
Allows air to flow
into bronchi and
lungs

18. Esophagus
Carries food from
the pharynx,
through the
diaphragm and
into the stomach

20. Phases of Swallowing
Oral preparatory
Oral
Pharyngeal
Esophageal

21. Oral Preparatory Phase
voluntary control
Oromotor feeding intervention
Oral manipulation results in the formation of a
BOLUS
amount of time varies depending on the texture of
food/liquid
Cranial nerves V, VII, IX, and XII

23. Oral Phase
voluntary control
Begins when the tongue elevates against the
alveolar ridge moving the bolus posteriorly
Ends with the onset of pharyngeal swallow.
1-3 seconds

25. Pharyngeal Phase
involuntary control
Starts with the trigger of the swallow at the anterior
faucial arches
Hyoid and larynx move upward and anteriorly and the
epiglottis retroflexes to protect the opening of the airway
Ends with the opening /relaxation of the cricoesophageal
sphincter
1-3 seconds

27. Final/Esophageal Phase
involuntary control
Starts with the contraction of the
cricopharyngeus muscle and ends with the
relaxation of the lower esophageal sphincter,
allowing the food into the stomach.
8-10 seconds

32. Sucking reflex
predominant method of feeding of fetus during
the first 8 - 10 months of life
Either:
Nutritive
Non-nutritive

33. Premature infants
33 weeks
gestational age or
less
nasogastric
tube/an IV line

34. 2 factors that determine
ability to feed
Sucking rhythm
Types of suction

35. Amount of liquid is
determined by 3 factors:
Rate or speed of sucking
Force of sucking/compression
Length of feeding time

36. Suckling
first sucking pattern
tongue moves back and forth, and the jaw opens
and closes, following the movement of tongue
1st 4 months of life

37. True Sucking
4 months of age
Hallmark: tongue begins to move up and down
6 months: Sipper cup with a spout
12 months: bottle to cup, bites on rim of cup
15-18 months: excellent coordination of SSB
24 months: efficiently drink from cup

38. Biting and Chewing
Infant: reflexive
4-5 months: phasic bite and release
7-9 months: Munching
12 months: rotary movements
18 months: well-coordinated rotary chewing

39. Biting and Chewing
24 months: circular jaw movements

40. Drinking
6 mos: interest in drinking from a cup
12 mos: emerging cup drinking skills
Cup with a lid and spout
24 mos
4-6 ounce cup without a lid
Drinks from straw

42. Dysphagia
Difficulty in swallowing
Results when obstacles in normal development
arise and are not overcome
Limiting variations in feeding:
Problems in individual oral structures
Problems in sensory processing

45. Jaw
Most important partner of the feeding team
Poor postural tone and poor central stability of
neck and trunk
Jaw thrust, tonic bite reflex, jaw clenching

46. Jaw Thrust
1 year olds use visual input and knowledge of
size to guide jaw movements
Lack of jaw grading
Strong downward extension of the lower jaw

47. Tonic Bite Reflex
When child doesn’t release the bite easily or
when there is tension associated with the bite
elicited from the biting surfaces of the gums or
teeth
May have resulted from an experience of
discomfort in the mouth from oral
hypersensitivity, constant suctioning or oral
hygiene

48. Tonic Bite Reflex
Results to jaw clenching  more constant
closure  risk of contractures
 LOM of the Jaw

49. Jaw Clenching
Involuntary tight closure of the jaw

51. Tongue
problems in the muscles that attach the tongue
to other structures of the body and move it in
different directions
Low or high tone
Tongue retraction, tongue thrust

52. Tongue Retraction
Results from abnormal postural tone
Breathing difficulties
Child may compensate by pressing tongue
against hard palate

53. Tongue Thrust
Very forceful protrusion of tongue from the
mouth
Movement is arrhythmical

55. Lips and cheeks
These two work together
Low tone:
Cheeks become inefficient barrier to food moved
against gums and teeth = food easily falls into
cheek cavity
Lips are not able to retain food and saliva in mouth
High tone: retracted position

56. Lip Retraction
lips are drawn back so they form a tight
horizontal line over the mouth
Difficulty in sucking, removing food or
liquid, transferring or retaining food placed in
mouth

57. Lip Pursing
Seen when child attempts to counteract effects
of lip retraction
Puckered lips

58. Cleft Lip
separation of the upper lip and often the upper
dental ridge

61. Palate
the anatomical divider between the oral and
nasal cavities

62. Cleft Palate
separation of the hard or soft palate

64. Cleft Palate
The infant has difficulty building up sufficient
negative pressure within the mouth to obtain an
efficient feeding pattern
Food/liquid/tongue may pass through the
opening

66. Sensory Processing
CNS is unable to control and process and
appropriate amount of sensory information at a
level that is comfortable for the child
Hypersensitivity  Hyperresponsivity
Hyposensitivity  Hyporesponsivity
Sensory defensiveness and Sensory overload

67. Sensory Processing
SSB synchrony is the center of sensory
organization for the entire body
Instability = poor SSB coordination

68. Sensory Processing
Often manifests as behaviors like teeth
grinding, tongue sucking, nail or finger
biting, prolonged bottle feeding, thumb
sucking, and pacifier usage
INPUT TO TMJ
Preferred reactions to stress e.g. bite nails, talks
incessantly, chew gums  stability

69. Sensory Processing
Treatment: satisfying the need for stimulation to
the TMJ, and increasing strength, stability and
grading in the muscles of the jaw

71. Questions
questions about feeding, eating, and swallowing
Assess mealtime participation
Developmental status and health history
Feeding history = any possible frustration and
the parents’ ability to cope with the child’s
feeding issues

72. Neuromotor Evaluation
generalized muscle tone, neuromuscular
status, and general development level
use of adapted seating systems = helps
determine the optimal position for feeding
Upright position or reclined

73. Evaluation of Oral Structures
& Oromotor Problems
Observation of symmetry, size and ROM of oral
structures
Increased oral tone may cause the tongue to be
retracted, humped, or have tip elevation and
may often be the primary cause of feeding
difficulties
Hypotonia may cause tongue to be flat, lack a
midline groove and extend beyond the lips

74. Eating and Feeding
Performance
Final aspect: observation of the actual
feeding/eating and swallowing process to assess
level of performance and to analyze how
motor, sensory, cognitive and communication
skills contribute to performance
parent-child interaction = clues about factors
that may affect the child’s food intake
Variety of textures

75. Videofluoroscopic
Swallow Study
To confirm or rule out swallowing problems
modified swallow study = identifying aspiration
or risk of aspiration
detecting problems related to head and neck
positioning, bolus characteristics, rate and
sequence of presentation, and food/liquid
inconsistencies.

76. Penetration vs Aspiration
flow of liquid/food
underneath the
epiglottis into the
laryngeal vestibule but
not into the airway.
It does not pass
through the vocal folds.
may be silent
It refers to food
entering the
airway before,
during or after
swallow.

78. Feeding Team
Planning and implementing a feeding program
depends on the treatment setting and needs of
the child
Pediatrician, nutritionist/dietitian, SLP, OT, child
behaviorist, developmental psychologist,
dentist, nurse, social worker, teachers, childcare
providers, parents/caregivers

79. Global Considerations
Feeding problems persist = new problems/skill
impairments to complicate intervention needs
consider medical and nutritional problems that
coexist with the feeding d/o and collaborate with
physician and nutritionist for optimum intervention
plan
OTs have to work closely with families and other
caregiver to ensure carryover within daily routines

80. OTs use a holistic
approach
Child factors
Performance skills
Activity demand, context
Family patterns

81. Safety and Health
child’s nutritional status and prioritize treatment
goals to meet basic nutritional needs
use of gloves during therapy services when
there is potential contact with oral mucous
membranes
understanding that certain foods carry a high
choking risk and require modifications or close
supervision with young children

82. Environmental
Adaptations
regularly scheduled meals at consistent times or
locations from day to day
Limit sensory stimulation
Consider order of presentation of foods and
liquids during meal sessions

83. Positioning Adaptations
Positioning of the feet, legs and pelvis  trunk
stability
Stability, muscle tone and activity in the trunk
muscles affect the child’s ability to move or stabilize
the head and neck
position and muscle activation of the child’s head
and neck influence jaw movements
Good jaw stability and freedom of movement
influence the child’s lip and tongue control.

84. positioning adaptations provide stability in the
trunk and support the child in midline orientation
with the head and the neck aligned in neutral or
slight flexion during feeding

85. Infants
Side-lying in caregiver’s
arm
Supine
adapted seat with small
rolls to provide head and
trunk support or R
shoulder protraction to
help an infant hold his or
her own bottle

86. Older infants/Toddlers
Regular high chair -
may provide
adequate trunk
support and may
easily be adapted
with small towel rolls
for additional foot
support or lateral
support

87. Older Children with
Neuromuscular Impairments
Rifton chair - to
provide optimal
support during
oral feeding

88. Optimal positioning
(Hulme)
Vertical head and trunk position
Hip flexion greater than 90 degrees
Knee flexion at 90 degrees
Feet supported in flat surface

89. Positioning
A chin - tuck position
Slight
contraindicated for
young infants who have
laryngomalacia or
tracheomalacia

91. 5 steps to extinguish oral
habits:
1. Root cause of behavior?
2. Why should the habit be eliminated?
3. Program with alternative means to address jaw
weakness and sensory stimulation
4. Conference with family/caregivers/support
team

92. 5 steps to extinguish oral
habits:
5. Convince child to give up the habit
Introduce a substitute

93. General Treatment
Strategies
Oral sensory stimulation:
Nuk brush, cold washcloth, or vibrating device
Strong flavors and cold temperatures

94. Oral Defensiveness
Increase child’s
tolerance to different
textures, tastes and
temperatures
Wilbarger intraoral
(inside the mouth)
technique
Jaw-tug technique
deep pressure
techniques

95. Hyposensitivity to
taste/texture
Noted to have less efficient patterns of moving
food around in the mouth, including chewing and
swallowing secondary to decreased muscle tone
and generalized weakness
Introducing increased food texture consistency
= choking hazard
At risk nutritionally

97. General Treatment
Strategy
Work for better sitting posture on the lap or in a
chair: trunk and pelvis should be in good
alignment with the shoulder girdle in forward
and abducted position, the cervical spine (neck)
is elongated with capital flexion (chin-tuck).
changes in feeding position should be done
gradually.

98. Jaw
Weakness: nonnutritive strengthening ax
Use quiet background music or music with
tempo of 60 bpm to create a calm feeding
environment

99. Jaw Retraction
In prone on feeder’s lap with arms forward across
the feeder’s thigh
Angle the support surface on the feeder’s lap so that
the child’s shoulders are higher than the hips
Gravity may cause the tongue and jaw to drop into a
more forward position
Gently place a hand under the child’s jaw producing
a slight traction forward to further enlarge the
airway.

101. Jaw
Apply carefully graded firm pressure to face,
gums, and teeth while maintaining the jaw in
closed position
low facial tone: Apply patting, tapping, stroking
and other types of tactile and proprioceptive
stimulation of the muscles that open and close
the jaw

103. Tonic Bite Reflex
Assist the child into tonic flexion of neck with
trunk and shoulder support
apply firm pressure on the upper and lower
gums then into the biting surface of the teeth
Use coated spoon to protect child’s teeth from
harm or discomfort

105. Tongue Retraction
1. (prone) stimulate the lips, move into the mouth
and stroke the tongue rhythmically and entice it
to follow your finger as it slides forward in front
of the mouth
2. (chin-tuck) gently tap under the chin on the
muscular area to provide greater tongue
stability and give it more tone for moving
forward

106. Tongue Retraction
(Prone) move into the mouth entering the cheek
pouch from the side then gently work your finger
towards the gums and tongue in which you begin
a downward vibration of the finger in the center
of the tongue to flatten it
on the middle of the tongue, press evenly
downward

107. Tongue Thrust
Reduced by being in a well-supported and
slightly flexed position
facilitate tongue lateralization
encourage the child to make silly faces in the
mirror or to lick lollipops or favorite flavors at the
corners of the mouth or within the cheeks

108. Tongue elevation
facilitated through;
touching the tip of the tongue with an oral motor
device
providing slight pressure on the anterior hard
palate just behind the front teeth

109. Cheeks
Low tone 
place fingers on the side of the child’s nose and
vibrate downward toward the bottom of the
upper lip slowly and evenly providing a long-
lasting relaxation of upper lip tightness

110. Lips Retraction & Pursing
Slow perioral and intraoral cheek stretches can
help promote lip closure
use cotton swabs with drops of liquid placed at
the corner of the lip or in the cheek pocket

111. Lips
teach straw drinking beginning with squeeze
bottle and aquarium tubing
Close the child’s lips as you slowly squeeze
liquid to the edge of the lips
Gradually lessen liquid squeezed into the
straw

112. Cleft Palate
Modifying feeding position and of the nipple
semi-upright position and use angle-necked
bottles

113. Cleft Palate
Football hold for
breast-feeding:
infant is held along
the side of the
mother’s body,
facing her rather
than across her lap

114. Cleft Palate
The Habermann nipple: for
infants with cleft palate to
deliver flow without requiring
suction
has a one-way valve that allows
infant to express fluid through
compression alone, without
requiring suction

115. Post-surgical Repair of
Cleft Palate
perform scar massage
initiate activities to reduce oral hypersensitivity

116. Adaptive Equipment
adaptive spoon, forks, cups and straws
promote independence and improvement in oral
motor control
increase independence in self-feeding
compensate for a motor or sensory impairment

117. Consider properties of
spoon & fork used
spoon with
shallow bowl may
help a child with
decreased lip
closure

118. spoon with bumps or
ridges in the bottom
of the bowl or a
chilled metal spoon
 provide additional
sensory input for a
child w/ decreased
sensory registration
Bites utensil 
Rubber

119. Utensils with shorter
handles or large grip
diameters  help a
child to self feed more
independently
Learning to use straw:
use a shorter or
smaller straw
relatively short straw
with a large diameter
 children who
require thickened
liquids or those with
decreased lip closure

120. cup with a handle 
Poor FMS
U shaped cut out cups
help to maintain a
neutral head position
when drinking liquid
Clear cut-out cups
allow to easily see
liquid entering the
child’s mouth when
physical assistance is
provided when
drinking

121. Modifications to Food and
Liquid Properties
Thickened liquids > thin liquids
easier to control with the lips and tongue, move
more slowly within the mouth, and allow child to
organize bolus for effective swallowing

122. Modifications to Food and
Liquid Properties
Examples:
Simply thick
Pureed or baby food fruits and vegetables
Dried infant cereals or mashed potato
Yogurt or pudding may be added to create
blenderized milkshakes

126. Behavioral power struggles
may develop during mealtimes
encourage parents to offer small amounts of a
new food across multiple meal sessions
Thx should try to create new positive
interactions
Offering choices and turn taking may help child
have a sense of control and increase willingness to
participate in feeding

127. Behavioral power struggles
may develop during mealtimes
provide clear expectations
break the activity down into small, achievable
steps

129. Prematurity and Tube
feeding
decreased tongue mobility, exaggerated jaw
excursions, decreased lip seal, diminished
sucking pads, and irregular respiratory patterns

130. Other problems:
neurological immaturity
abnormal muscle tone
lack of proximal stability
weakened state
exaggerated extensor
patterns of movement,
irritable state
insufficient energy to
consume sufficient
quantity of food
dislike of mealtimes
depressed oral reflexes
decreased tongue
mobility
oral hypersensitivity due
to tube feedings
disorganization of SSB
pattern

131. Prematurity and Tube
Feeding
manifestations may still vary depending on the
infant’s gestational age

136. Components of Oromotor
Treatment Program
1. Improving postural control of head, neck and
trunk
capital flexion and activation of lateral and
diagonal control of the abdominal muscles
in supine, sidelying and prone

137. Components of Oromotor
Treatment Program
2. Improving control of pharyngeal airway
in prone to bring tongue forward to clear the
airway

138. Components of Oromotor
Treatment Program
3. Using touch and movement communicatively
find a comfortable holding position on the lap for
tube feedings, for play around the face and mouth,
and for general interaction

139. Components of Oromotor
Treatment Program
4. Normalizing response to
stimulation
5. Identifying and facilitating
swallowing reflex
stimulation of faucial area with
cold temperatures

140. Components of Oromotor
Treatment Program
6. Reducing impact of Gastroesophageal reflux
medical management precedes surgical
management

141. Components of Oromotor
Treatment Program
7. Improving tone and movement in the lips and
cheeks
vocalizing, patting lips to make interesting sounds
and firmly applying facial lotion to cheeks
Stroking firmly with circular motions around lips
encourage greater lip activity and a forward
posturing for suck

142. Components of Oromotor
Treatment Program
8. Improving tone and movement in the tongue
downward bouncing or patting on the tongue with
finger, toy, teether or Nuk brush
done in the context of sound play or with rhythm of
folk music

143. Components of Oromotor
Treatment Program
9. Facilitating a rhythmical suckle swallow
initially stroke the tongue downward and forward by
therapist’s or infant’s finger
as suckling rhythm emerges, water, juice or small
amounts of pureed fruits and vegetables can be
placed on stroking finger
eventually use a plastic medicine dropper, syringe,
modified pacifier or a moistened cotton swab

144. Prematurity and Tube
Feeding
each component of the program is important, 
the most basic underlying elements of function
or dysfunction should receive the greatest
emphasis in the program

145. Blindness
need to control rate of eating and size of
spoonfuls in order to feel safe and to prepare
mouth to swallow food and breathe in a
rhythmical coordinated fashion

146. Blindness
Put the child in a familiar position or chair for
eating and develop a routine
Tell the child that the food is approaching or
touch the upper or lower lip in a familiar place so
the child will open the mouth

147. Blindness
Gradually fade the support
keep tastes separate as much as possible
Verbal directions + physical prompts  allow
them to experience and kinesthetically
understand movements and sequences that are
efficient and socially acceptable

148. Blindness
Help to establish a personal frame of reference
at the table
Consistency
Teach him to bend the trunk forward so that the
face is directly above the plate to help avoid
major spills

149. Blindness
Teach the child to use
characteristics that can be
sensed using utensils to
identify food
Weight in utensil/cup =
different-sized bites or
different amounts of liquid

150. Blindness

151. Minimal Movement
activation of righting and equilibrium reactions
for higher level of Sensorimotor integration and
coordination
developing greater stability in the trunk and
shoulder girdle

152. References:
[1] Case-Smith, J. (2001). Occupational
therapy for children. St. Louis Missouri, USA:
Mosby, Inc.
[2] Solomon, J. (2006). Pediatric skills for
occupational therapy assistants. St. Louis
Missouri, USA: Mosby, Inc.
[3] Wagenfeld, A. (2005). Foundations of
pediatric practice for occupational therapy
assistants. USA: SLACK Inc.