Introduction

Feeding and swallowing are addressed together in the therapy of newborns and young children. This is the most significant distinction between newborns and children with dysphagia and adults.

The physician may want to employ various evaluation techniques before treatment, to establish the infant or child’s degree of readiness for treatment. Beginning with the suck swallow response, a child’s feeding behavior is learned. The interaction of the oral, pharyngeal, laryngeal, pulmonary, and gastrointestinal systems, as well as the caregiver’s attentiveness, helps to guarantee that appropriate feeding progresses as the child’s demand for more and varied food grows.

When the infant’s feeding is abnormal, the doctor should keep a close eye on both the infant and the caregiver during the feeding

Observations may lead to changes in the feeding posture, the bolus utilized to feed, and the environment in which the feeding activity takes place.

Goals of a Feeding Assessment

• Recognize the caregiver’s main feeding concern.
• Obtain feeding history from Birth through Current Age.
• Fully assess the four areas that affect feeding development. 
• Observe a feeding session with the parent feeding – note: Parent/child interaction; positioning; utensils used; environment.
• Attempt feeding: Compensations if the child is cooperative.
• Provide simple strategies to leave the parent with if appropriate

Positioning 

Birth-3 Months

Swaddling is advised during feedings from birth to 2 or 3 months.

• Swaddling organizes and calms the infant, allowing him or her to focus solely on sucking/swallowing and breathing.
• Swaddling becomes inefficient between the ages of 2 and 3 months when the baby becomes more active.
• Feeding posture: chin tucked, arms in, hips stable

Require the following:

• Liquid
• Meltable Solid – Cheese Puff or Graham Cracker

Benefits

• Assists in relaxation.
• Organizes the baby throughout feeding times so that he or she just has to concentrate on the Suck Swallow Breathe Sequence.

Cons

• Can overheat if swaddled too tightly.
• Hip dysplasia is present in 17% of newborns. Without therapy, this normally goes away on its own.

Swaddling Techniques

1. Cross your arms across your chest, elbows bent.
2. Hips and knees will be flexed, and the knees will be slightly splayed.
3. If the wrap is too tight, you should be able to get a couple of fingers between the baby’s chest and the wrap.

Bottle Feeding

Bottle feeding can be introduced if the infant has demonstrated adequate oral-motor control and can manage an increase in bolus size. The amount of time it takes to shift from taste trials to bottle-feeding depends on the infant’s abilities. Some newborns may be able to transfer rapidly, in just one or two sessions, while others may take numerous sessions before displaying readiness to progress.

Following the introduction of bottle feeding, a variety of adjustments or adaptive feeding approaches can be used to address oral-motor limitations or incoordination. When it comes to sucking and swallowing coordination, nipple selection is crucial. The therapist will examine the nipple’s characteristics, the fluid’s viscosity, and the infant’s skills and coordination while choosing a nipple. Nipples are available in a variety of materials, sizes, forms, and flow rates, all of which might affect feeding success. It’s worth noting that, while choosing the right bottle nipple is vital, coordination and safety will be closely evaluated in the end to determine flow rate tolerance.

Other adaptive feeding approaches, in addition to nipple selection, can be used to treat impaired sucking and swallowing coordination. External pacing is a technique that involves imposing breaks after a predetermined number of sucking. This approach is used to treat the incoordination of the suck-swallow-breathe cycle, which can lead to apnea. Feeding-induced apnea is more common in preterm newborns, but it can also occur in term or older children.

 External pacing is accomplished by either lowering the bottle to remove milk from the nipple or completely removing the nipple from the mouth. Pacing is done in a variety of ways, based on the infant’s tolerance and feeding cues. With maturity and practice, the infant should eventually be able to self-pace, displaying increased suck-swallow-breathe coordination.

Use of Spoons

Spoons come in a number of sizes and shapes to suit a variety of therapeutic requirements and skill levels. When moving to purees, the spoon you use can help with oral development and feeding success.

It is critical that the spoon characteristics correspond to a child’s ability level. For a child who is having trouble controlling a bolus, a smaller spoon will provide a more manageable size bite with which to practice their skills. A feeding therapist can teach parents how to use certain spoon positioning techniques to help their child’s tongue and lip motions, which are easier to perform with a smaller spoon.

A spoon with a shallow-bottom bowl would assist youngsters with limited lip closure to clear the bolus from the spoon more independently because of the reduced range of motion necessary to close their lips around the spoon. There are even specialty spoons available. The Beckman E-Z spoon is a little flat spoon that can be used to insert the bolus into the cheek quickly and easily. The maroon spoon is a specialty spoon with a shallower bowl that aids lip closure reduces tongue thrust, and reduces oral hypersensitivity.

New-born: Difficulty with Breathing

1. If the baby forgets to breathe, he or she will immediately fall asleep.
2. Pacing drills – Take 2-3 swallows and then nipple tip down, leaving the nipple at the chin and re-establishing a latch after the breath is taken.
3. To reduce the rate of milk flow, consider holding the baby more upright and keeping the bottle at a horizontal level.

Therapy Session Tips

• Reinforcement: Verbal appreciation in the right amount should be given, and sibling/parent eating should be reinforced.
• If at all possible, keep distractions to a minimum because the youngster will go into reflexive eating mode.
• Use positive behavior support by telling the youngster what you want them to do. Don’t offer food in its original containers; otherwise, it will become a habit.
• Food is just food; don’t categorize it as healthy or harmful.

4 General Treatment Strategies

1. Pre-Feeding Warm-Up 
2. Systematic Desensitization
3. Behavioural Approach
4. 3 Plate Presentation

Therapeutic Feeding Session

Warm-Up Before Feeding – Usually used with children who have neurological impairments, sensory processing abnormalities, or who are medically vulnerable or have behavioral issues.

• Establish positioning
• Gum Massage
• Buccal Stretches
• Masseter Stretches
• Non-nutritive chew
• Thermal Stimulation (if indicated – for those with absent swallows; 
• Delayed swallows; silent aspiration)
• Treatment Strategy with or without food based on child’s level of acceptance (SD, Behavioural, or 3 Plate Presentation)

Systematic Desensitization

The process of acclimating a person to an undesirable stimulus through a systematic process of acceptance

Systematic Desensitization Procedure

• Use a gloved hand and/or a dry spoon to begin.
• Press down with your fingers while counting out loud 1, 2, and 3!
• Always make an effort to

• Touch to Palm (or back of hand if the palm is too much)
• Touch to Upper Arm/Shoulder.
• Touch to Midline Chest.
• Touch to Chin.

Behavioral Approach

“Take a Bite” is a behavioral approach.

• To keep the child interested, parents should keep a box of toys at home for “homework” periods exclusively. (Examples include puzzles, bubbles, and light-up toys). Board games, cards, and coloring will appeal to older youngsters.
• 1st, make sure you’re in the right place.
• Begin by using a dry spoon.
• Use a key phrase that the parent has agreed on, such as “open” or “take a mouthful.”
• Day 1: Set the tone for the “game.”
• Say “open” or “take a bite” as a cue.
• Provide 20-30 seconds of high joy and toy reinforcement if the child opens his/her mouth and receives the entire bowl of the dry spoon in his/her mouth.
• If he/she refuses, the child will receive no attention, and you will be turned away.

3 Plate Presentation

• Use a plate with 3 divided sections.
• Provide 2 preferred foods and 1 non-preferred food (or previously accepted food)
• Have the child start with a preferred food and move around the plate 
• Clockwise taking bites (or another predetermined mode of interaction with the new food (touch, lick, etc.) until 10-20 “bites” have been completed.
• This method gives the child some control as he/she can choose the preferred foods to use.
• Healthy foods are not always possible in the beginning to provide 2 preferred foods.

Conclusion

Children with feeding problems are a diverse group with a variety of etiologists and underlying strengths and weaknesses that promote or inhibit skilled feeding. The evidence for the positive is strong to moderate. Oral-motor therapy has been shown to improve eating skills in newborns and young children with eating difficulties. The majority of the material gained, however, comes from research with limited intervention strategies and small sample size.

When new-born have concerns about their feeding development, it is critical that they be sent to a feeding specialist as soon as possible.

Delayed referral and therapy start-up can have a negative impact on feeding development and outcomes. Treatment efficiency will be reduced, and the duration of continued treatment will most likely be extended. A feeding therapist can assist you in continuing support for developmentally appropriate, personalized adaptive strategies Feeding techniques and placement devices, in combination with hands-on therapy, can help patients to enhance feeding results

When it comes to creating trust with the youngster and his or her family, it’s best to start with Systematic Desensitization/Dry Spoon. If necessary, behavioral reinforcement mechanisms can be applied at this point. Instead of going through the puree process, you might start with a dry spoon and work your way up to more difficult foods if the child is exclusively a behavioral feeder. The 3 Plate Presentation is normally initiated after the child has consumed table foods during the treatment session without gagging or vomiting. 3 Plate determines portion amounts and carryover inside the home.

Reference:

Pediatric dysphagia Challenges and Controversies Julina Ongkasuwan,Eric H. Chiou