Lectura Control 2 - Asignatura 3
Lectura Control 2 - Asignatura 3
Lectura Control 2 - Asignatura 3
ABSTRACT
1
Department of Pediatrics; 2The Eudowood Division of Johns Hopkins University School of Medicine, David M.
Pediatric Respiratory Sciences; 3The Department of Oto- Rubenstein Building, Suite 3017, 200 North Wolfe Street,
laryngology-Head and Neck Surgery; 4Department of Baltimore, MD 21287 (e-mail: [email protected]).
Physical Medicine and Rehabilitation, Johns Hopkins Forecasting the Future: Challenges and Opportunities
Medical Institutions, Baltimore, Maryland; 5Department in Developmental Communication Disorders; Guest Edi-
of Speech-Language Pathology and Audiology, Children’s tor, Nan Bernstein Ratner, Ed.D.
Hospital of Wisconsin; 6Division of Pediatric Gastroenter- Semin Speech Lang 2016;37:298–309. Copyright
ology, Department of Pediatrics, Medical College of Wis- # 2016 by Thieme Medical Publishers, Inc., 333 Seventh
consin, Milwaukee, Wisconsin. Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
Address for correspondence: Maureen A. Lefton-Greif, 4662.
Ph.D., CCC-SLP, BCS-S, Eudowood Division of Pediat- DOI: http://dx.doi.org/10.1055/s-0036-1587702.
ric Respiratory Sciences, Department of Pediatrics, the ISSN 0734-0478.
298
PEDIATRIC FEEDING/SWALLOWING/LEFTON-GREIF, ARVEDSON 299
Learning Outcomes: As a result of this activity, the reader will be able to (1) describe factors involved in
increased complexity of feeding/swallowing disorders in infants with multiple medical/surgical etiologies; (2)
state three management processes with pros and cons for attaining functional outcomes; (3) list three
currently used tools for diagnosis of dysphagia; and (4) state three new technologies that may become useful
for pediatric patients with dysphagia.
ages has increased.13–16 Nonetheless, 40% of tus, and neurologic sequelae associated with
children with feeding/swallowing disorders are their prematurity. Feeding-related problems
reported to have histories of preterm birth.17 for children with bronchopulmonary disease
Much of the attention to feeding/swallowing may last years.25 Importantly, chronic aspira-
disorders in these pediatric populations has tion may result in persistent respiratory prob-
focused on preterm infants in neonatal intensive lems and lung injury.26,27 To date, the “amount”
care unit (NICU) settings and during follow-up and frequency of aspiration secondary to swal-
after hospital discharge. Critical to the care of lowing dysfunction that can be tolerated is
these infants is increased recognition that they unknown; however, it is likely that age, nutri-
comprise a heterogeneous population, with tional status, individual differences, and overall
differing causes of preterm births and a wide health contribute to “tolerance.” The impact of
range of phenotypic variations. “Preterm birth aspiration on other organs is not known. Ani-
syndrome” has been proposed to account for mal research has shown that acid instilled into
these factors and guide efforts to reduce preterm the airways (potential model for reflux) of pigs
births further and to improve investigations caused varying degrees of injury to extrapulmo-
across populations of children born preterm.18 nary organs.28 Further investigation of whether
In addition, there have been changes related to aspiration secondary to oropharyngeal dyspha-
the lower and upper age limits associated with gia results in more diffuse injury in humans is
initiation of oral feeding and may increase our MANAGEMENT OF INFANTS AND
understanding of the mechanisms in the devel- CHILDREN WITH SWALLOWING/
oping brain that underlie oral feeding readi- FEEDING PROBLEMS: CURRENT
ness.45 Investigations are needed to determine AND FUTURE
the long-term outcomes associated with feed- The complexities for high-risk infants and
ing interventions as new technologies emerge. children have increased as the survival of pre-
Development of objective and reproducible term and medically/surgically compromised in-
noninvasive measures that enhance the clinical fants has increased as pointed out earlier in this
assessment is desperately needed. For example, article and per reports by multiple authors.
measures of swallow-respiratory coordination SLPs need extensive knowledge in a wide range
can provide objective data that may guide of health care and medical areas to evaluate and
evaluations and the course of management. make management decisions that take into
However, such technologies are costly and labor account scope of practice for SLPs and the
intensive and thus have not yet been transi- American Speech-Language-Hearing Associa-
tioned from research to routine clinical tion’s code of ethics.54,55 Decisions are made
care.46–48 best in the context of team approaches that may
vary considerably depending on availability of
resources. Regardless of the environment and
Structure, Activity, and Participation. This are needed before interventions to establish
framework aids in a holistic approach to assess- baselines and after interventions to understand
ment and management rather than focusing on the effects of rehabilitation and associated
impairments, which has been the traditional surgical and medical therapies.59 Recent initia-
approach for many therapy-focused professio- tives have focused on the use of well-targeted
nals. It focuses on function in the broad sense of outcomes toolboxes, which may facilitate the
participation and possible interfering factors. use of a common language for outcome meas-
Definitions of impairments, activity limita- ures. (See the National Institutes of Health
tions, and participation restrictions are funda- Toolbox for Assessment of Neurological and
mental to decision-making. Behavioral Function, which is comprised of a
Details and examples in relation to feeding multidimensional set of measures for ages 3 to
and swallowing can be found on the website 85, and Wright and Majnemer.59,60) Further
http://www.who.int/classifications/icf/en/. details are beyond the scope of this article.
This focus on functional participation sets the
stage for the future in decision-making by SLPs
and all other professionals involved in assess- Current Trends and Future Directions
ment and management of children with feeding Management decisions must take into account
and swallowing disorders. nutrition status, medical and surgical stability,
underlying movement patterns, and caregiver/ ing feeding in infants who are small for gesta-
child interactions during feeding and apart from tional age (SGA) has additional challenges
feeding. Readers are reminded that develop- regarding optimum timing for introduction of
ment of oral sensorimotor skills relates closely enteral feeding, how fast feeding volumes can
to development of trunk and head control. be advanced, and which milk and which feeding
A few therapeutic intervention techniques/ method is more appropriate in infants with
processes commonly used with infants and SGA.66 Arnon and colleagues reported that
children will be described briefly, with both stable SGA preterm infants on a very early
advantages and concerns, as well as anticipated feeding regimen achieved full enteral feeding
future possibilities. Historically and currently, and were discharged home significantly earlier
therapeutic techniques parallel those strategies and without excess morbidity than controls on a
that were originally described in the adult delayed regimen.67 These examples are given to
literature, with the exception of some of the stress the utmost importance of adequate
strategies used in the NICU to facilitate oral knowledge and experience for SLPs in the
feeding in preterm and other medically fragile NICU. There is great need for specialized
infants. SLPs in the NICU environment are training opportunities that SLPs do not receive
faced with the smallest and most fragile infants as part of a master’s program in most universi-
with need for extraordinary knowledge about ties in the United States.5 Coordinated efforts
Proper positioning of young infants is a hydrostatic pressures may assist the timing and
fundamental prerequisite to oral feeding, coordination of sucking, swallowing, and
whether at the breast or with bottle/nipple. breathing sequencing for bottle-feeders.75,76
Developmental level, airway stability, and abil- Research is needed not only in the individual
ity to follow directions guide decisions about aspects of nipples, bottle systems, and flow
positioning. Traditionally, infants are held in rates, but also interrelationships of both com-
semireclined position in the feeder’s arms. A mercial and cereal-based thickeners and effects
recent study reported trends in physiologic on gastrointestinal tract and aspiration conse-
benefits (e.g., decreased variability of heart quences with thickened liquids compared with
rate) when infants were fed in elevated side- thin liquids.77 One could hypothesize that
lying position.69 However, another study because the lungs are basically water soluble,
showed no difference in the feeding maturation occasional aspiration of thin liquids would be
between side-lying and more traditional semi- less damaging to lungs than even less frequent
reclined.70 There are reports of infants suffo- aspiration of thickened liquid. Clearly research
cating when breast-fed in a side-lying is needed.
position.71 The bottom line is that there is It is of concern that children are often
“no one size fits all.” Taken together, these placed on thickened liquids with no plan to
studies point out the importance of individual- provide a systematic process to allow children to
that describe therapeutic regimens and their patient reports by SLPs of progress and indeed
outcomes. An instrument has been developed attainment of age-appropriate oral feeding that
recently for determining the level of chewing may include elimination of non–oral tube feed-
function in children.80 Knowledge of chewing ing supplements for some. In coming years,
function level is useful to provide a common these kinds of anecdotal outcomes will not be
language for professionals to define chewing sufficient for initiation of or continuation of
disorders. However, the need persists for deter- interventions. Systematic approaches are nec-
mining intervention processes to achieve func- essary and will need to be based on the ICF and/
tional chewing outcomes. or RTT models that address feeding and swal-
lowing with emphases on functional outcomes
in broad aspects of participation rather than on
Sensory-Focused Interventions handicap or disability. It is critical that we
Programs have been developed that provide become proactive in both clinical and research
children with opportunities to have sensory areas as we build on the solid basis on which
experiences without pressure to get food or SLP involvement with infants and children
liquid into the mouth initially. Some of these who have a wide range of swallowing and
programs focus on opportunities for the child to feeding disorders.
“play” with food by putting fingers and hands
4. Lefton-Greif MA, Arvedson JC. Pediatric feeding 18. Villar J, Papageorghiou AT, Knight HE, et al. The
and swallowing disorders: state of health, popula- preterm birth syndrome: a prototype phenotypic
tion trends, and application of the international classification. Am J Obstet Gynecol 2012;206(2):
classification of functioning, disability, and health. 119–123
Semin Speech Lang 2007;28(3):161–165 19. Kelly MM. The medically complex premature
5. Zimmerman E. Pediatric dysphagia: a rise in infant in primary care. J Pediatr Health Care
preterm infants and a need for more formal training 2006;20(6):367–373
for speech-language pathologists. Int J Gynecology 20. Bakewell-Sachs S, Medoff-Cooper B, Escobar GJ,
Obstetrics and Neonatal Care 2016;3:15–20 Silber JH, Lorch SA. Infant functional status: the
6. Ciucci M, Jones CA, Malandraki GA, Hutcheson timing of physiologic maturation of premature
KA. Dysphagia practice in 2035: beyond fluorog- infants. Pediatrics 2009;123(5):e878–e886
raphy, thickener, and electrical stimulation. Semin 21. Goldenberg RL, Gravett MG, Iams J, et al. The
Speech Lang 2016;37(3):201–218 preterm birth syndrome: issues to consider in
7. Field D, Garland M, Williams K. Correlates of creating a classification system. Am J Obstet Gy-
specific childhood feeding problems. J Paediatr necol 2012;206(2):113–118
Child Health 2003;39(4):299–304 22. Goldenberg RL, Culhane JF. Low birth weight in
8. Newman LA, Keckley C, Petersen MC, Hamner the United States. Am J Clin Nutr 2007;85(2):
A. Swallowing function and medical diagnoses in 584S–590S
infants suspected of dysphagia. Pediatrics 2001; 23. Doyle LW, Anderson PJ. Long-term outcomes of
108(6):E106 bronchopulmonary dysplasia. Semin Fetal Neona-
34. Strober M, Peris T, Steiger H. The plasticity of respiration and nutritive swallowing. Dysphagia
development: how knowledge of epigenetics may 2007;22(1):37–43
advance understanding of eating disorders. Int J Eat 47. Selley WG, Parrot LC, Lethbridge PC, et al. Non-
Disord 2014;47(7):696–704 invasive technique for assessment and management
35. Wadhwa PD, Buss C, Entringer S, Swanson JM. planning of oral-pharyngeal dysphagia in children
Developmental origins of health and disease: brief with cerebral palsy. Dev Med Child Neurol 2000;
history of the approach and current focus on 42(9):617–623
epigenetic mechanisms. Semin Reprod Med 48. Lefton-Greif MA, Perlman AL, He X, Lederman
2009;27(5):358–368 HM, Crawford TO. Assessment of impaired co-
36. Zilbauer M, Zellos A, Heuschkel R, et al. Epige- ordination between respiration and deglutition in
netics in paediatric gastroenterology, hepatology, children and young adults with ataxia telangiecta-
and nutrition: present trends and future perspec- sia. Dev Med Child Neurol 2016
tives. J Pediatr Gastroenterol Nutr 2016;62(4): 49. Hiorns MP, Ryan MM. Current practice in paedi-
521–529 atric videofluoroscopy. Pediatr Radiol 2006;36(9):
37. Fox CM, Ramig LO, Ciucci MR, Sapir S, McFar- 911–919
land DH, Farley BG. The science and practice of 50. Willette S, Molinaro LH, Thompson DM,
LSVT/LOUD: neural plasticity-principled ap- Schroeder JW Jr. Fiberoptic examination of swal-
proach to treating individuals with Parkinson dis- lowing in the breastfeeding infant. Laryngoscope
ease and other neurological disorders. Semin 2016;126(7):1681–1686
Speech Lang 2006;27(4):283–299 51. Willging JP, Thompson DM. Pediatric FEESST:
Available at: http://www.nihtoolbox.org/Resour- 72. Beal J, Silverman B, Bellant J, Young TE, Klontz
ces/Recommendedcitationformats/Pages/default. K. Late onset necrotizing enterocolitis in infants
aspx 2016. Accessed: August 5, 2016 following use of a xanthan gum-containing thick-
61. Altimier L, Phillips RM. The neonatal integrative ening agent. J Pediatr 2012;161(2):354–356
developmental care model: seven neuroprotective 73. Drenckpohl D, Knaub L, Schneider C, et al. Risk
core measures for family-centered developmental factors that may predispose premature infants to
care. Newborn Infant Nurs Rev 2013;13(1):9–22 increased incidence of necrotizing enterocolitis.
62. Anderson V, Spencer-Smith M, Wood A. Do Infant, Child, & Adolescent Nutrition. 2010;
children really recover better? Neurobehavioural 2(1):37–44
plasticity after early brain insult. Brain 2011;134 74. Orenstein SR, Shalaby TM, Putnam PE. Thick-
(Pt 8):2197–2221 ened feedings as a cause of increased coughing
63. Kleim JA, Jones TA. Principles of experience- when used as therapy for gastroesophageal reflux in
dependent neural plasticity: implications for reha- infants. J Pediatr 1992;121(6):913–915
bilitation after brain damage. J Speech Lang Hear 75. Pados BF, Park J, Thoyre SM, Estrem H, Nix WB.
Res 2008;51(1):S225–S239 Milk flow rates from bottle nipples used for feeding
64. Kirk AT, Alder SC, King JD. Cue-based oral infants who are hospitalized. Am J Speech Lang
feeding clinical pathway results in earlier attain- Pathol 2015;24(4):671–679
ment of full oral feeding in premature infants. J 76. Lau C, Schanler RJ. Oral feeding in premature
Perinatol 2007;27(9):572–578 infants: advantage of a self-paced milk flow. Acta
65. Puckett B, Grover VK, Holt T, Sankaran K. Cue- Paediatr 2000;89(4):453–459