Ana Feliz M.S., CCC-SLP Lindsay A. Murray-Keane M.S., CCC-SLP

Pediatric Feeding Development and Disorders; Basic Management and Treatment Techniques
Ana Feliz M.S., CCC-SLP Lindsay A. Murray-Keane M.S., CCC-SLP Emily Stoddard M.S., CCC-SLP Monica Walchak M.A., CCC-SLP

Participant Learning Objectives
Review of normal neonatal and infant anatomy of the swallow mechanism Understand neonatal and infant feeding development Physiology of the normal swallow Know when the infant is ready to feed and being able to identify signs of difficulty The clinical feeding assessment List common recommendations Transition feeding from bottle to solids Define dysphagia and signs of aspiration Objective tests available and intervention Knowledge of various diets recommendations, positioning techniques, and modifications that can be made to feeding equipment. Dealing with trauma and injuries to the head, neck and face / TBI Management of cleft palate and lip

Neonatal and Infant Feeding development
Oral feeding is a complex process by which numerous physiological functions (neurological, cardiopulmonary, respiratory, and digestive) of the human body must work in synchrony to establish a functional efficient means of achieving oral alimentation. A common myth is that the body’s first function is feeding, however the body’s primary function is efficient respiration. To understand pediatric feeding, we must analyze anatomic structures, physiologic systems and the alterations/changes that happen with growth/development. Infants and children are not simply small adults therefore; we must analyze their anatomy, physiology and needs separately.

Anatomy of Toddler vs. Adult

Anatomy of Infant/Toddler
Significantly higher laryngeal position (thus smaller space between mandible and hyoid), which provides anatomic protection of the airway - Permanently heightened until first 2 years of life - Adult-like anatomy by age 4  The velum and tongue fill more of the oral cavity   Tongue   Very large relative to oral cavity   Does not have musculature and motor control to manually move tongue, jaw, and lips  Velum:   Large, fills space between epiglottis and tongue   Makes contact with top of epiglottis (unlike in adults)  Anatomic protection of airway during repetitive suck burst that precedes each swallow   Infants are obligatory nasal breathers   Velum lowered to allow nasal breathing Tips= In order to understand variation of normal look to examine as many mouths (normal and impaired) as you can to understand variability

Anatomy of Infant vs. Adult

Anatomy of Child through Adulthood
Laryngeal position migrates inferiorly by age 4 years Size of oral cavity increases with jaw growth Tongue   Becomes relatively smaller in oral cavity   Musculature and motor control are developed to volitionally move tongue, jaw, and lips  Velum:   Hypopharynx is elongated; Velum no longer in contact with epiglottis May make contact with Base of Tongue Anatomic protection of airway requires more coordinated muscultature contraction and coordination.  

Airway of an Infant

Head and Neck Anatomy

Congenital Defects of Anatomy
Being a pediatric clinician, It is important to understand congenital anomalies to prepare for management pre and post medical management DX examples: Micrognathia Hypoplastic nasal bones and mid face Pyriform aperature stenosis Clefts Laryngomalacia tracheomalacia Further explanation later in slides

Physiology of Normal Swallow
Each swallow passes liquid or food from the mouth to the stomach as it moves through 3 phases, called the oral, pharyngeal and esophageal phases. Valves within the system assist with the control of flow of bolus material. The valves are the lips, soft palate, the epiglottis, and the larynx. Video Before Slide: We swallow most often while we are eating or drinking. In addition, we swallow saliva throughout the day and less frequently when we sleep. We swallow approximately 600 times each day.

Oral Stage of Swallowing
Oral Phase consists of: Acceptance of the liquid into the oral cavity Initiation of latch (Labial seal to nipple, tongue cupping and creation of compression/suction pressure.) Expression of milk/formula from the breast/nipple Ability for the tongue and jaw to rhythmically and efficiently transport milk/formula posteriorly within the oral cavity. Terms in which and Oral stage of Swallow can be described are: Organized Disorganized Dysfunctional

Pharyngeal Stage of Swallow
Pharyngeal Phase involves: Velopharyngeal port closure to seal off nasopharynx and eliminate liquids being nasally regurgitated Initiation of pharyngeal constriction when bolus of liquids leaves to oral cavity posteriorly Timing of pharyngeal swallow may be normal when bolus leaves the oral cavity passing the faucal arches and passes into the valleculae Coordinated movement of multiple muscles: Pharyngeal constriction Hyolaryngeal excursion Epiglottic retro flexion Laryngeal closure Bolus transport through the hypopharynx to the cervical esophagus Terms in which and Pharyngeal stage of Swallow can be described are: Coordinated Uncoordinated

Neural control of the pharyngeal phase of swallow
Sensory Motor CN V, IX Palate CN V, VII, IX, X CN IX Tongue CN V, VII, XII CN V, X Pharynx CN IX, X CN X Larynx CN IX and X

Esophageal Stage of Swallow
Esophageal Phase is initiated with: The opening of the upper esophageal sphincter Peristalsis of bolus down esophagus Opening and closing lower esophageal sphincter

Physiology of Infant Nursing
*Establishment of latch to nipple *Initiate suck (compression and suction) utilizing tongue and jaw movement to express liquid from nipple. *Lingual cupping and wave to channel and transport liquids posteriorly *Anatomy is supportive of rapid and consecutive suck/swallow bursts *Suck-Swallow-Breath triad with respiratory pausing allowing for nasal breathing for respiratory recovery

Swallowing Oral Pharyngeal Esophageal
In the infant, this phase is limited to sucking liquid from a nipple and then moving it to the back of the mouth. The structures involved include the jaw, lips, tongue, teeth and palate. Pharyngeal The bolus passes from the mouth, through the pharynx, and into the esophagus while keeping the airway clear. The structures involved are the base of the tongue, back of the palate, epiglottis, and larynx. Esophageal Lasts for three to ten seconds in infants and is reflexive in nature. Food is passed from the upper part of the esophagus into the stomach.

Patterned Sucking Behavior
Sucking is observed inutero as early as 15 to 18 weeks gestation. In the extra-uterine environment, mouthing activity may be observed in a disorganized pattern by 27 to 28 weeks By 32 weeks, stronger sucking is noted and a burst-pause pattern is emerging. Sucking is generally not well established until 34 weeks.

Various States of a Neonate/Infant
Active sleep Drowsy Quiet sleep Quiet alert Active alert Irritable

Preterm neonates make have challenges with state control, regulation and transitions. State control and transitions should improve with maturation to infancy. Of note, the environment (lights, sounds, interactions with caregiver, positioning and expectations) all impact a patient’s state.

Cases: A 36 week premature neonate is sleeping in an open crib in a crowded hospital ward. Fluorescent lights above head, monitors beeping, MD/RN teams are speaking in competition with each other’s volumes for rounds. The PT. is unswaddled and Moro (Startle reflexes) are being triggered. RN must conduct a heel stick for glucose monitoring. The diaper is then changes and the baby is startled by the cool air and wipes. The baby is then picked up rapidly, seated in the RNs arms in a feeding position without swaddling. The nipple is inserted into her mouth. How is the Patient going to perform in feeding?

Cases: A 36 week premature neonate is sleeping in an open crib swaddled. The lights are dim, professionals are speaking but out of range of the crib and monitors are attended to in a timely manner. The RN knows it is about feeding time, so she gently unswaddled the neonate allowing for movement of limbs and gradual rousal. Pt. increases her activity, transitions to light sleep and then the diaper hygiene care is performed. Pt. begins mouthing her hands and lip smacking. RN provides the pacifier and then conducts the heel stick for glucose monitoring. RN swaddles the patient with her arms out and picks her up gently placing her into feeding position. Provided pacifier for ~1 minute to allow for state regulation then transitions to bottle/nipple for feeding. How is the Patient going to perform in feeding?

Feeding Readiness Preterm Term Position Extensor Flexor
Neck/trunk stability Poor Good Anatomical set for sucking Unfavorable Favorable Suck strength Weak Strong Lip seal Inadequate Adequate Jaw stability for repetitive sucking Unstable Hunger and thirst signals Sufficient Oral-motor reflexes Incomplete Intact Suck/Swallow/Breath Dysrhythmic Rhythmic Neurological status Disorganized Organized When infants have difficulty organized the liquid bolus and moving it toward the back of the mouth, swallowing becomes stressed. The slower and more inefficient the food movement, the greater the risk of accidental choking. Organization problems will be created any time there are limitations in the muscle tone of the oral and facial structures, or when difficulties with the reflexive movements pull the tongue, lips, or jaw in one direction.

Infant Reflexes Root reflex: Suck reflex: Moro reflex:
Elicited by stroking the corner of the baby's mouth The baby will turn his or her head and open his or her mouth to follow and "root" in the direction of the stroking Helps the baby find the breast or bottle to begin feeding Emerges around weeks in utero. Is fully present at birth and is integrated/inhibited at 3-4 months Suck reflex: When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability. Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or hands. Moro reflex: Occurs in response to a loud sound. Often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. A baby's own cry can startle him or her and trigger this reflex. The infant throws back his or her head, extends out the arms and legs, cries, then pulls the arms and legs back in. This reflex persists until about 5 to 6 months. Tonic neck reflex: When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts until about 6 to 7 months. Grasp reflex: Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp. The grasp reflex lasts until about 5 to 6 months of age Babinski reflex: When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age. Step reflex.: This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his or her feet touching a solid surface

Distinctions of Neonates
Premature Baby Late Pre-term Baby Full Term Baby A premature baby who is now at term is not the same when compared to a baby who is born at full term. Example: 27 weeker now PMA= 36 weeks Will Act developmentally, medically and physiologically different then a Pt. born at 36 weeks.

Premature Neonate Respiratory distress likely requiring a form of positive pressure respiratory support. A baby’s body’s primary purpose is to maintain physiologic stability and respiration. Growth issues due to higher alimentation needs and increased demand on an immature GI system

28 Weeks Gestation State Not well differentiated 97% sleep state
Transient drowsy and alert states – brief and fragmented Oral -Motor Onset of rooting Onset of suck-swallow Non-nutrive suck noted at weeks Reflex pathways between taste buds and facial muscles are established.

30 Weeks Gestation State Capable of a well defined quiet alert state which appears spontaneously Oral-Motor Non-nutritive suck not coordinated with swallowing Rooting response slow

32 Weeks Gestation State More distinctive
Quiet sleep increases while active sleep decreases Increase in alert and drowsy states Oral Motor Brief periods of hand to mouth activity Non-nutritive suck more organized Some single sucks still noted Swallow occurs before or after suck burst

32 Weeks Gestation (con’t)
Oral Motor 1 to 1.5 sucks per second on suck bursts Can coordinate sucking and swallowing Reflexive smile

34 Weeks Gestation Oral Motor May not be ready for po
State More clearly defined Clear difference between wake and sleep Active and quiet sleep alternate regularly with more time spent in active sleep Self comforting behaviors Oral Motor May not be ready for po Suck rate and rhythm stable within in suck burst Coordination of suck and swallow

Late Pre-term Baby A late pre-term baby can fool many caregivers because they are larger in size and do not have as many of the respiratory sequelae of smaller premature neonates. We must remember that a baby inutero at this age would be developing their fat layers and refining their suckling without the added pressure of full GI alimentation. Many studies focus on this population and there are specific issues in terms of medical management, growth and development.

36 Weeks Gestation State Arouses and controls self
More alert just after feeding or between feeding Oral Motor Rooting complete Suck consistent Fat/Suck pads begin to develop

38 Weeks Gestation State Full control of state cycles Oral-Motor
Excellent suck reflex Rooting complete Suck pads developed

40 Weeks Gestation State Clear distinct behaviors
Attention is generally 4-10 seconds Oral-Motor Bitter, sour and sweet taste receptors Strong suck

Full Term Infant Birth Trauma Acclamation to life outside the womb
Small appetite Promote Maternal bonding, kangaroo care and Breastfeeding as soon as possible.

Pre-Feeding Skills Involve the infant’s ability to
Engage and remain engaged in a physiologically and behaviorally challenging task Organize oral-motor movements so as to have long term functional benefits Coordinate breathing with swallowing to avoid prolonged apnea or aspiration of fluids Regulate the depth and frequency of breathing to maintain physiologic stability

The infant’s state of health The ability to regulate oxygen
Internal Factors that affect progression in the ability to feed orally: The infant’s state of health The ability to regulate oxygen Development of alertness Development of sucking strength and organization of the sucking pattern Thoyre S, and Carlson J

Newborn Stomach Size

Oral Feeding Skills Oral feeding skills have commonly been conceptualized by health care providers as an infant’s ability to organize and coordinate oral-motor functions to efficiently consume enough calories for growth. Early feeding skills are much more complex than that.

Provide a Stable environment conducive to neurodevelopment
Take home message is: WE have to make changes to medical and feeding plans however; we must be in tune with how these changes/ alterations may affect the Patient’s feeding environment and ultimately performance Early feeding skills can vary from feeding to feeding and even across a given feeding. Changes in the plan of care during the learning period add to the inherent variability in an emergent skill. Infants are weaned to open cribs Supplemental oxygen is decreased or eliminated Medications are discontinued of adjusted When making changes to medical and feeding plans, pause and ask yourself “How will this impact feeding function.”

Medical Conditions Affecting Feeding:
Abnormalities of the Upper Aerodigestive Tract Genetic Syndromes Sensory Defects Anatomic abnormalities of the larynx or trachea Disorders affecting suck-swallow-breathing coordination Craniofacial Congenital Defects

Common Diagnoses with associated difficulties with Eating orally.
Prematuritiy < 32 weeks G.A RDS; BPD; CLD requiring respiratory support Prolonged respiratory support (intubation, NIPPV, NCPAP, HFNC) Tracheoesophageal fistula Esophageal Atresia Congenital Cardiac Anomalies GI anomalies including structural anomalies or NEC. Tracheostomy or ventilation dependence. Pierre robin sequence Cleft lip and palate Trisomy 21 Neurological involvement (i.e., seizure, IVH, congenital anomalies) Hypontonia Vocal cord dysfunction s/p PDA ligation Hypoplastic midface Pyriform aperture stenosis Choanal atresia

Red flags for feeding difficulties
Suspected airway compromise Diagnosis of failure to thrive Suspicion of oral-motor dysfunction Sucking and swallowing incoordination Weak suck Apnea during feeding Severe irritability during feeds History of recurrent pneumonia Lethargy during feeds

Feeding and Swallowing Abnormalities-Requiring attention
Difficulty coordinating sucking and swallowing Weak suck Gagging during eating/drinking Congestion after eating/drinking Wet/Gurgly vocal quality during/after feeding Excessive Feeding times Unexplained food refusal and refusal to textures If considering non-oral means of nutrition (ND or NG tube placement) Tracheostomy/Respiratory distress/Oxygen dependence Spitting up Feeding only when asleep Shortness of breath during/after feeding Short sucking bursts Tension of the body during feeding/stress reactions Inability to manage secretions Suspected airway compromise Diagnosis of failure to thrive History of recurrent pneumonia Lethargy during feeds

Criteria for Nipple Feeding
Initiation of nipple feeding is dependent on Post-conceptual age of at least weeks. Physiological Stability (RR <60BPM; stable HR; SPo2 stably maintained on NC or NCPAP < 4cm H20 Fio2 <30%) Stable Respiratory Status Patients on elevated respiratory support, such as high flow nasal cannula or nasal CPAP (continuous positive airway pressure) should undergo clinical dysphagia evaluation prior to initiation of oral feeding. Enteral feeding schedule transitioned to bolus feeding Demonstration of feeding readiness at due feeding times (awakens and fusses, roots, hands to mouth, initiates suckling, Etc.)

Neonate and Infancy Positioning
Swaddling Elevated sidelying position Semiupright positioning

Non-nutritive suckling
Purpose State regulation, satisfy sucking desire, oral exploration Rhythm Stable number of sucks per burst and duration of pauses Rate Two sucks per second Suck/Swallow Ratio Very high ratio; 6:1 or 8:1

Markers for Assessment of Non-Nutritive and Nutritive Suck
Strength Initiation Suction Compression Breaks Suction Rhythmic Coordination Liquid Loss (Nutritive only) Endurance Efficiency

Nutritive Sucking Purpose Rhythm Rate Suck/Swallow Ratio
Obtain nourishment Rhythm Initial continuous sucking burst, moving to intermittent sucking bursts with burst becoming shorter and pauses longer over the course of the feeding. Rate One suck per second, constant over course of the feeding Suck/Swallow Ratio Young infant 1:1

Infantile sucking patterns:
Sucking is observed in utero as early as 15 to 18 weeks gestation. In the extra-uterine environment, mouthing activity many be observed at 27 to 28 weeks, though in a disorganized pattern. By 32 weeks, stronger sucking is noted and a burst-pause pattern is emerging. Sucking is generally not well established until 34 weeks.

Sucking Characteristics
Normal Easily initiated Rhythmical Strong Sustained Efficient Limited Poorly initiated Arrhythmic Weak Unsustained Inefficient Sucking movements must be strong and sustained well enough to trigger a let-down reflex in breast feeding mothers that allows milk to flow from the mother to the baby. Even if the infant eventually latches onto the breast and initiates sucking an excessively wide jaw excursion, lip retraction, or jaw thrusting can interfere with the ability to sustain a strong enough suck to begin the flow of milk. TEMPTATIONS TO POKE LARGER HOLES IN THE NIPPLE MANY FLOOD THE BABY AND REDUCE THE NEED TO DEVELOP A STRONGER SUCK.

Tongue Movements during nutritive suck
TYPICAL In/Out Up/Down Cups nipple Rhythmic Movements Small excursions ATYPICAL Thrust Retraction, humped Flat, lacks contour Clonus Fasciculations Fixes to Palate Lacks rhythm

Lips/Cheeks Movements during nutritive suck
TYPICAL Shape to nipple Pressure at corners ATYPICAL Loose approximation Seal Breaks Excessive liquid loss

Clinical Evaluation

Clinical Feeding Assessment
Medical and Feeding history Feeding Schedule Bottle Feeding Formula/Consistency Quantity Nipple Type Length of Feed Respiratory Support Pacing Techniques Spitting Coughing/Choking during feed Autonomic Stress Signals during feed Response to Therapeutic Touch (Sustained Touch, Massage, Kangaroo Care)

Neonatal Swallowing Evaluation
Body Postural Control and Muscle Tone Oral Anatomy Oral Reflex Examination Effect of Feeding on Physiological Homeostatis Respiratory Rate Oxygen Saturation Heart Rate Color Change

Neonatal Swallowing Evaluation
Oral Mechanism examination Voice status Control of Secretions Suckling Coordination, Rate and Rhythm, Distress – Coughing, Crying, Airway Congestion Effect of Compensatory Strategies Body Position and Swaddling, Nipple, Pacing, Formula Consistency Consultation for Related Problems Respiratory, GI Consultation for Instrumental Examination Modified Barium Swallow, Upper GI , FEES

Oral-Motor Assessment
LIPS/CHEEKS TYPICAL Fat pads Soft Approximate ATYPICAL Retracted Pursed Asymmetrical Touch Hypersensitive

JAW TYPICAL Neutral Good alignment ATYPICAL Recessed Deviation Asymmetrical Clenches Hangs Open

PALATE TYPICAL Intact ATYPICAL High, vaulted Cleft Hypersensitive Atypical shape

Readiness cues as clues of feeding performance
Does the neonate wake after diaper hygiene care if it is close to their due feeding time? Does he or she sustain a quiet alert/alert state to engage in feeding task? Does he or she demonstrate rooting, searching for nipple, mouthing hands, and non nutritive suckling prior to presentation of breast or nipple? Think of these as clues to their level of endurance and engagement in feeding tasks. Research has proven that neonates establish and advance their feeding skills more rapidly when we as caregivers pay attention to when they are showing us there are in a stable enough place to attend to tasks and build their neurobehavioral networks for feeding. Interpretation of clinical observations is key.

Caregiver Techniques Caregivers should think of various techniques as a tool bag of options that should be implemented once they have conducted an assessment of the Patient’s needs. Rationales and understanding of way and for what purpose these techniques are used are important. Carryover of techniques from caregiver to caregiver should be communicated efficiently to ensure similar learning environments for the patient.

Caregiver Techniques Bottle/Nipple selection
What type of nipple and bottle is needed for maximized patient independence? External Pacing Tipping bottle downward to eliminate liquids flow and utilize dry swallows Cheek support Unilateral firm cheek support to eliminate anterior loss of liquids. Jaw support If jaw excursion is wide, firm under chin external support can be provided Lingual stimulation Facilitation of lingual cupping with firm downward pressure pulsed.

Infant performance Coordination of suck, swallow, and respiration
Oral stage: Organized Disorganized Dysfunctional Pharyngeal Stage: Coordinated Uncoordinated Consistency of performance Need for non-oral supplementation Endurance Low Moderate High

Signs/symptoms of impaired oral feeding skills.
Diagnosis of Failure to Thrive Airway compromise Suspicion of oromotor dysfunction Weak-Disorganized/dysfunctional suck Poor Readiness-Lethargy or decreased arousal during feeds Episodes of Apnea during feeding History of recurrent pneumonia Clinical signs of aspiration Feeding periods longer than 30 or 40 minutes Unexplained food refusal

Signs of Infant Stress during PO nippling:
Hiccupping Gagging Coughing or sneezing Grunting Straining as if to have a bowel movement Squirming Having stiff legs, arms or fingers Being irritable; frantic; disorganized activity Eye brow furrowing Doll’s eyes (eye widening) Finger splaying Turning head from nipple; frequent breaks in sucking. Significant anterior loss of liquids (drooling) Physiologic instability ( i.e., apnea, desaturation, bradycardia)

Stress and Defensive Behaviors
Autonomic and Visceral Stress Signals Color Changes Startling Heart rate changes Yawning Sighing Tremoring or Twitching

Stress Cues That the Baby may display warranting Caregiver observations
Hiccupping Gagging Coughing or sneezing Grunting Straining as if to have a bowel movement Squirming Having stiff legs, arms or fingers Being irritable; frantic; disorganized activity

State Related Stress Signals
Eye floating Staring Strained or hyper-alertness Silent crying Sudden loss of alerting Sleeplessness and restlessness Looking away or gaze aversion

Common Recommendations
PO candidacy (i.e., NPO, PO trials w/ SLP only, PO trials with Caregivers/RN team) Frequency of PO nippling opportunities (i.e., Qshift, Qother, Cue based feeding) Type of bottle/nipple system (i.e., Hospital stock, personal system, specialized equipment) Positioning (i.e., side lying, elevated side lying, standard) External Pacing needs Limitations (i.e., Frequency of nippling, duration of nippling, volume of consumption)

Nippling Considerations
Establishing a nonnutritive suck pattern State of the feeder Respect the cues of the infant Influence of the environment on the feeder

NIPPLES SIZE Consider the length
The size affects the infant’s ability to close his mouth around the nipple and determine how far back in the throat the formula is ejected The length of the nipple should provide good contact between the nipple and the tongue for effective tongue movement

Selection of Nipples All nipple systems that are available should be researched by the manufactures claims as well as independent research groups. In an industry that is not standardized it can be challenging to understand all the options available. Each clinician in their region should become familiar with the systems in which are available most easily to their families. We must understand that babies are highly sensitize to small changes and we must be consistent.

FLOW RATE Nipple hole should provide a flow of liquid that the baby can swallow comfortably Too large a hole can cause choking and sputtering Too small a hole can cause frustration and can fatigue the infant quickly

Normal development of oral feeding skills: Transition feeding

Transition Feeding At 4-6months of age, typically developing infants are developmentally ready to start a transition where they will be learning to intake solids and liquids, beyond exclusive nipple feeding There are readiness periods for the ability to develop new skills, influenced by general neurodevelopmental and maturational changes that the infant is experiencing during this time Infants will transition in terms of: Types of food (liquids, to soft solids, to chewable foods) Utensils (nipple to spoon, cup, and straw) Independence (total dependence on caregiver to holding bottle, utensils, and finger feeding)

Feeding skills development as a motor learning task
The acquisition of new feeding skills is accomplished by practice experiences. The parent/caregiver will introduce new feeding experiences that are appropriate for the infant’s current developmental abilities The infant will develop new skills based on practice. She will progress from initial attempts to more refined abilities over time Newly acquired skills will form the basis for acquiring further advanced skills in the feeding development sequence

Influences on acquisition of new feeding skills
For the typically developing infant, there is considerable variation in terms of the ages at which skills are acquired There may be individual differences in terms of infants’ developmental readiness There is also considerable variability in terms of when a skill is first introduced and therefore when practice towards learning the skill can begin. This may include both cultural differences and variations between individual families However, there are sensitive/critical periods for feeding development infants are well suited to quickly learn these new skills during the birth to 2year old period If timely introduction to developmentally appropriate feeding is delayed, new skills are not as readily acquired.

Major developmental milestones for feeding Skills
Nippling Eating from a spoon Drinking from a cup Biting Chewing Drinking from a straw

Overview of Feeding Development
1 month old Only liquids by breast or bottle Consumes 2-6 ounces per feeding, 6+ feedings per day Reclined position 4- 6 months old Introduced to early purees and cup drinking Liquids by nipple remain primary intake Consumes 7-8 ounces of liquid per feeding, 4-6 feedings per day Semi-reclined in supported sitting Begins to hold bottle with hands 7-9 months Infant is eating liquids, pureed foods, and ground/mashed tablefoods Consumes ounces of liquid or solid per feeding, 4-6 feedings per day Sits upright with support (independently by 9 months) Begins to finger feed solids 9- 12 months Eats liquids and coarsely chopped tablefoods months Eats coarsely chopped tablefoods and liquids by cup Sitting unsupported at family table for meals 18-24 months Primarily self feeding Able to chew a wide range of textures 24- 36months Eats a wide range of solid foods Drinks from cup without spilling Almost completely self feeds

The 4-6 month old infant Neurodevelopmental and anatomical changes make the infant ready for new feeding experiences: Central nervous system development has resulted in integration of obligatory oral reflexes, as well as increased voluntary control There is improved gross motor control of trunk, head and neck that supports an ability to control more distal muscles, including those in the oral cavity The infant is able to tolerate positioning changes to more upright supported sitting Anatomical changes within the oral and pharyngeal spaces, including an increased space within the oral cavity supports up and down movement of tongue

The 4-6 month old infant’s first spoon feeding experiences
Infant is positioned in semi-upright position (between degrees), often in a feeding seat or high chair Smooth, runny puree is offered by spoon Initially, the infant uses an in-out suckling pattern of the tongue. The feeder often will scrape the contents of the spoon into the mouth along the upper lip, and some of the food is pushed out by the infant’s tongue The infant begins with this emerging skill and is able to move towards a more mature feeding pattern with practice

Spoon Feeding: skill development
4 months Initiates a sucking or suckling pattern when spoon approaches lips Lips do no assist with food removal Uses primitive suck swallow Food is pushed out of mouth 6- 7 months Anticipates spoon and maintains open mouth position. Tongue is still. Tongue continues to protrude, however less food is pushed out of mouth 8- 9 months Upper lip begins to move downward to assist with removal of food from spoon Tongue uses up-down suck movement 10 months Lower lip draws inward and upper lip more active to remove food from spoon months Tongue tip starts to be elevated for swallow Lip closure present No loss of food 24 months Tongue moves independently of jaw movement No tongue protrusion

Cup Drinking: skill development
4-6 months old Introduced to cup drinking; Uses suckling movements of tongue with extension-retraction movements and wide jaw resulting in liquid loss 12 months old Sucking pattern with tongue; reduced extension pattern of tongue Tongue may protrude for added stability Lips may be open during swallowing Infant begins to use tongue tip elevation during swallow 18 months old Biting on cup to stabilize Improved seal of lips on cup edge Tongue does not protrude 24 months old Stablizes jaw without needed to bite down on cup edge Lips closed during swallowing No tongue protrusion No spillage

Biting: skill development
5-6months: Primitive phasic bite pattern. No sustained biting 9 months: Holds sustained bite and feeder assists with breaking off a piece 18 months: Controlled sustained bite. May use neck extension to assist 24 months: Controlled, sustained bite. Able to grade mouth opening for various thicknesses

Chewing: skill development
5 mo: Phasic biting movement- stereotypic bite and release pattern 6 mo: Primarily vertical movements, with more variability in pattern- “munching” chew Lateralization of tongue only for food placed on side 9 months: Vertical movements with more variation in grading and speed Diagonal rotary movement with tongue lateralization emerging for food placed in middle of mouth 12 months: Can transfer food from midline to side of mouth with tongue lateralization 15 months: Diagonal movements are better coordinated 18 months: Begins to keep lips closed during chewing 24 months: Vertical and diagonal rotary movements Circular rotary movements when transferring food across midline

Straw Drinking: Skill Development
Wide variability in age when straw drinking is introduced Infants as young as 7-8 months old

Development of Feeding and Swallowing skills & the Disruption of Development
During the First 1-5 years of human development many critical windows of feeding development are achieved. When feeding development (like other areas of development) is interrupted by physiological processes, medical interventions or mismanagement it requires direct and systematic treatment to achieve the targeted goals. Types of developmental disruption: Failure for caregiver to progress towards mature feeding patterns and schedules Developmental Delay/Disorder Physiological dysfunctional in oral motor/Feeding. Medical interventions requiring prolonged/repeated intubations, prolonged NPO status, GI distress/Feeding intolerance.

Clinical Assessment Review of medical and developmental history
Assessment of Prefeeding skills including: Respiratory status Mental Status Positioning skills and needs Oral motor mechanism structure and physiology Vocal quality Reflexive and volitional cough Nutritive Assessment Oral stage of swallow Suspected pharyngeal phase of swallow skills Signs/symptoms of stress or airway protection deficits Complaints of symptoms of other GI upset Endurance for a mealtime Level of Self feeding or caregiver dependence for feeding.

Positioning as a foundation for Feeding and Swallowing function
*90 degree flexion at hips *90 degree flexion at knees *90 degree angle with stable feet support Neck and head in neutral position at the midline All persons prior to consideration of oral alimentation should be assessed for their positioning abilities or need for some form of adaptive seating systems. Seating/Positioning system range in their adaptation/equipment needs.

Principles of Positioning as a pre-cursor to Oral feeding
Infancy-Head neck support Infancy- semiupright/reclined feeding position Toddler- independent trunk with head and neck adequate neutral positioning Toddler- Developmentally appropriate to utilize seating systems to achieve degree positioning Older child- expected to be independent with positioning with adequate trunk and head/neck support. Impairments/Disorders with poor trunk control and inability to control head/neck warrant seating/positioning systems to achieve positioning prior to Oral feeding.

Positioning in Late Infancy into Toddlerhood
Poor independent head/neck support warranting reclined supported sitting Adequate head and neck support for supported sitting Independent sitting in developmentally structured chair (foot, lateral and high back support) Independent sitting in toddler sized chair

Standard High Chair Adaptations to aid in positioning

Disorders impacting Positioning affect oral feeding function
Poor trunk stability Poor body alignment Increased musculature tone/spasticity Head/Neck instability Head/Neck Extension

Various Positioning Needs

Dysphagia Refers to a swallowing problem that involves one or more of the three phases of swallowing. We do not know how much aspiration is needed to cause lung damage. However, we do know that lung damage is more likely when aspiration is frequent.

Behavioral/Sensory Feeding Disorders
Oral Sensory impairments: Hypersensitivity over-registers, hyposensitivity under registers or Mixed (hypo/hypersensitivity). Food refusal/limited food repertoire. (Small volumes of certain foods). Texture/taste/temperature sensitivity Impact of GI issues on feeding; most commonly seen with children that have or had a history of GI distress, nausea, reflux, uncontrollable emesis and/or decreased tolerance of feedings. Behavioral component will typically develop after a sensory impairment given mealtime difficulties. Mismanagement of feeding resulting in lack of feeding progression of textures This type of disorder can occur if the Pt. has the physiological ability to swallow however; not necessarily medically appropriate. If PO feeding and expectation of intake are too high for their medical status. Example: PO feeding with Salem pump in place; PO feeding with persistent GI distress/emesis; Force feeding.

Aspiration Occurs when food travels into the airway instead of into the stomach Often suspected by observation of coughing, wet voice, throat clearing, or diagnosis of pneumonia Aspiration may be seen on different textures so a child could be perfectly safe eating purees and solids but aspirate on thin liquids. If you suspect aspiration, contact your pediatrician to discuss the possibility of a swallow evaluation.

Objective Fluoroscopic Swallow study
Modified Barium Swallow (MBS) Videoflouroscopic Swallow Study (VFSS)

MBS Uses a fluroscope to assess the structures and functions of the oral and pharyngeal mechanisms, the larynx, proximal trachea, and proximal esophagus during a typical feeding.

FEES Uses a fiberoptic scope inserted through the nasal cavity to the junction of the nasopharynx and the hypopharynx to observe the structure and functions of the mid to lower portion of the pharynx, larynx, and subglottic trachea before and after the swallow

Instrumental Techniques
CERVICAL AUSCULTATION Uses a stethoscope to listen to sounds in the pharyngeal and laryngeal portions of the airway

Cervical Auscultation for Children and Adults
Use of stethoscope for listening to cervical sounds Movements in oral initiation and pharyngeal swallow Breath sounds Bolus flow/turbulence

Interventions Indirect: Feeder Interaction/Infant Advocate
Management of the feeding experience Timing, Location, and structure to feeding experience Direct: Treatment Techniques Swallowing rehabilitation Compensatory strategies for feeding/swallowing Modified diet (liquids and solids) Delivery method of food and liquids Caregiver and Parent instruction

Indirect Interventions
Management of co-morbidities Positioning Respiratory Status Establishment of schedule, location of meals, mealtime expectations, menu options to maximize calorie/alimentation needs. Establishing a behavior reinforcement/elimination program. How will the Patient know that they are achieving the target behavior? Must meet their developmental level.

Direct Interventions Direct: Treatment Techniques
Swallowing rehabilitation Varied Swallowing techniques can be utilized dependant on the Patient’s developmental level and ability to follow directives. Compensatory strategies for feeding/swallowing Altered delivery system Reduced rate of eating Multiple swallowing per bolus (independent or elicited) Modified diet (liquids and solids)

Caregiver Education and Training
It is a nature desire for a caregiver or parent to feel the need to nourish a patient. Swallowing is a complex practice that many caregivers have never had to think about so it is a hard concept to understand that a patient may not want to eat , may not feel hunger/saitiaton, or may have compromised swallowing function. Pictures, animations, and objective swallow assessment aid in the education of caregivers.

Caregiver Education and Training
One of the greatest factors for assessment of “risk of aspiration” is level of caregiver dependence for feeding. When I patient cannot feed themselves or protest a feeding, their risk of aspiration increases. Caregiver tend to provide too large of a bolus at a high rate of speed. Each therapist and Caregiver must work together to identify the ways in which a patient can optimize their self feeding skills. Establishment of a reproducible feeding environment in which the patient is allowed to learn with a fair amount of consistent will increase success.

DIETS-Liquids Thin (Regular liquids)= Water, juice, milk
Naturally Thick= Fruit Nectars, Vegatable juice, creamed soups Nectar Thickened=May be achieved with recipe utilizing blends, commercially available thickeners or cereals Honey Thickened=May be achieved with recipe utilizing blends, commercially available thickeners or cereals

Diets-Foods Puree Chopped solids Soft solids Regular Solids Thin Thick
Lumpy Chopped solids Soft solids Dissolvable Regular Solids May require cutting into bite sized pieces depvending on self feeding skills.

Feeding Equipment

Feeding equipment

Traumatic injuries to the head, neck and face

Physical trauma Trauma to the head, neck or face may result in dysphagia Neurological damage Damage to peripheral cranial nerves May impact oral phase and pharyngeal phase of swallowing depending on the cranial nerve impacted Physical damage to oral/facial structures may also affect swallow function Compensatory strategies, including modification to diet consistency or method of delivery/utensils may be beneficial Specific placement of bolus within the oral cavity relative to structures that remain functional may also be indicated Primary neuromotor or anatomical cause for dysphagia related to traumamay be complicated by related injury, such as traumatic brain injury

Traumatic Brain Injury
Risk for dysphagia is greater for more severe traumatic brain injuries Dysphagia may occur as a result of several factors including oropharyngeal neuromotor and sensory deficits, cognitive-communication deficits, behavioral impairments, and concomitant injuries (i.e. physical injury to head/neck, prolonged intubation/ventilation, tracheostomy) Strong relationship between cognition and safe oral feeding Reduced alertness and attention may impact awareness of food/liquid when presented to the patient. It may also impact volitional aspects of swallowing (oral preparatory and oral phases), as well as delaying trigger of pharyngeal swallow Disordered attention and distractability may result in holding food in mouth and forgetting to swallow Disordered sensory perception may cause reduced awareness of residue within the mouth Impulsivity may result in reduced awareness of appropriate bolus size and pacing These difficulties may be the primary cause of a patient’s dysphagia or exacerbate difficulties for a patient with underlying physiological/anatomical dysphagia related to their injuries. Patients with cognitive deficits may have increased difficulty learning and applying strategies or other therapy techniques to compensate for dysphagia

Management of Feeding and Swallowing – Cleft Lip & Palate

Embryology Primary palate (upper lip, alveolar ridge, premaxilla) forms between 5-8 weeks of gestation. Maxillary processes enlarge and press median nasal prominences toward midline. Median nasal prominences fuse and form intermaxillary segment. Labial component forms philtrum of upper lip. Lateral lip forms from maxillary processes. Palatal component of intermaxillary segment forms bony premaxilla. Lateral nasal processes fuse with median nasal processes to form nasal alae. Secondary palate (hard/soft palate from posterior premaxilla margin to end of uvula) forms between 8-10 weeks of gestation. Mandible growth accelerates and mandible drops, creating space in oral cavity for tongue to drop from nasal cavity into place. Maxillary processes drop to horizontal position, forming shelves, and fuse along midline from front to back beginning at incisive foramen The hard palate forms followed by soft palate. Muscles of soft palate develop between weeks of gestation.

Definition and Etiology of Clefts
Cleft lip, Cleft palate, and Cleft lip and palate are congenital anomalies that occur in various configurations and degrees of severity. Clefting is caused by either incomplete fusion or total lack of fusion of the tissues that form the lip and palate during the first trimester of development. Etiologies include chromosomal disorders, genetic disease, teratogenically induced disorders, and mechanically induced abnormalities.

Cleft Anatomy

Multidisciplinary Craniofacial Team
Pediatrician Plastic surgeon Speech-Language Pathologist Pediatric dentist Pediatric otolaryngologist Orthodontist Oral Surgeon Audiologist Psychologist Social Worker Geneticist 123

Role of the Speech-Language Pathologist (SLP)
Management of dysphagia and feedings Comprehensive evaluation of feeding skills and ability to meet nutrition goals. Identification of feeding impairment and risks of aspiration. Identification and trial of potential equipment needs/ therapeutic strategies and development of feeding modifications to improve intake and eliminate aspiration risk. Objective Swallow Study as indicated (e.g., video fluoroscopic swallow study) Train the caregivers for efficient and safe oral feeding. Outpatient follow-up for developmental transitions and preparation for pre and post operative feeding. Speech and Language evaluation and therapy

Feeding in the Neonatal and Early Infancy Period
125

Criteria for Nipple Feeding
Initial feeding evaluation for infants with cleft lip and/or palate should be completed by SLP shortly after birth. Initiation of nipple feeding is dependent on same criteria as infant without craniofacial anomaly. Post-conceptual age of at least weeks. Physiological Stability (RR <60BPM; stable HR; SPo2 stably maintained on NC or NCPAP < 4cm H20 Fio2 <30%) Stable Respiratory Status Patients with cleft lip/palate have oral dysphagia with increased risk of impaired pharyngeal swallow coordination. A compromised respiratory system may lead to further disorganization of the suck-swallow-breathe triad, which would increase risk of airway protection deficits and aspiration. Patients on elevated respiratory support, such as high flow nasal cannula or nasal CPAP (continuous positive airway pressure) should undergo clinical dysphagia evaluation prior to initiation of oral feeding. Enteral feeding schedule transitioned to bolus feeding Demonstration of feeding readiness at due feeding times (awakens and fusses, roots, hands to mouth, initiates suckling, Etc.)

Infant Pre-Feeding Readiness skills
Breast feeding and bottle feeding accomplished via a combination of the generation of negative pressures creating Suction in conjunction with Compression of the nipple to express milk. Rhythmic and efficient Suck-Swallow-Breath coordination Adequate Airway protection

Infants with Clefts Dysphagia prevalent.
Severity of feeding deficit depends on degree of cleft. Increased risk of failure to thrive. Altered Infant-parent bonding. First visualization of cleft. Stress of NICU stay, stress and frustration of feeding difficulties and feeding time, mourning of standard practices (e.g., breastfeeding) Infants with cleft lip and/or palate alone should be able to orally meet their nutrition needs with modifications in the feeding method. SLP involvement at birth

Cleft Classifications
Unilateral Cleft Lip Microform cleft Incomplete cleft Complete cleft Bilateral Cleft Lip Combination of any type(s) of unilateral cleft Unilateral Cleft Palate Submucousal Soft palate Soft and hard palate Bilateral Cleft Palate

Feeding Differences for Patients with Cleft Lip
Severity of feeding deficit depends on degree and placement of cleft. Difficulty with establishing a conventional labial seal. Complete labial seal around nipple is not essential to create suction; an anterior closure can be obtained between the tongue and alveolar ridge creating suction behind the tongue. Suction may be reduced if cleft is complete and includes the alveolus. Nipple compression should be a relative strength if palate is intact.

Breastfeeding for Patients with Cleft Lip
Should be encouraged. Work with SLP and Lactation consultants. Accommodations for latch can be made. Change feeding positioning so the mother’s breast tissue fills the gap in lip/gum. Trial holding the two sides of lip together without blocking the nostrils to restore suction. Location and degree of cleft may alter ability. Unilateral cleft typically achieve better results because the breast forms to the cleft. Higher risk of reduced negative pressure for suction with complete bilateral cleft. Efficiency should be closely monitored. Restricted rate of milk flow and inability to monitor amount of milk consumed are potential problems.

Degrees of Cleft Lip

Feeding Differences for Patients with Cleft Palate
Severity of feeding deficit depends on degree and placement of cleft. Establishing a conventional labial seal should be intact in absence of labial cleft Intraoral skills: Impaired suck Loss of negative pressure for suction secondary to continuity between oral and nasal cavity impairs ability to express milk from breast or bottle. Impaired nipple compression Compression should be a relative strength, however degree of cleft (Unilateral vs. Bilateral cleft) will affect surface for compression. If nipple is compressed into the cleft, milk extraction will be limited and may be directed into nasal cavity. Loss of coordination between suck-swallow-breathe pattern. Instead of typical 1:1 suck-swallow-breathe ratio, they use inefficient pattern of multiple sucks until a bolus extracted from nipple, swallow, then stop feeding for several breaths resulting in prolonged inefficient feeding times. Nasal regurgitation secondary to opening between oral and nasal cavity. Excessive air intake. Risk of early satiation, discomfort, and regurgitation/emesis. Lengthy feeding time. A newborn should not take more than minutes to finish a bottle or nursing session. Impaired intraoral skills listed above results in increased length of time for feeding process. Risk of expending more calories than consumed. Feeding difficulties are a risk factor for speech problems

Breastfeeding for Patients with Cleft Palate
In general, breastfeeding should be encouraged; however, due to the inability to create negative suction pressure, breastfeeding is generally inefficient for babies with cleft palate, warranting bottle feeding. Exceptions may include submucousal cleft or soft palate cleft; however, efficiency should be closely monitored. An alternative is to express milk using a breast pump and store it for bottle feeding. Alternate skin-to-skin bonding techniques and non-nutritive suckling should be offered.

Degrees of Cleft Palate

SLP feeding goals Find a feeding technique as close to normal as possible. Ensure patient ability to meet nutrition needs via least restrictive feeding modality. Ensure parent comprehension of feeding techniques and swallow precautions. Prepare parents for upcoming surgeries and ensure comprehension of post-operative feeding precautions.

Need to Know Basic Feeding Technique
Begin with small frequent feedings in the first weeks of life. Confine feeding time to minutes. Upright position to facilitate proper milk flow and reduce risk of otitis media. Facilitate lingual compression of nipple via nipple positioning against an intact portion of the hard palate. Consider pliable bottles to help inject milk into mouth via manual squeezing Allow the baby to suck and breathe a few times before beginning any compression of the bottle. Begin with gentle compression and slowly increase the pressure. Consider faster flow nipples. Trial cutting a 5mm length “X” in the tip of the nipple with a scissor, razor blade, or scalpel to facilitate faster flow. Consider using a “red premie” nipple or boiling a regular nipple so it is softer and easier to compress. Burp frequently to avoid excess air in stomach.

Specialized Feeding Equipment
Squeezeable options allow for caregiver to aid in bolus administration Variety of options may be trialed to determine the most efficient system. Provide caregiver training for efficiency and safe swallowing to eliminate airway protection deficits.

Specialized Bottles to aid in Oral feeding

Close-Up

Pre-Operative counseling
Provide education and counseling to parents regarding post-operative feeding techniques. Provide treatment to facilitate feeding transitions in preparation for post-operative feedings skills (i.e., transition to cup drinking prior to palate surgery).

Cleft Lip Post-Operative Feeding Tools
Variety of options may be trialed to determine most efficient system and avoid damage to surgical site. Syringe with soft silicone tubing Silicone Spoon Squeezable bottle with soft silicone tubing Honey bear squirt bottle Pigeon Bottle/spouted spoon system Medela Special Needs Feeder

Typical Feeding Skill Development
Birth – 4 months- nipple feeding 4-6 months- begin “transition feeding” start spoon feeding smooth purees start open cup drinking at about 6 months 9-12 months- soft mashed foods, dissolvable solids By months- chewable tablefoods

Age (months) Development/posture Feeding/oral sensorimotor Source: Adapted from Arvedson and Brodsky10 (pp. 62–67). Birth to 4–6 Neck and trunk with balanced flexor and extensor tone Visual fixation and tracking Learning to control body against gravity Sitting with support near 6 months Rolling over Brings hands to mouth Nipple feeding, breast, or bottle Hand on bottle during feeding (2–4 months) Maintains semiflexed posture during feeding Promotion of infant–parent interaction 6–9 (transition feeding) Sitting independently for short time Self-oral stimulation (mouthing hands and toys) Extended reach with pincer grasp Visual interest in small objects Object permanence Stranger anxiety Crawling on belly, creeping on all fours Feeding more upright position Spoon feeding for thin, smooth puree Suckle pattern initially Suckle suck Both hands to hold bottle Finger feeding introduced Vertical munching of easily dissolvable solids Preference for parents to feed 9–12 Pulling to stand Cruising along furniture First steps by 12 months Assisting with spoon; some become independent Refining pincer grasp Cup drinking Eats lumpy, mashed food Finger feeding for easily dissolvable solids Chewing includes rotary jaw action 12–18 Refining all gross and fine motor skills Walking independently Climbing stairs Running Grasping and releasing with precision Self-feeding: grasps spoon with whole hand Holding cup with 2 hands Drinking with 4–5 consecutive swallows Holding and tipping bottle >18–24 Improving equilibrium with refinement of upper extremity coordination. Increasing attention and persistence in play activities Parallel or imitative play Independence from parents Using tools Swallowing with lip closure Self-feeding predominates Chewing broad range of food Up–down tongue movements precise 24–36 Refining skills Jumping in place Pedaling tricycle Using scissors Circulatory jaw rotations Chewing with lips closed One-handed cup holding and open cup drinking with no spilling Using fingers to fill spoon Eating wide range of solid food Total self-feeding, using fork

Advancing Feeding Skills for Children with Cleft palate
Spoon fed solids/babyfood can be introduced at typical age (4-6mo) Special consideration for placement, consistency, bolus size, pacing. Cup drinking should be started at typical time (about 6 months) May not be able to use “spill-proof” or valved sippy cups due to inability to generate sufficient suction.

Importance of timely introduction to developmentally appropriate feeding skills
Critical/sensitive periods for feeding skill development. Chewing 6-7 months Facilitate adequate feeding during post-operative period. Efficient cup drinking should be mastered before palate repair secondary adverse impact of intraoral nipple placement on surgical wound healing. Outpatient follow up with SLP for developmental transitions and pre/post-operative training.

Post Operative Cleft Palate Repair Feeding Tools:
Syringe with soft silicone tubing Silicone Spoon Squeezable bottle with soft silicone tubing Honey bear squirt bottle Pigeon Bottle/spouted spoon system Medela Softcup feeder Open cup Spoutless sippy cup

Feeding Prognosis Patients with isolated cleft lip and/or palate become successful feeders and meet their nutrition needs with modifications in positioning, equipment, and timing. Patients with comorbidities (either associated with their cleft or unrelated) are often at increased risk of dysphagia and reduced feeding efficiency, requiring further evaluation, monitoring, and possibly non-oral means of alimentation, including: Prematurity Micrognathia Pierre Robin Sequence Trisomy 21

Ana Feliz M.S., CCC-SLP Lindsay A. Murray-Keane M.S., CCC-SLP

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Ana Feliz M.S., CCC-SLP Lindsay A. Murray-Keane M.S., CCC-SLP

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