Twin Functions: How Feeding and Speech are Intertwined

Twin Functions: How Feeding and Speech are Intertwined
By Brandi Watts, M.S, CCC-SLP Children’s Hospital of Richmond Feeding Program

Objectives State developmental milestones and how different system integrate functions-Feeding, Speech/Language, Gross Motor and Cognition State how delays in one developmental area can negatively effect function in other areas List types of complications and how they impact feeding and speech

Milestones Handout References:
Feeding and Physical Motor info: Morris and Klein (2000) Speech and Language info: The Rosetti Infant-Toddler Language Scale (Rosetti, 1990) Cognitive info: Hawaii Early Learning Profile (HELP) Checklist ( ) & Developmental milestones: A guide for parents Powell, J. and Smith, C.A. (1994).

Developmental Milestones: 0-3 months
Feeding Speech & Language Cognitive Physical/Motor Held in a degree angle for feeding Consume 7-8 oz. of liquid per feeding Reflexive suckle pattern is used to draw the liquid into the mouth Moves in response to a voice Attends to a speaker’s mouth or eyes Vocalizes 2 different sounds other than crying or cooing Shows pleasure when touched and handled Shows active interest in person/object >/= 1 minute Listens to voice for 30 seconds Most movements are reflexive Require external support Able to lift and turn head while lying on tummy by 3 months Review of developmental milestones across systems. “Speech & Language” section includes both expressive (how much the child can say) and receptive (how much the child can understand) language develpment

Feeding Speech & Language Cognitive Physical/Motor Eat and drink in an upright position Recognize and eagerly await the approach of the bottle/spoon Tongue lateralizes towards food placed laterally Recognizes own name Babbles Vocalizes to express displeasure Vocalizes feelings via intonation Enjoys repeating newly learned activity Uses hands and mouth for sensory exploration Localizes tactile stimulation Able to sit without support Easily reach for and grasp toys/objects Explore shape, texture, weight, and taste with their mouth

Feeding Speech & Language Cognitive Physical/Motor Mouth plays primary role in sensory discovery, which sets the stage for successful transition to lumpy solids Consecutive vertical chewing patterns Stabile bite through soft cookie as feeder breaks off piece in mouth Responds to “no” most of the time Maintains attention to speaker Stops when name is called Waves in response to “bye-bye” Vocalizes 4 different syllables Touches toy or adults hand to restart activity Smells different things Anticipates the trajectory of a slow moving object Responds to facial expressions Able to roll, crawl, or creep Able to sit with minimal support Explore objects by mouthing, banging, shaking, grasping, and releasing Functional reach, refinement of grasping, and finer manipulative skills by 9 months

Feeding Speech & Language Cognitive Physical/Motor Able to drink from a straw Emerging diagonal rotary chewing pattern Able to manage coarsely chopped tablefoods and softer meats Identifies 2 body parts on self Says “mama” and “dada” meaningfully Vocalizes with intent Says 1-2 words spontaneously Listens to speech without being distracted by other sources Knows what “no no” means Responds to simple verbal requests Imitates new gesture Able to creep, pull to stand, cruise furniture, and take independent steps Refined reach, grasp, and release Able to isolate the index finger for pointing and poking

Feeding Speech & Language Cognitive Physical/Motor Able to manage coarsely chopped table foods and easily chewed meats Accept liquids via the cup, straw, bottle or breast Emerging diagonal rotary chewing pattern Follows 1-step commands during play Understands some prepositions Identifies 3-6 body parts on self/doll Understands 50 words Responds to simple verbal requests Demonstrates drinking from cup Hands toy back to adult Reacts to various sensations such as extremes in temperature and taste Pull to stand, cruise furniture, take first steps Refinement of reach, grasp, and release Reach for utensil or food and attempt to pull it into the mouth (partial self-feeding)

Feeding Speech & Language Cognitive Physical/Motor Sustained bite through a hard cookie, with associated movements in the arms and legs Able to feed themselves with their fingers, mild assistance needed with scooping Able to manage a pre-loaded spoon Understands “sit down” and “come here” Chooses 5 familiar objects upon request Imitates and/or uses 2-3 word phrases and uses 50 words Follows 2-step commands Understands pointing Walk and run Able to sit in booster seat

Feeding Speech & Language Cognitive Physical/Motor Able to self-feed the majority of the meal Able to manage every kind of food and liquid Demonstrate non-stereotypical vertical, diagonal rotary, or circular rotary chewing patterns, depending on type of food Points to 4 action words in pictures Understands the concept of “one”, sizes Uses 3 word phrases frequently Responds to simple questions Identifies 4 objects by function Plays with water and sand Obeys 2 part (related/separate) commands Understands many action verbs Walks alone Begins to run and kick Able to stand on tiptoe Walks up and down stairs with support Begins to use one hand more frequently

Feeding Speech & Language Cognitive Physical/Motor Increased food selectivity due to preference vs. lack of skills or coordination Chewing and jaw gradation is now fully developed Tongue-tip elevation and tongue-jaw movements are more refined Understands 5 common action words Answers yes/no questions correctly Uses plurals States first and last name States gender Able to recognize sounds in the environment Understands what is food and what is not food Understands the concepts of "now," "soon," and "later" Able to hold a cup in one hand Able to wash hands independently Able to pedal a tricycle Able to hold a crayon well

Examples of Causes for Feeding or Speech Delays
Neurological/Mechanical-cleft palate, tracheostomy, ankyloglossia, cerebral palsy, apraxia, low tone, gross motor delays, autism Medical-Recurrent ear infections, thrush, teething, enlarged tonsils/adenoids, frequent emesis caused by reflux or slow gastric emptying, severe food allergies, even constipation! Environmental-Parents unaware of typical development with expectation too high or to low, parents who have difficulty reading their child’s physical cues, lack of appropriate stimulation to encourage skills development during the appropriate developmental window

Neurological and Mechanical Complications for Speech and Feeding
Cleft palate-Nasal regurgitation, intelligibility Tracheostomy-Sensory Motor complications Ankyloglossia-”Tongue-tie” Cerebral palsy-Anterior tongue thrust Apraxia-Motor Planning for Volitional movement Low tone-Open Mouth Posture Gross motor delays-Body Pyramid of Stability Examples of Syndromes/Conditions: Cerebral palsy, Down’s Syndrome, Russell Silver Syndrome, Prematurity

Medical Complications for Speech and Feeding
Respiratory issues-BPD, Laryngomalasia Recurrent ear infections Thrush/Teething Enlarged tonsils/adenoids Frequent emesis caused by gastrointestinal complication i.e. reflux or slow gastric emptying Severe food allergies-Eosinaphilic Esophagitis Constipation Cancer, Metabolic issues

Respiratory “No food or drug will ever do for you what a fresh supply of oxygen will.” Tony Robbins Bronchopulmonary dysplasia (BPD)  Chronic lung disease (CLD) Laryngotracheobronchomalacia BPD can lead to CLD

Bronchopulmonary Dysplasia
Commonly seen in premature infants (more than 10 weeks early) who require O2 therapy Characterized by mild, moderate, and severe Dependent upon how much supplemental O2 is required and for how long Diagnosed by: Chest X-ray May show areas of inflammation or other issues such as a collapsed lung Blood tests r/o infection Echocardiogram r/o cardiac etiology Points to discuss: Increasing effort to breath which burns more calories. Nutrition is important! Many of these infants will be on a higher calorie formula or supplemental feedings Also, more effort required to coordinate breathing and swallowing. Fatigue is an issue. Many infants require close pacing with feeding These are the children who get sick with the “simplest” cold.

Laryngotracheobronchomalacia
“Softening of the Airway” Three areas where we commonly see this Larynx Trachea Bronchi With laryngomalacia, expect to hear inspiratory stridor. Expiratory stridor/wheezing heard with tracheo- and bronchomalacia. Generally, infants outgrow this around 2 years of age However, may require surgery if severe Diagnosed with flexible endoscopy and/or bronchoscopy Varying degrees of each You will likely hear worsening stridor/wheezing with the work of eating. Like BPD, children will often need pacing with eating OR small meals more frequently to account for fatigue. May require surgery for “pinning” or stenting if severe.

Laryngotracheobronchomalacia
Strong relationship between tracheomalacia, laryngomalacia and GERD Thought to be related to high negative intrapleural and abdominal pressures which in turn, affects the lower esophageal sphincter (LES). Best practice is for reflux management (positioning, diet modification, medication) in these children to avoid complications related to GER Of course, reflux is something we should all be monitoring closely while treating these children. - Can be cyclical; patient with reflux which in turn irritates the laryngeal/tracheal cartilages and makes the malacia worse Bibi, H., Khvolis, E., Shoseyov, D., Ohaly, M., Dor, D., London, D., & Ater, D. (2001). The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia. Chest, 119(2), Retrieved March 6, 2015, from

Gastrointestinal Reflux Constipation Motility Pain Sensation Short Gut

GERD Reflux, or gastroesophageal reflux (GER), occurs when the contents of the stomach pass back up through the Lower Esophageal Sphincter (LES) into the esophagus.

Causes of Reflux Weak or non functioning Lower Esophageal Sphincter (LES) Increased Production of Stomach Acid Low Trunk Tone High Trunk Tone Allergies Slow Gastric Emptying Constipation

Signs of Reflux Vomiting Nasal flaring or reddening of the nose
Watering eyes Increased respiration Excessive swallowing Increased congestion Coughing Inconsistent feeding behaviors Difficulty sleeping or going down to sleep Breakfast is more difficult Fussiness Volume limiting Excessive drinking Arching Posturing

Evaluation of Reflux Clinical evaluation and observation is your best tool for diagnosis. Upper GI Remember, this is only a moment in time in a situation that is vastly different from normal feeding Often treated without having an Upper GI

Treatment of Reflux Postural changes Thickening liquids
Upright after meals, elevate bed Thickening liquids Dietary changes Decrease allergens or acidic foods Decreasing volume and increasing number of meals Medications Acid reducers Acid reducers neutralize acid already present in the stomach Example: Zantac Protein pump inhibitor (PPI) Stops the stomach from producing the acid Example: Prevacid Nissen Fundoplication Surgical procedure where the top of the stomach is wrapped around the LES to prevent reflux.

Constipation Never underestimate the importance of daily bowel movements!! Food goes in, it has to come out or the system backs up. Kids can still go daily and get impacted. Texture and consistency should be like oatmeal

BRISTOL STOOL CHART

Constipation: Diagnosis
Largely based on history: Straining and flushing of the face while attempting bowel movement Hard and dry bowel movements No bowel movements at all for several days Abdominal cramps and pain Nausea and/or vomiting Weight loss Traces of stool in the underwear (indicative of a backup in the rectum)

Constipation: Medical Treatment
Common Medications: Miralax Milk of Magnesia Senna Enemas and Suppositories

GI Motility Issues Motility issues can be seen at any point in the GI tract from the lips to the colon Depending on where the motility issue is will change the name of the dysfunction Esophageal Slow gastric emptying

Slow Gastric Emptying Definition Know the anatomy of the GI tract!
Also called gastroparesis. Food moves too slowly through the intestinal tract or becomes static at certain points. Know the anatomy of the GI tract! At the bottom of the stomach is the pyloris sphincter. The pyloris keeps stomach contents from entering the small intestine before it has been broken down and mixed with acid.

GI Tract Anatomy The pyloris empties into the small intestine which is comprised of three sections: the duodenum, the jejunum and the ileum. The sections of the small intestines are important to know when assessing G-tube kids Most kids have tubes that empty directly into the stomach If absorption or reflux is an issue, will often have tubes that enter through the stomach and extend into the duodenum, jejunum or ileum.

GI Tract Anatomy Often kids who are on continuous feedings will have G-J tubes. After the ileum is another valve that prevents bacteria laden contents in the colon from going backward. Lastly is the colon.

Clinical Indicators of SGE
Volume limiting Vomiting hours after meals are consumed Sour smelling emesis Inconsistent feeding performance from meal to meal or day to day (emptying is a non-linear process) Meals are often more difficult as the day progresses

SGE Treatment: Medical
Periactin An antihistamine Side effects might increase emptying speed as well as hunger signals Only side effect is temporary drowsiness which fades over about a month If you don’t take a break from Periactin, then the beneficial side effects fade Periactin can lower the threshold for seizures.

SGE Treatment: Medical
Erythromycin Old school antibiotic used in lower doses than when used as an antibiotic You don’t have to worry about making kids antibiotic resistant because most bacteria these days aren’t impacted by it Because it isn’t used widely as an antibiotic any more, it’s often hard to get a pharmacy to compound it. Erythromycin works to speed emptying because it aggravates the GI mucosa Stomach aches are often a side effect.

SGE Treatment: Compensatory
Meal schedules More numerous meals of smaller volumes. Changes in formula to include elemental formulas

Food Allergies Definition:
The body’s immune response to a food that the body views as foreign. Therapist is often the first to catch and refer to Allergist Most common food allergies include: peanut, milk, soy, corn, wheat, egg

Signs of Allergies to Foods
Hives Eczema Diarrhea Dumping Respiratory issues such as wheezing Fatigue Upper respiratory congestion Vomiting Reflux Watering or itchy eyes Coughing

Food Allergies: Evaluation
Skin Prick Test RAST testing Elimination diet Only one able to diagnose food intolerances The Skin prick test and RAST testing both at risk for false positive and false negative results

Special Note on Severe Food Allergies
Eosiniphilic Esophagitis Usually seen in conjunction with gastritis (overall GI inflammation) The body produces eosinaphils (clumps of white blood cells) in the esophagus causing tearing, striations and severe pain Treated with elimination diet and oral steroids such as Pulmicort. You can have EoE even if you only have environmental allergies Use of Hypoallergenic formulas such as Elecare and EO28

Environmental Impacts on Feeding and Speech
Parents not aware of developmental norms-example-prematurity Parents unable to read child’s cues accurately-chewing skills and stage 3 foods No stimulation or stimulation introduced outside of the developmental window

Environmental How is the home equipped?
Highchairs Constant activity level in the home Adequate food supply Utensils available: spoons, bottles, etc. How many people reside in the home? Family meals v. Eating on the go? Preschool? Baby sitter? Siblings present? Pets? Distraction v. No distraction?

How to Treat?? Identify the underlying causes by asking clarifying, open ended questions Refer to the appropriate medical professionals if mechanical, neurological or medical issues are suspected. Professions can include: Pediatrician, Otolaryngologist, Gastroenterologist, Developmental Pediatrician, Immunology Refer to Occupational Therapist, Physical Therapist, Speech-Language Pathologist, Audiologist, Psychologist for a whole body approach Parent education

What does this mean in the classroom?
Special seating Decreasing distraction by moving student to a different part of the room, less students at the table 1 to1 assistance Use of motivators Food rotation Prize incentives Keeping food logs for the family Collaboration with SLP or OT Referral for services

Twin Functions: How Feeding and Speech are Intertwined

Similar presentations

Presentation on theme: "Twin Functions: How Feeding and Speech are Intertwined"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Twin Functions: How Feeding and Speech are Intertwined

Similar presentations

Presentation on theme: "Twin Functions: How Feeding and Speech are Intertwined"— Presentation transcript:

Similar presentations

About project

Feedback