1. Advancing Oral Intake in a Child with Aspiration: A Single Case Study
Sara Clarke, Michele Cole Clark, Nikki Smith, Bonnie Minter, Barbara McElhanon, & William G. Sharp

2. Disclosure Statement
Have no relevant financial relationships in the products or services described, reviewed, evaluated or compared in this presentation.

3. Abstract
This case study describes multidisciplinary intervention for a 19-month old boy with a history of aspiration and gastrostomy tube dependence. Prior to intervention, Oral Pharyngeal Motility Studies (OPMS) at 6, 12, & 19 months observed an absent swallow with silent tracheal aspiration. The patient was admitted to an intensive feeding treatment program to address a non-functional pharyngeal compensatory strategy, and to improve bolus management across oral and pharyngeal phases of swallowing to decrease his risk of aspiration. Treatment was associated with an increase in functional swallowing, a decrease in non-functional compensatory strategies, improved oral intake, and elimination of tube feeding.

4. Introduction
Aspiration is the entry of material into the airway below the level of the true vocal folds.
Aspiration during swallowing can occur due to dysphagia and/or insufficient management of nasal/oral secretions.
Children with aspiration are at risk for scarring of the lungs, chronic lung issues, and lung failure.

5. Background
Current management approaches include:- 1) primary recommendation prohibits oral intake (NPO) + enteral nutrition; 2) alteration of food consistencies determined by the results of instrumental swallowing studies; 3) out patient clinical trials with SLP or feeding expert, usually weekly
The current case study describes a novel approach aimed at advancing oral intake in a child recommended for NPO. Treatment involved structured mealtime protocols with detailed data collection guiding treatment development, multidisciplinary oversight to assure safety and permit medical monitoring, and multiple therapeutic sessions per day.
The admission goals address the non-functional pharyngeal strategy (gargle), improve the oral preparatory phase, and establish a functional oral transit phase and pharyngeal phase of the swallow in order to decrease his aspiration risk.

6. Methods
Participant:
John (pseudonym) was a 19 month-old boy with a history of aspiration and gastrostomy (G-) tube dependence.
Complicating his presentation was a medical history significant for an anoxic event in the first 36 hours of life with subsequent infantile seizures, dysphagia, aspiration, gastroesophageal reflux, and hypoxic ischemic encephalopathy.
Prior to intervention, Oral Pharyngeal Motility Study-OPMS testing at ages 6, 12, & 19 months identified silent tracheal aspiration and highlighted absent swallow with repeated frank aspiration during trials of all consistencies.
Due to poor oral intake, John underwent placement of a nasogastric (ng-)tube shortly after birth; and remained intact until a G-tube was placed at 12 months.

7. Methods Oral Motor Competence:
John received outpatient non-nutritive oral motor therapy with a speech pathologist leading up to his admission. At that time, John demonstrated  0% lingual variety of movement, 0% durational jaw strength, poor range of movement of the upper cheeks and lips, which did not meet clinical competence for puree by mouth. At admission, John met minimal competence for bolus control of puree texture; however, not deemed clinically ready for PO intake secondary to silent tracheal aspiration on all consistencies. 

8. Methods
Setting:
John was admitted to an intensive multidisciplinary day treatment program. Professionals involved in overseeing his care included a pediatric gastroenterologist, speech language pathologist, dietician, and behavioral psychologist.
Admission lasted 8 weeks (Monday through Friday), with four 40 minute therapeutic sessions conducted each day. One session per day involved intensive oral motor therapy using Beckman Oral Motor Intervention protocol (Beckman, D.A., 1998 rev 2012). Three sessions involved a structured protocol to monitor the target gargle occurrences following our general behavioral protocol developed in coordination between the speech pathologist and behavioral psychologist.
Trained therapists conducted sessions in rooms equipped with one-way mirrors and an adjacent observation room for data collection.
Evaluated the use of an empty spoon swallow prompt to address whether this strategy would reduce engagement in the nonfunctional compensatory strategy used to avoid aspiration. (See Table 1 for treatment steps)

9. Table 1: Treatment Goals and Rationales
Phase
Goal
Rationale
Introduction of a structured mealtime protocol (SP): To develop a SP and monitor rate of gargle during therapeutic meals. All bites were presented at midline using a bolus size of 0.1cc of thin puree texture food (measured by viscometer for accuracy) on a small maroon spoon. The therapist presented each bite using a single verbal instruction (“Take a bite”) and checked the mouth for food every thirty seconds after depositing the bite. If the mouth was clean and no gargle was occurring or had ceased for 10 seconds, the therapist presented the next bite. A total of 115, 5-bite sessions across 7 days (580 total bites) were presented during this phase. 
This phase provided baseline data regarding rate of gargle and allowed the treatment team to monitor whether this non-functional compensatory strategy decreased with high repetition. It also provided the opportunity to closely monitor John’s medical status following the introduction of food with multidisciplinary support.    
Evaluation of empty spoon swallow prompt (ESSP): To determine whether an ESSP would assist with the oral preparatory phase for organized oral transit and subsequent swallow. During the ESSP, the therapist presented an empty spoon immediately after the bolus was deposited. The therapeutic contribution to treatment was assessed using an alternating treatment design, which involved 10-bite sessions comparing SP versus SP + ESSP (See Figure 1). A total of 11, 10-bite sessions across 2 days (110 total bites) were presented during this phase.
This phase allowed for the systematic evaluation of the potential contribution of a relatively simply therapeutic tool - i.e., the ESSP. We hypothesized that the use of the ESSP (lip closure around the spoon combined with placing slight pressure on the anterior 1/3 of the tongue with the empty spoon) may act to prompt the oral preparatory phase for organized oral transit and subsequent swallow would accomplish a decrease in opportunities for aspiration events.
Repetition with SP + ESSP:  To determine if SP + ESSP was associated with remission of gargle over time. A total of 155, 10-bite sessions across 14 days (1,446 total bites) were presented during this phase.
If treatment was associated with decreased gargle coinciding with more rapid swallow occurrence, this would set the stage to advance bite volume, modifications in food viscosity, and expanding the variety of foods consumed during meals.
Advancement of oral intake: To systematically increase the volume of food consumed during meals using a bolus fading procedure based on gargle occurrence stability (gargle occurrence <20% across 2 meal blocks). As terminal bolus was achieved, a similar process was used to modify the viscosity of the food. Advanced to honey thick, then to puree texture as gargle occurrence remained below 20% across two treatment days; a drink was subsequently added to the meal at 3.0 cc.
With gargle reduced/eliminated during most meals combined with no evidence of continued aspiration based on medical monitoring, treatment shifted to tube weaning. The treatment team, however, continued to use data collection with corresponding decision rules to introduce new feeding demands to monitoring the patient’s response and minimize risk for an adverse event.  1 2 3 4

10. Methods: Data Collection:
The primary dependent variables were 5 second acceptance, mouth cleans, and gargle occurrence.
5 second acceptance was defined as when the entire bolus is deposited in the child’s mouth after 5 seconds of the initial presentation.
Mouth clean was defined as no residual food remaining inside the mouth within 30 seconds after the food initially was deposited.
Gargle was defined as an audible perception of forced movement of bolus residue in a superior/inferior direction, from the pharynx to the hypopharynx and/or the nasopharynx, after posterior oral transit of the bolus into the pharynx.
We recorded the occurrence and nonoccurrence and duration of gargle for each bite accepted
We calculated the percentage of bites with gargle occurrence by dividing the number of bites in which the behavior occurred by the total number of bites entering the mouth and converting that number to a percentage.

11. Summary of Treatment Outcomes
Decreased engagement in the nonfunctional compensatory strategy used to avoid aspiration.
Caregivers demonstrated high fidelity of treatment protocols.
Multidisciplinary treatment approach demonstrated significantly higher change in decrease of gargle occurrences (97.37% vs. 1.09%), and significant difference in the change of grams consumed (5 grams vs. 764 grams; 100% g-tube wean)
This client was able to move from NPO with enteral feeds to all feeds by mouth, and begin age appropriate dissolvable chewing practice.

12. Discussion
This case study examined a multidisciplinary treatment team intervention for pediatric feeding disorders in a day treatment setting.
Results provide provisional support for an intensive oral motor intervention for oral and pharyngeal phase practice supported with structured feeding protocols to advance oral intake among children evidencing NPO status secondary to dysphagia (and absent structural and/or motor concerns).
Treatment was associated improvement in oral motor status, which permitted advancement in safe oral intake and  systematic increase in grams consumed. At discharge John was consuming 100% of needs by mouth with no signs or symptoms of aspiration. John demonstrated no medical symptomatology of aspiration at any point in the admission