Vol. 11 Issue 49
Swallowing and feeding issues in medically complex children
Children with medically complex diagnoses often present with swallowing and feeding problems that can complicate the initial diagnosis. Speech-language pathologists must be prepared to treat these unique diagnoses with creative and effective methods to ensure safe and adequate swallowing, nutrition and weight gain in infants and toddlers.
Children born prematurely or those with bronchopulmonary dysplasia (BPD), congenital heart disease or defects, or craniofacial anomalies often have a variety of other problems associated with their diagnosis that ultimately can affect their ability to swallow, according to Beth Solomon, MS, CCC-SLP, clinical and education coordinator in the Speech-Language Pathology Section, Rehabilitation Medicine Department, of the National Institutes of Health (NIH) in Bethesda, MD. For instance, preemies may present with infant respiratory distress syndrome (IRDS), necrotizing entercolitis (NEC), or gastroesophageal reflux (GER). Clinicians must be aware of the underlying problem before treating a child for a swallowing or feeding disorder.
Common characteristics of children born prematurely are reduced endurance, inability to control body temperature, lung immaturity and irregular respiratory patterns. They often present with apnea, the absence of breathing, and bradycardia, a lower than normal or slowing of the heart rate.
Children born prematurely often have difficulties swallowing and feeding as a result of abnormal neuromotor patterns, such as an inability to coordinate sucking, swallowing and breathing, Solomon told ADVANCE. The strength of the baby's suck may be limited, thus causing inadequate intake; and the baby may present with structural problems in the oral cavity, pharynx and larynx. To treat swallowing and feeding difficulties in this population, suggestions for speech-language pathologists would include: making modifications to the environment and/or feeding schedules, offering oral-sensorimotor stimulation, and changing the child's position or utensils used.
IRDS is the inability to produce surfactant, the substance that lines the alveoli in the lungs. This condition commonly is associated with prematurity. Symptoms include rapid and labored breathing, fatigue and poor circulation.
Swallowing and feeding problems related to IRDS include discoordination of suck/
swallow/breathe, poor endurance or fatigue, alterations in the sucking mechanisms, and poor oral intake. This pediatric population typically outgrows the disorder as the body matures and develops if there is minimal lung damage and no other associated medical conditions.
NEC is a gastrointestinal disease that causes inflammation of the colon and intestine and destruction of part of the bowel. It is frequently seen in premature infants between 3 and 10 days old.
Treatment may include antibiotics, decompression of the stomach, bowel rest, fluid and electrolyte replacement, and surgical resection. Oral feedings may be discontinued due to prescribed bowel rest. Possible regression of normal sucking and swallowing skills may result.
Speech-language pathologists working with this population should reduce any oral-sensory sensitivity if it should develop, facilitate oral-motor development, and utilize small, frequent meals, Solomon recommended. A restricted diet prescribed by the physician may present obstacles to the clinician treating a child with NEC.
Preemies also may present with GER, which is the backwash of the stomach contents into the esophagus, pharynx and possibly the larynx. The condition often causes a burning sensation and general discomfort and ultimately may be responsible for choking, coughing, breathing difficulties and lung infections in infants and toddlers.
GER can result in poor weight gain, irritability, and infant/parental stress during feedings. Management approaches include medication, dietary changes, positioning, and frequency and timing of meals.
BPD is another common disorder among premature infants. The chronic pulmonary insufficiency often results from prolonged artificial ventilation. This population presents with poor endurance, inadequate oral intake, and difficulty coordinating suck/
swallow/breathe. In addition, these children have an increased risk of swallowing dysfunction and GER.
Physiologic parameters, such as heart rate and respiratory status, must constantly be monitored. Clinicians should attempt to decrease the child's work of breathing, decrease oral-tactile sensitivity, manipulate the feeding schedule, and utilize reinforcement and pleasurable experiences, Solomon advised.
Congenital heart disease and defects also can affect the feeding and swallowing mechanism of an infant or toddler. These young patients may appear fatigued or have reduced endurance, poor oral intake and weight gain, and discoordination of suck/swallow/breathe. They also may experience apnea or bradycardia. Heart conditions may go undiagnosed initially.
Approximately one out of every 750 children are born with a cleft lip or palate. Solomon stated that children with cleft lip or palate may have difficulty establishing intra-oral pressure, initiating a suck, and achieving a tight seal around the nipple.
If the child is diagnosed with a soft palate cleft, there is the possibility of nasal regurgitation of fluids through a hole leading to the nose. The child also may experience difficulty in achieving adequate intra-oral pressure for sucking.
Pierre Robin Sequence is a craniofacial anomaly that is a combination of cleft palate, micrognathia and glossoptosis. Micrognathia is a smallness of the lower jaw, and in glossoptosis the tongue falls toward the back of the mouth.
"The greatest difficulty for the child is respiratory," Solomon said. "When the tongue falls back into the airway, the baby is at risk for difficulties in breathing. When you start to introduce fluids in terms of nutrition to the baby, you have to make sure that you are able to get that intra-oral pressure and have the child positioned appropriately upright and forward so the tongue doesn't fall back and occlude the airway during swallowing."
Children may turn blue, have poor intake, and experience a lot of breathing difficulties. They tend to be irritable and not want to feed. In some instances, feeding or tracheostomy tubes may be recommended.
When providing treatment for any of these disorders, it is important that speech-language pathologists be aware of the child's history. Clinicians must be able to recognize a variety of signs and symptoms to prevent the baby from becoming distressed. The baby's heart rate, oxygenation levels and respiratory levels must be monitored; and signs of lethargy, possible seizures, or changes in skin tone or muscle tone must be noted.
If an infant shows signs of lethargy, Solomon recommends changing the baby's diaper or giving the baby a cooling bath. Swaddling children and putting them into a fetal position are calming methods during periods of distress. Environmental noise also should be minimized.
"There is no cookbook method to all of this," Solomon said. "Finding the comfort zone is very child-specific."
The speech-language pathologist may want to discuss with the child's physician about alternating a child's medications or changing the timing, if needed.
While symptoms for some of these conditions may disappear as the baby matures and develops, problems with sucking, swallowing or appropriate airflow may persist. Speech-language pathologists must work to ensure that infants and toddlers with complex medical conditions are swallowing safely and receiving adequate nutrition and hydration to foster weight gain and growth. If swallowing and feeding issues are not handled appropriately, failure to thrive or malnourishment issues may occur, requiring alternative feeding methods such as oral-gastric, nasal-gastric or gastrostomy tubes.
For more information contact:
m Beth Solomon, National Institutes of Health, (301) 496-8831; e-mail: Beth_Solomon@nih.gov
Nicole Klimas is assistant editor of ADVANCE.