Pediatric Swallowing

The infant isn’t an anatomical miniature of the

Adult:
There are anatomical differences between infants and adults:

1. Infants’ oral cavity is small and totally filled by the tongue due to a small and slightly retracted
lower jaw (in adults there is more space )
2. Set of sucking pads in the child’s cheeks which will ensure stability during sucking
3. Soft palate and epiglottis are in contact when at rest to provide additional valve at back of oral
cavity
4. Larynx and hyoid cartilage are higher in the neck and closer to the base of the epiglottis thus
providing an added protection of the airway
5. Infants Eustachian tube runs horizontally from the middle of the ear into the nasopharynx
Where in adults or older children it is rather in a vertical angle position

Types of swallowing:
There is more than one type of swallowing and they change based on anatomy – neurology and
physiology

Thus there is functional modification in swallowing due to anatomical changes and physiological and
neurological maturity and changes

Types of swallowing
Fetal swallowing (12 to 40 weeks after birth)
11th week: 1st acts of deglutiton or swallowing

12th week: formation of taste buds

Effective tongue lapping and swallowing with more and more amniotic fluid swallowed by the
fetus where :

 Kidney starts functionning + ingested waste stocked  meconium formation (which is a

the dark greenish feces that have collected in the intestines of an unborn baby and are
released shortly after birth
 Morpho-genetic role of fetal swallowing where sucking is ineffective due to absence of
pressure differences and tongue lapping is eloped for swallowing .( this tongue lapping
and propulsion and retropulsion of he tongue will help grow the mandible )
That is why if there is failure of disoautomatism we might find retrognathia(lower jaw
isset further back than the upper jaw) so this can make us think there was a problem in
fetal swallowing same with micrognathia (lower jaw is undersized) and sequence of pier
robenz (bad placemnt of the tongue in the oral cavity )
  Sensory links are being built by the infant between the intrauterine light and the
neonatal light thus helping in odor and taste discrimination (Olfactory and taste sensory
channels + Thermo-tactile sensation) where later on the child well seek smells and
tastes similar to the mother

Swallowing of neonates and infants (0 to 6-8 months

after birth)
 ‘’Sensory expectation’’ of the neonate due to the fetal memory which is already built via
the sensory links
 Physiology of deglutition: shows that the intestines only tolerates body-temperature
nutritional fluids →if they are not body temperature then there will be slowed gastric
emptying and ↗ gastro-esophageal reflux.
 Suction in atmospheric environment varies than when it was in the aqueous
environment with the amniotic fluid
Before the suction was not important due to the lack of pressure differences; he used to
only do tongue lapping but in this stage tongue lapping is not sufficient he needs after
birth to place nipple in mouth aspirate the milk and propel it to the stomach via suction
 This maturation occurs towards the Last weeks of intrauterine life; where suction is a
very complex act that requires intact neurological and anatomical equipment and it is
triggered or inhibited by a series of reflexes known as archaic reflexes .

Archiac Reflexes :assessment of each is done via its

corresponding stimullation
 Rooting Reflex : requires stimulating the cheeks or the lips by the touch then the baby
automatically turn the face toward the stimulus with mouth opening and propulsion of
the lips and tongue.
this reflux will prepare to putting the nipple in the mouth and feeding
 Gag reflex : it is a protective reflex that inhibts and reverses the swallowing. When the
sensory system identifies a strange substance different from the milk whether in
temperature or consistency or taste this reflex may be triggered . it might indiccate food
refusal
 Tongue orienting reflex : look for the stimulation by touching the tongue of the new
born which will induce a movement of the tongue tip to the side of the stimulus .
His ability has a predictive significance for future chewing or mastication.
 Bite Reflex : Component of suction ; alteration of opening and closing vertically the
mandible with well round movements during suction.when closing the mandible it is
used to press the nippleinorder to make the milk flow out (usually persists with poly
handicaped kids like in CP and i twill disturb the spoon feeding or cup drinking
 Sucking Reflex : it is triggered by the itroduction of the fingerin the mouth
 Cough Reflex : protective reflex against chocking ; neurological maturation won’t make
it disappear but it might be eliminated or decreased due to some pathologies
  All archiac reflexes except for cough reflex disappear with maturation but the gag
reflex doesnt disappear but it becomes more to the back
 But in neurological disorders they might persist and in adults they may reappear
and so they need to be inhibitted

Nutritive Sucking
Used to get nutritional intake

Its a rhythmic sequence of 3 to 4 bursts as follow :

1. Lips are well inserted around the baby bottle nipple.

2. Cheeks will contract
3. Jaw will close making the milk flow out
4. The tongue works as a pump with well arranged antero-posterieur movements +
peristaltic type: tip or apex of tongue are in slight protrusion, the edges are in curved
arch enclosing the nipple and crushing it towards the palate thus an intra-oral
depression formed
5. Accumulated milk in the posterior section of the oral cavity. But it is Not yet swallowed
→ Oral cavity and oropharynx separated (velum lowered and comes into contact with
the base of tongue) milk is not swallowed yet
6. Before swallowing in all this phase the baby is able to breathe because of the larynx
ascension

Several bursts later:

• Posterior section of the oral cavity is full of milk.

• Tongue pushes the milk towards the back into the oropharynx.
• Breathing stops.
• Once the milk passes through the cryco-pharyngeal zone into the oesophagus, breathing starts
over.
• Process starts over again.
• Very fast → impression that breathing has never stopped.
 
Successful sucking depends on the child’s ability to ensure these pressure variations
Impact of anatomical and neurological abnormalities like cleft palate – coordination
impairments in neurological pathologies.
Unsuccessful Sucking:
Usually when the milk is leaking sideways from the mouth the child will try to
compensate: by increasing the movement of opening and closing the mandible –
therefor increasing air leakage (no good oral compression) where intraoral depression
won’t be well formed so few or no milk will be aspirated.
15 mins of breastfeeding
Essential amount for milk intake happens during 1 st 4 mins to satisfy hunger
Large pause intervals: sleepiness, non-nutritive episodes (Fundamental on
psychological level) after the 4 mins those take place.
Mother baby interaction moments from communication to social experiences…
 1st 4 mins are also essential for this mother baby relationship

Neurological maturation and primary reflexes inhibition

Are important to perform this transition to adult swallowing. It happens through different steps:

o Nerve fibres’ myelination: starts at the late age of intrauterine life allowing
better nerve induct connection
o Central nervous system maturation is important
o Interneuron connections and neurological maturation where the lapping
movement realize in the intrauterine life serves the newborn the suction
swallowing reflex . Then the suction which is an automatic reflex is triggered by
any tactile olfactory or tastatory stimulation at the lips or the tongue . when the
baby is doing constant training on the suction with the neurological maturation
happening gradually he will inhibt the primary oral reflexes . in case of
interneuron connection that is established by the first breastfeeding and it will
allow the baby to memorize the sensation or sensory information and the
motor program.
The automatic reflex function which is the suction is reinforced and becomes
more complex due to cortical memorization. This evolution requires an intact
neurological system with multiple daily and repetitive sensorimotor
experiences
o Brain plasticity: -brain’s ability to change and adapt as a result of experience.
The capacity of various cerebral structures to develop in various ways and allow
the establishment of compensatory network can supplement the lost function.
Like in aphasia it can partially lead to a better function
Thus early intervention in infants is very important because brain plasticity is
better in babies
o Chronobiology: repetitive breastfeeding at specific times . it helps in
synchronizing the biological rhythm of the newborn .
Difficulty in introducing oral feeding in neonates with continuous anterior
feeding must be linked with this phase

Transition to adulte swallowing (6-8 months to 6

years)
• 6-8 months: Adult swallowing appears with the introduction of varied diet using the spoon

• The baby will start by Suction of the spoon but veery soon he will Transfer to oral phase

• Both strategies are used

• 7 months with the abcence of molar and premolars → Mixed textures are what will be
introduced →here the Adult preparatory phase uninstalled yet and the baby cant grind the food
in the fibres
 • Rythm milk bottle sucking vs spoon feeding are almost the same rhythm

• AT 11 month start by giving the child bread – biscuits which are easy to suck and swalow

• 2 years → first premolars where the child still faces difficulty chewing some fibers like beens etc.

• At the age of 2 years he will be using Vertical movements of the mandible, but lateral
movements appear later

• ≈ 6 years: well organised adult chewing starts to appear

( explanation : because his fine motor skills at 6 years is much better )

During the 1st few weeks to month of life the feeding gradually changes from reflexsive to a learned
behavior .

The progression from reflexive to voluntary independent feeding occurs along the development
continuim that involves complex interplay between everything motor, sensory, oral motor, cognitive and
communication, social emotional development and mealtime environment.

Those stages :

• Exclusive Breast or Formula Feeding

• First Foods

• Increasing Variety

• Independent Feeder

Were identified as key stages in feeding development and feeding problems may occur in any of these
stages or even in the transitional phases between them

Exclusive of breast or Formula Feeling

New-born

st
1 few months
First Food

Physical - motor development Sensory development Oral - motor development

• Postural control and
internal stability increase
enabling baby to:
• Sit with support in
an upright position.
• Rotate trunk and
head voluntarily.
• Bring hands and
toys to mouth for
exploration.
• Use whole hand to
grasp objects
(palmar grasp) such
as toys.
• First foods provide
new sensory
experiences.
• Body movements
such as head turning,
facial expressions are
used to respond to
sensory stimuli. 
Responses may be
open to
interpretation.
• Tongue thrust may still be
present but has diminished.
• Range of tongue movements
increases to include up and
down movements.
• Suck and swallow are
differentiated –food can be
taken into the mouth, held
and then swallowed
voluntarily.
• Gag reflex moves to back
third of the tongue.

• Able to roll over.

• Feeding in a 'very' reclined

position is no longer safe,
due to the risk of aspiration.

Signs of Readiness for 1st food

• Good head control.

• Mouths hands and toys independently.

• Able to sit in an upright position with support either on the lap or in a suitable high chair.

• Tongue thrust has diminished.

• Opens mouth when food is offered.

 • Enjoys watching others eat.

• Signs of developmental readiness are a better indicator than age.

Increasing Variety : Very important table

Physical - motor development Sensory development Oral - motor development

• Control and stability of the head and • Understanding Oral-motor skills develop supporting progression of food
trunk continues enabling baby to: of sensory textures. 
concepts such
• Become more mobile. • Tongue lateralisation develops
as warm- cold,
• Sit unsupported. Suitable rough- • Able to move food from side to side in the
seating for feeding provides smooth mouth. 
support of hips, knees and develop.
• Differentiation of tongue and jaw movements
feet at 90 degrees
• Multiple develops to enable:
• Reach purposefully to grasp Experiences
with the same • Diagonal rotary chewing.
and bring finger foods to the
mouth. taste and • Chewing pattern of jaw movements.
texture
• Transfer food from hand to increase • Jaw stability develops to enable:
hand. acceptance of • Improved spoon feeding control.
• Use pincer grip to self- new foods.
feeding of smaller pieces of • Drinking from an open cup but relies on
food. parent for help with holding and tipping.

• Use hands and utensils to • Lips - needed for control of food and to maintain the
explore food and develop bolus in the mouth.
skills in self-feeding.
 Independent Feeder
Physical - motor development Sensory development Oral - motor development

• Mobility increases as children develop the • An increasing variety of tastes • Movements of lips, teeth,
ability to: and textures is managed and tongue and jaw are
enjoyed. coordinated to achieve more
• Walk independently.
efficient feeding.
• Smell or appearance of food
• Complete all transitions including
may be associated with • Size of bite is graded.
getting on and off a chair
perceived taste.
independently. • Food is transferred to
• Typically displays some the teeth (or gums)
• Arm, wrist, hand and finger movements
apprehension in trying new for chewing.
disassociate enabling refining of:
foods.
• Rotary chewing
• Hand-eye coordination
But movements are used
supporting self-feeding.
more frequently.
• Gradually increases willingness
• Correct and efficient use of
to try new foods – uses sensory • Lips keep mouth
feeding utensils.
stimuli to assist with food closed while chewing.
• Skills in serving and preparing choices.
food e.g. spreading bread,
pouring a drink.

At 4 to 7 month introduce spoon

At 7 month solid food

Communication and cognitive development:

1) Exclusive Breast or Formula Feeding:
a. Relies on parents to interpret needs.
b. Sensory and motor skills → exploration supporting cognitive development.
c. Feeding of breast milk or formula→ satisfies hunger
d. External cues and routines → feeding is about to occur.
e. Gestures purposefully to indicate hunger + Gives cues to indicate satiety.
2) First Food:
a. Repeated experiences → Understanding of associations with the process of feeding.
b. Communicates using vocalisations, facial expressions and body movements
Communications may be open to interpretation.
c. Understanding of object permanence, consequences and causality, begins to develop.
d. Uses carers’ emotional responses to help interpret what the experience means.
3) Increasing Variety:
 a. Cognitive development influences mealtime behaviours: Understanding,
Communication, Desire for Independence and autonomy, Physical experiences, etc.
4) Independent Feeder:
a. Mealtime interactions opportunities for developing language + cognitive skills.
b. Develops the ability to discriminate between food.
c. Generalising skills + responding to different expectations.

Social and Environmental Development:

1) Feeding across all stages: relationship mother (or carers)/ baby → provides opportunities for:
a. Interaction
b. Socialising
c. Forming attachments
d. Regulating emotions
e. Achieving satisfaction
f. Developing trust.
g. Enjoyable feeding experiences → ↗↗ social interactions + emotional development.

Mealtimes:
1) Sharing and social interaction + the provision of foods to meet nutritional requirements
2) Strongly influenced by cultural norms and parent’s individual beliefs.
3) Social and Emotional development+ Physical, Sensory and Oral motor development + Cognitive
and Communication development → shaped by the mealtime environment.
4) Opportunity to: practice motor skills, develop communication and cognitive skills and support
social and emotional development.
5) Mutual trust Child/ Carers.

Adult swallowing

Children Swallowing Disorders:

Causes (according to the ASHA):

• Developmental disability:

• Neurological disorders

Ex: cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain
injury, muscle weakness in face and neck)

• Prematurity, low birth weight

• Complex medical conditions

Ex: heart disease, pulmonary disease, gastroesophageal reflux disease (GERD), delayed gastric emptying

• Structural abnormalities
Ex: cleft lip/palate, laryngomalacia, tracheoesophageal fistula, esophageal atresia, head and neck
abnormalities and choanal atresia

• Genetic syndromes

Ex: Pierre Robin, Prader-Willi, Treacher-Collins

• Medication side effects

• Sensory issues

• Social, emotional and environmental issues

Bottle and Breast Feeding:

Physiology:

Suck  Swallow  Breath

In case of prematurity as of 32 weeks they show some emergent skills in sucking and swallowing but
those skills are not ready for a full feeding at 32 weeks rather for 34 or 37 of gestation for those skills to
be mostly somehow ready and well developed to perform oral feeding. Follow up is important in this
case same with assessed therapy to ensure good oral feeding.

It takes extra weeks for the infants’ neurological system to fully develop to support the coordination
needed for a full oral feeding experience. The difficulty with sucking and swallowing can persist even
after this stage, so therapy is highly important.

In case of Lip or Tongue Tie; infant immediately has trouble with sucking in the absence of any obvious
medical or developmental problem. The infant may be presented with restrictive frenulum of the lip or
tongue which will negatively affect breastfeeding and feeding with the bottle.

For breastfed infants the mother may experience unusual nipple soreness. If the frenulum is too tight
the infant can’t get a good latch of the nipple and he can’t adequately move the tongue; it may not be
obvious but the SLP must be looking for it and it may be corrected with a minor surgery.

In case of Cleft lip or palate; because the lips and the palate are essential in helping the infant regain a
good feed and proper suck and propulsion of milk out of the bottle. But most infants with this problem
can seek well enough intervention with adaptations of bottle for example. An SLP can help determine if
the infant will be able to breastfeed and what kind of nipple adaptation of feeding system will he be able
to be successful. Adaptations can be to the nipple of the bottle the leakage far before the surgery.

In case of neurological conditions like CP DOWN Syndrome etc.… It might affect the muscle tone where
feeding will become very challenging for the baby to get a good latch on the nipple to suck milk out of it
we might see fatigue in the baby.

In case of Cardiac Problems infant will often have a hard time feeding they might be fatigue or be
unable to finish the feeding, and each time they swallow the breath stop will or may cause a change in
the heart rate due to cardiac problem. Some babies may try to compensate it by frequent breaks during
the feeding which may be helpful.
Spoon and Cup Feeding
• The ability to suck soft, runny foods from a spoon → demands a sophisticated oral skills thus
introducing solid foods like cereals may be after 4 month and to be able to drink from a cup is
after 6 month of age

• At first the infant will be using the same in-out suckling motion of the tongue used previously →
by around six months of age they don’t have to move their tongue in and out of the mouth to
get the food to the back of the mouth for the swallow

• Now they are better at using their lips

If the child is having trouble with spouted cup → SLP can give adaptations and choose what kind of cup
is to be used.

When drinking from an open top cup child must be able to:

 sit up

 hold their head up

 close their jaw and lips on the edge of the cup

 use their tongue to pull the liquid into the mouth ( with better usage of the lips ).

Solid Food:
Difficulty to take solid food may be classified in different main categories:

1. motor problems: children who have trouble with coordinated movement of lips tongue and jaw
will likely have trouble with successful eating
2. physical problems: those with craniofacial problems like cleft palate and jaw abnormalities will
encounter feeding difficulty. Those problems may be in the intestinal tract that will later on
prevent digestion of food. Same with posture or tonic impairments.
3. sensory problems: some kids may have trouble processing the different sensations related to
food, temperature, texture, smell taste and color of food (they may relate it it to food they had
issues with it ). Kids with such problems may face food selectivity or food refusal and they will
have limited intake of food

Long term impact of Pediatric dysphagia

Poor weight gain

Aspiration pneumonia

Compromised pulmonary status

Enteral parental nutrition

Dehydration malnutrition
Food aversion

Speech problems later on because his swallowing skills help in speech production by strengthening of
oral facial muscles

Academic problems because his cognitive skills may be affected

Taste buds aren’t provided by right stimulation to build a wider range of reference

Sensory Food Aversions in Infants and Toddlers

May be in regards of taste, texture, temperature, and or smell.

They may appear via :

1. gagging and vomiting

2. cough and chocking when food is introduced
3. spitting of the food to avoid eating it
4. Grimacing whenever presented
5. Irritability when shown the food

The resulting impact or action of child may appear as :

a. Refusal of continuation of eating

b. Refusal of trying other food maybe because they have something in common

Organs of taste:
Definition of Taste: the flavours perceived by the tongue and the odours and smells perceived via the
nose

 Both smell and taste use chemoreceptors, which essentially means they are both sensing the
chemical environment. This chemoreception in regards to taste, occurs via the presence of
specialized taste receptors within the mouth that are referred to as taste cells and are bundled
together to form taste buds. It is the sense of smell that is used to distinguish the difference.
Chemoreceptors detect the presence of chemicals.
Mechano-receptor: Any receptor that provides an organism with information about mechanical
changes in its environment such as movement, tension, and pressure.

A. Chemoreceptors: Taste buds:

→ used to recognize the chemical substances: sugar, salt, bitter, acid
and umami.
B. Mechanoreceptors: Tongue stereognosis →used to recognize the
nature of the objects.
The filiform taste buds (the most numerous) : have No role in taste.
 But they allow the tongue to identify the food’s temperature,
consistency and texture.

The rest of what is called ‘’taste’’ is an odour perceived by the olfactory epithelium.

Odour perception:

 Ortho-nasal perception

 Retro-nasal perception → Temperature + Insalivation.

Hyper-reactivity:

Chemoreceptors/ Mechanoreceptors/ Both → can lead to Food Aversions.

Food Aversion
• Neurological damage, autism or artificial nutrition since birth → eating disorders rate rises to
80%.

• Symptoms observed:

Lack of appetite

Refusal of new food except the ones chosen that give no reactive response based on categories
of smell taste colour texture

Food selectivity can go from refusal of pieces to be very extreme close to anorexia and inability
to feed orally
 Slowness and behavioural problem during meals where they select the food they will eat and
those they won’t; time of meal will be very lengthy the normal child will show those behaviours
but a child with CP for example may close his mouth to avoid eating, turn head sideways, propel
food outside of mouth

Nausea, vomiting especially when they are forced to eat

Food aversions and Associated Disorders

Mostly sensory issues

• Gastroesophageal Reflux

- Nausea triggered → there will be relaxation of the lower sphincter of the oesophagus
even before vomiting

- Incidence ↗ in poly-handicapped children. Because, of posture, positioning, structural

abnormalities, coordination issues due to neurological abnormalities and neuromuscular
skills, tonicity problems, persistence of primary reflexes due to sensitivity, digestive
pathologies like delayed gastric emptying,etc.

• Speech and mastication disorders

- Lack of babbling or any form of oral expression because mobility of tongue in oral cavity is
triggering a nausea or negative sensation

- Hyper-sensitivity inhibited →leading to Greater motility of the tongue in the oral cavity without
risk of triggering the reflex.

- - Child more easily nourished → Improved relationship with the mother improves →
language development encouraged.
- Suction is linked with sounds as: /p/ -/m/-/f/- labial sounds
- Mastication is linked with sounds as : /p/-/t/-/d/-/n/

Always consider the Differential Diagnosis (ex: hypertrophic tonsils causing a gag reflex, tongue out of
the oral cavity which can cause lots of drooling...)

Assessment:
Relies on:
Parents Report:
Clinical Observation
Objective Test Measurements: like GSS, FEES,

Parents’ Interview:
1) Purpose
2) Who/ Which specialist referred the child:says a lot about parents and referral pathways
3) Birth History: Complications during pregnancy, Delivery (complications-term/preterm), Birth
weight.
4) Neonatal history
5) Previous hospitalization and their reason
6) Previous surgeries, date, reason, impact
7) Medications
8) Allergies/Intolerances
9) Feeding history

Feeding History
• - Breastfeeding

• - Bottle feeding

• - Spoon from caregiver

• - Fingers (self-feeding)

• - Cup: no spill cup + open cup

• - Straw gives info about tonicity sensibility

• - Ustensils (self-feeding) to check autonomy

• - Alternate feeding methods (tube feeding, parenteral feeding, etc...) was it continuous or not,
when did it stop, and how, experience

• - Historically, child consumes adequate amount and variety of:

→ Liquids

→ Fruits

→ Vegetables

→ Grains

→ Dairy

→ Meats
 • - Transition between ≠ textures.

• - Age of introducing ≠ textures.

• History of:

- Dehydration

- Poor Weight Gain

- Coughing/choking during or after or even before eating/drinking

- Gagging/vomiting during or after or before eating/drinking

- GERD/ regurgitation

- Wet vocal quality during or after eating/drinking analysed via developmental vocal
skills and based on baby’s cries

- Problematic behaviours during or after eating/drinking

Medical History:
 Congenital malformations, chromosomal abnormalities.

 Diseases/ disorders of nervous system.

 Diseases/ disorders of circulatory system.

 Diseases/ disorders of respiratory system.

 Diseases/ disorders of digestive system

 Diseases/ disorders of musculoskeletal system

 Neoplasms: location + treatment

 Mental, behavioural, neurodevelopmental disorders.

 Injuries, poisoning and other consequences of external causes.

 Hearing / visual impairment

Pulmonary State:
The child can cough not only as sign of aspiration, he can cough due to esophageal disease,
inappropriate texture, all influenced by the child’s posture

Digestive State:
If there is any transition of the bolus impairment, constipation, diarrhea. Poly handicapped kids may
suffer from stomach ache because texture is not well adapted
Tonus and Posture Disorders:
Look for dystonia, hypo-tonia, spasticity etc.

In hypertonic attitudes we may see an extension of the head and neck which will make the laryngeal
ascension even harder

Head flexion is very important to look for

In normal kids with head extension he can swallow if he forces himself, but a CP kid will have a very high
risk of aspiration in this case

General Sensibility:
Look both intraoral and oral and:

 Body hygiene care

 Accepts to have his hand dirty

 Accepts to walk barefoot on sand, grass...

Dynamic investment of orality

 Oral exploration (hands/feet in mouth)?

 Mouthing of objects?

 Sucking habits (teat, thumb)?

Duration of the Meal:

- Frequency of meals/ snacks

- Average length of meal ( to check if fast rate or slow rate)

- Adaptations of the caregiver

- Reactions of the patient

- Analyse the parameters that we can work on:

 Texture

 Temperature of food and fluids

 Oro-facial motricity

 Positioning of the caregiver

 Pace of the spoon coming

 Autonomy

 Duration between meals: does he have enough time to get hungry ?

  Pain

 Pharyngo-laryngeal Congestion

 Sensory Disorders

Oral Sensory Disorders:

Look for food preferences, texture, taste and behavior during meals and feedings

Oral Phase Disorders:

- Sensibility Impairment: Hypo sensibility (lack or poor transmission of sensory information from
mouth or pharynx etc. which will lead to drooling or salivary loss because the child is keeping
little to no saliva in the mouth; choking or aspiration due to absence of swallowing, absence of
cough reflex, abstention of the motor reaction when food is introduced due to hypo sensibility)
and Hyper sensibility (there will be aggravation or over triggering of the sensitivity thus
triggering a massive motor response when oral or pre-oral cavity are stimulated, they may be a
gag reflex starting from irritability to vomiting)
- Motor Assessment and Disorders: to see tone of the movement and the non-nutritive sucking;
we may have a motor disorder like persistence of primary reflexes, resistance of sucking reflexes
and tongue lapping when there should be precise and developed skills(the persistence of
sucking and tongue lapping reflexes will forbid maintaining the food under the molars which will
also be a problem because the tongue will be guiding the food under the molars and therefor
there will be problems in mastication and it will influence. Lingual protrusion will be stimulated
at the touch of the tongue to the utensil liquid etc. thus there will be tongue propulsion to
outside and the food will be propelled when introduced rather than guided towards the molar
and the tongue is not able to access the oral cavity due to residues.
If there is persistence of the bite reflex the closure of the mouth when swallowing and eating
will not be present
- Mastication Assessment: it is one of the transitional skills that the child will be acquiring to
reach adult feeding and swallowing
We start of by: checking that the child has the necessary molars to grind the food, good oral
hygiene, and we must check to differentiate that the bite reflex is not mistaken as mastication.
( rotary movement is the difference not only open and closure of mouth)( bite reflex aids in
suction and breastfeeding)
Once those criteria’s are checked start the assessment as follow:
Ensure that the patient has a real mastication via:
Ensuring that the head is in flexion position so the bolus can fall down in case it is not
well controlled rather than swallowed and aspirated
Give the child a biscuit that melts very quickly with saliva and cracks well
The biscuit will be put on the inferior molar and observe the movement of the tip of the tongue,
the child will be able to control it with the help of saliva. If the tip of the tongue remains in the
middle position with no movement from front to back then there is poor prognosis
But if the tip of the tongue heads toward the side of the stimulus then there is good promising
prognosis
We must make sure to assess both sides because sometimes 1 side works better than the other.
 The piece of biscuit then will be introduced on the tongue in the anterior and the
median part. It is important to observe if the tongue is able to send the piece under the molar or
if the piece will be pushed toward the palate and a sucking movement takes place
Observe the movement of the tongue and how is it controlled; whether it is a sucking
movement by sticking it up to the palate or by pulling it via the tongue to the molars to be
grinded later on.
Finally give the rest of the biscuit and observe how the child puts it in the mouth where
we can see labial prevention etc.
After this id done with the biscuit:
Repeat the same assessment with a madeleine which is a traditional cake but here in opposite
to the biscuit there will be no auditory feedback of the cracking (evaluation may be good in
biscuit but not hear due to absence of auditory feedback), (helps in treatment via providing food
that has an auditory feedback when introduced thus helping in mastication introduction)
Observe how mastication process takes place:
When it happens with the anterior molars and the pre molars rather than the posterior molars
this can be linked as a sign of hypersensitivity
Must observe the frequency number force of grinding and jaw movements and their
efficiency
Must observe if the child is able to clean the residues; does he perform secondary
swallowing in-order to check the motor ability of the tongue, the intra-oral sensitivity ( after the
cake and the biscuit)
It is important and good to observe the child during mealtime to check the fatigue-
ability, the adaptations ad compensation by and to the child
Assessment can be done in-front or in presence of the child’s family to check the
adaptations by the caregiver the caregiver-child relationship.
During the assessment also look for:
Hand eye coordination
Labial pre-hention
Antero-posterior movement of the tongue that will propel the food outside the mouth if
there is no good rotary movement and guiding of the bolus towards the molars
The same difficulties may be with liquids and with the absence of the piston like
movements of the tongue where thus part of the liquid flows passively into the larynx causing a
laryngeal cough
Check for postural impairment and saliva swallowing which may lead to laryngeal
congestion of saliva
Check for pharyngeal phase impairment by the presence of aspiration
Check the child’s compensatory strategies
Watch the mother feeding the child to give notes and rectify any action done wrong and
to see beneficial attitudes she may be using as adaptations
Check for secretion managements if it is adequate or not during the assessment
Phonation evaluation by asking the child to produce sounds or speak if he is able to
Check for signs of stress during the assessment

After the assessment:

 We can assess the oxygen saturation via an oximetry

We can assess respiratory rate

Perform a pain assessment

Clinical evaluation of suction disorders

Start by :

Searching for sucking reflex via : placing pinky finger of the examiner on the baby’s palate –
checking the rhythm, power and pace – quality of suction -Taste: of a washed hand and gloves vs
soaked finger in breast/baby’s milk or sugar solution – Check the Placement of the tongue in the oral
cavity

Then observation of Suction during Feeding:

Check for:

Temperature of the milk

Duration: 10 mins for baby born – 4 to 5 mins for experienced infant

Number of pauses + how many times the baby fell asleep during the first 4 minutes which can
be a symptoms of underlying fatigue and it’s important to check the tonicity of the tongue

Milk leaking from labial commissures.

Content of the bottle entirely taken

During a Pathological Suction: At least 3 criterias will be impaired from the following:

Duration is reliable index.

Pauses, sleeping, leaking shouldn’t be present during the first 4 mins.

Content of bottle should be taken.

Areas of intervention:
Feeding Orality Development: is a process that must involve the parents and their skills

It should be a positive experience that derives pleasure comfort and security to the child

It must include the child in an active role to derive autonomy in later stages if possible:

This active role is derived via motivation and proposition of the actions not forcing – and giving him
chances to do it himself – and give him opportunities to touch and grasp – experiment – put in the
mouth – also it is important to respect the child’s refusals and try again after some time in a manner
that uses proposition instead of imposition to get the child to be a compliant part in this experience.
Gnoso-praxis Difficulties (cognitive-motor)
We have to insure good positioning or installation of the child:

During the stimulation we must ensure postural stability making sure the child is secure and well
contained in-order to prevent the posture being a hindrance to the intervention

During the feeding the child will be in a:

Half-lying position

Supported at the base of the skull with a pelvic twist

Supported on all the back and under the feet to help in good installation

Adult seating comfortably

For older children: High Chair or seat with armrests.

Head must be in flexion

In-order to promote oral exploration:

The following ca be done in different activities:

• Dental Rattles of different shapes, textures, volumes.

• Baby toothbrush.

• Encourage the coordination hand-mouth (provide different situations, or position...) to

reach a good autonomy with guidance of OT.

Regarding the Suction Stimulation:

Start by an Olfactory Stimulation: like make the child smell the milk on pacifier bottle of mom’s
finger

Oral stimulation: start as follow:

 Global approach of the body: massage of feet hands head before mouth

 Propose the stimulation and check for approval or refusal: in-case of:

o No reaction: keep up with stimulation

o Refusal: Stop and wait

o Acceptance: Check suction inside the mouth and doing/Stimulating antero-

posterior movements of the finger. (Apply pressure with the finger or the
pacifier from earlobe toward the mouth slow enough to give the child time to
search for the finger or stimulus gradually but firmly. Once he accepts this
approach go to the oral cavity and check the suction.

o Respect the state of alertness of child

  Non Nutritive sucking: put a sugary solution or milk on pacifier to stimulate this type of
sucking vary the tastes
 Gestures to help the suction:
o Posture adaptation.
o Bring together the labial commissures in case of leakages and apply a firm
pressure under the chin to be sure there will be good oral containment or labial
contouring on the pacifier
o Baby bottle adaptation. Usually premature and cleft palate patients have issues
in suction but need adaptation in their baby bottle. Enlarging the nipple
manually by the parents isn’t recommended because size of enlargement and
rate of flow are not compatible

Regarding the transmission to the spoon:

 Ideally this transmission is done from 4 to 7 months of age but refer to those about
social environment
 During which we will be working on diversification of textures and taste .
 Adaptations concerning this transmission include:

- Choices of the spoon (usually rigid to allow support on the tongue; but in case of bite
reflex try to use a softer one

- Placement in the mouth: is to be done as follow by: exerting a firm support on the
tongue by spoon and then once the mouth is closed the spoon will be removed flat to
solicit the lips to do a good labial prehention.

- In case of problems in closing the mouth: 2 methods of control can be taken:

1. Frontal control: sit facing the child and put tongue under lips and major is
controlling the maxillary to promote mouth closure

2. Lateral control: sit in a lateral (side) position to the child and index finger is
under the lower lip and major under the maxillary to control it

- In case of protrusion of the tongue: apply firm pressure on the second pier of the
tongue but watch for gag reflex and apply some zigzag moves with the spoon forward to
guide the tongue to go backward thus inhibiting the propulsion of food outside the
mouth

- Work on Tone and motricity of the cheeks and lips: always work on awareness of
orofacial zones by drawing activities funny faces inflate the cheeks etc.

Regarding the introduction of solid foods and chewing:

 Work on introducing easily chewable food under the molars like cooked vegetables
biscuits or crackers that melt easily with saliva
 We can use food cut in fries shape because it is easier to grab and manipulate
 Perform exercises for mastication via different tools such as:
o Therapeutic chewing tools like chewy tubes
 o Introduce tactile feedbacks and auditory feedbacks: start by crackers then
harder silent food
o Make variations when working on mastication by targeting 3 criterias:
 Size because it relates to all gnosis activities
 Texture stimulate because it helps in praxis and oral motor function
 Consistency which works on praxis and oral sensory input
o Encourage lateral movements of the tongue (not only rotational ones; because
lateral helps in later guidance of food to under the molars and to medial part of
tongue.
o Strengthening oral motor functions for example by aspiration of the cheeks
labial praxis, velum, tongue etc.

Regarding the Drooling

 Depending on the cause we will be doing the treatment

 Adaptation of posture is required
 Reinforce the orofacial tonicity via massages blowing and praxia movements that target
specific muscles
 Obtain the closing of the mouth
 Stimulate the swallowing → via applying a pressure on the floor of mouth from front to
back
 Sensibility of the oral contour → via regularly wiping the mouth of the child by tapping
 Cryotherapy: apply the ice on the back of the tongue from back to front by pressing
firmly ice can be aromatized. Try playing with ice at first if he refuses this approach
 Medical and surgical Treatments.

Regarding preventing aspiration:

Adapt the posture, texture, equipment and utensils and respect feeding pace

Regarding Oro-facial Hypo-tonia

Mentioned in how to promote sensory exploration when working on orofacial tonicity

Regarding Artificial nutrition:

 Ask about the quantity, time and flow of the artificial nutrition
 Help the child build sensor-motor experiences via the stimulations we offer.
 Offer olfactory stimulation at the beginning of nutrition. But be carful for installation of
patient and have olfactory stimulation at beginning of the nutrition to help
 For older child:
o Involve him in the different stages of feeding (food shopping, preparation of
meals, setting the table, etc.)
o He is seated at the table with the whole family during meals even if he is not
eating he can experience explore the food.
o Offer him some food to scramble, to explore.
Sensory Difficulties
 Progression of the simulative zone must be done as follow:

Global approach of the body  simulate the Head - face- outside the oral
cavity  Inside the oral cavity

 Respect the child’s tolerance limit

 Take into consideration:
o Vestibular System: when positioning the child give him sometime before
proposing further stimulation
o Hearing and vision: involve the child in all the activities like preparing the meals
and shopping of food
o Touch-Tactile:
 In case of hyper sensibility: use strong pressure
 In case of hyposensitivity: use tickles, caresses
o Smell: by asking parents to let child smell different foods and feel all the aromas
o Taste:
 Hypersensitive children → tend to prefer warm foods.
 Hyposensitive children → use hot or cold food to stimulate taste(need
overstimulation)
o Need of OT or psychomotor therapy is needed especially when working on the
global approach and sometimes food selectivity can be overall where he cant
feel comfortable to get in contact with different textures

Desensitization massages (Senez)

After completing the global approach go toward the intraoral approach and start stimulating in the
following steps:

Upper gum right then left  Lower gum right then left Apical and median region of the
palate Right then the left side of the palate Quick energetic strike on the tip of the tongue

 Gradually increase the range of motion

 Massages must not trigger a nausea be careful and simple

 Duration: 8x/day for 7 months

 Some kids have way too severe food aversions so Preliminary stimulations are required

Preliminary stimulations for children with more severe

food-aversions:
Front-top of the skull Both temples One eye-top of the skull The other eye-top of the skullBoth
cheeksThe mouth-top of the skull

In a fast and firm pressure

Oro-facial hypo-sensibility:
Work on:

 Awareness of the oro-facial zone:

o Vibration on the bony parts + intra-orally using electrical toothbrush.

o Brush the teeth with electric toothbrush.

o Wet the face and blow on it.

 Nutrition and hydration:

o Maximize sensations at the mouth level with strong tastes (spices - paprika – lemon
-salt- sour foods – nestle – mustard) + crunchy foods (work on tactile and auditory
feedback).

o Hot or very cold foods using a metal spoon.

o Cold and/ or sparkling drinks because they give good stimulation.

 Drooling.

Behavioural Difficulties:
 Signs that might indicate behavioural difficulties:

• Cibophobia or fear of food

• Disinterest for food

• Food selectivity

• Refusal to eat

• Avoidant behaviours during meals

• Nervousness, anxiety during meals

• Fear to swallow, to choke

• Refusal of introducing new foods

• Food forcing

 Treatment Ideas
o Play pretend.
o Worksops allowing the child to scramble and experiment the food.
o Cooking workshops
o Taste progressively different foods with different textures and
consistency: transition by introducing a food of the same colour for ex.

 Pedopsychiatrist and/or Psychologist can be needed in such cases.

Family’s Support and Education
• Invite parents to participate as much as possible in what you propose to their child (to feel they
are part of the therapy)

• Regularly propose to the parents small activities to re-create at home (modelling and activity
type are not recommended to be a replay of the therapy session rather let it be functional and
having this mother child relation)

• Take the time to explain your approach and goals (listen and if it is feasible or not by them and
adapt it to their need)

• Encourage the parents to involve their child in preparing meals and sense of responsibility and
autonomy

• Food shopping

• Allow the child to touch and smell the different foods of the meal

• Announce the moment of the meal so that the child can anticipate

• Encourage the parents to apply learning by imitation

• Raise parents awareness concerning their child’s tolerance limits by giving a brochure –
commenting on reactions of child – verbalise actions of child-small PowerPoint on the tablet.

• Give Tips recommendations and explanations

• What to avoid and what to do

• Check approach with child where she may find positive adaptations she may benefit from

• Guidance and Adaptations

Multidisciplinary team:

Patient and family

They are center of our work

Doctor
1st source to contact by parents; his role is:

- Identifies patients with swallowing disorders.

- Informs the patient about the different available possibilities to treat him (tube feeding etc.).
 - Treats swallowing disorders and their consequences according to his specialty (pulmonologist:
treats lung disease. Gastro on gastro esophageal tract- cardiologist: works on cardiac system and so on)

- Takes the decision concerning the feeding method.

- Unifies and coordinates the care provided for the patient.

Nurse
- Sees the patient several times a day and accompanies him in his recovery.

- Provides care and explanations concerning the cannula for example.

- Verifies the proper application of feeding recommendations like chin down posture she has to
make sure it is applied correctly

- Helps the patient to feed if needed. Sometimes the patient can only eat when the nurse is
present

- Contributes to a large extent to the moral support of the patient and his family.

Dentist
Especially in textures needing mastication

- Evaluates and treats gingival and dental dysfunction.

- May specialize in prosthetics to improve swallowing.

Dietician
- Monitors the patient's nutritional state and ensures that feeding by the mouth or through feeding tube
provides enough calories and hydration.

- Assesses the need for food fortification/supplements. How to make sure he can switch food
with same calorie intake to get a liking to this food

- Educates patients and their carers on appropriate food choices and fluid intake and offers
recipe examples. SLP chooses texture and she gives the recipes to ensure hydration and good
calorie intake

- Ensures that the patient keeps or regains his appetite.

Physiotherapist
- Maximizes head function and neck position to improve optimal positioning when swallowing in
order to minimize the risk of aspiration.

- Provides relaxation massages and scars massages.

- Allows the patient to move better.

 - Teaches the patient to breathe effectively.

Occupational/ Psychomotor Therapist

OT: use utensils correctly and appropriately; her goal is to make the child independent, positioning

- Advises on appropriate aids and adaptations (such as seating, cutlery and crockery)

for eating and drinking, to promote a positive environment and independence for clients.

- Assists on positioning for eating and drinking.

- Evaluates and treats sensory and motor impairments

Psychologist
- Helps the patient to accept his illness and move forward, help clinically diagnose those illness

- Accompanies the patient to discover his ‘’new body’’ to which he hasn’t got used to it yet.

- Prevents and avoid a possible depression of the patient or of any member of his family.

Social Worker
- Assists and counsels patients and families in adjustment to disability.

- Helps the patient and his family deal with third-party payment issues.

- Can help financially by referring to NGOs or organisations etc.