Feeding Part Two (Recovered) (Recovered)

Feeding Assessment in Infants Case Study
Kay Thurston, MS,CCC/SLP,CLC
Objectives
Discuss components of an optimal observation of feeding skills Discuss factors that complicate feeding assessment Identify feeding skill sensitive questions to ask the family Identify when it is appropriate to refer an infant for more in depth evaluation Discuss swallow evaluations
Prerequisite Skills for oral feeding
Intact anatomy and physiology, intact sensory and tactile systems, adequate muscle tone and postural support of the oral, pharyngeal and respiratory systems, stable autonomic nervous system, adequate state regulation and enough energy to support the entire process. Alexander 1993
Why is feeding so often difficult?

Developmental skill Dependent on the opportunity to participate in developmentally appropriate activities Interdependent on motor skill acquisition Dependent on medical stability Caregiver regulated moving to self regulated in the first year of life Requires active reciprocal communication between partners
Factors that complicate feeding assessment
Timing
Infant state Infant schedule Infant willingness to participate Primary caregiver schedule and availability
Emotion
Feeding emotionally charged Family often feels isolated and alone, judged, and sense of failure
Factors that complicate feeding assessment
Complicating this sense of judgment, is your need to ask a great deal of questions which has potential to compound emotions
Medical history Feeding history Typical days schedule Foods offered Amount eaten Where they eat Preferred foods Rejected foods
Feeding Assessment Tools

Feeding individualized and complex Oral motor skill development highly variable Need to consider within medical, developmental and cultural context Difficult for standardized tests to accommodate all of these variables Many are checklists or are subscales of a test Many require training and certification

Formal Feeding Assessments

Published Evaluations - Infant Specific NOMAS Neonatal Oral Motor Assessment Scale Palmer, Crawley & Blanco. 1993 PIBBS - Preterm Infant Breast-feeding Behavior Scale Nyqvist, Rubertsson, Ewald & Sjoden. 1996 EFS - Early Feeding Skills Assessment for Preterm Infants Thorye, Shaker & Pridham. 2002 Feeding Flow Sheet Vandenberg. 1990 Infant Feeding Evaluation Swigert. 1998 Feeding Readiness Scale Ludwig & Waitzman. 2007
Formal Feeding Assessments

Infant/Child Evaluations Clinical Feeding Evaluation Wolf & Glass. 1992 Developmental Pre-Feeding Checklist Morris & Klein. 1987 NCAST Parent Child Interaction Feeding Scales - 2009 SOMA Schedule for Oral Motor Assessment Reilly, Skuse & Wolke. 2000 Oral Motor Feeding Rating Scale Jelm. 1990 Brief Assessment of Motor Function: Oral Motor Scales Sonies, Cintas, Parks, Miller & Gerber. 2007
Memorial Outpatient Feeding Clinic Approach
Multidisciplinary team
Developmental Pediatrician Dietician Occupational Therapist Speech Language Pathologist
Comprehensive Evaluation Trained with Dr. Kay Toomey
Sequential Oral Sensory Approach SOS
Five Basic Questions

Is the feeding safe? Is the feeding efficient? Is the feeding developmentally appropriate? Is the feeding pleasurable? Does this child need further evaluation?
Prior to Assessment Optimal Scenario
Gather and review medical information

Discharge summary from NICU Medical records Growth charts Therapy treatment notes Pediatrician office visit notes
Prior to Assessment - Reality

Often minimal information available Use what know to consider likely scenarios
Diagnosis Report from other treating therapists Report of family concerns Report of gross/fine motor skill development
Feeding Assessment Components

Family Concerns Medical History

Pregnancy/birth history NICU Nutritional status/regime at discharge from hospital Surgery/readmissions/illnesses since discharge Medications/allergies
Developmental History
Developmental milestones Developmental interventions/support since discharge from hospital Current developmental therapies
Nutritional History
Nutritional plan at discharge from hospital Formula changes Current nutritional plan, formula/preparation Growth chart Typical day schedule of foods offered, amount accepted Review of foods accepted/rejected by food groups
Oral Mechanical Observation Feeding Observation

Optimal if done prior to feeding Assess oral structures, symmetry
Observation infant feeding during evaluation Typical foods offered by caregiver Novel foods by caregiver, therapist Oral motor skill assessment
Sensory Observation
Ability tolerate sensory input food on hands, face, active engagement Caregiver tolerance for sensory input
Motor observation
Postural stability over all Postural stability as related to feeding Tone/motor patterns
Speech Language Observation

Social interaction Communication with caregiver, parent and novel adults
Summary Recommendations
Feeding Assessment Infant Liquid Feeder
Bottle, bottle, nipple!

You must understand how bottles/nipples differ from one another To accurately assess infant liquid feedings Make appropriate recommendations
Bottles and Nipples

Number of different bottles and nipples overwhelming for parents! New bottles and nipples all the time. Advertisements in parenting magazines. Vast array at grocery store, Target and Babies R Us. Stay up to date what is available in your area
Ease of obtaining bottle/nipples
Guidelines for Nipple Selection
Nipple efficiently, without burning calories or exhausting infant. Nipple safely, without compromising physiologic stability. Developmentally supportive Enhance Parent success
How do nipples differ?
Material Shape Flow rate Size
Material
Rubber Nipples
tan color variable texture tend to have a taste generally softer faster collapse easier
Silicone Nipples
clear firmer generally slower less likely to collapse
Nipple Shapes
Orthodontic Nipple
larger surface easily collapses unpredictable flow promotes flat tongue
Straight Nipples
tongue cups nipple Lateral margins tongue lift/curl flow predictable less likely to collapse
Flow Rate
Flow rate should match infant ability to efficiently feed without compromising physiological stability Preemie nipples - traditionally they were made to flow fast red nipple
Newer premature nipples actually designed to give smaller bolus per suck may have single hole Dr. Browns premature nipple
Cross Cut nipples unpredictable and usually fast

Require infant to have strong enough suck to pull open cross cut Thickened feedings Never manually create a cross cut by cutting nipple
Destroys integrity of nipple, cannot standardize cut
Flow rates
Variable flow nipples typically for thickened feedings Differ by how you can adjust flow rate turning nipple to different position clicking nipple to different position Shortest line or slowest flow usually faster than standard nipple Never manually create variable flow compromises integrity of nipple, cannot standardize cut
How fast does it flow?
Size
Match to the infants mouth. Fill the oral space without compromising airway Standard vs. wide base
increased sensory input assist with organization
Standard Nursery Nipples

Shape easy to match Disposable Standard shape rubber One time use only General flow rates
Clear rim - standard blue controlled flow green slowest single hole
Readily Available Bottles
Dr. Browns bottle

interior chamber cleaning concerns helpful for infant swallow air/GER Premie nipple,Ycut Graduating flow rates
Advent
silicone broad base may be helpful for infant breastfeeds best Variable flow, increasing flow rates
Readily available slow and variable rate nipples

Slow Flow Silicone Firm Deliver smaller bolus size per suck Consider if infant eager but very sloppy/spitty May tire with effort
Variable Rate Usually silicone Increase flow by turning nipple in mouth Consider if feeds thickened Slowest rate faster than standard nipple
Cleft Palate Nipples/ Bottle Systems
Mead Johnson
Fits any standard nipple Pliable, easy to squeeze Nipple with bottle narrow often too long, x-cut, unpredictable flow Works well with NUK upside down Good starting bottle Relatively inexpensive Order by phone, internet and ship to home
Pigeon Bottle

Childrens Medical Ventures Large rubber nipple One way valve Fast flow may be too much for premature or fragile infants Expensive Instructions in Japanese Bottle is hard to squeeze
Haberman Bottle Systems

Medela Available in regular and mini Silicone Variable flow rate One way valve Squeezable reservoir tip Expensive Look different
Bionix Controlled Flow Baby Feeder

Bionix Medical Multiple flow rates

0 no flow 5
Premie or standard nipple Adjustable during feeding Expensive 12/$299.99 Multiple parts Cleaning concerns Difficult to assemble
Theres not a perfect bottle! The Baby controls sucking and breathing. The feeder can affect change in the flow rate or bolus size. A premature infants feeding success is often a reflection of their brain maturation and not the nipple. Medically fragile infants benefit from feeding assessment and close monitoring to determine appropriate nipple system. Infants with structural abnormalities also benefit from close monitoring to determine best nipple system. Growth may change relative shape of cleft and impact efficiency.

Infant: Pre-solids feeding assessment
Keep in mind 5 questions throughout observation

Safety, efficiency, pleasure, appropriateness, need for further evaluation
First determine family/caregivers concern Why and by whom were they referred for a feeding evaluation?
Infant Assessment Family Interview

Ask open ended questions Reassure family that you are not judging them Remember feeding is highly emotional, be prepared for tears, anger, grief The family may still be recovering from lengthy stay in NICU The family may be emotionally, physically and/or financially exhausted
History
Pregnancy Tell me about your pregnancy
Complications Medications
Delivery Tell me about your babys birth.

Term or preterm Birth weight Did your baby need to stay in the hospital?
Infant Assessment family interview
History
NICU Tell me about your babies stay in the NICU.
How long did your baby stay in the NICU? Did your baby need help breathing in the NICU? How long was your baby on the breathing machine? Tell me about feeding in the NICU. How was your baby feeding when you were discharged from the hospital? When did your baby feed best?
History
Health since discharge from the hospital Tell me about your babies health since you came home from the NICU.
Surgeries Re-admissions Illnesses Testing
Does your baby take any medications? Does your baby have any allergies? Is your Dr. happy with your babys weight gain? Tell me about your babys daily schedule.
Does he nap during the day? Sleep all night?
Developmental History
Nutritional History
Formula Preparation Schedule/volume Bottle/nipple type
Tell me about your infants strengths Tell me about your infants challenges Does your infant participate in any developmental therapies? Tell me about your babys feeding when he came home from the NICU.
Nutritional History Tell me about your babys feeding now. How has your babys feeding changed since you were discharged? Formula changes, schedule changes, volume changes What formula is your baby on now? Issues with vomiting, diarrhea, constipation or skin rashes? How do you prepare your babys formula? How much milk does your baby take in his bottle? How long does it take for your baby to finish a bottle?

What kind of bottle and nipple is your baby using now? Have you tried other bottles or nipples? Look at the nipple! Shape, size, material, condition If they are using an unusual bottle/nipple find out how/why they started to use it. Describe a typical days schedule Does your baby enjoy his bottle? When does he feed best/worst? Tell me about your babys weight gain. Is your Pediatrician concerned about your babys weight gain? Interventions trialed increasing calories
Infant Feeding Assessment Feeding Observation

Infant appearance during interview Motor development Tone
Over all Facial
Social interaction with family and novel adults

Communication style Tolerance of novelty
Infant Feeding Observation

Watch during feeding Tone/Motor skills
Developmentally appropriate?
Supports offered by caregiver?

Positional changes Postural supports Swaddling Chin/jaw supports
If supports not offered gently suggest them you may find out why family does not use them

Gentle suggestions Im noticing that Baby Jon is having a hard time keeping his body in an organized position for feeding I wonder if we swaddled him if he would have more energy available for nippling? You may discover important information

Social Interaction Infant cues and caregiver response Hunger cues present
Obvious or subtle
Engagement during feeding

Verbal Tactile Eye contact
Stress/distress cues during feeding

Obvious or subtle

Facial tone Facial symmetry Oral exam if not done before

Presence of clefts Ankyloglossia
Oral Movement patterns

Non nutritive Nutritive suck
Suck/swallow ratio
Immature Emerging mature

Respiratory patterns Color State/alertness Assess for changes during and after feeding Want to ask if this feeding is typical If not how is it different
Infant Feeding Assessment Is the feeding safe?

Has the child had a previous swallow? If so what were the recommendations? Have there been any changes to plan? Changes to medical status?
Infant Feeding Assessment Is the Feeding Safe?

Is there any evidence or history of dysphagia? If the infant is on thickened feedings ask how his feedings are prepared
Tell me how you make your Babys milk.
Look at the formula/milk before watching a feeding. Does it appear to be the correct thickness? What nipple is the infant using has it been altered in any way? Look at the nipple Check the rim for identifying information Observe infant closely during feeding for both overt and subtle signs of swallowing issues
Infant Feeding Assessment Warning Signs

Overt or obvious Choking Gagging Coughing Refusing to feed Wet vocal quality after feeding Physiological instability
Infant Feeding Assessment Warning signs

Subtle cues during feeding Watery eyes Eyebrow raising Hyper-alert look Nasal flaring Color changes Sudden state/tone changes
Infant Feeding Assessment Warning Signs

Other subtle cues/patterns Ongoing need for supplemental oxygen Increasing oxygen needs Frequent illnesses Poor weight gain Refusal to feed Taking minimal volumes Sleepy baby
Is the feeding safe?

If you are concerned about the safety of the feeding, why? Is the infant demonstrating subtle or overt signs of distress? Is this typical of all feedings? Do changes in flow rate, positioning improve coordination?
Infant Feeding Assessment Is it efficient?

Observe infant face and body Is feeding effortful? Suck/swallow ratio
Change from NNS
Anterior leakage Respiratory changes State changes
Is the feeding efficient?

How much tension is on the nipple? How long does a typical feeding take? Does the infant require stimulation or cueing to finish? Is the infant gaining weight?

If the infant is sloppy or gulpy Look at flow rate May need slower nipple Positional support consider swaddling, sidelying, or upright If the infant is working too hard for a minimal volume or feeding is lengthy Look at flow rate, nipple material Consider postural support Is there excessive jaw excursion? If the feeding is thickened may need variable or fast flow nipple
Is the feeding efficient special considerations

Cleft palate size and shape of cleft may change with anatomical growth Nipple baby used in hospital may not be appropriate now Goal is the same, most efficient transfer of fluid without compromising stability or exhausting infant
Appropriate weight gain
First examine the nipple they are currently using
Is the feeding efficient special considerations
Oral exam noting size/shape/extent of the cleft Observe infant feeding with their nipple If the infant is very sloppy the flow may be too fast If the infant is working too hard the flow may be too slow, the nipple may be too small
Infant Feeding Assessment Is it developmentally appropriate?

What is the infants chronological age? What is the infants adjusted age? What is the infants developmental age? Do the infants oral skills match adjusted or developmental skills? If not why?
Medical status Limited experience
Infant Feeding Assessment Is it pleasurable?
What is the infants state at the beginning of the feeding? Does the infants behavior change during the feeding? After how much volume? What is the infants state at the end of the feeding?
What is the infants state at the end of the feeding?

Satiated or exhausted
Does the infant appear engaged? Is the infant an active participant in the feeding?

Active Participant Demonstrate hunger cues
Rooting, mouthing, fussing

Open mouth with tongue down Lean into bottle Maintain flexed posture Hands to midline
Signs of pain or discomfort during feeding?

Head bobbing Repeated swallowing Gurgly sound Arching Pulling away from the bottle Disorganization Vomiting
What is the infants overall presentation? Fussy Irritable Stressed Hungry then satisfied Relaxed Drowsy Exhausted
What is the overall presentation of the infants caregiver?

Stressed Relaxed Engaged Overwhelmed Exhausted

If it is not pleasurable, why? Consider position or handling changes Consider nipple changes Consider postural changes Consider scheduling changes
Infant Feeding Assessment

Does this infant need further evaluation? Answer the first four questions1. Is the feeding safe? 2. Is the feeding efficient? 3. Is the developmentally appropriate? 4. Is the feeding pleasurable for infant and caregiver?
Infant Feeding Assessment

Does this infant need further evaluation? Remember the first four questions. Were you able to change the answer to any of the questions during the evaluation? Do you feel you can facilitate improvement/changes?
Safety

If you are concerned for the safety of the feeding - REFER for further evaluation Explain your concerns to the family Inform the Pediatrician Be succinct and explain exactly what you observed during the feeding
When did the infant demonstrate difficulty
Beginning, middle, throughout feeding, at the end Subtle or overt cues describe them exactly Medical status alerts
Be specific, give examples of infant red flag behaviors
Efficiency
If you are concerned about the efficiency of the feeding weight gain - what is impacting infant ability take sufficient calories without expending more? Is this something you can change?
Bottle/nipple Positional supports Swaddling Schedule changes
Efficiency
Can you verify infant current caloric intake? Determining if it is sufficient for growth?
Dietician
If it is not sufficient the infant may require an increased calorie formula. This requires coordination with the infants primary care physician. Do you have a relationship with Pediatrician?
Dietician support
Efficiency
Do you have supports needed to monitor weight gain?

WIC Pediatrician Dietician To appropriately monitor weight gain you need frequent weight checks on the SAME scale
If you do not have adequate support to monitor weight gain, caloric intake, and formula modifications, this infant requires further evaluation.
Efficiency
If the infant is consuming adequate calories without significant energy expenditure, there may be other factors, medical issues, that are impairing growth and infant ability to thrive. This infant requires further evaluation.
Is the Feeding Developmentally Appropriate?

Do the infants oral feeding skills appear consistent with overall developmental level? If not, what seems to be inhibiting infant oral skills?
Medical status Respiratory status Mismatch between infant cue and caregiver response Lack of skill building opportunity/experience
Is the Feeding Developmentally Appropriate?
Is this something you can address in therapy?

Demonstration developmentally appropriate skill building experiences Positional supports Bottle/nipple changes Caregiver education
Is the feeding pleasurable
Is the feeding pleasurable for both infant and caregiver?

replicable
Is the infant actively involved in the feeding?

Alert and intentional - not distracted Interactive with caregiver
If not, why? Is the caregiver calm, relaxed and responsive? If not, why? Is there something you can change/teach/modify to improve feeding experience?
Postural changes Scheduling changes
Video Infant feeding
Feeding Assessment Part Two Infant/Child Solid Feeder
Infant/Child Solid Feeding Assessment

Five basic questions are the same: 1. Is the feeding safe? 2. Is the feeding efficient? 3. Is the feeding developmentally appropriate? 4. Is the feeding pleasurable for both infant and caregiver? 5. Does this infant require further evaluation?
Infant/Child Solid Feeding Assessment Parent Interview
Parents with older infants often VERY frustrated Isolated Feelings of failure Fear of judgment Threat of hospitalization Caregivers problem solve Short term solutions/success Imperative that you reassure families you are asking questions to guide assessment NOT to assign blame!

Determine Parent primary concern with feeding first Obtain Medical, Developmental history as before Detailed Feeding history is important
Breast or bottle fed How infant fed initially Initial Problems feeding

Frequent emesis, fussy/crying Happy or colicy baby Diarrhea or constipation issues Skin rashes/dryness Sleeping/nap patterns

Changes to bottle/nipples since discharge

Reason for changes
Changes to formula
Reason for changes How change made gradual or sudden
Solids
Age first presentation Where infant seated for solids Infant acceptance of solids
Infant/Child Solid Feeding Assessment- Parent Interview

Typical days schedule of meals/snacks Time meal/snacks offered What is offered

What is eaten What is refused Amount eaten Who is present during meal/snack
Be specific not just crackers ask for types Graham, saltine, ritz, etc. If cheerios will child eat any type of cheerios? Will child eat all brands name brand, generic, homemade

Typical schedule of meals/snacks Where is the child seated for meals? Where is the child seated for snacks? How long do meals last? How long snacks last? Is food available other than at meals/snacks? How does caregiver know when the infant/child is hungry? Distractions used or available during meals/snacks?
What liquids does the child drink other than his milk/formula?
How much other liquids Are liquids available throughout the day or only at meal/snack times Bottle, cup, sippee, breast Naps during the day Sleep through the night Food available during the night, how often, how much
What is the infant/childs sleep schedule

Useful to run through food groups Asking about foods in each of three groups
Carbohydrates bread, pancake, waffles pasta, rice, hot/cold cereal, crackers, cookies, tortilla, chips Protein/Milk meats, beans, hummus, peanut butter, milk, yogurt, ice cream, pudding Fruit/Veggies baby food and regular, raw or cooked, whole, smashed

Final question Are there any other foods or liquids that we havent talked about that your child eats on a regular basis? Consider parent information Are patterns emerging?
Continued reliance on liquids for nutrition Preferences for certain textures Preferences for temperatures
Infant/Child Feeding Observation

Observe Caregiver feeding child Goal is to observe typical meal/interaction
Usual feeding place and position Familiar foods Normal feeding time if possible
Observe both infant/child and caregiver behaviors

Reciprocity and engagement
Infant observations
General tone Oral structures Developmental level Manipulation of food Postural stability Social engagement Communication ability Social interaction Supports provided Cueing provided Tolerance level for mess
Caregiver observations


Generally start in highchair with solids first Caregiver feeding typical foods Observe infant oral motor skill and behavior
Anticipation active opening mouth, leaning into Tongue lateralization emerging or mature Chewing anterior or on molar pads How does the infant/child manipulate food
Whole hand, single finger What does child do with food
Tolerate sensory input How does posture change overtime
Match between infant behavior and caregiver response

How does caregiver tolerate messy eating
Use of modeling, reinforcement and distractions

Does the caregiver attempt to re-engage child in feeding
Model real eating, pretend eating
How does the caregiver interact with child Caregiver body language/facial expression
Infant/Child Feeding Observation Novel Food Presentation

Further assess infant oral motor skill development Determine if infant ready for next step Assess Spoon Feeding does infant anticipate spoon, opening lips, lean into, accept Hard Munchable acceptance, tongue movement, oral exploration, fun dipper Meltable Solid - acceptance, biting central or lateral, tongue movement patterns

Family/ Caregiver Education Demonstration strategies to advance skills Spoon Feeding lateral presentation facilitation active lip closure

Hard Munchable oral exploration not consumption Facilitation of tongue lateralization Handy dipper for purees Child directed with modeling

Hard Meltable oral exploration and consumption Facilitation of munching/biting Tongue lateralization Also handy dipper for puree Child directed with modeling

Liquid Assessment last Begin with childs typical bottle or cup Observe oral motor skills, efficiency transfer Introduce novel container Further assess infant oral motor skill develoment Willingness accept new container Demonstration/Family caregiver education Cup Honey Bear
Infant/Child Feeding Assessment Answering the questions

Is the feeding safe? Concerns for solids, liquids or both? What happened that raises a safety issue? Is choking/coughing self protective? Are foods being offered at home developmentally appropriate? Is there a mismatch between expectation/diet offered and skill level? Interventions trialed
helpful or not
Infant/Child Feeding Assessment Answering the questions

If there is a mismatch between oral motor skill level and diet, can the infant/child eat appropriate foods safely? Family/caregiver education Developmentally appropriate diet Recommendations to increase caloric density in accepted foods Strategies/Activities to facilitate oral skill building
Safety Concerns

Explain your concerns to the family Be specific and give examples of infant behavior Coordinate with primary care physician Be specific, provide examples To evaluate structure ENT referral To evaluate safety of swallow
Airway/structural anomalies, vocal cord function Swallow concerns or Reflux/Vomiting
Recommendation for swallow evaluation Be aware of different diagnostic tests Modified Barium Swallow, Video Swallow
Modified Barium Swallow

Purpose: evaluate safety and efficiency of swallow The infant/child is seated upright in a tumbleform. Orally fed barium mixed with glucose water. Orally fed food with barium mixed in or frosting Variety of nipples, cups, bottles Alter consistency of barium Alter position of child
Upper GI
Purpose: evaluate the anatomy of esophagus and stomach, may identify GER Infant/child given barium to drink Positioned in supine, turning to each side during procedure MAY be able to visualize swallow if fed orally Abnormal feeding position Unable to assess compensatory strategies
Position changes Diet modifications
Fiberoptic Endoscopy
Invasive procedure Scope passed through nares and visualizes vocal cords Able to assess anatomy before and after the swallow
Following swallow assessment

Results of study must be weighed Compensatory strategies trialed Reassessment Normal MBS means that infant was safe at that moment
Ongoing concerns warrant further evaluation
Abnormal MBS much more predictive

can be a first sign neurological concerns

Is the child gaining weight? Is the current schedule of meals/snacks and food provided offering appropriate calories?
Family limiting Self limiting
Is there something else impacting childs ability to maintain nutritional needs appropriately?
Postural supports
Is the feeding developmentally appropriate?

Do the infant/childs oral feeding skills appear commensurate with developmental level? If not why?
Self limiting experiences GER, Sensory Family limiting lack of experiences, cultural diet differences or perception of child as too fragile Mismatch between developmental skill and foods offered
Chronological age vs developmental age
Is the feeding pleasurable for both infant/child and caregiver?
Active participation by both infant and caregiver

Willing interaction/trust building No coercion, hiding food or force feeding No distraction with non food objects No fake eating
If not why?
Mismatch between expectation and skill level? Sensory/GER learned experiences
Does this infant/child need further assessment?

If feeding is not safe REFER If feeding is efficient and child is not gaining weight - REFER If feeding is not efficient and you do not have supports to assess caloric intake, caloric needs, monitor weight gain, or make specific recommendation to increase calories in currently accepted foods REFER If feeding is not pleasurable can you identify the reason? For example negative experiences pairing pain with feeding due to GERD?
Does this child need further assessment?
If the feeding is not pleasurable and you suspect ongoing issues with pain or discomfort with feeding REFER
Feeding assessment with partially or non - orally fed infant/child
Prior to assessing infant oral skills it is imperative to have the following: Thorough understanding infant/childs past and present medical status Reasons for ongoing supplemental nutrition Opportunity to examine previous swallow evaluations, feeding clinic recommendations Support of family and Physician Self awareness
Your skill level Comfortable stretch of skills with support vs
operating in the dark
Assessment with partially or nonorally fed infant/child

Go Slow! Feeding can be fatal Assess infant status at rest
Secretion management Respiratory rate Need for oral suction Spontaneous mouthing Oral reflexes
Feeding Assessment with partially or non - orally fed infant/child
Assess infant status with non nutritive experiences

Changes in oral secretions Secretion management Respiratory stability Infant interest in mouthing/sucking Developmental level
Feeding Assessment with Partially Orally fed Infant/Child
Assess infant with minute tastes

Secretion management Respiratory changes Suck/swallow ratio and coordination Willingness to accept food/liquid
Feeding Assessment with Partially or non orally fed infant/child

The same questions apply Is oral feeding safe? Is the feeding efficient? Is the feeding developmentally appropriate? Is the feeding pleasurable?
Partially or non oral feeder Is the feeding safe?
If the feeding does not appear safe is it

Liquids Solids Both
Why does it appear unsafe?

What is the child doing?
Result of oral motor skill development, mismatch skill/diet, swallow function? If swallow function - REFER
Partially or non oral feeder Is the feeding efficient?
If the feeding is not efficient why not?

Postural control/stability Rate of presentation Oral motor skill/function Medical status/stability Caloric density of foods offered
Can you address this in therapy? If the feeding is not efficient and you do not have supports to make changes and monitor growth - REFER
Partially or non oral feeder Is the feeding pleasurable?

If the feeding is not pleasurable why not? Are there any foods/liquids the infant enjoys and eats willingly? Is the infant behavior self protective? Is the infant behavior learned response to pain? Swallow dysfuntion? If you suspect the infant continues with significant pain paired with feeding - REFER
Partially or non oral feeder Is the feeding developmentally appropriate?

Are oral motor skills commensurate with developmental level? If not what is preventing child from developing oral skills?
Medical status/stability Lack of skill building experiences Caregiver limiting Infant self limiting
Is this something you can address in therapy?
Assessment with partially or non orally fed infant/child

Often the most appropriate recommendation for an infant that has never orally fed is a referral to a Feeding Clinic for comprehensive evaluation.
Feeding Assessment -Take Home

Feeding/Oral Motor Assessment is complex Requires detailed information from caregiver
Medical and developmental history Daily schedule

Observation of typical feeding Observation of novel feeding Evaluation of childs developmental level Awareness/sensitivity to cultural differences and family goals
Video of Spoon, finger feeding
Malia Case Presentation
Medical History

Fetal tachyarrhythmia at 29weeks (HR240) Non Immune Fetal Hydrops Atrial Flutter Mother admitted to hospital 2 weeks prior to delivery
Urgent C section at 31 weeks
Maternal steroids Digoxin and flecainide therapy HR improved several days prior to delivery No improvement in hydrops Decreased fetal movement Biophysical profile 2/10 Fetal bradycardia with uterine contractions
Delivery
Apgars 2/4/6 Birth weight 2900g 6lb 4oz
Estimated real weight 4lbs

Severely hydropic and depressed at birth No respiratory effort Difficult to visualize airway due to profound swelling Bilateral thoracentesis Traumatic intubation Low HR requiring chest compressions
NICU Course
Bilateral Chest Tubes Assisted ventilation x 14 day Thrombus R atrium Wolff-Parkinson-White Syndrome Stage III ROP requiring bilateral laser surgery HUS/MRI stable cystic changes bilateral caudate head
Feeding in the NICU

History weak voice with only minimal improvement Demonstrated readiness cues at 34 weeks gestation
attempting breastfeeding first
Ongoing physiological instability at breast or bottle ENT consult 5/21/2010 revealed vocal fold damage
Left arytenoid cartilage dislocated (resulting in L cord immobility) surgically repaired R mid vocal cord damage Unable fully occlude airway
Feeding
Video Swallow 5/24/2010 in L sidelying position

Aspiration of thin Safe on nectar thick in left sidelying with slow flow nipple
Unable to maintain all nutritional needs orally Gastrostomy tube 6/23/2010 Discharged at 80 DOL, 42 weeks
Nippling small volumes 20-25%
Feeding Clinic Follow Up July 2010

Chronological age 3 months Corrected age 3 weeks Social and interactive infant Gaining weight Combination Gtube/Oral feedings
Six feedings of 105ml/day
Oral Feedings continue nectar thick Recipe family using providing insufficient calories did not account for gel thickener displacement Increased GER symptoms
Frequent gagging, retching and vomiting during gavage feeding or oral feeding
Feeding Clinic Recommendations

Continue nectar thick Provided with correct recipe to adjust for addition of non nutritive gel thickener Continue offer oral feeding first
emphasis on pleasurable oral intake
Reassess swallow function following ENT follow up appointment Transition to 7 feedings daily
Smaller volume every 3 hours Manage infant symptoms of GER
Developmental Follow Up August Chronological age 4 months

Adjusted age 1 month 3 weeks Socially interactive Smiling, visually attentive Delayed Motor Development Unable turn head fully to left Limited tolerance prone positioning Unable lift head from surface in prone Increased tone and tightness in lower extremities
Developmental Follow Up - August

Ongoing GER symptoms

Requires venting throughout oral feedings Mother feeding in sheepskin covered bouncy seat to assist with upright positioning, decrease emesis Limiting time or experience in any other position Variable oral intake
Recommendations
Home Program developed and given to family

Supervised time in prone, modified prone for GER Gentle stretches to cervical spine Activities to increase active head turning to left Activities to encourage active kicking Review of GER positioning Follow up in two months
Developmental Follow Up October Chronological Age 6months

Adjusted age 4 months Very social and engaging reciprocal smiling, cooing Decreased GER symptoms Increased oral intake nippling most Tolerating prone - lifting head Rolling Continue mild tightness in LE but increased play and exploration with feet Continue mild cervical tightness
Recommendations
Continue follow in IDAC at nine months Feeding Clinic Follow Up in one week Continue home activities to encourage
Tummy time prone positioning Rolling to each direction Head turning to each side Sidelying for toy play
Feeding Follow Up - October

ENT re-evaluation September results Improvement, but still some visible cord damage Cleared for initiation of trials of thin and reassessment of swallow function Infant willingly accepted viscosity change without signs of aspiration
Initially decreased thickness to strength nectar
Initiating spoon feeding
Swallow Reassessment October

Chronological age six months Adjusted age four months Infant nippling all Successfully transitioned to strength nectar Spoon feeding purees
Swallow Results
Infant positioning with L lateral neck flexion and R rotation, resists positioning in midline protective? Silent aspiration of nectar and honey
Able tolerate honey thick with slow flow nipple but decreased efficiency Signs of decreased sensory awareness
Continued to suck until nipple removed
Delayed swallow initiation Pooling in valleculae prior to swallow Aspiration during swallow
Factors Impacting Swallow Function

Premature Birth Assisted Ventilation Structural abnormalities Impact of GER on swallow function
Recurrent GER episodes blunting sensation Recurrent aspiration blunting sensation/awareness
Impact of anatomical growth

Downward and forward position of larynx Decreasing inherent protection
Recommendations

Continue honey thick with slow flow nipple Emphasis on pleasurable oral intake Feeding Therapy with Speech or Occupational Therapy Continue with spoon feeding Ongoing Developmental Follow Up
Feeding Follow Up February 2011

Chronological Age 10 months Corrected Age 8 months Developmental skill level 6-7months Most recent ENT evaluation January 2011
Unable to evaluate vocal cord integrity/function Area edematous and inflamed GER Increased reflux medication dosage

Social and engaging, reciprocal smiling and laughing, joint eye contact Babbling but limited voice
Feeding follow up February 2011
Video of Malia in high chair
Feeding Assessment Wrap Up
Was the feeding safe?
Was the feeding efficient?
Was the feeding developmentally appropriate?
Was the feeding pleasurable?
What recommendations would you make?
Lessons from Malia

Development is interdependent Nutrition is primary Never underestimate the power of an involved family and developmentally sensitive care Even the best families are stressed and may confuse or forget the best teaching at discharge Follow up is essential Swallowing is complex Silent aspiration is silent
Feeding/Swallowing
Dramatic increase feeding disorders in last decade

Increased survival rates medically fragile, extremely premature infants
Typically developing children 25-25% have feeding/swallowing issues Medically complex/developmentally delayed percentages much higher 33-80% Risk factors for feeding/swallowing
Low birth weight Medical complexity Prematurity
Thanks To:
Malia Joy and family for allowing us to share her story. David for technical support with PPT
Remember the goal is long term feeding success!
Part II - Site visits
Site visits to include: Up to 4 hours of time by 1 to 2 team members (PT, OT or ST) from Memorial Hospital for Children, depending on location and topics of interest. Offered at any of the 20 central EI sites throughout Colorado. One or two case studies would be presented by the local E.I. staff with either in-person (child) visit, video tape, or oral presentation. A case study form would need to be sent to the Memorial staff one week prior to the visit. This would be a problem solving/idea collaboration session, not a formal consultation. Further education on development of the infant < one year of age could be discussed. Visits would be provided during the months of April, June or September, 2011.
Early Intervention Site Visits

Deadline for sign-up will be March 15, 2011 Cindy Gardner (Peds Rehab manager) will be the contact person to schedule site visits at 719-365-9637 cindy.gardner@memorialhealthsystem.co m.
Case Review Outline

(Please use as a guideline; may need additional paper for lengthy information. Medical summaries, & results of any tests or studies are also very helpful)
Date of Birth:
Diagnosis (if any):
Past medical history: Birth History: (gestational age, birth weight, APGAR scores, cord pH, complications etc) Illnesses, surgeries, hospitalizations, therapies:
Social history: (lives with____;# siblings____;
Present status: Sensory/Motor: (developmental milestones/test results, posture, muscle tone, movement patterns, sleeping patterns, tolerance to touch/movement/clothing/bathing etc) Feeding: (typical pattern/ amount/frequency) ( difficulties, spitting up, discomfort) Strengths, things child does well: Problems, things child has difficulty with: Familys goals for the child: Specific interventions tried, to address the goals: (were they successful or not?) ---------------------------------------Discussion, recommendations/suggestions made at the time of this case review:
Feeding Evaluation Template

Name: DOB: MRN: ACCT: Date of Evaluation: Chronological Age: Corrected Age: Parents: Physician: Referring Physician: Diagnosis: ______________________ was seen for a feeding evaluation. ________was brought into the evaluation by ____________________. Their concerns include______________________. ________________ was evaluated by ________________________ Developmental Pediatrician
_______________________ Occupational Therapist Registered ________________________ Speech Language Pathologist ________________________ Registered Dietician
Background:
Birth history: ____ week gestation
Initial Feeding History: breast/bottle fed, amounts, problems, when solids introduced
Past Medical History Medications Allergies Other relevant info Review of systems Physical Examination Feeding Assessment: Current daily feeding routine Meal Time Foods offered/eaten Breakfast Snack Lunch Snack Dinner Snack Bedtime Night feedings
Drink
Feeding Routine: Mothers lap/arms High chair Family style Walks around Food available all the time T.V. on Toys present; distractions Other:
Naps:
Time(s)/length
Night: Sleeps through night/wakes up Night feedings: amounts/frequency Foods eaten at home include: C-consistently, O-occassionally, D-dropped, R-refuses
carbs Bread Waffles Pancakes Cereal Rice Noodles Chips Cheetos Cookies Crackers
beef
baked - nuggets - hamburger bananas - roast pork eggs cheese peanut butter yogurt pudding ice cream
protiens chicken-
fruit/veggies apples oranges pears grapes strawberries peaches melons carrots green beans peas mashed potato french fries
Foods refused include:
During todays evaluation _____________ was offered the following foods. ( puree, hard munchable, meltable, hard/soft mechanical drink)
list observation infant child interaction with food spontaneously and with modeling/cueing note oral motor development
Sensory Screen: Motor Screen/Postural Stability: Speech Language Screen: Summary: Strengths: Challenges: Recommendations: Plan: Goals:
References
REFERENCE LIST Arvedson, J., Clark, H., Lazarus, C., Schooling,T. & Frymark, T. (2010). Evidence-based systematic review: effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19:321-340. Bakewell-Sachs S., Medoff-Cooper B., Escobar G.J., Silber J.H., & Lorch S.A. (2009, May). Infant functional status: The timing of physiologic maturation of premature infants. Pediatrics, 123, 878-86. Bell, H.R. & Alper, B.S. (2007). Assessment and intervention for dysphagia in infants and children: beyond the neonatal intensive care unit. Semin Speech Lang. 28(3):213-222. Bingham, P.M., (2009). Deprivation and dysphagia in premature infants. J Child Neurol. 24(6):743-749. Bozzette, M., (2007). A review of research on premature infantmother interaction. Newborn and Infant Nursing Reviews. 7(1):49-55.
References

Bronwen, N.K, Huckabee, M.L., Jones, R.D. & Frampton, C.M.A., (2007). The first year of human life: coordinating respiration and nutritive swallowing. Dysphagia. 22:37-43. Brown, L. (2007). Heart rate variability in premature infants during feeding. Biological Research for Nursing. 8(4):283-293. Brown, L.F., Thoyre, S., Pridham, K., & Schubert, C. (2009). The mother-infant feeding tool. Journal of Obstetrical, Gynecological, & Neonatal Nursing. 38, 491-503. Buswell, C.A., Leslie, P., Embleton, N.D., & Drinnan, M.J. (2009). Oral -Motor Dysfunction at 10 months corrected gestational age in infants born less than 37 weeks preterm. Dysphagia. 24(1): 20-25. Chang,Y.J. & Lin, C.P. et al. (2007). Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants. Journal of Nursing Research. 15(3). 215-223. Cho, J., Holditch-Davis, D. & Miles, M.S. (2010). Effects of gender on the health and development of medically at-risk infants. Journal Obstet Gynecol Neonatal Nurs. 39(5):536-549. DaCosta, S.P. & Van Der Schans, C.P. (2008). The reliability of the Neonatal Oral-Motor Assessment Scale. Acta Paediatr. 97(1): 21-26. DaCosta, S.P., Van Der Schans, C.P., Boelema, S.R., Van Der Meij, E., Boerman, M.A. & Bos, A.F. (2010). Development of sucking patterns in pre-term infants with bronchopulmonary dysplasia. Neonatalogy. 98(3):268-277. DaCosta, S.P., Van Der Schans, C.P., Boelema, S.R., Van Der Meij, E., Boerman, M.A. & Bos, A.F. (2010). Sucking patterns in fullterm infants between birth and 10 weeks of age. Infant Behav Dev. 33(1): 61-67. Daelmans, B., Dewey, K., & Arimond, M. (2009). New and updated indicators for assessing infant and young child feeding. Food Nutr Bull. (2 suppl): S256-262. Delaney, A.L. & Arvedson, J.C. (2008). Development of swallowing and feeding: prenatal through first year of life. Dev Disabil Res Rev. 14(2): 105-117. Dodrill, P., McMahon, S., & Ward, E. (2004). Long-term oral sensitivity and feeding skills of low risk preterm infants. Early Human Development. 76, 23-37. Emond, A., Emmett, P, Steer, C. & Golding, J. (2010). Feeding symptoms, dietary patterns, and growth in young children with autism spectrum disorders. Pediatrics. 126(2):337-342. Forcada-Geux, M., Pierrehumbert, B., Borghini, A., Moessinger, A., & Muller-Nix, C. (2006). Early dyadic patterns of Mother-Infant interactions and outcomes of prematurity at 18 months. Pediatrics. 118(1): 107-114.
References

Gewolb, I.H. & Vice, F.L. (2006). Abnormalities in the coordination of respiration and swallow in preterm infants with bronchopulmonary dysplasia. Developmental Medicine and Child Neurology. 48, 595-599. Griffin, I.J. & Cooke, R.J. (2007). Nutrition of preterm infants after hospital discharge. Journal of Pediatric Gastroenterology and Nutrition, 45, Suppl 3:S195-203. doi: 10.1097/01.mpg.0000302972.13739.64 Hawdon, J.M., & Beauregard, N. (2000). Identification of neonates at risk of developing feeding problems in infancy. Developmental Medicine & Child Neurology, 42, 235-239. Howe, T-H., Sheu, C-F., Hinojosa, J., Lin, J., & Holzman, I. R. (2007). Multiple factors related to bottle-feeding performance in preterm infants. Nursing Research. 56, 307-311. doi: 10.1097/01.NNR.0000289498.99542.dd Jadcherla, S.R., Wang, M.,Vijayapal, A.S., & Leuthner, S.R. (2009). Impact of prematurity and comorbidities on feeding milestones in neonates: A retrospective study. Journal of Perinatology (e pub ahead of print). doi:10.1038/jp.2009.149 Kirk, A.T., Alder, S.C. & King, J.D. (2007). Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology, 27(9), 572-8. Laing, S., McMahon, C., Ungerer, J., Taylor, A., Badawi, N. & Spence, K. (2010). Mother-child interaction and child developmental capacities in toddlers with major birth defects requiring newborn surgery. Early Human Devlopment, Epub ahead of print PMID:20888152. Landry, S.H., Smith, K.E. & Swank, P.R., (2006). Responsive Parenting: Establishing early foundations for social, communication, and independent problem-solving skills. Developmental Psychology. 42(4): 627-642.
References

Law-Morstatt, I., Judd, D.M., & Snyder, P. (2003). Pacing as a treatment technique for transitional sucking patterns. Journal of Perinatology, 23, 483-488. Lee, T.Y., Lee, T.T., & Kuo, S.C. (2009).The experiences of mothers in breastfeeding their very low birth weight infants. Journal of Advanced Nursing. [Epub ahead of print]. doi:10.1111/j.13652648.2009.05116 Lefton-Greif, M.A. & McGrath-Morrow, S.A. (2007). Deglutition and respiration:development, coordination, and practical implications. Semin Speech Lang. 28(3): 166-179. Lefton-Greif, M.A. (2008). Pediatric Dysphagia. Phys Med Rehabil Clin N Am. 19: 837-851. Ludwig, S. & Waitzman, K.A. (2007). Changing feeding documentation to reflect infant driven feeding practice. Newborn and Infant Nursing Reviews. 7(3). 155-160. McCain, G.C. (2003). An evidence-based guideline for introducing oral feeding to healthy preterm infants. Neonatal Network. 22: 45-50. McGrath, J. M., Braescu, A.V. & Bodea, M.S. (2004). State of the science: Feeding readiness in the preterm infant. The Journal of Perinatal & Neonatal Nursing. 18, 353368. Medoff-Cooper, B., Bilker, W. & Kaplan, J.M. (2010). Sucking patterns and behavioral state in 1 and 2 day old full term infants. Journal Obstet Gynecol Neonatal Nurs. 39(5), 519-524. Medoff-Cooper, B. & Irving, S.Y. (2009). Innovative strategies for feeding and nutrition in infants with congenitally malformed hearts. Cardiol Young 19(2):90-95. Medoff-Cooper, B. (2005). Nutritive sucking research:from clinical questions to research answers. Journal of Pediatric Neonatal Nursing. 19: 265-628.
References

Law-Morstatt, I., Judd, D.M., & Snyder, P. (2003). Pacing as a treatment technique for transitional sucking patterns. Journal of Perinatology, 23, 483-488. Lee, T.Y., Lee, T.T., & Kuo, S.C. (2009).The experiences of mothers in breastfeeding their very low birth weight infants. Journal of Advanced Nursing. [Epub ahead of print]. doi:10.1111/j.13652648.2009.05116 Lefton-Greif, M.A. & McGrath-Morrow, S.A. (2007). Deglutition and respiration:development, coordination, and practical implications. Semin Speech Lang. 28(3): 166-179. Lefton-Greif, M.A. (2008). Pediatric Dysphagia. Phys Med Rehabil Clin N Am. 19: 837-851. Ludwig, S. & Waitzman, K.A. (2007). Changing feeding documentation to reflect infant driven feeding practice. Newborn and Infant Nursing Reviews. 7(3). 155-160. McCain, G.C. (2003). An evidence-based guideline for introducing oral feeding to healthy preterm infants. Neonatal Network. 22: 45-50. McGrath, J. M., Braescu, A.V. & Bodea, M.S. (2004). State of the science: Feeding readiness in the preterm infant. The Journal of Perinatal & Neonatal Nursing. 18, 353368. Medoff-Cooper, B., Bilker, W. & Kaplan, J.M. (2010). Sucking patterns and behavioral state in 1 and 2 day old full term infants. Journal Obstet Gynecol Neonatal Nurs. 39(5), 519-524. Medoff-Cooper, B. & Irving, S.Y. (2009). Innovative strategies for feeding and nutrition in infants with congenitally malformed hearts. Cardiol Young 19(2):90-95. Medoff-Cooper, B. (2005). Nutritive sucking research:from clinical questions to research answers. Journal of Pediatric Neonatal Nursing. 19: 265-628.
References
Miller, C.K. & Willging, J.P. (2007).The implications of upper-airway obstruction on successful infant feeding. Seminars in Speech and Language. 28(3):190-203. Mizuno, K., Nishida,Y., Taki, M., Hibino, S., Murase, M., Sakurai, M. & Itabashi, K. (2007). Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain breathing during feeding. Pediatrics, 120:1035-42. Morris, S.E., & Klein, M.D. (1987). Pre-Feeding Skills. Arizona: Therapy Skill Builders Newnham, C.A., Milgrom, J. & Skouteris, H. (2009). Effectiveness of a modified mother-infant transaction program on outcomes for preterm infants from 3 24 months of age. Infant Behavior & Development. 32:17-26. Nixon, G.M., Charbonneau, I., Kermack, A.S., Brouillette, R.T. & McFarland, D.H. (2008). Respiratory-swallowing interactions during sleep in premature infants at term. Respiratory Physiology & Neurobiology. 160: 76-82. Palmer, M., Crawley, & Blanco. (1993). Neonatal Oral Motor Assessment Scale: a reliability study. Journal of Perinatology. 13(1):28-35. Pickler, R.H. (2004). A model of feeding readiness for preterm infants. Neonatal Intensive Care 17, 31-36. Pickler, R.H., Best, A.M., Reyna, B.A.,Gutcher, G.R. & Wetzel, P.A. (2005). Predictions of feeding performance in preterm infants. Newborn Infant Nursing Reviews. 5(3). 116-123. Pickler, R.H., Best, A.M., Reyna, B.A.,Gutcher, G.R. & Wetzel, P.A. (2006). Predictors of nutritive sucking in preterm infants. Journal of Perinatalogy. 26: 693-699. Prasse, J.E. & Kikano, G.E. (2009). An overview of pediatric dysphagia. Clin Pediatr(Phila). 48(3):247251. Premji, S.S., McNeil, M.N. & Scotland, J. (2004). Regional neonatal oral feeding protocol: changing the ethos of feeding preterm infants. Journal of Neonatal Nursing. 18(4). 371-384.
References
Prins, S.A., Von Lindern, J.S., Van Dijk, S. & Versteegh, F.G. (2010). Motor Development of Premature Infants born between 32 and 34 weeks. Int J Pediatr, Epub 2010 Sep 7. Puckett, B., Grover, V.K. Holt, T., & Sankaran. (2008). Cue-based feeding for preterm infants: a prospective trial. American Journal of Perinatology. 25(10), 623-8. Rogers, B. & Arvedson, J. (2005). Assessment of infant oral and sensorimotor and swallowing function. Ment Retard Dev Disabil Res Rev. 11(1): 74-82. Richter, G.T. (2010). Management of oropharyngeal dysphagia in the neurologically intact and developmentally normal child. Current Opinion in Otolaryngology & Head and Neck Surgery. Epub ahead of print PMID:20885326. Samara, M., Johnson, S., Lamberts, K., Marlow, N. & Wolke, D. (2010). Eating problems and growth at 6 years of age in a whole population sample of extremely premature children. Dev Med Child Neurol. 52(2): e16-22. Schadler, G., Suss-Burghart, H.S., Toschke, A.M., von Voss, h., von Kries, R. (2007). Feeding Disorders in ex-prematures: causes response to therapy long term outcome. Eur J Pediatr. 166:803-808 Scheel, C.E.., Schanler, R.J. & Lau, C. (2005). Does the choice of bottle nipple affect the oral feeding performance of very-low-birthweight (VLBW) infants? Acta Paediatrica. 94: 1266-1272 Shaker, C.S. & Woida, A.M. (2007). An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy, developmental support and teamwork. Neonatal Network. 26(2), 77-83. Sheppard, J.J. & Fletcher, K.R. (2007). Evidence-based Interventions for Breast and Bottle Feeding in the Neonatal Intensive Care Unit. Seminars in Speech and Language. 28(3). 204-212. Sonies, B.C., Cintas, H.L., Parks, R., Miller, J. Caggiano, C., Gottshall, S.G., & Gerber, L. (2009). Brief assessment of motor function: content validity and reliability of the oral motor scales. Am J Phys Med Rehabil. 88(6):464-472. Stern, M., Karraker, K., McIntosh, B., Moritzen, S., & Olexa, M. (2006). Prematurity stereotyping and mothers interactions with their premature and full-term infants during the first year. Journal of Pediatric Psychology. 31(6):597-607.
References

Stuart, S. & Motz, J.M.(2009).Viscosity in infant dysphagia management: comparison of viscosity of thickened liquids used in assessment and thickened liquids used in treatment. Dysphagia. 24(4):412-422. Thoyre, S.M., Shaker, C.S. & Pridham, K.F. (2005). The early feeding skills assessment for preterm infants. Neonatal Network. 24(3), 7-16. Thomas, J. A., (2007). Guidelines for bottle feeding your premature baby. Advances in Neonatal Care. 7(6): 311318. Vincer, M.J., Allen, A.C., Joseph, K.S., Stinson, D.A., Scott, H. & Wood, E. (2006). Increasing prevalence of cerebral palsy among very preterm infants: a population based study. Pediatrics. 118(6): 1621-1626. Vohr, B.R., Poindexter, B.B., Dusick, A.M., McKinley, L.T., Wright, L.L., Langer, J.C. & Poole, W.K. (2006). Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics, 118: 115-123. Warren, S.F. & Brady, N.C. (2007). The role of maternal responsivity in the development of children with intellectual disabilities. Ment Retard Dev Disabil Res Rev. 13(4):330-8. Warren, S.F., Brady, N., Sterling, A., Fleming, K. & Marquis, J. (2010). Maternal responsivity predicts language development in young children with fragile X syndrome. Am J Intellect Dev Disabil. 115(1):54-75. Wilson, E.M. & Green, J.R. (2009). The development of jaw motion for mastication. Early Human Development. 85(5): 303-311. Wolf, L. & Glass, R. (1992). Feeding and Swallowing Disorders in Infancy: Assessment and Management.

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Feeding Assessment in Infants Case Study

Kay Thurston, MS,CCC/SLP,CLC

Prerequisite Skills for oral feeding

Why is feeding so often difficult?

Factors that complicate feeding assessment

Factors that complicate feeding assessment

Feeding Assessment Tools

Formal Feeding Assessments

Formal Feeding Assessments

Memorial Outpatient Feeding Clinic Approach

Comprehensive Evaluation Trained with Dr. Kay Toomey

Sequential Oral Sensory Approach SOS

Five Basic Questions

Prior to Assessment Optimal Scenario

Gather and review medical information

Prior to Assessment - Reality

Feeding Assessment Components

Family Concerns Medical History

Feeding Assessment Components

Feeding Assessment Components

Oral Mechanical Observation Feeding Observation

Optimal if done prior to feeding Assess oral structures, symmetry

Feeding Assessment Components

Speech Language Observation

Feeding Assessment Infant Liquid Feeder

Bottle, bottle, nipple!

Bottles and Nipples

Guidelines for Nipple Selection

How do nipples differ?

Material Shape Flow rate Size

Cross Cut nipples unpredictable and usually fast

How fast does it flow?

increased sensory input assist with organization

Standard Nursery Nipples

Readily Available Bottles

Dr. Browns bottle

Readily available slow and variable rate nipples

Cleft Palate Nipples/ Bottle Systems

Haberman Bottle Systems

Bionix Controlled Flow Baby Feeder

Bionix Medical Multiple flow rates

Infant: Pre-solids feeding assessment

Keep in mind 5 questions throughout observation

Infant Assessment Family Interview

Infant Assessment Family Interview

Delivery Tell me about your babys birth.

Infant Assessment family interview

Infant Assessment Family Interview

Infant Assessment Family Interview

Infant Assessment Family Interview

Infant Assessment Family Interview

Infant Feeding Assessment Feeding Observation

Social interaction with family and novel adults

Infant Feeding Observation

Supports offered by caregiver?

Infant Feeding Observation

Infant Feeding Observation

Engagement during feeding

Stress/distress cues during feeding

Infant Feeding Observation

Facial tone Facial symmetry Oral exam if not done before

Oral Movement patterns