Dysphagia
Submitted by
Dr. Erin Redle - erin.redle@cchmc.org
Barb Conrad - Manager - conrad@esclc.org

Please click on any topic below to take you
to that particular section of the guidline.

Dysphagia and the Schools

• ASHA has determined that in the spirit of IDEA 2004, there are four main specific reasons SLPs should be identifying and treating children with dysphagia in the educational setting.
• These specific reasons include:

1. The school system must ensure the child is safe in the school setting; this includes safe from aspiration and choking.
2. If students are not properly nourished or hydrated they will not be in an optimal state for learning.
3. If students are aspirating, they are at risk for increased illness which could result in missing school, which will also reduce the child’s ability to learn.
4. If a student requires an extended period of time to eat, he or she could require additional time for meals at the expense of educational time (ASHA, 2007)

• Additionally, in a response to a request to add dysphagia as a covered service for speech pathology, the response was “We believe that the definition is sufficiently broad to include services for other health impairments, such as dysphagia…”
  
  • Assistance to States for the Education of Children with Disabilities and Preschool Grants for Children with Disabilities; Final Rule, 156, Fed. Reg, 46576 (2006) (to be codified at 34, C.F.R. § 300 & 301)
  • Can access this @ http://www.wrightslaw.com/idea/comment/46547-46579.reg.001-100.definitions.pdf
    
• Also in this document was a discussion of adding dysphagia to the definition of other health impairment. The Federal Register states “We decline to include dysphagia… in the definition of other health impairment because these conditions are commonly understood to be health impairment.”
  
  • Assistance to States for the Education of Children with Disabilities and Preschool Grants for Children with Disabilities; Final Rule, 156, Fed. Reg, 46576 (2006) (to be codified at 34, C.F.R. § 300 & 301)

  
  

Definition of Feeding and Swallowing Disorders

There is currently a lack of consensus on the definitions of feeding and swallowing disorders; many definitions overlap.

• Feeding: Refers to the process of ingesting food, including the sucking and chewing needed to prepare the food prior to the actual swallow (Arvedson & Brodsky, 2002). Feeding development requires the integration of skills across several different but related systems necessary for eating and drinking including psychological, neurological, gastrointestinal, somatosensory, and motor systems.
  
• Sensorimotor Development: Refers to the acquisition of the motor skills and sensory awareness needed for mature eating patterns. Sensorimotor development encompasses accepting food and liquid into the mouth, orally preparing the food or liquid into a cohesive bolus, and transferring the bolus posteriorly to initiate the pharyngeal phase swallow (Arvedson & Brodsky, 2002).
  
• Feeding Disorder: “Disordered placement of food in the mouth; difficulty in food manipulation prior to the initiation of the swallow, including mastication; and the oral stage of the swallow when the bolus is propelled backward by the tongue. In pediatrics, this term may be used to describe a failure to develop or demonstrate developmentally appropriate eating and drinking behaviors” (ASHA, 2001, p. 453).
  
• Dysphagia: “A swallowing disorder” (ASHA, 2001, p. 186). Signs and symptoms may include deficits in the mouth, pharynx, larynx, and/or esophagus.
  
• Oral Phase Swallowing Disorders: Problems include oral-motor difficulties and may also be the result of sensory disorders (Miller & Willging, 2003).
  
• Pharyngeal Phase Swallowing Disorders: Aspiration or penetration before, during, or after the actual swallow, residue remaining in the pharynx after the swallow, or movement of the bolus into the nasal cavity (Logemann, 1998).
  
• Penetration: “Entry of food or liquid into the larynx at some level down to but not below the true vocal folds” (Logemann, 1998, p. 5).
  
• Aspiration: “Entry of food or liquid into the airway below the true vocal folds” (Logemann, 1998, p. 5).

Common Etiologiesin Pediatric Feeding ans Swallowing Disorders and Their Impact on Feeding and Swallowing

Collaboration is Crucial in Pediatric Dysphagia

• Cannot effectively, efficiently treat feeding and swallowing disorders in vacuum.
• Best practice is team approach (ASHA, 2001; Miller et al., 2001).
• Establish team roles based on competency in the areas of feeding and swallowing; establish roles prior to evaluating and treating children
• Roles overlap, need to determine which professional will address overlapping areas.
• May need to have a “case manager,” ASHA suggests SLPs are uniquely qualified to fill this role.

Overview of the Evaluation of Feeding and Swallowing Disorders

• Evaluation of children with feeding and swallowing disorders ideally should include an interdisciplinary team of professionals including speech pathology, occupational therapy, psychology, nutrition, social work, and any necessary pediatric sub-specialists including gastroeneterology, otolaryngology, and neurology (Arvedson & Brodsky, 2002; Manikam & Perman, 2000; Miller et al., 2001). This is not always possible in the school setting.
• Speech language pathologists are involved in both clinical and instrumental evaluations of children.
• Clinical evaluations (can be completed in schools):
  • Should begin with a thorough medical, feeding, and developmental case history (Arvedson, 2000; Arvedson & Brodsky, 2002; Babbitt et al., 1994; Newman, 2000).
    • § To obtain the most complete information, the school therapist will need to gather information from both the caregivers and the schools. The caregivers can provide developmental and feeding information and the medical records can provide additional medical and feeding information.
    • Realistically, this information can be gathered by a combination of sources. Some parents have complete copies of the child’s important reports and evaluations and some reports and evaluations contain developmental information,
    • A release of information will need to be signed by the parent.
      
  • Should include a caregiver interview to gather information about the child’s behavior during home mealtimes (Babbitt et al., 1994).
  • Behavior with eating should be further assessed through the direct observation of the parent child interaction during the assessment (Babbitt et al., 1994; Manikam & Perman, 2000).
  • SLP evaluates the oral sensorimotor skills needed for feeding and simultaneously observes the child for clinical signs of swallowing dysfunction (Arvedson, 2000; Newman, 2000; Rogers & Arvedson, 2005).
  • There is currently no single comprehensive evaluation tool available to diagnose sensorimotor delays (Rogers & Arvedson, 2005); the diagnosis of sensorimotor disorders is primarily based on clinical judgment and comparison to limited available normative data.
  • Should closely monitor for clinical signs of swallowing dysfunction but be aware there is a very high incidence of silent aspiration in pediatrics (Arvedson, Rogers, Buck, Smart, & Msall, 1994; Lefton-Greif & Loughlin, 1996; Newman, 2000).
• Instrumental Evaluations: provide a direct visualization of the swallowing mechanism.
  • Videofluoroscopic swallow study (VFSS): Most common instrumental assessment of swallowing function in children (Arvedson & Lefton-Greif, 1998).
    • Child ingests barium and swallowing is captured through x-ray onto video.
    • Can view all phases of the swallow; frequently limited to oral, pharyngeal (not esophageal).
    • “Gold-standard” for assessment of penetration and aspiration
    • Limitations include: Radiation exposure, need for compliance, no information about secretion management, only captures a moment in time.
    • Appropriate to refer when the child can participate in the exam and you question or suspect aspiration.
      
  • Fiberoptic endoscopic evaluation of swallowing (FEES): Another instrumental assessment used in the pediatric population (Hartnick, Hartley, Miller, & Willging, 2000; Leder & Karas, 2000; Miller & Willging, 2003; Willging, 1995).
    • Small endoscope passed through the nose into pharynx.
    • Direct observation of structures before and after the swallow.
    • Brief moment of white out with each swallow (reflection of light with the camera).
    • Provides information about secretion management (can see aspiration of secretions).
    • Only provides information about pharyngeal phase of swallowing.
    • The child is not exposed to radiation.

Detailed Clinical Assessment

Clinical Evaluation of Feeding and Swallowing

• All evaluations include an assessment of:
  • General observations of overall development
  • The oral mechanism
  • Feeding behaviors
  • Oral motor skills
  • Signs of pharyngeal dysphagia
    
• General Observations
  • Level of interaction
  • Cognition
  • Overall tone
    • Is it overall low, typical, or high?
  • Respiration/respiratory patterns
    • Rapid breathing, shallow breathing, labored breathing
  • Secretion management
    • Can the child handle their own saliva? Drooling? Wet vocal quality prior to feeding?
• Oral Mechanism
  • Observe lips, tongue, jaw, face, cheeks for
    • Symmetry at rest
    • Symmetry with movement
    • Dentition
    • Can have the child complete a few oral mechanism tasks such as pucker, kiss, blow, smile… but just because the child can or cannot execute does not indicate the child will or will not have a feeding or swallowing problem
  • Exam dentition
    • Ensure that it is present and in good condition (decay can be painful and impact feeding)
• Feeding and Oral Motor Assessment
  • Positioning
    • Head control
    • Trunk control
    • Both are necessary for successful, mature feeding and swallowing
  • Textures
    • Different classifications exist including the Developmental Food Continuum (Toomey & Ross, 2004) and the National Dysphagia Diet (National Dysphagia Diet Task Force, 2002).
    • Be prepared to assess a variety of age appropriate textures, but by school age (even preschool age) child should be able to consume puree, meltable solid, mechanical soft, chewy solid (e.g. meat).
• All of the skills listed below are listed from least mature pattern to the most mature pattern, with the most mature pattern indicated by an asterisk. These skill progressions all come from Morris and Klein (2000).
  
  • Lip closure for spoon placement
    • Minimal closure
    • Upper lip assists with closure on spoon
    • Upper and lower lip close to clear the spoon
      
  • Biting
    • Phasic: reflexive closure the jaw; not volitional
    • Controlled bite soft foods
    • Controlled bite solid foods
    • Biting tends to progress from biting in the front to lateral biting
      
  • Tongue movements with bolus manipulation/chewing
    • Suckling (anterior-posterior, in and out of mouth)
    • Sucking (true up and down movement of the tongue)
    • Mashing (push food against roof of mouth for movement)
    • Lateralization (tongue moved bolus/food to lateral teeth or surfaces)
    • Diagonal transfer (food inconsistently moved to lateral teeth)
    • * Active in rotary chew
    • Child will only do what they have to, easy to chew foods will not facilitate most mature chewing patterns
      
  • Chewing
    • Munching (up and down jaw movements)
    • Diagonal (inconsistent tongue lateralization with jaw movements)
    • * Rotary (jaw moves up and down as tongue moves food around mouth in efficient, circular pattern)
    • Chewing refines until 8 years of age (Gisel, 1988)
      
  • Cup drinking (open cup)
    • Suckling pattern (tongue moves in and out of cup for tastes)
    • Sucking with biting on cup for stabilization
    • Sucking without biting
      
  • Non-developmental oral motor patterns (frequently the result of altered neurological system)
    • Cheek/lip retraction at rest
    • Jaw thrusting/ with protrusion with tongue movement
    • Tongue retraction at rest or with food placement
    • Tongue thrusting
    • Tonic bite
• Pharyngeal Assessment
  • Signs/symptoms of swallowing dysfunction (possible aspiration or penetration)
    • Coughing (immediately or delayed)
    • Change in respiration (increase in rate, more shallow breathing)
    • Choking
    • Gagging
    • Changes in vocal quality (wet, gurgle)
    • Color changes (gray, blue)
    • Multiple swallows per bolus
    • Sneezing
    • Food/liquid coming out nose
      
  • Most aspiration in children is silent, can only detect with instrumental assessment (Newman, Keckley, Petersen, & Hammer, 2001; Arvedson, Rodgers, Buck, Smart, & Msall, 1994)
  • Also need to consider importance of history (e.g. respiratory complications) in making determination for instrumental assessment
  • May want to establish baseline measure
  • May want to discuss with administration prior to making recommendation but ultimately have to ensure the child is safe
  • When making a referral, be sure to include clinical information gathered in school setting, may want to use VSS referral form (http://www.asha.org/docs/html/GL2007-00276-F5.html)

Overview of Treatment of Feeding and Swallowing Disorders

• Treatment for children with feeding and swallowing disorders can be direct with the goal of therapy to improve the child’s actual skills, or indirect with the goal of therapy focusing on modifying the other aspects of feeding and swallowing, such as food consistency and caregiver feeding skills.
  
• Regardless of the type of therapy, it should focus on improvement of the overall abilities of the child for feeding and swallowing (Arvedson, 1998; Newman, 2000).
  
• Feeding therapy focuses on increasing acceptance and volume; this type of therapy is frequently conducted in conjunction with psychology (Kerwin, 2003).
  
• Oral motor therapy is frequently recommended for direct treatment of oral sensorimotor delays with the goal of increasing the strength and coordination needed for successful oral feeding (Alper & Manno, 1996; Arvedson & Brodsky, 2002; Morris & Klein, 2000; Newman, 2000; Wooster, 2000).
  • Rommel et al. (2003) found close to 50% of children referred to outpatient clinic for feeding disorders had an oral motor component
  • Oral motor skill deficits are identified as a contributing factor in children previously thought to have no organic basis to their feeding disorder (Reilly, Skusse, Wolke, Stevenson, 1999)
    
• Sensorimotor skills may also be directly or indirectly targeted in therapy through modifications of foods and liquids (Arvedson & Brodsky, 2002; Gisel, Applegate-Ferrante, Benson, & Bosma, 1996).
  
• Pharyngeal swallowing therapy is most often not as direct as it is in adults. It does include swallowing maneuvers (Newman, 2000). Indirect attempts to alter swallow physiology by altering the sensory properties of the food and liquids introduced to the child may also be utilized (Arvedson & Brodsky, 2002; Newman, 2000).
  
• The inclusion of parents in the therapeutic process is crucial for the treatment of feeding and swallowing disorders (Arvedson & Brodsky, 2002; Manikam & Perman, 2000).
  • Parents routinely receive direct training as a component of treatment programs for children with feeding problems (Anderson & McMillan, 2001; Birch, Gunder, Grimm-Thomas, & Laing, 1998; Blisset & Harris, 2002; Farrell, Hogopian, & Kurtz, 2001; Galensky, Miltenberger, Stricker, & Garlinghouse, 2001; Luiselli, 2000; Werle, Murphy, & Budd, 1993).
    

Treatment Strategies for Children with Feeding and Swallowing Disorders (Detailed)

• Goals for treatment should be determined by
  • Safety
  • Developmentally appropriate
  • Motor skills
  • Cognitive skills
    
• Treatment can include
  • Behavior/feeding
  • Oral sensorimotor skills
  • Pharyngeal swallowing
  • Facilitate safe swallow
    
• Treatment for Oral Defensiveness
  • Whole body approach to reducing oral defensiveness is recommended
  • Graded approaches to any type of touch activities are a must; need to start slow and work slowly toward oral cavity
  • When working on the face/peri oral region, use firm pressure
  • Work distal to proximal, lateral to midline, out to in
  • DO not stress the child
  • Activities should be used during and apart from mealtimes
  • Activities should be incorporated into a routine and not be lengthy
  • Have to fit in with the school routine
  • Can be aggravating to the child if they go on and on
  • Use classroom routines as an opportunity to incorporate activities; welcome songs, toothbrushing, etc.
  • (Arvedson & Brodsky, 2002)
    
• Positioning for Trunk and Head Stability
  • Goal is to establish positional stability for the child on which to build oral motor skills
  • Ideal position:
    • Neutral head, neck, and trunk position
    • Pelvis flexed
    • Shoulders stable and depressed
    • Hips at 90º
    • Neutral feet (90º)
  • Hypertonic children need assistance with inhibition of tone to promote trunk stability
  • Hypotonic children require overall postural stability and alignment
  • To facilitate stability:
    • Towel rolls
    • Commercial Inserts
    • Adaptive seating
    • Tumbleform chair
    • Rifton chair
  • Use your team!! OTs and PTs are the experts
    
• Jaw stability
  • Remember, dependent on head, trunk stability
  • In typical children develops through oral experiences
  • Facilitate oral experiences!
    • Mouthing
    • Biting; biting should follow an anterior to lateral progression (bite in the front, then on the side).
    • Introduce resistance activities; have the child bite into something hard or pull on something when they are biting into an item.
  • Specific activities
    • Sing “Old MacDonald,” pretend to be different animals while biting.
    • Tug-of-war with the child holding in mouth, therapist in hand
    • Sing “If You’re Happy and You Know It” and do different biting activities (no hands, on the side, in the front).
    • Bite into chewy items to leave teeth marks.
    • Practice holding things in your mouth with “No hands” (licorice, straws, anything); progress from anterior to lateral.
    • Hold cups in your teeth with no hands; can place liquids or candy into cup to make it heavier.
• Spoon Feeding
  • Need to address lip closure
  • Facilitate lip closure to the best of patient’s ability; the underlying etiology may minimize child’s ability to do this
  • Can use flat whistles to encourage closure- may be difficult to blow through but just want lip closure
  • Can use cups as spoons (especially with purees) to facilitate lip closure; cut out cups may make this easier
  • (Morris & Klein, 1987)
    
• Biting
  • All the activities suggested for jaw strength and stability
  • “No hand biting”
  • Using mouth to pick up and place food into a cup
  • Pretend to be animals
  • Go bobbing for…apples (can be hard, may try to find something easier to bite into)
    
• Chewing
  • All the activities listed for jaw stability and biting
  • Tongue lateralization
    • Start by putting food on the side
    • Hide (food on side of mouth) and seek (with tongue)
    • Push on the finger (placed on outside of cheek)
    • Race a Goldfish from one side to the other
    • (Morris & Klein, 2000)
• Cup Drinking
  • Need to establish jaw stability/strength
  • Work on lip closure on cup
  • Move from a puree to a thick liquid to a thinner liquid; this gives more time for oral preparation to transfer for swallowing
  • Touch cup to lip and remove
  • Provide external jaw support
  • (Morris & Klein, 1997)
    
• Straw Drinking
  • Be careful with safety; straw drinking frequently results in a bigger bolus which may be a problem for children with potential swallowing dysfunction
  • Can use a juice box or squeeze bottle
    
• Treatment of Pharyngeal Disorders
  • Children are different than adults
  • Sometimes children are NPO
    • Remember that even if you put something in their mouth this will increase secretions and can be a problem with aspiration
  • Positioning
    • Flexion vs. extension; flexion is preferred
    • Neutral head position
  • Texture changes
    • Can make thicker, thinner
    • Thickening of liquids
  • Alternate solids and liquids
  • Slowing flow rate and limiting bolus size
  • Electrical stimulation, only for those who are certified (Freed, Freed, Chatburn, & Christian, 2001)
    

Behavioral Strategies for the SLP and Feeding

• Behavioral Interventions
  • This can be challenging for SLPs
    
• Different techniques used to treat feeding and swallowing problems
  • Positive reinforcement
  • Negative reinforcement
  • Differential attention
  • Extinction
  • Punishment
  • Swallow induction training (Kerwin, 1999; Kedesdy & Budd, 1998)
    
• Reinforcers
  • A stimulus introduced in response to a behavior
  • KEY POINT: you MUST figure out what is reinforcing to the individual!!!!
  • Example: stickers vs. candy vs. attention vs. free time
    
• Positive Reinforcement
• Introducing a desirable stimulus to increase a behavior
• Examples
  • Praise
  • Clapping
  • Imitation
  • Money
  • Stickers
    
• Negative Reinforcement
  • Removing a non-desired stimulus with the expectation of increasing a behavior
  • Something you don’t want to have happen occurs until the desired activity is produced
  • Can be painful/undesired stimuli
  • Animal model: think a choke collar on a dog
  • Example: someone honks on the horn (not desired) until you go (desired) and then they stop honking
    
• Differential Attention
  • Positively reinforcing desired behaviors and IGNORING non-desired behaviors
  • E.g. positive reinforcement for taking a bite and ignoring when they spit the bite in your face
    
• Extinction
  • Removing a stimulus to reduce a behavior
  • Best example: holding a spoon in the child’s face until they take a bite to reduce avoidance behaviors
  • Behavior will increase before it decreases
  • SLPs should not do this but may consult with psychologists who do
    
• Punishment
  • Introducing a non-desired stimuli to reduce a behavior
  • E.g. spanking, electric shock therapy
  • SLPs should not do this but may consult with psychologists who do
    
• Swallow Induction Training
  • Introduced and used by psychologists, it involves using a probe (either a metal probe or a gloved finger) to physically stimulate a swallow by eliciting a hypothetical swallow response on the anterior faucial pillars
  • The swallow response may be a true swallow or it may be elicited through first eliciting a gag response
  • Outside the scope of practice for an SLP, should only be implemented by a trained psychologist.

Summary Chart of Behavioral Intervnetions

Links/Websites

ASHA Sites (may need to be an ASHA member to access some of these sites)
Guidelines for Speech Language Pathologists Providing Swallowing and Feeding Services in the Schools
http://www.asha.org/docs/html/GL2007-00276.html

Dysphagia Services in the Schools (ASHA members only)
http://www.asha.org/slp/schools/prof-consult/dysphagiasis.html

The ABC’s of Dysphagia Management in the Schools
LINK

Managing Dysphagia in the Schools
LINK

Speech-Language Pathologists Training and Supervising Other Professionals in the Delivery of Services to Individuals With Swallowing and Feeding Disorders
http://www.asha.org/docs/html/TR2004-00135.html

Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders
http://www.asha.org/docs/html/PS2002-00109.html

Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Individuals With Swallowing and/or Feeding Disorders
http://www.asha.org/docs/html/KS2002-00079.html

Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders: Technical Report
http://www.asha.org/docs/html/TR2001-00150.html

Feeding and Swallowing Disorders in Children
LINK

Behavior Resources

Negative Reinforcement
http://www.youtube.com/watch?v=MPHcw2vz9H0

Extinction
http://www.youtube.com/watch?v=2pRq0f_-cMU

Federal Register
http://www.wrightslaw.com/idea/comment/46547-46579.reg.001-100.definitions.pdf

Oral Motor Development and Therapy
Normal Oral Motor Development
http://www.cedwvu.org/programs/feeding/development.doc

Oral Motor Exercises (note- these are for swallowing, not for speech as indicated on the website)
LINK

General Information on Feeding and Swallowing Disorders

Pediatric Feeding and Swallowing Disorders (general)
LINK

References

Alper, B. S., & Manno, C. (1996). Dysphagia in infants and children with oral-motor deficits: Assessment and management. Seminars in Speech and Language, 17, 283-309.

American-Academy-of-Pediatrics. (1999). Guide to Your Child's Nutrition. New York: Villiard Books.

American-Speech-Language-Hearing-Association. (2001). Roles of speech-language pathologists in swallowing and feeding disorders: Technical report. ASHA 2002 Desk Reference, 3, 181-199.

Anderson, C. M., & McMillan, K. (2001). Parental use of escape extinction and differential reinforcement to treat food selectivity. Journal of Applied Behavior Analysis, 34, 511-515.

Arvedson, J. C. (1998). Management of pediatric dysphagia. Otolaryngologic Clinics of North America, 31, 453-476.

Arvedson, J. C. (2000). Evaluation of children with feeding and swallowing problems. Language, Speech, and Hearing in Schools, 31, 28-41.

Arvedson, J. C., & Brodsky, L. (2002). Pediatric Swallowing and Feeding: Assessment and Management. (2nd ed.). Albany, N.Y.: Singular Publishing Group.

Arvedson, J. C., & Lefton-Greif, M. A. (1998). Pediatric Videofluoroscopic Swallow Studies. San Antonio, TX: Communication Skill Builders.

Arvedson, J. C., Rogers, B., Buck, G., Smart, P., & Msall, M. (1994). Silent aspiration prominent in children with dysphagia. International Journal of Pediatric Otolaryngology, 28(2-3), 173-181.

Babbitt, R. L., Hoch, T. A., Coe, D. A., Cataldo, M. F., Kelly, K. J., Stackhouse, C., et al. (1994). Behavioral assessment and treatment of pediatric feeding disorders. Developmental and Behavioral Pediatrics, 15, 278-291.

Birch, L. L., Gunder, L., Grimm-Thomas, K., & Laing, D. G. (1998). Infants’ consumption of a new food enhances acceptance of similar foods. Appetite, 30, 283-295.

Blisset, J., & Harris, G. (2002). A behavioural intervention in a child with feeding problems. Journal of Human Nutrition and Dietetics, 15(4), 255-260.

Boesch, R. P., Daines, C., Willging, J. P., Kaul, A., Cohen, A. P., Wood, R. E., et al. (2006). Advances in the diagnosis and management of chronic pulmonary aspiration in children. European Respiratory Journal, 28(4), 847-861.

Burklow, K. A., Phelps, A. N., Schultz, J. R., McConnell, K., & Rudolph, C. (1998). Classifying complex pediatric feeding disorders. Journal of Pediatric Gastroenterology and Nutrition, 27(143-147).

Byars, K. C., Burklow, K. A., Ferguson, K., O'Flaherty, T., Santoro, K., & Kaul, A. (2003). A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings. Journal of Pediatric Gastroenterology and Nutrition, 37, 473-480.

Chamberlin, J. L., Henry, H. M., Roberts, J. D., Sapsford, A. L., & Courtney, S. E. (1991). An infant and toddler feeding group program. American Journal of Occupational Therapy, 45, 907-911.

Craig, G. M., Scambler, G., & Spitz, L. (2003). Why parents of children with neurodevelopmental disabilities requiring gastrostomy feeding need more support. Developmental Medicine and Child Neurology, 45, 183-188.

Dodrill, P., McMahon, S., Ward, E., Weir, K., Donovan, T., & Riddle, B. (2004). Long-term oral sensitivity and feeding skills of low risk pre-term infants. Early Human Development, 76(1), 23-37.

Farrell, D. A., Hogopian, L. P., & Kurtz, P. F. (2001). A hospital- and home-based behavioral intervention for a child with chronic food refusal and gastrostomy tube dependence. Journal of Developmental and Physical Disabilities, 13(407-418).

Fox, M. K., Pac, S., Devaney, B., & Jankowski, L. (2004). Feeding infants and toddlers study: What foods are infants and toddlers eating? Journal of the American Dietetic Association, 104(Supplement 1), 22-30.

Franklin, L., & Rodger, S. (2003). Parents' perspectives on feeding medically compromised children: Implications for occupational therapy. Australian Occupational Therapy Journal, 50, 137-147.

Freed, M., Freed, L., Chatburn, R. L., & Christian, M. (2001). Electrical stimulation for swallowing disorders caused by stroke. Respiratory Care, 46, 466-474.

Galensky, T. L., Miltenberger, R. G., Stricker, J. M., & Garlinghouse, M. A. (2001). Functional assessment and treatment of mealtime behavior problems. Journal of Positive Behavior Interventions, 3(4), 211-224.

Gisel, E. G., Applegate-Ferrante, T., Benson, J., & Bosma, J. F. (1996). Oral motor skills following sensorimotor therapy in two groups of moderately dysphagic children with cerebral palsy: aspiration vs. nonaspiration. Dysphagia, 11, 59-71.

Gisel, E. G., Birnbaum, R., & Schwartz, S. (1998). Feeding impairments in children: diagnosis and effective intervention. The International Journal of Orofacial Myology: Official Publication of the International Association, 24(7), 27-33.

Hall, K. D. (2000). Pediatric Dysphagia: Resource Guide. San Diego: Singular Thompson Learning.

Hartnick, C. J., Bissell, C., & Parsons, S. K. (2003). The impact of pediatric tracheotomy on parental caregiver burden and health status. Archives of Otolaryngology and Head and Neck Surgery, 129(10), 1065-1069.

Hartnick, C. J., Hartley, B. E., Miller, C., & Willging, J. P. (2000). Pediatric fiberoptic endoscopic evaluation of swallowing. Annals of Otorhinolaryngology, 109(11), 996-999.

Kedesdy, J. H., & Budd, K. S. (1998). Childhood Feeding Disorders: Biobehavioral Assessment and Intervention. Baltimore: Paul H. Brookes Publishing Company.

Kerwin, M. E. (2003). Pediatric feeding problems: A behavior analytic approach to assessment and treatment. The Behavior Analyst Today, 4, 162-177.

Kingsley, R. E. (2000). Concise Text of Neuroscience (2nd edition ed.). Philadelphia: Lippincott, Williams and Wilkins.

Kosko, J. R., Moser, J. D., Erhart, N., & Tunkel, D. E. (1998). Differential diagnosis of dysphagia in children. Otolaryngology Clinics of North America, 31(3), 435-451.

Kovar, A. J. (1997). Nutrition assessment and management in pediatric dysphagia. Seminars in Speech and Language, 18(1), 39-49.

Leder, S. B., & Karas, D. E. (2000). Fiberoptic endoscopic evaluation of swallowing in the pediatric population. Laryngoscope, 110(7), 1132-1136.

Lefton-Greif, M. A., & Loughlin, G. M. (1996). Specialized studies in pediatric dysphagia. Seminars in Speech and Language, 17(4), 311-329.

Logemann, J. (1998). Evalution and Treatment of Swallowing Disorders (Second Edition). Austin: PRO-ED, Inc.

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ASHA Information

This information will be forthcoming.

FAQs

Feeding and Swallowing in the School FAQs:

Q. How are feeding and swallowing educationally relevant?
A. ASHA (2007) has identified 4 specific reasons feeding and swallowing are educationally relevant. These include:

1. Ensuring safety in the school setting, including safe from aspiration and choking.
2. Students must be properly nourished or hydrated to be in an optimal state for learning.
3. Aspiration places a child at risk for additional missed days of instructional time.
4. Students who take too long to eat will miss additional educational time trying to maintain nutrition and hydration

Q. What are signs of swallowing dysfunction?
A. Signs/symptoms of swallowing dysfunction (possible aspiration or penetration) include:

• Coughing (immediately or delayed)
• Change in respiration (increase in rate, more shallow breathing)
• Choking
• Gagging
• Changes in vocal quality (wet, gurgle)
• Color changes (gray, blue)
• Multiple swallows per bolus
• Sneezing
• Food/liquid coming out nose
• Clear nasal drainage specifically with oral intake

However, aspiration is likely to be silent in pediatrics.

Q. How do I refer for a video swallow study?
A. While there is no specific set procedure, you should talk to the patient and the patient’s family prior to contacting a physician for a referral. Most facilities require that a physician actually order the swallow study. You can generally ask the primary pediatrician or any other sub-specialist familiar with the child’s feeding and swallowing (e.g. pulmonology, GI, ENT). Be prepared to describe what signs/symptoms of swallowing dysfunction you see.

Also helpful would be to write up some description of the type of the observed signs/symptoms of swallowing dysfunction that initially caused concerned. This information needs to be shared with the SLP who completes the VSS. Write out as many specifics as possible including textures, volumes, positioning, the type of cup/straw, and possibly single vs. consecutive cup sips or bites to best replicate what the child does in the classroom.

You may also want to discuss the recommendation for a VSS with your administration prior to recommending to the family. You do have an ethical responsibility to ensure the child is safe.

Q. What if I don’t feel competent to treat a child with a feeding or swallowing problem?
A. While you are ethically bound by the ASHA code of ethics to provide assessment and/or intervention services if you know a child has a dysphagia, you are also ethically bound to only treat what you are competent to treat. If you do not feel comfortable to evaluate or treat, consult with your administration. They may be able to provide some additional continuing education or a consultant to assist with plan development and implementation.

Q. I have a family that wants their child to drink water at school, even though he was aspirating-can they do this?
A. Currently, there is no research to support the use of a free water protocol in the pediatric population. This should be discussed with the child’s physician and district administrators prior to implementation.