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Dra. Myrian Adriana Pérez García
• Venezuelan Otorhinolaringologist• Former coordinator of the laryngology, fonation and swallowing unit of
Children´s Hospital “J.M de los Ríos”• Former Specialist of Instituto de Otorrinolaringología de Caracas• Chair of the UNILAR Unidad Laringológica del Este (Estern
Laryngological Unit). Caracas - Venezuela• Autor of the Book:
– MANUAL DE DISFAGIA PEDIÁTRICA• Professor of the Diplomado Teórico-Práctico de Laringología Básica
Dr. Myrian Adriana Pérez Dr. Myrian Adriana Pérez GarcíaGarcía
BARCELONA, SPAIN. JULY: 2nd-6th
Evaluation of Deglutition in in ChildrenChildren
Evaluation of Deglutition in in ChildrenChildrenwww.unilar.com.ve
ContentsContentsContentsContents
• Suction-swallowing and breathing process maturation (Anatomy/physiology).
• Otorhinolaryngologist evaluation of deglutition (functional endoscopic evaluation of swallowing).
• Pediatric Laryngopharyngeal reflux (It´s relationship with dysphagia).
• Swallowing disorders: Diagnose and Management.
3
DysphagiaDysphagiaDysphagiaDysphagia
• Difficulty:
• Sucking-Swallowing-feeding
• Motor-Sensitive
• Safety-Efficiency
4
BackgroundBackgroundBackgroundBackground
• Poor Epidemiological data: incidence/prevalence.
• Relatively common in early infancy
• 35% infants presents food selectivity
• 80% Neurological diseases presents dysphagia (Cerebral palsy).
• 90% Associated with malnutrition.
• 80% Oral and pharyngeal phase altered.
• 78% Pediatric Laryngopharyngeal reflux it´s related to dysphagia.
5
Anatomy and PhysiologyAnatomy and Physiology
Suction-swallowing and breathing process maturation
Suction-swallowing and breathing process maturation
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Suction-swallowing and breathing process maturationSuction-swallowing and breathing process maturationSuction-swallowing and breathing process maturationSuction-swallowing and breathing process maturation
• Critical and Sensitive Periods
• Prenatal
• Postnatal:
• Preterm
• Full-term
7
PrenatalPrenatalPrenatalPrenatal
• Swallowing 10th-12nd w
• Sucking 18th- 24th w
• Sucking reflex 28th w
• Rooting reflex 32nd w
8
PrenatalPrenatalPrenatalPrenatal
• Patterns: Reticular formation and brain cortex area
• Respiratory pause-swallowing-respiratory pause(32nd)
• Inspiration-swallowing-expiration(36th)
• Nutrition totally orally(34th-37th)
9
PostnatalPostnatalPostnatalPostnatal
• Anatomically/Functionally
• Preterm
• Full-term
10
PRETERM
1. Cannot coordinate suction-swallowing and breathing
2. Immature sucking3. Poor negative pressure4. Pharyngeal phase not well
coordinated.
FULL-TERM
1. Coordinate suction-swallowing and breathing
2. Food-seeking behavior: rooting3. Effective sucking4. Normal pharyngeal phase
coordination
11
PostnatalPostnatal
PostnatalPostnatalPostnatalPostnatal
• FULL-TERM
• 1st-3rd mo
• 4th-6th mo (transitional)
• 6th-7th mo (developmental)
• 10th-12nd mo
• -36th mo
12
11stst - 3 - 3rdrd mo mo11stst - 3 - 3rdrd mo mo
• Excitatory reflex
• Rooting reflex
• Sucking reflex (pump-like reflex)
• Normal rate:
• Suck/Swallow 1:1 - 3:1
• Liquids and solids equal
• Gag reflex
13
44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)
• Preparatory and oral phase
• No excitatory lower lip reflex
• No rooting reflex
• Posterior gag reflex
• Preparatory and oral phase
• Solid food- posterior tongue positioning
• 5th months, small bites
• Spoon feeding initiation: some developmental skills
14
44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)44thth / 6 / 6thth mo - 9 mo - 9thth (Transitional) (Transitional)
• Rithmic bites
• Spoon feeding for thin, smooth puree
• Upright position
• Both hands to hold bottle
15
99thth - 18 - 18thth mo (Developmental) mo (Developmental) 99thth - 18 - 18thth mo (Developmental) mo (Developmental)
• Precise picking small pieces of food
• Pincer grasp
• Cup drinking
• Finger feeding
• Teeth
16
Normal SwallowNormal Swallow Normal SwallowNormal Swallow
• Oral Preparatory Phase
• Oral Phase
• Pharyngeal Phase
• Esophageal Phase
17
• Craneal Nerve: IX, X, XI
• Swallow center: pons
• 5 events:
• Velarpharyngeal sphincter
• Pharyngeal muscle
• Hyoid bone
• Vocal fold
• UEE
Functional Endoscopic Evaluation of Functional Endoscopic Evaluation of SwallowingSwallowing
Otorhinolaryngologist Evaluation of deglutition
Otorhinolaryngologist Evaluation of deglutition
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Feeding GoalsFeeding Goals Feeding GoalsFeeding Goals
• Preserve and guarantee Preserve and guarantee
• Good nutrition/ hydration statusGood nutrition/ hydration status
• Safety and efficiencySafety and efficiency
19
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• History: Prenatal, Postnatal
• Physical Examination
• Non-instrumental/Instrumental
• Feeding Observation
• Non-instrumental/Instrumental
20
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• History:
• Description of child´s mealtimes:
• Food types
• Frequency
• Duration
• Respiratory system
• Weight
21
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• History:
• Alert!:
• Feeding time more than 30-40 min
• Respiratory Distress
• Not gaining weight (2-3 m)
22
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Physical Examination:
• Baseline health
• Medical status
• Non-instrumental
23
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Physical Examination:
• Instrumental:
• Anatomical abnormalities
• Pooling secretions
• Vocal folds
• Safety
24
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Feeding Observation
• Non-instrumental:
• Feeding position
• Sucking reflex
• Rooting
• Mouth/lips closure
• Jaw Movements
• Spliting
25
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Feeding Observation
• Non-instrumental:
• Feeding position
• Sucking reflex
• Rooting
• Mouth/lips closure
• Jaw Movements
• Spliting
26
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Feeding Observation
• Instrumental
• Feeding Observation
• Instrumental
27
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Feeding Observation
• Instrumental
• Feeding Observation
• Instrumental
28
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• Feeding Observation
• Instrumental:
• FEES (FEEST)
• VFES
• Feeding Observation
• Instrumental:
• FEES (FEEST)
• VFES
29
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
• FEES Protocol:
• NB- 4mo: Bottle, water, milk
• 4 - 6mo: Bottle, water, juice, apple sauce, condensed milk, spoon.
• 6mo- 1y: + yoghurt, small cup, jelly, cake.
• 1y - older: + straw, , worst meal
• FEES Protocol:
• NB- 4mo: Bottle, water, milk
• 4 - 6mo: Bottle, water, juice, apple sauce, condensed milk, spoon.
• 6mo- 1y: + yoghurt, small cup, jelly, cake.
• 1y - older: + straw, , worst meal
30
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
31
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
32
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
33
Clinical Feeding EvaluationClinical Feeding Evaluation Clinical Feeding EvaluationClinical Feeding Evaluation
34
And DysphagiaAnd Dysphagia
Pediatric Laryngopharyngeal RefluxPediatric Laryngopharyngeal Reflux
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Pediatric LPRPediatric LPR Pediatric LPRPediatric LPR
Laryngopharyngeal Reflux (LPR)
• UES Dysfunction
• Backflow to the larynx
• Esophagus clearance normal
• Respiratory symptoms
• Cough and hoarseness
• Regurgitation
• Dysphagia
Gastroesophageal Reflux (GERD)
• LES Dysfunction
• Backflow to esophagus
• Esophagus clearance altered
• GI symptoms
• Heartburn
• Regurgitation
36
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Laryngopharyngeal Reflux (LPR) • Endoscopic findings:
• Belafsky Scale:
37
Subglottic edema(pseudopsulcus)
Ventricular Obliteration ArytenoidErythema/Hyperemia
Vocal fold edema
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Laryngopharyngeal Reflux (LPR)
• Endoscopic findings:
• Belafsky Scale:
38
Laryngeal Edema Posterior comissure hypertrophy
Granuloma /Granulation tissue
Laryngeal mucus
• Results:
• < 7 (no reflux)
• 7-11 (mild reflux)
• > 11 (severe reflux)
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Laryngopharyngeal Reflux (LPR)
• Endoscopic findings:
39
Laryngomalacia Regurgitation
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Laryngopharyngeal Reflux (LPR)
• Endoscopic findings:
40
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Physiopathology
• Sensitive:
• Hyposensivity: Laryngeal Adductor Reflex
• Hypersensivity: Oral
• Motor: LES low pressure
41
• Air pulse- Arytenoids
• Normal response: 2-4mmHg
• Reflex:
• Vocal fold closure
• Swallowing
• Cough
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and DysphagiaPhysiopathology
42
LPR
Regurgitation
Acid/PepsinAnd/or
Oral and Pharyngeal erythema
Laryngeal edema
Altered Sensitivity
Oral
Larynx
Vomiting
Adductor reflexMicroaspiration
DysphagiaDysphagia
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Diagnosis
• Esophageal Manometry
• 24 pH double probe
• Esophagoscopy
• Fiberoptic nasopharyngolaryngoscopy
• Videofluoroscopy
• Fibro endoscopic evaluation of swallowing
43
Pediatric LPR and DysphagiaPediatric LPR and Dysphagia Pediatric LPR and DysphagiaPediatric LPR and Dysphagia
Management
• Upright position
• 2 hours after meal
• Avoid citric, lactose products
• Small Frequent meals
44
• Pump-bomb Inhibitors
• Prokinetics
• H2 antagonists
Diagnose and ManagementDiagnose and Management
Swallowing DisordersSwallowing Disorders
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DysphagiaDysphagia DysphagiaDysphagia
Interdisciplinary team approach
46
•OtorhinolarygologistOtorhinolarygologist•Speech PathologistSpeech Pathologist•NutritionistNutritionist•GastroenterologistGastroenterologist•Pediatric surgeonPediatric surgeon•PediatricianPediatrician•NeumologistNeumologist•NeurologistNeurologist
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
DysphagiaDysphagia DysphagiaDysphagia
47
•Primary problem areasPrimary problem areas•Severity of swallowing disorder Severity of swallowing disorder •Saliva poolingSaliva pooling•Other diseases (LPR, pulmonary infection)Other diseases (LPR, pulmonary infection)•Nutritional/Hydration statusNutritional/Hydration status•Actual SkillsActual Skills
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
Diagnosis
DysphagiaDysphagia DysphagiaDysphagia
Severity Swallowing Disorder
48
PhonoaudiologicalPhonoaudiological Protocol for dysphagia risk evaluation (PARD) (1).Severity levels: 7Consistencies, strategies/time/cough→ ManagementLevel I: Normal DeglutitionLevel II: Functional DeglutitionLevel III: Mild Oropharyngeal dysphagiaLevel IV: Mild to moderate Oropharyngeal dysphagia
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
DysphagiaDysphagia DysphagiaDysphagia
Diagnosis
49
PhonoaudiologicalPhonoaudiological Protocol for dysphagia risk evaluation (PARD) (1).Severity levels: 7Consistencies, strategies/time/cough→ ManagementLevel V: moderate Oropharyngeal dysphagiaLevel VI: moderate to severe Oropharyngeal dysphagiaLevel VII: severe Oropharyngeal dysphagia
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
DysphagiaDysphagia DysphagiaDysphagia
Severity Swallowing Disorder
50
Level I: Normal DeglutitionLevel II: Functional Deglutition
More timeLevel III: Mild Oropharyngeal dysphagia
Diet changes, may need some therapyLevel IV: Mild to moderate Oropharyngeal dysphagia
One (1) consistency restriction. Therapy for avoiding aspiration risk.Need nutritional suplement
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
DysphagiaDysphagia DysphagiaDysphagia
Severity Swallowing Disorder
51
Level V: Moderate Oropharyngeal dysphagiaOral and feeding tube. Therapy. Restriction two (2) consistencies
Level VI and VII: Moderate to severe Oropharyngeal dysphagiaNon-oral feeding
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
DysphagiaDysphagia DysphagiaDysphagia
Non-surgical management
52
•Posture-positioning changes•Volume, consistency, texture, temperature bolus changes•Non-nutritive program•Nutritive program•Botulinum toxin if needed
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
DysphagiaDysphagia DysphagiaDysphagia
Surgical management
53
•Nasogastric feeding tube•Gastrostomy tube•Surgical management of salivary glands•Vocal fold medialization•Cricopharyngeal miotomy•Tracheostomy•Laryngopharyngeal Division
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
ConclusionsConclusions ConclusionsConclusions
54
•Emphasis in whole infant status (safety, comfort, pleasure).
•Oral feeding is not always the “GOAL”.
•Real Goals : Pulmonary stability and Nutritional well-being
•If we diagnose LPR we must give treatment for it!
•Close follow up to make changes when needed
(1)Padovani AR, Moraes DP, Mangili LD, Andrade CRF. Procolo fonoaudiológico de avaiaciao do risco para disfagia (PARD).Rev Soc Bras Fonoaudiol.2007;12(3):199-205
Thank youThank youwww.unilar.com.ve