Paediatric Dysphagia: An Introductory Presentation on Swallowing Disorders

What is Dysphagia?

Dr Cynthia Sawasawa Paediatric dysphagia -Week 1What is dysphagia "Any disruption to the swallow process that results in the compromise to the safety, efficiency, or adequacy of nutritional intake" (Dodrill & Gosa, 2015).Feeding and swallowing difficulties These are difficulties that affect the normal process of eating and drinking which may cause difficulties in feeding such as sucking, manipulating a bolus and chewing. Additionally, they may cause difficulties in one or more phases of the swallow mechanism (Van den Engel-Hoek et al., 2015)

Prevalence of Feeding and Swallowing Difficulties

25 % - 40 % in typically developing children 80% in children with developmental disorders Prevalence 85% in children with complex medical conditions The prevalence of FSD in the South African paediatric population is unknown

Brain and Swallowing Functions

Brain and swallowingFunctions of the parts of the brain Dura Skull bone Cerebrospinal fluid Blood vessel

Brain Lobes and Their Functions

Frontal lobe Parietal lobe · movement · intelligence · intelligence · reasoning · reasoning · telling right from left · behavior · language · memory · sensation · personality · reading Temporal lobe Occipital lobe · vision · memory · hearing · vision Cerebellum · emotions · balance · coordination · fine muscle control

Brain Stem Functions

Brain stem · breathing · blood pressure · heartbeat · swallowing · speech · behavior

Cranial Nerves for Feeding and Swallowing

Cranial nerves responsible for feeding and swallowing

Cranial Nerve Sensory / Motor Nerve Function

Trigeminal Nerve (V)

Trigeminal (V) 5 Sensory and Motor Sensory: Face, cheeks, lips, jaw, forehead, eyes, eyebrows, nose (pain, temperature, touch, proprioception), anterior 2/3 of the tongue, mouth , soft palate Motor: Jaw lateralization and closure, anterior movement of tongue, palatal elevation

Facial Nerve (VII)

Facial (VII) 7 Sensory and Motor Sensory: Taste to the anterior 2/3 of the tongue, touch to the lips Motor: Facial expressions, mouth closure, hyoid movement, upper oesophageal opening

Glossopharyngeal Nerve (IX)

Glossopharyngeal (IX) 9 Sensory and Motor Sensory: Taste to posterior 1/3 of tongue, sensation to tonsils-soft palate-upper pharynx Motor: pharyngeal and laryngeal elevation, hyoid elevation, pharyngeal dilation

Vagus Nerve (X)

Vagus (X) 10 Sensory and Motor Sensory: Palate, pharynx, larynx, trachea, lungs, epiglottis. Motor: Elevation/depression of soft palate, elevation of posterior tongue, elevation/closure of larynx, pharyngeal constriction, lowering of larynx after swallow, cricopharyngeal function, oesophageal peristalsis

Hypoglossal Nerve (XII)

Hypoglossal (XII) 12 Motor Motor: Tongue movement

Anatomic Differences: Infant vs. Adult

Anatomic differences between an infant and an adult Hard Palate Soft Palate Vallecula Nasopharynx Maxilla- Nasopharynx Tongue Oropharynx 0 Soft palate Tongue Hypopharynx Vallecula Hypopharynx 0 Hyoid Hyoid 0 0 Epiglottis 0 0 Larynx - Esophagus Trachea- 0 0 Trachea Esophagus Mandible 8 Larynx Epiglottis 0

Oral Cavity Differences

Anatomic Location Child Adult Oral cavity · Tongue fills mouth ·Lacking teeth (edentulous) .Tongue rests against lips and sits against palate ·Cheeks have sucking pads ·Relatively smaller than mandible ·Sulci are important for sucking Mouth is larger, tongue rests on floor of mouth · Teeth present (dentulous) . Tongue rests behind the teeth and is not against palate . Buccinators are muscles for chewing only · Mandibular-maxillary difference is relatively normal · Sulci have little functional benefit

Pharynx Differences

Pharynx No distinct oropharynx ·Obtuse angle at skull base in nasopharynx . Elongated pharynx (distinct oropharynx exists ·90º angle at skull base

Larynx Differences

Larynx · 1/3 adult size .1/2 true vocal fold of cartilage · Narrow, vertical epiglottiis • Less than 1/3 true vocal fold of cartilage • Flat, wide epiglottis

Floor of the Mouth Muscles

Suprahyoid Muscles

Floor of the mouth muscles - Suprahyoid Digastric (anterior belly) Mylohyoid Stylohyoid Geniohyoid Digastric (posterior belly)

Infrahyoid Muscles

Floor of the mouth muscles - Infrahyoid Omohyoid (superior belly) Thyrohyoid Sternohyoid Sternothyroid Omohyoid (inferior belly)

Suprahyoid and Infrahyoid Muscle Actions

Suprahyoid Infrahyoid Muscle Action Muscle Action Mylohyoid Elevates the floor of the mouth and hyoid Omohyoid Depresses the hyoid Digastric belly (anterior and posterior) Elevates the hyoid Sternohyoid Depresses the hyoid Geniohyoid Elevates hyoid or lowers the mandible Sternothyroid Pulls the larynx backwards Stylohyoid Upward and backward movement of the hyoid Thyrohyoid Depresses hyoid

Reflex Development in Utero

Reflex development in Utero

Reflex Gestational Age

• Pharyngeal swallow 12 weeks gestation
• Sucking reflex 15 weeks gestation
• Gag reflex 27 weeks gestation
• Rooting reflex 32 weeks gestation
• Suck-swallow-breathe coordination 34 weeks gestation

Oral Reflexes Present at Birth

Oral reflexes present at birth

Reflex How to stimulate Response Cranial nerves Presents Diminishes

Gag Reflex

Gag Touch posterior tongue or pharynx Mouth opening, head extension and floor of mouth opening IX 27 weeks Persists

Phasic Bite Reflex

Phasic bite Pressure to gums Rhythmic up and down jaw movement V 28 weeks 9-12 months

Transverse Tongue Reflex

Transverse tongue Touch / stroking lateral surfaces of the tongue OR gums Tongue moves towards the side of the stimulation XI 28 weeks 6 - 9 months

Tongue Protrusion Reflex

Tongue protrusion Touch to anterior tongue Tongue protrudes from mouth XII 38-40 weeks 4 - 6 months

Rooting Reflex

Rooting Touch / stroke infant's mouth/cheek Infant turns head toward stimulation V XI 32 weeks 3 - 6 months VII XII

Sucking Reflex

Sucking Place nipple in mouth Up and down tongue movement; smaller V VII Birth 24 months or older vertical jaw excursion, jaw moves more independently IX XII X Cortex

Normal Feeding Milestones

Normal feeding milestones

Age Type of food Manner of feeding and utensils

Feeding Milestones: 0-6 Months

0 - 6 months Breastmilk or Formula Sucking Breast, bottle, cup, syringe

Feeding Milestones: 6 Months

6 months Introduction of Complementary feeds e.g., porridge, pureed vegetables Sucking Spoon feeding

Feeding Milestones: 6-8 Months

6 - 8 months Breastmilk / Formula Complementary feeds (pureed / textured purees ) Breast, bottle, spoon feeding

Feeding Milestones: 8-12 Months

8 - 12 months Breastmilk / Formula Juices Complementary feeds (mashed foods with texture or lumps ) Finger food Breast, bottle, spoon feeding Introduction of cup drinking

Feeding Milestones: 12-15 Months

12 -15 months Liquids Mashed foods Finger foods Breast, bottle, spoon feeding, cup drinking. (self-feeding)

Feeding Milestones: 15-24 Months

15 - 24 months Family food Self feeding, cup drinking, breast / bottle feeding

Feeding Milestones: 12-36 Months

12 - 36 months Liquids Straw drinking

Oxygen Saturation in Infants

Oxygen saturation

Typically developing 95% - 100%

Infant 90+ %

Normal Pulse Rate for Infants and Children

Normal pulse rate for infants and children

Age Pulse Rate Range

• Newborn baby (0 - 3 months) 100 - 150
• Infants ( 3 - 6 months ) 90 - 120
• Infants ( 6 - 12 months) 80 - 120
• Children (1 - 10 years) 70 - 130

Criteria and Scoring of the Apgar Scale

Criteria and Scoring of the Apgar Scale

Score Colour Heartbeat Reflex irritability Muscle tone Respiratory effort

Apgar Score: 0

0 Blue, pale Absent No response Flaccid, limp Absent

Apgar Score: 1

1 Body pink, extremities blue Slow (below 100) Grimace Weak, inactive Irregular, slow

Apgar Score: 2

2 Entirely pink Rapid (over 100) Coughing, sneezing, crying Strong, active Strong cry

Levels of Prematurity

Levels of prematurity

Gestation Definition

• Normal 40 weeks
• Moderate or Late preterm 32 < 37 weeks
• Very preterm 28 < 32 weeks
• Extremely preterm <28 weeks

Example for Working Out Corrected Age

Example for working out corrected age Zanele is currently 6 months old. She was born at 32 weeks gestation. What is her corrected age? 40 weeks (normal length of pregnancy) - 32 weeks = 8 weeks (or 2 months) premature THEREFORE 6 months (current age) - 2 months (premature) = 4 months corrected age Assessments and results would be interpreted as though Zanele was 4 months old