By: Donna Edwards, MA CCC-SLP, BCS-S
As we begin our pediatric series, I thought it best to build on the previous article “Dysphagia in Children and Young Adults with Neuromuscular Disorders” by Lenie van den Engel-Hoek, PhD who in her opening paragraph introduces us to dysphagia and a relationship to choking.
Eating is a learned skill incorporating a myriad of complex neurophysiological processes that are impacted by a multitude of variables in the meal time environment, in the presentation by and expectations of the feeder, and in the inherent uniqueness of the pediatric patient, family and culture that we serve. Over this series we will delve into various aspects of typical/atypical feeding and swallowing.
For decades professionals have explored use of clinical techniques and research endeavors to provide improved oral feeding for children and thus optimize safety, growth, development, maturation and enhancement of mealtimes with family. Our ultimate goal has been optimization of feeding skills, enhancement of nutrition/hydration for growth and development, family interactions during meal times and support of cultural traditions.
Despite our diligence and understanding of feeding and swallowing disorders, our awareness of choking risk in pediatrics is often misaligned with current data.
This article was reposted from Dysphagia Cafe.
By: Lisa A. Olsen, OTD, OTR/L
The purpose of this paper is to visually demonstrate through the use of a concept map, the multidimensional and multifaceted aspects of feeding and eating, with pediatric patients and identify the need for a collaborative multidisciplinary team approach to this seemingly ordinary activity of daily living (ADL) (Miller, et. al., 2001). The American Occupational Therapy Association (AOTA) Practice Framework, & position paper for Specialized Knowledge & Skills for Feeding, provides foundational guidelines of how occupational therapy (OT) should be involved in this daily occupation (AOTA, 2008, 2007).
A Concept Map is utilized in order to effectively discuss and visually describe the topic of Pediatric Feeding involving skills, competency and function. The topic and format is intended to inform occupational therapy practitioners, occupational therapy students and non- OT healthcare professionals. The concept map supports the effort to coordinate evaluation and treatment as a team and as an individual OT clinician to facilitate pediatric feeding success and to identify the interrelationship between the medical, physical, sensory, behavioral, social, emotional and environmental aspects of feeding.
Assist the practitioner to identify the multifaceted and multidimensional aspects of feeding and eating; inform identification of interventions used to facilitate successful pediatric feeding by occupational therapists and other healthcare professionals and, educate OTRs, OT students and non-OT healthcare professionals regarding the multidimensional aspects of pediatric feeding and the role of OT in feeding.
The concept map is broken into sections to demonstrate the interrelationships between the physical, medical, sensory, behavioral, psychosocial, emotional, spiritual and environmental aspects of feeding and eating. It presents a holistic view of facilitating successful function and engaging in purposeful activity (AOTA, 2008). The map itself utilizes color clusters to show different categories and relationships with the concepts and elements of feeding. Connecting words help tell the story of how feeding is multidimensional, multifaceted and multidisciplinary to include the role of OT as well as nursing, physicians and other health care personnel (AOTA, 2008).
The concept map indicates the process of evaluation and assessment as the first step in addressing pediatric feeding. Typical assessment includes: gathering of patient medical history, medical testing, physical exam and instrumental assessments for the swallow such as the modified barium swallow study (MBSS) (Wilcox, Liss, & Siegel, 1996); flexible endoscopic evaluation of swallowing (FEES) (Hoppers & Holm, 1999); Cervical Auscultation-(stethoscope listen to swallow); upper GI; and review of lab tests, general x-ray, CT, MRI and ultrasound. Further, the feeding specialist or OT practitioner will then perform a clinical assessment reviewing the status of the anatomy, head and neck, swallowing mechanisms, function/dysfunction of the cranial nerves, oral motor skills and performance and actual feeding trials when possible (Howe & Wang, 2013).
Testing methods can include use of the Morris & Klein pre-feeding scales (2000) to identify age levels related to skills and the use of the Schedule for Oral Motor Assessment (Ko, Kang, Ko, Ki, Chang, & Kwon, 2011). Sensory function of global sensory processing and sensory responses of the oral motor area are evaluated with both nutritive and non-nutritive means. Assessment as well as intervention also includes attention to positioning and the environment. Additional components of consideration include: position used when feeding and not feeding; child’s tolerance of position changes; caregiver management of position; us of or indication for seating/equipment; alignment of the trunk, head, neck and jaw, and the child’s responses to noise, light and distractions (Morris & Klein, 2000).
The psychosocial aspect of feeding is evaluated as eating takes place in community; at home or in public; for celebration, or life sustaining purposes. Occupational therapy looks at the holistic needs and influences of this activity of daily living and how important it is to the individual socially, emotionally, spiritually and functionally (AOTA, 2008, 2007). Family time, one on one time with the care giver, gatherings with friends or colleagues are all part of the psychosocial aspects of the feeding and eating occupation.
Sensory concerns such as taste, touch and smell of the food as well as the utensils, equipment, sounds and distractions and their influence on feeding are also identified.
The map then indicates how issues of sensation and sensory processing influence feeding and can have an impact on behavior demonstrating a relationship between behavior and sensory difficulties (Davis et. al., 2013). Behavior can be influenced by overall sensory processing expressed as fight or flight, poor self-esteem; irritability; produce battles, struggles and stress with care givers, and can be influenced by peers and social pressure (Clawson, Kuchinski, Bach, 2007; Davis et. al., 2013).
Finally, the concept map identifies the areas of direct intervention by the OT related to oral motor activities and eating activities (Sheppard, 2008). The map identifies the different stimulation activities to the oral motor structures and the activities related to manipulation of foods, utensils, equipment, positioning, the environment, and experiences of emotion and performance (Clark, Lazarus, Arvedson, Schooling, & Frymark, 2009).
In conclusion, the concept map provides a visual explanation of how OT works with pediatric patients to facilitate successful feeding and eating with multidimensional and multidisciplinary considerations (Arvedson, Clark, Lazarus, Schooling & Frymark, 2010). Occupational Therapy takes a holistic, multifaceted, multidimensional and multidisciplinary approach towards success with pediatric feeding (AOTA, 2008). This concept map allows the OT to inform fellow practitioners, students and other healthcare professionals in how the process of pediatric feeding requires a team approach (Miller, et. al., 2001).
To read more on dysphagia, visit our sister site Dysphagia Cafe
About the Author
Lisa Ann Olsen, OTD, OTR/L is a pediatric occupational therapist practicing in Orange County, California. She received her B.S. from the University of Southern California and her doctorate from Creighton University in Omaha, Nebraska. Dr. Olsen presented her conceptual model for pediatric feeding skills at the 2014 OT Association of California annual conference. She has her CA Advanced Practice license for Swallowing Assessment, Evaluation, and Intervention.
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