Dysphagia in the Schools (Part 1): An introduction for SLPs

Dysphagia in the Schools (Part 1): An introduction for SLPs


Welcome to Part 1 Dysphagia in the Schools:
An Introduction for SLPs. This is the first segment in a 4 part series. After participating in this module, please
proceed to presentations 2 through 4. This webinar is presented by the Virginia
Department of Education. My name is Julian White, and together with
Dr. Cynthia O’Donoghue, we have prepared a discussion on dysphagia management for Speech-language
pathologists in the schools. School Speech-language pathologists are providing
services to an increasing number of children with feeding and swallowing disorders. SLPs also are an important resource to the
team of specialists providing care for these children. This tutorial will provide a basic overview
of how school-aged children typically swallow, and briefly discuss what can go wrong that
results in swallowing and feeding difficulties. Included in this tutorial are the following
topics: normal swallowing anatomy, normal development of the swallow, typical swallow,
what can go wrong with the swallow, possible abnormalities of a swallow, and why this information
is important to me as an SLP in the School Setting. There may be some terms used in this tutorial
that you will want to review. It is important to remember that dysphagia
is a feeding or swallowing disorder that can occur anywhere from the mouth to the stomach Swallowing is a complex process, all the more
so because it occurs in the same anatomic region as respiration and breathing and phonation,
specifically in the area of the larynx and pharynx. For a successful and safe swallow to occur,
one has to coordinate 31 muscles, 6 cranial nerves, and several levels of the central
nervous system. Swallowing and feeding management of pediatric
dysphagia can be challenging for infants or younger children, particularly given the rapid
anatomical changes the child undergoes during the first few years of life. There are several differences in anatomy between
the infant and the adult, or even an older child’s anatomy. Infants have smaller oral and pharyngeal cavities,
and the majority of the mouth is filled by the tongue, which is optimal for nipple placement. An infant’s anatomy acts as a natural protective
mechanism, since both the pharynx and larynx are elevated in the neck, making it less likely
for aspiration to occur. As the infant matures, there is a backward
and downward shifting of the anatomical structures important for a normal swallow. By age five, the tongue moves lower in the
oral cavity, the pharynx becomes more compact, and the larynx has descended to the level
of cervical vertebra six. This is particularly important to know for
children with chronic conditions or underlying etiologies such as children with Down syndrome
who may have been able to swallow safely as infants, but as the child grows and the larynx
drops, aspiration risk may actually increase. Now we are going to briefly review the typical
development of feeding, which is important for you to understand so that you can identify
potential signs of dysphagia or “red flags.” Your observations when completing the case
history and feeding observations will guide decisions for your students with feeding or
swallowing issues. The advancement of feeding and swallowing
behaviors are influenced by multiple aspects of a child’s growth and maturation, including
anatomical, cognitive, social, emotional, sensory, and motor. During the first two years of life, several
developmental motor milestones underlie a child’s feeding progression. The charts provided on the next several slides
outline the development of feeding skills in relation to motor development. This is important to review as a school-based
SLP because delayed motor development in infancy can be a red flag for feeding impairments
later on as the child matures. Kelly Hall points out that, “Children who
do not develop age-appropriate feeding skills before 12 months typically have a more difficult
time developing normal feeding skills” (Hall, 2001). On each of the next two slides, there is a
chart of typical feeding development and motor development for your review and use. I do want to point out two recommendations
from the American Academy of Pediatricians (AAP) to keep in mind. One is that the AAP does recommend exclusive
breastfeeding until the infant is 6 months of age. It also does not recommend initiating purees,
such as baby foods, until 6 months, whether the baby is breast or bottle fed. You can also find this chart as a handout
attached to this presentation. Now we’re going to review the phases of
the normal swallow This picture from Dr. Arvedson and Dr. Brodsky
depicts the phases of the swallow. In order, the pictures show the oral phase,
the beginning of the pharyngeal phase, the pharyngeal phase with adequate airway protection,
the end of the pharyngeal phase, and the esophageal phase. The first phase of the swallow is the oral
preparatory phase where food passes the open lips, enters the mouth, and the formation
of the bolus occurs. Bolus preparation will vary based on the food
consistency ingested, for example liquids versus solids. The oral preparatory phase is where chewing
occurs. Once a cohesive bolus (or ball of food) is
formed, the tongue pushes the food, or the bolus, against the hard palate, and the soft
palate is lowered to help reduce premature spillage of the liquid or food into the pharynx. During the oral phase, the tongue moves in
a backward “stripping” movement to propel the bolus toward the pharynx. Once the bolus passes the anterior faucial
pillars, the oral phase ends and the pharyngeal stage begins. During both the oral preparatory and the oral
phases, the airway is open and breathing is occurring normally. Once the bolus moves past the anterior faucial
pillars, the pharyngeal phase begins. This phase is dynamic with multiple events
occurring at the same time. The soft palate moves up, the epiglottis folds
down, and the larynx moves up and forward. Also during the complex pharyngeal phase,
the true vocal folds close protecting the airway, and the pharyngeal constrictor muscles
squeeze to move the bolus down towards the esophagus, flowing through the upper esophageal
sphincter, or UES. All of these actions occur rapidly (typically
in about a second) and may be called the swallow “reflex” or triggering of the swallow. This is the phase where aspiration most frequently
occurs. The esophageal phase begins when the head
of the bolus passes through the upper esophageal sphincter, after which involuntary peristalsis,
a wave like motion, moves the bolus down through the esophagus. At the end of the esophagus, the bolus then
passes through the lower esophageal sphincter (the LES) and into the stomach. I want to note here that ASHA Guidelines for
Speech-Language Pathologists do outline that SLPs should be aware of how the esophageal
phase can impact the pharyngeal and oral phases. Within our scope and practice, we are charged
with having the knowledge and skills to recognize patient signs and symptoms associated with
esophageal dysphagia. This is a timely transition into our discussion
of abnormal swallowing and feeding. Now we’re going to take what we know of
the normal swallow and transition into the parts of feeding and swallowing that can be
impaired, and why that matters. A feeding and swallowing impairment, or dysphagia,
is more likely to occur in children with atypical development, such as congenital or acquired
neurological conditions, structural abnormalities, or other complex medical conditions. Studies show that 30-80% of children with
developmental disorders have feeding and/or swallowing dysfunction. Here are some of the most common signs of
feeding/swallowing disorders in school age children. Symptoms of dysphagia can include overt discomfort
such as coughing and choking with meals, but can also result in weight loss or poor weight
gain, behavioral issues during meal times, or even excessive drooling. Of course, one of the major concerns with
swallowing disorders is aspiration. This is concerning because it can result in
recurrent respiratory illnesses, pneumonia, weight loss, and permanent lung damage in
still developing young lungs. It can also result in death, particularly
in the medically fragile population. This image shows a picture of lungs with changes
consistent with chronic aspiration. Here is a list of red flags specific to each
phase of the swallow. This is certainly not an exhaustive list,
and some of these red flags may also indicate dysfunction in more than one phase of the
swallow. Red flags for pharyngeal and esophageal phases
are not as readily seen as oral phase difficulties. These problems can include wet vocal quality,
congestion, gagging, drooling, food refusal, or volume limiting. Although aspiration is a primary concern in
children with dysphagia, it is particularly critical in the pediatric population, to recognize
other significant consequences of impaired feeding and swallowing such as “failure
to thrive” or “undernutrition.” We know that abnormal feeding behaviors can
significantly impact quality of life for both the child and the family. This list is from the ASHA website and it
details possible long-term consequences of swallowing problems. Remember that feeding and swallowing disorders
can have psychosocial effects on both the child and family So why does all of this information apply
to the school-based SLP? ASHA Guidelines state that it is part of a
school-SLP’s scope of practice to ensure safe and efficient eating in the school setting. For a comprehensive review of pediatric dysphagia
management, I refer you to ASHA’s Practice Portal under the Clinical Topic “Pediatric
Dysphagia.” IDEA (2004) also specifies that school districts
have the responsibility to ensure children are safe at school, which includes eating
in a safe and efficient manner, that children have adequate nutrition and hydration in order
to fully access and participate in their curriculum, and are healthy enough to attend school. As I shared at the beginning of this module,
the number of children requiring dysphagia management in the schools is increasing, in
part due to the increasing survival rates of premature infants and children with severe
disabilities. According to research done by Linscheid in
2008, the incidence of swallowing and feeding disorders in children can range between 25–45%
in typically developing children and up to 80% of children with developmental disabilities. This certainly increases the chances that
there are children with feeding and swallowing disorders in most school systems. This is particularly prevalent for our students
with underlying medical diagnosis and developmental disabilities. For example, studies show that upwards of
99% of children with cerebral palsy have high rates of dysphagia and/or silent aspiration. Silent aspiration means they show no outward
signs of problems, such as coughing or choking. Further, children diagnosed with autism spectrum
disorder are 5 times more likely to have a feeding or swallowing problem. And finally, remember that children with feeding
and swallowing disorders require an interdisciplinary team approach, which involves caregivers,
medical professionals, the school-based speech-language pathologist, and likely others in the school
system. Here are the references for Part 1 of this
4 part series For additional resources please see the attached
document entitled “Pediatric Feeding and Swallowing Resources”. This completes Part 1 of Dysphagia in the
Schools: An Introduction for SLPs. To receive a certificate of completion for
this module, you must pass the VDOE knowledge check with a score of 80% or higher. Return to the VDOE SLP Professional Development
page to take the knowledge check. For continued learning, Dysphagia modules
2, 3 and 4 are also available on the VDOE SLP website. Thank you for participating in this webinar
presented by the Virginia Department of Education

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