Feeding in tracheostomy & ventilator-dependent patients
Children's Feeding Program provides multidisciplinary care for children with medical conditions affecting feeding and growth, helping them achieve their greatest feeding potential. Among the most medically complex patients this program serves are children with tracheostomies and children who are ventilator-dependent. The following is an overview of the program's unique treatment approach which combines elements of behavioral intervention, structured oral motor intervention and systematic desensitization of sensory issues in addressing prevalent feeding concerns and encouraging the development of feeding and swallowing skills for these medically complex patients.
The two main concerns when assessing and treating the oral feeding needs of children with tracheostomies and ventilator dependency are oral motor function and learned behavioral responses to food and non-food oral stimuli. There are three main components to oral motor function that have to be assessed in order to create an effective treatment plan: the sensory system, motor function (strength, range of motion and coordination of muscles) and the physical structures.
The first barrier to overcome in treatment is oral hypersensitivity resulting from complicated medical histories (i.e., intubation, extubation, extended nasogastric tube placement and tracheostomy placement), frequent suctioning of secretions and prolonged lack of stimulation. Oral hypersensitivity creates difficulty progressing through the typical developmental stages because children with these issues tend to avoid touches and textures which allow them to explore and experience their environment. This results in increased or absent gag reflex in response to stimuli. The second component to consider is the motor function of the oral and pharyngeal cavity. Atypical neuromuscular responses such as hypertonia and hypotonia, difficulty managing secretions, and absence of or delayed swallow reflex are issues that children with tracheostomies and ventilator dependency often demonstrate. A child's physical structures are the third component in the assessment and treatment planning phase. Common abnormalities include dental occlusions, cleft lip/palate, shortened lingual frenulum, and enlarged tonsils and/or adenoids.
Assessing and planning treatment for children with tracheostomies also includes evaluation of their learned behavioral responses to stimuli and caregiver-child interactions during feedings. For children with complex medical histories involving medical procedures, there is an association between stimuli approaching their faces and discomfort. This can lead to extreme hypersensitivity and oral aversion, evident in behaviors ranging from volitional/non-volitional gagging or emesis to crying, screaming and turning or pushing away to avoid anything presented near the face or mouth. In order to work toward acceptance of oral motor exercises and feeding utensils, even without food and drink on them, systematic desensitization and shaping procedures must be used to decrease sensitivity and increase associations of objects coming toward their faces with pleasure rather than pain.
Interventions to address sensory and motor functions include Beckman oral motor exercises which involve assisted movement and strengthening to target hypersensitivity, range of motion, strength, and high or low tone for the lips, tongue, cheeks and jaw. Exercises are introduced slowly and systematically until completely tolerated in the clinic setting. Parents are taught to complete the exercises in the clinic setting before implementation in the home environment. In order to address learned behavioral responses, structured protocols are utilized involving positive reinforcement including television, toys and social praise to introduce dry utensils. A shaping technique of rewarding small, successive feeding steps of increasing duration/difficulty is used in conjunction to protocols to help reduce anxiety while building tolerance and skills. Compliant acceptance of the stimulus in the oral cavity is the first skill targeted.
Once acceptance is achieved, thickened, dyed water will be introduced. Various methods for facilitation of swallow initiation include stimulation of the anterior facial pillar, re-presentation of expels, and positive reinforcement for spontaneous or volitional swallowing. The use of positive reinforcement allows the child to learn new skills at a faster pace than traditional approaches which are not likely to include a behavioral component. Once the child is demonstrating a swallow at 50% accuracy, a modified barium swallow study (MBS) should be obtained to assess the swallowing function with foods/liquids of varied thicknesses, from pudding, honey or nectar to thin liquids, if possible. Optimally, the feeder for the MBS is someone who has been trained in the feeding protocol using the utensils and food with which the child is familiar.
It is also recommended that at some point during treatment children receive an assessment for a speaking valve from the feeding therapist, respiratory therapist and pulmonologist. In-line and traditional speaking valves could increase the efficacy of the swallow function by increasing airflow to the upper airway which increases sensation. Increased sensation leads to improved awareness and ultimately management of secretions (i.e., throat clearing, coughing or swallowing). A second feeding-related benefit of a speaking valve is the restoration of subglottic air pressure which could positively impact the swallow. Improved swallowing function allows therapy to focus on introducing a pureed diet and, ultimately, increasing volume consumed by mouth.
by Brandi Watts, MS, CCC-SLP, Speech/Language Pathologist, Donna Purcell, PsyD, LCP, Behavioral Psychologist, and Betsy Clawson, PhD, LCP, Behavioral Coordinator, Children's Feeding Program
Originally published in Early Edition Vol. X, No. 3