Lumiere children's therapy

Lumiere Children’s Therapy: Feeding Tubes

For children who are at risk for complications when eating by mouth, feeding tubes can provide necessary nutrition in a safe manner. Problems with swallowing may occur in one of the four stages of the swallow as described in a previous post,  Swallowing Difficulties in Children. There are six types of feeding tubes available to children with swallowing problems. Below explains the advantages and disadvantages of each type of feeding tube, as well as treatment for children with a feeding tube.

Nasal Feeding Tubes

Nasal feeding tubes are tubes that are entered through the nose down the esophagus. There are three types of nasal feeding tubes: nasogastric, nasoduodenal, and nasojejunal. Deciding between the three types depends on whether your child can tolerate feedings into the stomach. Nasoduodenal and/or nasojejunal tubes are recommended if a child demonstrates chronic vomiting, inhaling or aspirating stomach contents into airway, and/or does not empty feedings well since those tubes bypass the stomach.

Nasogastric Tubes (NG)

NG tube enters through the nose feeding into the stomach through the esophagus (connects the throat to the stomach).

  • Advantages

    • No anesthesia is required for insertion of tube

    • Tubes may be replaced at home

    • Feedings are usually quick

    • NG are used for shorter duration cases, usually 1-6 months

    • Stomach provides a larger capacity for feedings

  • Disadvantages

    • NG tube is visible on face

    • NG tube can be irritating so younger children may pull it out

    • Increased risk of aspiration (food or liquid entering airway) from reflux

    • Increased nasal congestion

    • Possibility to cause oral aversions and/or increase amount of reflux

Nasoduodenal Tubes (ND)

ND tubes enter through the nose and extend into the beginning of the small intestine called the duodenum. The small intestine is the location of the majority of digestion in a person’s body, therefore bypassing the stomach.

  • Advantages

    • No anesthesia is required for insertion of tube

    • Can reduce reflux. Reflux is when stomach bile irritates the food pipe by coming back up the esophagus

    • Reduced risk of aspiration (food or liquid entering airway) from reflux

    • ND are used for short term use, usually 1-6 months

  • Disadvantages

    • Feedings are given slowly over 18-24 hours

    • Child may be self-conscious with visible tube coming from nose

    • Tube may be irritating with younger children possibly pulling it out

    • Potential intolerance to feedings entering small intestine causing bloating, cramping, and/or diarrhea

Nasojejunal (NJ)

NJ tubes are similar to ND as they enter through the nose extending into the small intense. NJ tubes extend further into the small intestine called the jejunal. The tube is designed for children who demonstrate difficulty with feedings into their stomach.

  • Advantages

    • No anesthesia is required for insertion of tube

    • Reduces risk of reflux

    • Reduced risk of aspiration (food or liquid entering airway) from reflux

    • Tubes are primarily recommended for short term use (1-6 months)

  • Disadvantages

    • Feedings are given slowly over time

    • Tube is visual, so may be irritating and/or children may feel self-conscious

    • There are potential intolerances to feedings such as bloating, cramping, or diarrhea

Stomach Feeding Tubes

Feeding tubes are entered directly into the stomach instead of through the esophagus. There are three types of stomach feeding tubes: gastrostomy, gastrojejunal, and jejunostomy. The following are common conditions that may require the use of a stomach tube.

  • Problems of the mouth, esophagus, stomach or intestines presented at birth

  • Prematurity, brain injury, developmental delay, and neuromuscular conditions causing sucking and swallowing disorders

  • Failure to thrive, which is when a child is unable to gain adequate weight to grow appropriately

Gastrostomy Tube (G)

The G-tube is inserted through the abdomen directly into the stomach, completely bypassing the throat. If a child requires tube feeding for over 3 months and/or having difficulties with nasal tubes, gastrostomy tubes are usually recommended.

  • Placement of tubes: There are three types of methods for inserting G-tubes: percutaneous endoscopic gastrostomy (PEG), laparoscopic, and open surgical procedure. All procedures take about 30-45 minutes to administer.

    • PEG: most common technique for first placement of G-tube as it does not require surgery. The doctor is able to use a thin, flexible tube with a camera to insert the tube through the mouth and into the stomach

    • Laparoscopic technique: performed by making small incisions into the abdomen and inserting a tiny telescope to help with placement

    • Open surgery: Alternative for cases where a PEG placement is not appropriate

  • Advantages

    • PEG placement does not require surgery

    • Decreased clogging of tube since diameter is larger

    • Larger reservoir in stomach compared to small intestine

    • Child may feel less self-conscious since tube is not visible

    • Decreased chance of tube being pulled out

  • Disadvantages

    • Risk of aspiration due to reflux

    • Family is required to provide extra care to cleaning of tube

    • Surgery may be required depending on placement.

    • Possible skin irritation from leakag

Gastrojejunal (GJ)

A GJ tube is similar to a G-tube as the tube is placed through the skin into the stomach. The difference is a GJ tube has two feeding ports on one tube so that the food enters into the stomach and then down into the small intestine (jejunum portion). G-tubes may be converted into GJ tubes if the child is not tolerating stomach feedings.

  • Advantages

    • Reduced risk of aspiration

    • May reduce reflux

    • Less costly than J-tube placement

    • Tube is hidden, so child may be less self-conscious

  • Disadvantages

    • Potential intolerance of tube

    • Extra care required

    • Potential skin irritation

    • Tube may clog more easily due to smaller diameter

Jejunostomy (J)

A J-tube is placed directly into your child’s small intestine through the skin. This type is not as common for children.

  • Advantages

    • Reduced risk of aspiration and reflux

    • Tube is hidden

  • Disadvantages

    • Potential intolerance to placement of tube

    • Extra care required

    • Potential skin irritation from leakage

    • Tube is small and more likely to clog

    • Surgery is required for placement of jejunostomy

    • Feedings are slow


Treatment of Children with Tube Feedings

Depending on the type of tube and duration of tube feeding, children with tube feedings are at risk for developing oral aversion to food through the mouth. Oral aversion is when a child experiences a fear of eating or drinking and avoids sensation around or in the mouth. Children who are tube-fed often, develop oral aversions because many have learned that food hurts based on a history of medical issues involved with eating (reflux, aspiration, food allergies, and/or motility). In some cases, feeding tubes are used to supplement adequate nutrition but children may be able to eat orally with some limitations on foods, consistencies, textures, and liquids. If your child has been approved to eat some food orally, it is highly encouraged. In order to reduce the risk of developing oral aversion, the following is recommended by speech therapists:

  • Oral sensation. Children with oral aversions will try to avoid sensation around and in the mouth. Children with feeding tubes should continue to experience the same oral sensation in normal routines as children who eat orally, especially oral care. Adequate oral care such as teeth brushing is not only important to reduce aspiration (food getting into the airway) from reflux, but also continues to provide oral sensation. Consider getting a child-proof vibrating toothbrush for extra sensation. During nightly routines, apply lotion to the face while massaging the cheeks, place chapstick on the lips, and make funny faces in the mirror to encourage facial muscle movement.

  • Participate in mealtimes. Children with feeding tubes often miss out on the social, exploratory, playful aspect of eating. Allow your child to continue to experience the fun of eating by helping prep for dinner, setting the table, sitting with the family, and even playing with the food on the table! If your child is able to eat pre-approved food, be sure to have appropriate food available. Most children with oral aversion would prefer not to participate in the act of eating, but continues to benefit from the social aspect of mealtimes.

  • Playing with food. In many feeding therapy approaches, the first step to consuming food orally is accepting food using the other senses: touching, smelling, and licking. Create artwork using edible food by painting with pureed food, making edible play dough, and building structures with variety of food. Show children that food can be fun and non-threatening.

If your child currently has a feeding tube or is planning to receive one, feeding therapy is highly recommended to ensure your child is receiving adequate nutrition and quantity from oral feedings. Speech therapists can provide systematic feeding approaches, including but not limited to mealtime focus, S.O.S. (Sequential Oral Sensory), ABA (Applied Behavior Analysis), baby or child-led weaning, and hunger-based cues. Lumiere Children’s Therapy can provide feeding therapy for your child as well as a home exercise program to assist with carryover into the home environment.

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References

“Addressing Oral Aversions.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/navigating-life/oral-eating/feeding-therapy-oral-aversions/.



“ARK's Y-Chew® Oral Motor Chew.” ARK Therapeutic, www.arktherapeutic.com/arks-y-chew-oral-motor-chew/.



“Enteral Tube Program | Home Care Instructions after Placement of a Gastro-Jejunal (G-J) Tube | Boston Children's Hospital.” Boston Childrens Hospital, www.childrenshospital.org/centers-and-services/programs/a-_-e/enteral-tube-program/family-education/giving.



“Feeding Therapy.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/navigating-life/oral-eating/feeding-therapy-oral-aversions-2/.



“Gastrostomy Tube (G-Tube).” Edited by Steven Dowshen, KidsHealth, The Nemours Foundation, Jan. 2018, kidshealth.org/en/parents/g-tube.html.


Mattingly , Rhonda. “Management of Pediatric Feeding Disorders.” U of L Pediatric Feeding. U of L Pediatric Feeding, 2017, Louisville , University of Louisville .


“Tube Types.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/tube-feeding-basics/tubetypes/.


VanDahm, Kelly. “Chapter 9: The Nutritional Foundation.” Pediatric Feeding Disorders Evaluation and Treatment, Therapro, Inc, 2012, pp. 227–227.

Lumiere Children’s Therapy: Swallowing Difficulties in Children

Swallowing is a complicated process that is both voluntary and involuntary. Many people take swallowing for granted since it becomes second nature to most. Observe the complexity of a swallow by paying close attention to the many stages involved when taking a bite of food or sip of water. For some children, eating and swallowing can cause numerous difficulties leading to poor growth, failure to gain weight and inadequate nutrition. The medical term for swallow difficulty is called Dysphagia.

There are three types of Dysphagia: oral, oropharyngeal and esophageal. For the purpose of this article, we will focus on oral and oropharyngeal dysphagia as speech therapists can diagnose and treat these types.

Stages of a Swallow

There are four stages to an efficient swallow: oral preparation, oral stage, pharyngeal, and esophageal. Dysphagia can occur in one or more of the four phases of a swallow, possibly leading to food or liquid entering the airway causing aspiration.

  • Oral Preparation: In this stage, the teeth chew the food as saliva adds moisture in order to create a cohesive ball or bolus.

    • Signs/symptoms of difficulty in this stage:

      • Child has trouble chewing a variety of textured food that should be age-appropriate

      • Liquid or food spills out of the mouth while eating

      • Excessive amounts of drooling during meals or between meals

      • Takes over 30 minutes to finish a meal

      • Over-stuffing their mouth with food or only allowing small amounts of food into mouth

  • Oral Stage: In this stage, the person voluntarily pushes the food to the back of the mouth by the tongue in preparation to swallow food.

    • Signs/symptoms of difficulty in this stage:

      • Child holds food in the mouth for a long time before swallowing

      • Requires multiple swallows on one piece of food

      • Some food remains in mouth after swallowing

  • Pharyngeal Stage: The food passes through the throat into the esophagus. During this stage, the windpipe or airway is protected by a flap called the epiglottis so food does not enter the lungs.

    • Signs/symptoms of difficulty in this stage:

      • Breathing difficulty during meals as noticed by skin color change, changes in heart rate, or increased breathing

      • Coughing and choking during or after meals

      • Spitting up, vomiting or gagging during meals

      • After or during meals, the child talks with a raspy or wet sounding voice

      • Frequent congestion in chest after meals

  • Esophageal stage: Food travels from the esophagus into the stomach during this stage.

    • Signs/symptoms of difficulty:

      • Frequent constipation

      • Complaints of stomach pain

      • Sensation of food coming back up the pipe

      • Excess vomiting after meals


Signs and symptoms of swallowing problems may be difficult to notice if a child does not express complaints.  Other signs to watch for during meals may include the following:

  • Crying during mealtimes because the child does not want to eat

  • Refusal of food and/or certain textures

  • Distracting behaviors such as excess talking, frequently getting up, or negative behaviors

  • Long meal times due to slow eating or refusal of meals

  • Facial grimacing during mealtime for older children and arching of the back for infants

  • For infants, decreased responsiveness such as blank stares during feedings

  • Food or liquid coming out of nose during or after feedings

Aversions

There are two other types of feeding/swallowing disorders related to the oral preparatory stage: oral and sensory aversion.

Oral aversion is usually a self-defense mechanism that kids use to avoid foods that they know they cannot process due to lack of skills. Chewing and swallowing can be a very complicated process requiring adequate jaw strength, tongue elevation and lateralization and rhythmic chewing and coordination. For children that lack strength and/or coordination in one of these areas, swallowing can be complicated and even dangerous. To assess if your child may have oral motor difficulties, take a bite of a food, such as a cookie, and count the amount of chews it takes you before swallowing. Observe your child eating the same type of cookie and count the amount of chews it takes him or her, while observing the jaw movements. Adequate jaw movements should be a circular/diagonal motion, not simply up and down as in a munching pattern.

Sensory aversion is usually a symptom of a  sensory-processing disorder. Sensory aversions may appear as hypo-sensitivity (lack of sensory awareness) or hyper-sensitivity (excessive sensory awareness). If the child is hyposensitive, the child lacks awareness of the food impacting his/her ability to manipulate the food before swallowing. Symptoms may appear as over-stuffing the mouth, leftover food in the mouth and excess drooling. If the child is hypersensitive, symptoms may include vomiting, gagging, spitting up food or refusing behaviors at dinner.

Consequences of a swallowing disorder

Difficulty with swallowing may cause an array of complications if not properly treated. These complications may include, but are not limited to, the following:

  • Malnutrition: Malnutrition is when the body is not receiving enough nutrients and vitamins through the consumption of food needed to keep tissues and organs working properly. Malnutrition may occur due to undernourishment or overnourishment. Undernutrition is when the child is not receiving essential nutrients due to lack of food consumption. Overnutrition occurs when the child consumes an abundance of food but lacks the necessary vitamins in those foods. Overnutrition may also involve lack of exercise, excessive eating, and/or taking too many vitamin supplements.


    • Signs of malnutrition:

      • Pale and dry skin complexion

      • Easily bruises

      • Thin hair or hair loss

      • Gums that bleed easily

      • Swollen or cracked tongue

      • Sensitivity to light

      • Rashes or changes in skin pigmentation

    • Treatment for malnutrition: Pediatricians will recommend speech therapy as well as working closely with a dietician to increase oral intake of nutritious food.  If malnutrition continues, treatment may involve inserting a thin tube through the nose that carefully enters the stomach or small intestine. If long-term tube feeding is recommended, a tube may be placed directly into the stomach or small intestine through an incision in the abdomen.

  • Dehydration: Dehydration is when children lose an excessive amount of water and salts without replacing the fluids through diet.

    • Signs of dehydration:

      • Limited tears when crying

      • Decreased need to go to the bathroom

      • Irritability

      • Eyes that have a sunken look

      • Dry or sticky mouth

      • Dizziness or lethargic tendencies

    • Treatment for dehydration: Treatment varies based on the severity of dehydration. For mild cases, children will be advised to drink plenty of fluids (preferably water) and rest in a cool room. For more severe cases, children may be required to drink oral rehydration solution (ORS) which is a combination of sugar and salts that rehydrate the body. If a child refuses liquids, alternative feedings such as tube feeding may be required.

  • Aspiration pneumonia: When food, saliva or stomach acid enters your lungs, it is called pulmonary aspiration. Healthy lungs are able to clear foreign bacteria, but if the lungs are unable to clear the food or liquid, pneumonia may occur.

    • Symptoms of aspiration pneumonia:

      • Shortness of breath

      • Bad breath

      • Excessive coughing, and sometimes coughing up blood or phlegm

      • Chest pain or wheezing

      • Excessive sweating

      • Fever

    • Treatment of aspiration pneumonia: Treatment usually involves antibiotics and supportive care for breathing such as oxygen, steroids or breathing machine.

  • Ongoing need for a feeding tube. As mentioned before, a feeding tube may be deemed necessary if your child is unable to consume enough nutrition through the mouth. There are four types of feeding tubes: nasogastric tubes, nasoduodenal tubes, nasojejunal tubes and gastric or gastrostomy tubes. (Our next blog will focus on the types of feeding tubes and provide more information.)

  • Inadequate weight gain: Attending regular pediatrician check-ups can ensure your child is growing at a healthy rate.

Treatment for Swallowing Disorders

Treatment depends on the child’s age, health conditions, physical and cognitive abilities, and most importantly, specific feeding and swallowing concerns. Feeding therapy is a a team approach consisting of the child, speech therapist, dietician, occupational therapist, pediatrician and family members. The main goals of therapy are to support adequate nutrition and hydration, minimize complication risk and maximize the child and family’s quality of life.

If you feel your child may have difficulty with any stage of the swallow process, express concerns with your pediatrician immediately. Lumiere Children’s Therapy can provide feeding therapy to help your child reach their highest potential for adequate nutrition and quality of life. Contact us here.



References:

Children's Hospital. “Dysphagia.” Children's Hospital of Philadelphia, The Children's Hospital of Philadelphia, 24 Aug. 2014, www.chop.edu/conditions-diseases/dysphagia.

“Dehydration.” Edited by Patricia Solo-Josephson, KidsHealth, The Nemours Foundation, June 2017, kidshealth.org/en/parents/dehydration.html.

“Pediatric Dysphagia: Causes.” Averican Speech-Language-Hearing Association, ASHA, www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965§ion=Causes.

https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965&section=Treatment

Lowsky, MS, CCC-SLP, Debra C. “Food Refusal - Is It Oral Motor or Sensory Related?” ARK Therapeutic, 10 Nov. 2014, www.arktherapeutic.com/blog/food-refusal-is-it-oral-motor-or-sensory-related/

“Malnutrition.” Is There Really Any Benefit to Multivitamins?, www.hopkinsmedicine.org/healthlibrary/conditions/adult/pediatrics/malnutrition_22,Malnutrition.
“Tube Types.” Feeding Tube Awareness Foundation, www.feedingtubeawareness.org/tube-feeding-basics/tubetypes/.