Perspectives on Swallowing and Swallowing Disorders (Dysphagia)

Editor's Corner

Brobeck, T. C. — 2008-10-08

Development of Swallowing Function Along the Prenatal to Postnatal Continuum

Scarborough, D., Miller, J., Fletcher, K. — 2008-10-08

Developmental information is the cornerstone of diagnosis and intervention in pediatric dysphagia. Ongoing research has refined specific parameters of growth and development of the swallow from the prenatal through the postnatal period. The intent of this article is to review the latest findings regarding normal development of feeding/swallowing from the time the fetus is in utero through the postnatal period. This information may provide clinicians valuable tools to make adaptations within the clinical decision making process.

Individualized Developmental Care in the Neonatal Intensive Care Nursery

VandenBerg, K. A., Ross, E. S. — 2008-10-08

Advances in medical care have improved the success of medical interventions in treating high-risk and premature infants, but long-term developmental outcomes are less positive. The neonatal intensive care unit (NICU) setting influences infant brain development and organization, as well as the parent-infant relationship. One advanced-practice role for a speech-language pathologist (SLP) is that of a newborn developmental specialist (NDS). The NDS working in the NICU understands the influence of medical, environmental, and caregiving interactions on the neurologic and neurobehavioral organization of the infant. The NICU setting advanced practice skills are grounded in an individualized, developmentally supportive care model, such as the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Neurodevelopmental assessment focuses on the competence of the infant. The developmental assessment and intervention strategies are individualized to support the infant's own goal strivings. In this framework, interactions with infants become modified to increase competence and organization. The SLP working in the NICU is in a unique position to facilitate communication between the infant and the parent, as well as between the infant and professional caregivers. The SLP can help the parent interpret and respond appropriately to the infant's communication by focusing on non-verbal stress and stability cues, and by planning all interactions with a goal of co-regulation. Interactions with infants and families in this Model in the NICU have beneficial lifelong implications.

Feeding in the NICU and Issues That Influence Success

Ross, E. S. — 2008-10-08

Premature infants are both medically fragile and immature; both of these factors influence their ability to safely feed. Speech-language pathologists (SLPs) working with these infants must recognize normal development of feeding skills as well as diagnose feeding problems and develop individualized treatment plans. Assessments should include all three phases of swallowing (oral, pharyngeal, and esophageal) in the context of overall stability, and interventions need to be individualized to the unique needs of each infant. Decreasing the flow rate of fluid and providing pacing are frequently used strategies to support the medically fragile infant. Therapeutic programs that do not appreciate the role of both individual developmental progression and medical comorbidities are not appropriate, given that volume is not the only goal of feeding. Rather, SLPs must focus on skill acquisition for long-term success within the larger context of parental nurturing. Medical comorbidities significantly influence both the initiation and the progression of oral feeding in this population. The individual variation in development, as well as the medical fragility in this population, challenges the neonatal intensive care unit (NICU) therapist to appreciate the complexity of feeding and to work in collaboration with the other members of the team.

The Aerodigestive Clinic: Multidisciplinary Management of Pediatric Dysphagia

Haibeck, L., Mandell, D. L. — 2008-10-08

The purposes of this article are (a) to explore the relationship between pediatric upper airway obstruction and dysphagia and (b) to highlight the benefits of using a multidisciplinary approach when assessing infants and children with upper respiratory and swallowing disorders. The functions of breathing and swallowing are tightly coordinated in infants and young children, and pediatric upper airway disorders can often adversely affect the swallowing mechanism and may even predispose the individual to aspiration. Some of the more common causes of pediatric airway obstruction seen in this setting are laryngomalacia, vocal fold paralysis, laryngeal cleft, and Pierre Robin's sequence. In the setting of all of these disorders, associations may also exist with gastroesophageal reflux (GER) and laryngopharyngeal reflux, and this topic is also reviewed. In the multidisciplinary assessment of young children with aerodigestive disorders, fiberoptic flexible endoscopic evaluation of swallowing has gained traction as a useful test for simultaneous evaluation of pediatric upper airway obstruction and dysphagia and has provided complimentary information to the more traditional pediatric videofluoroscopic swallowing evaluation. A representative case study is provided that illustrates the relationship between pediatric upper airway obstruction and dysphagia and demonstrates the effectiveness of a multidisciplinary approach.

Food for Thought on Pediatric Feeding and Swallowing

Arvedson, J. C. — 2008-10-08

"Food for Thought" provides an opportunity for review of pertinent topics to add to updates in areas of concern for professionals involved with feeding and swallowing issues in infants and children. Given the frequency with which speech-language pathologists (SLPs) make decisions to alter feedings when young infants demonstrate silent aspiration on videofluoroscopic swallow studies (VFSS), the need for increased understanding about cough and its development/maturation is a high priority. In addition, understanding of the role(s) of laryngeal chemoreflexes (LCRs), relationships (or lack of relationships) between cough and esophagitis, gastroesophageal reflux (GER), and chronic salivary aspiration is critical. Decision making regarding management must take into account multiple systems and their interactions in order to provide safe feeding for all children to meet nutrition and hydration needs without being at risk for pulmonary problems. The responsibility is huge and should encourage all to search the literature so that clinical practice is as evidence-based as possible; this often requires adequate understanding of developmentally appropriate neurophysiology and function.