[Dysphagia] Pediatric Swallowing Evaluation

[pressmah at sjhmc.org (pressmah@sjhmc.org)]

This is the type of child who can most benefit from a multidisciplinary
approach which can be found at a feeding center that specializes in
pediatrics.  Hilda Pressman

-----Original Message-----
From: Susan Berlinger [mailto:smberlinger@mindspring.com]
Sent: Friday, January 28, 2005 2:04 PM
To: dysphagia@b9.com
Subject: [Dysphagia] Pediatric Swallowing Evaluation


A pediatric evaluation was conducted yesterday on a delightful 2.1 year old
child. Since pediatric evaluations are referred to me on a limited basis at
this time- I continually try to increase my competence level. I often refer
to "Pediatric Swallowing and Feeding by Arvedson and Brodsky". Would like to
get any suggestions regarding how you would proceed and am I on base.  I
apologize in advance for this lengthy posting.

 

This child was an oral eater until 18 months old. Family indicated no real
problems for the first year. At around 6-7 months of age Gerber products
were used. He ate successfully on stage 1 and 2 up to about 14 months. At
times, he would eat Cheerios, place then in his mouth and then would
dissolve. When stage 3 was attempted he started to gag. He would refuse food
by clamping his mouth shut or by vomiting.  Due to potential malnutrition, a
nasal tube was inserted for 2 months, followed by a peg tube and replaced
this past November with Mic-Key button type. Metaclopromide and Prevacid
prescribed for GERD. He now tolerates his feeds well with considerably less
vomiting episodes. An extensive GI and neurologic workup during his
hospitalization was completed. Findings were all within normal limits with
the exception of significance for blunted duodenal mucosa, without
intraepithelial lymphocytes. Genetic testing was recommended to rule out
Celiac disease. Results did not support a diagnosis of celiac disease All
other portions of his workup were normal.  CAT-Scan and MRI were
unremarkable. He was diagnosed with Dwayne's Palsy. He was born 6.8 lbs via
C-section as the umbilical cord was wrapped around his neck. No trauma was
reported. Birth term was 36 weeks.  Mother reported that baby was
exceptionally alert and had a strong rhythmically suck pattern. This was not
observed during the evaluation. He was breast fed for only 3 days as mother
did not produce adequate breast milk. Enfamil was used for a short period of
time. He had jaundice when he was 3 days old until 2 weeks old and was
treated colic from approximately 1 to 6 months of age. Communication skills
were excellent. 

 

This child was observed to be extremely apprehensive and significantly
stressed. He would pull back, cry and one could see facial tremors when he
first entered in the room. He calmed down as he became more comfortable;
however, he had a keen awareness of his environment.  Family reported that
he often becomes stressed and this was when he would vomit. He would not
allow any food by mouth; two times he would simulate drinking and eating
independently but would not put any water in his mouth. He would gag when he
placed the rice crispy bar on his lips. Facial symmetry noted, normal
mandible, lips remain somewhat open at rest due to his open-bite, tongue
protrudes slightly at midline, clinician observed intra-orally only when dad
tickled him and he opened his mouth, soft palate high and hyper gag reflex.
Mother indicated child has a weak to mild cough but this was not observed
during the assessment. Good vocal quality, pitch and volume. Communication
skills were excellent.

 

Videoflouroscopic exam has not been completed due to NPO status and food
refusal. Esophgram completed and results unremarkable. Family reports that
Tyler tolerates 4 cans of Pediasure Fiber formula each day.  Most days he
would keep his meals down. Sometimes he may have mild reflux described "kind
of like a burp but managers to keep the rest down".  Vomiting episodes are
typically triggered by stress, excessive excitement or rough-housing. Family
reported that he does not like to touch things that are soft things (i.e.,
play doe) but enjoys gnawing on a piece of plastic. If it is not food he is
happy to gnaw on it. Family reported that he was entered in a swimming for
tots class. He swallowing a lot of water and family is concerned that he
associated this negative behavior with eating and thus refuses oral feeds

 

I question whether this child has an oral phase dysphagia along with
immature oral patterns. Several factors should be addressed. This child may
display immature oral delay due to lack of experience, a possible behavioral
component and oral hypersensitivity. Lack of Experience: Oral feed stopped
at approximately 18 months of age.  He has had very little oral stimulation;
therefore he lacks the necessary experience to know what the oral structures
are supposed to do with the food presented in the oral cavity. Behavioral
Component: He has experienced discomfort/stress when gagging, regurgitating,
and choking which may create a negative association. In addition family
reports he was traumatized when he swallowed a lot of water when in swimming
classes. He also may realize he gains family attention when he
fusses/refuses. Hypersensitivity: He may be hypersensitive to food within
the oral region. This may be due to lack of experience in the oral structure
and I question whether there is a cranial nerve deficit problem. 

 

I would appreciate any feedback. 

 

 

Susan Berlinger, SLP.D., CCC-SLP

Doctor of Speech & Language Pathology

Boca Raton Speech & Communication Center, Inc.

Shever International Plaza

7284 W. Palmetto Park Rd. Suite 201

Boca Raton, Florida 33433

(561) 416-4046 Office

(561) 417-9530 Fax 

 <mailto:sberlinger@adelphia.net;smberlinger@mindspring.com>
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