Advancing Oral Intake in a Child with Aspiration: A Single Case Study
Sara Clarke, MicheleCole Clark, Nikki Smith, Bonnie Minter, BarbaraMcElhanon, & William G. Sharp
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This case study describes multidisciplinary intervention for a 19-month old boy with a history of aspiration and gastrostomy tube dependence. Prior to intervention, Oral Pharyngeal Motility Studies (OPMS) at 6, 12, & 19 months observed an absent swallow with silent tracheal aspiration. The patient was admitted to an intensive feeding treatment program to address a non-functional pharyngeal compensatory strategy, and to improve bolus management across oral and pharyngeal phases of swallowing to decrease his risk of aspiration. Treatment was associated with an increase in functional swallowing, a decrease in non-functional compensatory strategies, improved oral intake, and elimination of tube feeding.
Aspiration is the entry of material into the airway below the level of the true vocal folds.Aspiration during swallowing can occur due to dysphagia and/or insufficient management of nasal/oral secretions.Children with aspiration are at risk for scarring of the lungs, chronic lung issues, and lung failure.
Current management approaches include:- 1) primary recommendation prohibits oral intake (NPO) + enteral nutrition; 2)alteration of food consistencies determined by the results of instrumental swallowing studies; 3) out patient clinical trials with SLP or feeding expert, usually weeklyThe current case study describes a novel approach aimed at advancing oral intake in a child recommended for NPO. Treatment involved structured mealtime protocols with detailed data collection guiding treatment development, multidisciplinary oversight to assure safety and permit medical monitoring, and multiple therapeutic sessions per day.The admission goals address the non-functional pharyngeal strategy (gargle), improve the oral preparatory phase, and establish a functional oral transit phase and pharyngeal phase of the swallow in order to decrease his aspiration risk.
Participant:John(pseudonym) was a 19 month-old boy with a history of aspiration and gastrostomy (G-) tubedependence.Complicatinghis presentation was a medical history significant for an anoxic event in the first 36 hours of life with subsequent infantile seizures, dysphagia, aspiration, gastroesophageal reflux, and hypoxic ischemic encephalopathy.Prior to intervention, Oral Pharyngeal Motility Study-OPMS testing at ages 6, 12, & 19 months identified silent tracheal aspiration and highlighted absent swallow with repeated frank aspiration during trials of all consistencies.Dueto poor oral intake, John underwent placement of a nasogastric (ng-)tube shortly after birth; and remained intact until a G-tubewas placed at 12months.
Oral Motor Competence:Johnreceived outpatient non-nutritive oral motor therapy with a speech pathologist leading up to his admission. At that time, John demonstrated 0% lingual variety of movement, 0% durational jaw strength, poor range of movement of the upper cheeks and lips, which did not meet clinical competence for puree by mouth. At admission, John met minimal competence for bolus control of puree texture; however, not deemed clinically ready for PO intake secondary to silent tracheal aspiration on all consistencies.
Setting:Johnwas admitted to an intensive multidisciplinary day treatmentprogram. Professionalsinvolved in overseeing his care included a pediatric gastroenterologist, speech language pathologist, dietician, and behavioral psychologist.Admissionlasted 8 weeks (Monday through Friday), with four 40 minute therapeutic sessions conducted each day. One session per day involved intensive oral motor therapy using Beckman Oral Motor Intervention protocol (Beckman, D.A., 1998 rev 2012). Three sessions involved a structured protocol to monitor the target gargle occurrences following our general behavioral protocol developed in coordination between thespeech pathologistand behavioral psychologist.Trained therapists conducted sessions in rooms equipped with one-way mirrors and an adjacent observation room for data collection.Evaluated the use of an empty spoon swallow prompt to address whether this strategy would reduce engagementin the nonfunctional compensatory strategy used to avoid aspiration. (See Table 1 for treatment steps)
Table 1: Treatment Goals and Rationales
Data Collection:The primary dependent variables were 5 second acceptance, mouth cleans, and gargle occurrence.5 second acceptancewas defined as when the entire bolus is deposited in the child’s mouth after 5 seconds of the initial presentation.Mouth cleanwas defined as no residual food remaining inside the mouth within 30 seconds after the food initially was deposited.Garglewas defined as an audible perception of forced movement of bolus residue in a superior/inferior direction, from the pharynx to the hypopharynx and/or the nasopharynx, after posterior oral transit of the bolus into the pharynx.We recorded the occurrence and nonoccurrence and duration of gargle for each bite acceptedWe calculated the percentage of bites with gargle occurrence by dividing the number of bites in which the behavior occurred by the total number of bites entering the mouth and converting that number to a percentage.
Summary of Treatment Outcomes
Decreased engagement in the nonfunctional compensatory strategy used to avoid aspiration.Caregivers demonstrated high fidelity of treatment protocols.Multidisciplinary treatment approach demonstrated significantly higher change in decrease of gargle occurrences (97.37% vs. 1.09%), and significant difference in the change of grams consumed (5 grams vs. 764 grams; 100% g-tube wean)This client was able to move from NPO with enteral feeds to all feeds by mouth, and begin age appropriate dissolvable chewing practice.
This case study examined a multidisciplinary treatment team intervention for pediatric feeding disorders in a day treatment setting.Results provide provisional support for an intensive oral motor intervention for oral and pharyngeal phase practice supported with structured feeding protocols to advance oral intake among children evidencing NPO status secondary to dysphagia (and absent structural and/or motor concerns).Treatment was associated improvement in oral motor status, which permitted advancement in safe oral intake and systematic increase in grams consumed. At discharge John was consuming 100% of needs by mouth with no signs or symptoms of aspiration. John demonstrated no medical symptomatology of aspiration at any point in the admission