Infant Assessment I nfant Assessment: • • Overall state of regulation, including posture and positioning • Respiratory status and quality of voice/cry • Exam of oral peripheral mechanism • Non-nutritive sucking • Nutritive suck/swallow/breathe • Spoon feeding and soft solids if appropriate • Estimate of global developmental status • Review of family system and mealtime practices 25
Oral Mechanism Exam • Face, Ears, and Nose – Tone, asymmetries, spacing of eyes, – Shape and position of ears, ability to breath through nose • Mouth – Size/shape/strength/excursion of jaw, lips, dental status and condition - including shape of teeth, size/shape/tone/strength/range of motion of tongue, labial and lingual frenulum connections, size/shape and movement of palate, presence and viscosity of saliva, evidence of thrush, gag reflex, rooting reflex, bite reflex 26
Tongue Tie Classification 27
Brief Review of Infant Feeding Highlights • 1 months: uses both suck and suckle • 2-3 months: longer, more rhythmic sucking bursts • 3-4 months: sucking pads diminishing and oral cavity lengthening, sucking becomes less reflexive • 4-6 months: sucking now more volitional and a more precise series of coordinated movements; mouth and digestive system getting read for purees • 6-7 months: holds open mouth still to receive spoon • 6-8 months: can take a single sip from an open cup held by an adult 28
Brief Review of Infant Feeding Highlights (cont.) • 6-9 months: munch chew develops – Baby can also pick up pieces of food with fist – and begin to pass from hand to hand • 9-12 months: chewing improves to include more vertical and lateral movements • 12-15 months: can bite through a soft cookie and can begin consideration of weaning from the bottle or breast to a more mature drinking vessel 29
Criteria for Instrumental Evaluation • Risk for aspiration by history or observation • Prior respiratory infections/diagnoses (pneumonia, croup, RSV, bronchiolitis, asthma, etc) • Suspicion of pharyngeal/laryngeal problem on basis of etiology • Gurgly/wet vocal quality or breath sounds, increased work of breathing, during or following feed • * Remember that MBSS and FEES are complimentary and should not be viewed as “one or the other.” 30
Aspiration & Penetration • Aspiration- when material • Penetration – passage of (food, secretions, and/or material into the laryngeal gastric contents) incorrectly vestibule followed by a enter the larynx below the rapid expulsion back into vocal folds into the the pharynx during tracheobronchial tree swallowing 31
Consequences of Aspiration • MILD: No clinically significant history, but documented on instrumental swallow study. Mealtime and feeding modifications likely. • MODERATE: Lung damage and pulmonary disease requiring oxygen, use of bronchodilators, steroids, or pulmonary toileting. Mealtime and feeding modifications required. • SEVERE: Acute pulmonary event requiring ventilator assistance with potential for brain damage (hypoxia) or even death. May occur during a seizure, vomiting, or swallowing an unsafe bolus. Consideration of supplemental/alternate feeding method (NGT/GT). 32
MBSS • Images oral cavity, pharynx, • Delineates aspiration related larynx, and upper esophagus factors during all four phases of – Before, during, or after swallow swallow • Defines esophageal transit – Texture specificity time and basic motility – Estimated of risk • DYNAMIC view of • Non-invasive swallowing • Utilizes barium products • Limited to 2 minutes of combined radiation exposure 33
MBSS is NOT • To rule out aspiration or determine if the child has ever or will ever aspirate (important finding but NOT the reason for the exam) • Portable • Simulation of a real meal • An appropriate evaluation for primary concerns of chewing or texture sensitivities • For patients that have never eaten by mouth or yet had a clinical evaluation of swallow • For esophageal function (upper esophagus and transit times only) • Ideal of for children with severe positional challenges • To be repeated more than every 6-months unless warranted by significant medical/developmental changes 34
FEES • Visualizes pharynx and • Optimal for babies 3-12 larynx before and after months of age and children > swallow 4 years of age (cognitively) • Has a “white out” phase • Invasive • Uses real food with color • No radiation, but portable enhancements • Can be used in a variety of • Can be used to visualize and positions/postures assess an entire • Can evaluate safety with meal/feeding secretions 35
FEES is NOT: • Able to comment on ORAL or ESOPHAGEAL phases of swallowing • Fully able to comment on the PHARYNGEAL phase either • Unable to evaluated coordination between tongue, laryngeal excursion, and UES relaxation • Requires patient compliance and tolerance of scope 36
HB Case Study • 6 month old male • Referral concerns: poor weight gain and motor delays • Parents also endorsed: concerns about weight/growth and reported coughing with liquids and regularly overnight • Medical history significant for: – RESPIRATORY: hospitalization of RSV in Feb 2017, with persistent coughing and congestion x 3 months; (positive remote familial history of CF) – GI: history of GERD, three separate trials of Zantac (Omeprazole not covered), no meds now, still vomiting and spitting up 5-10 times daily, also currently with diarrhea x 3 days 37
HB Case Study • Medical history significant for: – SLEEP: snoring, sleeping best in swing – DEVELOPMENT: Torticollis (getting weekly PT services at outside/community hospital), EI eval also in place • No other sensory, behavioral, or social concerns identified • Early Feeding History: not a successful breast feeder (unable to latch and “would scream”). Started on bottles of formula during neonatal stay. Multiple formulas trialed. Family found most success with a soy ready-to-feed formula. Purees started early- 4-months- due to weight and GER concerns. 38
HB Case Study • Current Feeding: 6 bottles/24 hours. Soy formula. Intake volumes vary: 3- 7 oz per feed. Purees (stage 1 and 2) offered twice per day in Bumbo chair. Eats 2-3 oz of puree at each sitting. • Oral Mech Exam notable for: torticollis, tongue tremor at rest, class 2/3 tongue tie (with restricted posterior elevation but adequate tongue tip protrusion) • Spoon feeding observation notable for: needed supports in high chair, good anticipatory mouth opening, age appropriate anterior loss, increasing tongue tremor, positive regard for food and eating 39
HB Case Study • Bottle feeding notable for: nice sucking bursts but exaggerated jaw movements and increased cheek retractions , increased tongue fasciculations/ tremor after feeds , increased congestion after feed – MD auscultation of the lungs following the bottle feed notable for "increased work of breathing“ – took a total of 1 oz in 5 minutes – spit up 5 mins after feed • RD assessment: Underweight and short stature. “Weight for length is 30%ile however weight for age consistent with severe malnutrition; growth velocity is less than expected.” 40
HB Case Study • Diagnosis: OROPHARYNGEAL DYSPHAGIA with related concerns for posterior tongue tie, continued GERD, failing weight, and torticollis. • Recommendations following initial eval: 1. increase caloric concentration of formula to 24 Cal/oz 2. use only one bottle and nipple- AVENT, slow flow 3. get a high chair for spoon fed meals 4. ENT consult for tongue tie 5. swallow study 41
HB Case Study • Swallow study (and 2 view chest x-ray) completed 6 weeks later at 8 months of age – Prior to visit parents shared: congestion had continued, coughing overnight had increased, watery loose stools had persisted x 5 weeks – Chest Xray notable for low lung volumes and mild airway thickening 42
HB Swallow study images‐ thin and then nectar 43
HB Recommendations Following Swallow Study • Continue spoon fed purees in high chair BID – Introduction of crispy dissolvables • Trial of nectar thickened formula by level 2 nipple x 3 months • ENT consult for consideration of tongue release – Occurred 1 week after MBSS and MD did not feel lingual frenulum was restrictive 44
Current Considerations for Torticollis • Postural rotation and/or tilt in the neck with resultant asymmetrical position of head and neck, and secondary craniofacial asymmetry of structures. • Muscles may be shortened, positions may be less comfortable • Vagus nerve also travels down the back of the neck and partially innervates swallowing and digestive motility system. 45
Current Considerations for Tongue Tie • Ankyloglossia’ or ‘anchored tongue’ – is a common but often overlooked condition. • Oral assessment needs to include provider elevating the posterior portion of the tongue. • Ghaheri, et al (June 2017) article shows excellent outcomes (at 1 month f/u s/p release) including: maternal confidence with BF, maternal nipple pain, and infant reflux symptoms all improved- along with improved milk transfer 46
Current Considerations for GERD • GERD can be a major detriment to adequate nutrition. • Regurgitation may be occurring without emesis. • Signs and symptoms include: positional pain, irritability, aspiration (upper and lower airway diseases), halitosis, chronic OM, increased drooling, brassy cough, coughing/choking, sleep disturbances, apnea, laryngospasms, laryngitis, sinusitis, and even life threatening apneic event • Medications (H2-blockers and PPIs) can help reduce pain but don’t reduce the occurrence of reflux. 47
Occupational Therapist
Case Study: T. • 8 y.o. Male • Diagnoses: • Autism • Partial Epilepsy • Mild Neurocognitive Disorder • Oral phase dysphagia • Food Aversion • End Stage Renal Disease s/p kidney transplant November 2013 • Hx of G-tube placement at 2 months of age (no longer present) • Craniotomy for temporal lobectomy September 2016 49
Case Study: T. • Initial Feeding Clinic Visit – age 5 years 4 months • At that time, he was fully fed by g-tube for calorie needs with occasional oral tastes • Kidney transplant had occurred at age 5 years 1 month • At that time, no interest in eating with no appetite. No joy in eating with grimacing with each bite. • Only foods/drinks he was interested in were root beer and occasional bites of yogurt. He licked salty foods. He was able to tolerate sitting with his family for meals • No concerns for swallowing; no history of swallow study • Fair ability to clear spoon and complete spoon feeding • No observed bites or chewing • Initial recommendations from OT: Feeding therapy, psychology evaluation, altering tube feeding schedule to improve hunger/satiety, school evaluation for special education services, participation in snack time at school for peer influence • Areas assessed include: position/stability, oral exam, oral motor skills, sensory processing skills 50
Case Study: T. • Follow up visit (3 months later) indicated more willingness to taste new foods and expanded variety of beverages and new foods he was interested in licking (sauces) • Displayed significantly delayed skills for chewing and biting, as he did not have any foods in his repertoire that required chewing • Updated recommendations included: progressing towards thicker beverages, reward based program for increasing table foods and variety, and introducing a no thank you bowl • Initiated regular OT feeding therapy following this visit with the full team 51
Case Study: T. • Participated in frequent (2x/month) feeding therapy from ages 5 years 8 months through 7 years 9 months. Gradual increase to oral eating with removal of g-tube at 7 years 1 month [Recognize that it typically takes children 2-3 years to move through all stages of oral skill development, and therefore, feeding therapy should be a slow process if skills are truly attained] • Status updates/changes: • Participated in Autism clinic at 7 years 5 months and based on his evaluation, was diagnosed with: • Autism Spectrum Disorder • Language Disorder (Mixed Receptive and Expressive Language Disorder) • Monitor for possible Intellectual Disability • At 7 years 10 months, T had a left temporal lobe resection for seizures 52
Case Study: T. • Individual Treatment Techniques • Tactile exploration for desensitization; required tool use initially – Sensory bins at home (ex. Shaving cream, dried beans, play doh, finger paint) • Sensorimotor Gym activities – ball pit, tunnel • Oral Motor Warm Ups • Food Chaining (Initial focus on smooth foods, beverages, and licks of crunchy/flavored foods) • Drinking some formula by mouth • Steps of Eating including kissing food goodbye, smelling, licking • Reward systems, Behavioral approaches, Turn taking • Dipping foods • Assist with set up and clean up of meals, meal preparation • Once accepting a wide variety of smooth/blended foods, progressed towards chewing skills (6 years 4 months) • Chewing practice with hard foods, crumbing, meltables, fork mashed foods • Initially, used either munching or tongue mashing or attempted to swallow whole and used liquids to wash down foods & frequent grimacing • Moved to lateral bites • At 6 years 10 months, family with increasing concerns for fine motor skills, and focus of OT shifted to fine motor skill 53 development however, at 7 years 3 months, family saw decrease in progress of eating skills and returned to focus on feeding during OT
Case Study: T. • At 8 years 4 months, T returned to feeding clinic for a full team assessment • At that time, T was eating by mouth with a shrinking food repertoire, increased sensitivities to smells, very specific desires for how his food is prepared, appears difficult for him to swallow at times, and overall behavior is a general concern • Diet included chocolate milk, lemon lime sparkling water, lemonade, soda, peanut butter sandwiches, macaroni and cheese (without pepper added), tortellini (can be many varieties), pretzel goldfish, grapes, olives, cheese pizza, bean and cheese burritos, hot dogs, hummus, tortillas. Refused vegetables and most meats. • Many reported sensory concerns including seeking out spinning, jumping, and crashing and loves rough- housing. Sensitive to noise. Cannot tolerate many smells. Sometimes intolerant of being messy. Avoidant of unexpected touch. • Updated recommendations included: Feeding group, Participating in meal prep/clean up, Children’s cookbooks, re-introducing the “steps of eating”, present foods outside of their packaging, Apps for toothbrushing, general sensory processing resources, information regarding Feeding Matters (organization) 54
Case Study: T. • Group Treatment Techniques • 4 children ages 6-9, 6 sessions every other week • Focus on meal preparation with visual supports, food exploration, increased autonomy for food choices, provided homework each session • Homework included: • Food log for new foods • Choosing recipes to make at home • Completion of 12 bite challenge • Tasting a new flavor/spice • Choosing a food job at home • Provided handout for continued activities at home including creating a family cookbook, keep a new food log, planning social events when food is involved, have designated nights for T to meal plan, and plant a garden/join a CSA/visit farmer's markets to become more engaged with where food comes from 55
Case Study: T. • Current Status & Future Directions • At the conclusion of the group, T’s parents were excited by his progress and motivated to continue to move forward • Continues to have a limited diet however is more willing to engage in food exploration and able to progress through Steps of Eating with less stress To summarize: T is an example of a child with a medically based diagnosis necessitating g-tube use, who was able to successfully wean from the g-tube at age 7 with significant support, and lengthy intervention with slow steady progress, from many clinicians and his parents, however, continues with behavioral and sensory based challenges in regards to feeding and eating 56
Dietitian
Rarely is a feeding problem just a knowledge deficit • Nutritional adequacy of the diet • Impact of feeding disturbance on growth, physical development and milestone development • Impact on social and emotional development • Impact on interaction with caregiver and family function • Barriers to feeding- economic, social, knowledge, time or motivation • Evaluation of underlying medical issues or anatomical differences that affect feeding • Drug or supplement nutrient interaction 58
Case Study‐ GC • Inappropriate infant feeding, failure to thrive and feeding aversion • GC was a term AGA infant born out of US. She was fully breast fed and grew well until around her second month of life when her parents began a sleep training program. She was the couples second child and they were determined to help her sleep better than their first. • Scheduled breast feeding 4 times each day in 24 hours • Slept through the night at 3 months of age 59
Growth Chart – WHO weight/age 60
WHO ‐ Wt/Length 61
Lactation History • Good growth birth through 2 months • At 2 months Mom began a sleep training program " how to get your baby to sleep 12 hours at 2 months ". Fed only 4 x at breast in 24 hours. Suspect Mom's milk supply then decreased. -Growth stopped for GC. • Risk for failed lactation include: infrequent nursing, maternal obesity, menses returned at about 8 weeks pp, move and stress • Signs of failing lactation: poor growth in infant, fatigue, clawing and kneading breasts during feeding 62
Hospital Diagnosis and Treatment admission at 10 month of age • Chronic energy malnutrition • NG feeding • Lactation failure • No breast feeding ( AC/PC weight lacking ) • Oral aversion • Bottle and food introduction • Inappropriate feeding • Family education • Mild hypotonia • Referral to feeding clinic • Repeat new born metabolic screen (missing) • Early intervention 63
Hospital Discharge Plan • NG feeding with 100% nutrition needs met by tube • No breast feeding ( disagree ) • Oral exploration of purees • Feeding clinic referral 64
PARENT/CAREGIVER CONCERN OR REPORT: 1- "how do we get rid if her NGT?" - how much would she need to take orally to get the tube out? 2 - why do you think she needed the NGT in the first place? 3- why is whole milk recommended, and is there a suitable alternative? - dad is lactose intolerant 4- how do we know when she has achieved catch up weight? 65
Feeding Clinic Visit – 12 Months of Age • CURRENT FEEDING STATUS: Partnership of oral and NGT feeds. • NGT: 6 oz Standard Infant formula given three times per day via gravity. Sometimes pump assisted over one hour. – Mom had cut back on NG volume & night feeds • ORAL: Also breast fed on demand, typically twice per day and night, offered two highchair times daily. She puts food in her mouth but no chewing or swallow, with some intentional tongue thrusting out • Adverse to bottle 66
Assessment/Intervention • Catch-up growth rapid • Modify feedings schedule and TF volume • Oral phase dysphagia- adverse to drinking • Gentle feeding practices/responsive feeding • Showing feeding readiness • Honey bear with straw • Excellent latch and no oral/motor anatomical factors • Milk supply rebounded • Making development gains • FTT / chronic energy malnutrition- resolved 67
Responsive Feeding • Bring her to happy high chair time 4 times/day • Smooth purees, homemade or store (stage 1 or 2) • Partner feeding with loaded spoon • Exploratory food play- smearing, smelling, taste • Praise • Quick clean with a song. • Goal-gain trust and interest in her mouth 68
Video #1 69
Video #2 70
Video #3 71
Notes/Results • Parent learning style/health beliefs • Continued intervention between evaluation by messaging, video comments and PCP contact • Feeding tube removed 6 weeks later (in for 2.5 months)! Growth stable and adequate hydration. Nursing 2-3 times in 24 hours • 2 team visits (1 with MD) • 2 nutrition/lactation single discipline visits with 3 messages between visits 72
Follow up 1 month after NG tube removed – 13 months • CURRENT FEEDING STATUS: • Eating 3 meals each day + 1 snack. Nursing in am- before nap and at bedtime. Co-sleeping at night and they all share 1 bedroom. • Drinking water between meals. • Excellent variety • B:2 1/2 oz oatmeal with almond milk, peanut butter, chia seeds, ground flax seeds. 2oz raspberry kefir • L: 4oz scr. egg & spinach, 1 TBSP hummus, 1/2 pc bread & 1tsp butter • Snack -hummus, 18 cheerios, 1 oz kefir, 1/8 avocado, ~10 swallows of water • D: 2 oz Gerber peas and carrots purée *1 1/2 ounces Gerber pear purée mixed with half teaspoon extra virgin olive oil ,Nibbles of cucumber spears ,1 tsp hummus, 2oz cannellini beans, 1/2 piece wheat bread( crust removed), • 15 mL goat milk ( by spoon - didn't want to drink it) 73
Psychologist
Behavioral treatment for feeding problems 1) Desensitize the child to food cues. 2) Encourage , but do not force, the child to eat. 3) Do not allow the child to “ graze ” during the day. 4) Ignore resistant or oppositional behavior during mealtimes. 5) Praise eating behavior, even for small bites or attempts. 6) Remove toys/ attention-getting devices during mealtime. 7) Allow toddlers to take more responsibility in feeding. 8) Encourage the child to eat in the presence of other people who are eating. 9) Follow meals with interesting reinforcers . 10) Preface meals with a calm-down time . 75
How to treat food refusal? 1) Hunger induction (get 100% of hydration needs, but you want them to get hungry – Most adults don’t eat because they are hungry, but because it is a habit. After it becomes a habit, then hunger will come. ) 2) Escape extinction for refusal (can’t get away until they take a bite) 3) A structured meal and snack schedule (3 meals and 2 snacks) 4) Positive reinforcement for acceptance (toys, positive praise, etc.) 5) Gradually increasing response effort (extremely small at first = “molecules”) 6) Extinction of inappropriate behavior (ignoring annoying behaviors) 76
Mechanisms for improvement: • Appetite improves on Schedule -Eliminating between meal grazing -Serving meals/snacks in kitchen/dining room -Limit intake of fluids, if indicated -Limiting the length of meals and snacks • Chaining and Linking to new foods -Introduce similar foods in taste, color, or texture -Move to new brands of familiar foods • Fading Mechanisms -Mix new foods into preferred foods in tiny amounts -Flavor-Flavor conditioning – cover vegetables with ketchup 77
Is “Positive Reinforcement” necessary? • Why? Food is not a primary reinforcer for many children with feeding issues . • The reinforcer is used as a tool, but will not need to be used forever. • Schedules of reinforcement – Continuous schedule with praise or reward every time initially – Fade this to be less and less in time. • Matching law – Reward has to exceed what you want them to do initially. • Remember: The ultimate goal is to develop natural reinforcers (e.g., food) 78
“Behavior Extinction” goals: • Extinction of attention-maintained behavior – often called “planned ignoring” • Extinction of escape-maintained behavior – often called “escape prevention” • With parents we call it… – “just waiting until he or she cooperates” • “What if my child is throwing food?” – Pick it up and ignore – Shape putting it into a “no thank you” bowl 79
One Behavioral Model: 12-Bite Challenge • For older children: teach connections situations -> thoughts -> feelings -> actions • Catch “ Thinking Traps ” • Minimize coercion ; foster encouragement • Categorize foods into Mild, Moderate, and High levels of difficulty – start with Mild! • Create “I did it” rewards : Social, activity, and tangible • Develop a tracking sheet to post up at home with area to write thoughts down about this food. 80
Another Model: Plate A, Plate B technique ( and why we don’t use this… ) • For children that are normal weight in outpatient settings • Present six 10-minute meals a day , use a timer • Offer one plate (A) containing pea-sized bites of novel food, one plate (B) containing large bites or pieces of preferred foods, and a drink • The child gets a bite of preferred food and a drink only after eating a bite of new food • Systematically increase bite size • Communicate the expectation that the child can do this and be an eternal optimist • What if kids don’t eat? “ We all make choices in life and we will have a meal again soon .” 81
Case Study: • 7 year old girl with low weight • Picky vs. problem eater? • ADHD has been formally diagnosed and she is on stimulant medication • Sensory issues affect her comfort in accepting certain textures • Unwilling to sit for meals, even for preferred foods • Parents haven’t been able to find ways to reward her that remain powerful enough...
It’s all about “Shaping” and “Fading” • Shaping involves clear and attainable expectations , coupled with meaningful reinforcement . 83
Behavioral Approaches: • Keep Stress/Pressure low around eating • Meal and snack structure with clear expectations coupled with reinforcement - “We all make choices!” • Family meals together at the table (television, tablets, and phones are off) with family-style serving • No “short-order” cooking: Two preferred foods & one non-preferred food at each meal • Child is involved in menu planning and family meal preparation at least once a week • Give attention to eating and appropriate mealtime behaviors, rather than inappropriate behaviors • Don’t use food to manage behavior 84
Developmental Pediatrician
Goals / Objectives: • Discuss how medical and developmental conditions may impact feeding and growth • Discuss what red flags might indicate need for a medical team visit • Ask for feedback on our requests for feeding treatment in the community under the various systems of EI, private therapy, schools and other medical systems. 86 86
Developmental aspects • Motor skills have typical timelines of development, with variation common. • Abnormal or delay of skills can lead to inefficient and unsafe feeding • Reasonably effective early sucking and swallowing skills may provide intake, but may not move on to the next level for higher textures 87
State regulation difficulty • Example neonatal abstinence Syndrome – Excessive sucking, incoordination of feeding, vomiting and loose stools are common • Also common if breathing fast, babies with hypoxia effects, hyperalert babies. • Treat with swaddling, low noise, low lighting, low fuss. 88
Pain / GERD • Happy spit up is common and normal for 75-90 percent of babies up to age one - but not a disorder unless there are consequences - such as being a poor feeder 89
Common Presenting Symptoms of GERD in Pediatric Patients Infant Older Child/Adolescent Feeding refusal Abdominal pain/heartburn Recurrent vomiting Recurrent vomiting Poor weight gain Dysphagia Irritability Asthma Sleep disturbance Recurrent pneumonia Respiratory symptoms Upper airway symptoms (chronic cough, hoarse voice)
How best to treat GERD? Meds to reduce acid or increase good peristalsis Positioning Surgery ? probiotics ? Wait it out ? Thickeners Formula Changes Allergen avoidance Essential oils, ionized water, massage, acupuncture 91
Pitfalls in GERD treatment • Meds can have side effects Acid reducing PPIs and H2 Blockers might put kids at risk of colonization with – resistant bacteria- (then lower respiratory infections), might alter the internal biome in a negative way and might alter calcium metabolism leading to fractures ( as appears to happen in elderly) • But evidence is they do reduce GER – Prokinetic agents may be cramping, cause sedation, motor side effects or irritability 92
Pitfalls.... • Positioning is temporary, and kids want to move, crawl or roll. • Thickening is really hard to standardize and not very helpful in keeping food down – chronic coughs are common and a tsp of rice per ounce adds a lot of calories. Some thickeners have been associated with late onset NEC and the risks are not fully worked out. 93
Pitfalls... should we modify the food? • Many varying opinions and statistics in studies, and most of the time already tried some by family. • We see it working at times, with hypoallergenic formulae, RTF vs powder, dairy free, real foods blended and maternal diet restriction. But there are no guarantees. • So, we often modify the food itself, the volume and timing, along with position and meds. 94
Motor conditions • Cerebral Palsy - primarily full body involved • Hypotonia • Weakness 95
Physical anomalies • Clefts, Lips, hard palate, soft palate, submucus • Hemifacial conditions • Retrognathia and micrognathia 96
Physical Conditions • Respiratory • Cardiac • Genetic 97
Evaluation of a full year of referrals to Feeding Program (total N=83) •Chart review of the FTT referrals only •(n=27) 98
Age distribution
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