1. Dr Sheelu Srinivas
Consultant ENT Surgeon & Department Coordinator
Fortis Hospital B.G. Rd

2.  Nothing would be more tiresome than eating and
drinking if God had not made them a pleasure as
well as a necessity.
~Voltaire

3. Feeding & swallowing
 Feeding includes the act of preparing food and
getting it to the child either orally or through
alternative means.
 Swallowing includes the manipulation of food in the
mouth and directing its passage from the oral cavity
down to the stomach.

4. Age (months) Development/posture Feeding/oral sensorimotor
Source: Adapted from Arvedson and Brodsky10 (pp. 62–67).
Neck and trunk with balanced flexor
Nipple feeding, breast, or bottle
and extensor tone
Hand on bottle during feeding (2–4
Visual fixation and tracking
months)
Birth to 4–6 Learning to control body against gravity
Maintains semiflexed posture during
Sitting with support near 6 months
feeding
Rolling over
Promotion of infant–parent interaction
Brings hands to mouth
Sitting independently for short time Feeding more upright position
Self-oral stimulation (mouthing hands Spoon feeding for thin, smooth puree
and toys) Suckle pattern initially Suckle suck
Extended reach with pincer grasp Both hands to hold bottle
6–9 (transition feeding)
Visual interest in small objects Finger feeding introduced
Object permanence Vertical munching of easily dissolvable
Stranger anxiety solids
Crawling on belly, creeping on all fours Preference for parents to feed
Pulling to stand
Cup drinking
Cruising along furniture
Eats lumpy, mashed food
First steps by 12 months
9–12 Finger feeding for easily dissolvable
Assisting with spoon; some become
solids
independent
Chewing includes rotary jaw action
Refining pincer grasp
Refining all gross and fine motor skills Self-feeding: grasps spoon with whole
Walking independently hand
12–18 Climbing stairs Holding cup with 2 hands
Running Drinking with 4–5 consecutive swallows
Grasping and releasing with precision Holding and tipping bottle
Improving equilibrium with refinement
of upper extremity coordination.
Swallowing with lip closure
Increasing attention and persistence in
Self-feeding predominates
>18–24 play activities
Chewing broad range of food
Parallel or imitative play
Up–down tongue movements precise
Independence from parents
Using tools
Circulatory jaw rotations
Chewing with lips closed
Refining skills
One-handed cup holding and open cup
Jumping in place
24–36 drinking with no spilling
Pedaling tricycle
Using fingers to fill spoon
Using scissors

5. Three phases of swallowing
• oral preparatory phase
Oral phase 1 s liq
20 s solid
• oral propulsive phase
• aspiration is most likely to occur
Pharyngeal phase
1s • involuntary and totally reflexive
• lower esophageal sphincter
Esophageal phase
8-20 s • gastroesophageal reflux.

6. Airway & swallowing

7. Factors leading to feeding & swallowing disorders
Arvedson and Brodsky, (2002), ASHA (2002), Kurjan, Newman (2000) and Swigert (1998)
central nervous system
abnormalities or injuries (e.g.,
neural tube defects; genetic
Premature birth/LBW Anatomic defects like clefts syndromes; • cerebral palsy;
pre-, peri- or post-natal
trauma, such as stroke or
traumatic brain injury
oral and upper digestive tract
and/or food texture
hypersensitivity (e.g., some
Intellectual disability Dysphonia
children with autism; •
secondary to use of nasogastric
tube in some children

8. Inter relationships among development of feeding &
swallowing & other developmental domain
Ability to Delay in self
Motor skills
hold things feed
Communication Ability to Attitude
development express need towards food
Delayed Need to be
Medical
feeding fed with food
condition
patterns textures

9. Impact
 Aspiration-lung infections
 Dehydration
 Malnutrition

10. Early assessment & intervention
“Feeding and swallowing skills change
dramatically during the first three years of life.
Developmental gains in feeding and swallowing are
due to the combined influences of anatomic
growth, neuromotor maturation and learning”
(ASHA, 2004).

11. Why aversion/hypersensitive later?
 lacks the opportunity to build associations between
positive sensations in the mouth and the reduction of
hunger, or the social interaction
 Tube feedings cause GER-associate feeds with
discomfort & pain
 Negative and invasive stimulation to the face and
mouth -suctioning, intubation, tube insertion
 Mouth becomes unfamiliar with touch, taste, texture,
and other stimuli that had pleasurable associations &
become physically hypersensitive to touch and taste

12. Behavioral expression fall in 3
categories
 resistance to accepting food orally;
 lack of energy and endurance to do the 'work' of
eating;
 oral-motor -disabilities resulting in an inability to
produce the necessary motor skills for ingestion.
Determine if the problem has a strictly physiologic
origin or whether it may be exacerbated by the feeding
interaction between child and feeder.

13. Role of ENT Surgeon
 Feeding issues
 20 % swallowing / dysphagia

14. Diagnosis
 FEES ST/DIAGNOSTIC NASOENDOSCOPY
 VFS

15. Functional Endoscopic Evaluation
of Swallowing

16. Cricopharyngeal dysfunction
pooling

17. Video fluoroscopy

18. Aspiration

19. Fluoroscopy picture

20. Establishing a feeding & swallowing
Team
 Individualized
 SLP,OT
 Therapy to enhance strength, range of motion &
coordination of the lips ,tongue, cheek & jaw muscles
 Decrease oral aversion due to sensory problems
 Decrease behavioral resistance to feeding
 Decrease risk of aspiration
 Others: food texture, feeding equipment &
compensatory strategies

21. Components of the Plan.
 environment
 positioning during feeding
 equipment for food preparation and feeding
 diet content (including food and liquids), quantity and
texture
 feeding techniques
 precautions, including emergency procedures
 training plans for personnel implementing the plan,
 monitoring safety, progress and effectiveness of the plan
 process for communicating with families

22. strategies
 Oral awareness
 Mouthing
 Special utensils
 school-based PT has knowledge and training to
provide input to the school team that includes:
 positioning (tonal issues, head/trunk control);•
 seating options (e.g., wheelchair, adapted chair); and•
 assistance with assistive technology needs.•
 Dietitian or Nutritionist.

23. Tube Feeding

24. Surgical intervention

25. Tongue tie release

26. Drooling Surgery

27. Thank you !
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 http://sheelusrinivas-entpractice.blogspot.in/