1/23/2013

Oral Motor Skills in Breastfeeding Infants Jennifer Pollock, CCC-SLP, CLC Februaryy 5,, 2013

The Reason I’m Here…

1

1/23/2013

A Little Info About Speech Pathology zSpeech Pathologists are generally required i d tto h have a M Masters t ffrom an accredited program zGold Standard is the American SpeechLanguage-Hearing Association’s “CCC” zAssessment & Treatment in various settings, diagnoses and age groups

My Baby Needs WHAT Therapy??!! zSpeech Therapy zOccupational Therapy zPhysical Therapy

2

1/23/2013

4 OM Components in Breastfeeding: zStrength zCoordination zRange of Motion zSensitivity

Obvious to an SLP? Or Not So Much? zObvious- milk leaking from the mouth, i bilit tto iinitiate inability iti t and/or d/ maintain i t i llatch, t h weak suck, etc. zNot so obvious- insufficient milk supply, nipple pain/soreness, frequent mastitis, etc. zThis is why we work together!

3

1/23/2013

Basic Anatomy of the Infant Oral Cavity

Initial Oral Reflexes zRooting reflex zSucking reflex zSwallowing reflex

4

1/23/2013

Swallowing Reflexes zBiting reflex zVomiting/gag reflex zCoughing reflex

The Ever-Important Latch zBu’Lock, et al. (1990) demonstrated the i t l t h iin b tf di b d importance off latch breastfeeding based on cineradiography studies in 1950’s and confirmed by ultrasound in the 1980’s.

5

1/23/2013

Latch Video from Ameda.com

The Proper Latch z Baby opens mouth wide enough to grasp not only the nipple but the areola. z Lips should be turned outward and in contact with the breast.

6

1/23/2013

Cheeks are for sucking (and smooching!) z Negative air pressure vacuum via intraoral vacuum. z Sucking pads in cheeks provide stability.

Proper Latch, cont. zBaby’s jaw extends over milk ducts zTongue raises against soft palate zMuscles involved include- suprahyoid, infrahyoid, mylohyoid, geniohyoid, masseter, medial and lateral pterygoid, and temporalis. temporalis zTongue elevates lateral borders to form a trough to direct milk to be swallowed.

7

1/23/2013

Proper Latch, cont. zPeristalsis begins from tongue to h oropharynx. zTongue tip remains anterior to maintain seal of the mouth.

Poor Latch Leads to… zPoor suction and extraction of milk zNipple damage and pain zDecreased milk supply zNeed for supplementation zAerophasia zReduced wt. gain zEarly weaning

8

1/23/2013

Poor Swallowing Leads to… zOral or pharyngeal stasis zP zPenetration t ti zAspiration zRespiratory compromise zFeeding refusals zPoor weight gain zNeed for supplementation and/or use of product designed for specific issues.

Latch on Approach

9

1/23/2013

Positioning to Facilitate Latch zInfant and mother belly-to-belly. zBoth comfortable and supported. zVariety of positions attempted to find most effective for baby, prevent nipple soreness, etc.- Football, Cradle, Cross cradle Sidelying cradle, Sidelying, “Down Down Under” Under , “Beauty Beauty Pageant Sash” , etc.

10

1/23/2013

Positioning, cont. zFootball

Cradle

Cross-Cradle

The Ever-Important Suck zNaylor (2001) stated that in the baby’s first year, orall motor t function f ti progresses to t match other biologically driven developmental processes. zThe S-S-B sequence is generally thought to be appropriately developed by around 37 weeks gestation in healthy term infants.

11

1/23/2013

The Physiology of Sucking zNewborns have innate oral reflexes and di ti t anatomical distinct t i l ffeatures t to t facilitate f ilit t sucking in the neonatal period. zJaw retraction zTongue positioning zLarynx positioning zTongue size

Sucking in Response to Flow Rate zAs breastfeeding begins, the infant sucks more rapidly. idl zCue the maternal milk ejection reflex! zSucking slows as milk flow occurs and audible swallows heard. zThe amount of milk flowing influences the strength and bursts of sucking and pausing.

12

1/23/2013

Suck Differences: Nutritive vs. NonNutritive z Non-nutritive suckingrate typically 6 to 8:1 and 1-4 swallows per burst. z Nutritive suckingusually 1:1 butt may ll 1 1b change toward end of feeding.

Oral Dysfunction in Infants Due to: zPrematurity zLBW zMetabolic disorders zNeurological disorders zCongenital abnormalities zUse of NG tubes zJust because!!

13

1/23/2013

Watch Closely for Problems Early On! zRighard (1992) demonstrated that proper l t h ttechnique latch h i iin the th first fi t week k off lif life was crucial to breastfeeding duration. z When poor latch not corrected, probability 10x’s more likely to use a bottle in the 1st month and wean early. Exclusive and partial breastfeeding rates were higher in those whose suck was corrected.

What to Assess: z Maternal history, previous lactation experience z Mother-infant interaction z Newborn behavior z Non-nutritive N t iti sucking ki assessment z Breastfeeding assessment z Bottle assessment

14

1/23/2013

Why Have Speech See These Babies?? zBauer, et al. (2008) states that Speech Th Therapists i t should h ld perform f an evaluation l ti “to ensure a safe and efficient introduction of oral feeding”. z“Feeding performance depended on a favorable oral motor condition…on strong sucking, rapid rhythm, and on suckingswallowing-respiration coordination”.

Non-Nutritive Sucking Assessment zExaminer typically uses a gloved finger in th infants the i f t mouth. th zFeel for tongue placement and movements. zMay also see use of a pacifier.

15

1/23/2013

Suck Training, Continued zFinger provides light pressure to the midline idli off the th tongue, t then th pulling lli th the finger out slowly to encourage the baby to suck it back in.

Bottle Feeding- We Can Help! zPeterson and Harmer “Balancing Breast and dB Bottle: ttl Reaching R hi Y Your B Breastfeeding tf di Goals zNipple shape and transition of base to tip is key when selecting appropriate product zWatch for gagging gagging, “straw” straw suck and retracted tongue

16

1/23/2013

Nipple Shapes to Consider

Nipple Flow Rate z“Slow flow” is not always the same!! z26 nipples evaluated and rated in the Peterson & Harmer book zDripping does not mean it’s a fast flow zRate of flow at start of feed=how infant accepts the bottle

17

1/23/2013

Nutritive Sucking and Swallowing Assessment zMay be at breast or bottle or both zSLP examines management of secretions, suck-swallow-breathe coordination, swallowing, and breathing zMay refer for Video Oropharyngeal Swallow Study (VOSS)

VOSS

18

1/23/2013

Suck Training z Should be performed by a trained professional. z Done D b by SLP b before f ab breastfeeding tf di session. i z 2-5 minutes to avoid making baby tired or stressed. z May see orofacial treatment- massage, tapping w/finger, etc. Bovey, et al. (1999) says “less is more”. ” z Maybe used in conjunction with finger-feeding with an SNS or small feeding tube.

Finger Feeding

19

1/23/2013

Rock On, Baby!!!!!

References z Bauer, M.A., Prade, L.S., Keske-Soared, M., Haeffner, L.S.B., & Weinmann, A.R.M. (2008). The oral motor capacity and feeding performance of preterm newborns at the time of transition to oral feeding. Braz J Med Biol Res, 41(10), 904-907. z Bu’Lock, F., Woolridge, M. W., & Baum, J. D. (1990). Development of coordination of sucking, swallowing and breathing: Ultrasound study of term and preterm infants. Developmental Medicine & Child Neurology, 32, 669–678. z Genna, C.W. (2008). Supporting Sucking Skills in Breastfeeding Infants. Sudbury, MA: Jones and Bartlett Publishers, Inc. z Marmet, C & Shell, E. (1984). Training neonates to suck correctly. MCN Nov-Dec MCN, Nov Dec (9) (9), 403 403-407. 407 z Morris, S.E. (1998). Issues in the anatomy and Physiology of Swallowing: Impact on the Assessment and Treatment of Children with Dysphagia. Retrieved from www.new-vis.com

20

1/23/2013

References, Continued z Naylor, A.J. & Morrow, A.L. (April 2001). Developmental Readiness of Normal Full Term Infants to Progress from Exclusive Breastfeeding to the Introduction of Complementary Foods. Retrieved from www.pronutrition.org/pubview.php/12/ z Neiva, F., Cattoni, D., Ramos, J., & Issler, H. (2003). Early weaning: Implications to oral motor development. Journal of Pediatrics (Rio J), 79(1), 07-12. z Peterson, A. & Harmer, M. (2010) Balancing Breast and Bottle: Reaching your breastfeeding Goals. Amarillo, TX: Hale Publishing, L.P. z Righard, L. & Alade, M.O. (1992) Sucking technique and its effect on success of breastfeeding. Birth,19, 185-9. z Waxman, W F. F (2012) Oral O l Motor M t Skills Skill and d th their i R Relationship l ti hi tto Breastfeeding. Retrieved from http://www.mercazrakefet.org z Zerzan, J. (2007). Gaining and Growing: Assuring nutritional care of preterm infants. Retrieved from http://depts.washington.edu z Photos- Janet Tolley, www.freedomguerrilla.com, knol.google, US Government, atm.ucdavis.edu, arabiaenglish.babycenter.com

Contact Information zMemorial’s Kids at Koke Mill z3132 Old Jacksonville Rd zSuite 140 zSpringfield, IL 62704 z217-862-0400 [email protected]

21

1/23/2013