Orofacial Myofunctional Disorders
Pediatric feeding disorders in infants and toddlers (0-2 y/o)
1. Development and aspects related to normal eating, drinking and
swallowing
Swallowing food = complex
involves reflexive and voluntary motor control + intraoral sensory processing
demands good coordination with breathing Normal feeding depends on successful interaction of a child’s health, development,
temperament, experience and environment any of these factors can cause a feeding
problem 1.1 Motor control and motor learning
Motor control = process of creating a sequence of movements for the performance of
coordinated and skilled actions
Motor learning = acquisition of skills or skilled movements as a result of practice
SENSORY INPUT Smell, taste, sight, hearing, proprioceptive and vestibulary system
SENSORY INPUT
Sensory processing
Stimulus regristration
Adding meaning to stimulus
Integration with other stimulus information
Integration with previous sensory information
Adequate adaptive response
Regristration of response for future use
FEEDBACK & FEEDFORWARD (to predict bolus size, temperature, consistency…) Motor learning and neuroplasticity (= ability of the brain to change and adapt to new
conditions)
Principles:
‘repetition matters’
‘intensity matters’
‘transference’
‘use it or lose it’ important in the treatment of progressive diseases.
‘age matters’ training influences more readily the younger system than the older
nervous system early start of intervention
‘specificity’ training should closely parallel the desired task (e.g.: if you want to
learn to eat from a spoon, you have to eat with a spoon)
important with feeding disorders
1.2 Development of (sensori)motor skills
0-3 months: reflexes, generalized movements
3-4 months: purposeful movements
Verticalisation
Increased stability
Increased mobility
Feeding skills follow
Overview milstones in senorimotor development related to feeding see Appendix 1 1.3 Psychology of eating and swallowing
preknowledge + course dysphagia 1.4 Neurology of swallowing
preknowledge + course dysphagia
Appetite
Controlled in hypothalamus
Regulated by hormones
short term: start/end meal
long term: intake necessary nutrients
Infants and children self-regulate: oral intake varies up to 30% daily 1.5 Shape and growth of pharyngeal anatomic structure
preknowledge
Course text see Appendix 2 BUT infant older child
Infants
Tongue: bigger compared to whole oral cavity
Tongue muscles: extrinsic muscles more evelope than intrinsic
intrinsic musles: shape
extrinsic muscles: movement
Fat pads, sucking pads in the cheeks role in stabelising to insert the nipple +
making the oral cavity small enough (together with the tongue) to make sucking
movement
No teeth (fully developed at 2 y/o)
6-8 months old major function isn’t chewing BUT they give sensory input
No true oropharynx to swallow, suck and breath easier
larynx is high, tongue is way in the back + pharynx has to stretch
angle of the pharynx has to become more accurate (90 degrees)
1.6 Nutritional requirements and growth
Amount depends on age, weight, condition and health
Up to 3 months: 140-160 ml/kg
3 moths – 2 years: 100-120 ml/kg
Complete diet: fats, carbohydrates, proteins, vitamins and trace elements
Growth charts length, weight, head circumference 1.7 Taste development
Born with preference for sweet tastes & energy-rich foods
Through experience other taste preferences are learned
Breastfeeding VS bottle feeding both neutral + slightly sweet
Learned tasted acceptance the sooner the better
Disgust & rejection (on sight) starts around 14 months
Neophobic stage (= fear of new foods) 20 months – 8 years old
= normal response
1.8 Food consistency during first 18 months
Expansion of textures: same order + variation in timing
Age
Food consistency
0-6 months
Liquid by nipple
4-6 months
Strained smooth food by spoon
6-7 months
Lumpy food by spoon
+ Finger foods (ex: baby biscuits)
8-12 months
Crushed food with small chunks by spoon or own hands
+ Finger foods (ex: bread, vegetables)
<12 months
Cup drinking
12-18 months
Slightly mashed food self fed by spoon
+ Hard, chewable food (ex: raw vegetables)
Inherited avoidance of textures
not liking food because of the texture (genetic) 2. PFD: general approach
2.1 Definition of pediatric feeding disorder
Feeding problems: 25-50% neurotypical & 80% developmental disabilities
Food selectivity (picky eaters)
Reduced appetite for or interest in food
Slow feeding (> 30 minutes)
Food pocketing not swallowing food
Feeding problem may evolve into feeding disorder
PFD (pediatric feeding disorder) or not? depends on the definition UNILATERAL APPROACH
ASHA, 2014
“Pediatric dysphagia”
= impaired oral, pharyngeal and/or esophageal phases of swallowing
to narrow, complete focus on swallowing DSM-5, APA, 2013
“Avoidant/restrictive food intake disorder (AFRID)”
= eating or feeding disturbance with persistant failure to meet appropriate nutritional and/or
energy needs Positivie points AFRId
Incorporates nutritional complications
Acknowledges that feeding disorders are common in certain medical conditions
Document Outline
Orofacial Myofunctional Disorders
Pediatric feeding disorders in infants and toddlers (0-2 y/o)
1. Development and aspects related to normal eating, drinking and swallowing
Smell, taste, sight, hearing, proprioceptive and vestibulary system
Infants
Growth charts ( length, weight, head circumference
Inherited avoidance of textures
2. PFD: general approach
2.1 Definition of pediatric feeding disorder
Feeding problem may evolve into feeding disorder
UNILATERAL APPROACH
ASHA, 2014
“Pediatric dysphagia”
DSM-5, APA, 2013
ICD-10, WHO, 2016
“Other feeding disorder of infancy and childhood”
UNIFYING APPROACH
Goday et al., 2019 (using ICF)
Diagnostic criteria ( see Appendix 3
2.2 Prevalence and groups at risk
2.3 Clinical reasoning in PFD
Referal
Anamnesis
Clincal exam ( see Appendix 5
Instrumental exam
Suspicion for aspiration
Further exam
For example: metabolic, repiratory, allergy, psychotherapeutic counseling…
( ICF-framework: broader mealtime factors need to be considered to adhere to a “whole child” approach = critical to optimizing feeding function
Multidisciplinary
2.4 Parental coaching
3.1 PFD in breastfeeding & bottle feeding
3.1.1 NORMAL breastfeeding & bottle feeding
Oral reflexes
Shift: reflex ( skill
Mature sucking
Immature sucking shows ( only expression OR no/very poor suction
Suck-swallow-breath coordination
Nutritive sucking
NS is harder than NNS because of the coordination
Typical breastfeeding
What should a breastfeed look like?
Is breastfeeding more difficult?
Typical bottle feeding
3.1.2 PFD in breastfeeding & bottle feeding
1. Anamnesis
2. Clinical examination
Obseravtion tools
3. Instrumental exam / referral
4. Logopedic diagnosis
5. Possibilities
6. Treatment plan
Onset problems in breastfeeding
Breast pumping!
Conditional problems + coordination problems
Posture
Feeding matter
Flow
Consistency
Problems in oral motor skills
Posture
Stimulation of reflex activity
Feeding matter
Flow
Consistency
Timing
Frequent choking
Posture
Feeding manner
Flow
Consistency
Problems after a good start
Posture
Flow
Consistency
Timing
Problems in transition breastfeeding ( bottle feeding
Flow
Feeding manner
3.2 PFD in spoon feeding
Aspects in spoon feeding
Starts 4 – 6 months: reflexive activity( & motor skills and stability (
Responsivity
Response to stimulus (sensory input): normal/ too high/ too low
Spoon feeding = a lot of new sensory input!
1. Anamnesis
2. Clinical examination
3. Instrumental exam / referral
4. Logopedic diagnosis
5. Possibilities
6. Treatment plan
Problems in oral motor skills
Posture
Spoon
Consistency
Feeding manner
Problems in responsivity
Spoon
Consistency
Feeding matter
3.3 PFD in chewing
Aspects in chewing
Starts 7 – 8 months (sensitive period 6 – 12 months !)
1. Anamnesis
2. Clinical examination
3. Instrumental exam / referral
4. Logopedic diagnosis
5. Possibilities
6. Treatment plan
Problems in oral motor skills
Feeding manner
Consistency
Problems in responsivity
Feeding manner
Consistency
3.4 PFD in cup drinking
Aspects in drinking from a cup
Starts from 8-10 months (culture related; 6 – 18 months)
Drinking from a straw; 12 months – 2 years
1. Anamnesis
2. Clinical examination
3. Instrumental exam / referral
4. Logopedic diagnosis
5. Possibilities
6. Treatment plan
Problems in oral motor skills
Posture
Feeding manner
Cup
Consistency
Problems in responsivity
Posture
Consistency
Cup
Feeding manner
Velopharyngeal disorders
1. The velopharyngeal mechanism
1.1 Velopharyngeal opening/closing
Velopharyngeal closure
= mechanism that closes the nasal cavity from the oral cavity
Two activities for closure
Depending on relative contribution of both components
These patterns vary between individuals and depend on
Velopharyngeal opening
Passive component
Active component
1.2 Velopharyngeal function in relation to speech
Nasality
Vowels
Consonants
Voiceless consonants
Voiced consonants
Coarticulation
( voiced consonants, open vowels and closed vowels
1.3 Velopharyngeal function in relation to swallowing and the Eustachian tube
( prevents reflux of food and drink through the nose
( m. tensor veli palatini and m.tensor tympani
Disorder in velopharyngeal sphincter
Velopharyngeal inadequacy
All deviating symptoms have a certain cause
Nasal resonatory disorders due to problems in velopharyngeal closure
Problems with closing off air
Nasal resonatory disorders due to problems in velopharyngeal opening
Nasal airflow disorders
Etiology: first term pregnancy
Feeding
Bottle feeding: high nasal reflux because of the big flow of milk sometimes
Implications for feeding
Speech & Language development
Phonetic speech development in babies and infants
Causes
Treatment of VPD: cosiderations
Etiology?
Age
CLP: Multidsciplinary clinical pathway
0W: Feeding advice for CLP
Breast feeding
3M-6M-1Y/O: Closure Lip – Soft palate
From 5Y/O: Possible additional surgery
6Y/O: Closure Hard palate
Hard palate closure
Bone grafting: graft places in between two halves of the alveolar bone
Psychological support
Teamwork
Onset direct therapy depends on
Treatment of many years, timing!
Early intervention
Direct therapy
Main goal = intelligible speech
Target sound selection: start with easiest ( more difficult sounds
OMFT & Blowing/sucking exercises
OMFT is useful if
Blowing/sucking exercises are useful if
Those exercises are NOT useful to improve speech!! ( different neurology
Hyperfunction or hypofunction of orofacial area
1. Anatomy & fysiology: 3 functional systems
Function: articulation (= speech) + mastication (= feeding)
2. Morphology & Typology
Strong relationship between
Functions govern Stucture & Structure governs Function
Clinicians tend
OMD related to hypertonicity
Podcast
Mr. Greenbaum devides TMD in 3 categories. Which are they?
Anatomy videos + text
Bone structures oral cavity
Zygomatic arch: Temporal fossa + Infratemporal fossa
Maxilla
Mandible
Temporo-mandibular joint
= bi-arthroidal hinge joint that allows complex movements necessary for life
Involves fibrocartilaginous surfaces & articular disc ( two cavities
Dubble joint: two separate synovial cavities above each other
Articular disk = inside the joint ( thin in front & thick behind
Divides joint into two sections ( each with its own synovial membrane
Two types of movement
Ligaments
Oto-mandibular ligaments =
These ligaments: implicated in tinnitus associated with TMD
Muscles of mastication
Start of muscle = arising
Structures + location
Lateral pterygoid muscle
Fibers run backwards & little lateraly
Medial pterygoid muscle
Temporalis muscle
Start = wide area on side of the skull within the temporal line
Masseter
Actions & movements
Closing the jaw
Opening
Hyoid muscles
Upwards & forwards
Upwards & backwards
Upwards by means of a pully
Downwards
Infrahyoid muscles
Resting position
Resting position TMJ =
Nerve supply
Muscles that act on the TMJ are innervated by
OMD related to hypotonicity
1. Etiology, OMD types & consquences
Sucking habits
Consequences
Biting habits
Consequences
Open mouth behaviour/ mouth breathing
Consequences
Atypical tongue position at rest
Atypical swallowing (infantile)
2. Assessment & Anamnesis
3. Treatment (OMT)
Our goal = to work on the functions
Appendix 3: Diagnostic criteria (Goday et al., 2019 (using ICF))
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