We are pleased to announce that our SLP chat tonight,
Wednesday, May 15, 2002, will be hosted by Nancy B. Swigert,
MA, CCC-SLP, who will lead us in a chat about Pediatric Dysphagia. 
Nancy Swigert is the owner of Swigert & Associates, Inc., a private
practice which has provided speech-language pathology services in
Lexington and the surrounding Central Kentucky area for over twenty
years. Through a contractual arrangement she also serves as Director
of the Speech-Language Pathology Department at Central Baptist
Hospital, a large acute care facility in Lexington.  Ms. Swigert sees
children and adults at the hospital (in-patient and out-patient), at
her office and in home settings.
Her main interests are in the area of pediatric and adult dysphagia
and pediatric and adult neurogenic disorders.  She authored The Source
for Dysphagia with LinguiSystems in 1996 (revised 2000), The Source for
Dysarthria in October 1997, The Source for Pediatric Dysphagia in
October 1998, and The Complete Clinical Dysphagia Evaluation in 2001. 
She lectures extensively in the areas of dysphagia, dysarthria,
apraxia and outcomes.

Nancy Swigert is Past-President of the Kentucky Speech-Language-Hearing
Association, the Council of State Association Presidents, and was
President of the American Speech-Language-Hearing Association in 1998. 
She is a Fellow of ASHA and was twice awarded the Honors of the
Kentucky Speech-Language-Hearing Association.

<Robin>  Hello!  We are chatting tonight with Nancy B. Swigert, MA, CCC-SLP, about the topic of
          Pediatric Dysphagia.
<Robin>  Nancy, will you give us an overview of Pediatric dysphagia and what an SLP would expect to see ?
<Nancy Swigert>  Pediatric dysphagia may include difficulty sucking and swallowing and coordinating
          the suck-swallow-breathe sequence. In older children it might include difficulty drinking
          from a cup or removing food from a spoon, difficulty chewing.
<Nancy Swigert>  Signs and symptoms might include loss of food from the front of the mouth, coughing,
          choking, gagging, holding food in the mouth.
<Nancy Swigert>  Dysphagia also encompasses food aversion, and other behavioral manifestations.
<Robin>  We received a question which I'd like to present to Nancy Swigert.
<Robin>  Here is the question:  I am very interested in working in a facility with the pediatric
          population. I am currently completing my CFY year in the schools.  My background consists 
          mainly of children with language and articulation disorders and adults with dysphagia
          and neurogenic disorders. Is there specific training that I could receive to help me in
          this? In graduate school we didn't have any course in this population.
<Nancy Swigert>  There are courses on pediatric dysphagia offered around the country. That's a
          good place to start. I would also recommend calling an SLP in your area who specializes
          in pediatrics, and asking to come and shadow them.
<sam>  Good answer
<Robin>  Nancy, do you offer courses?
<Nancy Swigert>  Yes - many settings around the country invite me to come and speak, and on
          occasion I offer courses directly. None planned in next few months though.
<Nancy Swigert>  ASHA also has some nice CE products on peds dysphagia.
<lucy>  Thanks. Up to what age range are we discussing?
<Robin>  Lucy, what age group are you interested in?
<Nancy Swigert> Lucy-we'll talk about kids of any age.
<lucy>  Great! In your experience when upgrading diets of students who have not had swallow
          studies in years, what is your criteria before planning treatment?
<Nancy Swigert>  Lucy - what kind of upgrade are we talking about? From thick to thin liquids?
          From soft foods to more chewable foods? Do we suspect any pharyngeal dysphagia?
<lucy>  Puree or mechanical soft to chewable foods .. I always request a MBS but am not supported..
          My kids have severe cerebral palsy and other multiple disabilities..
<Nancy Swigert>  That's a tough call -- luckily most kids have oral (vs. pharyngeal) dysphagia.
          If the student does not show signs of pharyngeal dysphagia - coughing, choking, impaired
          lung sounds, resp. infections, then I would be comfortable trying to upgrade without the
          instrumental. However, err on the side of caution, especially with really sick kids.
<lucy>  My star student just started accepting puree after several months of oral therapy
          including a lollipop... she does accept some puree but can't move the food from the
          anterior to the posterior.. I work on lip closure but she does not appear to "Feel" the
          food and will loose it before the swallow... I was thinking of using the syringe to place
          the food on midline of the tongue.
<sam>  You may try posterior placement.
<Nancy Swigert>  Great - try some specific activities to increase anterior to posterior movement
          of tongue - moving lollipop front to back, for example.
<Nancy Swigert>  I'm not a big fan of syringe feeding for kids, especially, as this will never
          develop better oral movement. Try sam's suggestion of placing food from spoon further
          back-- and then give jaw and lip support. Do you know how to do that?
<lucy>  i do try jaw and lip suppor but it is not working ...her tongue does not move enough
          to manage the bolus.
<lucy>  Any thoughts on nasal regurgitation..... again md cp.
<Nancy Swigert>  Nasal regurgitation indicates Velopharyngeal incompetence -- is the kid
          hypernasal? Has this one had a videofluoroscopic exam?
<sam>   Positioning would be best to reduce reflux - if VP closure is the issue I would say that
          your best bet is feedback.
<Nancy Swigert>  Lucy- I think this kiddo is going to need more oral motor work -- have you
          tried food with more texture to see if this added sensory input increases her ability
          to move the food? Can she chew/munch at all?
<Nancy Swigert>  Is this child fed non-orally? How is her nutrition supported?
<lucy> Nasal student, extreme saliva issues, had surgeries which were unsuccessful, drools
          continuously, poor jaw support, many uncontrollable motions... very hard to work with...
<Nancy Swigert>  Unsuccessful surgeries designed to do what? Repair VP insufficiency?
          Uncontrollable head, tongue movements?
<sam>  I assume the student has difficulty with stimulability, right?
<lucy>  Sensory input... have tried all types but still has a problem with tongue movement;
          likes soda, there was a study done on how the bubbles allow for a timely swallow.
<sam>  I saw that one!
<Nancy Swigert>  Doesn't sound like stimulating the swallow is her problem but that she can't
          get the bolus to the back of the mouth to initiate a swallow.
<lucy>  The surgery for drooling was to change the duct to minimize the drooling...Nancy, that
          is exactly what i think it is...
<lucy>  Any suggestions for moving the bolus ???
<Nancy Swigert><lucy>- Try some foods that are long and skinny (raw potato strips, licorice)
          that you can hold onto while the child has part in her mouth. Ask her to mouth the food
          front to back.
<lucy>  She can't follow one step directions... very low functioning but good idea.
<Nancy Swigert>  If the child has jaw thrust, jaw instability or jaw retraction, you can also
          try putting the child in prone (over a pillow so head is higher) - this helps neutralize
          the jaw position.
<sam>  Increased sensory foods -- like what you were suggesting -- may assist with transit
          issues as there is more input for bolus location.
<Nancy Swigert> Lucy, how about trying some downward pressure on the tongue with the spoon to
          stimulate tongue cupping and see if that helps.
<lucy>  child with nasal loss= stop liquids although thickened until mbs??
<sam>  nope, work on feedback -- nasal regurgitation could mean incomplete VP closure.
<Nancy Swigert>  No, I wouldn't stop liquids based on nasal regurgitation --- lots of times that
          has nothing to do with aspiration.
<lucy>  If the frenulum is too short .. do you think that may be a reason why she can't move the
<Nancy Swigert>  I would get a MBS on the nasal kid
<Nancy Swigert>  It might be part of it, but have seen many kids with restricted frenum who eat
          fine...how tight is it?
<lucy>  What about food on a vibrator... we get that as a recommendation. I have never done it.
<Nancy Swigert>  Food on vibrator -- I usually use vibration separately to increase tone...but
          I think it would be confusing to get food on a vibrator.
<sam>   I have a quick question about positioning . What positions should be utilized with infants
          for bottle feeding who may exhibit different oral dysphagias?
<Nancy Swigert>  First consider if the infant feels stable and secure - best done by swaddling
          them into a bit of a neutral position, shoulders rounded and arms near face.
<sam>  very good
<Nancy Swigert>  Then, slight neck flexion (but not chin down like we do with adults) - many do
          better somewhat upright, which works with an angle-neck bottle best. Some kids do better
          in side-lying to increase stability.
<sam>  Keep infant in lap or cradle position?
<Nancy Swigert> Sam- I like to hold the infant facing me so I can watch reactions better, in a
          somewhat upright position. But, some infants feel more stable when cradled.
<sam>  Thank you...any other positions?
<lucy> Nancy, how do you feel about sippy cups with the spout..when there is a tongue thrust.
<Nancy Swigert> Lucy -- I think it tends to promote the tongue thrust...
<Robin>  Nancy, here's another question from one of our viewers:  Any problems out there with
          toddlers putting solid foods into their mouths but not chewing or swallowing the solid
          foods ever. Just spitting everything back out and never able to chew and then swallow
          anything solid? Any treatments out there for this problem?
<Nancy Swigert>  Robin, I wonder if this child really has oral motor deficits he so can't get the
          food to the chewing surface and therefore spits it back out?
<Robin>  Good point...where would you start in treatment if this was the case?
<sam>  Sensory integration techniques may be warranted.
<Nancy Swigert>  After an assessment of oral motor skills, might start with manipulation of toys
          in the mouth to increase sensory awareness. Then on imitation of oral movements if child
          can imitate.
<Nancy Swigert>  Then, on careful placement of small bolus over on the chewing surface to see if
          child can munch it there and then swallow it.
<Robin>  thank you....theres another question from a parent: I have a son who was recently
          diagnosed with oral motor apraxia after dropping down the growth chart and having
          severe difficulty eating. The first person who seemed to know what might be going on was
          a speech therapist who was doing a swallowing eval. My son gags severely with most types
          of food, has an oral aversion and even has difficulty with some liquids.
<Robin>  Do you have any suggestions for this parent?
<Nancy Swigert>  Child also needs OT eval by OT with sensory integration expertise to see if
          sensory issues are partly to blame.
<Nancy Swigert>  The child probably also needs oral motor work to allow for better bolus
<Nancy Swigert>  Kids with this kind of oral aversion are often kids who weren't introduced to
          solid foods (i.e. cereals) at the devel. age of six months -- then later when they are,
          their sensory and motor systems aren't ready for it.
<Robin>  Interesting point....do you often co-treat with OT?
<Nancy Swigert>  When I can, on sensory kids like this, yes. I am very careful to deliniate our
          role vs. OT's role, though.
<slput>  What do you think the role (in general) is for the SLP in terms of dysphagia in the
          public school setting?
<Nancy Swigert>  I always think SLPs should take the lead in dysphagia treatment in any setting.
<sam>  I agree
<slput>  I have been the 'dysphagia specialist" in my district for three years...
<Nancy Swigert> Slput- that's great!! Do you work with the OTs and PTs there?_
<slput>  Yes I do.
<Nancy Swigert> Slput- how well do the classroom teachers and aides follow through on your
<slput>  The problem I have had is drawing the line between providing appropriate services and
          simply feeding the kids...some do, most don't.
<Nancy Swigert>  Yes, it is difficult not to fall into the trap of "feeder".
<sam>  Yes, it is
<sam>  In the LTC setting I serve in, I see how SLPs have the primary role for dysphagia
          assessment - I can't see how it wouldn't be included in our scope of practice in other
<slput>  It has taken almost all of the three years to "lay the groundwork".
<sam>  Theraputic feedings can often be misinterpreted as simply feedings by nursing staff -
          or others for that matter.
<Nancy Swigert>  Yes, it is a lot of work to outline the parameters and get a team approach
          going -- did you have good prep on peds dysphagia in grad school, or learn (like most
          of us) by hook or crook?
<slput>  It is like starting fresh in LTC but with even less support.
<slput>  I learned most of it while working in healthcare..also lots of ceu and text books..peds
          can be much different than adults.
<Nancy Swigert>  Yes, very different - sounds like you worked hard to get yourself prepared.
<slput>  I think I may have burned myself out actually....dreaming of just being a "speechie"
          in a regular school.
<Nancy Swigert>  Slput - you know, that's the great thing about our field. We can reinvent
          ourselves every few years, change the focus of our patient load, our job site, and
          never leave the profession.
<Nancy Swigert>  Slput-why not look around for a change of venue?
<slput>  Thanks! that's what I need to hear.
<sam>  It seems that tracheostomy, laryngectomy, and pediatric feeding have been put on the           
          back burner in many of our post-secondary institutions
<slp>  FYI, Nancy Swigert has authored The Source for Pediatric Dysphagia
<slp>  A very useful guide for tx.
<Nancy Swigert>  Thanks slp --  Linguisystems posted an announcement on the Products page of
          this website-- thanks for the nice comments!
<slput>  I am looking around but I hope to have some involvement with dysphagia/peds....
          yes EXCELLENT book!
<Robin>  Nancy, thank you for joining us tonight and sharing your expertise.
<sam>  Thank you Nancy
<Nancy Swigert>  I enjoyed it!
<Robin>  Hi jen, we are just winding down our chat with Nancy Swigert about pediatric dysphagia.
<Nancy Swigert>  Jen- do you have a question before I sign off?
<jen>  I will review the chat session later thanks
<Robin>  Ok jen....we will be working on editing our chat transcripts so that the archive will
          be up to date soon.
<slput>  Thank you, Nancy !
<Robin>  Thanks again for joining us everyone!
<jen>  Thank you,
<Robin>  Thanks again Nancy...goodnight all!