Pre-Chaining Therapy: Common Sense Approach to Infants with Oral Sensory Motor Dysfunction (Feeding Disorders)
Posted Mar 07 2013 2:49am
Pre-Chaining therapy in my opinion, is the most important treatment of all the work I do as a feeding specialist. Pre-Chaining is our therapy program to prevent feeding aversion ("Pre-Chaining"because we want to fix problems before Chaining is needed) for infants who are premature, have health issues and/or are at risk for missing the typical developmental transitions of eating (spoon at 6 months, table foods by 12 months, bottle to cup drinking, etc.) There are also more typically developing, term infants who need this type of therapy. Unfortunately, many of the red flags of feeding disorders are dismissed or missed completely. Parents KNOW something is wrong, but they are often told, "he'll outgrow it" or weight is ok, but they know that feeding is very, very 'off' somehow. I was asked a question about babies and Pre-Chaining therapy. What do I look for and how do I assess/treat? So thought I would share. I look at infants with great care. I try to see everything that contributes when feedings don't work at all or when they start unraveling. I LISTEN to parents concern, if they are concerned, I am even more concerned. They know their baby. I pray that God gives me eyes that SEE these infants. Each baby is different and I must customize treatment to each baby, but there ARE patterns. I will try to explain what I look for...so, here goes... Therapists...do you know how to diagnose and treat "oral sensory motor dysfunction" in infants? Yes, oral SENSORY MOTOR dysfunction, NOT oral motor sensory. Do you know what this is? I use this term for infants as I develop a comprehensive treatment plan. I am trying to help the infant who struggles severely to feed in a safe, coordinated, calm manner. What problems do I see that would fall under oral sensory motor dysfunction? (What infants have "OSMD"-if you will). Infants who struggle to tolerate a bottle nipple and can only breastfeed. The baby may simply not seem to know how to bottle and/or spoon feed and may only have one source of nutrition via breastfeeding. All attempts to feed in a different manner from breast are unsuccessful and stressful. Infants who have state regulation issues...('colic' symptoms, poor transitions in state) Infants who then struggle to move on to cup or spoon... who tolerate only one or two flavors of baby food. Infants who can feed only in a sleep state. Infants who gag severely with bottle nipple presentation or cannot tolerate a pacifier, distressed, hyperalert infants who also have sleep issues AND add to that mix, in some babies, there is also the gradual pulling away from feeding due to allergy (eczema, bumpy skin, increasing aversion, GI changes-constipation, gassiness and vomiting). NOT to mention, choke, cough, watery eyes, oral spillage, gulpy swallows and the whole dysphagia presentation.... I believe when the baby struggles so much to eat, whether they have one or two of the above symptoms or all of them, it results in a cascade of events, in which the baby is taken out of the realm of achieving successful feeding. It is like dominoes that will not fall...there is no timed, ordered sequence to feeding, there is no reliable motor plan, the infant cannot find a place to fall into an organized state and feedings don't work. Feedings are chaos. This creates anxiety and in some cases, justifiable panic for the parents, further disrupting the feeder child relationship-interaction. The parent or the therapist (please don't do this!!) may choose a high flow nipple to try to 'get the feeding down' and this opens up an entire Pandora's box of ADDITIONAL problems (fatigue, aerophagia, pharyngeal-nasal backflow, laryngeal penetration and even aspiration). When these feeding problems happen in infancy, you do not have a BEHAVIORAL feeding disorder. The infant cannot CHOOSE not to eat. It is beyond their cognitive capability. These issues mean there is a physical oral sensory motor biobehavioral problem that changes feeding behaviors. Behaviors grow out of these issues. If that wasn't enough of a problem there are also some babies who have an anatomical problem as well (vocal cord dysfunction, paralyzed cord, laryngeal cleft, undiagnosed dysphagia) or physical challenges (tone, torticollis, developmental, cardiac or genetic disorders). So you have this long laundry list of challenges to overcome at feeding times...8-12 times per day in early infancy. The infant never experiences normal feeding. What happens is, "it hurts, it is scary or I can't breathe....therefore I eat like this"...as the baby does not experience what is typical feeding, therefore the baby does not learn feed in a typical manner. I would love to hear input from others in speech and occupational therapy, parents and other professionals But this is how I see this, how I treat it and how I watch these kids carefully because in my opinion, many of them become the older children with severely selective eating and feeding aversion.