Special Start Training Program

Evaluation of Neonatal Sucking: Normal, Disorganized, Dysfunctional

• Presented by:

• Marjorie Meyer Palmer,M.A.

• Speech Pathologist

• Neonatal and Pediatric Feeding Specialist

Course Objectives:

To identify poor feeders by the sucking pattern they demonstrate

To differentiate a disorganized suck from a dysfunctional suck

Infant Oral Anatomy

tongue filled mouth

pear shaped palate

sucking pads in buccal cheek

uvula approximates epiglottis

tongue tip against palate

Tongue filled mouth

Pear shaped palate

Sucking pads

Tongue approximates palateUvula approximates epiglottis

Infant designed for function

To take oxygen nasally

To take nutrition orally

Observe the normal oral resting posture

Interrupted Function

Infant with BPD, chronic lung disease

Open mouth posture

Labored respiration

Breathing is both nasal and oral

Interrupted Function

Infant with Arnold Chiari malformation

Spina bifida

Open mouth posture

Oro-facial hyptonia

Emergence of Primitive Oral Reflexes

gag reflex

rooting reaction

transverse tongue reflex

phasic bite

non-nutritive suck

nutritive suck

Gag Reflex

Rooting Reaction

Transverse Tongue Reflex

Non-nutritive Suck

Short, rapid excursions of jaw

Rate of 2 sucks/second

Cupped tongue configuration

Non-Nutritive Suck

Nutritive Suck

3-6 months:Transition from Reflexive to Volitional

volitional suck

bilabial closure

tongue tip elevation

quiet jaw

Neonatal Intensive Care

The experience

Neonatal Intensive Care

Environment

Medical Intervention

Oro-facial procedures

Development of oral-motor skills

Impact on oral-sensory system

Impact on oral-motor development

Early Diagnosis of Oral Feeding Disorders

NOMAS® (Neonatal Oral-Motor Assessment Scale)

Developed by Marjorie Meyer Palmer, M.A., 1985

Differential Diagnosis of Neonatal Sucking Patterns*

Normal

Disorganized

Dysfunctional

• *Based upon the NOMAS®, developed by Marjorie Meyer Palmer, M.A.

Disorganized Suck

“refers to a lack of rhythm of the total sucking activity”

Crook, 1979

“BPD prevents the infant from breathing and swallowing efficiently during sucking and swallowing”

Craig, CM et.al., 19”99

Dysphagia-

swallowing disorder with difficulty that may occur in any or all stages of swallow: oral, pharyngeal, esophageal

Dysphagia

double aortic arch

infant at 35 weeks PCA

stridorous sounds with bottle feeding

less stridorous with breast feeding

Dysphagia

Infant with TEF repairchoking with feeds

material collects above the surgical repairesophagus will recover

Dysphagia

infant with VACTERL syndrome

TEF fistula repair

now two months corrected age

has developed compensatory strategies

Sensory Aspects of Neonatal Sucking

Perseveration

Responds to initial stimulus

Once stimulus has been removed activity does not diminish

Activity continues indefinately

Poor intra-oral sensory perception

Developing Sensory Aversion

Infant born at 30 weeks gestation

now 40 weeks PCA

BPD, chronic lung disease

observe subtle head movement

poor care giving skills

Developing Sensory Aversion

premature infant now 9 weeks corrected age

observe head movement, facial expression, eyes

expression component of suck still reflexive

suction component of suck volitional

After a series of pain episodes infants learn to escape heartburn by refusing to eat or by limiting the size of

their meals*

PE Hyman, M.D., Journal of Pediatrics, 1994, 125:S103-9.

Visceral Hyperalgesia

Sensory-based oral feeding aversion

7 month old infant

born with diaphragmatic hernia

gastrostomy tube/Nissen fundoplication

non-oral feeder

For more information:

www.nomasinternational.org

www.marjoriemeyerpalmer.com