Author: KB
A 6 year old boy with mild cerebral palsy was referred to a feeding specialist by his occupational therapist for severe drooling and poor tongue movement.
INITIAL EVALUATION
Based on the child?s medical history, physical exam, and observation of movement and function, initial exam revealed the following;
Oral-motor Skills:
The patient was able to smile, close his lips, pucker, and open his mouth, (normal mobility) but had decreased oral-motor strength. The tone of the muscles of his face was low and he often held his mouth open.
He was able to stick his tongue straight out but couldn?t lateralize it (move it side to side) or touch his teeth or upper lip with the tip of his tongue (tongue tip elevation). He had an extremely hypersensitive gag reflex (He vomited with tongue exercises). He also had severe drooling for which he tried medication, (Robinul), without success. He had mildly slurred speech but was understandable and had a clear strong voice.
Eating/swallowing:
During meals, he often stuffed a lot of food into his mouth before trying to chew. He was a messy eater with poor control of the food in his mouth and often had food spilling out or stuck to the roof of mouth. He used a rotary chewing pattern (age appropriate) with difficulty keeping his lips closed. There were no signs of swallowing problems (coughing or choking during the meal).
Gastrointestinal issues:
He had daily vomiting, retching, bad breath, coughing and was sensitive to smells. He had normal bowel movements.
Ear, Nose, and Throat issues:
He had a recent tonsillectomy and adnoidectomy, as well as frequent sinus infections.
Behavior Issues:
He was a picky eater and was teased at school and called ?spit boy?. He was afraid of doing oral exercises because it made him feel like he needed to vomit.
INTERVENTIONS:
1. GI Intervention: The patient was referred to a pediatric Gastroenterologist who determined that he had gastroesophageal reflux. The doctor decided to treat the patient medically first with Zantac with brief improvement of symptoms and then Prilosec.
Result: His vomiting, retching, bad breath, and hacking stopped. He had decreased drooling, less sensitivity in mouth and to smells.
2. Oral-Motor: He was followed weekly for 30-minute sessions working on the following exercises which were recommended for daily practice at home.
a. Tongue lateralization (using a mirror, pushing applejacks from one side of his mouth to the other with his tongue, placement of puree foods in his cheeks to increase sideways movement of his tongue).
b. Improve tongue tip elevation (midline protrusion, pushing tongue and applejack placed on front of the tongue behind the top front teeth, , licking lips).
Result: After 6 months, he was able to lateralize and elevate his tongue, had improved articulation, land had less drooling.
3. Behavioral: Behavioral techniques were used to remind the patient to swallow more frequently. Verbal reminders were given to ? close your mouth and swallow?. A sticker was used daily on the patient?s hand, as a reminder to swallow when he saw the sticker (this only worked for one day). A new routine was established during meals; placing his utensils down between bites, verbal cues were given to take smaller bites and to use liquids between solids to help with mouth clearance of residual food.
Result: With frequent verbal cues, the patient is now drooling less and able to keep his shirt dry for most of the day. He continues to need cues to take small bites and place his utensils down.
FOLLOW-UP:
The patient is receiving occupational therapy services for sensory issues and will continue to follow up with GI. Caregivers report that drooling increases in the evening, which may be related to the prilosec wearing off. They are considering adding a 2nd dose in the evening. The patient will be starting speech therapy.
|
