Therapeutic positioning for eating and digestion.
To achieve that goal, more needs to be going on than the intake of food. That intake must be accompanied by internal processes that result in successful digestion and, at the same time, maintain the basic function of breathing. While it may seem obvious, too often it is this goal that gets lost in the enthusiasm for helping the child to sit upright to eat.
Good positioning is essential in order to swallow or receive food through a tube and digest it properly, while continuing to breathe easily and comfortably. It is often overlooked as a relatively simple approach to what may otherwise become a medical treatment issue. If a child is not positioned well for receiving food, he or she may choke, vomit or have great difficulty breathing. The solution may not need to be as radical as going from oral to enteral feeding; but, rather, finding out why the choking, vomiting or breathing difficulty is occurring. The position in which the child gets nourishment may be causing the problem.
Knowledge here is the key. By understanding the internal processes that are going on when a child is trying to eat, parents can make important observations about why problems are occurring and work effectively with the child's physician, nurse and physical therapist (PT) or occupational therapist (OT) in helping to solve eating, digestion and nutrition issues.
The "inside" story
Eating and digestion require space. By this, I don't mean elbow room, but room inside. If a child cannot hold both body and head upright, it is hard for the internal events involved in swallowing and digesting to take place. That is why positioning as far as nutrition is concerned is so important. Health is as great a concern as comfort.
Positioning provides the body with an internal framework so that the digestion process can go on effectively inside it. If the body is slumping forward, the weight of the chest, head and shoulders is resting on the stomach. The result is too much pressure on the stomach. When it tries to pump food out into the small intestine, the result can be vomiting. If the head is extended forward, that can open the airway to food and fluids, and choking occurs.
The test for whether the child requires assistance with positioning is whether he or she can hold both the upper body and head upright enough to be in alignment with symmetry. (I will discuss this position more fully further on in this article.) If the answer to the "uprightness" question is "no" for either head or upper body, positioning should be considered. That consideration is really a two-part matter: seated positioning and sidelying positioning. In either case, gravity is a major part of the process. Seated positioning provides the direct path for food to follow in the most efficient manner. In sidelying, the point is to create "uprightness" and use gravity by providing an "incline." This is achieved through a piece of equipment referred to as a sidelyer (see the final picture in this article).
For a seated position to work, the child needs a stable base of support at the spine, The pelvis must be level - with equal weight on both hips - and slightly tilted forward. If this base of support is not established, the child will spend energy that is needed to maintain other functions - such as breathing and swallowing - just struggling to stay stable in a chair. Sometimes it is hard to remember that functions we think of as automatic or reflexive - swallowing and breathing - are jeopardized when instability demands constant attention and concentration.
To check a seated position, the child should be in an appropriately child-sized seat. The seat may be part of mobility equipment - a stroller, wheelchair or scooter. Cheek to see that the child's pelvis is in a slight forward tilt. This means the body, as seen from the side, is shaped like the letter "L." The lower back is curved slightly inward and the head is aligned over the shoulders. Be careful to avoid a "C"-shaped body position, with the head forward and the body folding toward the center.
If the child does not have enough muscle control to hold an "L" position, a level pelvis will not be enough to maintain stability. Support for both the forearms on a firm surface - a table surface, lap tray or broad-enough arm rests - can take pressure off the stomach because it holds the shoulders up and bears the weight of the upper body. Added stability will come from having the child's feet firmly positioned on a footrest, the floor or a low stool.
Alignment and symmetry
Along with establishing postural stability, a second critical aspect of therapeutic positioning is alignment and symmetry on both sides of the "midline." This means that if an imaginary line is drawn down the middle of the child's body, the left and right sides would look about the same, with parts of the body arranged fairly symmetrically on each side. The nose, navel, knees and toes should all point in the same direction. The head, neck and shoulders should be aligned and the legs parallel. If the child is eating orally, his or her neck should not be extended. The chin should be tucked forward a little to keep from opening the airway during a swallow.
If these conditions cannot be sustained in the sitting position, sidelying is the mealtime alternative, even for children who can attain postural stability briefly. The average time for food to move out of the stomach - digestion - is two to two-and-a half hours. It may not be feasible or desirable to keep the child in a sidelyer for this extent of time. The clinical team can work together with parents to customize a positioning plan best-suited for the child.
Return to the goal: good nutrition. The issue is not only one of sitting, but of being in the best position to support digestion. Even for children who can sit, mealtime sitting may not equal that "best position" if alignment and symmetry cannot be maintained during digestion.
For example, scoliosis - or spinal curvature - can throw positioning off and influence digestion. This is because food must get down into the lower part of the stomach in order to stretch the stomach muscle and stimulate it to pump the food out to the small intestine. With scoliosis, it may be difficult to achieve the alignment and symmetry to create the internal framework necessary for these internal functions. Sidelying would be appropriate at mealtime for children with scoliosis.
If seated positioning is not an option for mealtimes, inclined sidelying can really help the child. It can get him or her fairly aligned, keep the neck out of extension, and also take advantage of gravity which helps food go down to the stomach when swallowed. If the child is lying flat, food may pool or lie mostly on the posterior wall of the stomach and be vomited up hours later after it should have left the stomach.
Sidelying actually can have a plus over sitting. Inclined sidelying permits the tongue to come out easily and also allows for easier swallowing. A swallow occurs when the tip of the tongue rises up and rolls over the palate. Even if the child is being fed enterally, swallowing is usually still occurring. This is good. It not only helps the child swallow saliva, it primes the digestive tract all the way down.
If the child is fed by tube, inclined right-sidelying helps food to flow from the stomach into the small intestine more easily. That is because food flows from top to bottom in the gastro-intestinal tract, and from left to right in the stomach.
Make sure the child's trunk is elongated - stretched out and lengthened, rather than "crumpled." A shoulder that is held up and forward, for example, can inhibit breathing. These are basic approaches to sidelying. Different disabilities require different sidelying positioning. Therefore, for the safest use of such positions, check with your PT or OT to identify positions and the proper equipment to sustain them.
Equipment and support
Specialized equipment and supports help to maintain and support positions. If the child does not have trunk stability, without support, he or she will simply "crumple" in the middle, complicating the flow of food internally
In a seated position, if the seat is too long (too deep), it will be especially difficult to maintain a good position. A firm seat base and a firm, cushioned chair back are needed so the body can assume the "L" shape. A seat belt also helps to stabilize the pelvis and help the child maintain the "L." It should be attached snugly over the pelvis, not across the abdomen. The point of the seat belt is support, not restraint. It secures level positioning of the pelvis in the seat, providing the basis for postural stability. If the belt is positioned across the abdomen, it is not only uncomfortable. It may not be snug enough to secure the pelvis so that it is truly stable in the seat.
Support may also be needed on either side of the trunk and the head. Armrests or a lap tray can be provided to rest the forearms in a wheelchair. Additional support may be needed for the shoulders and on either side of the knees. Foot supports will keep the base of support evenly distributed across the child's thighs and feet.
Support is as important an issue for sidelying as for seated positioning. As mentioned above, the type of sidelying equipment used Will depend on the child's specific needs. This is something to work out with your PT or OT
A team effort
Mealtime is often not well understood in terms of attention to positioning and the difference positioning can make to nutrition. Mealtime is more of a parent-child occurrence. However, integrating perspectives of therapists with this personal time can make a significant difference for the child's nutrition.
When therapeutic positioning for mealtime is necessary, the child has more ability to eat and digest food comfortably and safely. The object is to create an internal framework to allow critical internal functions - eating, digesting, breathing - to take place. Mealtime positioning is as important a discussion to have with the child's clinical team as how to help a child walk, roll over or dress. Understanding the processes that need to take place and the best approaches to supporting those processes can make parents effective partners on the child's clinical team.
SEATED POSITIONING CHECKLIST:
* The child is in his or her own appropriately
child-sized seat. * The child's hips are positioned firmly and level at
the back in the seat. * The seat belt is firmly fastened under the child's
pelvic bone. * The child's forearms are firmly supported on a table
surface, lap tray, or arm rest. * Your child's feet are firmly positioned on a footrest,
the floor, or a low stool. * The child's chin is tucked slightly under. * In the sitting position, the child's body is aligned
and symmetrical. * The child's breathing is easy and even, rather than
labored, indicating no internal respiratory distress.
INCLINED SIDELYING CHECKLIST
* The child is aligned in the sidelyer, maintaining
"mildline" symmetry. * The child's head is supported on a pillow or block. * The child's shoulders, back, and hips are secure
against the back of the sidelyer. * The sidelyer straps are secure. * The sidelyer provides support between underarms
and hips. * The child's bottom leg is straight in the sidelyer. * The child's bottom arm is not caught under his
or her body, but lies on the sidelyer surface, bent
at the elbow and shoulder. * The child's breathing is easy and even, labored,
indicating no internal respiratory distress.
Lee Barks, R.N., M.N., A.R.N.P, is the president and owner of Developmental Health, Inc., a firm that provides consulting services to rehabilitative and long-term-care programs. She also works as a pediatric nurse practitioner at Pediatrics Plus, a private practice in Orlando, Florida, and as a consultant to the early intervention program at the Arnold Palmer Hospital for Children and Women in Orlando. Lee lives near Orlando with her husband and teenage son and daughter.
Mary Bray, M.E.D., O.T. and Debra Gerber, PT were technical contributors to this article.