Therapeutic positioning for eating and digestion.Positioning is a critical element in the success of both enteral enteral /en·ter·al/ (en´ter'l) enteric.
1. Within or by way of the intestine, as distinguished from parenteral.
2. Enteric. and oral eating. However, often not enough attention is given to it as an essential ingredient in achieving the goal of good nutrition.
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 vomit /vom·it/ (vom´it)
1. to eject stomach contents through the mouth.
2. matter expelled from the stomach by the mouth. 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 vomiting, ejection of food and other matter from the stomach through the mouth, often preceded by nausea. The process is initiated by stimulation of the vomiting center of the brain by nerve impulses from the gastrointestinal tract or other part of the body. or breathing difficulty is occurring. The position in which the child gets nourishment nour·ish·ment
Something that nourishes; food. 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 occupational therapist A person trained to help people manage daily activities of living–dressing, cooking, etc, and other activities that promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL. (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 elbow room
sufficient scope to move or to function
Noun 1. elbow room - space for movement; "room to pass"; "make way for"; "hardly enough elbow room to turn around"
room, way , 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 small intestine
Long, narrow, convoluted tube in which most digestion takes place. It extends 22–25 ft (6.7–7.6 m), from the stomach to the large 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 (theory) reflexive - A relation R is reflexive if, for all x, x R x.
Equivalence relations, pre-orders, partial orders and total orders are all 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 scooter: see motorcycle. . 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 mid·line
A medial line, especially the medial line or plane of the body.
n the line equidistant from bilateral features of the head. ." This means that if an imaginary line In general, an imaginary line is any sort of line that has only an abstract definition, and does not exist in fact.
As a geographical concept, an imaginary line may serve as an arbitrary division (such as a border). is drawn down the middle of the child's body Noun 1. child's body - the body of a human child
juvenile body - the body of a young person
baby tooth, deciduous tooth, milk tooth, primary tooth - one of the first temporary teeth of a young mammal (one of 20 in children) , 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 Scoliosis Definition
Scoliosis is a side-to-side curvature of the spine.
When viewed from the rear, the spine usually appears perfectly straight. - or spinal curvature spinal curvature
Any of several deformities characterized by abnormal curvature of the spine, such as kyphosis or scoliosis. - 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 The tip of the tongue (TOT) phenomenon is an instance of knowing something that cannot immediately be recalled. TOT is a near-universal experience with memory recollection involving difficulty retrieving a well-known word or familiar name. 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 digestive tract
See alimentary canal.
The organs that perform digestion, or changing of food into a form that can be absorbed by the body. 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 e·lon·gate
tr. & intr.v. e·lon·gat·ed, e·lon·gat·ing, e·lon·gates
To make or grow longer.
adj. or elongated
1. Made longer; extended.
2. Having more length than width; slender. - stretched out and lengthened length·en
tr. & intr.v. length·ened, length·en·ing, length·ens
To make or become longer.
lengthen·er n. , rather than "crumpled crum·ple
v. crum·pled, crum·pling, crum·ples
1. To crush together or press into wrinkles; rumple.
2. To cause to collapse.
1. ." 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 crum·ple
v. crum·pled, crum·pling, crum·ples
1. To crush together or press into wrinkles; rumple.
2. To cause to collapse.
1. " 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 snug 1
adj. snug·ger, snug·gest
1. Comfortably sheltered; cozy.
2. Small but well arranged: a snug apartment. See Synonyms at comfortable.
a. 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 Respiratory distress
A condition in which patients with lung disease are not able to get enough oxygen.
Mentioned in: Lung Cancer, Non-Small Cell .
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 very near; at hand.
See also: 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 re·ha·bil·i·tate
tr.v. re·ha·bil·i·tat·ed, re·ha·bil·i·tat·ing, re·ha·bil·i·tates
1. To restore to good health or useful life, as through therapy and education.
2. and long-term-care programs. She also works as a pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. nurse practitioner nurse practitioner
n. Abbr. NP
A registered nurse with special training for providing primary health care, including many tasks customarily performed by a physician. at Pediatrics Plus, a private practice in Orlando, Florida The city of Orlando is a major city in central Florida and is the county seat of Orange County, Florida. According to the 2000 census, the city population was 185,951. A 2006 U.S. , and as a consultant to the early intervention ear·ly intervention
n. Abbr. EI
A process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. program at the Arnold Palmer Hospital for Children The Arnold Palmer Hospital for Children is a pediatrics hospital located in Orlando, Florida, United States. A part of the Orlando Regional Healthcare System and supported by the Arnold Palmer Medical Center Foundation, it is located on the campus of Orlando Regional Medical Center 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.