Original title: Odruchy oralne u noworodków i niemowląt. Diagnoza i stymulacja

© Copyright by Mira Rządzka, 2024

Reviewed by:

dr hab. n. hum. Katarzyna Kaczorowska-Bray

prof. nadzw. dr hab. n. med. Bogumiła Stoińska

Publishing editor of Polish version:

Joanna Kosturek

Typographic design:

Alicja Kuźma

Cover design:

Basia Rządzka

ISBN 978-83-8294-320-7

Oficyna Wydawnicza „Impuls”
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www.impulsoficyna.com.pl,
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1st edition, Cracow 2024

Electronic publication layout
Epubeum

Salus puerorum suprema lex esto.
The welfare of children be the supreme law.

Table of Contents

1. Introduction

1.1. The importance of speech pathologist neurodiagnosis

1.2. Development of reflexive oral responses in the prenatal period

1.3. Normative oral reflexes and their evolution

1.3.1. The reflex reaction of sucking and swallowing

1.3.2. The rooting reflex (Rittig reflex)

1.3.3. The phasic bite reflex reaction

1.3.4. The reflexive reaction of opening, protruding, and closing the lips

1.3.5. The reflex vomit reaction (retching, pharyngeal)

1.3.6. The pushing reflex

1.3.7. The jaw reflex

1.3.8. Licking/protrusion reflex reaction

1.3.9. Lateral reflex reaction

1.4. Anatomical and resting conditions of the oral system in newborns and infants

1.4.1. Breathing and resting postures of the oral system

1.4.2. Feeding position

1.5. Specifics of oral reflexes in newborns and infants with Down Syndrome and cytomegalovirus

1.5.1. Down Syndrome

1.5.2. Cytomegalovirus

2. The aim of the study

3. Research methods and material

3.1. Characteristics of the group of studied newborns and infants

3.2. Group of children with Down Syndrome and a group of children with CMV

3.3. Research methods

3.3.1. Evaluation of anatomical conditions and resting postures of the oral system

3.4. Methods and stimulation techniques used

3.4.1. Myotherapy

3.4.2. N.A.P. Manual Therapy

3.4.3. Feeding Position Control

3.4.4. Shantala Massage

3.4.5. R. Castillo Morales’ Method

3.4.6. Kinesiology Taping

4. Results

4.1. Pathologies in primitive neonatal oral reflexes

4.1.1. Sucking and swallowing reflexes

4.1.2. Gag reflex

4.1.3. Biting reflex

4.1.4. Lips’ reflexes

4.1.5. Jaw reflex

4.1.6. Licking reflex

4.1.7. Pushing reflex

4.1.8. Lateral reflex

4.1.9. Rooting reflex

4.1.10. Resting postures of the tongue, lips, and jaw

4.2. Abnormalities in the execution of reflex oral reactions caused by anatomical defects

4.2.1. Difficulties with oral function in children with Down Syndrome

4.2.2. Oral difficulties in a child with cytomegalovirus

4.3. Effects of stimulation of disrupted reflex oral reactions

4.3.1. Therapeutic approach in tongue-tie (ankyloglossia)

4.3.2. Sucking and swallowing reflexes

4.3.3. Phasic bite reflex

4.3.4. Gag reflex

4.3.5. Lips reflexes: opening, protrusion, opening and closing

4.3.6. Resting postures of the oral area: lips, jaw and tongue

4.3.7. Rooting reflex

4.4. Selected issues of oral difficulties in children with Down Syndrome and cytomegalovirus

4.4.1. Disorders of oral reflexes in children with Down Syndrome

4.4.2. Disorders of oral reflexes in children with CMV

5. Discussion

5.1. From diagnosis through stimulation to feeding

5.2. The importance of the pre-oral phase and the sequential execution of reflexes and food intake

5.3. The essence and maturation of sucking and swallowing

5.4. Sucking and alternative feeding

5.5. Resting postures of the jaw, tongue, and lips as an introduction to proper air intake

5.6. Other oral reactions: examination and oral responses

5.6.1. The rooting reflex

5.6.2. Phasic bite reflex

5.6.3. Gag reflex

5.6.4. The pushing reflex

5.7. Feeding positions

5.8. The importance of ankyloglossia in food intake as the most common anatomical defect

5.9. Compensation and reflex dependencies

5.10. Disorders of oral reflexes in children with Down Syndrome

5.11. Oral reflex disorders in children with CMV

6. Conclusions

7. Final words

Appendix. Primitive neonatal oral reaction examination chart

Reference

List of tables and graphs

Abstract

About Author

Dear Reader!

Presented thesis, a doctoral dissertation resulting from many years of research and reflections on speech and language pathology work with the youngest patients. The publication is in an almost unchanged form.

As a supporter of early and individually selected interactions, the author is deeply convinced that the research results will help speech and language pathologists, speech therapists, physiotherapists, lactation consultants, and neonatologists. The author hopes that the chart for examining oral reflexes in newborns and infants, developed and attached to the book, will become a convenient and inspiring tool in the work of specialists.

The Author

Zielona Gora, December 2018

I sincerely thank those who supported me both intellectually and emotionally during the writing of this dissertation and in the process of preparing it for publication:

–Professor Dr. hab. med. Maria Beata Czeszyńska – for immense help in writing the dissertation;

–Reviewers: Professor Dr. hab. med. Bogumiła Stoińska, Professor Dr. hab. med. Urszula Godula-Stuglik, and Professor Dr. hab. hum. Katarzyna Kaczorowska-Bray – for constructive comments;

–Dr. hab. med. Karolina Kłoda – for constant motivation;

–Ms. Marta Karwot-Pięta – for discussions and valuable intellectual input;

–Dr. hum. Elżbieta Stecko – for inspiring me with the topic of early intervention;

–Karol’s parents – for allowing me to include their child’s photograph on the cover.

Special thanks to Jerzy, Basia, Michał, my parents, and my friends – for their constant support and patience.

Anna Lichnowska – for her efforts in translating my work.

Author

1. Introduction

1.1. The importance of speech pathologist neurodiagnosis

The need to carry out actions in the field of early intervention in newborns and infants is a need born of an ever-increasing number of “risk” children and the ongoing progress in neonatology and early rehabilitation, including early diagnosis and speech and language therapy interventions.

These actions are directed to patients with, among others, difficulties in oral food intake. Disturbances and other deeper problems often accompany feeding problems development. However, sometimes, they occur in isolation without being coupled with damage, constituting only the result of minor anatomical abnormalities, lowering the realization of the primitive neonatal oral reflex base or incorrect feeding position.

Feeding, swallowing and breathing are prototypical activities necessary for newborns and babies’ survival and proper development. These activities cross in the upper respiratory tract and represent the most complex neuromuscular process in the human body. Their disorder is often the first sign of future ones of the neurological condition of the newborn [1].

One of the many causes of these difficulties is a disorder or immature reflex oral reactions, classified as primitive neonatal reactions (PNR). Primitive neonatal reflexes is a collective name given to a group of inborn, unconditioned reflex responses, spontaneous behaviours and reactions to endogenous or environmental stimuli [1, 2, 3, 4, 5, 6, 7, 8, 9, 10].

Research reports also use unconditional neonatal reactions and physiological reflex reactions. The author acknowledges the phrases: “oral reflex responses”, “oral PNRs”, “physiological reflex responses”, and “unconditional responses” as synonymous. Described and standardized, they became the basis for assessing neurological status, including diagnosing feeding skills based on oral reflexes. There are various divisions of reflex reactions: defensive and facilitating food intake, endogenous, motor, sequential, antigravitational and rhythmic [11].

In recent years, manometric analyses of sucking and swallowing, video fluoroscopy, ultrasonography and flexible endoscopic testing have been introduced. Endoscopic swallowing testing contributed to understanding the importance of orderly and sequential development of food intake based on normative oral reflexes. The assessment of oral-sensorimotor functions of newborns and infants is included in the following scales:

–NOMAS Newborn Oral-Motor Assessment Scale (Palmer et al. from 1993),

–Systematic Assessment of the Newborn at the Breast (SAIB) (Association of Women’s Health, Obstetric and Neonatal Nurses, 1990),

–Assessment of Breastfeeding (Tobin, 1996),

–Evaluation of Infant Feeding (Swigert, 1998),

–Schedule for Oral-Motor Assessment (SOMA from 2000),

–Sensory Motor Speech Evaluation Test (SMSE, Müller from 1991).

In Poland, one of the newest tools is the Breast Sucking Skills Assessment Protocol by M. Machoś, 2015 and Assessment of Orofacial Reflexes and Speech Development Skills by M. Machoś, 2011.

Oral reflex reactions can be divided into protective and defensive: the reflex reaction of regurgitation and the reflex reaction of biting, as well as those that enable and facilitate food intake: the rooting reflex and the reflex of sucking and swallowing [9].

In the diagnostics, other reflex reactions are additionally assessed: labial (mouth opening, lip protrusion), tongue protrusion (E. Stecko identifies licking and tongue thrusting), and mandibular reflex. These reflexes’ maturity and synergistic effect, correlated with the proper respiratory tract and the correct anatomical structure of the oral cavity, enable food intake. Further evolution of reflexes and their maturation according to the calendar development enables the acquisition of new skills and improvement of the digestive functions of the oral apparatus as well as preparation for the complex process of phoneme articulation. PNR disruptions are reported to be the first signals of immaturity or future disorders related to the maturation of the structures of the CNS (central nervous system) [12, 13, 14, 15].

When a newborn or infant has disorders or lacks proper reflex oral reactions, preventing its food intake orally, therapeutic procedures are often introduced to stimulate, activate, and rebuild the reflex or eliminate pathological, undesirable oral behaviour. This action should be based on a reliable diagnosis conducted by a speech and language pathologist. Moreover, the selected stimulation should be adequate for each patient’s developmental possibilities and needs individually [16, 17]. Only such a procedure can counteract oral pathologies, which are not subjected to stimulation – they become the cause of such problems as:

–difficult maturation of food skills following the food calendar (drinking from a cup, biting, chewing),

–pathologies in swallowing activities (dysphagic disorders),

–development of a non-normative way of breathing (respiratory dysfunction),

–dysfunctional, atypical development of the oral phase of swallowing (persistent infantile swallowing pattern, reverse type swallowing dysfunctions),

–disorders in the formation of the stomatognathic system (malocclusion),

–disorders of the prototypical acquisition of the articulation system (articulatory disorders: dyslalia, speech distortions including increased nasalization).

1.2. Development of reflexive oral responses in the prenatal period

All primary neonatal reflexes, including oral ones, develop during fetal life, and their development depends on genetic, pre- and perinatal determinants [12, 18, 19, 20].

The structures responsible for the reflex motor and physiological base begin to form and gradually mature at an early stage of embryogenesis. The development of the central nervous system begins around the thirteenth day of gestation: the brain and spinal cord buds are formed [21]. Around the fortieth day of gestation, cerebral vesicles are formed. In the seventh week, the coordination of the functions of some organs is noticeable.

Observation of fetal oral behaviour documented the early development of the swallowing reflex and oral-motor skills [22, 23]. This early-forming ability is of great importance for regulating the volume and composition of the amniotic fluid, recirculating substances dissolved in it, and for the maturation of the fetal digestive tract [22]. The first swallowing (pharyngeal) movements were observed between the tenth and fourteenth week of gestation [24, 25]. In 14.–15 weeks of gestation, the coordination of swallowing and expulsion of amniotic fluid also begins (further refinement of the movements needed for breathing, sucking and phonation). The swallowing process develops in most fetuses by the fifteenth week of gestation, and a developed, fixed reaction of this reflex is observed after 22–24 weeks of gestation [23].

The reflex of protruding the tongue beyond the lips develops by the twenty-first week of gestation, and the ability to create a hollow on the tongue – in the twenty-eighth week. Anterior-posterior (sucking) movements develop between the eighteenth and twenty-eighth week.

Sucking and swallowing at this stage of fetal life are usually preceded by oral-facial self-stimulation [23]. The formation of the oral area: the oral sinus, the separation of the nasal cavity from the oral cavity, and the formation of the primary and secondary palate occur between the fourth and twelfth week of gestation [26].

The formation of the lung buds and the bronchial tree is the sixth week of fetal life. The upper lip, mandibular and maxillary areas are sensitized in the tenth week. In the twelfth week, the cooperation of the muscles that will be needed after birth for breathing, phonation and sucking begins: chest movements, relaxation of the diaphragm and abdominal muscles [21], opening and closing of the mouth in response to touch, spontaneous movements of pulling up, lifting upper lip, which is the initial stage of labial reflexes and preparation for the sucking reflex [27]. From the 17th week, the baby can bulge and protrude the lips forward, and sucking movements of the lips with a precise drawing of the amniotic fluid are observed. During ultrasound research, particular oral movements are visible:

–sticking out the tongue, licking: forward movements of the tongue, crossing the lips – the tongue may come into contact with the fetal fingers, uterine wall, placenta or umbilical cord [28];

–“cupping”: the crown of the tongue rises, the mediodorsal part of the tongue is lowered – this movement and its precision seem to be particularly important for food intake; it precedes swallowing [28];

–yawning.

At the end of the third month, the phonatory organ is well-developed – vocal cords, and the baby can produce sounds (cries). In the thirty-second week of gestation, the specific triad sucking – swallowing – breathing is fully formed and matured. A surfactant is necessary for normative, mature breathing after birth, produced in the child’s lungs from the twenty-fourth week of fetal life. It lines the inside of the alveoli and regulates the surface tension, preventing them from collapsing and overstretching.

The reflex reaction of biting, lateral and vomiting – are present in the oral behaviour of the fetus from the twenty-sixth to the twenty-eighth week, the rooting reflex around 32–40 weeks, and the tongue protrusion reflex – from 38 weeks.

The rhythm of sucking and swallowing is formed at the thirty-second week of gestation. It does not change by the fortieth week when it achieves final stabilization [29], and the coordination of sucking and swallowing matures.

About Author

MIRA RZĄDZKA – PhD in health sciences, speech and language pathologist, myofunctional therapist. She specializes in early interventions for newborns and infants with oral disorders, dysphagic disorders in children and adults, communication development disorders in children with ASD or genetic disorders, and disorders of oral system function. She is a therapist of L. Mathieson’s Manual Throat Therapy, Manual Dysphagia Therapy, ETTHNO Method in Esther de Ru’s approach, Shantala Special Care trainer, international instructor of the Buteyko Method, feeding therapist, Functional Orthodontics MFS Therapist. Long-time academic lecturer in speech and language therapy and pathology subjects. Author of many specialized publications for speech therapists, including in academic textbooks, reviewer of numerous publications on early speech therapy interventions and speech therapy aids. Author of the book “Odruchy oralne u noworodków i niemowląt. Diagnoza i stymulacja” (the most popular publication of the Impuls Publishing House in 2019 and 2020), the concept of myotherapeutic support for the development of oral functions in newborns and infants, and preparation of the patient for frenulotomy procedure (FRENULOTOMY Project. Child support, parental support), co-author of the book “Profilaktyka i terapia dysfunkcji oddechowych u dzieci”. Co-founder of the Polish Speech Therapists Association and initiator of the social action of speech therapists Free Speech Therapy Diagnosis Day (DBDL), owner of the Prophylactic-Therapeutic Clinic in Zielona Góra.