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aSuggest monitoring urine-specific gravities when available and quantity, color, and odor of urine, and adjust for periods of stress and temperature. Example: 28-kg child 100 ml x 10 kg = 1000 ml 50 ml x 10 kg = 500 ml 25 ml x 8 kg = 200 ml Total need = 1700 ml aSuggest monitoring urine-specific gravities when available and quantity, color, and odor of urine, and adjust for periods of stress and temperature. Example: 28-kg child 100 ml x 10 kg = 1000 ml 50 ml x 10 kg = 500 ml 25 ml x 8 kg = 200 ml Total need = 1700 ml

Table 5 Clinical indicators of feeding and swallowing dysfunction

Congestion

Noisy 'wet' sounds

Multiple swallows to clear bolus Unexplained fevers, unexplained irritability Coughing/choking/gagging before, during, or after swallow Food refusal

Difficulty managing secretions History of upper respiratory infections Apnea during feeding Failure to thrive, failure to maintain weight essential for the assessment, development of appropriate goals, and facilitation of a treatment plan that respects the developmental progression. A clinical assessment of the feeding process should include observance of facial muscle tone, oral reflex activity, functional oral motor skills, structural abnormalities, sensory responses, behavior and interaction during feeding, respiratory and phonatory status, and posture and positioning.

Radiographic and ultrasound studies can provide more detailed information about the oral structures and the competency of the oral, pharyngeal, and esophageal phases, including the detection of aspiration. Cervical auscultation can also be helpful in evaluating the pharyngeal phase of swallowing. In addition, these techniques can assist in determining the suitable solid and liquid texture and appropriate head and neck positioning. Hypertonicity leads to abnormal movements of the tongue, lip, and jaw. These abnormal movements can be manifested as tongue retraction, tongue tip elevation, tongue thrust, tonic biting, jaw thrust, jaw instability, lip retraction, and lip/cheek instability. An abnormally strong gag reflex, tactile hypersensitiv-ity in the oral area, and drooling can also complicate feeding. Individuals with CP are also at risk for dental problems due to poor oral hygiene, teeth grinding, hypersensitivity in the oral area, and hyperplasia of the gums from long-term use of phenytoin, a medicine commonly prescribed for seizure management.

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