Pediatric Feeding  and Swallowing Disorders

Pediatric feeding disorders are characterized by complex multifactorial symptoms. The assessment and intervention model is considered as important as the strategies themselves.

• Multifactorial Nature: Nearly 50% of children evaluated with feeding problems have both medical and oral problems.
• Team Approach: A multidisciplinary team approach is often indispensable for assessment and intervention.
• Models of Care: There are two main team models:
  • Multidisciplinary Model: Individual practitioners independently evaluate and treat with little collaboration or shared information. A key liability is the lack of integration of findings, impressions, and recommendations.
  • Interdisciplinary Model: This model promotes a collective process that encourages shared assessments and treatments, family participation, and negotiated mutual goals with timelines. This is the preferred model for complex feeding disorders.
• Typical Team Composition: An interdisciplinary feeding and swallowing team may include a pediatrician, nurse practitioner, speech-language pathologist (SLP), family counselor, occupational therapist, physical therapist, applied behavior analyst, feeding specialists, and support staff.

⚠️ Signs and Symptoms
Signs and symptoms of feeding disorders often stem from a combination of physiological, developmental, and behavioral factors.

• Oral Aversions/Refusal: Children often signal aversion and refusal of a bolus, which can present as bolus refusal, avoidance, aversion, or failure to transition between textures.
• Developmental Delays: Children with feeding problems often present with delays in acquiring feeding skills.
• Underlying Impediments (Barriers to Practice): Factors that block successful feeding practice include:
  • GI dysfunction (e.g., constipation, reflux)
  • Developmental, neurological, and motor delays
  • Anatomical variations and medical compromises
• Undesirable Mealtime Behaviors: Behavioral problems typically develop as the child works to avoid eating or to obtain adult attention/preferred items. These behaviors can include:
  • Refusal to go to the eating area
  • Crying or clenching teeth when food is presented
  • Batting the spoon/food away
  • Gagging, spitting food out, or vomiting
  • Holding food in the mouth for extended periods of time

🗣️ Role of a Speech-Language Pathologist (SLP)
The SLP serves as the oral-motor specialist and is central to assessing and treating the swallow and feeding skills.

• Clinical Assessment: The SLP conducts a critical evaluation that includes:
  • Medical and feeding history
  • Oral-motor evaluation
  • Observation during a mealtime (a key element)
  • Identifying the child's present level of oral function during feeding and non-feeding tasks.
• Instrumental Assessment: If clinical observations raise questions about the safety or timeliness of the swallow, the SLP may recommend and participate in objective instrumental assessments.
  • Videofluoroscopic Swallow Study (VFSS): Considered the gold standard for evaluating the pharyngeal swallow. The SLP works with the radiologist and caretaker to complete the study.
  • The VFSS often includes vignettes for replication of a difficult feeding situation, modification (applying and adjusting adaptations in real time), and feedback/documentation.
• Oral-Motor Treatment: The SLP focuses on practicing oral-motor skills once deterring factors (e.g., medical, postural) are controlled.
  • Stimulating Movement: Therapy works to stimulate the oral-motor movements necessary to advance to the next texture.
  • Pureed Swallowing: Requires a single anterior-to-posterior tongue movement with a stabilized jaw.
  • Advancing Textures (Chewing): Requires the acquisition of lateral tongue movement and increased jaw movement to manipulate, crush, and transport food. The SLP may use techniques like lateral spoon placement or pressing crunchy chewables on the molar surface to stimulate lateral tongue movement.

👨‍👩‍👧‍👦 How Can a Parent Help
The family is an integral part of the interdisciplinary team, and their participation is crucial for successful outcomes and generalization of skills.

• Active Participation: Parents are encouraged to be empowered and actively participate in the daily mealtime learning activities at the center.
• Setting Goals: Parents should be included in setting feeding goals and decision-making processes.
• Communication and Adherence: Maintain daily communication (e.g., via a travel journal) regarding bowel movements and meals at home. Effective communication increases the likelihood of adherence to the program.
• Learning Practical Skills: Families often prefer an apprenticeship-style approach to learning practical feeding skills and structuring mealtimes. Staff helps parents transition from "chaotic" to structured mealtimes where the parents are in control.
• Becoming the Expert: A core goal is for the parent to become the feeding expert for the child and to successfully transition the program to home and the educational setting.
• Support: Families benefit from the education, support, and guidance of a Family Counselor and connecting with other families who have faced similar challenges.
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​For more information, visit asha.org.

References: 
Roche, W. J., Eicher, P. S., Martorana, P., Berkowitz, M., Petronchak, J., Dzioba, J., & Vitello, L. (2011). An oral, motor, medical, and behavioral approach to pediatric feeding and swallowing disorders: An interdisciplinary model. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20(3), 65–74. https://doi.org/10.1044/sasd20.3.65 
https://pubs.asha.org/doi/10.1044/sasd20.3.65​