What are feeding and swallowing disorders?

Feeding disorders include problems gathering food and getting ready to suck, chew, or swallow it. For example, a child who cannot pick up food and get it to her mouth or cannot completely close her lips to keep food from falling out of her mouth may have a feeding disorder.

Swallowing disorders, also called dysphagia (dis-FAY-juh), can occur at different stages in the swallowing process:

Oral phase – sucking, chewing, and moving food or liquid into the throat


Pharyngeal phase – starting the swallow, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking


Esophageal phase – relaxing and tightening the openings at the top and bottom of the feeding tube in the throat (esophagus) and squeezing food through the esophagus into the stomach.

What are some signs or symptoms of feeding and swallowing disorders in children?

Children with feeding and swallowing problems have a wide variety of symptoms. Not all signs and symptoms are present in every child.

The following are signs and symptoms of feeding and swallowing problems in very young children:

  • arching or stiffening of the body during feeding
  • irritability or lack of alertness during feeding
  • refusing food or liquid
  • failure to accept different textures of food (e.g., only pureed foods or crunchy cereals)
  • long feeding times (e.g., more than 30 minutes)
  • difficulty chewing
  • difficulty breast feeding
  • coughing or gagging during meals
  • excessive drooling or food/liquid coming out of the mouth or nose
  • difficulty coordinating breathing with eating and drinking
  • increased stuffiness during meals
  • gurgly, hoarse, or breathy voice quality
  • frequent spitting up or vomiting
  • recurring pneumonia or respiratory infections
  • less than normal weight gain or growth


As a result, children may be at risk for:

  • dehydration or poor nutrition
  • aspiration (food or liquid entering the airway) or penetration
  • pneumonia or repeated upper respiratory infections that can lead to chronic lung disease
  • embarrassment or isolation in social situations involving eating


How are feeding and swallowing disorders diagnosed?

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your pediatrician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. A speech-language pathologist (SLP) who specializes in treating children with feeding and swallowing disorders can evaluate your child and will:

ask questions about your child's medical history, development, and symptoms
look at the strength and movement of the muscles involved in swallowing
observe feeding to see your child' s posture, behavior, and oral movements during eating and drinking
perform special tests, if necessary, to evaluate swallowing, such as:

modified barium swallow – child eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on an X-ray.
endoscopic assessment – a lighted scope is inserted through the nose, and the child's swallow can be observed on a screen.

The SLP may work as part of a feeding team. Other team members may include:

an occupational therapist
a physical therapist
a physician or nurse
a dietitian or nutritionist
a developmental specialist

Your child's posture, self-feeding abilities, medical status, and nutritional intake will be examined by the team. The team will then make recommendations on how to improve your child's feeding and swallowing.

What treatments are available for children with feeding and swallowing disorders?

Treatment varies greatly depending on the cause and symptoms of the swallowing problem.

Based on the results of the feeding and swallowing evaluation, the SLP or feeding team may recommend any of the following:

medical intervention (e.g., medicine for reflux)
direct feeding therapy designed to meet individual needs
nutritional changes (e.g., different foods, adding calories to food)
increasing acceptance of new foods or textures
food temperature and texture changes
postural or positioning changes (e.g., different seating)
behavior management techniques
referral to other professionals, such as a psychologist or dentist

If feeding therapy with an SLP is recommended, the focus on intervention may include the following:

making the muscles of the mouth stronger
increasing tongue movement
improving chewing
increasing acceptance of different foods and liquids
improving sucking and/or drinking ability
coordinating the suck-swallow-breath pattern (for infants)
altering food textures and liquid thickness to ensure safe swallowing

After the evaluation, family members or caregivers can

ask questions to understand problems in feeding and swallowing
make sure they understand the treatment plan
go to treatment plans
follow recommended techniques at home and school
talk with everyone who works with the child about the feeding and swallowing issues and treatment plan
provide feedback to the SLP or feeding team about what is or is not working at home


What causes feeding and swallowing disorders?

The following are some causes of feeding and swallowing disorders in children:

nervous system disorders (e.g., cerebral palsy, meningitis, encephalopathy)
gastrointestinal conditions (e.g., reflux, "short gut" syndrome)
prematurity and/or low birth weight
heart disease
cleft lip and/or palate
conditions affecting the airway
autism
head and neck abnormalities
muscle weakness in the face and neck
multiple medical problems
respiratory difficulties
medications that may cause lethargy or decreased appetite
problems with parent-child interactions at meal times

What does a speech-language pathologist do when working with children with feeding and swallowing disorders?

ASHA has developed a number of documents about the role of the SLP in working with individuals with feeding and swallowing disorders. These include the following:

Knowledge and Skills Needed by Speech-Language Pathologists Providing Services to Individuals with Swallowing and/or Feeding Disorders

It is ASHA's position that "speech-language pathologists play a primary role in the evaluation and treatment of infants, children, and adults with swallowing and feeding disorders." Working with children with feeding and swallowing disorders requires specialized knowledge and skills to best meet the needs of this population.

FEEDING THERAPY

SPEECH THERAPY, OCCUPATIONAL THERAPY, PHYSICAL THERAPY FOR CHILDRENS


INTRODUCTION TO THE SOS APPROACH TO FEEDING PROGRAM (Sequential-Oral-Sensory)
 
The SOS Approach to Feeding is a Transdisciplinary Program for assessing and treating children with feeding and weight/growth difficulties.  It has been developed over the course of 20 years through the clinical work. This program integrates motor, oral, behavioral/learning, medical, sensory and nutritional factors and approaches in order to comprehensively evaluate and manage children with feeding/growth problems.  It is based on, and grounded philosophically in, the “normal” developmental steps, stages and skills of feeding found in typically developing children.  The treatment component of the program utilizes these typical developmental steps towards feeding to create a systematic desensitization hierarchy of skills/behaviors necessary for children to progress with eating various textures, and with growing at an appropriate rate for them.  The assessment component of the program makes sure that all physical reasons for atypical feeding development are examined and appropriately treated medically.  In addition, the SOS Approach works to identify any nutritional deficits and to develop recommendations as appropriate to each individual child’s growth parameters and needs.  Skills across all developmental areas are also assessed with regards to feeding, as well as an examination of learning capabilities with regards to using the SOS program.
 
SOS APROACH TO FEEDING BASICS:

1 = Myths About Eating interfere with understanding and treating feeding problems.

2 = Systematic Desensitization is the best first approach to feeding treatment. 

3 = “Normal Development” of feeding gives us the best blueprint for creating a feeding treatment plan.

4 = Food Hierarchies/Choices play an important role in feeding treatment.
 
 
TREATMENT PHASE 
 
1.  For children who are less than 18 months of age, the program is structured as an “individual” therapy session.  An “individual” therapy session to the Team always
 includes the child and at least one parent, and the therapist.  The parent is in the therapy room eating with their child and the therapist at each treatment session
 
2. For children older than 7 years of age, the program is structured using an adaptation of the SOS Program (called the “Food Scientist Adaptation”) and may take place in an individual session or in a peer feeding group.  Whether or not the child is placed in a peer group is dependent on the number of other same aged peers with similar issues who are currently in treatment in the Clinic.  In addition, how well the child functions in, and can utilize, a peer group, is taken into consideration.
 
3.  For children between 18 months and 7 years of age, the preferred treatment modality is in a peer group.  The preference for this treatment modality is based on several years of treating children in traditional individual therapy sessions, as well as on consulting with parents and teachers, and completing observations of the children in other peer group settings (daycare, preschools, schools).
 

TREATMENT DESCRIPTION:

1.  Each session begins with a set routine; perceptual preparation, sitting stability exercises, breathing and oral-motor exercises, hand washing, description/teaching about the food.
 
2.  Therapists next work on the childrens’ oral-motor and perceptual deficits through the choices of the foods made, and the way in which they are presented (tastes, sizes, textures, shapes, colors, consistency, temperature).
 
3.  The children are advanced up a detailed hierarchy of 32 steps to eating with each new food presented.   Therapists interact with the food and children in a way to help the children achieve each of the 32 steps from a skill standpoint.
 
 
4.  Positive social reinforcement is use to support mastery of each step on the 32 steps to eating hierarchy.  Social reinforcement is used as it is the most natural type of reinforcement for eating, and allows for the best carry over of the program into the home environment.  
 
5.  Range of foods at each step on the hierarchy is worked on first, because our work has demonstrated that range drives volume.  If needed, volume of food ingested is also directly worked on.  However, internal research indicates that the children in our Feeding Group program gain 1 pound and 1 inch, on average, across the 12 weeks of Group sessions.  This is in a group of children who typically have not gained any weight or height for the 3 months prior to enrolling in the treatment program.  In addition, these children consume an additional 200 calories per day, on average, after 12 weeks of Feeding Group sessions.
 
The program format is essentially the same whether a child is being seen in a Feeding Group, or in Individual Feeding Therapy.