Chapter 9:
Pediatric Feeding and
Swallowing Disorders
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.1
Focus Questions
• What are pediatric feeding and swallowing
disorders?
• How are pediatric feeding and swallowing
disorders classified?
• What are the defining characteristics of
prevalent types of pediatric feeding and
swallowing disorders?
• How are pediatric feeding and swallowing
disorders identified?
• How are pediatric feeding and swallowing
disorders treated?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.2
Introduction
• When eating/feeding is compromised, it
can impact physical, cognitive,
psychological, and communicative
development
– Impact on communication: feeding promotes
bonding and attachment, and supports
communicative routines (e.g., turn taking and
joint attention)
• If disorder is present, feeding specialist
(SLP) focuses on strengthening the oralmotor system, including functions,
muscular tone, and sensation
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.3
Case Study #1: Lily
• 2-year old Chinese-American girl with cerebral
palsy and oral motor dysfunction
• At two weeks of age, modified barium swallow
study showed aspiration during bottle feeding
and poor coordination of tongue during sucking
– placed on a gastronomy tube
• Now 2 years old, parents would like to begin
feeding Lily orally
• Lily is in a wheelchair, has use of her hands, and
is cognitively delayed and unable to follow
directions
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.4
Case Study #1 Questions
• How do you think Lily’s feeding and
swallowing difficulties affect her family?
• Given that Lily has been on a feeding tube
for two years, why would her parents want
to pursue oral intake at this time?
• What other aspects of Lily’s life may be
affected by her dependence on a
gastronomy tube for nutrition?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.5
Case Study #2: David
• 3-month old child born prematurely (30
weeks) and has stayed in the NICU since
birth – youngest of four children
• At first, demonstrated coughing and
choking, so nurses thickened his formula –
but then he became very fatigued during
feeding and would not get adequate
nutrition before falling asleep
• Placed on nasogastric tube for
supplemental feeding
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.6
Case Study #2 Questions
• How might David’s NICU admittance affect
his family?
• What are some ways that David’s parents
might be involved with his feeding while in
the NICU?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.7
Case Study #3: Cory
• 2-year old boy with a normal birth
• 6 weeks: began projectile vomiting during breast
feeding, was given medication, and the problem
was resolved
• 6 months: refused introduction of baby foods,
but still breastfeeding well
• 9 months: growth was slowing down and
vomiting increased again
• 11 months: hospitalized for failure to thrive and
diagnosed with “behavioral feeding aversion”,
placed on a gastronomy tube
• Now, parents want him enrolled in intensive
behavioral feeding program to wean off the tube
feeding
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.8
Case Study #3 Questions
• How might Cory’s feeding problems affect
his family and his own psychological
wellbeing?
• What are some possible causes for Cory’s
food aversions?
• What are some factors that might predict
whether Cory will successfully be weaned
from the feeding tube?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.9
I. What are Pediatric Feeding
and Swallowing Disorders?
A. Feeding Disorders
• “persistent failure to eat adequately” for a period of
at least one month which results in significant loss
of weight or failure to gain weight
• Manifests prior to six years, but onset is usually in
first year of life
• Usually demonstrates one or more of the
following: unsafe or inefficient swallowing, growth
delay, lack of tolerance to food textures and
tastes, poor appetite regulation, and rigid eating
patterns
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.10
B. Swallowing Disorders
• Specific type of feeding disorder in which
child exhibits unsafe or inefficient
swallowing pattern that undermines
feeding process
• Swallowing (deglutition) is the act of
moving a substance (bolus) from the oral
cavity to the esophagus
• Increases the risk for:
– Penetration: food or liquid enters the larynx
– Aspiration: food or liquid passes through the
larynx into the lungs
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.11
Prevalence and Incidence
• Difficult to estimate, although 10% of young
children experience malnutrition (not all
because of feeding and swallowing
disorders)
• Disorders are prevalent in the context of
certain risk factors:
– Low birth weight (8% of all babies in U.S.)
– Neonatal Intensive Care Unit (NICU) – can
interfere with development of pleasurable oral
experiences and exposure to foods, and may
increase risk for food refusal, inappropriate meal
time behaviors, and/or inefficient ingestion
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.12
Terminology – Nutrition
• Nutrition: individual’s intake of calories and
nutrients to meet requirements for energy,
growth, development, and learning
• National Academy of Sciences:
recommended dietary allowances (RDAs),
standards of nutrition for normal, healthy
development
• Undernutrition and malnutrition:
requirements are not met, usually due to
environmental factors or developmental
disabilities
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.13
Terminology – Growth
• Growth: children’s height (length) and
weight achievements, and the relationship
between them
• Growth charts: provide a child’s relative
standing among all infants – allows for
differentiation between small children and
children whose growth is faltering
• Growth deficiencies:
– Underweight: less than expected based on age
– Wasting: less than expected based on height
– Stunting: height is less than expected based on
age
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.14
Feeding and Swallowing
Development
• Feeding is a reflexive activity, and should
be effortless, efficient, effective, and
pleasurable
• Proper nourishment is the most important
job for parents of a newborn
• First two years of life: move from a
reflexive feeder to an independent eater
with specific preferences for taste and
texture
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.15
Birth to Six Months
• Four primitive reflexes facilitate feeding
outside the womb:
– Suckling: stimulating the infant’s lips will result
in suckling, which will be followed by a swallow
– Rooting: stimulating the area around the infant’s
mouth will elicit a head turn in the direction of
stimulus
– Grasping: infant’s fingers will close tightly
around a stimulus placed in the palm
– Gagging: protective reflex that triggers a strong
physical reaction to substances entering the
laryngeal area
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.16
Six to 12 Months
• Increased trunk support and head control for
sitting – transition to solid foods
• Active biting and chewing – new teeth
• Shift in position from reclining to upright – more
face to face engagement and social interaction
• 8-9 months: independent sitting – everything
goes into the mouth as a way of exploring the
world
• Critical period in the child’s future acceptance of
foods
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.17
Twelve Months and Beyond
• Moving to be more independent eater –
may no longer wish to be fed by the
caregiver
• Increasingly has the words to express
wants
• By 18 months, get many calories through
regular table food (eating with the rest of
the family)
• By 24 months, total mastery of all foods is
expected
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.18
II. How are Pediatric Feeding and
Swallowing Disorders Classified?
• Based on descriptive features
– Focuses on clinical presentations or
observable symptoms
• Based on etiology
– Focuses on known or suspected causes of
the disorder
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.19
Descriptive Features
A. Timeframe of Disorders
•
•
•
Transient: short lived or readily
correctable
Episodic: occurs periodically
Chronic: ongoing over months or years
and cannot be resolved easily
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.20
Descriptive Features
B. Behavioral Characteristics
• Three sets of feeding and swallowing
problems (Kessler):
– Eating too little: excessive food selectivity
and severely restricted diet
– Eating too much: excessive overconsumption
– Eating the wrong things: consume
inappropriate non-nutritive substances (e.g.
pebbles, soap) - pica
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.21
Etiology
A. Organic Causes (66% of cases)
• Known physical causes for the disorder
divided into three categories:
– Neuromotor dysfunction: impairment of
neurological or motoric systems required for
safe and efficient feeding and swallowing
– Mechanical obstruction: obstruction in the
feeding and swallowing apparatus
– Medical/Genetic abnormality: illness,
trauma, or disability
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.22
Etiology
B. Non-organic Causes (34% of cases)
• Causes= is not clearly evident
• Four likely causes:
– Physical/emotional: reaction to the environment
(e.g., abuse, parental depression)
– Educational: inadequate caregiver knowledge
concerning feeding, eating, and nutrition
– Environmental: primarily financial constraints in
which food is under-available
– Behavioral: feeding and/or swallowing deficits
resulting from learned behaviors
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.23
Biopsychosocial Perspective
• Early physiological or medical problem
may trigger psychological and interactional
issues which contribute to maladaptive
behaviors
• Often difficult to categorize disorder as
organic or non-organic – instead the
disorder stems from a variety of biological,
psychological, and social influences
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.24
Failure to Thrive
• Widely-used term for children whose
weight or height deviates significantly from
the norm for the age and gender – due to
nutritional inadequacy:
– Due to limited access to food, intake of food,
and/or limited retention or absorption of food
• Not all children with FTT have a feeding
disorder and vice versa
• Some experts consider FTT a pejorative
terms, so pediatric undernutrition and
growth deficiency are preferred
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.25
III. What are the Defining
Characteristics of Pediatric Feeding
and Swallowing Disorders?
• Children with disorder usually exhibit one
or more of the following:
– Feeding and/or swallowing that is unsafe
– Feeding and/or swallowing that is inadequate
– Feeding and/or swallowing that is
inappropriate
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.26
Unsafe Feeding and Swallowing
• Unsafe feeding and swallowing poses a
risk for penetration or aspiration as well as
poor nutrition
– Unsafe swallowing (dysphagia) results from
dysfunction or damage of the child’s oralmotor system or an inappropriate eating rate
(either too fast or too slow)
– Unsafe swallowing may result in a physician’s
order for “nothing per oral” (NPO): child
cannot ingest anything through mouth
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.27
Causes and Risk Factors
• Accompanies several syndromes that feature
low muscle tone, delayed motor development,
and physical deformities
• Cerebral Palsy: risk factor for dysphagia
– First year of life:
• 57% exhibit problems with sucking
• 38% exhibit problems with swallowing
• 33% exhibit malnutrition or FTT
• Other conditions:
– Significant anomalies of oral structures
– Chronic or recurrent respiratory problems
– Cardiopulmonary diseases
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.28
Inadequate Feeding and
Swallowing
• Inefficiency: unable to meet caloric and
nutritional needs because process of
feeding and swallowing is not productive
• Overselectivity: restrictive in taste, type,
texture, and/or volume of foods eatern
• Refusal: complete refusal to feed, due to
ongoing medical issues, gastro-intestinal
distress, or traumatic experiences
• Feeding Delay: delayed development of
feeding skill milestones
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.29
Causes and Risk Factors
• Low birth weight: low or very low birth weight at risk for
feeding/swallowing disorders
• Developmental disabilities: Down syndrome, autism,
and cerebral palsy (and other conditions) may result in
motor or muscular weakness and/or sensory
defensiveness (autism)
• Prematurity: born at or before 37 weeks, may result in
immature systems (e.g., digestive)
• Prenatal drug exposure: alcohol, tobacco, cocaine,
heroin, etc. – linked to prematurity and low birth weight
• Diet restrictions: strict or modified diets (due to
diabetes, PKU, etc.) may result in feeding challenges
and resistance to eating
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.30
Inappropriate Feeding and
Swallowing
• Children exhibit undesirable or disruptive
behaviors during mealtimes that inhibits
successful feeding
– Examples: screaming, spitting, throwing,
hitting, drop food on the floor, eating at
inappropriate rates
• Eating too slow: nutritional deficiencies
• Eating too fast: choking or aspiration
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.31
Causes and Risk Factors
• Negative parent behaviors: over-stimulating,
under-stimulating, rigid and demanding,
chaotic and frenzied, overly concerned or
anxious
• For a positive feeding time…
– Infants must exhibit the following characteristics:
positive, alert, calm, show readable cues for
hunger and fullness, and willingness to try to
tastes and textures
– Toddlers must exhibit the following
characteristics: interested in eating, indicate
hunger and fullness, follow a predictable meal
schedule, positive behaviors
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.32
IV. How are Pediatric Feeding and
Swallowing Disorders Identified?
• Early Identification and Referral
• Comprehensive Assessment
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.33
Early Identification and Referral
• Children’s height and weight is carefully
monitored by the pediatrician on a growth
chart at routine “well-child” visits
• When feeding or swallowing problems are
suspected, pediatrician will make at least
two referrals:
– Ear-nose-throat specialist (ENT) or
gastroenterologist
– Feeding specialist
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.34
Comprehensive Assessment
• Case history
• Physical feeding/swallowing evaluation
• Observation of mealtime interactions
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.35
Case History
• Collected via interview
• Most important: child’s feeding history,
including length of meals, quality of intake,
progression from bottle to solids, and
history of formulas used
• Also important: discussion of child’s
developmental progression, including
cognitive and language abilities, gross and
fine motor skills, sensory processing, and
temperament
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.36
Physical Feeding and
Swallowing Evaluation
• Structural examination: physical nature of
oral-motor structures, looks for asymmetry,
drooling, and abnormal patterns or reflexes
• Functional examination: how the oral-motor
structures work together, looks at safety and
efficiency and quality of intake
• If any problems are seen, child may be
referred for modified barium swallow study
(MBS) – radiography follows a substance
through child’s swallowing process
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.37
Observation of Mealtime
Interactions
• Live observation by outside professional of
the child during mealtime interactions
– Examines for any breakdowns in childcaregiver communication and for unsafe or
inefficient oral feeding practices
• Feeding specialist studies scheduling of
meals, environment, foods presented, and
family traditions
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.38
V. How are Pediatric Feeding and
Swallowing Disorders Treated?
Multidisciplinary Alliance:
• Collaboration of parents and professionals
in working alliance to ensure effectiveness
of treatment
• Most involved professionals:
– Pediatrician
– Nutritionist
– Feeding specialist
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.39
Treatment Contexts
• NICU: Neonatal Intensive Care Unit
– Evaluations and interventions of feeding and
swallowing for medically fragile infants
– Encourages communication and stimulates oralmotor mechanisms
• Special Clinics
– Inpatient treatment in an intensive, hospital-based
program
– Accompanied by treatment in other contexts, like
home visits (allows specialist to study food prep,
meal options and timing, discipline, child
behavior, and feeding relationships in authentic
context)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.40
Treatment Goals and Approaches
• Physiology of Feeding and Swallowing
• Psychology of Feeding and Swallowing
• Alternative and Supplemental Feeding
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.41
Physiology of Feeding and
Swallowing
• Focus on muscle tone, articulator
movement, oral-motor sensitivity, and
body posture
• Hierarchical continuum of training targets
(short-term goals): start at child’s present
skill level and progress towards
independent eating (long-term goal)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.42
Psychology of Feeding and
Swallowing
• Focus on accepting certain food types or
textures, decreasing resistance and fussiness
during eating sessions, and following
predictable meal schedule
• Uses behavioral principles for treatment:
– Shaping – incrementally moves child towards
goal
– Conditioning and reinforcement – training of new
behavior through positive reinforcement
– Systematic desensitization – trains child to accept
an aversive sensory experience
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
9.43
Alternative and Supplemental
Feeding
• Enteral or tube feeding – liquid nutrition is
delivered through a tube (can be sole avenue
for nutrition or supplemental to oral intake)
– Short-term treatment: nasogastric tube
– Longer-term treatment: gastronomy tube or
jejunostomy tube
• Special support also given to caregiver-child
feeding relationship and to promoting oral
abilities even when not used for feeding
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
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Chapter 9: Pediatric Feeding and Swallowing Disorders