Feeding Development
Alison Spurr August 2014
Overview of Presentation
• Prevalence and Importance of Early
Identification
• Development of Feeding
• Reflexes
• Anatomy
• Development for first 2 years
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Feeding Evaluation Check list
Red Flags for further referral
Management of feeding difficulties
Case studies
Prevalence of feeding difficulties
• A wide variety of studies suggest 20% of
children struggle with some type of feeding
and/or growth problem during the first 5
years of life
• 5-10% of infants and young children have
significant feeding/growth problems
– These are the children that we need to identify
early and refer for early intervention
Importance of identifying problem
feeders
• Dubois et. al (2007) Picky eaters were more
likely to have a Body mass Index below the 10th
percentile at 4.5 years of age compared to the
children who were never reported as being
picky eaters at any one point in time.
• Motion, S., Northstone, K, Edmond, A.
(2001)The children who had persistent feeding
difficulties went on to have significant delays in
motor, language and behaviour milestones at
18months and 30 months of age
AUTISM DIAGNOSIS
• Identified as picky eaters long before referral for diagnosis
of ASD
– Later introduction of solids
– Described as “slow feeders” at 6 months
– From 15-54 months of age, consistently reported as
“difficult to feed”
– From 15-54 months of age, consistently reported as
“very choosy”
– From 15 months, had a significantly less varied diet,
which became increasingly more difficult than controls
– By 24 months, are more likely to have a different diet
from their family than controls
Edmond et.al. (2010)
Feeding Problems Cycle
Feed
Aversion
Deviant
parent
behaviours
eg. Force
feeding
Poor weight
Gain
Deviant
Parentchild
bonding
Increase in
parental
stress
Decreased
reading of
child’s cues
Feeding
Development
From Birth
Babies are born with the skills to
feed
• Reflexes
– automatic instinctive reactions in response to a
stimulus
• Anatomy
– Anatomy of the newborn differs from adult
Infant Reflexes
Swallowing Anatomy
Infant
Adult
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Anatomy of the New born
• Oral space is filled by the tongue – which is
in full contact with the gums, as well as the
hard and soft palate
• Buccal pads support sucking by providing
stability
• Soft palate and epiglottis are in contact
(obligatory nose breathers)
• Suction is created with tongue cupping and
jaw movement, creating negative pressure
Swallowing
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Normal Swallow & Anatomy
• LNORMAL.MOV
• xnormal.MOV
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Non-Nutritive Sucking
• No liquid flowing (other than own secretions)
→swallowing rate is low & the respiratory rate
remains at baseline levels.
• Sucking rate may be rapid as there is limited
interruption for swallowing.
• NNS = 2 sucks/ second.
• 6-8 sucks/ swallow/ breath.
• Infants' should be exposed to a variety of oral input
for NNS (own fingers/hands, dummy, adult finger,
teats, safe mouthing toys).
• NNS at the breast for infants transitioning to oral/ BF.
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Nutritive Sucking
• Apnoeic periods (‘deglutition apnoea’) occurring in association with
swallows.
• Rhythmic sucking, swallowing. Jaw movements & breathing are usually
co-ordinated in a 1:1 relationship.
• NS = 1suck/ second
• 1-2 sucks/ swallow/ breath
• Initial continuous sucking burst lasting up to 60-80 seconds, followed
by intermittent sucking (sucking bursts & pauses) over the feed.
• Duration of sucking bursts gradually decrease while length of pauses
increase.
• End of feed = only 2-3 sucks per burst with 4-5 second pause.
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Development of feeding
• Birth to 6 months. Suckle feeding.
– Liquid from breast or bottle
• 6 months: ‘first solids’ or purees
– In addition to breast/bottle feeding
• Approx. 8 months: increased texture
– Lumpy mashed and minced textures
– Chewable solids usually for mouthing and oral
exploration
Development of feeding
• 10 months: introduce new foods for biting
and chewing
• 12 months: eating harder chewable solids
• By 24 months: most children consuming
adult-like diet (variety of textures)
FEEDING DIFFICULTIES
FEEDING
(this is just the tip of the iceberg)
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All organs- respiratory, GI tract, cardiac
All muscles- fine/gross motor, posture, GI
All Senses- sensory experience
Learning – early experiences, capacity to learn
Development
Nutritional status
Environment – reflection of the problem, not the cause
Swallowing Difficulties
• A swallowing disorder or dysphagia, occurs
when there is a problem with the normal
ability to swallow food and or liquids.
• Causes
– oral and facial structure abnormalities,
– neurological and/or
– developmental difficulties
Swallowing Disorders
• LDURING.MOV
• XASDUR.MOV
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Swallowing Disorders
• Severity
– mild (addressed with modifications)
– Severe - food and fluid cannot be taken orally
and the individual must be fed enterally either
temporarily, partially or permanently.
• Swallowing difficulties can pose significant
dangers as food or fluid may enter the lungs
rather than the stomach.
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Swallowing Disorders
• Swallowing difficulties can occur at any stage of
the swallowing process.
• Oral stage: Issues with strength, movement,
coordination and sensation of the oral
musculature may cause difficulties with bolus
collection, containment, manipulation and transit.
• Pharyngeal Stage: difficulties with triggering
swallow reflex; poor or absent cough reflex. Issues
with bolus transit resulting in pooling and or
residue; refluxing into nasal passageways or
penetration and aspiration into the airway.
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Swallowing Disorders
• Oesophageal Stage: Problems with bolus transit;
residue; reflux; narrowing or pocketing of the
bolus.
• Medical specialists (eg gastroenterologist, ENT,
respiratory physician and or paediatrician etc)
need to be consulted for specialised investigation
and/or treatment. As difficulties can be due to a
variety of reasons, these need to be carefully
investigated.
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Red Flags
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Weight loss and/or failure to thrive
Lengthy feed times (longer than 30-40mins)
Refusal to eat or drink.
Poor ability to manage own secretions
Recurrent chest infections
Recurrent cough
Difficulties coping with certain types of
food/liquids
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Red Flags
• Coughing, spluttering, gagging at mealtimes
• Difficulty coordinating sucking swallowing and
breathing
• Wet, gurgly vocalisations during or
immediately after swallowing or at mealtimes.
• Nasal regurgitation or frequent sneezing during
a meal.
• Reflux and vomiting.
• Weak cough or inability to cough.
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Red Flags
• Multiple swallows to clear food and fluid
• Discomfort swallowing whilst eating or
drinking.
• Delayed or slow swallow trigger.
• Sweating, pallor or glassy eyes during meals.
• Desaturation levels during oral feeds.
• Increased heart rate during feeds.
• Sudden onset of feeding difficulties
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Check list for sucking
• Suck Evaluation Check list – see separate
hand out
• NB: For use in 0-3 months only
Common Feeding Problems in Babies
• Poor suck swallow breathe coordination
• Reduced endurance
• Oral aversion and oral hypersensitivity
• Structural – Cleft palate
- Tongue Tie
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Management Principles
• Depends on:
– The anatomic or physiological dysfunction
– Child’s prognosis
– Child’s developmental stage
– Child’s cognitive status and new learning skills
– Child’s level of independence/physical status
– Family resources (physical, financial, emotional)
Tongue Retraction
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• Postural support – provide flexed position &
stable support.
• Modifying tone of tongue- mvmts proximal to
distal (lateral gum ridge → on top of tongue) with
finger in a midline position. Shaking, jiggling,
tapping & stroking the tongue may be useful
movements.
• Longer nipple – that is firm with a round cross
section to provide greater contact on the tongue
(↑ proprioceptive input) & promote more
effective movements during sucking.
• BF – if adequate contact between tongue &
breast still cannot be achieved, use of a nipple
shield may be considered to create a longer
‘nipple’.
Lack of Central Grooving of the
Tongue
• Proprioceptive input – Downward pressure to the midline of the tongue
provides feedback re: proper position in the mouth and encourages
central grooving.
• Slight stroking forward combined with downward pressure may help
initiate appropriate sucking patterns.
• Can be applied with a finger prior to feeding or with the teat during
feeding (firm straight nipple with round cross section).
• BF – breast nipple may be too soft to provide sensory input needed during
feeding. May consider nipple shield if appropriate sucking pattern elicited
on finger or teat, but not on breast (with caution).
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Excessive Tongue-Tip Elevation
• Postural support – stable feeding position to
reduce neck extension. Increase flexion in body.
• Facilitation of tongue movements – quick swiping
or vibration to the tip of the tongue will help bring
it down.
• Assist with mouth opening – stimulation to the
lips & slight downward pressure on the jaw to
encourage greater jaw opening → tongue tip ↓
for easier nipple/ teat placement
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Tongue Protrusion
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• Postural support – bring head into a slightly flexed
position & provide stable support to the head.
• Building tone in the tongue – firm tapping to the midline
of the tongue, moving from the tip toward the base may
help bring the tongue further into the mouth.
• Facilitating appropriate tongue movements – tongue
protrusion results in a compression pattern dominating
sucking. Techniques to facilitate normal tongue
movement i.e central grooving to increase negative
pressure suction → efficient feeding (finger & firm
straight teat with round cross section. Not broad, flat →
compression)
• Facilitating lip activity – Use of cheek support with
thumb & index finger to facilitate better lip seal.
Reduced Spontaneous Mouth
Opening
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• Prepare the infant’s state – arousal techniques to alert
the baby.
• Elicit the rooting reflex.
• Assist mouth opening – gentle downward pressure &
traction to the jaw (chin) may help open the mouth.
Useful in eliciting the wide mouth opening necessary
for BF.
• Inhibit jaw clenching – vibration to mouth or hold the
mandible between thumb & index finger & provide
extremely small-range, low amplitude, side-to-side
mvmt of the jaw.
• Pressure to the gums – firmly stroking outer portion.
Start at midline of gums stroke towards back → Upper
& Lower gums R & L
Weak Suck
• Facilitating a stronger sucking pattern – provide maximal stability for
optimal positioning, using firm cheek & jaw support. A smaller bottle
may make it easier for the feeder to place fingers to provide 3 points
of stability.
Slight traction on the teat/ nipple by gently pulling may also promote
stronger sucking.
• Increase the flow of liquid – to allow the infant to get a larger bolus in
response to a weak suck (i.e. fast flow teat). Many babies with a weak
suck can co-ordinate swallowing & breathing with a larger bolus.
However must be done with caution (may be too large → coughing/
choking).
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Reduced Lip Seal
• Focus on underlying problem – i.e. Facial
weakness/ hypotonia, excessive jaw
excursion or tongue protrusion.
• External support – support to cheeks & lips
to help increase lip approximation around
the teat/ nipple.
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Reduced Cheek Stability
• Increase facial tone – tapping, vibration,
quick stretch (during a sucking pause of
greater than 2 seconds).
• External support – Cheek & jaw support.
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Prolonged Sucking – Feedinginduced Apnoea
• Long sucking bursts without interspersing breaths at appropriate
intervals → oxygen desaturation&bradycardia.
• Difficulty ‘pacing’ sucking & swallowing with breathing.
• Often strong, rapid sucking & may have difficulty initiating breathing,
even after the nipple/ teat has been removed from the mouth.
• More pronounced at the beginning of the feed.
• More common in premature babies → related to maturation.
– Mx: External pacing – feeder assists infant in appropriately interspersing breaths
during sucking bursts (count 3-5 breaths).
– Decrease the rate of flow – thicker liquid or slow-flow teat → time to organise the
swallow/ breath pattern.
– Youtube: Paced Feedings
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Disorganised Suck
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Duration of sucking bursts & pauses may vary considerably.
Uneven pattern of breathing and swallowing within the sucking burst.
Coughing & choking are frequently noted.
Possible causes – general neurologic disorganisation, mild respiratory
problems, or a nipple flow rate that is incompatible with the infant’s
sucking.
Mx:
– Assisting with external organisation – e.g.wrapping, ↓ distractions.
– Acknowledging respiratory problems.
– External pacing.
– Reducing the flow rate - ↑ rhythmic coordination (thicker liquid, slower-flow teat.
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Coordination of Suck, Swallow,
Breathing
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Feed when baby best able to organise self
- timing, wrapping, rocking
Express before feed
Use external pacing
Variable flow teat
Thicken the feed
Consider respiratory support
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Poor Initiation of Sucking
• Focus on underlying problems – poor state & organisational abilities,
oral tactile hypersensitivity or neurologically based (hypertonia/
hypotonia).
• Controlling excessive rooting – provide firm stabilisation & control of
the head through positioning (↓ head shaking from side to side).
Stabilise front of the head with jaw control & cheek support if needed.
Place teat firmly on the midline of infant’s tongue with slight
downward pressure to give central point of stabilisation.
• Assist with mouth closure – jaw support.
• Facilitating appropriate tongue movements
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Excessive Jaw Movement
• Postural support – jaw support with 3rd/ 4th finger to the mandible to
allow adult to grade range of movement.
• Increased neck flexion – head in strong neck flexion. The chin should
be close to the chest, with the chest then providing pressure and
helping to grade jaw movement.
May need to use an angled bottle → always monitor infant’s
respiratory pattern.
• Neuromotor preparation – for jaw thrusting (hypertonicity) → reduce
overall body muscle tone (support from Physio or OT).
• Facilitating appropriate tongue movements
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Short Sucking Bursts
• Infant takes only 1-3 sucks in a burst before pausing for multiple
breaths.
• Pauses are too frequent & too long compared to the length of the
sucking bursts.
• Swallowing &/ or respiratory difficulties may lead to this pattern.
• Adaptive responses from infant – limiting the no. of sequential boluses
→ swallowing problem.
-frequent pauses to ‘catch up’(self-pacing) → respiratory problem.
Mx:
– Swallowing-related incoordination – VFSS ax.
– Respiratory-related incoordination – provide respiratory support.
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