Feeding and swallowing disorders (also known as dysphagia) include difficulty with any step of the feeding process—from accepting foods and liquids into the mouth to the entry of food into the stomach and intestines. A feeding or swallowing disorder includes developmentally atypical eating and drinking behaviors, such as not accepting age-appropriate liquids or foods, being unable to use age-appropriate feeding devices and utensils, or being unable to self-feed. A child with dysphagia may refuse food, accept only a restricted variety or quantity of foods and liquids, or display mealtime behaviors that are inappropriate for his or her age.
Dysphagia can occur in any phase of the swallow. Although there are differences in the relationships between anatomical structures and in the physiology of the swallowing mechanism across the age range (i.e., infants, young children, adults), typically, the phases of the swallow are defined as
Oral Preparation Stage—preparing the food or liquid in the oral cavity to form a bolus-including sucking liquids, manipulating soft boluses, and chewing solid food.
Oral Transit Phase—moving or propelling the bolus posteriorly through the oral cavity.
Pharyngeal Phase—initiating the swallow; moving the bolus through the pharynx.
Esophageal Phase—moving the bolus through the cervical and thoracic esophagus and into the stomach via esophageal peristalsis (Logemann, 1998).
Incidence and Prevalence
The 'incidence' of pediatric dysphagia refers to the number of new cases identified in a specified time period. The 'prevalence'of pediatric dysphagia refers to the number of children who are living with pediatric dysphagia in a given time period.
Estimated reports of the incidence and prevalence of pediatric feeding/swallowing impairment vary widely due to multiple factors, such as variations in the populations sampled, how feeding and/or swallowing impairment is defined, and the choice of assessment methods and measures (Arvedson, 2008; Lefton-Greif, 2008). Pediatric feeding and/or swallowing impairment incidence and prevalence data from the review papers cited below reflect this high variability.
- It has been reported that 25%-45% of typically developing children demonstrate feeding and swallowing problems (Arvedson, 2008; Bernard-Bonnin, 2006; Brackett, Arvedson, & Manno, 2006; Burklow, Phelps, Schultz, McConnell, & Rudolph, 1998; Lefton-Greif, 2008; Linscheid, 2006; Manikam & Perman, 2000; Rudolph & Link, 2002).
- Prevalence is estimated to be 30%-80% for children with developmental disorders (Arvedson, 2008; Brackett, Arvedson, & Manno, 2006; Lefton-Greif, 2008; Manikam & Perman, 2000).
- Significant feeding problems resulting in severe consequences (e.g., growth failure, susceptibility to chronic illness) have been reported to occur in 3%-10% of children, with a higher prevalence found in children with physical disabilities (26%-90%) and medical illness and prematurity (10%-49%; Manikam & Perman, 2000).
- It is reported that the prevalence of pediatric dysphagia is increasing due to improved survival rates of children born prematurely, with low birth weight, and with complex medical conditions (Arvedson, 2008; Lefton-Greif, 2008).
Signs and Symptoms
Signs and symptoms of swallowing and feeding disorders vary based on the age of child, but may include
- back arching;
- breathing difficulties when feeding that might be signaled by
- increased respiratory rate during feeding,
- skin color change such as turning blue,
- stopping frequently due to uncoordinated suck-swallow-breathe pattern,
- desaturation (decreasing oxygen saturation levels);
- changes in normal heart rate (brachycardia or tachycardia) in association with feeding;
- coughing and/or choking during or after swallowing;
- crying during mealtimes;
- decreased responsiveness during feeding;
- difficulty chewing foods that are texturally appropriate for age (may spit out partially chewed food);
- difficulty initiating swallowing;
- difficulty managing secretions (including non-teething related drooling of saliva);
- disengagement cues, such as facial grimacing, finger splaying, or head turning away from food source;
- frequent congestion, particularly after meals;
- frequent respiratory illnesses;
- loss of food/liquid from the mouth when eating;
- noisy or wet vocal quality noted during and after feeding;
- prolonged feeding times;
- refusing foods of certain textures or types;
- taking only small volumes, over-packing the mouth, and/or pocketing foods;
- vomiting (more than typical "spit up" for infants);
- weight loss or lack of appropriate weight gain.
Common causes of pediatric dysphagia include
- developmental disability (i.e., disability with onset before the age of 22 that warrants lifelong or extended medical, therapeutic, and/or residential supports and is attributable to a mental or physical impairment or a combination of mental and physical impairments);
- neurological disorders (e.g., cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, muscle weakness in face and neck);
- factors affecting neuromuscular coordination (e.g., prematurity, low birth weight);
- complex medical conditions (e.g., heart disease, pulmonary disease, gastroesophageal reflux disease [GERD], delayed gastric emptying);
- structural abnormalities (e.g., cleft lip and/or palate, laryngomalacia, tracheoesohageal fistula, esophageal atresia, head and neck abnormalities, choanal atresia);
- genetic syndromes (e.g., Pierre Robin, Prader-Willi, Treacher-Collins, 22q11 deletion);
- medication side effects (e.g., lethargy, decreased appetite);
- sensory issues as a primary cause or secondary to limited food availability in early development (e.g., in children adopted from institutionalized care; Beckett et al., 2002, Johnson & Dole, 1999);
- behavioral factors (e.g., food refusal);
- social, emotional, and environmental issues (e.g., difficult parent-child interactions at mealtimes).
Results or long-term effects for a child diagnosed with pediatric dysphagia include
- poor weight gain velocity and/or under nutrition (failure to thrive),
- aspiration pneumonia and/or compromised pulmonary status,
- food aversion,
- oral aversion,
- rumination disorder (unintentional and reflexive regurgitation of undigested food that may involve re-chewing and re-swallowing of the food),
- ongoing need for enteral or parenteral nutrition.
Roles and Responsibilities
Speech-language pathologists play a central role in the assessment, diagnosis, and treatment of infants and children with swallowing and feeding disorders. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2007).
Appropriate roles for SLPs include
- providing prevention information to individuals and groups known to be at risk for pediatric dysphagia and feeding disorders, as well as to individuals working with those at risk;
- educating other professionals on the needs of children with dysphagia and the role of SLPs in diagnosing and managing pediatric dysphagia;
- conducting a comprehensive assessment, including clinical and instrumental evaluation; identifying normal and abnormal swallowing anatomy and physiology; and identifying signs of possible or potential disorders in the upper aerodigestive tract;
- participating in decisions regarding the appropriateness of instrumental evaluation procedures, being included in decision-making about the severity and nature of swallowing deficits, interpreting data and applying results obtained from instrumental assessments to the formulation of dysphagia treatment plans and to the determination of the child's potential for safe and adequate oral intake;
- extracting information about swallowing function from the results of procedures performed by different medical specialists–including procedures such as manofluorography, cervical auscultation, scintigraphy (which in the pediatric population may also be referred to as radionuclide milk scanning), pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy;
- diagnosing pediatric dysphagia;
- referring the patient to other professionals as needed to rule out other conditions, determine etiology, and facilitate patient access to comprehensive services;
- making decisions about management of pediatric dysphagia;
- considering culture as it pertains to food choices, perception of disabilities, and beliefs about intervention (Davis-McFarland, 2008);
- developing treatment plans that incorporate the family's dietary preferences, providing treatment, documenting progress, and determining appropriate dismissal criteria;
- recommending a swallowing and feeding plan for daily management of swallowing and feeding activities that is referenced in the Individualized Education Program (IEP), Individual Family Service Plan (IFSP), or 504 Plan;
- recommending related services when necessary for daily classroom management and therapy;
- counseling children and their families and providing education aimed at preventing further complications related to dysphagia;
- serving as an integral member of an interdisciplinary feeding and swallowing team;
- providing quality control and risk management;
- consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate;
- remaining informed of research in the area of pediatric dysphagia and helping advance the knowledge base related to the nature and treatment of dysphagia;
- advocating for individuals with dysphagia and their families at the local, state, and national levels.
As indicated in the Code of Ethics (ASHA, 2010), SLPs who serve this population should be specifically educated and appropriately trained to do so. Experience in adult dysphagia does not qualify an individual to provide dysphagia assessment or management services to children. An understanding of adult anatomy and physiology of the swallow provides a good basis for understanding dysphagia in children; however, additional knowledge and skills pertaining to the pediatric dysphagia population are needed.
See the Assessment section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The assessment of swallowing and feeding disorders forms the basis for developing management strategies. SLPs may need to use multiple forms of assessment to make informed treatment decisions.
The purpose of a pediatric swallowing/feeding assessment is to
- diagnose a swallowing and/or feeding disorder,
- determine which phase(s) of swallowing may be involved in the disorder,
- provide a profile of contributing causes that will enable the clinician to
- determine if the infant or child should be referred to an interdisciplinary team for comprehensive clinical assessment of feeding skills,
- determine whether additional instrumental assessment is needed to further delineate the child's dysphagia characteristics,
- determine if collaborative medical or allied health evaluations are needed,
- select and recommend appropriate, symptom-specific interventions and a program plan.
The pediatric swallowing/feeding assessment may result in
- clinical description of the characteristics of the disorder, including related functions that affect the disorder (e.g., airway, behavioral, craniofacial, gastrointestinal, motor, neurologic, nutritional, respiratory),
- diagnosis of a disorder of swallowing and/or feeding function,
- prognosis for change (in the individual or in relevant contexts),
- identification of contributing causes,
- determination of educational relevance of a diagnosed swallowing and feeding disorder (for children in a school setting),
- referral to an interdisciplinary team for comprehensive clinical assessment of feeding skills,
- referral for additional assessment, including instrumental assessment,
- referral for additional collaborative medical or allied health evaluations when indicated,
- recommendation for intervention and support, including school-based therapy and classroom management, where appropriate,
- identification of potentially effective interventions.
SLPs conduct assessments in a manner that is sensitive to the family's cultural background, religious beliefs, and preferences for medical treatment. Families are encouraged to bring food and drink common to their household and utensils/implements typically used by the child; typical feeding practices are observed during assessment (e.g., if the child is typically fed sitting on a parent's lap, then this is observed during the assessment).
Practitioners take into consideration the following factors when assessing swallowing and feeding disorders in the pediatric population.
- Etiologies of swallowing deficits differ and may not be defined clearly in some pediatric populations.
- There are distinct differences in the relationships of anatomic structures and physiology of the swallowing mechanism among infants, young children, and adults. In addition, the developing infant and child experience changes in relative and absolute size and shape of oral and pharyngeal structures.
- In infants, the tongue fills the oral cavity and the velum hangs lower, the hyoid bone and larynx are positioned higher than in adults, and the larynx elevates less than in adults during the pharyngeal phase of the swallow.
- Once the infant begins eating pureed food, each swallow is discrete and the oral and pharyngeal phases are similar to that of an adult (although with less elevation of the larynx).
- As the child matures, the jaw grows down and forward and the tongue moves down. The space between the tongue and the palate increases, and the larynx and the hyoid bone lower, elongating and enlarging the pharynx (Logemann, 1998).
- Infants and children may have congenital abnormalities of the anatomy and physiology.
- Unlike most adults, infants and children cannot verbally describe their symptoms; family, caregivers, and professionals must rely on nonverbal forms of communication, signs of swallowing and feeding problems, information from monitoring devices in Neonatal Intensive Care Unit (NICU), and thorough case histories to get a full picture of the child's situation.
- Infants and children grow and develop even when they have chronic conditions, so swallowing may change over time.
- Age correction is applied in the case of premature infants; the actual feeding skills are assessed based on those expected for the infant's corrected age, rather than his or her chronological age.
The U.S. Food and Drug Administration (FDA) has cautioned consumers about the use of commercial, gum-based thickeners for infants from birth to 1 year of age, especially when the product is used to thicken breast milk. SLPs should be aware of these cautions and consult as appropriate in their facility to develop guidelines for using thickened liquids with infants. (See FDA consumer cautions, 2011, 2013).
Due to the heterogeneity of diagnoses and the complexity of managing dysphagia across the age spectrum, a team approach is often ideal, if not necessary, for diagnosis and management of pediatric dysphagia. Formation of the team begins with involvement of the family or caregivers.
Additional assessment team members might include representatives of different disciplines to provide a comprehensive assessment of the infant/child. Team members may include
- an SLP who specializes in swallowing and feeding,
- one or more physicians (e.g., a pediatrician, neonatologist, physiatrist, otolaryngologist, pulmonologist, endocrinologist, neurologist, neurosurgeon, cardiac surgeon, and/or gastroenterologist),
- a registered dietitian,
- a nurse or nurse practitioner,
- an occupational therapist,
- a psychologist,
- a social worker,
- a board certified lactation consultant,
- a physical therapist.
Other medical and rehabilitation specialists may be needed; individual team members and disciplines may vary depending on the type of facility, professional expertise needed, and specific population being served.
A clinical evaluation of swallowing and feeding is usually the first step in a comprehensive evaluation to determine the presence or absence of a swallowing disorder. This evaluation may be completed during an individual session by a SLP with expertise in pediatric swallowing and feeding issues or as part of a more comprehensive evaluation conducted by a feeding team. The clinical evaluation addresses the swallowing-based activities of eating, drinking, and secretion management and, in addition, may address the activities of taking oral medications and teeth brushing.
The clinician considers signs of involvement in one or more of three categories when determining contributing causes.
Physiological—medical disorders, in particular those involving neurological, craniofacial, gastroenterological, pulmonary, and metabolic systems. These disorders may be temporary, chronic, or progressive in nature.
Developmental—issues associated with failure to develop mature skills for swallowing-based activities at expected milestone ages; typically associated with deprivation of timely and appropriate practice for acquisition of skills or a secondary effect of a physiological and/or behavioral swallowing and feeding disorder.
Behavioral—disorders involving (a) motivation for eating and/or engaging in other appropriate feeding/swallowing-based activities and (b) the social and interactive aspects of engaging in feeding activities. This category includes behaviors that are associated with refusal to engage, as well as self-abusive, aggressive, disruptive, or other maladaptive behaviors. Sensory issues may play a role in some behavioral responses.
The clinical evaluation typically includes
- case history, based on a comprehensive review of medical/ clinical records, as well as interviews with the family and other health care professionals;
- assessment of overall physical, social, behavioral, and communicative development;
- observation of the child eating or being fed by a family member or caregiver using foods from the home and typically used utensils, as well as those that may be rejected or cause problems;
- structural assessment of face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa;
- functional assessment of muscles and structures used in swallowing, including symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement;
- observation of head-neck control, posture, developmental postural and oral reflexes, and involuntary movements noted in the context of the child's developmental level;
- functional assessment of swallowing ability, including but not limited to typical developmental skills and task components-suckling and sucking in infants, mastication in older children, oral containment, and manipulation of the bolus;
- impression of airway adequacy and coordination of respiration and swallowing;
- assessment of developmentally appropriate secretion management skills, which might include frequency and adequacy of spontaneous dry swallowing and ability to swallow voluntarily;
- assessment of behavioral factors, including but not limited to acceptance of pacifier, nipple, spoon, and cup, and range and texture of developmentally appropriate foods and liquids tolerated;
- assessment of consistency of skills across the feeding opportunity to rule out any negative impact of fatigue on feeding/swallowing safety;
- assessment of alterations in bolus delivery and/or use of rehabilitative/habilitative or compensatory techniques on the swallow.
- For children with motor disorders, the clinician should assess in the child's typical feeding position and note lip, tongue, and jaw actions during feeding; the clinician should assess fine motor skills and ability to use feeding utensils, efficiencies with varying textures, time to clear the oral cavity, mastication skills, and coordination of breathing and swallowing. Signs of impairment may include increased heart rate, excessive coughing, gagging, tongue thrust, or withdrawal (New York State Department of Health, Early Intervention Program, 2006b).
See the Clinical Evaluation section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Clinical Evaluation Considerations for Infants Including NICU
The clinical evaluation for infants (birth to 1 year, including those in the Neonatal Intensive Care Unit [NICU]) includes evaluation of prefeeding skills, assessment and promotion of readiness for oral feeding, and evaluation of breast- and bottle- feeding ability. SLPs should have extensive knowledge about embryology, pre-natal and perinatal development, and medical issues common to the preterm and medically fragile newborn, as well as typical early infant development. The underlying neurophysiology, family-focused environment, infant-family bonding, as well as specific oral sensorimotor function, form the basis for evidence-based practice in the NICU.
The clinical evaluation of the medically fragile infant typically includes
- a case history that includes gestational and birth history and any pertinent medical history;
- a physical examination that includes developmental assessment, observations of physiologic and medical stability, and respiratory status;
- the determination of oral feeding readiness by considering
- medical stability,
- ability to maintain physiological state,
- ability to engage in non-nutritive sucking (NNS);
- developmentally appropriate clinical assessments of feeding and swallowing behavior (nutritive sucking [NS]) as appropriate;
- an assessment of suckling/swallowing problems and determination of abnormal anatomy and/or physiology associated with these findings;
- the identification of additional disorders that impact feeding and swallowing;
- the determination of the optimal feeding method;
- an assessment of duration of mealtime experience, including the need for supplemental oxygen;
- an assessment of issues related to fatigue and volume limitations;
- an assessment of the effectiveness of parent and infant interactions for feeding and communication.
The U.S. Food and Drug Administration (FDA) has cautioned consumers about the use of commercial, gum-based thickeners for infants from birth to 1 year of age, especially when the product is used to thicken breast milk. SLPs should be aware of these cautions and consult as appropriate in their facility to develop guidelines for using thickened liquids with infants. (See FDA consumer cautions, 2011, 2013).
- Evidence indicates that several research tools have been developed to assess sucking behavior; however, these tools are limited to the measurement of only a subset of relevant aspects of sucking behavior and to assessment of only bottle feeding or breast feeding, but not both. These tools also require expensive/complicated measuring equipment. There is a need for the development of a user-friendly, reliable, and noninvasive tool to assess breast feeding and bottle feeding in infants. (Da Costa, van den Engel-hoek, & Bos, 2008).
See the Assessment: Clinical Examination section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Readiness For Oral Feeding
There is little consistency across or within most facilities regarding an infant's readiness for oral feeding. Likewise, there is no consistent protocol covering criteria for initiation of feedings and how the decision is made. In many NICUs, it is a unilateral decision on the part of the neonatologist; in others, the SLP, neonatologist, and nursing staff share observations during their assessments of readiness for oral feedings. The decision is based on the individual skills of each infant.
Key criteria to determine readiness to feed include
- stability in physiologic parameters (e.g., digestive, respiratory, heart rate, and oxygenation);
- motoric stability in the form of muscle tone, flexion, and midline movements;
- behavioral state (ability to alert) and stability in behavioral state.
The practitioner must consider the values and beliefs of the family related to oral intake and feeding, in conjunction with the recommendations from the medical and therapeutic team, to determine the most appropriate time to initiate oral feeding.
Non-Nutritive Sucking (NNS)
Non-nutritive sucking (sucking for comfort without fluid release, as with a pacifier, finger, or recently emptied breast) does not determine readiness to orally feed, but is helpful for assessment. NNS patterns can typically be evaluated with skilled observation and without the use of instrumental assessment. A non-instrumental assessment of NNS includes evaluation of the infant's
- oral structures and functions, including palatal integrity, jaw movement, and tongue movements for cupping and compression (lip closure is not required for infant feeding, as the tongue typically seals the anterior opening of the oral cavity);
- ability to turn and open the mouth (rooting) when stimulated on the lips and to accept a pacifier into the mouth;
- ability to use both compression (positive pressure of the jaw and tongue on the pacifier) as well as suction (negative pressure created with tongue cupping and jaw movement);
- strength of compression and suction, as well as any other oral-motor dysfunction that might be related to neurological or motor disorders;
- ability to maintain physiological state during NNS.
Nutritive Sucking (NS)
Once the NNS component of feeding has been assessed, the clinician can move toward determining the appropriateness of nutritive sucking (NS). When possible, nutritive sucking skills are assessed when the infant is engaged in breast feeding as well as bottle feeding, if both feeding modes are to be utilized, to determine how/if feeding mode impacts the quality of the infant's feeding performance. SLPs demonstrate sensitivity to familial values and beliefs regarding bottle and breast feeding and collaborate with mothers, nurses, and lactation consultants to identify parental preferences for feeding modalities. If the feeding is offered, the assessment includes evaluation of the sucking/swallowing/breathing pattern, efficiency, endurance, and infant response to feeding.
- Sucking/swallowing/breathing pattern is critical because safety concerns (desaturation in oxygen with feedings, bradycardia or apnea with feedings, and aspiration) are of primary importance in the infant population. Any loss of stability in physiologic, motor, or behavioral state from baseline should be taken into consideration at the time of the assessment.
- Efficiency (volume per minute) is directly related to the integration of suction and compression. Loss of fluid negatively influences efficiency and is often a reflection of the infant's attempt to manage a large bolus, rather than a marker for poor oral-motor tone. The reason for fluid loss is best determined by observing the oral-motor tone and strength during NNS, as infants with poor oral-motor tone will demonstrate similar skill deficits during NS.
- Endurance (ability to remain engaged in the feeding to finish the required volumes) is typically a function of maturation.
The infant's communication behaviors during feeding can be used as cues to guide dynamic intervention. Cues can communicate a number of things to the caregiver, including the infant's ability to tolerate bolus size, the need for more postural support, and if swallowing and breathing are no longer synchronized. In turn, the caregiver can use these cues to optimize feeding by responding to the infant's needs at any given moment in dynamic fashion (Shaker, 2013).
SLPs collaborate with mothers, nurses, and lactation consultants prior to assessing breast-feeding skills. The clinician needs a working knowledge base of breast-feeding strategies in order to facilitate safe, efficient breast feeding in the NICU. There are few standardized assessments for evaluating potential breast-feeding of medically fragile infants in the NICU and other clinical environments. The Management of Acute Malnutrition in Infants (MAMI) Project (n.d.) proposes a set of common factors that breast-feeding assessment tools should address, including evaluation of
- infant's behavior,
- infant's state, including respiratory rate and heart rate,
- mother's behavior,
- position of the infant,
- nipple attachment,
- effective/efficient feeding (efficiency of suck/swallow/breathe pattern),
- health of breast,
- health of infant.
The assessment of bottle-feeding includes evaluation of
- the infant's state, including respiratory rate and heart rate,
- suck/swallow/breathe coordination (normal or disorganized),
- nipple type and form of nutrition,
- infant position,
- quantity of intake,
- length of time infant takes for one feeding,
- infant's response to attempted interventions.
In addition to the areas of assessment noted above, the evaluation for toddlers (1-3 years) and pre-school/school-age children (3-21 years) may include
- review of any past diagnostic test results,
- review of current programs and treatments, as appropriate,
- assessment of current skills and limitations at home and in other day settings,
- assessment of the child's willingness to participate/level of engagement,
- evaluation of the child's independence/need for supervision and assistance,
- use of intervention probes to identify strategies that might improve function.
As an increasing number of high-risk infants survive and enter educational programs, school-based SLPs often play a significant role in the management of students with swallowing and feeding problems in school settings. The Rehabilitation Act of 1973 (Section 504) (U.S. Department of Labor, n.d.) and the Individuals with Disabilities Education Improvement Act (IDEA 2004) mandate services for health-related disorders that affect the ability of the student to access educational programs and participate fully.
Addressing swallowing and feeding disorders is educationally relevant and part of the school system's responsibility for the following reasons.
- Students must be safe while eating in school including having access to appropriate personnel, food, and procedures to minimize risks for choking and for aspiration while eating.
- Students must be adequately nourished and hydrated so that they can attend to and fully access the school curriculum.
- Students must be healthy (e.g., free from aspiration, pneumonia or other illnesses related to malnutrition or dehydration) to maximize their attendance at school.
- Students must develop skills for eating efficiently during meals and snack times so that they can complete these activities with their peers safely and in a timely manner.
The school-based swallowing and feeding team consists of members who serve in the school system as well as medical professionals outside the school (e.g., physicians, dietitians, psychologist). Core members of the team, who are responsible for decisions regarding dysphagia, include the SLP, family /caregiver, classroom teacher, nurse, occupational therapist, physical therapist, and school administrator. Additional members can include the school psychologist, social worker, and cafeteria staffer.
School-based dysphagia services include a referral process, family/guardian notification and involvement, screening and evaluation, and development of an IEP and/or a 504 plan. The school system's policy manual will include policies and procedures for addressing dysphagia. The goal of a system-supported process is to develop procedures that are utilized consistently throughout a school district.
The evaluation process begins with a referral to a team of professionals within the school district who are trained in the screening, identification, and treatment of dysphagia. The referral can be initiated by a family member/guardian, school staff member, or outside professional.
Following the initial referral, the school contacts the family member/guardian to discuss the evaluation process, to obtain consent for an evaluation of the student's swallowing and feeding, and to gather information about the child's medical and health history, as well as how the student is fed at home.
Review of the referral is considered part of the screening process. The family member/guardian and teacher interviews also serve as part of the screening and evaluation process. Following the screening, a comprehensive, interdisciplinary swallowing and feeding evaluation may be warranted.
The school-based dysphagia team conducts a multidisciplinary observation and clinical evaluation of the student during snack- or meal- times at school. Modifications and/or strategies are part of the diagnostic process. The information from this evaluation may be used to draft a swallowing and feeding plan, which may be temporary depending on the need for further diagnostics.
Collaborating With Medical Professionals
The collaboration between the school-based dysphagia team and medical professionals includes consideration of whether a referral is warranted for medical assessment, medical clearance, or ongoing medical care. Typically, this consideration would arise for the student with a medically complex condition as opposed to the student with a medically stable condition, for whom special care during the school day is not specified in the Individualized Education Program (IEP), Individual Family Service Plan (IFSP), 504 Plan, or Individualized Health Plan (IHP).
If the dysphagia team determines that medical assessment is advisable prior to initiation of a school-based dysphagia program or during the course of a program, they can recommend that the family seek medical consultation (e.g., for a VFSS referral and/or other medical assessments).
Although SLPs do not require a medical prescription or other form of medical approval to perform clinical evaluations or implement intervention programs, there are instances when a prescription, referral, or medical clearance may be requested from the student's primary care physician or other health care provider (e.g., when requesting VFSS or FEES evaluations). This request may be made through the family or directly to the provider (after discussion with the family), when the school has approval for direct communication with the health care providers. These requests for medical collaboration may include
- prescription or medical clearance for clinical dysphagia assessment and/or intervention for students
- who receive part or all of their nutrition or hydration via enteral or parenteral tube feeding,
- with medically complex conditions,
- whose medical status is a significant variable for determining the appropriate assessment and treatment strategies;
- approval of the IHP by the primary care provider or school physician for a student with medically complex needs.
Reimbursement In Schools
Some school districts submit claims to third-party payers for reimbursement of swallowing and feeding services rendered in the schools. When a SLP is the service provider, he or she is responsible for all submitted claims for those services and must understand payer requirements (e.g., state Medicaid, private health insurance) to ensure compliance. Requirements of third-party payers (which may differ from school policies) may include
- the definition of qualified provider,
- student eligibility for services as defined by the payer,
- required documentation (e.g., referral, certification, and recertification by the physician; goals; and progress notes),
- supervision of support personnel, including SLPs who are not licensed or ASHA-certified (ASHA 2004),
- diagnosis codes and/or procedure codes for services provided.
The two commonly used instrumental evaluations of swallowing for the pediatric population are
- Videofluoroscopic Swallowing Study (VFSS),
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with or without sensory testing to evaluate the laryngeal adductor response or LAR (Fiberoptic Endoscopic Evaluation of Swallowing and Sensory Testing or FEESST).
These procedures examine swallowing dynamics under conditions that simulate eating; they are typically conducted by the SLP and physician (e.g., radiologist) as a team. Instrumental assessments performed by other professionals often help the SLP formulate his or her recommendations (e.g., by helping the clinician differentiate between aspiration resulting from swallowing and aspiration resulting from gastroesophageal reflux).
During instrumental assessment of swallowing, the clinician may use information from cardiac, respiratory, and oxygen saturation monitors to determine any changes to physiologic or behavioral condition. Other signs to monitor include color changes, nasal flaring, and sucking/swallowing/breathing patterns.
The roles of the SLP in the instrumental evaluation of swallowing and feeding disorders include
- participating in decisions regarding the appropriateness of these procedures,
- conducting the VFSS and FEES/FEESST instrumental procedures,
- interpreting and applying data from instrumental evaluations to (a) determine the severity and nature of the swallowing disorder and the child's potential for safe oral feeding and (b) formulate dysphagia treatment plans, including recommendations for optimal feeding techniques;
- being familiar with and using information from diagnostic procedures performed by different medical specialists that yield information about swallowing function. These procedures include manofluorography, cervical auscultation, scintigraphy (which in the pediatric population may also be referred to as radionuclide milk scanning), pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy.
- A videofluoroscopic or fiber-optic endoscopic evaluation of swallowing should be carried out if necessary (and if there are no clinical contraindications) to improve visualization of the upper aerodigestive tract, assess aspiration and residue, facilitate techniques and therapeutic strategies to reduce aspiration and improve swallowing efficiency, compare baseline and post-treatment function, and to further diagnose (Taylor-Goh, 2005).
- "Ultrasound, scintigraphy, manometry and [electromyography (EMG)] are each tools to evaluate discrete components of swallowing function; therefore it is not appropriate to use any as a stand-alone evaluation technique" (Taylor-Goh, 2005, p.65).
See the Instrumental Assessment section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Procedures take place in a child-friendly environment with toys, visual distracters, rewards, and a familiar caregiver, if possible and when appropriate. Various items to facilitate success and replicate a typical mealtime experience, including preferred foods, familiar food containers, utensil options and seating options, are included in the room.
Preparing the Child
- For the child who is able to understand, the clinician explains the procedure, the purpose of the procedure, and the test environment in a developmentally appropriate manner.
- The clinician allows time for the child to acclimate to the room, the equipment, and the professionals who will be present for the procedure.
- For procedures that involve presentation of a solid and/or liquid bolus, the clinician instructs the family to schedule meals and snacks so that the child will be hungry and more likely to accept foods as needed for study.
The clinician allows a period of time for the child to develop the ability to accept and swallow a bolus, if the child has not eaten by mouth (NPO); and for children who have difficulty participating in the procedure, time to bring behaviors under control prior to initiating the instrumental procedure.
- The clinician provides families and caregivers with information about dysphagia, the purpose for the study, the test procedures, and the test environment.
- The clinician requests that the family provide
- familiar foods of varying consistencies and taste that are compatible with contrast material (if facility protocol allows),
- a specialized seating system from home (including car seat or specialized wheelchair) as warranted and if permitted by facility,
- the child's familiar and preferred utensils, if appropriate.
Procedural Considerations for Instrumental Evaluations
- Prior to the evaluation, clinicians are encouraged to collaborate with the medical team regarding feeding schedules that will maximize feeding readiness during the evaluation.
- Children are positioned as they are typically fed at home and in a manner that avoids spontaneous or reflex movements that could interfere with the safety of the examination. Modifications to positioning are made as needed and are documented as part of the assessment findings.
- Anxiety and crying may be an expected reaction to any instrumental procedure. Anxiety may be reduced by using distraction (eg., videos), allowing the child to sit on the parent's or caregiver's lap (for FEES procedures), and decreasing the number of observers in the room. If a natural feeding process (e.g., position, caregiver involvement, and use of familiar foods) cannot be achieved, the results may not represent typical swallow function, and the study may need to be terminated with results interpreted with caution.
- For FEES procedures, special consideration should be given to smaller anatomical features in the infant/toddler population. The diameter of endoscopes designed for infants and children is 1.4 to 1.7 mm.
- Infants are obligate nasal breathers, and compromised breathing may result from the placement of a fiberoptic endoscope in one nostril when a nasogastric tube is in place in the other nostril. Clinicians will discuss this with the medical team in order to determine options, including temporary removal of the feeding tube and/or use of another means of swallowing assessment.
- Equipment for positioning for VFSS will vary depending on the size of the child and his or her medical condition (Arvedson & Lefton-Greif, 1998; Gisel, Applegate-Ferrante, Benson, & Bosma, 1996). Infants under 6 months of age typically require head, neck, and trunk support. Replication of the child's typical feeding position is attempted to the extent possible.
Special Considerations in the NICU
Although the need for instrumental assessments in the Neonatal Intensive Care Unit is not frequent, these procedures are recommended at times. For example, an instrumental swallowing assessment for medically stable infants who are ventilator dependent and require a tracheotomy is advantageous in promoting safe and timely oral alimentation (Leder et al., 2010). The SLP working in the NICU works collaboratively with the medical team to determine if the infant's swallowing concerns warrant instrumental examination.
Interpretation and Recommendations Following Instrumental Evaluations
- The SLP and other team members involved in the assessment (e.g., radiologist, otolaryngologist, gastroenterologist) review the results and agree on characteristics of the swallow and on anatomical features.
- Following team discussion, conclusions and recommendations are finalized, taking into consideration: instrumental swallowing sampling paired with results of the clinical dysphagia evaluation; adequacy of the child's swallow for eating efficiency and airway protection; the child's pulmonary health and medical status; and family beliefs and preferences.
- Recommendations are made to compensate for physiological and anatomical abnormalities and to improve swallowing efficiency and adequacy for airway protection.
- Recommendations consider low Laryngeal Adductor Response (LAR) in children (i.e., response only to higher pressure puffs or unresponsive in FEESST), since low LAR is correlated with recurrent pneumonia, gastroesophageal reflux, pooled secretions, laryngeal penetration and aspiration (Link, Willging, Miller, Cotton, & Rudolph, 2000).
Videofluoroscopic Swallow Study (VFSS)
See the Videofluoroscopy section of the pediatric dysphagia map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
VFSS, also known as modified barium swallow, is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal and upper esophageal function. During this radiographic procedure, the SLP presents food and liquid mixed with barium in order to assess the dynamic function of the oral, pharyngeal and upper esophageal function of the swallow. The barium is necessary to view structures during the swallow. The VFSS delineates the biomechanics of the swallow and the patterns of bolus motility, including but not limited to, swallow reflex time, nasopharyngeal reflux, pharyngeal clearance, and laryngeal penetration and aspiration.
When appropriate, the VFSS protocol examines the effectiveness of modifications to enhance swallowing safety/efficiency, including
- alternating liquids with solids to improve clearance through the hypopharynx and esophagus,
- changing positions for bottle/nipple feeding and spoon feeding, including special positional consideration for the breast fed infant. (e.g. having the infant who is typically breast fed in a side-lying position for the VFSS),
- employing rehabilitative and compensatory maneuvers on bolus transport during swallowing,
- modifying bolus delivery method (e.g., changes in nipples and other utensils),
- modifying bolus delivery rate (e.g., changing nipple flow rate, external pacing altering fluid viscosity); modifications in flow rate and positioning are considered prior to viscosity changes in order to preserve typical feeding development (Gosa, Schooling, & Coleman, 2001),
- modifying food consistency.
Indications for VFSS
Indications for VFSS include
- the need for observing the oral preparatory, oral transit, pharyngeal and/or esophageal phases of swallowing,
- the diagnosed or suspected presence of abnormalities in anatomy of nasal, oral, pharyngeal or upper esophageal structures that would preclude endoscopic evaluations,
- an aversion to insertion of an endoscope,
- the presence of a respiratory disorder and/or a persistent feeding refusal problem for which a swallowing disorder might be a contributing cause,
- the need to determine treatment or management strategies to minimize the risk of aspiration and increase swallow efficiency (Arvedson & Lefton-Greif, 1998).
- The radiologist and SLP work together to plan and conduct the study.
- Types and consistencies of food and liquid to be used are based on results of the clinical evaluation.
- Test materials typically are presented in a standardized order (e.g., for infants, begin with liquids since they are primarily on formula-based diets). The order of presentation may be modified at the professional's discretion for optimal cooperation and test success.
- The child is secured in a seat that offers good head-neck and torso support.
- The child is fed by a familiar family member or caregiver.
- Every effort is made to maintain the child in a calm-alert state during testing.
- Radiation dosage
- Acceptable radiation exposure levels are set by the radiology department and controlled by the radiologist.
- The SLP and radiologist work together to ensure that the observations are completed within the dosage limits for the child's age; dosage amount is As Low as Reasonably Achievable (ALARA) as recommended by the International Commission on Radiological Protection (ICRP) without impacting the accuracy of the swallowing assessment. Frame rates should also be discussed.
- Adults in the fluoroscopy suite wear protective equipment to minimize their exposure to scattered radiation. However, dosage levels for children are less than those permitted for adults and generally considered acceptable for adult observers.
- Pregnant women might not be permitted in the examining room during the study; if permitted by the facility, a pregnancy-specific lead apron is worn. Be aware of facility guidelines.
- Lateral and anterior-posterior views of mouth, pharynx and upper esophagus are taken as needed for each of the bolus types.
- Ideally, at least one esophageal "follow-through" is viewed, in which the fluoroscopy camera follows the bolus as it moves through the esophagus and is propelled completely into the stomach.
Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with or without Sensory Testing (FEESST)
See the Endoscopy section of the pediatric dysphagia map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
During the FEES procedures, a fiberoptic endoscope is inserted through the nose and into the throat to provide a direct visualization of structures as well as a dynamic view of the oral-pharyngeal transfer and an indirect evidence of the pharyngeal-esophageal transfer during swallows. Saliva swallowing can be evaluated, and the anatomy and physiology of saliva swallow can be viewed in the absence of acceptance of food and/or liquids. The swallow is then assessed with presentation of food and liquid.
The FEESST, a modification of FEES, is a test of the Laryngeal Adductor Response (LAR), a reflexive vocal fold adduction in response to a pressure- and duration-calibrated air puff delivered anterior to the arytenoids along the aryepiglottic folds. It provides an intensity level at which the LAR is elicited.
Indications for FEES Procedures
Indications for FEES procedures include
- the need for visualizing structures as well as observing a dynamic view of the oral-pharyngeal transfer with or without presentation of food and/or liquid,
- previous VFSS findings indicating the need for further instrumental assessment in order to formulate management strategies,
- the child is not a good candidates for VFSS, because he or she
- has never eaten orally
- cannot be positioned adequately for VFSS
- cannot be transferred to the radiology suite,
- the need for assessing the LAR sensitivity and vocal fold dynamics.
- The appropriate endoscope size is chosen and a decision is made about whether the endoscope should be equipped with air puff capability.
- The endoscope is then passed by the SLP or physician, and the child is given an opportunity to calm.
- The nasal, oral, pharyngeal and laryngeal anatomy is examined.
- FEESST is administered if indicated to determine LAR sensitivity and vocal fold dynamics.
- The child is fed a variety of preferred and problem foods under fiberoptic observation.
- Monitoring (e.g., cardiovascular) during FEES procedures may be warranted for children with significant pulmonary disease, cardiac arrhythmia, seizure disorders, or other medical conditions
- It is advisable to have suction equipment available and trained personnel on hand during testing.
- Consider the possible risks for localized nasal trauma and bleeding.
- Special care is taken with use of topical anesthesia in medically fragile infants and children. Clinicians are encouraged to consult with the child's medical team prior to using anesthesia with these children.
See the Treatment section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The primary goals of feeding and swallowing intervention for children are to
- safely support adequate nutrition and hydration,
- determine the optimum feeding methods/technique to maximize swallowing safety and feeding efficiency,
- collaborate with family to incorporate dietary preferences,
- attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eat and chew meals with peers in the preschool),
- minimize the risk of pulmonary complications,
- maximize the quality of life,
- prevent future feeding issues with positive feeding/oral experiences as able given medical situation,
- help the child eat and drink efficiently and safely to whatever degree is possible.
The overall health of the child is the primary concern in treatment of pediatric dysphagia. Families may have strong beliefs regarding the medicinal value of some foods or liquids. Such beliefs and holistic healing practices may be contraindicative to recommendations made. The intervention processes and techniques must never jeopardize the child's safety, nutrition and pulmonary status.
Medical, surgical, and nutritional considerations are all important components of a treatment plan. For example, if gastroesophageal reflux is a factor, adequate management is fundamental to other aspects of treatment. Underlying disease state(s), chronological and developmental age of the child, social/environmental arena, and psychological/behavioral factors all affect treatment recommendations.
Treatment needs to address oral-motor function, positioning, seating, muscle tone, and sensory-motor issues. Functional intervention approaches focus as directly as possible on training the specific swallowing or feeding task to minimize inappropriate and maladaptive behaviors. Questions to ask in order to develop an appropriate treatment plan include
Can the child eat and drink safely? Consider the child's pulmonary status, nutritional status, overall medical condition, mobility, swallowing abilities and cognition, in addition to the child's swallowing function and how these factors impact feeding efficiency/safety.
Can the child receive adequate nutrition and hydration by mouth alone, given length of time to eat, efficiency, and fatigue factors? If the child cannot meet nutritional needs by mouth, what recommendations need to be made concerning supplemental non-oral intake and/or the inclusion in the child's diet of orally fed supplements? Consider tube feeding schedule, type of pump, rate, calories, etc.
How can the child's functional abilities be maximized? This might involve decisions about whether the individual can safely eat an oral diet that meets nutritional needs, whether that diet needs to be modified in any way, or whether the individual needs compensatory strategies in order to eat the diet. Does the child have the potential to improve swallowing function with direct treatment?
How can the child's quality of life be preserved and/or enhanced? Consider how long it takes to eat a meal, fear of eating, pleasure obtained from eating, social interactions while eating, and so on (Huckabee & Pelletier, 1999). The family's customs and traditions around mealtimes and food should be respected and explored.
Are there behavioral and sensory-motor issues that interfere with feeding and swallowing? Do these behaviors result in family/caregiver frustration or increased conflict during meals? Is a sensory-motor based intervention for behavioral issues indicated?
Clinicians must realize that there are inherent differences between adult and infants/young children swallowing and feeding, and that these differences have an impact on treatment. For example
- There are distinct differences in the relationships of anatomic structures and physiology of the swallowing mechanism among infants, young children, and adults that effect swallowing and feeding function.
- Infants and children grow and develop even when they have a chronic condition, which means that swallowing and feeding function may change over time.
Treatment selection will depend on the child's age, cognitive and physical abilities, and specific swallowing and feeding problems. When considering treatment options, keep in mind that infants and young children with swallowing disorders, as well as some older children with concomitant intellectual disabilities, often need intervention techniques that do not require them to follow simple verbal or nonverbal instructions. Intervention might consist of changes in the environment or indirect treatment approaches for improving safety and efficiency of feeding.
Aspects for change that can affect oral and pharyngeal transit include posture and position, timing and pacing, bolus characteristics (e.g., texture, temperature, taste), and sensory input. Depending on the assessment results, intervention may focus on supporting hydration and nutrition, minimizing risk for pulmonary complications, facilitating oral/pharyngeal/respiratory coordination, and modification of behavioral and sensory issues.
- "The speech-language pathologist should lead both the assessment and planning of dysphagia therapy" (New Zealand Guideline Group, 2006, p.83).
- The speech-language pathologist should consider collaborative or multidisciplinary teaming as an efficient and coordinated approach to the management of feeding or swallowing difficulties (NHS, 2008; Taylor-Goh, 2005).
See the Treatment: General Findings section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Behavioral interventions are based on principles of behavioral modification and typically focus on increasing appropriate actions or behaviors, including increasing compliance, and reducing maladaptive behaviors. Behavioral interventions include such techniques as shaping, prompting, modeling, stimulus fading, antecedent manipulation, alternate behavior, and differential reinforcement, as well as implementation of basic mealtime principles (e.g., scheduled mealtimes in a neutral atmosphere with no food rewards).
- "The speech-language pathologist will identify which behavioral strategies facilitate the eating and drinking process and communicate these to the relevant caregivers. These may include: situational strategies prior to, during and after mealtime; verbal cues; written cues and/or symbols; physical cues; visual cues" (Taylor-Goh, 2005, p.68).
- Modifications to the environment to reduce distractions and noise level, increase lighting, and facilitate social interaction may optimize the mealtime experience (Taylor-Goh, 2005).
See the Behavioral Interventions section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Positioning techniques involve adjusting the child's posture or position during feeding. These techniques serve to protect the airway and offer safe transit of food and liquid. No single posture will provide improvement to all patients/clients, and in fact, postural changes differ between infants and older children. However, the general goal is to establish central alignment and stability for safe feeding. Techniques include
- chin down-tucking chin down toward neck,
- chin up-slighty tilting head up,
- head rotation-turning head to the weak side to protect the airway,
- upright positioning-45 degree angle at hips and knees, with supports as needed,
- head stabilization-supported so as to present in chin neutral position,
- cheek and jaw assist,
- reclining position-e.g., using Boppy pillow or reclined infant seat with trunk and head support,
- side-lying positioning for infants.
- Evidence indicates that for children with cerebral palsy, "positioning has a positive effect on feeding safety and efficiency by decreasing the risk of aspiration and diminishing mealtime" (Snider, Majnemer, & Darsaklis, 2011, p.71).
- Body positioning should be identified for optimal swallow function. Position of trunk, limbs, shoulder and head support should be considered. Positioning interventions may involve specialized seating equipment (Taylor-Goh, 2005).
See the Positioning Techniques section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Diet modifications consist of altering the viscosity, texture, temperature, or taste of a food or liquid to facilitate safety and ease of swallowing. Typical modifications may include thickening thin liquids (e.g., breast milk, formula) or softening, chopping, or pureeing solid foods. Taste or temperature of a food may be altered to provide additional sensory input for swallowing. Dietary modifications incorporate preferences, to the extent feasible. Consult with families regarding safety of medical treatments, such as swallowing vitamin supplements or drinking thin liquids, which may be contraindicated by disorder. Diet modifications should consider the nutritional needs of the child, and a dietitian should be consulted when appropriate.
The USFDA has cautioned consumers about commercial, gum-based thickeners for use with infants from birth to one year of age, especially when thickening breast milk. SLPs should be aware of these cautions and consult as appropriate in their facility to develop guidelines for using thickened liquids with infants. (See U.S. Food and Drug Administration (FDA) consumer cautions (2011, 2013).
- "The Speech & Language Therapist will assess the effect of modified presentation of the bolus upon swallow function, in order to identify the method that facilitates the safest and most efficient swallowing" (Taylor-Goh, 2005, p. 67).
- Adjustments to the placement, size, consistency and temperature, taste and texture of the bolus, as well as changes in pacing, utensil, and frequency and timing may be necessary (Taylor-Goh, 2005).
See the Diet Modification section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Adaptive feeding equipment or change in feeding utensils may be used to control bolus size or achieve the optimal flow rate of liquids. For infants, the selection of the appropriate type of bottle or nipple may promote the coordination of sucking, swallowing, and respiration during feeding; for older children, spoons of various shapes and sizes can help regulate bolus size and facilitate more effective feeding, particularly in children with oral phase deficits (Arvedson, 1998). Varied nipples and containers should be tried to find optimal rate of flow. Infants may improve efficiency of nipple feedings with a self-pacing system and vacuum-free bottles; individual differences must always be considered, as exceptions to general principles may be needed.
- The use of cup feeding to supplement breastfeeding does not offer any benefit in maintaining breastfeeding after hospital discharge and may result in a longer hospital stay (Collins, Makrides, Gillis, & McPhee, 2008; Flint, New, & Davies, 2007).
- For children with cerebral palsy, "feeding devices many not be useful in enhancing feeding efficiency. However…adapted equipment may serve to enhance certain oral-motor behaviors and increase independence" (Snider, Majnemer, & Darsaklis, 2011, p. 73).
- For up to 6-weeks post-surgery for repaired cleft lip in infants, breastfeeding may yield greater weight gain when compared to spoon-feeding (Bessell, et al., 2011).
See the Equipment/Utensils section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Biofeedback includes instrumental assessments that provide visual feedback to aid in the treatment of feeding or swallowing disorders. Children with sufficient cognitive skills can be taught to interpret the visual information provided by these assessments (e.g., surface electromyography, ultrasound, nasendoscopy) and make physiological changes during the swallowing process.
- Some instrumental procedures (e.g., surface [electromyography (EMG)], ultrasound, videoendoscopy) can be used to provide biofeedback to patients undergoing swallowing therapy (Taylor-Goh, 2005).
See the Biofeedback section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Maneuvers are specific strategies used to change the timing or strength of particular movements of swallowing (Logemann, 2000). Some maneuvers require following multi-step directions and may not be appropriate for young children and/or older children with cognitive impairments. Examples of maneuvers include
- Effortful swallow-increases posterior tongue base movement to facilitate bolus clearance.
- Masako or tongue hold-tongue is held forward between the teeth while swallowing; this is performed without food or liquid in the mouth to prevent coughing or choking.
- Mendelsohn maneuver-designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway.
- Supraglottic swallow-vocal folds are usually closed by voluntarily holding breath before and during swallow in order to protect the airway.
- Super-supraglottic swallow-effortful breath hold tilts the arytenoid forward which closes the airway entrance before and during the swallow.
- The effectiveness of compensatory strategies such as postural changes and maneuvers should be evaluated prior to implementation, and optimal body positioning should be identified (Taylor-Goh, 2005).
See the Maneuvers section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Oral-motor treatments include stimulation to or actions of the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles that are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions. Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive (e.g., tapping, stroking, and vibration) to the more active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises).
- The speech-language pathologist "will provide therapy to maintain and/or improve oral-motor function, including range of motion, chewing and swallowing exercises, and thermal and tactile stimulation. This may be contraindicated for cardiac and certain degenerating conditions" (Taylor-Goh, 2005, p. 69).
- The speech-language pathologist will consider and potentially modify "oral-motor skills to include organization of non-nutritive suck in infants" (Taylor-Goh, 2005, p.67).
See the Oral Motor Treatments section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Pacing and Cue-based Feeding Strategies
Pacing involves controlling the rate of presentation of food or liquid and the time period between bites or swallows to moderate the rate of intake. Feeding strategies include behaviors that facilitate safe swallowing, such as alternating bites of food with sips of liquid or swallowing 2-3 times per bite or sip. For example, pacing and feeding strategies that slow the feeding rate allow sufficient time between swallows to ensure that a bolus has cleared before continuing, minimizing the risk of aspiration and facilitating safe feeding and swallowing.
Most NICUs have introduced “cue-based” feeding in place of “volume-driven” feeding. Cue-based feeding relies on cues from the infant such as lack of active sucking, passivity, pushing nipple away, or a weak suck that may indicate the infant is disengaged. Preterm infants communicate through their behaviors which should guide the caregiver in understanding thresholds of stress. When the quality of feeding takes priority over the quantity ingested, feeding skill develops pleasurably and at the infant’s own pace. As a result, intake is improved (Shaker 2013). The SLP in the NICU teaches parents and other caregivers to recognize these hallmarks to provide positive oral experiences as appropriate and recognize and interpret the infant's cues during NNS.
Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize the intraoral cavity by providing compensation or physical support for children with congenital abnormalities (e.g., cleft palate) or damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved. Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved functional feeding skills.
- In children with cerebral palsy "the use of oral appliance is more effective than no or alternative interventions enhancing oral sensorimotor skills" (Snider, Majnemer, Darsaklis, 2011, p. 73).
- In children with unilateral cleft lip and palate, pre-surgical infant orthopedics "with passive and active appliances had no positive effects on feeding or consequent nutritional status" (Uzel & Alparslan, 2011, p. 592).
See the Prosthetic Treatments section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Sensory stimulation techniques vary and may include thermal-tactile stimulation (e.g., using iced lemon glycerin swab) or tactile stimulation (e.g., using a NUK brush) applied to the tongue or around the mouth. Children who demonstrate aversive responses to stimulation may need approaches that reduce the level of sensory input initially, with incremental increases as the child indicates tolerance. The opportunity for sensory stimulation may be needed for those with reduced responses, over-active responses or limited opportunities for sensory experiences.
- Children receiving non-oral feeding may receive an oral sensorimotor program to normalize sensation and promote skill development (NHS, 2008; Taylor-Goh, 2005).
See the Sensory Stimulation section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Tube feeding includes alternative avenues of intake (e.g., nasogastric tube [NG], transpyloric tube [placed in the duodenum or jejunum], or gastrostomy [G-tube placed into the stomach or GJ-tube placed into the jejunum]). These approaches may be considered if the child's swallowing safety and efficiency cannot reach a level of adequate function or does not support nutrition and hydration adequately. In these instances, the swallowing and feeding team will consider whether the child will need the alternative source for a short or extended period of time to determine the optimum tube feeding selection to best meet the child's needs. Alternative feeding does not preclude the need for feeding-related treatment.
- In children with neuromuscular weakness "gastrostomy feeding can improve and maintain adequate nutrition" (Hull et al., 2012).
- "Contextual factors unique to child and family and process factors related to information exchange and support are important in understanding and improving the decision-making process with regard to tube feeding" (Mahant, Jovcevska, & Cohen, 2011).
- "Tube feeding is associated more with increased stressful or traumatic experience, a decrease in normalcy, and negative impacts upon the motherhood constellation themes than with improvements in the mother-child relationship, freedom from feeding battles, or improvements in the child's medical situation" (Wilken, 2012).
See the Tube Feeding section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Clinicians working in the NICU need to be aware of the many variables that influence both infant feeding and the clinician's ability to develop appropriate treatment plans, including the multi-disciplinary nature of the practice area. The NICU is considered an advanced practice area, and inexperienced SLPs should be aware of the risks of working in this setting.
In all cases, the SLP must have an accurate understanding of the physiologic mechanism driving the symptomatic feeding "problems" seen in this population. Understanding the physiologic concern gives the SLP the knowledge to choose appropriate treatment interventions and provide a solid rationale for their use in the NICU.
The SLP is in the unique position of being able to assess the infant's current feeding potential and predict their future feeding performance based on where the infant is along the maturation continuum and the infant's physiologic and state stability as communicated through their response to various oral experiences. SLPs counsel families regarding appropriate feeding techniques to maximize feeding safety, with sensitivity to values and beliefs for breast vs. bottle feeding.
Treatment for infants must take into consideration the importance of communication and readiness.
In all interactions with preterm and medically fragile infants, SLPs are encouraged to hold paramount their role as communication specialists. In the role of communication specialists, SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infant's communication signals. In order to do this, SLPs treating preterm and medically fragile infants are well versed in typical infant behavior and development so that they may recognize and interpret changes in behavior that provide cues as to their well-being or stress while at rest or during activities such as interaction and feeding. Behavior in the infant can be expressed by changes in
- Autonomic system-pattern of respiration (pauses, tachypnea), color changes (red, pale, dusky, mottled), and visceral signs (e.g., spit up, gag, burp).
- Movement-postural alignment (hyperflexed, extended), muscle tone (flaccid, hypertonicity), movement patterns in extremities, trunk, head and face, and level of motor activity.
- State-the range of available states of consciousness (i.e., deep sleep, quiet alert, and crying), the smoothness of transition between them, and the clarity of their expression.
- Attention-the infant's ability to orient and focus on environmental stimuli, such as face, sounds, or objects.
Readiness for oral feeding in the preterm or acutely ill full term infant is associated with the infant's ability to come into and maintain awake states and to coordinate breathing with sucking and swallowing (McCain, 1997), as well as with the presence or absence of apnea. Apnea is strongly correlated with longer transition time to full oral feeding (Mandich, Ritchie, & Mullett, 1996).
Supportive interventions to facilitate early feeding and/or to promote readiness for feeding include kangaroo mother care (KMC), nonnutritive sucking (NNS), and feeding protocols.
Kangaroo Mother Care (KMC)
KMC, skin-to-skin contact between a mother and her newborn infant, can be an important factor in helping the infant achieve readiness for oral feeding, particularly breast-feeding, and earlier discharge from the hospital. Other benefits of KMC include temperature regulation, promotion of breast feeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability.
See the Sensory Stimulation section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Non-Nutritive Sucking (NNS) Facilitation
Non-nutritive sucking involves allowing an infant to suck without taking milk, either at the breast (after milk has been expressed) or with the use of a dummy (e.g., pacifier) and is used as a treatment option to eventually encourage oral intake. The SLP providing and facilitating oral experiences with NNS must take great care to ensure that the experiences are positive and do not elicit stress or other negative consequences. The SLP also teaches parents and other caregivers to provide positive oral experiences as appropriate and recognize and interpret the infant's cues during NNS.
See the Oral Motor Treatments section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Feeding protocols (e.g., ad-lib, demand, semi-demand) provide clear criterion for the initiation and systematic advancement of oral feeding. Protocols may consider a variety of factors including infant readiness, demand for feeding, infant cues, infant stress, or infant development and state.
- Evidence indicates that "feeding protocols may improve the transition from gavage to oral feeding in the healthy premature infant when compared to traditional feeding methods" (Medhurst, 2005).
See the Feeding Protocols section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/ caregiver perspective.
Management of students with dysphagia in the schools addresses the impact of the disorder on the student's educational performance. Based on the results of a comprehensive, interdisciplinary dysphagia evaluation, a detailed swallowing and feeding plan is developed and documented on the student's IEP, IHP, or 504 plan, if the student is determined to be eligible for services.
Individual Education Plan (IEP) /504 Plan
An IEP meeting is held, during which the interdisciplinary dysphagia team meets to discuss the student's swallowing and feeding issues. Evaluation results including team recommendations are reviewed and discussed. Goals/objectives and accommodations are written and agreed upon by the team. If the student does not have an existing swallowing and feeding plan, a plan will be created during this meeting.
Swallowing and Feeding Plan
The swallowing and feeding plan includes training, service delivery, and daily management. The plan ensures that the student will receive adequate nutrition efficiently and in the safest manner possible. A plan typically includes recommendations/guidelines on positioning, equipment, diet/food preparation, feeding plan techniques and precautions. Personnel will require adequate education and training related to the swallowing and feeding plan by the SLP. It is important to verify and document the educational training within the plan.
Individual Health Plan (IHP)
The IHP, also called the emergency plan, is drawn up at the IEP conference by the school nurse. The IHP provides information on specific precautions related to the student's dysphagia and is kept in an easily accessible place in the classroom. Classroom personnel are trained on the IHP. The swallowing and feeding plan may be attached to the IHP for additional information on the student's swallowing and feeding safety precautions.
Intervention and Monitoring
SLPs may provide direct intervention to students with swallowing and feeding concerns for oral sensorimotor skills, sensory stimulation, and so on. Other students may need only monitoring of swallowing and feeding status. Services should be recorded in treatment logs (Home, Beauxis, & Fish-Finnigan, 2003).
Consumer Information: Feeding and Swallowing Disorders (Dysphagia) in Children
Dysphagia Management for School Children: Dealing with Ethical Dilemmas
Pediatric Assessment Templates
Radiation Safety for the SLP
Sample Forms: Swallowing and Feeding Services in Schools [PDF]
Swallowing and Feeding Services in Schools (On Demand Webinar)
Work Setting Resources: NICU
Arvedson, J. C., & Lefton-Greif, M. A. (2007). Ethical and legal challenges in feeding and swallowing intervention for infants and children. Seminars in speech and language, 3, pp. 232-238.
SIG 13's Perspectives
Ethical Issues in Swallowing
Organizations and Related Content
La Leche League International
National Foundation of Swallowing Disorders
Pediatric Feeding Association
American Speech-Language-Hearing Association. (2004).Medicaid guidance for speech-language pathology services: Addressing the "under the direction of" rule [Position statement]. Available from www.asha.org/policy.
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American Speech-Language-Hearing Association. (2010). Code of ethics [Ethics]. Available from www.asha.org/policy.
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Davis-McFarland, E. (2008). Family and cultural issues in a school swallowing and feeding program. Language, Speech, and Hearing Services in Schools, 39, 199-213.
Flint, A., New, K., & Davies, M. W. (2007). Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews, 2.
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Lefton-Greif, M. (2008). Pediatric dysphagia. Physical Medicine and Rehabilitation Clinics of North America, 19, 837-851.
Linscheid, T. R. (2006). Behavioral treatments for pediatric feeding disorders. Behavior Modification, 30(1), 6-23.
Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin, TX: Pro-Ed.
Logemann., J.A. (2000). Therapy for children with swallowing disorders in the educational setting.Language, Speech, and Hearing Services in Schools, 31, 50-55.
MAMI (Management of Acute Malnutrition in Infants. Funded by UNICEF-led IASC Nutrition Cluster. (n.d.). Project reports available from http://www.ennonline.net/research/mami
Mandich, M. B., Ritchie, S. K., & Mullett, M. (1996). Transition times to oral feeding in premature infants with and without apnea.Journal of Obstetric, Gynecologic, & Neonatal Nursing, 25, 771-776.
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Pinelli, J., & Symington, A. (2005). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.Cochrane Database Syst Rev, 4.
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Rudolph, C. D., & Link, D. T. (2002). Feeding disorders in infants and children. Pediatric Gastroenterology and Nutrition, 49(1), 97-112 .
Shaker, C. S. (2013). Cue-based feeding in the NICU: Using the infant's communication as a guide. Neonatal Network: The Journal of Neonatal Nursing, 32(6), 404-408.
Shaker, C. S. (2013, February 01). Reading the Feeding. The ASHA Leader
Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: a quantitative synthesis of treatment outcomes.Clinical Child & Family Psychology Review, 13(4), 348-365.
Snider, L., Majnemer, A., & Darsaklis (2011). Feeding interventions for children with cerebral palsy: a review of the evidence.Physical & Occupational Therapy in Pediatrics, 31(1), 58-77.
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