ASHA Logo

Pediatric Dysphagia

Overview

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.

Signs and Symptoms

Signs and symptoms of swallowing and feeding disorders vary based on the age of child, but may include

Causes

Common causes of pediatric dysphagia include

Results or long-term effects for a child diagnosed with pediatric dysphagia include

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

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.

Assessment

See the Assessment section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Overview

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

The pediatric swallowing/feeding assessment may result in

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).

Special Considerations

Practitioners take into consideration the following factors when assessing swallowing and feeding disorders in the pediatric population.

Precaution

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).

Team Approach

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

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.

Clinical Evaluation

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

Expert Opinion

  • 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

Precaution

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 Highlights

  • 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

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

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.

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, 2013a).

Breast-Feeding

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

Bottle-Feeding

The assessment of bottle-feeding includes evaluation of

Clinical Evaluation Considerations for Toddlers and Preschool/School-Age Children

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

Considerations for Evaluation in the School Setting

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.

Educational Relevance

Addressing swallowing and feeding disorders is educationally relevant and part of the school system's responsibility for the following reasons.

Team Approach

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.

Evaluation Process

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.

Referral

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.

Screening

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.

Evaluation

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

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

Instrumental Evaluation

The two commonly used instrumental evaluations of swallowing for the pediatric population are

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

Expert Opinion

  • 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.

Test Environment

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

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.

Preparing Families

Procedural Considerations for Instrumental Evaluations

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

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

Indications for VFSS

Indications for VFSS include

Test protocol
Radiology Procedure

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

Test Protocol
Precautions

Treatment

See the Treatment section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Overview

The primary goals of feeding and swallowing intervention for children are to

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:

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

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.

Expert Opinion

  • "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.

Treatment Options

Behavioral Interventions

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).

Evidence Highlight

Expert Opinion

  • "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.

Postural/Positioning Techniques

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

Evidence Highlight

  • 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).

Expert Opinion

  • 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 Modification

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.

Precaution

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).

Evidence Highlight

Expert Opinion

  • "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.

Equipment/Utensils

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.

Evidence Highlights

Evidence Indicates

  • 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

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.

Expert Opinion

  • 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

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

Expert Opinion

  • 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

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).

Expert Opinion

  • 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

The use of pacing for infants or children involves controlling or titrating the rate of presentation of food or liquid and the time between bites or swallows to moderate the rate of intake. Feeding strategies for children may include alternating bites of food with sips of liquid or swallowing 2-3 times per bite or sip. For infants, pacing can be accomplished through limiting the number of consecutive sucks, which limits the bolus size, for example. Strategies that slow the feeding rate or limit the bolus size may allow for more time between swallows to clear the bolus, or support more timely breaths. This may in turn reduce the risk of aspiration and optimize safety during feeding and swallowing.

Most NICUs have begun to move away from volume-driven to cue-based feeding. Rather than setting a goal to empty the bottle, the feeding experience is viewed as a partnership with the infant. Cue-based feeding relies on cues from the infant such as lack of active sucking, passivity, pushing nipple away, or a weak suck that typically indicate the infant is disengaging from feeding. The infant is communicating the need to stop. Preterm infants communicate through their behaviors which should guide the caregiver in understanding thresholds of stress and supporting safety during feeding. The infant's cues provide information regarding physiologic stability, which underlies the coordination of breathing and swallowing. These cues guide the caregiver to intervene to support safety. 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, 2013b). The SLP plays a critical role in the NICU supporting parents and other caregivers to understand and contingently respond to the infant's communication during feeding.

Prosthetics/Appliances

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.

Evidence Highlights

Evidence indicates

  • 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).

Expert Opinion

See the Prosthetic Treatments section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Sensory Stimulation

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.

Expert Opinion

  • 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

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.

Evidence Highlights

  • 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).

Expert Opinion

See the Tube Feeding section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Treatment Considerations in the NICU and Infant Care Units

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.

Communication

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

Readiness

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.

Evidence Highlight

See the Oral Motor Treatments section of the pediatric dysphagia evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Feeding Protocols

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 Highlight

  • 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.

Treatment Considerations in School Setting

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).

Resources

ASHA Resources

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

Dysphagia Teams

Ethical Issues in Swallowing

Organizations and Related Content

feeding matters

La Leche League International

National Foundation of Swallowing Disorders

Pediatric Feeding Association

speechBITE

References

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.

American Speech-Language-Hearing Association. (2007). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2010). Code of ethics [Ethics]. Available from www.asha.org/policy.

Arvedson, J.C. (1998). Management of pediatric dysphagia. Dysphagia in Children, Adults, and Geriatrics, 31, 453-476.

Arvedson, J. C. (2008). Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Developmental Disabilities Research Reviews, 14, 118-127.

Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010). Evidence-based systematic review: Effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19, 321-340.

Arvedson, J. C., & Lefton-Greif, M. A. (1998). Pediatric videofluoroscopic swallow studies: A professional manual with caregiver guidelines. San Antonio, TX: Communication Skill Builders.

Beckett, C. M., Bredenkamp, D., Castle, J., Groothues, C., O'Connor T. G., Rutter, M., et al (2002). Behavior patterns associated with institutional deprivation: A study of children adopted from Romania. Journal of Developmental and Behavioral Pediatrics, 23(5), 297-303.

Bernard-Bonnin, A. (2006). Feeding problems in infants and toddlers. Canadian Family Physician, 52, 1247-1251.

Bessell, A., Hooper, L., Shaw, W.C., Reilly, S., Reid, J., & Glenny, A.M. (2011). Feeding Interventions for Growth and Development in Infants with Cleft Lip, Cleft Palate or Cleft Lip and Palate. Cochrane Database Syst Rev, 2.

Brackett, K., Arvedson, J. C., & Manno, C. J. (2006). Pediatric feeding and swallowing disorders: General assessment and intervention.Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 15(3), 10-14.

Burklow, K. A., Phelps, A. N., Schultz, J. R., McConnell, K., & Rudolph, K. (1998). Classifying complex pediatric feeding disorders.Journal of Pediatric Gastroenterology & Nutrition, 27(2), 143-147.

Collins, C. T., Makrides, M., Gillis, J., & McPhee, A. J. (2008). Avoidance of bottles during the establishment of breast feeds in preterm infants.Cochrane Database Syst Rev, 4.

Da Costa, S. P., van den Engel-hoek, L., & Bos, A. F. (2008). Sucking and swallowing in infants and diagnostic tools. Journal of Perinatology,28(4), 247-257.

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.

Gisel, E. G., Applegate-Ferrante, T., Benson, J., & Bosma, J. F. (1996). Positioning for infants and children for videofluoroscopic swallowing function studies. Infants and Young Children, 8, 58-64.

Gosa, M., Schooling, T., & Coleman, J. (2011). Thickened liquids as a treatment for children with dysphagia and associated adverse effects: a systematic review. ICAN: Infant, Child, & Adolescent Nutrition, 3(6), 344-350.

Huckabee, M. L., & Pelletier, C. A. (1999). Management of adult neurogenic dysphagia. San Diego, CA: Singular.

Homer, E., Beauxis, N., & Fish-Finnigan, A. (2003). Treatment of dysphagia in the schools: Three case studies.Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 12(1), 20-26.

Hull, J., Aniapravan, R., Chan, E., Chatwin, M., Forton, J., Gallagher, J., et al. (2012). British thoracic society guideline for respiratory management of children with neuromuscular weakness. Thorax, 67, Supplement 1, i1-40.

Individuals with Disabilities Education Improvement Act (IDEA). (2004). Available from http://idea.ed.gov/

Johnson, D. E., & Dole, K. (1999). International adoptions: Implications for early intervention. Infants and Young Children, 11, 34-45.

Leder, S. B., Baker, K. E., & Goodman, T. R. (2010). Dysphagia testing and aspiration status in medically stable infants requiring mechanical ventilation via tracheotomy*. Pediatric Critical Care Medicine, 11(4), 484-487.

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.

Mahant, S., Jovcevska, V., & Cohen, E. (2011). Decision-making around gastrostomy-feeding in children with neurologic disabilities. Pediatrics , 127(6), 1471-1481.

Manikam, R., & Perman, J. A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, 30(1), 34-46.

McCain, G. C. (1997). Behavioral state activity during nipple feedings for preterm infants. Neonatal Network, 16, 43-47.

Medhurst, A. (2005). Feeding protocols to improve the transition from gavage feeding to oral feeding in healthy premature infants: a systematic review.Evidence in Health Care Reports, 3(1), 1-25.)

National Health Service (NHS). (2008). Best practice statement: caring for the child/young person with a tracheostomy. Edinburgh (Scotland): NHS Quality Improvement Scotland.

New York State Department of Health, Early Intervention Program. (2006a). Clinical practice guideline: Report of the recommendations. Down syndrome, assessment and intervention for young children (age 0-3 years). Albany, NY: Author.

New York State Department of Health, Early Intervention Program. (2006b).Clinical practice guideline: Report of the recommendations. Motor disorders, assessment and intervention for young children (age 0-3 years). Albany, NY: Author.

New Zealand Guideline Group. (2006). Traumatic brain injury: Diagnosis, acute management, and rehabilitation. Wellington, New Zealand: Author.

Pinelli, J., & Symington, A. (2005). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants.Cochrane Database Syst Rev, 4.

U.S. Department of Labor. (n.d.). Rehabilitation Act of 1973, Section 504. Retrieved from www.dol.gov/oasam/regs/statutes/sec504.htm.

Rudolph, C. D., & Link, D. T. (2002). Feeding disorders in infants and children. Pediatric Gastroenterology and Nutrition, 49(1), 97-112 .

Shaker, C. S. (2013a, February 01). Reading the Feeding. The ASHA Leader

Shaker, C. S. (2013b). Cue-based feeding in the NICU: Using the infant's communication as a guide. Neonatal Network, 32(6), 404-408.

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.

Taylor-Goh, S., ed. (2005). Royal College of Speech and Language Therapists clinical guidelines: 5.8 Disorders of feeding, eating, drinking & swallowing (dysphagia). Bicester, UK: Speechmark Publishing Ltd.

U.S. Food and Drug Administration. (2011). News & events. Retrieved from http://www.fda.gov/NewsEvents/newsroom/PressAnnouncements/ucm256253.htm.

U.S. Food and Drug Administration. (2013). FDA expands caution about simply thick. Retrieved from www.fda.gov/ForConsumers/ConsumerUpdates/ucm256250.htm.

Uzel, A., & Alparslan, Z. N. (2011). Long-Term effects of presurgical infant orthopedics in patients with cleft lip and palate: a systematic review. Cleft Palate-Craniofacial Journal, 48(5), 587-95.

Wilken, M. (2012). The impact of child tube feeding on maternal emotional state and identity: a qualitative meta-analysis. Journal of Pediatric Nursing, 27(3), 248-55.

Additional Resources

Miller, C.K. & Willging, J. P. (2012, April 24). Making every moment count. The ASHA Leader.

Swigert, N. B. (1998). The source for pediatric dysphagia. LinguiSystems.