Assessment section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), comprehensive assessment is conducted to identify and describe
- impairments in body structure and function, including the swallowing phases that are affected;
- co-morbid deficits or conditions, such as developmental disabilities or syndromes;
- limitations in activity and participation, including the impact on overall health (including nutrition and hydration) and the child’s ability to participate in routine activities (e.g., family meals, meals at daycare and school, birthday celebrations with friends);
- contextual (environmental and personal) factors that serve as barriers to or facilitators to successful nutritional intake (e.g., child’s food preferences; family support in implementing strategies for safe eating and drinking); and
- the impact of feeding and swallowing impairments on quality of life of the child and family.
Person-Centered focus on Function: Pediatric Feeding and Swallowing for examples of assessment data consistent with ICF.
When assessing feeding and swallowing disorders in the pediatric population, clinicians consider the following factors:
- Congenital abnormalities and/or chronic conditions can affect feeding and swallowing function.
- Feeding skills of premature infants will be consistent with neurodevelopmental level rather than chronological age or adjusted age.
- Positioning limitations and abilities (e.g., children who are wheelchair dependent) may affect intake and respiration.
- Infants cannot verbally describe their symptoms, and children with reduced communication skills may not be able to adequately do so—clinicians must rely on a thorough case history; data from monitoring devices (e.g., in the neonatal intensive care unit (NICU); and nonverbal forms of communication (e.g., behavioral cues signaling feeding or swallowing problems).
As infants and children grow and develop, the absolute and relative size and shape of oral and pharyngeal structures change. See figures below.
Anatomical and physiological differences include the following:
- 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 those of an adult (although with less elevation of the larynx).
- As the child matures, the intraoral space increases as the mandible grows down and forward, and the oral cavity elongates in the vertical dimension. The space between the tongue and the palate increases, and the larynx and the hyoid bone lower, elongating and enlarging the pharynx (Logemann, 1998).
Chewing matures as the child develops (see e.g., Gisel, 1988; Le Révérend, Edelson, & Loret, 2014; Wilson, & Green, 2009). Concurrent medical issues may affect this timeline. Foods given during the assessment should be consistent with the child’s current level of chewing skills.
A team approach is necessary for appropriately diagnosing and managing pediatric feeding and swallowing disorders, as the severity and complexity of these disorder vary widely in this population (McComish et al., 2016). The SLP who specializes in feeding and swallowing disorders typically leads the professional care team in the clinical or educational setting.
In addition to the SLP, team members may include
- family and/or caregivers;
- lactation consultant (infants);
- nurse (clinical and/or school);
- occupational therapist;
- physician (e.g., pediatrician, neonatologist, otolaryngologist, gastroenterologist);
- physical therapist;
- social worker;
- classroom teacher; and
- classroom teaching assistant.
Additional medical and rehabilitation specialists may be included, depending on the type of facility, the professional expertise needed, and the specific population being served.
See ASHA’s resources on
interprofessional education/interprofessional practice [IPE/IPP], and
person- and family-centered care.
A clinical evaluation of swallowing and feeding is the first step in determining the presence or absence of a swallowing disorder.
The evaluation addresses the swallowing-based activities of eating, drinking, and secretion management and may include oral hygiene (brushing, flossing, rinsing) and the management of oral medications.
SLPs conduct assessments in a manner that is sensitive and responsive to the family’s cultural background, beliefs, and preferences for treatment. Families are encouraged to bring food and drink common to their household and utensils typically used by the child. Typical feeding practices are used during assessment (e.g., if the child is typically fed sitting on a parent’s lap, then this is observed during the assessment).
The clinical evaluation typically includes the following:
- 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.
- Structural assessment of the face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa.
- Functional assessment of muscles and structures used in swallowing, including assessment of symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement.
- Observation of head–neck control, posture, oral and pharyngeal reflexes, and involuntary movements and responses in the context of the child’s developmental level.
- 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 utensils that the child may reject or that may be challenging.
- 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 and transfer of the bolus.
- Assessment of behavioral factors, including but not limited to (a) acceptance of pacifier, nipple, spoon, and cup and (b) 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.
- Impression of airway adequacy and coordination of respiration and swallowing.
- Assessment of developmentally appropriate secretion management, which might include frequency and adequacy of spontaneous dry swallowing and ability to swallow voluntarily.
- Assessment of modifications in bolus delivery and/or use of rehabilitative/habilitative or compensatory techniques on the swallow.
- Consideration for interventions and referrals (e.g., medical or surgical specialists, nutritionist, psychologist or social worker, occupational therapist, physical therapist).
Clinical Evaluation: Infants
The clinical evaluation for infants birth to 1 year of age—including those in the NICU—includes evaluation of prefeeding skills, assessment of readiness for oral feeding, and evaluation of breast- and bottle-feeding ability.
SLPs should have extensive knowledge of embryology, pre-natal and perinatal development, and medical issues common to the preterm and medically fragile newborn as well as knowledge of typical early infant development. A referral to the appropriate medical professional should be made when anatomical
or physiological abnormalities are found during the clinical evaluation.
The clinical evaluation of infants typically includes
- a case history that includes gestational and birth history and any pertinent medical history;
- a physical examination that includes a developmental assessment and an assessment of respiratory status;
- the determination of oral feeding readiness;
- an assessment of the infant’s 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 sucking/swallowing problems and a determination of abnormal anatomy and/or physiology that might be associated with these findings, including a short fenulum (e.g. Francis, Krishnaswami, & McPheeters, 2015; Webb, Hao, & Hong, 2013);
- the identification of additional disorders that may have an impact on feeding and swallowing;
- a 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/caregiver and infant interactions for feeding and communication; and
- consideration of the infant’s ability to obtain sufficient nutrition/hydration across settings (e.g., hospital, home, daycare setting).
Readiness For Oral Feeding
Protocols for determining readiness for oral feeding and specific criteria for initiating feeding vary across facilities. 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.
Key criteria to determine readiness for oral feeding include
- physiologic stability—for example, stability of digestive, respiratory, heart rate, and oxygenation parameters;
- motoric stability—stability of muscle tone, flexion, and midline movements; and
- behavioral state (ability to alert) and stability of behavioral state.
Decisions regarding the initiation of oral feeding will be based on recommendations from the medical and therapeutic team with input from the parent and caregivers.
Non-Nutritive Sucking (NNS)
Non-nutritive sucking (NNS)—sucking for comfort without fluid release (e.g., with a pacifier, finger, or recently emptied breast)—does not determine readiness to orally feed, but it is helpful for assessment. NNS patterns can typically be evaluated with skilled observation and without the use of instrumental assessment.
A noninstrumental assessment of NNS includes evaluation of the following:
- The infant’s oral structures and functions, including palatal integrity, jaw movement, and tongue movements for cupping and compression. (Note: Lip closure is not required for infant feeding because the tongue typically seals the anterior opening of the oral cavity.)
- The infant’s ability to turn the head and open the mouth (rooting) when stimulated on the lips or cheeks and to accept a pacifier into the mouth.
- The infant’s ability to use both compression (positive pressure of the jaw and tongue on the pacifier) and suction (negative pressure created with tongue cupping and jaw movement).
- The infant’s strength of compression and suction.
- The infant’s ability to maintain physiological state during NNS.
Nutritive Sucking (NS)
Once the NNS component of feeding has been assessed, the clinician can determine the appropriateness of nutritive sucking (NS). Any loss of stability in physiologic, motoric, or behavioral state from baseline should be taken into consideration at the time of the assessment.
NS skills are assessed during breastfeeding and bottle feeding, if both modes are going to be used. SLPs need to be sensitive to family values and beliefs regarding bottle feeding and breastfeeding; they consult with parents and collaborate with nurses, lactation consultants, and other medical professionals to help identify parent preferences.
Assessment of NS includes evaluation of the following:
- Sucking/swallowing/breathing pattern—ability to coordinate suck/swallow/breathe pattern
- Efficiency—volume of intake per minute
- Endurance—ability to remain engaged in the feeding to finish the required volumes, while sustaining appropriate feeding patterns
The infant’s communication behaviors during feeding can be used as cues to guide dynamic assessment. Cues can communicate 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 in a dynamic fashion at any given moment (Shaker, 2013b).
SLPs collaborate with mothers, nurses, and lactation consultants prior to assessing breastfeeding skills. This requires working knowledge of breastfeeding strategies to facilitate safe and efficient swallowing and optimal nutrition.
In addition to the clinical evaluation of infants noted above, breastfeeding assessment typically includes evaluation of the
- infant’s general health;
- infant’s current state, including respiratory rate and heart rate;
- infant’s behavior (e.g., positive rooting, willingness to suckle at breast);
- infant’s position (e.g., well supported, tucked against mother’s body);
- infant’s ability to latch onto the breast;
- efficiency and coordination of infant’s suck/swallow/breathe pattern;
- health of mother’s breast; and
- mother’s behavior (e.g., comfort with breastfeeding, confidence handling infant, awareness of infant’s cues during feeding).
For an example, see
Community management of uncomplicated acute malnutrition in infants
< 6 months of age (C-MAMI; 2015) [PDF]
The assessment of bottle-feeding includes evaluation of the
- infant’s general health;
- infant’s current state, including respiratory rate and heart rate;
- infant’s behavior (willingness to accept nipple);
- efficiency and coordination of infant’s suck/swallow/breathe pattern;
- nipple type and form of nutrition (breast milk or formula);
- infant position;
- quantity of intake;
- length of time infant takes for one feeding; and
- infant’s response to attempted interventions (e.g., different nipple for flow control, external pacing, different bottle to control air intake, different positions such as side feeding).
The assessment of spoon-feeding includes evaluation of optimal spoon type and the infant’s ability to
- move their head toward the spoon with their mouth open;
- turn their head away from the spoon to show that they have had enough;
- close their lips around the spoon;
- clear food from the spoon with their top lip;
- move food from the spoon to the back of their mouth; and
- attempt to spoon-feed independently.
Clinical Evaluation: Toddlers and Preschool-/School-Age Children
In addition to the areas of assessment noted above, the evaluation for toddlers (ages 1–3 years) and pre-school/school-age children (ages 3–21 years) may include
- review of any past diagnostic test results;
- review of current programs and treatments;
- assessment of current skills and limitations at home and in other day settings;
- assessment of willingness to accept liquids and a variety of foods in multiple food groups;
- consideration of ARFID concerns, such as dependence on diet supplements to meet nutrition needs;
- evaluation of independence and need for supervision and assistance; and
- use of intervention probes to identify strategies that might improve function.
Evaluation and Eligibility in the School Setting
SLPs play a significant role in the management of students with swallowing and feeding problems within school settings. They typically develop and lead the team to address the needs of student with feeding and swallowing issues. They provide assessment and treatment to the student as well as education to parents, teachers, and other professionals who work with the student on a daily basis. See Homer (2016) for in-depth information related to feeding and swallowing services in the schools.
Rehabilitation Act of 1973, Section 504. 29 U.S.C. § 701 (1973) 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.
IDEA was enacted to protect the rights of students with disabilities and to ensure that these students receive a free and appropriate public education (FAPE). Although feeding, swallowing and dysphagia are not specifically mentioned in IDEA, the U.S. Department of Education acknowledges that chronic health conditions could make a student eligible for special education and related services if the disorder interferes with the student’s strength, vitality, or alertness and limits the student’s ability to access the educational curriculum.
Addressing swallowing and feeding disorders may be considered 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.
Each school system’s policy manual will include policies and procedures for addressing feeding and swallowing assessment and intervention. The goal of a system-supported process is to develop procedures that are consistent throughout a school district. School-based services typically include a referral process, a screening and evaluation, and the development of a feeding and swallowing intervention plan.
- 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 feeding and swallowing disorders. The referral can be initiated by a family member or guardian, school staff member, or outside professional.
Following the initial referral, the school contacts the family member or 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 and his or her typical diet.
- Screening—Review of the referral is considered part of the screening process. Interviews with the family member or guardian and the student’s teacher serve as part of the screening and evaluation process. Following the screening, a comprehensive, interdisciplinary swallowing and feeding evaluation may be recommended.
- 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.
The school-based feeding and swallowing team consists of parents and professionals within the school as well as professionals outside the school (e.g., physicians, dietitians, and psychologists). Core members of the team 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 staff.
The team (a) works together to inform the evaluation process, (b) contributes to the development and implementation of the individualized education program (IEP) for safe swallow, and (c) oversees the day-to-day implementation of the IEP strategies to keep the student safe from aspiration while in school.
If the team determines that medical assessment is advisable prior to initiating a school-based feeding and swallowing program or during the course of a program, the team can recommend that the family seek medical consultation (e.g., for a videofluoroscopic swallowing study [VFSS] referral and/or other medical assessments).
School-based SLPs do not require a doctor’s order to perform a clinical evaluation of feeding and swallowing or to implement intervention programs. However, there are times when the SLP needs to contact the student's primary care physician or other health care provider—either through the family or directly, with the family’s permission.
Collaboration with outside medical professionals is indicated when medical clearance is needed for an assessment and/or intervention for a student who
- receives part or all of his or her nutrition or hydration via enteral or parenteral tube feeding;
- has a complex medical condition and who experiences a significant change in status;
- has recently been hospitalized with aspiration pneumonia;
- has had a recent choking incident and has required emergency care; and/or
- is suspected of having aspirated food or liquid into the lungs.
See ASHA’s resources on
interprofessional education/interprofessional practice (IPE/IPP) and
collaboration and teaming for guidance on successful collaborative service delivery across settings.
Instrumental evaluation is conducted following a clinical evaluation when further information is needed to determine the nature of the swallowing disorder. Instrumental evaluation can also help to determine if swallow safety can be improved by modifying food textures, liquid consistencies, or positioning.
These studies are a team effort and may include the radiologist, radiology technician, and SLP. The SLP or radiology technician typically prepares and presents the barium items, whereas the radiologist records the swallow for visualization and analysis.
The two most commonly used instrumental evaluations of swallowing for the pediatric population are
During an instrumental assessment of swallowing, the clinician may use information from cardiac, respiratory, and oxygen-saturation monitors to monitor any changes to physiologic or behavioral condition. Other signs to monitor include color changes, nasal flaring, and suck/swallow/breathe 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 feeding and swallowing treatment plans, including recommendations for optimal feeding techniques; and
- 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.
General Considerations for Instrumental Evaluations
Determining the appropriate procedure to use depends on what needs to be visualized and which procedure will be best tolerated by the child. Prior to the instrumental evaluation, clinicians are encouraged to collaborate with the medical team regarding feeding schedules that will maximize feeding readiness during the evaluation.
VFSS may be appropriate for a child who is currently NPO or has never eaten by mouth to determine whether the child has a functional swallow and which types of food he or she can manage. The decision to use VFSS is made with consideration for the child’s responsiveness (e.g., acceptance of oral stimulation or tastes on the lips without signs of distress) and the potential for medical complications. Careful pulmonary monitoring during a modified barium swallow is essential to help determine the child’s endurance over a typical mealtime.
When conducting an instrumental evaluation, consider the following:
- Anxiety and crying may be expected reactions to any instrumental procedure. Anxiety may be reduced by using distraction (e.g., 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.
- Positioning for VFSS depends 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.
- 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.
- 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.
- 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.
Procedures take place in a child-friendly environment with toys, visual distracters, rewards, and a familiar caregiver, if possible and when appropriate. Various items are available in the room to facilitate success and replicate a typical mealtime experience, including preferred foods, familiar food containers, utensil options, and seating options.
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 the study.
If the child has not eaten by mouth (NPO), the clinician allows a period of time for the child to develop the ability to accept and swallow a bolus. For children who have difficulty participating in the procedure, the clinician allows 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 tastes 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 the facility; and
- the child’s familiar and preferred utensils, if appropriate.