Treatment section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The primary goals of feeding and swallowing intervention for children are to
- support safe and adequate nutrition and hydration;
- determine the optimum feeding methods and techniques 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., eating meals with peers in the preschool, meal time with family);
- minimize the risk of pulmonary complications;
- maximize the quality of life; and
- prevent future feeding issues with positive feeding-related experiences to the extent possible, given the child’s medical situation.
Consistent with the World Health Organization’s (2001) International Classification of Functioning, Disability, and Health (ICF) framework, goals are designed to
- facilitate the individual’s activities and participation by promoting safe, efficient feeding;
- capitalize on strengths and address weaknesses related to underlying structures and functions that affect feeding and swallowing;
- modify contextual factors that serve as barriers and enhance those that facilitate successful feeding and swallowing, including development and use of appropriate feeding methods and techniques; and
- promote a meaningful and functional mealtime experience for children and families.
Person-Centered focus on Function: Pediatric Feeding and Swallowing for examples of goals consistent with ICF.
Medical, surgical, and nutritional considerations are important components in treatment planning. Underlying disease state(s), chronological and developmental age of the child, social and environmental factors, and psychological and behavioral factors also affect treatment recommendations.
For children with complex feeding problems, an interdisciplinary team approach is essential for individualized treatment (McComish et al., 2016). See ASHA’s resources on
interprofessional education/interprofessional practice [IPE/IPP], and
collaboration and teaming.
Questions to ask when developing an appropriate treatment plan within the ICF framework 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 affect feeding efficiency and 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, and so forth.
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, and 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?
The health and well-being of the child is the primary concern in treating pediatric feeding and swallowing disorders. Families may have strong beliefs about the medicinal value of some foods or liquids. Such beliefs and holistic healing practices may not be consistent with recommendations made and may be contraindicated.
Treatment selection will depend on the child’s age, cognitive and physical abilities, and specific swallowing and feeding problems. Keep in mind that infants and young children with feeding and 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. In these cases, intervention might consist of changes in the environment or indirect treatment approaches for improving safety and efficiency of feeding.
Postural and Positioning Techniques
Postural and positioning techniques involve adjusting the child’s posture or position during feeding. These techniques serve to protect the airway and offer safer transit of food and liquid. No single posture will provide improvement to all individuals, 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.
- chin down—tucking chin down toward neck;
- chin up—slightly tilting head up;
- head rotation—turning head to the weak side to protect the airway;
- upright positioning—90° angle at hips and knees, feet on floor, with supports as needed;
- head stabilization—supported so as to present in chin-neutral position;
- cheek and jaw assist;
- reclining position—e.g., using pillow support or reclined infant seat with trunk and head support; and
- side-lying positioning for infants.
Diet modifications consist of altering the viscosity, texture, temperature, portion size, or taste of a food or liquid to facilitate safety and ease of swallowing. Typical modifications may include thickening thin liquids, softening, cutting/chopping, or pureeing solid foods. Taste or temperature of a food may be altered to provide additional sensory input for swallowing.
Diet modifications incorporate individual and family preferences, to the extent feasible. Consult with families regarding safety of medical treatments, such as swallowing medication in liquid or pill form, which may be contraindicated by the disorder. Diet modifications should consider the nutritional needs of the child in order to avoid undernutrition and malnutrition.
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 with their facility to develop guidelines for using thickened liquids with infants. See FDA consumer cautions (U. S. Food and Drug Administration, 2017).
Equipment and Utensils
Adaptive equipment and utensils may be used with children who have feeding problems to foster independence with eating and increase swallow safety by controlling bolus size or achieving the optimal flow rate of liquids.
Examples of adaptive equipment include
- modified nipples;
- cut out cups;
- weighted forks and spoons;
- angled forks and spoons;
- sectioned plates;
- non-tip bowls; and
- Dycem® to prevent plates and cups from sliding.
Maneuvers are strategies used to change the timing or strength of movements of swallowing (Logemann, 2000). Some maneuvers require following multistep directions and may not be appropriate for young children and/or older children with cognitive impairments. Examples of maneuvers include the following:
- Effortful swallow—posterior tongue base movement is increased 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—elevation of the larynx is voluntarily prolonged at the peak of the swallow to help the bolus pass more efficiently through the pharynx and 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.
Oral–motor treatments include stimulation to—or actions of—the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles. Oral–motor treatments range from passive (e.g., tapping, stroking, and vibration) to active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Oral–motor treatments 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.
Feeding strategies include pacing and cue-based feeding.
Pacing—moderating the rate of intake by controlling or titrating the rate of presentation of food or liquid and the time between bites or swallows. 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 by limiting the number of consecutive sucks. Strategies that slow the feeding rate may allow for more time between swallows to clear the bolus and may support more timely breaths.
Cue-based feeding—relies on cues from the infant, such as lack of active sucking, passivity, pushing the nipple away, or a weak suck. These cues typically indicate that the infant is disengaging from feeding and communicating the need to stop. They also provide information about the infant’s physiologic stability, which underlies the coordination of breathing and swallowing, and they guide the caregiver to intervene to support safe feeding. 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, 2013a).
Most NICUs have begun to move away from volume-driven feeding to cue-based feeding. Rather than setting a goal to empty the bottle, the feeding experience is viewed as a partnership with the infant. In the NICU, the SLP plays a critical role, supporting parents and other caregivers to understand and respond accordingly to the infant's communication during feeding.
Sensory Stimulation Techniques
Sensory stimulation techniques vary and may include thermal–tactile stimulation (e.g., using an 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 demonstrates tolerance. Sensory stimulation may be needed for children with reduced responses, overactive responses, or limited opportunities for sensory experiences.
Behavioral interventions are based on principles of behavioral modification and focus on increasing appropriate actions or behaviors—including increasing compliance—and reducing maladaptive behaviors related to feeding. Behavioral interventions include such techniques as antecedent manipulation, shaping, prompting, modeling, stimulus fading, and differential reinforcement of alternate behavior, as well as implementation of basic mealtime principles (e.g., scheduled mealtimes in a neutral atmosphere with no food rewards).
Biofeedback includes instrumental methods (e.g., surface electromyography, ultrasound, nasendoscopy) that provide visual feedback during feeding and swallowing. Children with sufficient cognitive skills can be taught to interpret this visual information and make physiological changes during the swallowing process.
Intraoral Prosthetics and Appliances
Intraoral 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.
Referral to dental professionals for assessment and fitting of these devices.
Tube feeding includes alternative avenues of intake such as nasogastric [NG] tube, transpyloric tube (placed in the duodenum or jejunum), or gastrostomy (G-tube placed in the stomach or GJ-tube placed in 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 adequately support nutrition and hydration. In these instances, the swallowing and feeding team will (a) consider the optimum tube-feeding method that best meets the child’s needs and (b) determine whether the child will need tube feeding for a short or extended period of time. Alternative feeding does not preclude the need for feeding-related treatment.
Clinicians working in the NICU need to be aware of the multidisciplinary nature of this practice area, the variables that influence infant feeding, and process for developing appropriate treatment plans in this setting. 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. This understanding gives the SLP the necessary knowledge to choose appropriate treatment interventions and provides a solid rationale for their use in the NICU.
In their role as communication specialists, SLPs monitor the infant for stress cues and teach parents and other caregivers to recognize and interpret the infant's communication signals. SLPs treating preterm and medically fragile infants must be well versed in typical infant behavior and development so that they can recognize and interpret changes in behavior that provide cues that signal well-being or stress during feeding.
Behaviors can include changes in the following:
- 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
Readiness for oral feeding in the preterm or acutely ill full-term infant is associated with (a) the infant’s ability to come into and maintain awake states and to coordinate breathing with sucking and swallowing (McCain, 1997) and (b) 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.
For children who have been NPO for an extended period of time, it is important to consult with the physician to determine when to begin oral feeding. When exploring this option, it is also important to consider any behavioral and/or sensory components that may influence feeding.
Kangaroo Mother Care (KMC)
Kangaroo mother care (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 breastfeeding. Other benefits of KMC include temperature regulation, promotion of breastfeeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability.
Non-Nutritive Sucking (NNS) Facilitation
Non-nutritive sucking (NNS) involves allowing an infant to suck without taking milk, either at the breast (after milk has been expressed) or with the use of a pacifier. It is used as a treatment option to encourage eventual 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 and to recognize and interpret the infant’s cues during NNS.
Feeding protocols include those that consider infant cues (i.e., responsive feeding) and those that are based on a schedule (i.e., scheduled feeding).
The following factors are considered prior to initiating and systematically advancing oral feeding protocols:
- demand for feeding,
- infant cues that signal stress,
- neurodevelopmental level, and
- general health status.
The management of feeding and swallowing disorders in toddlers and older children may require a multidisciplinary approach—especially for children with complex medical conditions.
Similar to treatment for infants in the NICU, treatment for toddlers and older children takes a number of factors into consideration, including the following:
- Readiness for oral feeding—Toddlers and older children who are beginning to eat orally for the first time or after an extended period of non-oral feeding will need time to become comfortable in the presence of food and to explore food without experiencing physiological responses (e.g., for children with significant gastrointestinal problems).
- Communication—In terms of communication, SLPs can help caregivers understand emerging vocabulary related to food (e.g., names of foods and various flavors) as well as how children might be using feeding behaviors (e.g., food refusal responses) to communicate.
- Physical conditions—Treatment for children with conditions and disorders that affect movement (e.g., cerebral palsy or muscular dystrophy) will need to take into consideration length of time to fatigue, optimal feeding methods, and positioning to maximize safe feeding and swallowing.
Management of students with feeding and swallowing disorders in the schools addresses the impact of the disorder on the student’s educational performance and promotes the student’s safe swallow in order to avoid choking and/or aspiration pneumonia. Students with recurrent pneumonia may miss numerous school days, which has a direct impact on their ability to access the educational curriculum. In addition to an IEP or 504 Plan, other documentation may be required, including the following:
- Swallowing and feeding plan—includes training, service delivery, and daily management. A plan typically includes recommendations and guidelines on positioning, equipment, diet and food preparation, feeding techniques, and precautions. Personnel will require adequate education and training by the SLP related to the swallowing and feeding plan. It is important to verify and document the educational training within the plan.
- Individual health plan (IHP)—is drawn up at the IEP conference by the school nurse. The IHP provides information on specific precautions related to the student’s feeding and swallowing 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.
Feeding and swallowing challenges can persist well into adolescence and adulthood. Precautions, accommodations, and adaptations must be considered and implemented as students transition to post-secondary settings. See ASHA’s resource on
transitioning youth for information about transition planning.
Periodic assessment and monitoring of significant changes are necessary to ensure ongoing swallow safety and adequate nutrition throughout adulthood. A risk assessment for choking and an assessment of nutritional status should be considered as part of a routine examination for adults with disabilities, particularly those with a history of feeding and swallowing problems. See, for example, Moreno Villares (2014) and Thacker, Abdelnoor, Anderson, White, & Hollins, (2008).
Service Delivery section of the Pediatric Feeding and Swallowing Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.
In addition to determining the type of treatment that is optimal for the child with feeding and swallowing problems, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. Decisions are made based on the child’s needs, his or her family’s views and preferences, and the setting where services are provided.
Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of the treatment format often depends on the child’s age, the type and severity of the feeding or swallowing problem, and the service delivery setting.
Provider refers to the person providing treatment (e.g., SLP, occupational therapist, or other feeding specialist). Recommended practices follow a collaborative process that involves an interdisciplinary team including the child, family, caregivers, and other related professionals. When treatment incorporates accommodations, modifications, and supports in everyday settings, SLPs often provide training and education in how to use strategies to facilitate safe swallowing.
Dosage refers to the frequency, intensity, and duration of service. Dosage depends on individual factors, including the child’s medical status, nutritional needs, and readiness for oral intake.
Setting refers to the location of treatment and varies across the continuum of care (e.g., NICU, intensive care unit, inpatient acute care, outpatient clinic, home, or school).