Feeding is the process involving any aspect of eating or drinking, including gathering and preparing food and liquid for intake, sucking or chewing, and swallowing (Arvedson & Brodsky, 2002). Feeding provides children and caregivers with opportunities for communication and social experience that form the basis for future interactions (Lefton-Greif, 2008).
Swallowing is a complex process during which saliva, liquids, and foods are transported from the mouth into the stomach while keeping the airway protected. Swallowing is commonly divided into the following four phases:
Feeding disorders are problems with a range of eating activities that may or may not include problems with swallowing. Feeding disorders can be characterized by one or more of the following behaviors:
Swallowing disorders (dysphagia) can occur in one or more of the four phases of swallowing and can result in aspiration—the passage of food, liquid, or saliva into the trachea—and retrograde flow of food into the nasal cavity.
The long-term consequences of feeding and swallowing disorders can include
The incidence of feeding and swallowing disorders refers to the number of new cases identified in a specified time period. The prevalence of feeding and swallowing disorders refers to the number of children who are living with feeding and swallowing problems in a given time period.
It is assumed that the incidence of feeding and swallowing disorders is increasing because of the improved survival rates of children with complex and medically fragile conditions (Lefton-Greif, 2008; Lefton-Greif, Carroll, & Loughlin, 2006; Newman, Keckley, Petersen, & Hamner, 2001) and the improved longevity of persons with dysphagia that develops during childhood (Lefton-Greif et al., 2017).
Estimated reports of the incidence and prevalence of pediatric feeding and swallowing disorders vary widely due to factors including variations in the conditions and populations sampled, how feeding disorders and/or swallowing impairment are defined, and the choice of assessment methods and measures (Arvedson, 2008; Lefton-Greif, 2008). The data below reflect this variability:
Disruptions in swallowing may occur in any or all of the phases of swallowing—oral preparatory, oral transit, pharyngeal, and esophageal. Signs and symptoms vary based on the phase(s) affected and the child's age and developmental level. They may include the following:
Underlying etiologies associated with pediatric feeding and swallowing disorders include
Atypical eating and drinking behaviors can develop in association with dysphagia, aspiration, or a choking event. They may also arise in association with sensory disturbances (e.g., hypersensitivity to textures), stress reactions (e.g., when trying new foods), or undetected pain (e.g., teething, tonsillitis). See for example, Dodrill (2017) and Manikam and Perman (2000).
Speech-language pathologists (SLPs) 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, 2016b).
Appropriate roles for SLPs include the following:
Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children. An understanding of adult anatomy and physiology of the swallow may provide a good basis for understanding dysphagia in children; however, additional knowledge and skills specific to pediatric populations are needed. As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be educated and appropriately trained to do so.
As indicated in the Speech-Language Pathology Assistant Scope of Practice (ASHA, 2013), speech-language pathology assistants (SLPAs) may demonstrate or share information with patients, families, and staff regarding feeding strategies developed and directed by the SLP. However, they may not perform diagnostic evaluations of feeding and swallowing, including swallowing screenings/checklists; tabulate or interpret results and observations of feeding and swallowing evaluations performed by SLPs; or perform oral pharyngeal swallow therapy with bolus material.
Assessment and treatment of swallowing and swallowing disorders may require use of appropriate personal protective equipment.
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
See 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:
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:
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
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 dysphagia teams, 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:
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
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
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)—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:
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:
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
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
The assessment of spoon-feeding includes evaluation of optimal spoon type and the infant's ability to
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
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.
The 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:
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.
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
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
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:
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.
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 primary goals of feeding and swallowing intervention for children are to
Consistent with the World Health Organization's (2001) International Classification of Functioning, Disability, and Health (ICF) framework, goals are designed to
See 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 dysphagia teams, 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 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.
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).
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
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:
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 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 (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:
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)—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) 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:
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:
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:
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).
See the 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).
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Pediatric Dysphagia page:
In addition, ASHA thanks the members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU); Special Interest Division 13, Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training; and the Working Group on Dysphagia in Schools, whose work was foundational to the development of this content.
Members of the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit included Justine J. Sheppard (chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio). Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 2000-2002 and 2003-2005, respectively).
Members of the Swallowing and Swallowing Disorders (Dysphagia) Committee on Cross-Training included Caryn Easterling, Maureen Lefton-Greif, Paula Sullivan, Nancy Swigert, and Janet Brown (ASHA staff liaison). Celia Hooper, vice president for professional practices in speech-language pathology (2003-2005), served as monitoring vice president.
Members of the Working Group on Dysphagia in Schools included Emily M. Homer (chair), Sheryl C. Amaral, Joan C. Arvedson, Randy M. Kurjan, Cynthia R. O'Donoghue, Justine Joan Sheppard, and Janet E. Brown (ASHA liaison). Brian B. Shulman, vice president for professional practices in speech-language pathology, served as the monitoring officer.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d). Pediatric Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Dysphagia/.