Clinical Evaluation of Feeding and Swallowing

Common referral criteria

• Suck/swallow incoordination, weak suck

• Apnea, gagging, new onset feeding difficulty

• Underweight or growth faltering

• Aspiration risk, chronic respiratory illness

• Feeding refusal, poor arousal, prolonged mealtimes

Red flags/Key Questions diagram

• airway: gurgly, coughing, multiple swallows. repeated chest infections

• feeding duration: longer than 30 min or more 2.5 hrs per day

• lack of weight gain

• Children with PEG placement may undergo retching/vomiting, indicative of GER

• Stress at mealtimes: does not get the child to eat more, stressful for parents

what are the best predictors for dysphagia>

gurgly voice, coughing, multiple swallows

eating longer than ___ min can lead to malnutrition

45-60

Vetted Questionnaires

• Parent-completed

• Clinician-administered

• Often used in conjunction with clinical evaluation

• Limited psychometric data—best used as supportive tools

Vetted Questionnaires- Parent-completed

Infant Feeding Questionnaire (IFQ)

Vetted Questionnaires- Clinician-administered

Dysphagia Disorder Survey (DDS)

Limited psychometric data—best used as supportive tools

Vetted Questionnaires

Medical & Developmental history risk factors

• Maternal illness, prematurity, birth trauma

• CPAP, intubation, prolonged NICU stay

• Early signs of neurological risk (e.g., Grade III–IV IVH, HIE)

Family & Social History

• Who is involved in feeding? What are family priorities?

• Context: cultural, educational, socioeconomic

• Home setting, feeding routines, daycare environment

• Note: stressors (e.g., secondhand smoke, caregiving burdens) may impact feeding

Family & Social History contexts

cultural, educational, socioeconomic

Feeding History

• Ask specific questions

• Red flags: aspiration, frequent pneumonia, stridor, reflux

what are some specific questions to ask for feeding history

• “Describe what happens when the milk flow is too fast?”

• “Does she have trouble chewing?”

prefeeding observation

• Observe “at rest” posture and tone

• Caregiver-child interaction

• Is the child ready to feed?

• Oral readiness ≠ just rooting or mouthing

what specific things should you note during a prefeeding observation?

• Respiratory effort and stability

• State regulation and self-calming

• Sensory responses (tactile, vestibular, etc.)

what do you look for in a prefeeding observation when asking if the child ready to feed?

• Postural tone and symmetry

• Regulation of alertness

• Tolerance of upright positioning

• Coordination of suck–swallow–breathe

Oral readiness ≠

just rooting or mouthing

Restriction of tongue movement due to a short or tight lingual frenulum.

Tongue tie (anklyoglossia)

A tight upper labial frenulum that may restrict upper lip elevation.

lip tie

Less commonly discussed; tight tissue connecting cheeks to gums, potentially affecting oral mobility.

buccal tie

potential impacts of tongue ties- they may contribute to:

• Difficulties with latch during breastfeeding (more in infancy)

• Oral phase challenges in feeding (less clearly defined in older children)

• Articulation concerns (though this link is controversial and not always supported)

• Oral hygiene or dental spacing issues

clinical controversy tongue tie

• Evidence is mixed and evolving regarding the long-term benefits of frenotomy (clipping).

• Many cases are overdiagnosed or treated without considering compensatory function or developmental norms.

• Not all ties are functionally significant—structure alone should not dictate intervention.

preferred approach of tongue tie

emphasize function over structure in assessment (e.g., can the child elevate, lateralize, protrude tongue?)

(for tongue ties) Collaborate with lactation consultants, occupational/SLPs, and pediatricians to:

• Trial feeding therapy and oral motor support first (let’s try this first)

• Address any compensatory strategies or muscle imbalances

when would you recommend clipping for a tongue tie?

only when functional impairment persists despite conservative management

NICU Feeding Evaluation- observe infant at rest for…

• Appearance, posture, tone

• Response to touch/light

• RR, HR, oral motor patterns

in a NICU Feeding Evaluation watch for signs of ____

respiratory distress

Respiratory rate (RR) should generally be 60 or below

during a NICU feeding evaulation, what is essential and what is minimized?

• Interdisciplinary collaboration is essential (nurses, therapists, physicians, caregivers)

• Minimize adverse environmental stimuli (light, noise, touch)

for NICU feeding evaluations, feeding specialists must understand physiology of ______ and _______

sucking/swallowing and related diagnoses

Feeding readiness is closely linked to…

neurologic, cardiac, pulmonary, GI, and genetic status

goal for NICU feeding evaluation

Maximize safety and oral feeding success for stable infants

Prioritize _______ and individualized feeding goals in the NICU feeding evaluation

physiologic stability (are they stable during feeding?) this is number 1 priority

in a NICU feeding evaluation, what encouraged when possible?

breastfeeding; bottle-feeding also respected

Feeding Readiness

• Alert state

• Hunger cues

• Rooting/NNS

First feeding occurs when _______ and ______ are confirmed.

stable vitals and respiratory function

major goals of infant bottle feeding

• Facilitate pleasurable, coordinated feeding

• Quality over Quantity!

• Monitor for signs and/or symptoms of distress/aspiration

what do you observe for in infant bottle feeding?

• Suck-swallow-breathe rhythm

• Oral motor patterns

• Endurance and regulation

what 2 things impacts coordination?

Nipple shape and/or flow rate

Infants may need to trial various _______

nipple types

"Slow flow" is always slow

NO!

Disengagement (in bottle feeding) looks like:

• Reduced interest

• Slower sucking

• Falling asleep

• Higher RR

What is assessed for toddlers/older children

• liquids

• purees/soft solids

• solid foods

toddler/older child feeding assessment of liquids

• Cup type-Is this age-appropriate?

• Oral motor skills associated with cup type (labial closure, bolus extraction, etc.)

Cup type-Is this age-appropriate?

Considerations for reduced gross motor/fine motor skills

toddler/older child feeding assessment of purees/soft solids

• Note volume tolerated per sip/spoon.

• Assess child’s control over bolus and textures (spillage?)

• Acceptance/Refusal behaviors

toddler/older child feeding assessment of soft solids

• Observe jaw, lip, and tongue coordination.

• Vertical munching, diagonal munching, rotary chew

Red flags for referral for MBSS

• FREQUENT signs of silent aspiration (e.g., recurrent pneumonia, unexplained desaturations)

• Persistent coughing, choking, or gagging during feeding despite conservative strategies

• Congestion felt in the back/chest DURING a feeding or that significantly worsens after a feeding

• Need to evaluate effectiveness of current compensatory strategies (e.g., pacing, thickening)