Peds: Chap.10 Assessment and Treatment of Feeding

Feeding, Eating, and Swallowing: Overview, Mealtime, and Cultural Influences

• Feeding: Bringing food to mouth; includes self-feeding and caregiver feeding.

• Eating: Keeping and manipulating food in the mouth; chewing and swallowing.

• Swallowing: Complex process of moving food/liquid from mouth to stomach.

Mealtime – Significance and Considerations

• Developmental Importance: Promotes bonding, communication, social skills, and routine.

• Structure: Predictable routine encourages regulation and learning.

• Environment: Calm, distraction-free settings help children focus on feeding.

• Family Dynamics: Mealtime reflects parenting styles, expectations, and interaction.

Cultural Influences on Feeding

• Dietary choices: Some foods/textures may be introduced earlier/later based on cultural norms.

• Feeding practices: Hand-feeding vs. self-feeding, bottle vs. breast, use of utensils.

• Mealtime routines: Where, when, and with whom meals are eaten vary across cultures.

• Perceptions of picky eating: Cultural norms influence whether behaviors are seen as problematic.

• Caregiver roles: Different expectations for child independence in feeding.

Feeding Disorders: Incidence and Influences

Gastroesophageal Reflux (GER)

• Stomach contents flow back into the esophagus

• Symptoms: pain, vomiting, food refusal, arching during feeds

• Can affect growth and feeding success

Food Allergies

• Immune response to specific foods (e.g., dairy, nuts, eggs)

• Symptoms: rash, swelling, vomiting, diarrhea, anaphylaxis

• May lead to limited diet and food aversion

Oral Motor Functions, Sensory and Behavioral

Oral Motor Function

• Involves coordination of lips, tongue, jaw, cheeks

• Impairments can affect sucking, chewing, swallowing

• May result in drooling, food loss, gagging, or fatigue during meals

Sensory Issues

• Over- or under-responsiveness to food textures, temperatures, smells, or tastes

• Can cause food refusal, limited food repertoire, or distress at mealtimes

• Often addressed with sensory integration and graded exposure

Behavioral Issues

• May include food refusal, tantrums, or rigid mealtime routines

• Often develop in response to medical or sensory challenges

• Managed with consistent routines, caregiver education, and behavioral strategies

Role of the
Occupational Therapist

• Anatomy & Physiology:
  Includes lips, tongue, jaw, cheeks, palate, pharynx, larynx, esophagus – all must coordinate for safe swallowing and efficient eating.

• Growth & Developmental Milestones:

  • Suck-swallow-breathe: birth

  • Spoon feeding: ~4–6 months

  • Chewing/mashing: ~8–12 months

  • Self-feeding: ~12–18 months

• Nutrition:
  Essential for growth, brain development, and immune function; includes adequate intake of protein, fats, vitamins, minerals, and fluids.

• Medical Conditions:
  Examples: prematurity, cerebral palsy, GERD, cleft palate. Can cause oral motor delays, fatigue, food refusal, or need for alternative feeding methods.

• Social & Emotional Factors:
  Family stress, mealtime conflict, trauma, or caregiver interaction styles can negatively affect feeding behavior and appetite.

Development of Oral Structures

• Oral Cavity:
  Small and filled by the tongue in infancy; grows to allow more refined movements for chewing and speech.

• Pharynx:
  Short and compact in infants; lengthens with age to separate respiratory and digestive tracts more clearly.

• Larynx:
  Positioned high in the neck at birth (closer to epiglottis); lowers as the child grows, allowing for speech but increasing aspiration risk.

• Trachea:
  Airway passage that is narrow in infants; grows in diameter and length with age, improving respiratory safety during feeding.

• Esophagus:
  Immature peristalsis in infancy; matures to support more efficient swallowing and reduced reflux over time.

Cranial Nerves

• CN V – Trigeminal

  • Function: Sensation to face & mouth; motor to muscles of mastication

  • Role in Feeding: Chewing, jaw movement, oral sensation (e.g., detecting food in mouth)

• CN VII – Facial

  • Function: Facial expression; taste to anterior 2/3 of tongue

  • Role in Feeding: Lip closure, cheek movement (buccinator), salivation, taste

• CN XII – Hypoglossal

  • Function: Motor control of the tongue

  • Role in Feeding: Tongue movement for chewing, bolus formation, and propulsion during swallowing

Phases of Swallowing

• Oral Preparatory Phase

  • Voluntary

  • Food is chewed and mixed with saliva to form a bolus

  • Lips close, cheeks control food, tongue moves food for chewing

• Oral Phase

  • Voluntary

  • Tongue pushes the bolus to the back of the mouth toward the pharynx

• Pharyngeal Phase

  • Involuntary

  • Soft palate rises, airway closes, and bolus moves through pharynx

  • Risk of aspiration if coordination is poor

• Esophageal Phase

  • Involuntary

  • Bolus moves down the esophagus to the stomach via peristalsis

Comprehensive Feeding & Swallowing Evaluation

• Initial Interview & Chart Review

  • Review medical history, diagnoses, growth patterns

  • Interview caregivers about feeding concerns, routines, and goals

• Structured Observation

  • Observe typical mealtime at home or clinic

  • Note posture, oral motor skills, sensory responses, behavior, caregiver interaction

• Assessment Tools

  • Examples:

    • Schedule for Oral Motor Assessment (SOMA)

    • Dysphagia Disorder Survey

    • Behavioral Pediatric Feeding Assessment Scale (BPFAS)

• Additional Diagnostic Evaluations

  • Videofluoroscopic Swallow Study (VFSS)

  • Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

  • Allergy testing, pH probe, upper GI series (if needed)

Key Considerations for Feeding Difficulties

• Feeding problems often have multiple underlying factors (medical, sensory, behavioral).

• If left unaddressed, they can lead to new complications (malnutrition, oral aversion).

• Problems typically occur frequently and across settings (home, school, clinic).

• Always assess for medical and nutritional issues that may be contributing.

• Feeding challenges often demand increased caregiver time and energy.

• Interventions should aim to support and maintain family routines, not disrupt them.

Feeding Intervention Strategies

• Environmental Adaptations

  • Reduce distractions (noise, screens)

  • Establish consistent mealtime routines

  • Use calming sensory input (dim lighting, soft music)

• Positioning Adaptations

  • Follow 90-90-90 rule (hips, knees, ankles at 90°)

  • Ensure head and trunk alignment

  • Use supportive seating (e.g., booster, Rifton, footrests)

• Adaptive Equipment

  • Built-up or angled utensils

  • Nosey cups or cut-out cups

  • Non-slip mats (e.g., Dycem), plate guards, divided plates

Feeding Strategies and Dysphagia Management

• Self-Feeding

  • Encourages independence and motor skill development

  • Use hand-over-hand assistance, adaptive utensils, and consistent routines

  • Start with easy-to-grasp foods and finger foods

• Modifications to Food Consistencies

  • Pureed: smooth texture for limited oral motor skills

  • Mechanical soft: mashed, ground, or finely chopped

  • Regular: typical textures for age/development

• Modifications to Liquids

  • Thin: like water or juice

  • Nectar-thick: slightly thicker (e.g., tomato juice)

  • Honey-thick: pours slowly (e.g., milkshake)

  • Thickening may reduce aspiration risk in dysphagia

• Dysphagia

  • Swallowing difficulty that may lead to aspiration, choking, or poor nutrition

  • Requires coordinated care (OT, SLP, medical team)

  • Interventions: positioning, pacing, texture modification, swallow techniques

Common Feeding Challenges

• Sensory Processing Disorders

  • Over- or under-reactivity to food textures, smells, tastes

  • May gag, refuse, or avoid certain foods

  • Intervention: sensory desensitization, graded exposure, play-based feeding

• Behavioral Feeding Issues

  • Learned behaviors like refusal, tantrums, or mealtime control struggles

  • May result from past negative feeding experiences or inconsistent routines

  • Intervention: structured mealtimes, positive reinforcement, caregiver training

• Food Refusal or Selectivity

  • Child eats a limited variety or avoids entire food groups

  • Often linked to sensory, medical, or behavioral issues

  • Intervention: food chaining, modeling, repeated exposure

• Delayed Transition to Textured Foods

  • May resist moving from purees to solids

  • Causes: oral motor delays, sensory aversion, anxiety

  • Intervention: introduce small texture changes gradually, oral motor support

• Delayed Transition from Bottle to Cup

  • Can be due to oral motor weakness, sensory preferences, or habit

  • Intervention: offer cups early (around 6 months), use transition cups, model cup use

Special Considerations in Feeding Interventions

• Neuromuscular Interventions

  • Focus on improving strength, coordination, and tone

  • Techniques: oral motor exercises, jaw stabilization, cheek support, pacing

  • Often used in conditions like cerebral palsy, muscular dystrophy

• Transition from Nonoral to Oral Feedings

  • Gradual process for children with feeding tubes

  • Goals: build oral tolerance, positive associations with eating

  • Use play, taste exposure, and oral motor prep to support transition

• Cleft Lip and Palate

  • Structural gaps in the lip/palate affect suction and swallow

  • Use special bottles (e.g., Haberman), upright positioning

  • Surgical repair typically required; long-term feeding and speech support may be needed

• Other Structural Anomalies

  • Examples: micrognathia, glossoptosis, laryngeal cleft

  • May require surgical correction, adaptive feeding strategies, or referral to specialists

  • Feeding plan must be individualized and medically coordinated

IDDSI – 7 Levels of Food Consistencies

7

Regular

Normal food with no modifications

6

Soft & Bite-Sized

Soft, tender food cut into ≤15mm pieces (adult); requires some chewing

5

Minced & Moist

Moist, soft foods, finely chopped (≤4mm); minimal chewing needed

4

Pureed

Smooth, lump-free; holds shape but requires no chewing

3

Liquidised / Moderately Thick

Can be drunk from a cup; no chewing; pours quickly but not as thin as water

2

Mildly Thick

Thicker than water; flows off spoon easily; suitable for slow swallowers

1

Slightly Thick

Similar to nectar consistency; barely thicker than water

0

Thin

Regular liquids like water, juice