Paediatric Feeding and Swallowing Seminar Notes

Learning Objectives

  • Understand normal feeding and swallowing processes in infants and children.

  • Describe speech pathology practice scope for paediatric feeding & swallowing disorders.

  • Describe causes, characteristics, and consequences of paediatric feeding disorder (PFD) in children.

  • Explain rationale behind assessment approaches and interventions for children with PFD.

  • Apply evidence to support PFD assessment and intervention.

Definitions and Notes

  • Foetal life: Before birth, including preterm infants.

  • Neonatal life: 0-2 months of corrected age.

  • Corrected age: Adjusted age; premature baby's chronological age minus weeks/months early they were born.

  • Young infant: Exclusively breast/formula fed, < 6 months old.

  • Infant: Child 0-12 months old.

  • Toddler: Child 1-2 years old.

  • Young child: Child 2-6 years old (early childhood).

  • Brand names: Specified when particular reason exists; comparable products may exist.

  • Caregiver/Parent: 'Parent' interchangeable with 'caregiver'; child may not have biological parent as primary caregiver.

Prenatal ‘Feeding’

  • 4-8 weeks post-conception: Major organs developing.

  • 4th week: Oesophagus present.

  • 10-14 weeks: Pharyngeal swallow begins.

  • 18-24 weeks: True sucking movements begin.

  • 26+ weeks: Non-nutritive sucking (NNS) begins.

  • 28-32 weeks: Earliest oral feeding possible.

  • 30-36 weeks: Increased organization of oral movements observed.

  • 34-37 weeks: Total oral nutrition possible.

Infant Feeding

  • Breast and/or bottle feeding.

  • Breastmilk/human milk and/or special infant formula.

  • High frequency.

  • Dependent on:

    • Specific anatomical and physiological features.

    • Skills:

      • Nutritive sucking: Negative pressure generation plus compression (vs non-nutritive sucking).

      • Coordination of sucking, swallowing, and breathing.

    • Responsive caregiver.

Infant Reflexes

  • ROOT (integrated 3-4 months)

    • Contact around mouth -> baby turns towards touch and opens mouth

  • SUCKLE (integrated 3-6 months)

    • Touch to top of tongue or palate -> baby sucks and swallows

  • TONGUE PROTRUSION (integrated 3-6 months)

    • Contact to lips -> tongue protrudes to draw breast/bottle into mouth

  • TONGUE LATERALISATION (integrated 6-9 months)

    • Contact to side of tongue -> tongue moves towards stimulus

  • PHASIC BITE (integrated 9-12 months)

    • Pressure to the gums -> up and down jaw movement

  • GAG (diminishes around 6-9 months)

    • Contact near back of mouth -> pharyngeal contraction to expel foreign object

  • COUGH (persists)

    • Contact in or near entrance to laryngeal vestibule -> vocal folds close, then expel air forcefully

Infant Reflex Timeline

  • Birth: Liquid diet of breastmilk or formula.

  • 4 months:

    • Tongue protrusion reflex diminishes.

    • Rooting reflex diminishes 3-6 months.

  • 6 months:

    • Introduction of first solids (around 6 months).

    • Transverse tongue reflex diminishes 6-9 months.

  • 9 months:

    • Introduction of lumpy solids (around 7 to 9 months).

    • Phasic bite reflex diminishes 9-12 months.

  • 12 months:

    • Introduction of finger foods (around 9 to 12 months).

    • Gag reflex becomes less sensitive but persists into adulthood.

Infant Nutritive Sucking

  • Rooting and sucking reflexes

  • Mouth fills with milk

  • Active drinking starts

  • Nutritive sucking

Infant Feeding Cues

  • (No specific cues listed in this section of the transcript)

Starting Solids

  • Most infants begin solids “around 6 months, and no earlier than 4 months” (corrected for prematurity).

  • Within the 4-6 month age range, possible indicators of readiness include:

    • Ability to sit with support

    • Head control

    • Fine motor skills (reach, grasp)

    • Interest

  • Considerations:

    • Texture

    • Seating

    • Equipment

    • Caregivers

Early Eating Skills

  • 6 months old

    • I am…

      • Sit in a high-chair

      • Sit with support

    • I can probably…

      • Accept a spoon

      • Open my mouth when I see food/drink

    • So, I might…

      • Sometimes get a spoon or messy fingers to my mouth

      • Bring my hands to my mouth

      • Swallow thin purees

      • Swallow liquids

  • 9 months old

    • I am…

      • Hold my head up

    • I can probably…

      • Feed myself with a spoon or my fingers

      • Pick up objects and bring them to my mouth

      • Chew and swallow some very soft solid foods

      • Move food around my mouth

    • So, I might…

      • Start drinking effectively from a cup

      • Munch (up and down)

  • 12 months old

    • I am…

      • Sit with minimal support

    • I can probably…

      • Mostly feed myself

      • More efficiently pick up objects and bring them to my mouth

      • Chew and swallow more soft solid foods

    • So, I might…

      • Drink more effectively from a cup

      • Chew (diagonally)

  • 18 months old

    • I can probably…

      • Feed myself consistently

      • Use my tongue to more efficiently move food around my mouth

      • Chew and swallow some mixed consistency and firmer foods

    • So, I might…

      • Drink independently from a sippy cup

      • Chew (diagonally and emerging rotary)

  • 2 years old

    • I can probably…

      • Chew and swallow most consistencies

      • Use my tongue very efficiently to move food around my mouth

      • Verbally express hunger, satiety, and food preferences

      • Speak in short sentences, using 50+ words

    • So, I might…

      • Chew (rotary)

  • 3 years old

    • I can probably…

      • Increasingly use cutlery

      • Chew and swallow all consistencies safety

    • So, I might…

      • Drink from a range of cups without spilling

      • Use my hands and fingers more effectively

      • Chew (established rotary)

Spoon-feeding Continuum

  • 6 months: Purees

  • 9 months: Mash & soft solids

  • 12 months: Table foods

Baby-led Weaning Continuum

  • 6 months: ‘fingers’ of soft food or mash

  • 9 months: add diced

  • 12 months: add small pieces and chewier foods

SOS Continuum

  • Smooth puree

  • Mash

  • Hard munchables

  • Dissolvables

  • Soft cubes

  • Soft mechanicals

  • Hard mechanicals

Development at Mealtimes

  • Communicative

  • Motoric

  • Cognitive

  • Social

  • Sensory

The Scientist in the Highchair

  • Physicist: If I drop it, what happens?

  • Chemist: If I mix them together, what happens?

  • Engineer: Can I use a carrot as a spoon?

  • Physiologist: How much food do I need to eat to feel satisfied?

  • Sociologist: When and how do my family eat?

  • Psychologist: What does my caregiver do if I throw this?

Sensory Learning

  • Food throwing

  • Flavour

What Child Learns

  • Birth to 6 months

    • Caregiver proactive preparation: Prepare to feed when infant signals hunger.

    • Child skills and signals: Signal hunger/satiety through voice, facial expression, and actions

    • Caregiver responsivity: Responds to infants signals: feeds when hungry, stop with satiety

    • What child learns: Caregiver will respond and meet her needs

  • 6-12 months

    • Caregiver proactive preparation: Ensure child is comfortably positioned; establish family mealtimes/routines

    • Child skills and signals: Sit; chew and swallow semisolid foods; self-feed with fingers

    • Caregiver responsivity: Respond to child's signals; increase variety, texture, and tastes

    • What child learns: Respond positively to child's attempts to self-feed; To begin to self-feed; to experience new tastes and textures; that eating and mealtimes are fun

  • 12-24 months

    • Caregiver proactive preparation: Offer 3-4 healthy choices/meal; offer 2-3 healthy snacks each day; offer foods that can be picked up, chewed, and swallowed

    • Child skills and signals: Self-feed many different foods; use baby-safe utensils; use words to signal requests

    • Caregiver responsivity: Respond to child's signals of hunger and satiety; respond positively to child's attempts to self-feed

    • What child learns: To try new foods; to do things for herself; to ask for help; to trust that caregiver will respond to her requests

Communication Learning

  • Imitation

  • Requesting

Normal Speedbumps

  • Gagging

  • Spitting out

  • Food throwing/dropping

  • Food refusal

  • Food selectivity and neophobia

  • ‘Undereating’/’overeating’

  • Messy eating

  • Difficulty with cutlery and manners

Infant vs Adult

  • Infants…

    • Oropharyngeal anatomy organized around safe milk feeding

    • Eating/drinking driven by reflexes

    • Able to manage fluids only

    • Lower caloric requirement relative to size (growth and development, as well as basic bodily functions including movement)

    • Eats in response to homeostatic and behavioural cues

    • Mealtimes are about survival

  • Adults…

    • Oropharyngeal anatomy more ‘flexible’ and effective

    • Eating/drinking volitional, with a few protective reflexes still present

    • Able to manage a wide range of textures

    • Higher caloric requirement relative to size (basic bodily functions including movement)

    • Eats in response to homeostatic cues

    • Mealtimes are about…

Paediatric Feeding Disorders (PFD)

  • "The area of paediatric swallowing and feeding disorders is one of the most rapidly evolving patient care areas for medically based speech pathologists and other professionals serving children."

Paediatric Feeding Disorders (PFD) Definition

  • PFDs are complex conditions that can adversely impact a child’s health, nutrition, development & psychosocial function.

  • Require multidisciplinary diagnosis & intervention including speech pathology

  • Children presenting with PFD are a heterogeneous population and until recently there has been no universally accepted definition or diagnostic criteria

  • “PFD is defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.”

PFD Expanded Definition

  • A. Disturbance in oral intake of nutrients, inappropriate for age, lasting at least 2 weeks and associated with 1 or more of the following:

    • Medical dysfunction:

      • Cardiorespiratory compromise during oral feeding

      • Aspiration or recurrent aspiration pneumonitis

    • Nutritional dysfunction:

      • Malnutrition

      • Specific nutrient deficiency or significantly restricted intake of one or more nutrients resulting from decreased dietary diversity

      • Reliance on enteral feeds or oral supplements to sustain nutrition and/ or hydration

      • Feeding skill dysfunction:

      • Need for texture modification of liquid or food

      • Use of modified feeding position or equipment

      • Use of modified feeding strategies

      • Psychosocial dysfunction:

      • Active or passive avoidance behaviours by child when feeding or being fed

      • Inappropriate caregiver management of child’s feeding and/or nutrition needs

      • Disruption of social functioning within a feeding context

      • Disruption of caregiver- child relationship associated with feeding

  • B. Absence of the cognitive processes consistent with eating disorders and pattern of oral intake is not due to a lack of food or congruent with cultural norms.

Other Diagnostic Labels

  • ARFID

  • Paediatric dysphagia

  • Picky/selective/fussy eating

  • Infantile anorexia

  • Eating disorders, including pica, anorexia nervosa, bulimia nervosa

Diverse Practice Contexts

Speech pathologists work with a diverse population of children with feeding & swallowing needs in a variety of practice settings including:

  • NICU/SCN

  • Acute wards

  • Community health

  • Private practice

  • Special schools

  • Early intervention

  • Hospital outpatient clinics

  • Multi disciplinary clinics

PFD Team Members

  • Parents and child

  • Paediatrician, general practitioner, neonatologist

  • Medical specialists: gastroenterologist, respiratory, ENT, neurologist, developmental medicine, plastics

  • Dentist, orthodontist

  • Nurses, including maternal and child health nurse

  • Lactation consultant

  • Speech pathologist

  • Dietitian

  • Occupational therapist

  • Physiotherapist

  • Psychologist

  • Social worker

  • Infant mental health professional

  • Child life therapist

Models of Team Work

  • Multidisciplinary

    • Speech pathologist assesses and shares management plan with other team members across services, e.g., NDIS provider

  • Interdisciplinary

    • Speech pathologist and dietitian assess together and develop joint management plan with family, e.g., Feeding clinic

  • Transdisciplinary

    • Speech pathologist or OT or PT take on holistic shared management roles, e.g., Developmental care team

Scope of Speech Pathology Practice

  • "Speech pathologists work towards optimising…swallowing to support health, well-being and participation. Swallowing includes orally eating, drinking and taking medication, saliva control, sucking, chewing and mealtime participation, as well as protecting the lungs from food, drink and saliva."

Scope of Speech Pathology Practice: Swallowing

  • An ability to diagnose and treat disorders of swallowing (developmental and acquired) is an area of clinical competence (SPA, 2017)

  • Entry-level clinicians should have the knowledge and skills to work with paediatric clients presenting with “Non Complex” feeding & swallowing difficulties according to Dysphagia Clinical Guidelines (SPA, 2012)

  • This range of practice includes:

    • Swallowing

      • Range of Practice

        • Oral function for eating & drinking

        • Dysphagia: oral, pharyngeal & oesophageal

        • Mealtime management

Adult vs Paediatric Practice

  • Common - Clinical Reasoning

    • Background history

    • Identify FEDS problem

    • Administer relevant assessments: clinical evaluation +/- instrumental

    • Refer on if indicated to others in MDT

    • Clinical impression: describe why and how FEDS is disordered and determine prognosis

    • Management plan: Evidence based and linked to diagnosis

  • Unique - Paediatric Considerations

    • Paediatric specific causes of dysphagia

    • Typical FEDS development and signs symptoms

    • Adapt CE: multisensory approach look, listen, feel, be opportunistic and flexible

    • Adapt instrumental swallow exam

    • Family are core team members involved in all aspects of assessment and treatment planning

    • Paediatric specific interventions: teaching new skills

Causes of PFDs

  • Structural problems: naso-pharynx, oral cavity, pharynx, larynx, oesophagus

  • Neurological problems: acute, chronic or progressive

  • Multi-systemic conditions: genetic syndromes, complex prematurity, cardio-respiratory, gastrointestinal

  • Psychosocial factors

Neurologic (Acute central nervous system)

Includes:

  • Traumatic brain injury

  • Intracranial tumours

  • Infections (meningitis, encephalitis)

  • Intracranial haemorrhage (IVH, ICH)

  • Neonatal ischaemic stroke
    Neurologic (Chronic central nervous system)
    Includes:

  • Cerebral palsy

  • Hypoxic Ischaemic Encephalopathy (HIE)

  • Cortical atrophy, microcephaly, anencephaly
    Neuromuscular diseases
    Includes:

  • Myasthenia gravis

  • Muscular dystrophy & myopathies

  • Infantile spinal muscular atrophy

Neurologic (neurodevelopmental)

  • Overlap with genetic syndromes

  • Also includes non-syndromic neurodevelopmental conditions such as:

    • Cerebral Palsy

    • Autism

    • Oral dyspraxia

    • Global developmental delays

      • 'Standalone’ developmental delays (e.g., (oral) motor delays/disorders, sensory processing delays/disorders)

Anatomic/structural

Nasopharynx /oral cavity Include:

  • Choanal stenosis / atresia

  • Cleft palate +/- lip

  • Macroglossia

  • Ankyloglossia/tongue tie

  • Retrognathia

  • Craniofacial sequences: e.g. Pierre Robin sequence; retrognathia; glossoptosis +/- cleft palate

  • Dental decay and misalignment
    Larynx & trachea Include:

  • Laryngotracheal cleft

  • Vocal cord paralysis

  • Laryngotracheomalacia

  • Stenosis (supra or subglottic)

  • Tracheostomy
    Oesophagus

  • Tracheosophageal fistula

  • Sphincter dysfunction (UES/LES)

  • Oesophageal atresia or stenosis

/

Genetic/multisystemic

  • Genetic syndromes

    • PFD and dysphagia reflect the impact of structural & neurodevelopmental conditions e.g., Down syndrome, Prader-Willi syndrome, DiGeorge syndrome, SWANs

  • Premature birth

    • Feeding difficulties and dysphagia are prevalent in complex prematurity birth weight <1500grms and/or < 30 weeks GA

    • Reflection of multisystem involvement i.e., cardi- respiratory, neurological and gastrointestinal issues, extra-uterine environment

    • Feeding problems frequently persist beyond the neonatal period

Systemic illness

  • Multisystemic involvement

    • Respiratory, e.g., Chronic Lung Disease

    • Gastrointestinal issues, e.g., Gastroesophageal Reflux Disease

    • Cardiac abnormalities reduce feeding efficiency and safety, e.g., Congenital Heart Disease

    • Metabolic disorders affect multiple organs including brain, e.g., Niemann Pick Type C

Psychosocial

  • Lack of experience

  • Environmental issues

    • Limited caregiver knowledge about feeding (e.g., texture progression, mealtime structure) in young children

    • Limited caregiver capacity to respond to child's cues

    • Mismatch between parenting style and child temperament

    • Trauma, including family violence

    • Food insecurity

  • Parent-child attachment issues

  • Parent mental illness

PFD as a bio-behavioural Condition

  • = Interaction of biological and behavioural factors

  • Case example:

    • Infant vomits on textures secondary to severe oesophagitis caused by gastroesophageal reflux disease (GORD)

    • Textured food associated with pain on swallowing therefore start to avoid (learn via association)

    • Vomiting gets attention from caregiver (learn via consequences)

    • Oesophagitis and GORD remedied medically, however learned avoidance of textured food and vomiting persist

Beyond Signs & Symptoms

  • Signs and symptoms alert you to the presence of a paediatric feeding problem.

  • Clinical reasoning (e.g., based on knowledge of typical development, anatomy and physiology) are critical to diagnose and determine next steps

  • To make senses of signs and symptoms you need to answer the following:

    • What is the medical diagnosis and expected course of the disease?

    • What are the presenting feeding & swallowing symptoms?

    • What is the pathophysiology (how is structure or function impaired) of swallowing that underpins these symptoms ?
      # Signs, symptoms & pathophysiology PFD : Feeding skill and Psychosocial dysfunction

  • Signs & Symptoms
    Refusing age-appropriate or developmentally appropriate foods or liquids
    Accepting a restricted variety or quantity of foods or liquids
    Displaying disruptive or inappropriate mealtime behaviours for developmental levels
    Failing to master self-feeding skills expected for developmental levels Failing to use developmentally appropriate feeding devices and utensils

  • Possible causes:
    Oral motor delay / disorder
    Sensory processing difficulty
    Hypersensitive
    Hyposensitive
    Rigidity and repetitive behaviours
    Psychosocial factors

Signs, symptoms & pathophysiology Swallowing PFD : Feeding Skill Dysfunction

(Reilly et al., 2000)

  • Signs & Symptoms
    Drooling Not able to take sufficient volumes orally Prolonged feeds (>30 mins) Difficulty transitioning beyond puree at 8-12 months Gagging with new foods or textures Spitting food out Prolonged chewing Pocketing food in cheeks Unable to move to cup drinking by 12 months

  • Possible Pathophysiology Swallowing
    Oral hyposensitivity : decreased sensory response to food or fluid oral motor weakness, reduced sensation, decreased swallow reduced strength oral motor function sucking, chewing decreased strength in jaw and tongue muscles to support skill chewing, biting oral hypersensitivity : increased & excessive sensory response to food or fluid limitation of lateral tongue movements excessive tongue thrusting & pumping exaggerated oral reflex activity – e.g. rooting, bite

Signs, symptoms & pathophysiology PFD : Medical Dysfunction(Arvedson et al., 2020)

  • Signs & Symptoms
    History or recurrent pneumonia and feeding problems. Difficulty swallowing secretions Not able to take sufficient volumes orally.Prolonged feeds (>30-40 mins) Opens eyes or lifts eyebrows, rapid swallows Incoordination of sucking, swallowing, and breathing during oral feedings at breast or bottle Nasal regurgitation

  • Possible Pathophysiology Swallowing
    Reduced oral +/- pharyngeal sensation Reduced swallow frequency Laryngeal chemo reflex: startle, rapid swallowing, apnoea, laryngeal constriction and bradycardia. Newborns Velopharyngeal insufficiency or cleft

Signs, symptoms & pathophysiology PFD: Medical Dysfunction PFD: Nutritional Dysfunction(Reilly et al., 2000)

  • Signs & Symptoms
    Frequent refusal Distress at mealtimes No chewingStrong preference for purees (2yo) Frequent vomiting during and after feeds Choking/gagging Sub optimal nutrition/growth

  • Possible Pathophysiology Swallowing:
    Gastro-Oesophageal reflux Oesophageal dysmotility Delayed gastric emptying Oesophagitis Aspiration of refluxed materials

Function of feeding/swallowing

  • Survival

  • Nutrition and growth

  • Parent-child relationship

  • Early learning (e.g., when I suck, I get milk = cause-effect)

  • Participating in family and cultural life

Nutrition and growth

Quantity of food / fluid is restrictedReduced Energy IntakeMore time and effort feedingIncreased Energy OutputNet suboptimal nutrition:
Decreased height and weight. Suboptimal body fat stores Poorer muscle function Poorer cardio-vascular function Poorer immune function Reduced cortical activity Growth faltering ('failure to thrive’)= has crossed ≥2 major centiles on a growth chart (e.g., they were on the 50th percentile for weight, and now they are under the 5th percentile).

Respiratory health

  • Primary or secondary aspiration may be associated with:

    • Aspiration pneumonitis and/or pneumonia

    • Bronchiectasis/lung damage

  • Aspirated materials with increased bacterial load and/or pH may be more harmful

  • Respiratory health can be affected by neurological function, respiratory muscle weakness, kyphoscoliosis, pre-existing respiratory conditions, and undernourishment

Mental health and relationship

  • Increased caregiver stress (e.g., via high care demands, prolonged mealtimes, carer fatigue, grief, trauma)

  • Increased infant/child stress

  • Disruption to the development of trust and autonomy
    Ellyn Satter’s Division of Responsibility suggests that:
    Feeder is responsible for when, where and what a child is offered to eat Child is responsible for how much and whether they eat

Participation

  • Family mealtimes

  • Celebrations

  • Cultural and community events

  • Daycare/kinder and school

  • Cafes and restaurants

  • Holidays

Prognosis

  • Factors influencing prognosis:
    Feeding dynamics and relationship Nature and severity of PFD Nature and severity of the underlying medical condition (there may be population-specific outcome implications, e.g., CP vs cleft) Age of child (opportunity to intervene early may improve outcome) Developmental comorbidities (e.g., gross motor, cognition) Access to appropriate multidisciplinary diagnosis and intervention Examples of Population Specific Clinical Pathways:
    Alberta Health Service, A. H. (2016). Oral Feeding Guideline: Neonatal Intensive Care
    South Australian Perinatal Practice Guideline (2019). Management of Cleft Lip & Palate in the Neonatal Period

Why do we assess?

Understand and describe presentation (including history, background, and signs/symptoms)Determine whether a significant problem is present, considering:
Developmental norms Cultural context Safety Efficiency Function and participation Develop hypotheses related to:
Cause Pathophysiology Prognosis Determine appropriate next steps:
Appropriate referrals Further assessment (including instrumentals) Intervention—including initial targets (may trial as part of assessment)

ICF and paediatric FEDS

Ax Personal Factors Environmental Factors Body Functions Activity & Structures Participation
Parent report Intake diary Focus: Supporting child and familiespersonal andculturalpreferences Mealtime observation inhome/carecontext
(e.g., home visit, video, telehealth) Focus: Opportunities for FEDS practice inhome environment What food isavailable?
Do family eat together? Parent/caregiver report Mealtime observation Focus:
Can child participate in socialand family-based FEDS experiences? Mealtime observation Parent report Focus: Arefeeding skills age-appropriateand functional? e.g., Bottle/ breast, cup, spoon/fork, finger feeding, textures OMA Oral reflexes Clinical feeding assessment Instrumental swallow assessment Focus: Anatomy and physiologySucking
Biting Chewing SwallowingSafety and efficiency

Assessment toolkit

  • Referral information

  • Reports from other providers

  • Case history

  • Caregiver report tools

  • Oral sensory motor examination

  • Other pre-feeding assessment

  • Mealtime observation/clinical evaluation

  • Observational assessments

  • Instrumental assessments

  • Response to intervention/dynamic assessment

Referral information and case history:

Family, medical records, other professionals:
Reason for referral Social/cultural history Family concerns Family structure Medical history:Pregnancy and birth, neonatal history, Apgar score;Systems: respiratory, gastrointestinal, neurological, dental Interventions e.g., ventilation, surgeries, medications Allergies and intolerancesDevelopmental history
Feeding and swallowing history:Oral intake: amount, type, frequency, transitions to solids, when did it become difficult?Tube fed: amount, type, frequency Growth

Caregiver report measures

Collect structured general or specific information from caregiversOften provide a norm- or criterion-referenced numeric scoreCommon examples include
Feeding Flock tools: Early Feeding Skills Assessment Tool, Pediatric Eating Assessment Tool, Child Oral and Motor Proficiency Scale, Impact of Feeding on the Parent and Family Scales, Family Management Measure of Feeding Behavioral Pediatric Feeding Assessment Scale (BPFAS)Montreal Children’s Hospital Feeding Scale (MCH-FS)

Oral Sensory Motor Assessment

Oral peripheral examination: Observe state at rest and prior to feed Take note of structural anomalies Function of oral structures evident during non-nutritive sucking (NNS), facial expressions and vocalisation in infants; speech and facial expressions in older children Structured OME may be possible in older children; or can map function onto tool Observe secretion managementOral reflexes, e.g., rooting, sucking, swallowing, bite, transverse tongue; gag, cough, Absence of oral reflexes in neonatal period sign of potential neurological impairment (LMN)Persistence of oral reflexes beyond early infancy sign of potential neurological impairment (UMN)

Oral reflexes

Reflex Purpose Stimulus Response Diminishes Less sensitive in adulthood
Gag Expels foreign material from pharynx Contraction of palate and pharynx Touch to post. 2/3 of tongue (post. 1/3 in adults)
Cough Expel foreign material from the airway Epiglottis and vocal folds close and open again rapidly, pushing air out of the lungsForeign material entering airwayPersists into adulthood
Tongue protrusion Pushes food out of the infant’s mouth when they are not mature enough to cope with it Touch to anterior tongueTongue moves anteriorly and protrudes outside of mouth4-6 months
Transverse tongue (tongue lateralisation) Pushes food to side of mouth in a primitive chewing attempt; integrates into more refined movement for chewing Touch to lateral surface of tongue.Tongue moves towards stimulus6-9 months
Phasic bite Keeps material out of an infant’s mouth when they are not mature enough to manage it; integrates into more sophisticated chewing Pressure on gums Rhythmic opening and closing of jaw9-12 months

Other pre-feeding assessment in infants

Consider behavioural state and transition between states (deep sleep, light sleep, drowsy, quiet alert, active alert, crying)Observe respiratory function, oxygen saturation, and heart rate if possibleObserve overall neurodevelopment, including muscle tone, movement, communication, response to caregiverEvaluate non-nutritive suck using a dummy or gloved finger and look forResponse to stimulus within 3 seconds Negative pressure (suction) and positive pressure (compression) generatedRhythmic pattern observed (6:1-8:1 suck/swallow ratio)Small rhythmic jaw excursions Physiologic stability (e.g. change in sats/HR/RR/state)

Other pre-feeding assessment in older children

Look at overall neurodevelopment
Motor Speech Language Sensory processing Social Behaviour/mood
look for indications of medical problemsObserve interaction with caregiver

Feeding and Swallowing Assessment

Observe typical FEDS experience with primary caregivers in typical position Trial current fluid and foods using familiar utensils Look at child cues and behaviour, skills, volume taken, clinical S/S of challenges, feeder behaviours incl. responsiveness and pacing, feeder-child interaction, signs of (dis)stress, mealtime duration (<30 min), trigger for cessation Dynamic assessment!If safe, make changes to:
Positioning Textures Feeding equipment Size of bolus and speed of presentation EnvironmentConsider ceasing if safety concerns are present

Oral sensory responses

Engagement:Eye contactAttention to the food and the caregiverSmiling, babbling, squealingReaching for foodAttempting to self-feedExploring foodLicking fingersMouthing feeding utensils and food Disengagement: Gagging Vomiting Fussing during or before mealtimes Distractible Back arching/body stiffening Head turns/compression of lips Throwing food Spitting food
Gaze aversion Lip compression YawningHiccups Eyes shut Splayed fingers Flaccidity Dull looking face/eyes Back arching Crying/fussing Turning head away Pulling/pushing away Vomiting Eyes wide and bright Turns/looks to you Alert face Healthy colour Steady breathing May bring hand to mouthSmoothy movementslooks relaxedChild will react either positively (engagement) or negatively (disengagement)

Parent-child mealtime interaction

Consider:
“Timing of the feed/pressure to complete a meal Identifying the Division of Responsibility (between parent and child) The parent’s understanding of the child’s developmental level, health, eating skills and food types preferred Expectations of the parent Parental pressures to succeed e.g. fear of judgement/monitoring by health staff and fear of failure to meet the expectations from support personnel, additional pressure based on history of weight gain etc.

ABC model: parent-child feeding interaction

Antedecent (caregiver) i.e what happened before the behaviour?VerbalQuestions e.g. 'Would you like a bite?'Begging/ pleading e.g. 'Please take a bite for mummy'Bargaining/ coaxing e.g. 'You can play games on my phone if you take a bite'PhysicalRaised voice e.g. 'Take a bite now!'Threats e.g. 'Take a bite, or I'll take your toys away'Restraining the child e.g. holding down the child's armsForce feeding e.g. holding the spoon to the child's mouth until they accept it, forcing food into the child's mouth Behaviour (child i.e what was the behaviour?Verbal Verbal protest e.g. 'I don't like it'Physical Physical protest e.g. tantrums, crying, throwing food Escapes Leaves the table, runs away, pulls away from the feederWithdrawing Shut down response e.g unresponsive, not engagingConsequence (caregiver) i.e what happened after the behaviourVerbal Verbal punishment e.g. 'You're naughty for not eating that'Physical Restraining the child until the eat Force feeding Escapes Allowing escape from the situation e.g. letting the child leave the table without doing what was askedWithdrawing Withdrawing from the interaction e.g. giving up and ignoring the child

Recognising aspiration

Respiratory and overall health Clinical signs andsymp toms Predisposing factors Instrumentalassessment
Recurrent pneumonia/ frequent LRTIs:Poor weight gain;Ongoing need for supplemental oxygen: Wet voice during feeds; Wet breathing; Cough; Colour changesOxygen desaturationsApnoeaGagging;Watery eyesNasal flaring sudden state or tone changes Feed refusalBreathing sounds on cervical auscultation ;