Assessment and Treatment for Transitional Feeders: A Comprehensive Guide

Clinical and Instrumental Assessments for Transitional Feeders

  • Assessment Foundations: Practitioners must differentiate between a clinical (bedside) assessment and an instrumental assessment (e.g., MBS or FEES). Any signs or symptoms of aspiration, previously documented or observed, require an immediate referral for an instrumental assessment.
  • Screening Tools: Early identification of pediatric feeding disorders (PFD) is facilitated by specialized screening tools.
    • ICFQ-6 (Infant and Child Feeding Questionnaire): A six-question screener designed for early identification of PFD.
    • Red Flags: On the ICFQ-6, any response landing in the "orange" category is considered a red flag, indicating the child is outside the expected range and requires further feeding and swallowing assessment.
    • Application: Screening should be universal for children entering school or community programs (Early Intervention, medical outpatient) if feeding concerns are present, as these can impact educational and developmental outcomes.

The Assessment Story and PFD Framework

  • Windowing the Family Story: Assessment is not just a clinical check but a way to understand the history of the concern and the family's stress levels. Key historical questions include:
    • Has the concern been present since infancy or did it begin with the introduction of purees and solid foods?
    • What is the family's understanding of PFD, dysphagia, and the ongoing nature of therapy?
  • The PFD Domains: Evaluations must address all four domains of Pediatric Feeding Disorder (PFD):
    • Medical: Reviewing history and referring to specialists (GI, ENT, etc.).
    • Nutritional: Understanding diet variety (e.g., avoidance of fruits or proteins) and referring to a dietitian.
    • Feeding Skills: Assessing oral motor and sensory responses.
    • Psychosocial: Observing how the child responds to food, including behaviors like avoidance or anxiety.
  • Observation Contexts: Assessments should be conducted in naturalistic settings whenever possible. This includes using the child's own cups and food from home in outpatient settings, or observing in the home (EI) or cafeteria (school).

Clinical Assessment Structure

  • Chart Review and Case History: Essential data includes medical history, respiratory health, and GI concerns.
  • Key Interview Questions:
    • How long does it take to feed the child?
    • Are mealtimes stressful for the parent or child?
    • Is the child gaining weight adequately?
    • What utensils are currently used (e.g., cups, fingers)?
  • Intake Logs: A structured data collection method where parents record:
    • Date, day of week, and time of meal.
    • Food/liquid offered and the specific amount offered vs. eaten.
    • Method of delivery (mouth, finger, G-tube).
    • Response/Behavior: Refusal, vomiting, gagging, or throwing food.
  • Neuromotor and Oral Mech Exam: A standard clinical exam focusing on the anatomy and physiology of the oral mechanism.
  • Nutritive Assessment: Observations across all textures (purees, soft solids, regular solids) and utensils based on developmental norms.

Principles of Pediatric Feeding Therapy

  • The Iceberg Analogy: What is visible at the top (feeding concerns) is often driven by underwater factors like medical status, nutrition, and psychosocial health.
  • Responsive Feeding: Therapy must be positive or neutral, never punitive. The goal is to stop the negative cycle of anxiety and fear.
  • Food as the Tool: "Food is not plastic" and "food does not vibrate." Real food must be used to teach real chewing and swallowing skills.
    • Non-food tools (whistles, horns, chewy tubes) have limited evidence in literature to support efficacy in improving feeding skills.
    • Vibration should only be used if internal data suggests it facilitates a child's acceptance of real food.
  • Learning Pathways:
    • Pain or negative experiences (unidentified allergies or reflux) reinforce avoidance behaviors.
    • Attention given to refusal can accidentally reinforce non-eating.
    • Positive reinforcement, praise, and imitation (modeling) encourage successful engagement.
  • The Power of Modeling: Therapists should eat with the child, use a mirror for visual feedback, and use descriptive language (e.g., "This is squishy," "This is hard").
  • Repetition: It may take 1515 to 2020 presentations (or more) of a new food before a child accepts it.

Treatment Considerations for Sensory and Motor Function

  • Seating and Positioning: The gold standard is the 90,90,9090, 90, 90 position (upright, head/neck neutral, feet supported). Adequate trunk support is required to allow the child to dissociate lip, jaw, and tongue movements.
  • Oral Sensory Function Treatments:
    • Outside-In Approach: Start with the hands and move toward the mouth. Steps include: looking, smelling, passing the bowl, touching, serving with a utensil, putting it on their plate, licking, nibbling, and finally biting.
    • Systematic Desensitization: Incremental steps to reduce anxiety.
    • Food Chaining: Changing only one property of a food at a time (e.g., keeping a food cold and sweet but changing the color from pink to white; changing from brown/crunchy to red/crunchy).
  • Oral Motor Function Treatments:
    • Spoon Feeding:
      • J-Presentation: Placing the spoon on the mid-blade of the tongue with light pressure, waiting for lip closure, and pulling straight out (avoiding scraping on the roof of the mouth).
      • Side Presentation: Entering the mouth sideways to promote lip seal and reduce tongue thrust.
    • Tongue Lateralization: Placing food on the molars to encourage the tongue to move side to side. Tools like cheesecloth can be used to wrap food for safe munching practice.
    • Cup Drinking: Use small cups (Dixie cups, shot glasses, or cutout cups) to prevent the child from throwing their head back (neck extension). Start with thicker liquids (thin purees, drinkable yogurt) for better flow control.
    • Straw Drinking:
      • Pipette Technique: Controlled delivery of liquid via the straw to teach the concept of suction.
      • Honey Bear Cup: Squeezable cups that assist delivery while the child works on lip rounding.
      • Lip Blocks: Attachments for straws that provide a physical target to promote rounding vs. biting.

Roles and Responsibilities (Ellen Satter)

  • The Adult's Role: Determines what is offered, when it is offered (schedule/routine), and how it is offered. Avoid "grazing" to ensure a healthy hunger/satiation cycle.
  • The Child's Role: In a responsive feeding framework, the child determines which items to eat and how much to eat.

Safety and Pharyngeal Function

  • Silent Aspiration: Infants and medically complicated children have an underdeveloped laryngeal chemo-reflex, meaning they may aspirate without coughing. The absence of coughing or choking does not rule out aspiration.
  • Dysphagia Interventions: Maneuvers like the chin tuck or head turn can be used in children (typically preschool age or older) as long as they can follow directions and the maneuvers are validated by an MBS or VFSS.