Category: Feeding/Swallowing impairments

What is a child feeding disorder and what should I look for?

Feeding, swallowing, sensory and behavior feeding disorders can affect a child’s ability to develop and thrive. Feeding disorders include problems accepting food and getting ready to suck, chew, or swallow it. Swallowing disorders, also called dysphagia, can occur at different stages of the swallowing process:

  • Oral Phase- sucking, chewing, and moving food or liquid from the mouth into the throat
  • Pharyngeal Phase- starting the swallow, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking
  • Esophageal Phase- relaxing and tightening the openings at the upper and lower esophagus and squeezing food from the esophagus into the stomach http://www.asha.org/public/speech/swallowing/feedswallowchildren.htm

Sensory/behavioral feeding disorders

  • Oral Sensory impairments: Hypersensitivity over-registers, hyposensitivity under-registers or Mixed (hypo/hypersensitivity).
  • Stuffing, decreased oral awareness, loss of bolus, refusal, gagging, retching
  • Food refusal/limited food repertoire.
  • Texture/taste/temperature sensitivities
  • Impact of GI issues on feeding; most commonly seen with children that have or had a history of reflux, uncontrollable emesis and/or decreased tolerance of feedings.
  • Behavioral component will typically develop after a sensory impairment given mealtime difficulties.
  • Prolonged bottle/breast feeding

Common reasons for a comprehensive feeding and swallowing evaluation include:

  • Poor sucking
  • New onset of feeding difficulty
  • Difficult transitioning to age appropriate textures
  • Difficultly transitioning to age appropriate methods of intake (ie cup/spoon)
  • Limited food repertoire
  • Reduced volume of oral intake
  • Unexplained food refusal
  • Apnea during feeding
  • Gagging or coughing during feeding
  • Lengthy feedings or mealtimes (>30 minutes)
  • Wet/gurgly vocal quality after feedings/meals
  • Prolonged/multiple intubations
  • Oral-motor weakness
  • Vocal cord dysfunction
  • Failure to Thrive
  • Recurrent aspiration pneumonias
  • Diagnosis of a disorder typically associated with dysphagia (e.g. neurological diagnosis, syndromes etc.)

Spit UP!

From time to time all babies spit up! Just one of the reasons why we have so much laundry. Some babies bring up a small amount of spit up during burping, some during positional changes (like diaper changing or transitioning into the crib) and some with no stimulation at all. The amount can be from teaspoon sized to the entire feeding. There is more of a concern when an infant spits up an entire feeding. Small amounts of spit up even during every feeding can be considered normal as long as the infant is gaining weight and it doesn’t contain any blood. However further investigation should be considered when an infant spits up a large volume after or during a feeding especially if it appears to be the entire feeding. An infant that spits up a large amount after each feeding should be evaluated by a gastroenterologist. You should first discuss this with you pediatrician however if your child is not gaining or losing weight insist on a specialist. Underlying GI issues could be present thus causing such emesis. Some examples could be GERD or reflux, pyloric stenosis or dysfunction, delayed gastric emptying or gastroparesis, allergies or esophageal narrowing.
The most common of cause however is GERD. Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) or Laryngopharyngeal Reflux (LPR) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and larynx. A child or infant with EER or LPR is typically termed a silent refluxer in which they do not spit up. Instead they have a persistent cough and present with a hoarse cry or vocal quality.
The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD). GERD occurs when a valve known as the LES of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas.
While GER and EER/LPR in children often cause relatively few symptoms like heartburn or complain of a stomach ache. Symptoms in an infant can include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting), stomach aches, abdominal/chest pain (heartburn), sore throat, hoarseness, apnea (stops breathing), asthma/wheezing, chronic cough and throat clearing, chronic sinusitis and ear infections/fluid. Effortless regurgitation is very suggestive of GER. However, persistent vomiting (which is not the same) does not necessarily mean a child has GER.
Some basic changes that could assist with spit ups during and after feedings could be- feeding position (use a more upright angle), keep the infant upright after meals and avoid inversion (like during a diaper change), burp frequently, feed slower (choose a slower nipple), feed more frequent in less volume rather then larger volume less frequently.

DS
The above is the opinion of this writer. This should not take the place of your pediatrician. You should always consult your pediatrician for medical advise regarding introduction of feedings and related issues.

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Does my child need a feeding/swallowing evaluation

The first thing I would like to mention is that if you are reading this post please know that you are not alone. Up to 50% of infants and children can present with a feeding/swallowing disorder; about 3-12% turn into a severe impairment. Feeding and or swallowing impairments can be present from birth, have an acute on-set or develop over time. The etiology of the impairment will determine the development and play a key factor in treatment.I LOVE TO EAT!!

Some red flags warranting a feeding and or swallowing evaluation would be:

  • Poor sucking
  • New onset of feeding difficulty
  • Difficult transitioning to age appropriate textures
  • Difficultly transitioning to age appropriate methods of intake (ie cup/spoon)
  • Limited food repertoire
  • Reduced volume of oral intake
  • Unexplained food refusal
  • Apnea (stops breathing) during feeding
  • Gagging or coughing during feeding
  • Lengthy feedings or mealtimes (>;30 minutes)
  • Wet/gurgly vocal quality after feedings/meals
  • Prolonged/multiple intubations
  • Oral-motor weakness
  • Vocal cord dysfunction
  • Failure to Thrive
  • Recurrent aspiration pneumonias or unexplained pneumonias
  • Diagnosis of a disorder typically associated with dysphagia (e.g. neurological diagnosis, syndromes etc.)
  • unexplained weight loss or inability to gain weight.

It’s important to remember no matter how fabulous your pediatrician is, he/she will rarely see your child during mealtimes. Majority of feeding and swallowing evaluations originate from parental concern unless the infant/child is diagnosed with a syndrome, a neurological impairment or is not thriving. A feeding and swallowing evaluation can be completed in a variety of settings. The main settings would be a hospital (inpatient or outpatient), a outpatient clinic, a private practice or at home (typically via early intervention).
First you will need to speak with you pediatrician regarding your concerns. If he or she is in agreement then your child will be referred for a feeding and swallowing evaluation. Depending upon where you choose to go for the evaluation will determine your next step. If you want to go privately then you need to check with your insurance about out-of-network benefits. If you want to stay in-network then contact your insurance company about places that will accept your benefits. Lastly if you want to apply for early intervention (ages 0-3) then you will need to contact you local early intervention office (your pediatrician will need to assist you with this).
For the evaluation it is best to schedule you appointment around your child’s feeding time as he/she will be expected to eat and drink a variety of foods and liquids. Bring a variety of foods and liquids that you know your child will eat and foods that are of concern to you. You should also bring a variety of methods your child feeds from (ie bottle/special bottle (ie special needs feeder), sip/straw cup).
The Speech Pathologist will evaluate your child’s oral motor skills, sucking skills if age appropriate, oral sensory skills, chewing skills, swallowing skills, risks for penetration/aspiration. Some recommendations from the evaluation will be modification of diet (if needed), positioning changes, therapy, determination of the need for instrumental exam (modified barium swallow study) and further speciality consultations (physical and/or occupational therapy, gastroenterology, ENT, nutrition, allergist).
It is important to ask questions and clarification at the end of the evaluation. At the end of the evaluation you should feel a sense of empowerment with a clear plan on how you and your therapist are going to tackle this to help you little one. If you don’t, ask more questions until you do. Parental training is a vital role in the success of feeding and swallowing therapy.

The above is the opinion of this writer. This should not take the place of your pediatrician. You should always consult your pediatrician for medical advise regarding introduction of feedings and related issues.