Feeding/swallowing disorders ​

Feeding disorders are problems with a range of eating activities that may or may not include problems with swallowing. Feeding disorders can be characterized by one or more of the following behaviors:
  • Avoiding or restricting one's food intake (avoidance/restrictive food intake disorder [ARFID]; American Psychiatric Association, 2016)
  • Refusing age-appropriate or developmentally appropriate foods or liquids
  • Accepting a restricted variety or quantity of foods or liquids
  • Displaying disruptive or inappropriate mealtime behaviors for developmental level
  • Failing to master self-feeding skills expected for developmental levels
  • Failing to use developmentally appropriate feeding devices and utensils
  • Experiencing less than optimal growth (Arvedson, 2008)

Swallowing disorders (dysphagia) can occur in one or more of the four phases of swallowing and can result in aspiration—the passage of food, liquid, or saliva into the trachea—and retrograde flow of food into the nasal cavity.

The long-term consequences of feeding and swallowing disorders can include
  • food aversion;
  • oral aversion;
  • aspiration pneumonia and/or compromised pulmonary status;
  • undernutrition or malnutrition;
  • dehydration;
  • gastrointestinal complications such as motility disorders, constipation, and diarrhea;
  • poor weight gain velocity and/or undernutrition;
  • rumination disorder (unintentional and reflexive regurgitation of undigested food that may involve re-chewing and re-swallowing of the food);
  • ongoing need for enteral (gastrointestinal) or parenteral (intravenous) nutrition;
  • psychosocial effects on the child and his or her family; and
  • feeding and swallowing problems that persist into adulthood, including the risk for choking, malnutrition, or undernutrition.
 
Signs and Symptoms
Disruptions in swallowing may occur in any or all of the phases of swallowing—oral preparatory, oral transit, pharyngeal, and esophageal. Signs and symptoms vary based on the phase(s) affected and the child's age and developmental level. They may include the following:
  • Back arching.
  • Breathing difficulties when feeding that might be signaled by
  • increased respiratory rate;
  • changes in normal heart rate (bradycardia or tachycardia);
  • skin color change such as turning blue around the lips, nose and fingers/toes (cyanosis);
  • temporary cessation of breathing (apnea);
  • frequent stopping due to uncoordinated suck-swallow-breathe pattern; and
  • desaturation (decreasing oxygen saturation levels).
  • Coughing and/or choking during or after swallowing.
  • Crying during mealtimes.
  • Decreased responsiveness during feeding.
  • Difficulty chewing foods that are texturally appropriate for age (may spit out or swallow partially chewed food).
  • Difficulty initiating swallowing.
  • Difficulty managing secretions (including non-teething-related drooling of saliva).
  • Disengagement/refusal shown by facial grimacing, facial flushing, finger splaying, or head turning away from food source.
  • Frequent congestion, particularly after meals.
  • Frequent respiratory illnesses.
  • Gagging.
  • Loss of food/liquid from the mouth when eating.
  • Noisy or wet vocal quality during and after eating.
  • Taking longer to finish meals or snacks (longer than 30 minutes).
  • Refusing foods of certain textures or types.
  • Taking only small amounts of food, overpacking the mouth, and/or pocketing foods.
  • Vomiting (more than typical “spit-up” for infants).
 
Causes
Underlying etiologies associated with pediatric feeding and swallowing disorders include
  • complex medical conditions (e.g., heart disease, pulmonary disease, gastroesophageal reflux disease [GERD], delayed gastric emptying);
  • developmental disability (i.e., disability with onset before the age of 22 that warrants lifelong or extended medical, therapeutic, and/or residential supports and is attributable to a mental or physical impairment or a combination of mental and physical impairments);
  • factors affecting neuromuscular coordination (e.g., prematurity, low birth weight, hypotonia, hypertonia);
  • genetic syndromes (e.g., Down syndrome, Pierre Robin Sequence, Prader–Willi, Rett syndrome, Treacher Collins syndrome, 22q11 deletion);
  • medication side effects (e.g., lethargy, decreased appetite);
  • neurological disorders (e.g., cerebral palsy, meningitis, encephalopathy, pervasive developmental disorders, traumatic brain injury, muscle weakness in face and neck);
  • sensory issues as a primary cause or secondary to limited food availability in early development (e.g., in children adopted from institutionalized care; Beckett et al., 2002, Johnson & Dole, 1999);
  • structural abnormalities (e.g., cleft lip and/or palate and other craniofacial abnormalities, laryngomalacia, tracheoesophageal fistula, esophageal atresia, choanal atresia);
  • behavioral factors (e.g., food refusal); and
  • socio-emotional factors (e.g., parent–child interactions at mealtimes).

Atypical eating and drinking behaviors can develop in association with dysphagia, aspiration, or a choking event. They may also arise in association with sensory disturbances (e.g., hypersensitivity to textures), stress reactions (e.g., when trying new foods), or undetected pain (e.g., teething, tonsillitis). See for example, Dodrill (2017) and Manikam and Perman (2000)
 
Treatment
The primary goals of feeding and swallowing intervention for children are to
  • support safe and adequate nutrition and hydration;
  • determine the optimum feeding methods and techniques to maximize swallowing safety and feeding efficiency;
  • collaborate with family to incorporate dietary preferences;
  • attain age-appropriate eating skills in the most normal setting and manner possible (i.e., eating meals with peers in the preschool, meal time with family);
  • minimize the risk of pulmonary complications;
  • maximize the quality of life; and
  • prevent future feeding issues with positive feeding-related experiences to the extent possible, given the child's medical situation
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Sequential-Oral-Sensory (SOS) feeding protocol
We are happy to announce that 3 of our therapists are now trained in the SOS feeding protocol. An SOS approach to feeding therapy utilizes a systematic approach to address both the sensory processing and the oral motor skills a child needs to eat a wide variety of food groups and textures. Additional information on this approach can be found at: ​https://sosapproachtofeeding.com