Clinical Research

Nutrition in Clinical Practice

Volume 00 Number 0
Feeding Disorders in Children With Tracheostomy Tubes xxx 2020 1–7
© 2020 American Society for
Parenteral and Enteral Nutrition
DOI: 10.1002/ncp.10551
wileyonlinelibrary.com
Jennifer Henningfeld, MD1 ; Cecilia Lang, APNP2 ; Gina Erato, BA3 ;
Alan H. Silverman, PhD3 ; and Praveen S. Goday, MBBS, CNSC, FAAP3

Abstract
Background: We aimed to describe feeding dysfunction in a group of children with tracheostomy. Methods: Single-center,
retrospective chart review of all children with a tracheostomy who were evaluated by our interdisciplinary feeding program.
Demographic and diagnostic data, nutrition variables, acceptance of food consistencies, as well as 2 validated psychometric
instruments for assessment of feeding dysfunction were analyzed. Results: Thirteen tracheostomy-dependent children (5/13; 38%
ventilator dependent) were evaluated at a median age of 51 months (interquartile range [IQR], 26–69). The majority of children
(8/13; 62%) underwent evaluation after decannulation. Four children (30%) had a history of a cuffed tracheostomy tube. Eleven
children (85%) used a speaking valve prior to decannulation, only 2 of whom started before initial discharge with a tracheostomy.
Children with a tracheostomy had low-median weight- and height-for-age z-scores (−1.27 and −1.73, respectively), with normal-
median body mass index (BMI)–for-age z-score (0.175). Children received 75% of feedings via tube feeding (IQR, 13%–97%).
Compared with other children with feeding disorders, children with tracheostomy had delays in initial acceptance of most food
textures and general diet, and the Mealtime Behavior Questionnaire showed significantly worse overall scores (P = .01), and the
About Your Child’s Eating survey showed significantly higher parental perception of resistance to eating (P = .0001). Conclusion:
Requirement of enteral nutrition, poor oral-feeding skills, chronic malnutrition, and worse mealtime behaviors are associated
with tracheostomy. A history of ventilator dependence, cuffed tracheostomy, and inpatient speaking valve–use were infrequently
associated with interdisciplinary feeding-program evaluation. (Nutr Clin Pract. 2020;00:1–7)

Keywords
child; deglutition disorders; enteral nutrition; feeding and eating disorders of childhood; feeding behavior; growth and development;
pediatrics; swallowing; tracheostomy

Introduction ideally without laryngeal penetration or aspiration.7 About

Feeding in typical children progresses seamlessly from a
completely liquid diet through a variety of textures until the
child is consuming the complex diet that adults eat. Pediatric
feeding disorder has recently been defined as impaired oral
intake that is not age-appropriate and associated with
a medical, nutrition, feeding skill, and/or psychosocial
dysfunction.1 In infants and children with tracheostomy,
one-third of all children with feeding difficulties have
aspiration.8 Medical literature has debated the effect of a
tracheostomy on swallowing, with some literature suggest-
ing increased risk of dysphagia and aspiration. Studies have
From the 1 Medical College of Wisconsin, Division of Pediatric
Pulmonology and Sleep Medicine, Milwaukee, Wisconsin, USA;
2 Children’s Hospital of Wisconsin, Department of Respiratory Care

prolonged hospitalization, apart from being associated
with chronic malnutrition, impedes the usual progression
of feeding, and these infants miss critical windows for
feeding that affect feeding progression.2 This altered feeding
progression in children with tracheostomy has not been
subjected to detailed examination from an interdisciplinary
perspective.3,4 Finally, feeding in an otherwise medically
complex child is likely to cause social stressors on both the
child and family alike, which may result in dysfunctional
feeding strategies.5,6 Research is lacking on psychosocial
stressors because of dysfunctional feeding, mealtime
behaviors, and interactions in children with tracheostomies.
Swallowing is a complex neuromuscular process leading
to delivery of a food or liquid bolus to the stomach,
Services, Milwaukee, Wisconsin, USA; and the 3 Medical College of
Wisconsin, Division of Pediatric Gastroenterology and Nutrition,
Milwaukee, Wisconsin, USA.
Financial disclosure: None declared.
Conflicts of interest: Dr Goday serves as consultant to Nutricia and
serves on a Data Safety and Monitoring Board for Shire
Pharmaceuticals. The remaining authors have no conflicts of interest
relevant to this article to disclose.
Received for publication November 12, 2019; accepted for publication
May 31, 2020.
This article originally appeared online on xxxx 0, 2020.
Corresponding Author:
Praveen S. Goday, MBBS, CNSC, FAAP, 8701 W Watertown Plank
Road, Milwaukee, WI 53226, USA.
Email: pgoday@mcw.edu
2 Nutrition in Clinical Practice 00(0)
shown ≤87% prevalence of aspiration in tracheostomy-
dependent adult patients.9,10 Multiple mechanisms for
dysphagia and aspiration have been theorized in patients
with tracheostomy, including hindrance of laryngeal
elevation,9-11 esophageal obstruction or compression
with an inflated cuff,12 diminution of the laryngeal
protective reflex,13,14 and atrophy of laryngeal muscles
and uncoordinated closure due to chronically bypassing
the upper airways.15,16 The indication for tracheostomy
has evolved over time, including bypassing upper airway
obstruction and acting as a conduit for long-term invasive
ventilation, with the latter becoming a more frequent
indication. Although certain diseases require lifelong
tracheostomy, decannulation is possible in some children.
As children advance through the liberation process, they
progress in their developmental milestones, including oral-
feeding skills. A recent study evaluated all children who
were successfully weaned from mechanical ventilation and
decannulated.17 At the time of initial discharge with a
tracheostomy, most children were tube fed; however, at the
time of decannulation most children were tolerating some
oral feedings. It also showed that 60% of swallow studies
performed prior to decannulation-approved oral feedings.17
Our aim was to retrospectively evaluate the characteris-
tics of children with tracheostomy who required evaluation
in the Feeding, Swallowing and Nutrition Center (FSNC) at
Children’s Hospital of Wisconsin in Milwaukee, Wisconsin.
In addition to nutrition status, we also hoped to evaluate
the psychosocial stress of both caretakers and children with
either a history of or a current tracheostomy tube. We
hypothesized that feeding dysfunction and oropharyngeal
developmental delays will be more common in children
with a tracheostomy or a history of a tracheostomy when
compared with age-matched controls with known feeding
dysfunction. We also hypothesized that there will be an
increase in stressful mealtime behaviors.
Materials and Methods
This is a single-center, retrospective chart-review study of
all children aged <21 years who were discharged home from
the Children’s Hospital of Wisconsin with a tracheostomy,
with or without home mechanical ventilation, between
2000 and 2015 and who also required evaluation at FSNC.
We excluded patients with a congenital gastroesophageal
malformation that required surgical repair. Along with
demographic data, we collected pertinent pulmonary
and nutrition data. From a pulmonary perspective,
we collected age of tracheostomy placement, need for
mechanical ventilation, use of a cuffed tracheostomy
tube, use of a one-way speaking valve and tracheostomy
cap, and decannulation (if performed). From a nutrition
standpoint, we collected data regarding acceptance of
various food consistencies, developmental and behavioral
questionnaires, and anthropometric data at the time of the
initial evaluation by the FSNC. Institutional review board
approval was obtained. Questionnaires were administered
as routine screening during FSNC evaluation for clinical
purposes, and results were obtained via chart review.
Anthropometric and Nutrition Measures
We obtained anthropometric data and nutrition intake
data, including enteral nutrition support and historical oral
intake data. Oral and enteral intake was evaluated using
a 3-day diet record. It is standard practice in our clinic to
assess overall calorie and protein intake and micronutrient
nutriture based on the diet record. For the purpose of
this study, we only recorded overall calorie intake and
percentage of calorie intake, orally and enterally.
Feeding-Skill Measures
We assigned the ability to accept specific food textures to
the following ages: smooth purees – 6 months, mashed
foods and textured purees – 8 months, easily dissolvable
solids – 9 months, combination foods – 12 months, diced
solids – 14 months, toddler foods – 16 months, and general
diet – 18 months. Corrections were made for prematurity
when relevant. The delay in acceptance of a category was
calculated by subtracting the age at which the child accepted
the particular category vs the assigned age at which the child
should have been able to accept that specific texture of food.
In an effort to categorize delay in acceptance of specific
texture categories, when a child was not yet accepting a
specific category at the time of the FSNC visit, the age at
the time of the visit was used as the age of acceptance of
that food.
Developmental and Behavioral Measures
We also obtained psychological and behavioral measures
of child and caregiver functioning within a feeding
context. Specifically, measures assessed problem-feeding
behaviors, the caregiver and child feeding dynamic,
caregiver/parenting stress, and global child development.
The Mealtime Behavior Questionnaire (MBQ) is a 33-
question Likert scale instrument that measures caregiver
perceptions of child feeding dysfunction.18 Specific
subscales include child distraction/avoidance, food
manipulation problems, mealtime aggression, and choking,
gagging, and vomiting, which yield a composite total score.
The About Your Child’s Eating (AYCE) questionnaire
is a 25-question, caregiver-completed Likert scale instru-
ment that measures elements of the caregiver/child rela-
tionship within a feeding context.19 Subscales include child
resistance to eating, positive mealtime environment, and
parental aversion to mealtime.19
Henningfeld et al 3

The Parenting Stress Index–Short Form (PSI-SF) is a Table 1. Patient Characteristics.

caregiver self-report instrument that was used to assess
Characteristic N (%)
the overall level of stress that parents/caregivers experience
when conducting parenting tasks.20 The PSI-SF is a 36- Gender, male 8 (62%)
item instrument that yields a total stress score derived from Race
3 subscales: parental distress, parent-child dysfunctional White 8 (62%)
interaction, and difficult child.20 African American 2 (15%)
The Child Development Inventory (CDI) is a 300-item, Other 3 (23%)
caregiver observational scale to describe areas of develop- Tracheostomy characteristics
Tracheostomy only 8 (62%)
ment in children aged 15 months to 6 years. This inven- Tracheostomy with home mechanical ventilation 5 (38%)
tory specifically assesses social, self-help, motor, language Diagnosis leading to tracheostomy
development, and preschool achievement skills. The CDI Upper airway 3 (23%)
derives a total development score and developmental age Lower airway 7 (54%)
estimates.21 Both upper and lower airway 3 (23%)
All the above behavioral and developmental measures
have been shown to have good internal consistency and Control characteristics
construct validity.18-21
Characteristic N (%)

Controls Gender, male 8 (62%)

For the purpose of comparing children with feeding disor-
ders who do not have tracheostomy with the children with
feeding disorders that do have tracheostomies, a sample
was drawn from an existing clinical database of children
previously diagnosed with a feeding disorder. The children
with tracheostomy were matched according to their age, sex,
race, and general development with other children receiving
treatment at the FSNC.
Data Analysis
Participants. Paired samples t-tests were conducted on
demographic and developmental variables of sex, race, age,
and general development (as measured by the total CDI
score) to ensure appropriate matching and to determine
whether factors unrelated to tracheostomy status could
confound the study results. Additionally, paired samples
t-tests were conducted on measures of caregiver stress
(based on the PSI).
Anthropometric and Nutrition. To obtain comparative data
regarding anthropometric, nutrition, gastrointestinal, and
oral feeding, χ 2 analyses were conducted on weight-for-
age z-scores, height-for-age z-scores, BMI-for-age z-scores,
and oral vs enteral feeding. Percentages of children who
are physically able to accept thin liquids across groups and
children who can accept thickened liquids across groups
were also evaluated by χ 2 analyses.
Behavioral. To detect behavioral differences between chil-
dren with tracheostomy and a community sample, a one-
sample t-test was conducted comparing the tracheostomy
group with the mean and SD values of total score and
subscales of the MBQ and subscales of the AYCE. To detect
Race
White 8 (62%)
African American 2 (15%)
Other 3 (23%)
Age Median 60 months (IQR, 28-78)
a IQR, interquartile range.
behavioral differences between children with tracheostomy
and children with known feeding disorders, matched sample
t-tests were conducted on total score and subscales of the
MBQ and subscales of the AYCE. Independent sample
t-tests were also conducted to detect differences between
groups on a measure of caregiver stress (based on the PSI),
including a total score and subscales of parent distress,
parent-child difficult interactions, and difficult child.
Results
Thirteen tracheostomy-dependent children underwent eval-
uation at FSNC during the study period (Table 1).
Tracheostomy Characteristics
Of the 13 children who underwent evaluation at the FSNC,
all children had their tracheostomy placed within 7 months
of birth. Only 5 children (38%) required home mechanical
ventilation. Tracheostomy cuff was used inpatient for
4 children (31%) with only 3 of those children (23%)
needing a cuff as an outpatient. All children in the study
were weaned off mechanical ventilation and ultimately
decannulated. Eleven children (84%) attempted a one-
way speaking valve prior to decannulation, with 1 child
attempting prior to initial discharge with tracheostomy.
Ten children (77%) attempted tracheostomy capping prior
to decannulation. Three children were unable to cap their
4 Nutrition in Clinical Practice 00(0)

Table 2. Comparison of Growth and Feeding in Children With Tracheostomy and Controls.

Tracheostomy (mean ± SD) Controls (mean ± SD) P-value

Anthropometric measurements
Weight-for-age z-score −1.32 ± 0.94 −1.02 ± 2.05 .029
Height-for-age z-score −1.77 ± 0.97 −1.02 ± 1.49 .091
Body mass index (BMI)–for-age z-score 0.15 ± 1.01 −0.27 ± 1.67 .047
Oral vs enteral feeding
% of calories by enteral tube 55 ± 45.7 29.9 ± 43.4 .37
% of calories taken orally 45 ± 45.7 70.2 ± 43.4 .37

n (%) n (%) P-value

Acceptance of thin and thick liquids

% able to accept thin liquids 12 (92.3) 12 (92.3) 1.0
% able to accept thickened liquids 11 (84.6) 12( 92.3) .56

Table 3. Comparison of Delay in Acceptance of Various Food Consistencies in Children With A Tracheostomy and Controls.

Tracheostomy (mean ± SD) Controls (mean ± SD)

Delay in months P-value

Smooth purees 13.6 ± 19.5 2.5 ± 3.8 .059

Mashed foods 18.4 ± 20.8 4.6 ± 10.0 .06
Textured foods 23.8 ± 22.9 5.8 ± 10.3 .008*
Easily dissolvable solids 24.2 ± 21.9 8.1 ± 12.4 .052
Combination foods 28.4 ± 23.9 7.8 ± 12.3 .003
Diced solids 27.9 ± 23.3 7.5 ± 12.4 .01*
Toddler foods 26.1 ± 23.1 7.5 ± 12.5 .01*
General diet 24.8 ± 22.3 13.3 ± 19.2 .3

*p < 0.05.

tracheostomy due to upper airway obstruction, requiring
laryngotracheal construction prior to decannulation.
Anthropometric and Nutrition Data
Median age at evaluation in FSNC was 51 months (in-
terquartile range, 26–69). The majority of children (8/13;
62%) underwent evaluation after decannulation. Of the
5 children who were ventilator dependent, none required
mechanical ventilation at the time of evaluation in FSNC.
Tracheostomy-dependent children had lower weight-for-age
and height-for-age z-scores when compared with controls
with feeding disorders. Their BMI-for-age z-scores were
normal (Table 2). Six of the 13 children with tracheostomy
(46.1%) and 3 of 13 controls (23.1%) had height z-scores <
−2, but none in either group had height z-scores < −3.
Children with a tracheostomy were statically more likely
to have an enteral feeding tube than controls (10 vs 5,
respectively; P = .047). All children who required an enteral
feeding tube had a gastrostomy tube, except for 1 child with
a tracheostomy who had a gastrojejunal tube. The children
with tracheostomy were receiving a larger percentage of
their energy needs via enteral nutrition (55 ± 45.7) vs
controls (29.9 ± 43.4), but the results were not statistically
significant (P = .37) (Table 2). All children were receiving the
rest of their energy intake orally (ie, 45% [± 54.7] in children
with tracheostomy vs 70.1% [± 56.6] in the controls).
At the initial presentation to the feeding clinic, there was
no difference in the ability of patients with tracheostomy
and controls to accept thin liquids (12; 92.3% vs 12; 92.3%;
P = 1.0) or thickened liquids (11; 84.6% vs 12; 92.3%; P =
0.56) (Table 2). None of the children had any restrictions in
regard to solid-food consumption.
There was a delay in acceptance of most food textures by
children with a tracheostomy when compared with controls
(Table 3).
There was no statistically significant difference between
children with tracheostomy and controls in regard to CDI,
ages, aspiration on last swallow study, gagging, abdominal
pain, constipation, vomiting, diarrhea, acid-suppression
medication, food allergies, and environmental allergies (data
not shown).
Henningfeld et al 5

Figure 1. Frequency of feeding-disorder subtypes in children with tracheostomy and controls, based on the Mealtime Behavior
Questionnaire (MBQ) and About Your Child’s Eating (AYCE) questionnaires. Measure subscales and ranges: Mealtime Behavior
Questionnaire total score (33–165): distraction/avoidance (10–50), food manipulation (6–30), aggression (6–30), and choking,
gagging, vomiting (3–15); About Your Child’s Eating total score (1–100): child resistance to eating (11–55), positive mealtime
environment (4–20), and parent aversion to mealtime (5–25).

Mealtime Behaviors Children with tracheostomy appear to have worse feed-

When compared with matched controls on a measure of
mealtime behavior problems, the tracheostomy-dependent
children had significantly lower distraction/avoidance, more
food manipulation problems, less mealtime aggression,
higher choking/gagging/vomiting, and a higher total scale
score. On a measure of caregiver/child feeding interac-
tions, the tracheostomy-dependent children had signifi-
cantly higher resistance to eating when compared with
controls; however, tracheostomy-dependent children and
controls had no difference between mealtime environment
and parent aversion to eating (Figure 1).
Discussion
Our preliminary study is one of the first detailed explo-
rations of feeding disorders in a small group of children
with tracheostomy. All of these tracheostomy-dependent
children met the criteria for pediatric feeding disorder
by exhibiting significant feeding issues, including over-
all feeding-skill issues, poor overall growth, and psy-
chological issues associated with feeding and mealtime
behaviors.
ing disorders than other children with feeding disorders.
They are much more likely to have a gastrostomy tube
than matched controls. Our small study suggests that
tracheostomy-dependent children have a trend toward re-
ceiving more calories via the enteric tube. Their ability
to accept liquid safely at the time of evaluation was no
different than from controls; however, there were delays
in dietary progression through various dietary textures.
Interestingly, our study did not demonstrate any increase
in feeding disorders in children who required mechanical
ventilation, cuffed tracheostomy, or the use of a speaking
valve or tracheostomy capping prior to decannulation. The
discovery of feeding disorders and lack of identifiable risk
factors within the tracheostomy-dependent population in
this study may reflect the timing of the tracheostomy.
Since tracheostomies are often placed following prolonged
intubation at young ages, oral aversion is common. Addi-
tionally, the tracheostomy is often placed or remains in place
during critical windows of feeding-skills development, and
therefore, feeding skills are likely to be impacted.
Adult literature supports the use of a speaking valve to
help decrease aspiration and gain oral skills;22,23 however,
this has not been supported by pediatric data.24 We also did
6 Nutrition in Clinical Practice 00(0)
not find a significant correlation between speaking valve and
feeding disorders in our pediatric population, but to draw
conclusions from our study would be premature because
of the small sample size. The discordance between adult
and pediatric data may be explained by the fact adults
often had normal swallowing mechanics prior to an insult
requiring placement of a tracheostomy, whereas children
with tracheostomy often never acquired normal swallowing
skills prior to tracheostomy. That said, there are significant
theoretical benefits to the speaking valve, and early use of
the speaking valve should be encouraged until more data
are available.
Overall, the tracheostomy-dependent children had very
low weights and heights. Since the heights were much more
affected than the weights, they had normal BMIs. Given
that most of these children had gastrostomy tubes, it is
likely that their weights were being managed through use
of these tubes, leading to normal BMIs. Six of the children
had height z-scores < −2, but none had height z-scores
< −3; such scores would have qualified these children for
chronic malnutrition, based on World Health Organization
(WHO) criteria25 but not on the American Society for
Parenteral and Enteral Nutrition/Academy of Nutrition
and Dietetics (AND) criteria.26 Stunting, based on the
WHO criterion (height z-score < −2), is a well-established
risk marker of poor child development. Stunting before the
age of 2 years predicts poorer cognitive and educational
outcomes in later childhood and adolescence.27,28 Stunting
is also associated with a reduction in schooling, lower test
performances, lower household per capita expenditure, and
a greater likelihood of living in poverty in the developing
world.29 Our findings are similar to the stunted growth
seen in children with extremely low birth weight30 and
hypoplastic left heart syndrome,31 likely reflecting that these
children had significant medical problems commencing at
birth.
As children progress toward liberation from respiratory
technology, they also make gains in lungs maturation and
developmental gains outside of their airway , such as
requiring less speech, physical, and occupational therapy
and a decreased incidence of gastrostomy tube requirement
at the time of decannulation when compared with tra-
cheostomy placement.30 This study shows the progression
of oral skills is associated with feeding problems that are
likely associated with their airway management, resulting in
food manipulation problems and a higher rate of choking,
gagging, and vomiting. Surprisingly, these children also
have significantly lower rates of distraction/avoidance and
mealtime aggression; yet caregivers of these children also
describe them as showing greater resistance to eating and
report overall lower rates of positive mealtime environments
and higher caregiver aversion to mealtimes. It seems likely
that these are characteristics of a feeding dynamic related
to skills and safety concerns. Close supervision of skills
and safety should be emphasized, and caregivers should
be provided with ample support to prevent the onset of
behavioral etiologies of further feeding problems.
This study has limitations. First, this study represents a
very small cohort of a much larger tracheostomy-dependent
population because of our selection criteria. Further study
of all children with tracheostomy would help capture those
tracheostomy-dependent children who will never eat orally
because of a variety of factors, children who always ate by
mouth without feeding issues, and children with feeding dys-
function who have the potential to eat by mouth but are not
being actively advanced toward oral feedings by their care-
givers or therapists. This small cohort also limits our ability
to show statistical significance and may underestimate the
differences between the aged-matched controls. Second, it
is a retrospective study and does not show the progression
of skills over time. Prospective multi-institutional studies
across the continuum of pediatric tracheostomy are needed
to further characterize the feeding disorders in this cohort.
One of the goals of pediatric tracheostomy is to allow
children to achieve their full developmental potential. This
study emphasizes the need to support children outside
of their airway and mechanical ventilation. Pediatric tra-
cheostomy programs should increase collaboration with a
variety of other specialists, such as registered dietitians,
speech therapists, occupational therapists, gastroenterolo-
gists, and psychologists, to help children maximize their
full global developmental potential while they are acquiring
oral-feeding skills.
Statement of Authorship
J. Henningfeld contributed to the design of the work, collected
data, wrote the first draft, and approved the final manuscript;
C. Lang contributed to the design of the work, helped with
manuscript redrafting, and approved the final manuscript; G.
Erato collected data, helped with manuscript redrafting, and
approved the final manuscript; A. H. Silverman contributed
to the design of the work, helped with manuscript redrafting,
and approved the final manuscript; P. S. Goday contributed to
the design of the work, interpretation of the data, helped with
manuscript redrafting, and approved the final manuscript.
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