PEDIATRIC FEEDING

SCREENING PACKET

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 FEED THE PEDS ®
I I

#StartHere
( ) Print this off!

( ) Review Feeding Development Chart

( ) Complete Feeding Screening Form

( ) Fill Out Screening Results Form

( ) Make Any Necessary Referrals

( ) Share Results with Patient/Family/Team

All information, content and materials of this pediatric screener is intended for
use by only qualified medical providers and is to be used as a screening tool to
determine if further assessment is warranted. It is not intended to be used as a
comprehensive feeding evaluation or comprehensive diagnostic tool.

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 Feedi n g Development
Name: -------Age: ----Date: ----
Concerns:
C
·-
0 Jaw Lips Tongue .,
m
0 ID 0
Q
I
LL Seals; ,...
w w
·-
0, Phasic Cups .,
0

-C
Bite
Functions
as unit with
m
0
w � :::: w
C tongue, cheeks ,
0- I.. Protrusion
palate
Munch &
Chew Retraction
,,
I..
(/)
Active lip 0
0-

'°
0
Diagonal movements ::::,
Q
::::,
Chew Latera Iization
Strips food n
'° -
·-
0,
C ""C a, from spoon ,,
C

�
C
C
.....
·-
N � ..... ·-
""C
C
I.. 0
Improved
"'C ....,
V)
...... 3:
a, 0 Q) lip closure
>- ..c:
V)

u
�
N I..
�
·-C:
...,0C
C
ro
- .....
� �
�
CX)
Cl)
s...
nl Jaw-lip-tongue dissociation
0
a:::
�
<(
(/)
......... ·-
""C
s...
�
CX)
"'C 0 CX)
C V) nl
::::, a,
N
� 0:::
""C
::::J Sweeps N
�
nJ
:::c u Chews with
0
s... food from
lips closed
u .,
"T1
0
lips
.....
I..

N a. C: N
� E Tongue Tip Elevation �
I ::::, 0 I

w --,
u during swallow w
0- 0-

Skills typically mastered by 36 months.

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F E E D T H E p E D s TM Name: -------Age: ---- Date: ----
I I Concerns:

,,
Q Drooling 0 Exaggerated Q Bunched
0 Breast tD
tD
Q Gagging 0 Stable Q Exaggerated
0 Bottle
Q Choking 0 Thrusting Q Thrusting
0 SNS -·
Qoral habit 0 Clenching Q Functional Q Spoon
::,
Q Tonic bite Ul
Q Cup
Q Retraction Q Straw
Q Thick liquids
0 Functional n
Q Thin liquids
0 Impaired
Q Feeding
Tube .,
Q Pureed
Q Functional tD
Qsoft solid Q Impaired tD
Q Independent
Q Hard solid
Q Competent
0 Assisted -·
::,
Q Incompetent ::,
SENSORY Q Symmetrical
0 Supervision Ul
QMixed
,,
Q Asymmetrical

Q Hyposensitive Q Mesocephalic Q High

0 Posterior
Pelvic Tilt 0
Q Hypersensitive Q Dolchocephalie
Q Low 0 Anterior
Pelvic Tilt
.,
Qoefensive
Q Brachycephalic Q Fluctuating 0 Other: 3
 FEED THE PEDS®
Name: ------Age: ---- Date: ----
Further Assessment Needed (circle one): YES NO

• •ml!\n�

E --,
Si..
0
LL

Cl) (/)

- �

::J
Cl)
Q)
c:::
a,
::::,
0)
C
0
bO
C:
·-
C: (/)
�
Q) a,
a,
Q) ..c
Si..
u
(/)
0
(/)
C
a,
U)

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 FEED THE PEDS®

Referral Form

Patient Name: ______________ DOB: _____

Referring Provider: ___________ Date: _____

Please evaluate for the following:

Additional Comments:

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 References

l. Alexander R., Boehme R. & Cupps B. (1993). Normal Development of Functional Motor Skills: The First Year of
Life. Therapy Skill Builders. AZ.
2. Bahr, D. (2018). Feed your baby & toddler right: Early eating and drinking skills encourage the best
development. Future Horizons: Arlington, TX.
3. Folio, M. & Fewell, R. (2000). Peabody motor development chart. PDMS-2: Peabody
4. Developmental Motor Scales-Second Edition. Austin, TX: Pro-Ed.
5. M orris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for feeding development.
(2nd ed.). San Antonio, TX: Therapy Skill Builders.
6. Overland, L. & M erkel-Walsh, R. (2013). A sensory motor approach to feeding. Charleston, SC: Talktools.
7. Touwen, B.C.L., 1976. Neurological Development in Infancy. Clin Dev Med No. 58. Heinemann Medical Books,
London.
8. Sampallo-Pedroza, R.M ., Cardona-Lopez, L..F., & Ramirez-Gomez, K.E. (2015). Description of oral-motor
development from birth to six years of age. Revista de la Facultad de M edicin), 62(4):593 - 604. DOI:
http://dx.doi.org/10.15446/revfacmed.v62n4.452ll

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