bs_bs_banner

Journal of Intellectual Disability Research doi: 10.1111/jir.12617

992
VOLUME 63 PART 8 pp 992–1014 AUGUST 2019

Feeding and swallowing difficulties in children with Down

syndrome
M. A. Anil,1 S. Shabnam2 & S. Narayanan3
1 Masters in Speech Language Pathology, Department of Audiology and Speech Language Pathology, Kasturba Medical College,
Mangalore, Manipal Academy of Higher Education, Manipal, India
2 Masters in Speech Language Pathology, Department of Speech-Language Pathology, All India Institute of Speech and Hearing,
Mysuru, India
3 Department of Speech-Language Pathology, All India Institute of Speech and Hearing, Mysuru, India

Abstract poor orosensorimotor abilities which could have lead

Background The anatomical and physiological
characteristics such as neuromotor coordination
impairments and craniofacial and structural
abnormalities frequently interfere with the acquisition
of effective oral-motor skills which can in turn result
in the development of potential feeding problems and
swallowing dysfunction. The present study was un-
dertaken with the aim of assessing the feeding and
swallowing problems, if any, in children with Down
syndrome in the age range of 2–7 years.
Methods A questionnaire was formulated and
administered on 17 children with Down syndrome (10
females and 7 males) and 47 typically developing
children (20 females and 27 males).
Results The present study revealed that feeding
difficulties were predominantly present in children
with Down syndrome. These difficulties were found
in all the three phases of swallow and were greatest for
solids followed by liquids. They also had issues with
physical, functional and emotional aspects of feeding.
Further, the children with Down syndrome exhibited
Correspondence: M. A. Anil, Assistant Professor-Senior Scale,
Masters in Speech Language Pathology, Department of Audiology
and Speech Language Pathology, Kasturba Medical College,
Mangalore, Manipal Academy of Higher Education, Manipal, India
(e-mail: aa.malvika@gmail.com, malavika.aa@manipal.edu)
to the difficulties in feeding.
Conclusions The study highlights the importance of
including feeding assessment in the evaluation
protocol of infants and children with Down
syndrome.
Keywords Assessment, Down syndrome, Feeding,
Swallowing
Introduction
Feeding problems are commonly seen in children
with different genetic conditions, which arise as a
result of the complex interaction between medical,
anatomical, physiological and behavioural factors.
Down syndrome is one such genetic condition in
which feeding problems have been frequently
documented. It is one of the most common genetic
syndromes, occurring in 1 of 800 to 1000 live births
(Baird & Sadovnick 1989). The anatomical and
physiological characteristics such as neuromotor
coordination impairments, craniofacial and structural
abnormalities and dysfunctions can have direct and
indirect consequences on feeding (Cooper-Brown
et al. 2008). Studies of oral feeding in children with
Down syndrome (CWDS), particularly young
children, have shown a 50–80% frequency of feeding

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research
993
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome
problems (Pipes & Holm 1980; Van Dyke et al. 1990).
Children with Down syndrome have unique
anatomical and structural features which typically
impact on the functioning of eating, drinking and
swallowing mechanism. Along with oral-motor
problems, frequent dental anomalies such as
periodontal disease, tooth loss and severe bruxism
increases the risk of developing feeding problems in
them. The oral dysmorphology because of
malocclusion can prevent adequate chewing and
grinding of foods.
Longitudinal studies (Calvert et al. 1976; Pipes &
Holm 1980; Cullen et al. 1981; Aumonier &
Cunningham 1983; Spender et al. 1996) have
identified several issues in CWDS pertaining to
breast and bottle feeding, mastication, sucking,
transitioning to food textures and behavioural
problems such as refusal to swallow, spitting or
retention of food in mouth. Studies have reported
the abnormalities in the oral and pharyngeal phase
of swallow in CWDS. Spender et al. in 1996
reported oral-motor dysfunction in CWDS with
significant difficulty in eating solid foods. They also
displayed delayed acceptance of food, the poorly
coordinated movement for food from lips to the
pharynx, delayed initiation of feeding sequences for
solid and cracker texture and an overall decreased
control of the jaw. Faulks et al. (2008) identified
masticatory problems and reduced masticatory
efficiency in individuals with Down syndrome, as a
result of dental anomalies, dysmorphology, muscle
weakness and poor neuromotor control. Field et al.
(2003) revealed a high prevalence of texture
selectivity, oral-motor problems and swallowing
difficulties in CWDS. Mohamed et al. (2013) found
CWDS to have difficulties in chewing, swallowing
and food rejection. Chewing was also found to be
affected in a clinical evaluation of eating behaviour
where chewing was characterised by forward
placement of the tongue, the absence of the
maturational patterns and prolonged masticatory
cycle (Gisel et al. 1984). Several researchers have
also reported abnormalities in oesophageal phase.
Craig et al. (1982) found abnormalities in
oesophageal function in CWDS. Literature also
reports a high incidence of oesophageal atresia and
tracheoesophageal fistula in CWDS (Bianca et al.
2002). Abnormalities in oesophageal peristalsis and
lower oesophageal sphincter function leading to loss
© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
VOLUME 63 PART 8 AUGUST 2019
of food, food refusal, vomiting, gastroesophageal
reflux disease, choking and weight loss were also
observed (Wallace 2007).
With the birth of a child in the family with Down
syndrome, parents initially are in a state of shock,
concern, disappointment, anger, frustration and grief
(Lewis & Kritzinger 2004). In addition, the presence
of feeding problems that are seen in these children can
cause a negative impact on the life of their
parents/caregivers. The feeding problems can also
cause activity limitations and participation restrictions
which can lead to emotional problems. For example,
children often feel disappointed and frustrated when
they cannot eat along with their peers in their school
or with their family in a social gathering. This in turn
can affect their quality of life. The feeding problems
could affect the day-to-day functioning and their
social and emotional life, and he/she could perceive
the feeding problems as a big handicap.
Need for the study
Although some western studies have been carried out
to identify the nature of feeding problems in CWDS,
these are limited. Most of the studies have been
carried out on infants with Down syndrome. Since
feeding is a skill that develops by 2 years of age and
refines till 6 years of age (Delaney & Arvedson 2008),
it is essential to study the children in this age group as
well. Moreover, there is a dearth of studies
investigating the impact of feeding problems on the
child, which may, in turn, hinder the progress of the
child during the intervention. Meyer et al. (1994)
reported that the behaviours of both caretaker and
infant during feeding contribute significantly to the
overall success of the feeding interaction as well as
feeding performance. Parents/caregivers play an
important role in feeding the child, as they have the
first-hand exposure and experience in feeding their
child, awareness of the child’s feeding behaviours,
likes and dislikes of food and communication
behaviour during hunger. Consequently, they are the
best people to describe their child’s feeding problems.
Hence, this study involves the administration of a
questionnaire on the parent/caregiver to elicit
information about the physical, functional and
emotional aspects of feeding. Such studies in the
Indian context are limited. The paucity of literature
makes it clear that there are deeper underlying
 Journal of Intellectual Disability Research
994
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome
complex issues about feeding in CWDS that needs to
be investigated. The in-depth assessment of feeding
skills will provide valuable input to the speech-
language clinician during the treatment of feeding
problems in CWDS. This would help the speech-
language clinician in planning and prioritising the
goals during therapy. The information will also help
in counselling the caregivers, deciding the success or
failure of feeding therapy and thereby help in
predicting the prognosis of the child.
Aim
The present study aimed at assessing the feeding and
swallowing problems, if any, in children with Down
syndrome in the age range of 2–7 years. The specific
objectives of the study were as follows:
1. To assess the feeding and swallowing problems
in the oral, pharyngeal and oesophageal phases
in children with Down syndrome.
2. To assess the impact of feeding problems on the
physical, functional and emotional domains in
children with Down syndrome.
Method
The study was carried out in three phases. The first
phase involved the formulation of a questionnaire to
Number of speech-language pathologists who rated the item as‘ 4’ or‘ 5’
Content validity index ¼
Total number of speech-language pathologists involved in validation
assess feeding problems faced by CWDS. The
questionnaire was prepared by collating information
from literature, and the complaints concerning
feeding received from the clients registered in the
Special Clinic for Motor Speech Disorders,
Department of Clinical Services, All India Institute of
Speech and Hearing, Mysuru. The questions focused
on the physical problems faced by the children during
feeding and swallowing. There were questions which
focused on orosensorimotor issues, general feeding
issues, feeding history, modifications during feeding
© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
VOLUME 63 PART 8 AUGUST 2019
and the different phases of the swallow. The questions
were grouped under four sections: (1) demographic
data and general history which included the personal
details of the child, general history (prenatal, natal,
postnatal history) and details of different evaluations
(speech and language, psychology evaluation); (2)
craniofacial and orosensory assessment which in-
cluded craniofacial assessment, oral hygiene and
orosensory assessment; (3) feeding history which in-
cluded general feeding issues, feeding history and
modifications during feeding; and (4) assessment of
different phases of swallow which included questions
to assess the oral preparatory phase, oral phase, pha-
ryngeal phase and oesophageal phase of the swallow.
Each statement in the phases of swallow was accom-
panied with response choice of ‘no’ (a score of zero)
or ‘yes’ (a score of 1).
The content validity of the questionnaire and the
rating scale were assessed by obtaining the feedback
from three experienced speech-language pathologists.
They were asked to judge the appropriateness of the
questions included and the rating scale used. For each
of the item and domain in the questionnaire, experts
were instructed to provide a Likert style rating on a 5-
point scale where ‘1’ indicated extremely irrelevant,
‘2’ as irrelevant, ‘3’ as cannot say, ‘4’ as relevant and
‘5’ as extremely relevant. The formula used for the
calculation of the content validity index has been
provided below.
Any domain/question which obtained the content
validity score of greater than 0.8 was considered in the
final version of the questionnaire. A pilot study was
carried out on 10 CWDS and 10 typically developing
children, following which the final version of the
questionnaire was prepared.
In the second phase, the developed questionnaire
‘Questionnaire to Assess Feeding Problems in
Children with Down Syndrome’ given in Appendix 1
was administered on 17 CWDS (10 females and 7
males), and age and socioeconomic status matched 47
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
995
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

typically developing children (20 females and 27
males). The questionnaire was administered on the
parents/caregivers of CWDS. Video recording of the
feeding sessions was carried out to facilitate a better
understanding of the feeding problems presented by
the children as well as for later analysis. The children
were given different items to eat and drink (e.g.
biscuit: one Marie biscuit, a banana: a whole banana,
water: a glass of water, etc.) to permit a first-hand
observation of the feeding skills, and the feeding
problems faced by them were noted. The oromotor
abilities were assessed by administering the Com-
DEALL checklist for the assessment of oromotor
skills in toddlers (Archana 2008), which consists of
three domains, i.e. jaw movement, tongue
movements and lip movement with a total of 24
questions in it. The responses were rated on a 3-point
rating scale, where ‘0’ signified absent, ‘1’ signified
only spontaneously present and ‘2’ signified
consistently present, and a higher score on this
checklist indicates better oromotor abilities.
In the third phase, the Feeding Handicap Index
for Children (FHI-C) (Swapna & Srushti 2017)
given in Appendix 2 was also administered on the
parents of these children to measure the
handicapping effect of feeding issues in them from
parents’ perspective. The FHI comprised of a total
of 38 items, with 21 items in the physical domain,
12 in functional and 5 in the emotional domain.
Each item was scored on a 3-point rating scale,
where ‘never’ signified no problem (score: 0),
‘sometimes’ signified problem is seen sometimes
(score: 1) and ‘always’ signified problem is always
seen (score: 2). The possible range of total FHI
score that can be obtained by a child varied from 0
to 76 and the possible range for the scores on
physical, functional and emotional domains varied
from 0 to 42, 0–24 and 0–10, respectively. The
responses obtained from the parents/caregivers were
documented based on the rating scale.
Statistical analysis
The total scores obtained from the questionnaire
and FHI-C from all the participants were totalled
and statistically analysed. SPSS version 20 software
was used for the statistical analysis. Descriptive
statistics were used to obtain mean, and standard
deviation of scores obtained. Mann–Whitney U test
was carried out to compare the data across both the
groups. Friedman test was conducted to determine
whether there was a significant difference between
scores obtained in oral, pharyngeal and oesophageal
phase.
Results
The results have been presented under different
sections below:
Comparison between the groups on feeding
and swallowing
The clinical group (CWDS) was compared with the
control group (typically developing children) for the
total scores obtained on the phases of the swallow. A
higher score on the questionnaire indicated greater
feeding difficulties. The mean and standard deviation
obtained have been depicted in Table 1. On

Table 1 Mean ± standard deviation (SD) and |z| value of both the groups on phases of swallow

Phases of swallow N Clinical group N Control group |z| value

Oral phase (solids) 17 6.76 ± 4.75 47 0.34 ± 0.75 5.62*

Oral phase (liquids) 17 3.58 ± 4.13 47 0.06 ± 0.24 4.79*
Pharyngeal phase (solids) 17 4.76 ± 2.88 47 0.34 ± 0.81 6.17*
Pharyngeal phase (liquids) 17 1.17 ± 1.70 47 0.04 ± 0.20 4.59*
Oesophageal phase 17 0.64 ± 1.05 47 0.08 ± 0.40 2.85**
Total score 17 18.17 ± 13.55 47 0.89 ± 1.50 6.18*

Values are given as mean ± SD.

*P < 0.001.
**P < 0.01.

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research
996
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome
comparison, it was observed that the total mean
scores were higher for the clinical group than for the
control group. The results of the Mann–Whitney U
test revealed that there was a statistically significant
difference between the two groups across all the
phases of the swallow.
The feeding problems in CWDS were compared
across each phase (oral, pharyngeal, oesophageal).
The mean score for oral phase was found to be
highest followed by pharyngeal phase and
oesophageal phase. Friedman test was conducted to
determine whether there was a significant difference
between scores obtained in each phase. Results of
the analysis rendered a χ2 (2) = 5.29, P > 0.05
which was not statistically significant. The mean and
standard deviation obtained have been depicted in
Table 2.
In the oral phase, 52.9% of CWDS exhibited a
developmentally immature chewing pattern
(munching pattern). The oral manipulation for food
items was difficult for CWDS leading to loss of
food. They had poor bolus control and
manipulation and difficulty with swallowing large,
poorly chewed morsels. Because of the delay in the
initiation of oral movements and partly because of
pauses within each masticatory cycle, nearly 23.5%
of CWDS held food longer in the mouth without
chewing. Three out of 17 CWDS demonstrated
poor lip seal during swallowing leading to loss of
food while swallowing. Swallowing was found to be
compromised in CWDS because of lack of anterior
seal and poor sweeping action of the tongue,
thereby making bolus transit inefficient. Primitive
forward–backward movement of the tongue along
with tongue thrusting while swallowing was evident
in nearly 29.4% of CWDS. The poor lateralisation
Table 2 Mean ± standard deviation (SD) of the clinical group for
the scores across phases of swallow
Phases of swallow N Mean ± SD
Oral phase 17 20.92 + 15.77
Pharyngeal phase 17 14.14 + 10.15
Oesophageal phase 17 10.78 + 17.61
Values are given as mean ± SD.
© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
VOLUME 63 PART 8 AUGUST 2019
of tongue led to the pooling of food in the lateral
and anterior sulcus in 64.7% of CWDS. Of CWDS,
52.9% demonstrated a lack of awareness of food
residue in the mouth post swallow.
In the pharyngeal phase, 29.4% of CWDS retained
food in mouth after chewing, which could be
attributed to the delay in the initiation of
oropharyngeal movement for swallow. Few parents
complained of aspiration (occasionally) in their
children for both solid and liquid food items.
A few problems with the oesophageal phase were
also seen in the clinical group. Of CDWS, 11.7%
occasionally vomited after feeding and 23.5%
indicated of food being stuck at the lower
throat/chest and had burning sensation in mouth or
throat.
Within the oral and the pharyngeal phases of
swallow, the feeding difficulties were rated
separately for food items based on solids and
liquids. The mean score for solid (6.76 ± 4.75)
bolus was greater than liquid bolus (3.58 ± 4.1) for
the oral phase. For the pharyngeal phase too, the
mean score of solid bolus (4.76 ± 2.88) was greater
than the liquid bolus (1.17 ± 1.7). The overall total
mean score was found to be greater for a solid food
item, which indicated that CWDS had greater
feeding issues with solid food items. Wilcoxon
signed ranks test indicated that scores obtained for
solid versus liquid of the oral phase (z = 3.31,
P < 0.001) and pharyngeal phase (z = 3.53,
P < 0.001) were significant.
Comparison between groups on Feeding
Handicap Index for children
The mean scores obtained on the FHI-C were
compared between the groups. A higher score on this
tool indicated greater feeding difficulties. It was seen
that the clinical group had higher scores which
indicated greater physical, functional and emotional
problems related to feeding in them. Further, the
results of the Mann–Whitney test revealed that there
was a significant difference between the two groups
on the total FHI score and individually on the
physical, functional and emotional domains on the
FHI-C. The mean, standard deviation and /z/ values
obtained on the FHI-C for both the groups have been
depicted in Table 3 below:
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
997
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

Table 3 Mean, standard deviation and /z/ values obtained on the the score for tongue versus lip movements was
FHI for both the groups
significant (z = 3.15, P < 0.05), and the score for lip
versus jaw movement were also significant (z = 2.04,
Parameters Clinical group Control group /z/ value P < 0.05). The mean and standard deviation values for
the clinical group were computed using descriptive
Physical 10.38 ± 4.25 2.23 ± 2.62 5.071* statistics and have been depicted in Table 5.
Functional 4.12 ± 2.72 1.47 ± 0.86 4.214* The results revealed that the tongue movements
Emotional 2.19 ± 2.10 0.93 ± 1.04 2.098*
were highly affected followed by jaw movement and
Total FHI 16.69 ± 7.01 4.63 ± 3.25 5.144*
lip movement. In the present study, nearly 58% of
Values are given as mean ± SD.
CWDS had difficulty in lateralising the tongue
*p< 0.001. outside the mouth, and 82% of them had difficulty in
lateralising the tongue inside the mouth. Tongue tip
elevation was affected in 65% of the CWDS. The
Comparison of oromotor abilities across impairment in muscle control and coordination leads
groups to restricted tongue movements and poor tongue
The scores obtained for each child for each domain of coordination. Forty-seven per cent of the CWDS
Com-DEALL Oromotor Checklist in both groups demonstrated hypotonicity in the lips, while 57%
were totalled. It was observed that the mean scores for demonstrated hypotonicity of tongue. The large
oromotor abilities were greater for the control group hypotonic tongue present in seven CWDS coupled
than for the clinical group indicating greater oromotor with poor oromotor skills affected the ability of the
problems in the clinical group. Mann–Whitney U test tongue to crush food against the palate to form a
revealed that the clinical group had significantly cohesive bolus. The open mouth posture seen in 18%
higher scores than the control group. The mean, of the CWDS in the present study during rest could
standard deviation values and |z| values have been be related to the low muscle tone in the lips, jaw
depicted in Table 4. instability or loose ligaments in the
Since the clinical group demonstrated oromotor temporomandibular joint.
problems, the data were further analysed to see which
Table 5 Mean ± standard deviation (SD) of the clinical group for
structure was most affected and thereby contributed to
the scores across oromotor abilities
the feeding and swallowing difficulties. Friedman test
was conducted to determine whether there was a
Oromotor skills N Mean ± SD
difference in scores obtained across the jaw, tongue
and lip movement. Results of the analysis rendered a
χ2 (2) = 7.614, P < 0.05 which was statistically Jaw movement 17 72.54 + 23.89
Tongue movement 17 65.00 + 21.06
significant. A post hoc comparison of the scores of the Lip movement 17 83.45 + 19.00
oromotor abilities was conducted using the Wilcoxon
signed ranks test. Results of this analysis indicated that Values are given as mean ± SD.

Table 4 Mean ± standard deviation (SD) and |z| value of both the groups for the scores across oromotor abilities and phases of swallow

Oromotor skills N Clinical group N Control group |z| value

Jaw movements 17 8.70 ± 2.86 47 11.89 ± 0.42 5.55*

Tongue movements 17 12.70 ± 3.85 47 19.36 ± 1.46 6.33*
Lips movements 17 13.35 ± 3.04 47 15.57 ± 0.94 3.52*
Total score 17 34.76 ± 8.32 47 46.82 ± 2.52 6.15*

Values are given as mean ± SD.

*P < 0.001.

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research
998
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome
Sensory issues can also affect mastication leading to
poor oral exploration, difficulty in transitioning to
food of different textures and an inability to initiate,
grade or sustain oral patterns for feeding and
swallowing. In the present study, 35.3% of CWDS
demonstrated difficulty in transitioning to varied
textured food. Seventeen per cent of CWDS
demonstrated reduced perception of light touch on
the gum, and 41% of CWDS demonstrated difficulty
in biting while 47% demonstrated difficulty in
chewing solids and semisolids.
Discussion
The results of the study revealed several findings of
interest. First, there was a statistically significant
difference between the CWDS and typically
developing children on the extent of feeding
problems, with the feeding problems being present
to a greater extent in CWDC. Further, greater
problems were seen in the oral phase, followed by
pharyngeal phase and oesophageal phase; however,
these differences were not statistically significant.
The most prevalent feeding problem in the oral
phase was a developmentally immature chewing
pattern (munching). Food was held longer in the
mouth without chewing. Swallowing was found to
be compromised in CWDS because of lack of
anterior seal and poor sweeping action of the
tongue, thereby making bolus transit inefficient. The
commonly seen feeding problems in the oral phase
were absent jaw closure post food intake, coupled
with the difficulty in lateral movements of the
tongue leading to pooling of food in the lateral and
anterior sulcus and reduced anterior–posterior
tongue peristalsis with uncoordinated tongue
movements which led to difficulty in forming and
controlling bolus. It was also observed that CWDS
had difficulty in chewing with increased duration for
bolus manipulation and inappropriate oral transit
time. All these problems could be attributed to poor
oromotor mobility as revealed through Com-
DEALL. The feeding difficulties could also be
attributed to a cluster of behaviours associated with
oral hyposensitivity which were exhibited as poor or
reduced awareness of food on lips and tongue,
stuffing of food in the mouth and retention of food
in the mouth without chewing.
© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
VOLUME 63 PART 8 AUGUST 2019
Some of the most commonly observed problems in
the pharyngeal phase included retention of food in
mouth after chewing without swallowing which could
be attributed to the delay in the initiation of
oropharyngeal movement for swallow,
aspiration/choking during liquid intake. With respect
to the oesophageal phase, some of the most commonly
seen problem was vomiting after eating which could be
attributed to the swallowing of large poorly masticated
morsels or partly because of the reduced muscle tone
leading to poor digestion, oesophageal obstruction
and gastroesophageal reflux. They also indicated food
being stuck at the lower throat/chest and had burning
sensation in mouth or throat.
This result is in agreement with the studies done by
Mohamed et al. (2013) and Mitchell et al. (2003) who
found feeding difficulties in CWDS. Hennequin et al.
(2000) also found that suckling, swallowing and
chewing were delayed, and the feeding pattern was
found to be an intermediate pattern between a
primary suckle–swallow pattern and full rotary
chewing. They found that CWDS chewed food for
shorter periods because of lack of development of
mature masticatory pattern. Frazier and Friedman
(1996) also found in their study that CWDS faced
difficulties with advancing food textures, reduced
acceptance of food tastes, temperatures and smells.
They also reported that CWDS exhibited poor
awareness of food on lips, slow registration of food in
mouth, pocketing of food and stuffing of mouth
which indicated the cluster of behaviours associated
with oral hyposensitivity.
Within the oral and pharyngeal phases of a swallow,
feeding difficulties were scored for solids and liquids.
The results indicated that the children with Down
syndrome faced greater difficulties in solids than
liquids in both the phases of the swallow. The present
study is in consensus with the study conducted by
Mohamed et al. (2013) who found difficulties in the
transition from liquids to solids in CWDS. Gisel et al.
(1984) revealed that CWDS exhibited a reluctance to
chew and preferred sucking of food with decreased
masticatory efficiency when it comes to chewing
solids. They also found that CWDS tend to swallow
the food which may lead to overeating to compensate
for the loss of gustatory input. In the present study in
both the oral phase and pharyngeal phase, solids were
more affected than liquids indicating greater difficulty
in chewing and biting solids.
 Journal of Intellectual Disability Research
999
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome
Second, it was also seen that there was also a
significant difference between the groups on the
different domains of the FHI. This result signifies that
the feeding problems seen in CWDS affected their
physical, functional and emotional aspects of life. The
problems seen in the physical domain were
inadequate sucking, chewing, difficulty in eating with
fingers and/or spoon, difficulty drinking using straw,
difficulty drinking from cup/glass independently,
drooling, restricted tongue movement, inability to
rinse and spit, retention of food in mouth, difficulty in
swallowing and choking. They also had inappropriate
weight gain. Problems under functional domain
included spillage of food, aversion or avoidance of
specific food items, need for specific position while
feeding, need for smaller and frequent meal, need to
push the food back in the mouth, longer mealtime,
usage of liquid to swallow the food and need for use of
specific utensils while eating. Feeding problems
observed under emotional domain were expressing
dislike towards being dependent on others for feeding
and eating in social situations, refusal to eat and
temper tantrums during feeding.
Third, the CWDS exhibited significantly greater
number of oromotor problems compared with the
typically developing group. This could be attributed
to the hypotonicity in the oral structures leading to the
open mouth posture, poor jaw and lip closure, lack of
tight lip seal for sucking and difficulty in fine graded
jaw, tongue and lip movements which could have
affected eating and drinking. This finding is in
consensus with studies conducted by Mitchell et al.
(2003) and Field et al. (2003), where they discovered
a significantly higher prevalence of oral-motor
problems in CWDS associated with oral hypotonicity
leading to restricted tongue movements. Kumin and
Bahr (1999) revealed different degrees of hypotonia in
different oral structures where nearly 44%
demonstrated in lips and 80% in the tongue. Shapiro
et al. (1967) also reported that the lingual hypotonicity
in CWDS forms an obstacle to the development of
oral-motor coordination required for feeding.
Conclusions
To conclude, feeding difficulties are predominantly
present in CWDS. These difficulties were found in all
the three phases of swallow and were greatest for
solids followed by liquids. They also had issues with
© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
VOLUME 63 PART 8 AUGUST 2019
physical, functional and emotional aspects of feeding.
Further CWDS exhibited poor orosensorimotor
abilities which could have affected the feeding. The
study highlights the importance of including the
feeding assessment in the evaluation protocol of
infants and CWDS, which will help in counselling,
deciding the goals for feeding therapy and in
predicting the prognosis. Emphasis should also be
laid upon overcoming the activity limitations and
participation restrictions during feeding therapy,
which will help in improving the overall quality of life.
Although the study reached its aim, there were some
limitations. The sample size was limited regarding
and restricted to one geographical area. Hence, one
has to exercise caution before generalising the results.
A section on assessing oral apraxia could have been
included in the questionnaire, since it has been
reported that apraxia could be seen in some CWDS.
Source of funding
No external funding was received for the research
reported in the paper.
Conflict of Interest
We declare no conflict of interest in the paper titled
‘Feeding and Swallowing Difficulties in Children with
Down Syndrome’.
References
Archana G. (2008) A Manual from Communicaid: Assessment
of Oro Motor Skills in Toddlers. The Com DEALL Trust,
Bangalore.
Aumonier M. E. & Cunningham C. C. (1983) Breastfeeding
in infants with Down syndrome. Child: Care, Health and
Development 9, 357–76.
Baird P. A. & Sadovnick A. D. (1989) Life tables for Down
syndrome. Human genetics 82, 291–2.
Bianca S., Bianca M. & Ettore G. (2002) Oesophageal
atresia and Down syndrome. Down’s Syndrome, Research
and Practice 8, 29–30.
Calvert S. D., Vivian V. M. & Calvert G. P. (1976) Dietary
adequacy, feeding practices, and eating behavior of
children with Down’s syndrome. Journal of the American
Dietetic Association 69, 152–6.
Cooper-Brown L., Copeland S., Dailey S., Downey D.,
Petersen M. C., Stimson C. et al. (2008) Feeding and
swallowing dysfunction in genetic syndromes.
Developmental Disabilities Research Reviews 14, 147–57.
 Journal of Intellectual Disability Research
1000
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome
Craig H., Peter B. & Joyce G. (1982) Esophageal
dysfunction in Down’s syndrome. Journal of Pediatric
Gastroenterology and Nutrition 1, 101–4.
Cullen S. M., Cronk C. E., Pueschel S. M., Schnell R. R. &
Reed R. B. (1981) Social development and feeding
milestones of young Down syndrome children. American
Journal of Mental Deficiency 85, 410–15.
Delaney A. L. & Arvedson J. C. (2008) Development of
swallowing and feeding: prenatal through first year of life.
Developmental Disabilities Research Reviews 14, 105–17.
Faulks D., Mazille M. N., Collado V., Veyrune J. L. &
Hennequin M. (2008) Masticatory dysfunction in persons
with Down’s syndrome. Part 2: management. Journal of
Oral Rehabilitation 35, 863–9.
Field D., Garland M. & Williams K. (2003) Correlates of
specific childhood feeding problems. Journal of Pediatric
Child Health 39, 299–304.
Frazier J. B. & Friedman B. (1996) Swallow function in
children with Down syndrome: a retrospective study.
Developmental Medicine and Child Neurology 38, 695–703.
Gisel E. G., Lange L. J. & Niman C. W. (1984) Tongue
movements in 4-and 5-year-old Down’s syndrome
children during eating: a comparison with normal
children. American Journal of Occupational Therapy 38,
660–5.
Hennequin M., Allison P. J. & Veyrune J. L. (2000)
Prevalence of oral health problems in a group of
individuals with Down syndrome in France. Developmental
Medicine and Child Neurology 42, 691–8.
Kumin L. & Bahr D. C. (1999) Patterns of feeding, eating,
and drinking in young children with Down syndrome
with oral motor concerns. Down Syndrome Quarterly 4,
1–8.
Lewis E. & Kritzinger A. (2004) A parental experiences of
feeding problems in their infants with Down syndrome.
Down’s Syndrome, Research and Practice 9, 45–52.
© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
VOLUME 63 PART 8 AUGUST 2019
Meyer E. C., Coll C. T. G., Lester B. M., Boukydis C. Z.,
McDonough S. M. & Oh W. (1994) Family-based
intervention improves maternal psychological well-being
and feeding interaction of preterm infants. Pediatrics 93,
241–6.
Mitchell R. B., Call E. & Kelly J. (2003) Diagnosis and
therapy for airway obstruction in children with Down
syndrome. Archives of Otolaryngology – Head & Neck
Surgery 129, 642–5.
Mohamed B. A., Alhamdan A. A. & Samarkandy M. M.
(2013) Dietary practice and physical activity in children
with Down syndrome and their siblings in Saudi
Arabia. Developmental Medicine and Child Neurology 4,
235–9.
Pipes P. L. & Holm V. A. (1980) Feeding children with
Down’s syndrome. Journal of the American Dietetic
Association 77, 277–82.
Shapiro B. L., Gorlin R. J., Redman R. S. & Bruhl H. H.
(1967) The palate and Down’s syndrome. New England
Journal of Medicine 276, 1460–3.
Spender Q., Stein A., Dennis J., Reilly S., Percy E. & Cave
D. (1996) An exploration of feeding difficulties in children
with Down syndrome. Developmental Medicine and Child
Neurology 38, 681–94.
Swapna N. & Srushti S. (2017) Manual of Feeding Handicap
Index in Children (FHI-C). All India Institute of Speech
and Hearing, Mysore.
Van Dyke D. C., Peterson L. L. & Hoffman M. N. (1990)
Problems in feeding. In: Clinical perspectives in the
management of Down syndrome, pp. 102–6. Springer, New
York, NY.
Wallace R. A. (2007) Clinical audit of gastrointestinal
conditions occurring among adults with Down syndrome
attending a specialist clinic. Journal of Intellectual and
Developmental Disability 32, 45–50.
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1001
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

APPENDIX 1

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1002
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1003
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1004
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1005
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1006
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1007
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1008
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1009
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1010
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1011
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1012
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1013
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

APPENDIX 2

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd
 Journal of Intellectual Disability Research VOLUME 63 PART 8 AUGUST 2019
1014
M. A. Anil, S. Shabnam & S. Narayanan • Feeding and Swallowing in Down Syndrome

Accepted 27 February 2019

© 2019 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and
John Wiley & Sons Ltd