Family Meal Time

Assessment & Treatment in ● Inversely related to such things as

disordered eating, alcohol and substance
Pediatric Feeding & Swallowing use, violent acts, depression or thoughts
of suicide in adolescents
● Linked to increased self-esteem and
academic success
● Food exposure
● Expectations and rules
Long Island Speech-Language-Hearing Association
July 13, 2022
Harrison et. al, 2015
Jackie Klein, MA, CCC-SLP, MBA
Feeding Versus Swallowing Feeding and Swallowing
● “Feeding is the process involving any aspect of eating
or drinking, including gathering and preparing food and Feeding Swallowing
liquid for intake, sucking or chewing, and swallowing ● AFRID ● Issue with one more more
(Arvedson & Brodsky, 2002). ● Mealtime behaviors of the four phases of
swallowing
● Immature feeding patterns
● “Swallowing is a complex process during which saliva, ● Aspiration / penetration
● Immature use of utensils
liquids, and foods are transported from the mouth into ● Retrograde flow
the stomach while keeping the airway protected” (ASHA,
2021).

ASHA,2021
What is AFRID
● Avoiding or restricting one's food intake
(avoidant/restrictive food intake disorder [ARFID];
American Psychiatric Association, 2016)
● Defined by DSM-5 as, “failure to meeting nutritional needs
leading to low weight, nutritional deficiency, dependence
on supplemental feedings and/or psychosocial impairment.”
● Has taken that place of the DSM IV diagnosis of "feeding
disorder of infancy or early childhood," - originally
restricted to kids 6 and under. No longer age
limitations(Zimmerman & Fisher, 2017).
AFRID
● 1.5%–13.8% in children between the ages of 8 and 18 years with suspected
gastrointestinal problems or eating disorders (Eddy et al., 2015; Fisher et
al., 2014).
● Noris et. al., 2014 found 50% of kids with AFRID also had generalized anxiety
● Cases of ARFID are reported to have a greater likelihood in males and
children with gastrointestinal symptoms, a history of vomiting/choking, and a
comorbid medical condition (Fisher et al., 2014).
Can Not discount impact on Caregiver
Parlakian & Lerner in 2009 review:
● Among all parenting tasks, feeding their children is
one of a parents/caregivers major source of stress and
frustration
● Feeding was one of the most requested training topics
when parents were asked what supports would be
beneficial.
Parent stress and mental health can impact a child’s feeding
and mealtime (Hurley et. al., 2008).
Swallowing is across all aspects of the field - Schools
The Rehabilitation Act of 1973, Section 504. 29 U.S.C. 701
(1973) - mandates services for health related disorders that
impact a student’s ability to access education and fully
participate in their programing.
IDEA - feeding and swallowing is not specifically mentioned;
however,Dept.of Ed. took stance that health conditions could
qualify a student for services.
ASHA, 2021
Feeding and Swallowing can be A School’s Responsibility
Suck/swallow/Breathe
1. Students are required to be safe while eating at school. Necessary for successful
This includes supports to minimize risk feeding in infants

2. Students must be adequately nourished and hydrated to

access curriculum
3. Must promote student health
4. Students must demonstrate feeding skills to complete lunch
and snack in a safe and timely manner like their peers

ASHA, 2021
Four stages of the swallow Oral Preparatory Stage
Oral preparatory stage ● Food or liquid is
prepared orally
Oral stage ● Cohesive bolus should be
formed
Pharyngeal Stage ● Food items and how they
are being consumed will
Esophageal Stage impact this stage.
○ bottle, breast, cup,
straw
○ purees, solids,
mixed consistencies
○ biting, chewing
laterlizating

ASHA, 2021
Oral Stage Pharyngeal Stage
● Initiates with ● Begins with initiation
propulsion of the of swallow
bolus by the tongue
● Bolus travels through
pharynx

● This phase ends when ● Airway protection

the actual swallow
begins ● VP Closure to prevent
retrograde flow

ASHA, 2021 ASHA, 2021

Esophageal Stage
Physiological Differences in infants and older children
Anatomic Location Infant Older Child

Oral Cavity Tongue fills mouth Mouth is larger, tongue rests on floor of
● Bolus is carried to the mouth
stomach through the
process of esophageal Edentulous Dentulous
peristalsis
Tongue rests between lips Tongue rests behind the teeth and is not
and sits against palate against palate

Cheeks have sucking pads Buccinators are muscles for chewing only

Relatively smaller mandible Mandibular-maxillary relationship normal

ASHA, 2001 Sulci important for sucking Sulci have little functional benefit
Anatomic Location Infant
Pharynx No definite/distinct oropharynx
Obtuse angle at skull base
Larynx One third adult size
Half true vocal fold cartilage
Narrow, vertical epiglottis
Adapted from Arvedson & Brodsky,
(2002)
Older Child
Elongated pharynx, so distinct
Reflexes related to swallowing
oropharynx exists
● Gag reflex
○ Consists of tongue protrusion, head and jaw protrusion, and pharyngeal contractions
○ Evident at 26 to 27 weeks gestation - typically strong in full term infants
90 degree angle at skull base ○ Hyperactive gag may be evident in neurologically impaired children; or may be
difficult to elicit when profound motor dysfunction exists
○ No evidence that the presence or absence of a gag reflex impacts swallowing
abilities
○ May diminish somewhat at 6 months of age (when the onset of chewing and swallowing
solids is initiated)
● Phasic bite reflex
○ Present by 28 weeks gestation; rhythmic closing and opening of the jaws in response
Less than one third true vocal to stimulation to the gums; integrates at 9 to 12 months of age
fold of cartilage
Flat, wide epiglottis
Adapted from Arvedson & Brodsky, (2002)
reflexes related to swallowing continued Neonatal and Early infancy Period (0-3 months)
● Tongue protrusion ● The infant starts to develop primitive lateral tongue movements
○ Noted in full term infant in response to touching anterior portion of tongue
○ Begins to diminish by 4 to 6 months of age
○ Permitting the introduction of solids with a spoon ● Occasional coughing or choking may indicate poor coordination of the
suck-swallow-breathe sequence.
● Transverse tongue response
○ Emerges at 28 weeks gestational age ● At three months, the infant may sequence twenty or more sucks from the breast
○ Movement of the tongue toward the side of stimulation when the lateral surface or bottle; breathing follows sucking with no noticeable pauses; pauses for
of the tongue has been touched breathing are infrequent
● Rooting response
○ Observed as head turns toward side of stimulation of the cheeks or corner of ● Greater nipple control, reaching, smiling, and social play are all fostered by
mouth pleasurable and successful feeding experiences
○ Noted by 32 weeks gestation
○ Diminishes by 3 to 6 months of age
○ Should be elicited during breast or bottle feeding by stimulating the lower lip,
rather than on either cheek or side of the mouth
Fraker and Walbert, 2003
Arvedson & Brodsky, (2002)

Adapted from Arvedson & Brodsky, (2002)

Infancy (3-6 months) Late Infancy (6 months - 1 year)
● Most nourishment comes from nipple feedings for the first 4 to 6 months; ● Taking food from a spoon.
breast-fed and/or formula-fed infants do not require additional types of
food through year one. –
● Many infants begin taking other food when they reach the first
● Handling thicker and lumpier foods that may require chewing; the
transitional feeding stage at 6 months (per md recommendation). phasic bite becomes integrated at this time to allow for a more
mature chewing pattern to emerge (Fraker & Walbert, 2003).
● Baby food should be introduced around 6 months or when motor skills support
spoon feeding attempts (Fraker & Walbert, 2003). The child must have head
control and be able to sit with support or have special positioning. ● Self feeding with fingers or a spoon.
● Transitioning from breast or bottle to a cup is a move toward –
self-regulation; a decreased interest in sucking at the breast or from a
bottle often begins around 5 to 6 months. A four month old lacks the ● Drinking from a cup and managing the bottle independently. By nine
appropriate skills for cup drinking, so it is recommended that it is months the infant will use longer sucking sequences during cup
introduced at 6 months.
drinking.

Fraker and Walbert, 2003 Fraker and Walbert, 2003

Arvedson & Brodsky, (2002) Arvedson & Brodsky, (2002)

Late Infancy (6 months - 1 year) Older CHild 12 - 15 months
● Infants communicate interest in feeding by their posture, head and mouth movements ● During cup drinking, swallowing follows sucking with no pause; the
and vocalizations.
pattern is well coordinated typically without evidence of
● New textures should be introduced gradually; mixed textures tend to be confusing coughing/choking.
and difficult for a child to manage. The choking and aspiration risk is higher
with a mixed textured item.
● Upper incisors are used to clean the lower lip as it draws inward; a
● Chewing skills have been shown to vary.
child will use a sucking pattern with a spoon ; a munching pattern
● From 6 to 12 months there is gross change in posture and muscle tone; as the trunk continues to improve with tongue lateralization.
gains stability, the extremities gain mobility, the stage is then set for self
feeding activities.
● The child begins to self feed, develops a pincer grasp and holds his own
● As the neck and shoulder gain stability, the respiratory muscles, the larynx and cup.
oral-pharyngeal structures gain stability giving way to more mature feeding
patterns.
Fraker and Walbert, 2003
Arvedson & Brodsky, (2002)

Fraker and Walbert, 2003

Arvedson & Brodsky, (2002)
The older child 18 months
● More mature control of jaw movements for feeding. Rotary chewing skills
are emerging with solids, increased tongue lateralization
● Use controlled pattern to bite hard foods - biting also stabilizes jaw
for cup drinking
● Tongue elevates more consistently during swallowing and lips keep food in
mouth when chewing
● No loss of saliva or food anteriorly
The older Child 24 months
● Emerging jaw stabilization (without support) for cup drinking, and appropriate
lip closure around cup
● Able to grade the opening of the jaw when biting through foods of various
thicknesses
● Tongue movements continue to mature, with elevation noted more consistently;
tongue protrusion begins to extinguish. Tongue tip elevation is used for
swallowing; the tongue is used to clean food from upper and lower lips
● The child swallows solid foods; including those with a mixed textures
● The child presents with mature chewing and drinking skills

● Good hand to mouth skills

Fraker and Walbert, 2003 Fraker and Walbert, 2003

Arvedson & Brodsky, (2002) Arvedson & Brodsky, (2002)
 Feeding Birth -2
Birth - 6 Months 1 Month - uses both suck and suckle
2-3 months - longer suckling/sucking
3-4 months - three dimensional suck developing, sucking pads begin to shrink
4-6 months - getting ready for more solid foods (anatomically mouth and digestive)

6-9 Months Jaw movements fine tuning to shape and size of food in oral cavity
Lips and cheeks gain better control to help keep food in mouth
Tongue moves toward bolus placed laterally

9-12 Months More mature chew emerges

Jaw stabilizes food for “manual” help with biting
Lips have more movement
Food going from midline to side - emerging lateralization

12-15 Months Can bite through soft foods

Tongue tip organized to hit alveolar ridge to initiate swallow

18-21 Months Bite through hard solids (still some difficulty)

Chew with lips closed
Good control of swallow

21-24 Months Easily bite through hard solids

Chew more diagonal rotary and circular rotary
Easily move tongue to prepare food and form a more cohesive bolus
Arvedson, 2006
Adapted From: Bahr, 2013
Original Source From: .Bahr, 2001; Bahr, 2010; Coryllos, Genna, & Salloum, 2004; Geddes, Kent, Mitoulas, & Hartmann, 2008; Morris & Klein, 2000; Oetter, Richter, & Frick, 1995.
Signs of feeding and swallowing difficulties during
meals Senses
● Arches her back or stiffens when feeding
● Cries or fusses when feeding We eat with all
● Falls asleep when feeding
● Has problems breastfeeding
5 of our
● Has trouble breathing while eating and drinking senses:
● Refuses to eat or drink
● Eats only certain textures, such as soft food or crunchy food ● See
Smell
● Takes a long time to eat
● Has problems chewing ●
● Coughs or gags during meals ● Touch
Taste
● Drools a lot or has liquid come out her mouth or nose
● Gets stuffy during meals ●
● Has a gurgly, hoarse, or breathy voice during or after meals
● Spits up or throws up a lot
● Hear
● Is not gaining weight or growing ASHA, 2021
Team Approach is necessary
● We may need to facilitate that team!
● Who is on it and who do we recruit
● In most cases, it can not be done by the SLP alone
no delineation between feeding and swallowing
● If assumed to be structural or behavioral, evaluation will
not be different
● Underlying principle of, “is this child safe?”
● Revisit the four stages of swallowing during the
evaluation process as a guide
Are oral feedings appropriate Considerations during feeding evaluations
● What is child doing now? ASHA, 2021 established general overlaying principles that should
● ASHA, 2021 gives three key criteria for oral readiness for be considered during feeding and swallowing assessments:
feeds:
1. Physiologic stability 1. Medical conditions or structural issues
a. digestive system 2. Be mindful of neurodevelopmental level, chronological age
b. respiration and other vitals if necessary
c. health and adjusted age
3. Positioning - how is it impacting feeding and/or respiration
2. Efficiency - how much taking in 4. Likey a communication barrier - need to rely on other forms
3. Endurance - remain engaged, alert of communication - caregiver, doctors, instrumentations such
as pulse oximetry and monitors, behavioral observations
Components to the assessment
● Case history this needs to be thorough with full review of medical history, medication list
● Parental interview - essential along with food journaling
● Structural assessment that includes observation of structure as well as sensation, tone and
range of motion
● Observation of structural control and stability
● Reflexes if age appropriate
● determination of oral readiness (if infant)
● NNS if infant
● Eating both, customary bottles and utensils, natural feeding of everyday items including
those deemed challenging (bring a change of clothes)
● Caregiver interactions
● Looking at four stages of swallow regardless of age (to the extent possible)
● Consistency of skills - not just one or two bites. What impact does time have on skills?
● Will modifications help? Can they be tried during assessment?
Infants
Breast Feeding
● position, latch, coordination, effectiveness, baby parent interaction
and response, suck-swallow-breath, vitals if able, willingness to eat,
suck:swallow ratio and nipple flow
Bottle Feeding
● willingness to eat, suck swallow ratios, suck-swallow-breath, bottle
system and effectiveness, position, caregiver and infant response
Spoon
● move toward spoon or turning head away to communicate their wants, lip
seal around spoon, strip from spoon with top lip, feed or self feed

Adapted from ASHA, 2021

Adapted from ASHA, 2021
Older children nutritive vs non-nutritive suck
Solids -Bite, chew, lateralization, stasis, bolus size,
utensil use, self feeding Non-Nutritive Suck Nutritive Suck
● Established in utero ● For substance
Drinking - seal, loss, organization ● Does not necessarily ● ASHA, 2001 states during
equate to readiness to this portion of eval to
eat look for:
● More of a comfort suck ○ Suck/Swallow/Breath
○ Efficiency - volume
○ Endurance - stay with feed
● 30 minute rule

ASHA, 2021
What to look for FEEDING CHECKLISTS
Oral Phase Absent oral reflexes
Primitive/impaired oral reflexes
Weak suck
Multiple feeding checklists to assist with evaluation
Uncoordinated
Immature and/or disordered biting
Immature and/or disordered chewing
● ASHA has free checklists available
Poor propulsion
Poor containment
● Schedule for Oral Motor Assessment (SOMA)
Poor coordination of suck-swallow-breath ● Dysphagia Disorders Survey

Pharyngeal Absent swallow

Phase Delay in triggering swallow
poor coordination of suck-swallow-breath
Laryngeal Penetration
Aspiration
Choking
Pharyngeal residue
Nasopharyngeal reflux

Adapted from Dodrill & Goasa, 2015

SOMA What if we just are not sure?
Instrumental Assessments of Swallow
● Generally Videofluoroscopic Swallow Study (VFSS) and
Fiberoptic Endoscopic Evaluation (FEES)
● Child needs to eat to participate
● Prep caregivers and child (if old enough)
● Practice sitting and eating in office
● Keep in mind there are still pros and cons to each
WHO Sensory Preferences
https://www.asha.org/siteassets/uploadedfiles/icf-pediatric- Hypersensitivity -
feeding-swallowing.pdf
Need sensory input

Hyposensitive
Difficulty adjusting to sensory input

This may not be just be with food, and can be mixed.

Swallow Skills Prior to initiation of Services
Most likely determined by instrumentation ● Medical issues related to feeding and swallowing have to
Chewing be addressed (Pressman & Berkowitz, 2003)
● Need parent buy in
Cup drinking ○ lay out expectations
Straw drinking ○ What are parent goals
■ healthy eating vs. expanding repertoire - quantity and then quality
Lateralization ○ Need generalization of skills and foods

Biting
Need to set the Tone How do we help?
● This is for parents and children Many programs and therapists do either:
● Feeding needs to be positive again - not a source of
Operant conditioning Therapy
stress
● Expectations need to clear Desensitization Therapy

Can find literature both pro and against both.

Marshall et. al, 2015 found that operant condition was more
successful with children 2-6 years of age versus
Desentization.
Food Chaining Food Chaining
Uses multiple premises: ● Anchor Foods
○ foods already in reperiotre
○ helps participation
● Food Masking - pair new food with wet dip or condiment ● Transitional Food
already in repertoire to promote acceptance of new food. ○ familiar food used to encourage a new food trial
● Surprise Food
○ New food item

● Dry Food Masking - if wet is an issue - cinnamon sugars,

garlic salt, seasonings. Child is encouraged to explore new foods.

Fraker & Walbert, 2011 Fraker & Walbert, 2011

Food Chaining- Example Food Chaining - Give it a try
How can we go from goldfish crackers to a grilled cheese
sandwich?

Parents.com, 2021
SOS - Sequential Oral Sensory APproach to Feeding SOS
● Kay Toomey ● Child is avoiding something that is physically difficult;
● This is a certification program therefore learning avoidance behaviors emerge
● Transdisciplinary approach ● These behaviors are:
● SOS looks at the whole child - not just difficulty eating ○ the child letting you know that they do not have the skills to manage
○ sensory the feeding situation
○ motor/oral motor ○ a way to avoid the discomfort
○ behavioral/learning ● Goal is to teach management of skills and food so there is
○ medical/organs no discomfort to avoid
○ nutrition
○ environment
● Allows desentization to move up the a hierarchy and build
new skills
● Desensitization occurs with play and social interactions
Toomey & Ross, 2011
and is child directed

Toomey & Ross, 2011

SOS steps of Desensitization SOS
Visually Explore Manipulate Smell Touch Taste

Eat being the final stage

Assess child as you go - back up when needed

Toomey & Ross, 2011

Group Approach to Feeding
● Social approach to feeding - Why?
● Frustration and plateau with individual feeding
treatment sessions.
● Began to look at peer modeling as a strategy
● Initially tried this model with preschool age
children
Group Feeding Therapy
● Should not be seen as a replacement for individual
feeding treatment
● A group therapy approach should supplement ongoing
therapy
● Provides a social aspect of eating
● Avenue of information sharing for parents
Social Learning Theory SOCIAL LEARNING THEORY
Self- Efficacy
Observational Learning
Vestibulum congue
Observational imitation not synonymous
Creation of expectionations
Ability to teach
Modeling
yourself

Social
Learning

Cognitive Theory Behavioral Theory

Vestibulum congue Vestibulum congue learn, but not perform Behaviors are learned
Self Monitoring Self Regulation
Attention Reinforcement
Expectation Punishment
Awareness ABC
Group Structure Counseling For child if age appropriate
● Circle/welcome Ask the “why?”
● Art/Sensory
Do not avoid the elephant in the room
● Motor Break
● Oral Alerting
● Snack
Parental Support and counselling Parent Support
Modeling is most likely not enough to facilitate change with It is okay to be messy
parents (Bahr & Johnson, 2013).
Let children participate in meal prep
Kaminski et. al., 2007 outlined the four components of
successful caregiver training: Let children have say in what they are eating
1. Teaching positive interactions with children (positive
reinforcement, child level interactions)
2. Teaching effective emotional communication skills
(active listening, emotions)
3. Disciplinary consistency
4. Practice during therapy - Parents are part of program

Today.com, 2021
Counseling
● When is it outside the scope of an SLP?
● CBT is very effective with feeding behaviors
● We can not do it alone
Bottom LIne
● It is a combination
● It is child and family specific
● Environment plays a role
● There is no one size fits all
 Work Cited
American Psychiatric Association. (2016). Feeding and eating disorders [DSM-5 Selections]. Arlington, VA: Author.

Arvedson, J. C., & Brodsky, L. (2002). Pediatric swallowing and feeding: Assessment and management. Albany, NY: Singular Publishing.

Arvedson, Joan C. “Swallowing and Feeding in Infants and Young Children.” Nature News, Nature Publishing Group, 16 May 2006, https://www.nature.com/gimo/contents/pt1/full/gimo17.html.

jklein@bethlehemspeechservices.com
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https://doi.org/10.1044/sasd22.4.161.

Dodrill, Pamela, and Memorie M. Gosa. “Pediatric Dysphagia: Physiology, Assessment, and Management.” Annals of Nutrition and Metabolism, vol. 66, no. Suppl. 5, 2015, pp. 24–31., https://doi.org/10.1159/000381372.

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https://doi.org/10.1002/eat.22350.

Fraker, C. and Walbert, L. (2003). Evaluation and Treatment of Pediatric Feeding Disorders: NICU to Childhood. Temecula: Speech Dynamics Inc.

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“Feeding and Swallowing Disorders in Children.” American Speech-Language-Hearing Association, American Speech-Language-Hearing Association,
https://www.asha.org/public/speech/swallowing/feeding-and-swallowing-disorders-in-children/.

Fraker, Cheri, and Laura Walbert. “Treatment of Selective Eating and Dysphagia Using Pre-Chaining and Food Chaining© Therapy Programs.” Perspectives on Swallowing and Swallowing Disorders (Dysphagia), vol. 20, no. 3, 2011,
pp. 75–81., https://doi.org/10.1044/sasd20.3.75.

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Https://Www.seattlechildrens.org/Globalassets/Documents/for-Patients-and-Families/Pfe/pe2038.Pdf.
Toomey, Kay A., and Erin Sundseth Ross. “SOS Approach to Feeding.” Perspectives on Swallowing and Swallowing Disorders (Dysphagia), vol. 20, no. 3, 2011, pp. 82–87.,
Hurley, Kristen M., et al. “Maternal Symptoms of Stress, Depression, and Anxiety Are Related to Nonresponsive Feeding Styles in a Statewide Sample of WIC Participants.” The Journal of Nutrition, vol. 138, no. https://doi.org/10.1044/sasd20.3.82.
4, 2008, pp. 799–805., https://doi.org/10.1093/jn/138.4.799.

Marshall, Jeanne, et al. “Multidisciplinary Intervention for Childhood Feeding Difficulties.” Journal of Pediatric Gastroenterology & Nutrition, vol. 60, no. 5, 2015, pp. 680–687., Wyatt Kaminski, Jennifer, et al. “A Meta-Analytic Review of Components Associated with Parent Training Program Effectiveness.” Journal of Abnormal Child Psychology, vol. 36,
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Pressman, Hilda, and Merrill Berkowitz. “Treating Children with Feeding Disorders.” The ASHA Leader, vol. 8, no. 19, 2003, pp. 10–11., https://doi.org/10.1044/leader.otp2.08192003.10. Zlomke, Kimberly, et al. “Feeding Problems and Maternal Anxiety in Children with Autism Spectrum Disorder.” Maternal and Child Health Journal, vol. 24, no. 10, 2020, pp.
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