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Hanan Fathy

Ass.lecture Pediatric Nephrology

 A feeding disorder is identified when
a child is unable or refuses to eat or
drink a sufficient quantity or variety
of food to maintain proper nutrition.

It is important to distinguish between a feeding
problem that is the result of an inability to eat
versus one that is the result of refusal.

A child who is refusing to eat is believed to have

learned the behaviors that allow him/her to
avoid or attempt to control the feeding
situation, and the problem is therefore said to
be non-organic.

 A child who is physically unable to eat, on the

other hand, may be suffering from
neuromuscular, skeletal or metabolic

 These problems are said to be organic and

therefore require the attention of a physician to
Feeding skill: stages and timing
skills 0-3m 3-6m 7-11m 12-24m

Feeding sucks Sucks/bites Munches Chews

Texture Liquid Purees Chopped Table
Speech Coos Babbles Syllables Words
Fine motor Fingers Reaches Transfers Releases
Gross motor Lifts head Turns/sits Stands Walks
Appropriate food provided
Food introduced into the oral cavity

Suck or mastication prepare bolus

Bolus passes into the pharynx 6
Respiration ceases
Elevation of the larynx , glottic closure
Opening of upper esophageal sphincter
Pharyngeal peristalsis with clearance of the pharynx
Respiration resumes

Esophageal peristalsis
Opening of lower esophageal sphincter 7
Receptive relaxation allows storage of the food into
the stomach
Titurbation and controlled emptying of nutrients into
the small intestine
Intestinal digestion and absorption of nutrients.

Major Diagnostic Categories Associated with Feeding
and Swallowing Disorders in Infants and Children
• Encephalopathies (e.g., cerebral palsy, perinatal asphyxia)
• Traumatic brain injury
• Neoplasms
• Mental retardation
• Developmental delay
Anatomic and Structural
•Congenital (e.g., tracheoesophageal fistula, cleft
• Acquired 12
• Chromosomal (e.g., Down syndrome)
• Syndromic (e.g., Pierre Robin sequence, Treacher Collins syndrome)
• Inborn errors of metabolism
Secondary to Systemic Illness
Respiratory (e.g., chronic lung disease, bronch b y opulmonary

•Gastrointestinal (e.g., GI dysmotility, constipation)
• Congenital cardiac anomalies
Psychosocial and Behavioral
• Oral deprivation
Secondary to Resolved Medical Condition
• Iatrogenic
• Dysphagia and feeding problems are classified
according to which phase of swallowing is

• Oral motor dysfunction in children is seen most

commonly in those with neurodevelopment
disorders .

• These children will exhibit poor lingual and labial


• This will result in loss of food and a poor seal for

sucking or removing food from a spoon.
• These children may also have difficulty with coordination
of sucking, swallowing and breathing.

• Children with pharyngeal dysphagia may demonstrate the

symptoms of oral dysphagia, along with coughing, gagging
and choking with foods and liquids.

• However, the signs of pharyngeal dysphagia may be

subtle. In this situation, the children may suffer from
recurrent upper respiratory infections or have a history of

• The most common signs and symptoms of feeding

disorders and dysphagia are coughing or choking while
eating, or the sensation of food sticking in the throat or
• 25% in normally developing children 0-1 year.

• 50% of hospitalised infants for FTT

• 80% neurologically impaired

A child with a feeding disorder may
experience one or more of the following:

Weight for age consistently below
the 3rd or 5th percentile
Progressive decrease in weight to
below the 3rd or 5th percentile
Weight crosses more than two major
percentiles downward.
Weight < 80% of ideal weight for
Decrease in expected rate of growth
based on the child's previously defined
growth curve, irrespective of whether
below the 3rd percentile

Weight for height or height for age
falls below the 10th percentile
Child experiences three consecutive
months of weight loss
Child is diagnosed with dehydration
or malnutrition, which results in
emergency treatment
Child has NG tube with no increase
in the percent of calories obtained via
oral feeding for 3 consecutive months

• Patient Demographics:
• Mean Age: 3 years (39 months)
• Gender: 68% male, 32% female
• Developmental level:
• 53% Developmental Delays
• 47% Typical Cognitive Development

Patient Demographics
Medical Diagnosis Mean Percentage
Autism 10%
Developmental Delay 53%
Cerebral Palsy 7%
Prematurity 30%
Oral Motor Dysfunction 29%
GERD 58%
FTT 59%
Other-Medical 60%
No Diagnosis 5%
Slow feedings characterized by long meal
time.Typically longer than 30-40 minutes.
Change in feeding patterns or new problems with
Breathing interruptions or stoppage during feeding.
“Gurgly/wet” vocal quality before and after
Unable to coordinate sucking and swallowing.
Significant drooling or oral weakness observed.
History of recurrent pneumonia .

Irritability or behavior problems during meals.
Unexplained food refusal .
Sleepiness during feedings.
Failure to gain weight over 2-3 months.
Diagnosis of a disorder associated with feeding and
swallowing difficulties.
Does not achieve age appropriate feeding behaviors
 Not spoon feeding by 9 months
 Not chewing table food by 18 months
 Not cup drinking by 24 months
Feeding Disorders

 Etiologies
• Medical
• Oral Motor
• sensory
• Behavioral

Swallowing and feeding disorders in children and infants are complex
and may have multiple causes.
Underlying medical conditions that may cause dysphagia may include,
but are not limited to (Palmer, 2000; Rudolph and Link, 2002):
Neurological disorders
• intracranial hemorrhage
• myasthenia gravis
• cerebral palsy
• meningitis
• encephalopathy
Disorders affecting suck-swallow-breathing coordination
• choanal atresia cardiac disease
• tachypnea bronchopulmonary dysplasia 29
Connective tissue disease
• polymyositis
• muscular dystrophy

Iatrogenic causes
• surgical resection
• radiation fibrosis
• medications
Anatomic or congenital abnormalities
• cleft lip and/or palate
• abnormalities of the tongue .

Structural lesions
• thyromegaly

• cervical hyperostosis
• congenital web
• Zenker’s diverticulum
• ingestion of caustic material
• neoplasm

• Weak suck
• Choking or gagging during meals
• Tongue thrusting or inability to lateralize the
• Wet vocal sounds during or after meals
• Preferences for smooth or creamy textures

Common Oral-Motor Feeding Difficulties
Associated with Down Syndrome
Weak lip seal on nipple (fluid loss)
Tongue protrusion/thrust
Delayed chewing (secondary to delayed dentition
and or prolonged tongue thrust)
Difficulty with texture transition
Difficulty with thin liquids (increased fluid loss and
coughing) 33
Nutritional Risk Factors for Children with
Developmental Disabilities
Oral-Motor Feeding Difficulties
 Discoordination of suck swallow
 Structural abnormalities (cleft lip/palate;
 Poor oral containment (food/fluid loss)
 Tone abnormalities (hypo/hypertonic)
 Altered oral sensory response
 Delayed oral motor skill development
Oral-Motor Weaknesses
Difficulty with oral strength and coordination
required for eating.

• Open Mouth Posture • Poor lip movement (can’t

• Frequent drooling pucker / spread)
• Unable to bite through • Tongue Thrusting
foods • Retracted tongue
• Weak chewing • Poor tongue lateralization
• Poor bolus formation • Coughing / Choking
• Unable to close lips on during meals
• Where do they come from?
– Prematurity
– Chronic illness
– Multiple medical interventions/medications
– Underlying neuro issues

Sensory Integration Dysfunction
• The sensory system consists of:
• Proprioception – body awareness
• Vestibular – balance
• Tactile – touch
• Gustatory – taste
• Olfactory – smell
• Vision
• Auditory – hearing

• The CNS receives all of these types of input, interprets

them, and organizes a response

• Sensory Integration Dysfunction occurs when the brain

does not efficiently process sensory stimuli coming from
the body or the environment. 39
Sensory Impact on Feeding
• Children with tactile hypersensitivity are averse to smooth,
wet, slimy textures on their hands, face, body and/or in
their mouth.

• Children with tactile hyposensitivity have reduced

sensations of foods in the oral cavity and thus pocket or
lose control of them which can lead to gagging or choking.

• Upper body strength and coordination supports and is

required for mouth strength and coordination.

Feeding Sensory Red Flags
• Prefers to drink water • Negative response to
• Gags easily touch of wet, slimy, or
• May only smell or lick sticky substances
foods • Feeds/eats best when
• Wipes mouth/tongue sleepy or distracted
• May bite and chew • Does not tolerate others
without swallowing foods touching or putting things
in his/her mouth
• Stuffs mouth
• Mouths only certain items
• Eats only crunchy foods
• Separates & expels pieces
• Wants hands/face cleaned in mixed consistency food
• Oral motor weaknesses lead children to
experience eating as difficult and/or scary
and thus children do not develop a sense of
trust that they are capable of handling food.

• Sensory dysfunction leads children to

experience eating as scary when the child is
presented with aversive textures.

• Children with oral-motor weaknesses are most
capable of eating smooth, pureed textures
(pudding, yogurt, apple sauce) and are less able to
eat crunchy or solid foods.

• However, children with sensory dysfunction are

highly averse to smooth foods and are most
comfortable with crunchy or solid foods.

• Most children with feeding problems have both

oral motor weaknesses and sensory deficits.
•Avoidance of eating is initially an adaptive
behavior as it allows the child to avoid an activity
that is painful, difficult, scary and potentially
•Poor oral control and/or sensory aversion may lead
to gagging which reinforces fear and promotes
further refusal.
•The child will use a variety of behaviors to avoid
placement of food into his/her mouth.
•Parents often accidentally reward avoidance
behaviors by responding with positive attention
(playing, smiling, bargaining) or by removing the
•Pushing food away
•Throwing food
•Turning away
• Saying “No!”
•Refusing to open
•Expelling foods from
Steps for Diagnosis and Treatment of
Pediatric Feeding and Swallowing

Define problem feeding and swallowing

Identify etiology(ies)
Determine appropriate diagnostic tests
Plan approach to patient/family
Teach about problem, implement
Monitor progress
Evaluate progress (outcomes focused) 46
Evaluation of dysphagia and feeding
• Performing a history and physical

• Objectives of the history should include:

• Identifying the anatomic region involved and obtaining
clues to the etiology of the condition.
• This may include information regarding the onset,
duration and severity, presence of regurgitation, the
perceived level of obstruction and presence of pain or
hoarseness, and presence of other disorders.

• During the physical examination:
• The patient should be observed during the act of swallowing.

• A clinical dysphagia evaluation is usually completed by a

speech-language pathologist.

• The examination will include assessment of posture,

positioning, patient motivation, oral structure and function,
efficiency of oral intake and clinical signs of safety.

• In infants, the oral-motor assessment includes evaluation of

reflexive rooting and non-nutritive sucking (Darrow and
Harley, 1998).

• Infants and children may require additional assessments,

since growth, development, and changes in medical condition
may affect the swallowing process. 48
Diagnostic testing that may be employed includes
 Esophagoscopy: This test may be used to rule out neoplasm,
particularly in patients who complain of thoracic dysphagia or odynophagia.

 Esophageal manometry and pH probe studies: These tests may be used

when a motility disorder or gastric esophageal reflux disease is suspected.

 Electromyography: This test is indicated in patients with motor unit disorder

such as polymyositis, myasthenia gravis, or amyotrophic lateral sclerosis

 Fibroptic endoscopic examination of swallowing (FEES): This test is

performed with a transnasal laryngoscope to assess pharyngeal
 This test may be helpful when a VFSS (videofluorographic swallowing
study) is not feasible

 Ultrasound imaging: This testing has been used to a limited extent on

infants to assess the oral phase of swallowing. The technique is limited to
infants, since teeth will interfere with the sound signal. This method will
permit studying of infants during breast-feeding, since contrast media is not
required. 49
Videofluorographic swallowing study
Is the gold standard for evaluating the mechanism of swallowing.

VFSS is also referred to as modified barium swallow.

During this study, the patient will eat and drink foods mixed with
barium while radiographic images are observed on a video monitor
and recorded on videotape.

This test is ideally performed jointly by a physician and a speech-

language pathologist.

The study will demonstrate anatomic structures, the motions of these

structures, and passage of the food through the oral cavity, pharynx
and esophagus .
Videofluorographic swallowing study

This test may also be used to test the effectiveness of

compensatory maneuvers that are used to improve
This test cannot be performed on infants and children
who are unable to swallow.
In addition, infants and children with oral aversion and
some feeding disorders may not ingest a sufficient
amount of barium to provide a meaningful study.

Interdisciplinary Approach
 Interdisciplinary team evaluation:
• Medicine – Rule out physical causes of feeding
• Nutrition – Evaluate adequacy of current intake
• Social Work – Evaluate family stressors
• Speech/Occupational Therapy – Evaluate oral motor
status and safety
• Psychology – Assess contribution of environmental

• the causes of many of the disorders resulting in
feeding disorders or dysphagia may not be amenable
to pharmacological therapy or surgery as a result of
behavioral contributors to impairment.

• In these cases, a referral to a professional, such as a

speech pathologist, or feeding clinic is appropriate.

• A child may continue with signs and symptoms of a

feeding disorder even after correction of an
underlying abnormality due to a learned aversion to
feeding. In these cases, behavior therapy may be
Prerequisites for oral feeding attempts for infants and
young children include

• Cardiopulmonary stability
• Alert , calm state
• In young infants, demonstration of rooting
responses and adequate non-nutritive
• Appetite or observable interest in eating

Feeding therapy for infants and children may
include the following strategies

• Position and posture changes:

Trunk and head control are closely related to
development of oral-motor skills.

In particular, children with cerebral palsy and

accompanying motor deficits frequently have poor
head control and poor trunk stability.

Position changes need to be monitored closely for

adjustments over time.

Feeding therapy for infants and children may
include the following strategies
• Changes in food and liquid attributes: These attributes
may include, but are not limited to: volume, consistency,
temperature and taste.

• Oral-motor and swallow therapies: These procedures are

focused on developmental stages with goals to increase
the range of textures children can handle in their diets.

Oral-motor treatment can include direct exercises of the

oral mechanism.

Feeding therapy for infants and children may
include the following strategies
• Pacing of feedings: Pacing is a technique that regulates
the time interval between bites or swallows. This may
minimize the risk of aspiration. Some children may need a
longer time to swallow.

• Changing of utensils: The food bolus size can be

controlled through spoons of different shapes and sizes.
Occupational therapists may recommend adaptive
equipment and utensils.

• Esophageal phase swallow disorders are generally not

amenable to oral-motor and swallow therapy. Positioning
changes, changes in food characteristics and timing may
make a difference.
Feeding therapy for infants and children may
include the following strategies

• Specialized feeding techniques that are used for

feeding infants with cleft lip and/or palate have been
developed to overcome the lack of negative pressure
developed during sucking; these strategies may

• cross-cutting fissured nipples

• squeezing a soft bottle to help with the flow of
• pumping breast to deliver breast milk via bottle
When a patient is unable to achieve adequate
alimentation and hydration by mouth, enteral
feedings through a nasogastric tube or a
percutaneous endoscopic gastrostomy may be

The presence of a feeding tube is not a

contraindication of therapy. Removal of the feeding
tube may be a goal of therapy.

Tips to prevent feeding problems from
developing or persisting
 Present a wide range of foods before the child reaches 15 to 18
months of age

 Present preferred as well as non-preferred foods

 Stick to a consistent schedule; keep meals, naptime, and bedtime

at same times daily

 Make healthy foods readily available and unhealthy foods less


 Model healthy eating behaviors and discuss good eating habits

Tips to prevent feeding problems from
developing or persisting

 Teach your child to communicate about his/her hunger by relating

food to appetite

 Reinforce good mealtime behaviors (avoid praising amount of food


 DO NOT reinforce inappropriate behavior with toys or attention

 Try to maintain enough time and energy for meals

 Develop a few simple rules and follow them, don’t start what you
can’t finish