Learning to swallow begins at birth and slowly progresses to learning to eat: take food into the mouth, chew it, combine it into a manageable amount and size and then swallow it. Difficulty with swallowing and/or feeding can impact nutritional status, overall health, safety, and quality of life. Children achieve many milestones during development from infant to toddler to early childhood. Feeding and swallowing milestones are part of this development and it’s important to note if your child is experiencing any difficulties with eating and drinking. 

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Feeding Disorders

Feeding is the process involving any aspect of eating or drinking, including gathering and preparing food and liquid for intake, sucking or chewing, and swallowing (Arvedson & Brodsky, 2002).  Feeding is not only a life-sustaining need, it also serves as a social avenue for connection and communication among friends and family. Feeding disorders are difficulties with a variety of activities related to eating and drinking. Feeding disorders do not necessarily involve difficulty with swallowing. A Pediatric Feeding Disorder is defined as: “impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction” (Goday et al., 2019). 

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Pediatric Feeding Disorders may involve one or more of the following:

• Oral sensory component
• Refusal of age/developmentally appropriate food or liquids
• Restricted variety or amount of foods/liquids
• Disruptive behavior during mealtimes for age/developmental level
• Inability to self-feed
• Inability or refusal to use age-appropriate feeding utensils
• Less than optimal physical growth/development.

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Pediatric Feeding Disorders may be seen in children with one or more of the following:

• Autism
• Developmental disabilities (e.g, Down Syndrome)
• Complex medical conditions (e.g. heart or pulmonary disease)
• Genetic syndromes
• Sensory differences
• Structural differences (e.g. Cleft Palate)
• Low neuromuscular tone (e.g. prematurity, hypotonia, etc)
• Behavioral or social/emotional factors

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Swallowing Disorders

Swallowing is the surprisingly complex process where food, liquids and saliva are moved from the mouth into the stomach. There are 4 stages of swallowing: 

1. Oral preparatory - this is where food or liquid is voluntarily moved around in the mouth to form a “bolus” or ball that can be easily manipulated as one unit.
2. Oral transit - this stage begins when the food/liquid bolus is moved, with help from the tongue, backward toward the throat.
3. Pharyngeal - this stage begins with a swallow where the ball of food/liquid is forced downward into the pharynx (throat), past the airway and toward the esophagus.
4. Esophageal- this is the stage where the food/liquid is transported to the stomach by way of the esophagus.

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A swallowing disorder, referred to as Dysphagia, can occur in any of the stages of swallowing. Aspiration (food or liquid entering the airway and lungs) is a serious concern when a swallowing disorder is present. Consequences resulting from swallowing disorders:

• Food avoidance
• Aspiration pneumonia and other respiratory infections
• Reduced nutrition (undernutrition or malnutrition)
• Dehydration
• Limited weight gain
• Gastrointestinal complications
• Chronic swallowing difficulties 
• Reduced quality of life (increased stress around mealtimes, reduced connection, etc)

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Signs and Symptoms of Swallowing Difficulties:

• Back arching in infants/toddlers
• Breathing irregularity or difficulty when eating/drinking
• Coughing/choking 
• Red or teary eyes while eating or drinking
• Spitting food out
• Difficulty chewing age-appropriate foods
• Retaining food in the mouth after swallowing
• Refusing to eat or disengaging during mealtimes
• Frequent gagging
• Congestion after meals
• Food/liquid spilling out of the mouth
• Recurrent pneumonia
• Wet or gurgly vocal quality after eating/drinking
• Longer than 30 minutes to finish a meal

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Underlying causes of Swallowing Disorders in Children may include:

• Autism
• Developmental disabilities (e.g, Down Syndrome)
• Complex medical conditions 
• Genetic syndromes
• Sensory differences
• Structural differences (e.g. Cleft Palate)
• Low neuromuscular tone (e.g. prematurity, hypotonia, etc)
• Behavioral or social/emotional factors
• Medication side effects
• Neurological disorders

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Assessment and Treatment of Feeding and Swallowing Disorders

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If you have concerns about your child’s feeding and/or swallowing, speak with their pediatrician. An evaluation by a Speech-Language Pathologist may be recommended. The evaluation may include assessment of eating and drinking directly but also look at oral hygiene, sensory concerns, behaviors of caregivers, and the environment during mealtimes. Overall development will be considered during the evaluation as well as the structures and functions of the mouth, body posture, head and neck control, and cranial nerve function. In some cases an instrumental evaluation may be recommended which will allow the Speech-Language Pathologist to see what is happening during the swallowing process. These evaluations will be conducted in a hospital or clinic. Two common instrumental evaluations are: Videofluoroscopic Swallowing Study (VFSS) and Flexible Endoscopic Evaluation of Swallowing (FEES).

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Treatment of Feeding and Swallowing Disorders in Children

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Therapy for feeding and swallowing aims to ensure the safety of ingesting food and drinks by mouth. Adequate nutrition, enjoyment during mealtimes, and establishing age-expected eating skills are also important goals of feeding and swallowing intervention. Specific treatment strategies will be determined by the child’s age, cognitive and physical abilities, structural factors, sensory factors, medical history and behavioral considerations.

Some of the interventions and strategies the Speech-Language Pathologist may utilize include:

• Introduce new ways to support your child in trying new foods or textures
• Change how hot, cold, crunchy or soft foods are
• Adjust your child’s positioning during mealtimes
• Provide strategies to respond to negative behaviors
• Increase muscle strength in the mouth
• Teach increased tongue movement and more effective chewing.
• Increase participation during meals
• Support acceptance of new foods based on sensory preferences.
• Support drinking through a cup or straw or sucking through a bottle
• Create a positive environment around food and mealtimes

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Parents and families are an important part of feeding and swallowing therapy. Other health professionals may also be recommended to provide support such as: dentists, dieticians, pediatricians, physical therapists, occupational therapists and/or psychologists.

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Teletherapy for Swallowing Disorders

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Tele-therapy is a unique platform to bring personalized intervention directly to a person’s home. Some feeding and swallowing disorders may be treated via tele-therapy, but others are best suited for in-person treatment, depending on the unique diagnosis and circumstances of each person. Swallowing treatment for children via tele-therapy requires a parent or caregiver to be present during each therapy session to help prepare food and drinks and support correct positioning. A speech-therapist who specializes in dysphagia treatment can help you decide if tele-therapy for feeding and swallowing is the best option for your child. 

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