Management feeding and swallowing disorders in children

Management feeding and swallowing disorders in children

Feeding disorders include problems gathering food and getting ready to suck, chew, or swallow it. For example, a child who cannot pick up food and get it to her mouth or cannot completely close her lips to keep food from falling out of her mouth may have a feeding disorder.

Swallowing disorders, also called dysphagia (dis-FAY-juh), can occur at different stages in the swallowing process:

  • Oral phase – sucking, chewing, and moving food or liquid into the throat
  • Pharyngeal phase – starting the swallow, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway (aspiration) or to prevent choking
  • Esophageal phase – relaxing and tightening the openings at the top and bottom of the feeding tube in the throat (esophagus) and squeezing food through the esophagus into the stomach

Causes

The following are some causes of feeding and swallowing disorders in children:

  • nervous system disorders (e.g., cerebral palsy, meningitis, encephalopathy)
  • gastrointestinal conditions (e.g., reflux, “short gut” syndrome)
  • prematurity and/or low birth weight
  • heart disease
  • cleft lip and/or palate
  • conditions affecting the airway
  • autism
  • head and neck abnormalities
  • muscle weakness in the face and neck
  • multiple medical problems
  • respiratory difficulties
  • medications that may cause lethargy or decreased appetite
  • problems with parent-child interactions at meal times

Signs or symptoms of feeding and swallowing disorders in children

Children with feeding and swallowing problems have a wide variety of symptoms. Not all signs and symptoms are present in every child.

The following are signs and symptoms of feeding and swallowing problems in very young children:

  • arching or stiffening of the body during feeding
  • irritability or lack of alertness during feeding
  • refusing food or liquid
  • failure to accept different textures of food (e.g., only pureed foods or crunchy cereals)
  • long feeding times (e.g., more than 30 minutes)
  • difficulty chewing
  • difficulty breast feeding
  • coughing or gagging during meals
  • excessive drooling or food/liquid coming out of the mouth or nose
  • difficulty coordinating breathing with eating and drinking
  • increased stuffiness during meals
  • gurgly, hoarse, or breathy voice quality
  • frequent spitting up or vomiting
  • recurring pneumonia or respiratory infections
  • less than normal weight gain or growth

Recommendations regarding the diagnosis and management of feeding problems in young children. Populations included, but were not limited to, children with behavioral feeding disorders, craniofacial anomalies and neurodevelopmental disabilities. Levels of evidence are provided for recommendations throughout the text. Level I evidence requires at least one well done randomized controlled trial, systematic review, or meta-analysis. Level II evidence requires at least one (preferably more than one) comparison trial, non-randomized cohort, case-control, or epidemiologic study. Level III evidence is based on expert opinion or consensus statements.

Diagnosis

If suspect that child is having difficulty eating will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. A speech-language pathologist (SLP) who specializes in treating children with feeding and swallowing disorders can evaluate your child and will:

  • ask questions about your child’s medical history, development, and symptoms
  • look at the strength and movement of the muscles involved in swallowing
  • observe feeding to see your child’ s posture, behavior, and oral movements during eating and drinking
  • perform special tests, if necessary, to evaluate swallowing, such as:
    • modified barium swallow child eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on an X-ray.
    • endoscopic assessment a lighted scope is inserted through the nose, and the child’s swallow can be observed on a screen.

Assessment

  • Swallowing
  1. “Anatomic abnormalities should be suspected when children have problems swallowing”
  2. “A history of recurrent pneumonia should alert physicians to chronic aspiration…”
  3. “Stridor in relation to feeding could be due to glottic or subglottic abnormalities. Suck-swallow-breathing coordination can be affected by choanal atresia”

Assessment Instruments

Clinical Examination

  • When evaluating feeding disorders the following key elements should be considered:
  • “How is the problem manifested?
  • Is the child suffering from any disease?
  • Have the child’s weight and development been affected?
  • What is the emotional climate like during the child’s meals?
  • Are there any great stress factors in the family?”.
  • Medical history should include investigation of development, e.g., “antenatal and perinatal history”, family history, diet and dietary changes, feeding characteristics, e.g., “route and time of administration”  and “feeding position”, strategies previously used, and environments and behaviors at mealtimes.
  • An assessment of parent-child interaction should be completed during feeding. “Positive interactions, such as eye contact, reciprocal vocalizations, praise and touch, and negative interactions, such as forced feeding, coaxing, threatening, and children’s disruptive behavior (turning the head away from food, throwing food) should be noted”
  • Additionally, assessment should document behavior prior to the presentation of food. Specifically, behaviors such as prompting, reinforcement and consequences should be noted.

Treatment Swallowing and Feeding

Treatment varies greatly depending on the cause and symptoms of the swallowing problem.

Based on the results of the feeding and swallowing evaluation, the SLP or feeding team may recommend any of the following:

  • medical intervention (e.g., medicine for reflux)
  • direct feeding therapy designed to meet individual needs
  • nutritional changes (e.g., different foods, adding calories to food)
  • increasing acceptance of new foods or textures
  • food temperature and texture changes
  • postural or positioning changes (e.g., different seating)
  • behavior management techniques
  • referral to other professionals, such as a psychologist or dentist

If feeding therapy with an SLP is recommended, the focus on intervention may include the following:

  • making the muscles of the mouth stronger
  • increasing tongue movement
  • improving chewing
  • increasing acceptance of different foods and liquids
  • improving sucking and/or drinking ability
  • coordinating the suck-swallow-breath pattern (for infants)
  • altering food textures and liquid thickness to ensure safe swallowing

Behavioral Treatments

      • Mothers of children with “state regulation” feeding disorders should “modulate the amount of stimulation during feeding” (p. 1250) (Level III Evidence). Feeding should occur promptly before prolonged crying (not more than 30 minutes) and mothers should avoid arousing, burping, or wiping during feeding
      • Parents of children with “reciprocity” feeding disorders should be trained to be sensitive and responsive to infants’ feeding cues (Level III Evidence). “Complicated cases need a multidisciplinary approach where family physicians can play a key role in coordinating services”
      • Therapy for children with “infantile anorexia” consists of “helping parents understand their children’s special temperaments, set limits, and structure mealtimes to facilitate the internal regulation of eating and to counteract the external regulation produced by emotional interactions within the caregiving environment”
      • “Food rules” are encouraged, and “time out” may be an appropriate response to inappropriate behavior (Level II Evidence)
      • Food aversions can be treated by increasing appropriate behavior with positive reinforcement and decreasing maladaptive behavior with extinction. “Time out” may also be used
      • Parents of children with feeding problems associated with concurrent medical conditions should be taught management skills to motivate children to improve food intake (Level I Evidence)
      • Treatment should focus on the elimination of tube feeding and increased acceptance of oral feeding. Treatment should incorporate the “behavioural technique of extinction” (Level I Evidence), or “gradual desensitization” (Level II Evidence)
      • Tube Feeding (Cerebral Palsy) – Treatment should focus on the elimination of tube feeding and the increased acceptance of oral feeding. Treatment should incorporate the “behavioural technique of extinction” (Level I Evidence), or “gradual desensitization” (Level II Evidence)

References

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