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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.
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.
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Major Diagnostic Categories Associated with Feeding
and Swallowing Disorders in Infants and Children
Neurologic
• Encephalopathies (e.g., cerebral palsy, perinatal asphyxia)
• Traumatic brain injury
• Neoplasms
• Mental retardation
• Developmental delay
Anatomic and Structural
•Congenital (e.g., tracheoesophageal fistula, cleft
palate)
• Acquired 12
Genetic
• 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
•
dysplasia).
•Gastrointestinal (e.g., GI dysmotility, constipation)
• Congenital cardiac anomalies
Psychosocial and Behavioral
• Oral deprivation
Secondary to Resolved Medical Condition
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• Iatrogenic
• Dysphagia and feeding problems are classified
according to which phase of swallowing is
affected.
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A child with a feeding disorder may
experience one or more of the following:
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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
height.
Decrease in expected rate of growth
based on the child's previously defined
growth curve, irrespective of whether
below the 3rd percentile
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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
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• Patient Demographics:
• Mean Age: 3 years (39 months)
• Gender: 68% male, 32% female
• Developmental level:
• 53% Developmental Delays
• 47% Typical Cognitive Development
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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
feeding.
Breathing interruptions or stoppage during feeding.
“Gurgly/wet” vocal quality before and after
swallows.
Unable to coordinate sucking and swallowing.
Significant drooling or oral weakness observed.
History of recurrent pneumonia .
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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
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Feeding Disorders
Etiologies
• Medical
• Oral Motor
• sensory
• Behavioral
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PREMATURITY
REFLUX DISEASE
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 .
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Structural lesions
• thyromegaly
• cervical hyperostosis
• congenital web
• Zenker’s diverticulum
• ingestion of caustic material
• neoplasm
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• Weak suck
• Choking or gagging during meals
• Tongue thrusting or inability to lateralize the
tongue
• Wet vocal sounds during or after meals
• Preferences for smooth or creamy textures
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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
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Nutritional Risk Factors for Children with
Developmental Disabilities
Oral-Motor Feeding Difficulties
Discoordination of suck swallow
Structural abnormalities (cleft lip/palate;
dentition)
Poor oral containment (food/fluid loss)
Tone abnormalities (hypo/hypertonic)
Altered oral sensory response
(hypo/hyper-responsive)
Delayed oral motor skill development
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Oral-Motor Weaknesses
Difficulty with oral strength and coordination
required for eating.
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Sensory Integration Dysfunction
• The sensory system consists of:
• Proprioception – body awareness
• Vestibular – balance
• Tactile – touch
• Gustatory – taste
• Olfactory – smell
• Vision
• Auditory – hearing
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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
immediately
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• 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.
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• 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.
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• During the physical examination:
• The patient should be observed during the act of swallowing.
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.
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Interdisciplinary Approach
Interdisciplinary team evaluation:
• Medicine – Rule out physical causes of feeding
problem
• 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
factors
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• 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.
• Cardiopulmonary stability
• Alert , calm state
• In young infants, demonstration of rooting
responses and adequate non-nutritive
sucking
• Appetite or observable interest in eating
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Feeding therapy for infants and children may
include the following strategies
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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.
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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.
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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
Develop a few simple rules and follow them, don’t start what you
can’t finish
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