What is Feeding therapy?
Addressing feeding problems may be important for preventing or eliminating nutritional concerns, growth concerns including failure to thrive, unsafe swallowing which may lead to aspiration pneumonia and future poor eating habits/attitudes.
Feeding therapy may be conducted in an outpatient clinic or hospital. Staff involved in conducting the initial feeding evaluation and any subsequent therapy will depend on the location of the evaluation and the infant or child’s current concerns. The feeding team may include one or more of the following: a speech/language pathologist, occupational therapist, physical therapist, nutritionist, social worker or other medical professionals.
Initially the evaluator will gather information about the infant or child’s medical, feeding and developmental history. Measurements of weight, height, weight to height ratio, frame size and fat stores may be taken. An observation of a typical feeding then takes place. The evaluator may then change some aspects of the feeding and note the outcomes in order to develop a plan to address the current concerns.
The evaluation itself is looking at a number of feeding skills and behaviors
Most importantly the evaluator is assessing oral-motor and swallowing skills to determine if the infant or child has a physical problem or lack of oral-motor skill that is interfering with the child's ability to eat an appropriate diet safely. Many infants and children with GERD have delayed feeding skills because the pain they associate with feeding caused them to refuse feeding altogether or refuse certain types or textures of foods and they don't gain the needed oral-motor experience to develop the physical skills needed to safely consume the type of diet they should be consuming. These associations can also lead them to attempt to get the feeding process over quickly as possible so they do not take to the time to use the physical skills needed to eat safely. Some children with GERD may also require tube feedings again reducing their exposure to oral-motor experiences and effecting their feeding skill development.
Observation alone may not give the evaluator all the information they need in assessing the infant or child’s physical skills for feeding. They may need to schedule a swallow study to gain more information. The swallow study will allow the evaluators to look for structural abnormalities in the swallowing mechanism and assess risk factors for aspiration (penetration in to the lungs) of foods and liquids.
A swallow study also called a modified barium swallow (MBS) or videofluoroscopic swallow study (VFSS) is very similar to an upper GI series. A radiologist and a speech language pathologist most likely will be present and will videotape the study for further review following the actual study. Barium will be mixed into various foods and drinks. The evaluator may observe the infant or child swallowing various textures of foods and thin liquids and possibly thicker liquids if needed. Most evaluators try to have the feeding be as close as a typical feeding situation so that they can study his typical swallowing pattern, so they may ask you to bring your infant or child’s own bottle, spoon, cup etc. and possibly some of the foods and drinks your infant or child typically has at home. Of course it is nothing like a typical feeding as the child will be in the radiology suite and will have to be positioned upright - possibly in a special seating system that gives them the observers the best view of the swallowing process.
The evaluators will watch the infant or child orally prepare the bolus (the portion of food or drink taken into the mouth) for swallowing - at this stage they are looking to see how well he chews his foods or pools liquid and transfers it to the back of the mouth for swallowing. Then they will look at the pharyngeal phase of swallowing - at this phase they are looking to see how efficiently the bolus passes through the pharynx. They want to make sure the swallow is strong enough to pass the bolus onto the esophagus and to make sure there is no pooling in the several sinus cavities in the pharynx. If this happens the pooled material can later spill out and penetrate the trachea and into the lungs. Some studies follow the bolus through the esophagus and into the stomach but not all do. They will also look at his ability to clear his airway if it is penetrated- if a cough is triggered and clears the airway. They will look to see if his swallow pattern changes over time.
In addition to physical skills the evaluator will also look at sensory issues that may be interfering with intake as some children have difficulty taking in information from what they see, hear, smell, touch and taste. Many infants and children with GERD often develop sensory issues in that they are or have become hypersensitive. This hypersensitivity may affect the infant or child’s acceptance of the nipple, spoon or certain tastes or textures. Think about it. If your stomach and esophagus hurt constantly, people were giving you medicine all the time (some of which may not taste great), you did not sleep well and eating made you feel worse or you had a n-g tube, you would be a little irritated by sensations like tooth brushing and lumpy food too. Some children may also be hyposensitive as well. This may effect their ability to know when they mouth is too full or make foods taste too bland which can effect their physical skills for eating as well as their desire to eat.
Watching the child eat
Assessing the feeding environment is also important. The evaluator will look at who is feeding the child, their level of stress in feeding the child, and if techniques they are using are appropriate. They ask about at the location in which the feeding typically takes place. They note if the environment distracting and whether the child is positioned appropriately. They look at the size and type of feeding utensils used and whether they are appropriate. Lastly they ask about the infant or child’s feeding schedule and sequence of the feeding, noting if feedings are too long, too often and what and when certain types of foods and drinks are offered.
What foods does the child eat? Which are refused?
The infant or child’s diet is an important factor to evaluate in terms of what food and liquid types are being offered and accepted, amounts consumed and whether there are any nutritional deficits or growth concerns.
Observing mealtime behaviors
Finally the evaluator also notes any mealtime behaviors that may be interfering with adequate intake. In noting behaviors the evaluator will look at how the feeder and the infant or child communicate with each other during the feeding, manipulative or maladaptive behaviors on part of the feeder or child and the child’s self-feeding development. Many problems can occur in this area. The child may be clearly communicating that he finished eating by turning his head yet the feeder pushes the child to eat more. The feeder may offer an endless array of choices at meals allowing the child to manipulate what he will and will not eat. The child may not be allowed to self –feed because of the feeder’s desire to control the amount of intake or cleanliness of the feeding.
The role of reflux in developing unusual eating patterns
It is clear that many infants and children with GERD develop negative associations with feeding due to the reflux pain that feeding has caused them. If their pain is not managed adequately, the infant or child may develop secondary behavioral symptoms of food refusal, selectivity and oral sensitivity which can negatively impact growth and maturation and can lead to delayed acquisition of feeding skills. Infants and children with GERD may be hypersensitive to tactile sensations therefore do not explore objects with their mouths, which can lead to a lag in the development of the oral sensori-motor skills required for feeding. Introduction of spoon feeding may be delayed due to lack of readiness skills or noted increase of symptoms with introduction of solid foods. Young children also may have difficulty advancing to textured foods and may gag or choke while feeding. These symptoms (i.e., food refusal, selectivity and oral sensitivity) put stress on the feeding relationship between the young child and caregivers and may lead to counter-productive feeding practices.
The associations that infants and children make between the pain of GERD and feeding can remain even long after the pain of GERD has subsided. Young children may also be taken off medication when the obvious symptoms of reflux disappear yet their reflux may continue silently (meaning that stomach contents go into the esophagus but does not result in vomiting) and cause continued feeding problems. Therefore it is vital that the young child receive proper medical diagnosis and treatment of reflux, especially pain relief, before attempting a feeding intervention program. Although feeding therapy can be effective in addressing many types of feeding difficulties, without effective pain management, oral-motor, sensory and behavioral feeding interventions may yield disappointing, ineffective results.
Pamela Tyler MS CCC SLP
Speech Language Pathologist
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