Improving Feeding Skills
in Children with
Minnie Bray, M.S., CCC-SLP, BCS-S
Speech Language Pathologist
Board Certified Specialist-Swallowing Disorders
DSG Keys to Success Conference
January 26, 2019
Feeding and Swallowing Skills Think Bottom Up
Eating is a learned behavior Medical problems often lead to discomfort
Acquisition of skills follows a progression associated with eating, which leads to
selective eating or refusals, which leads to
with each new milestone building on skills delayed oral motor development, which leads
of the previous one to difficulty eating, which leads to more
If there is an interruption in this process, selective eating or refusals, and on and on
a feeding problem may develop
Dysphagia: difficulty moving food Very few children have a behavioral feeding
efficiently and safely from the mouth into problem in isolation
Penetration/aspiration are results of the Help with the underlying problem (bottom)
condition, and not the condition itself while addressing the mouth (top)
Gross Motor Skills and Feeding Gross Motor Skills Cont.
Positioning is the foundation for feeding What can parents do?
How are gross motor skills related to
◦ Tummy time
feeding? ◦ Avoid the “Container Baby Syndrome”
◦ Facilitate positioning for every feeding
◦ Abnormal muscle tone can interfere with body
alignment Motor therapy facilitates feeding
◦ Lack of trunk support greatly hinders ribcage ◦ Positioning: hips and knees at right angles;
expansion, interfering with respiration and Need good postural alignment when getting
increasing pressure on the stomach and ready to chew
◦ Basic exercises for trunk strength and rotation
Link between gross motor skill (weight shift on exercise ball, log roll, prone on
development and oral motor skill ball, side sitting during play, play games with
development trunk rotation)
Must achieve “gut comfort” before traditional
therapy approaches will be effective
Vomiting leads to negative feeding
Slow GI motility can increase reflux/vomiting
◦ Constipation is common in children with Ds
◦ Constipation causes slower GI motility and
When eating causes pain/discomfort, a
negative association with eating is formed
Collaboration is ongoing
Ear Nose and Throat Cardiac and Respiratory
Consider structural abnormalities
Narrow airways Common in infants with Ds
Chronic congestion impacts respirations Cardiac issue often leads to increased
and suck-swallow-breathe coordination respiratory rate
Enlarged adenoids and/or tonsils
Chronic middle ear fluid ◦ Swallow apnea of 1 second is okay if respiratory
rate is 30 (swallow-breathe-swallow-breathe)
◦ What about a respiratory rate pushing 60?
“Breathing always wins.”
◦ Eating is a lot of “work” and fatigue leads to
disorganized Suck-Swallow-Breathe” pattern
◦ Fast flow may be more “work” than a slow flow
◦ Consider pacing techniques
◦ Work with dietician regarding caloric intake
Feeding Therapy Feeding Therapy Cont.
Includes working with physicians to Feeding is a reciprocal exchange.
manage medical issues that affect feeding Look at Family Mealtimes
Establish scheduled meals/snacks
Includes motor, sensory, and behavioral
components ◦ Avoid grazing
◦ Water only between meals/snacks
Disordered feeding in a child is seldom
limited to the child alone; it also is a Mealtime Responsibilities
◦ Adults Decide: What is offered, When it is
Includes working with families so they offered, and Where it is offered
◦ Child Decides: What is actually eaten and
◦ Better understand the child’s feeding skills How much is eaten
◦ Help their child to advance skills
◦ Help parents separate their self-esteem with The “Purpose of Mealtime” goes beyond
nutrition and hydration
their child’s abilities
Feeding Therapy Cont. Positioning Across the Ages
Feeding interactions occur multiple times Positioning is the foundation for feeding
each day and impact attachment Energy should be on eating, not sitting
Recommended Not Recommended The Progression of Feeding Skills
Vertical Chewing (Tongue Lateralization)
The development of chewing takes time
When a child tires during a feeding, he will
revert backwards in skill
Balance oral motor skill development with
From Bottles to Solids Avoid “Tip and Scrape”
There’s no perfect bottle Tip and Scrape:
but choose one Baby is passive.
Introduce baby foods around six months more forward-backward
First goal is anticipation tongue movements.
Doesn’t require sucking.
Present a flat spoon and
wait for the baby to clear
Promotes top lip
movement, lip closure,
Baby is active.
Recommended Not Recommended for The Continuum of Foods
Spoon with narrow, Liquids
shallow bowl for easy Spoon with wide, Purees
clearance deep bowl Thicker Purees
Easy to grasp Soft Table Foods
◦ Soft Cubes
◦ Soft Single Texture Solids
◦ Soft Mixed Texture Solids
Table Food Requiring More Chewing
Midline Mashing Vertical Chewing/Midline Mashing
Vertical Chewing/Midline Mashing Transition to Cup Drinking
The transition to cup drinking is closely
linked to the transition to solids
Suckling and sucking from a bottle or
sippy cup involve a forward-backward
infantile tongue movement contradictory
to tongue lateralization needed for
Sippy cups are not recommended. Work
toward the straw and open cup.
Be prepared for messes.
Recommended Cups 1/15/2019
Honey Bear Straw Cup Recommended Cups Cont.
Recessed Lid Cup Cut Out Cup
Take and Toss
Infatrainer Cup Straw Cup
without the valve
360 cups are okay to
limit spills but not a
great teaching cup
Videofluorscopic Swallow Study Tube Feeding Considerations
(VFSS) Tube feedings are not a sign of failure!!!
Hydration/nutrition is the primary feeding goal
When do we refer for VFSS? Malnutrition results in weakness and further
Concerns of swallow safety and penetration/aspiration
based on signs/symptoms and medical history developmental delays. Weakness results in poor
When we think it would change the feeding routine or feeding skills and a decline in swallow safety.
Feeding utensils and consistencies
Repeating the VFSS—Considerations
Do we expect to see a change from previous results?
Will results accurately reflect abilities?
Have we considered radiation exposure?
What do the parents want?
Feeding is Messy Business References and Resources
It’s a marathon, not a sprint. As They Grow: Motor Development From Birth to
Six 2nd Edition by Jennifer Jones, Ph.D. BCS-S
Pediatric Feeding Disorders: Evaluation and
Treatment edited by Kellyl VanDahm, MS, CCC-
Prefeeding Skills, 2nd Ed. by Suzanne Evans
Morris, PhD., CCC-SLP and Marsha Dunn Klein,
M. ED., OTR/L
The Reflux Book: A Parent’s Guide to
Gastroesophageal Reflux by Beth Pulsifer-