Child Feeding & Swallowing Problems

Every parent has stories about that time when their child had a tantrum and threw their food. Of course it was in public. It was a disaster – the food went everywhere. And those dirty looks…

What happens if these feeding/food refusal/food avoidance tantrums are a daily, almost every mealtime occurrence? Is your guilty secret that you child only likes ‘junk’ food? And at this point ‘something is better than nothing’ – a child can’t live on air!

How do you know if your child’s funny quirks about foods are normal?

What about food refusal, fussiness about sauce, or tantrums if food touch each other?

You probably have a freezer packed with an unwanted oversupply of frozen butter-bean or quinoa banana mash puree cubes… You stock chicken nuggets because that’s all your child will eat and you try to hide that they only eat chips when you go on playdates in the park.

So what’s normal and when is it a ‘real’ problem that needs addressing?

Many children are fussy at mealtimes. This in itself is not necessarily a problem. When a child is a ‘picky eater’, refusing to eat certain foods or only eats food presented in a particular way it can be hard to work out if it is an eating or feeding disorder.

Both feeding and eating disorders are clinically seen as being within the same category and have overlapping diagnostic criteria. Both are characterised by a disordered relationship with food.

Feeding disorders are more commonly associated with children, and eating disorders more commonly associated with teens and adults^[1].

Eating behaviours that are causing a lack of nutrition, hindering growth, causing weight loss, dehydration are a health concern. Other behaviours such as food allergies, gagging, vomiting, consistently refusing foods or liquids may point towards an underlying medical swallowing condition.

Patterns of reducing appetite or reducing range of foods that are eaten may also point to a feeding disorder that require a team management approach. In this case a GP should have overview of the child’s medical health. An onward referral to the speech pathologist is recommended to assess the feeding or swallowing concern with a view to provide therapy.

There are a wide variety of known possible causes for feeding and swallowing problems in children. These include:

1. Muscle weakness in the face and neck Low muscle tone or strength impacts the physical ability to feed oneself, and affects the first oral stage of swallowing. For example, a sign of low lip tone may be that a child’s t-shirt is constantly wet from excessive drooling (aside from infant teething).
   Low oral muscle tone also impacts eating and drinking as food falls from the spoon or fork as when the lips do not seal around them well. Children with low tone often appear to be messy eaters. Muscle weakness or low tone makes chewing and swallowing effortful. This means a child tires more quickly when eating leading to smaller intake a slower weight gain.
2. Sensory issues This is one of the most common feeding issues that we encounter and treat in with our young clients. It is not intrinsically a neurological or developmental disorder and can be characterised as more of a stress response to sensations in the mouth. The main sensory issues are defensive.
   • Reactive sensory defensiveness is when an infant has had bad experiences with sensory inputs in their mouth. This is common with infants who have been in hospital and have been intubated for example. So when sensory input is provided, even food may be experienced as very strong and uncomfortable.
   • Primary sensory defensiveness is when sensory stimuli of the face or mouth, even the stimuli of food is perceived as danger or an attack. This can trigger the food refusal behaviours in the same way as a fight or flight response. Hence why children can express huge meltdowns or tantrums at mealtimes.
   • An eating aversion is the result of a complex combination of sensorimotor (sensory and motor), gastrointestinal, and environmental responses (meaning responses by others in their everyday and home life). This is typically perceived as a behavioural issue. Many of these children have subtle sensorimotor and gastrointestinal issues that make eating uncomfortable. So, these children may choose a non-eating behaviour to reduce or prevent discomfort.
3. Reflux. This is when the contents of the stomach, including the stomach acid, return to the oesophagus causing irritation and inflammation. Reflux can occur when eating or drinking. Symptoms include vomiting, coughing, gagging, your child sitting/lying in an unusual posture, unexplained change in mood.
4. Being premature or having a very low birth weight. These infants are often unable to coordinate sucking, swallowing and breathing until 34 weeks. Premature infants do not have sucking pads. Premature infants and those born with very low birth weight are prone to respiratory issues that impact their ability to coordinate suck-swallow mechanisms to feed effectively.
5. Cleft lip or palate. The physical effects of this make feeding a challenge because of the lack of control of whether milk goes when breast or bottle feeding. There is also the physiological problem of not being able to create a vacuum to suck when there is a cleft.
6. Developmental Disabilities. A 2000 study showed that 25% of all children and as many as 80% of children with developmental disabilities can experience a feeding disorder of some kind^[2]. The US based Centre for Autism and Related Disorders^[3] confirms the feeding disorders are most common among the population with developmental disabilities, and that food or drink refusal is common among children on the autism spectrum.

A child with a feeding disorder may show problems grasping or holding foods with their fingers. They may have difficulties sucking, chewing foods, holding food or drinks in their mouth. They may show persistent on-going aversions to food textures such as ‘slimy’ foods (ham or sweaty cheese) or sauces. They may refuse whole food groups such as refusing all fruits except small berries. Or, they may refuse all vegetables or all meat. It is much harder when they refuse a combination of these.

Food they do accept have to meet certain criteria; such as skin off, thin slices, not touching other foods.

They may refuse to touch food with their fingers, or only want food out of a pouch, for example yoghurt must come from a pouch not a bowl. These types of behaviours which make receiving adequate nutrition from a range of sources and make life generally difficult are typical of feeding disorders.

Swallowing has several stages to its process. A swallowing disorder can be a problem with any stage of the swallow process including:

1. Oral Stage: This includes the ability to suck, bite, chew, move foods around effectively from side to side for chewing, as well as moving it back towards the throat so that the swallow can be triggered.
2. Pharyngeal Stage: This stage is when the swallow starts and the food or drink is moved down the throat. The throat reflexively closes over the windpipe to stop food or drink from going down the wrong way.
3. Esophageal Stage: This stage pushes food and drink further down towards the stomach by squeezing the food down in a wave like pattern.

Here are some guidelines of typical swallowing and feeding milestones^[4]:

Age	Feeding and Swallowing development
Birth- 2 months	Nipple feeding by breast or bottle Hand to mouth movements begin Semi-reclined posture during feeding/mealtimes
2-3 months	Interacts with caregiver during feeding through gaze
3-4 months	Begins to put hands on bottle during feeding
5-6 months	Spoon feeding introduced (4-6 months) Cup drinking introduced Holds bottle with both hands
6-9 months	More uprights posture during feeding Increases lip closure around spoon Accepts spoon feeding or pureed food Begins to finger feed solids Vertical chewing pattern (munching) begins Is able to suck liquids from a cup Helps caregiver with spoon
9-12 months	Drinks from cup held by caregiver Progresses to thicker, more textured food Increases finger feeding of easily dissolvable foods Chewing matures to more rotary jaw actions Deliberately reaches for spoon
12-18 months	Grasps spoon with both hands for self-feeding Holds cup with both hands Is able to hold and tip bottle independently
18-24 months	Is primarily self-feeding Is able to chew a wide range of textures Oral movements are more precise
24-36 months	Holds cup with one hand Drinks from open cup without spilling Uses fingers to put food on spoon Uses fork Almost completely self-feeds Eats a wide range of solid foods

Your child may have a feeding or swallowing problem if they:

• Arch their back or stiffens when feeding
• Cry or fusses when feeding
• Falls asleep when feeding
• Has problems breastfeeding
• Has trouble breathing while eating and drinking
• Refuses to eat or drink
• Eats only certain textures, such as soft food or crunchy food
• Takes a long time to eat
• Has problems chewing
• Coughs or gags during meals
• Drools a lot or has liquid come out her mouth or nose
• Gets stuffy during meals
• Has a gurgly, hoarse, or breathy voice during or after meals
• Spits up or throws up a lot
• Is not gaining weight or growing

When is this a health concern?

Seek immediate medical opinion from your GP if your child is showing signs of losing weight, or their growth is not following their percentile curve.

1. For Babies

Please contact us if:

• Your baby refuses the nipple
• Milk is drooling out, or dribbling from nose
• Your baby cries with hunger but does not latch on properly
• Your nipples are cracked/bleeding from poor latching
• Your baby arches their back/ pulls away from the nipple or bottle, or refuses the nipple
• Your baby regularly vomits up milk

Behaviours like these are not typical feeding behaviours. This is often very stressful for the parents and infants. Feeding issues can also quickly medically escalate.

2. For toddlers and children

Mealtimes do not have to be a battleground. Please contact us if:

• Everyday feeding has become a challenge
• You are having to more than moderately adjust meals to accommodate fussy eating behaviours
• You are finding yourself constantly trying to find ingenious ways to ‘trick’ coax/ bribe your child into eating.
• You are constantly trying to find that one secret recipe that will tick all their criteria, just so your child will eat something new/ different
• Mealtimes have become a battle.
• You are having to prepare or present foods in particular ways
• Your child coughs, gags of vomits when feeding/drinking
• Your child takes a long time to eat/ abandons eating due to tiredness even when they are still likely to be hungry
• Your child refuses to touch certain textures, let alone put it in their mouth/ likes to use tongs
• Your child tries not to taste food, for example tries to chew it on one side of the mouth and swallow it down, or just drinks it down
• Your child has reduced the food that they will eat to a narrow range
• Your child avoids whole categories of food, eg. will not eat fruits/ veg /meats
• Your child has rituals around food
• Your child will not sit at the table and is often hopping around trying to get away from the table
• Your child avoids feeding even when you know they are hungry

Talkshop’s speech pathologists have attended specialist paediatric feeding courses and work successfully with children with feeding disorders. We are able to assess and manage feeding concerns once infants have started on solids, generally aged 4-6 months.

Babies who are on bottle or breast milk only are referred to a Lactation Consultant service.

Feeding and Swallow Assessments

The assessments are usually conducted at home so your child can be comfortable in their own surroundings. The home visit is set up to be a playdate with a picnic. Assessment of your child’s relationship with food is explored through storytelling and using soft toys or puppets.

We go through some mouth exercises where we make lots of silly faces but we’re actually looking at the structure and function of your child’s mouth and jaw including the soft tissues and musculature of the tongue, cheeks and lips. We look at their tone, strength, and coordination. We also look at the behaviour of the tongue when swallowing to check for tongue thrust, and we look below the tongue for a tongue tie. This is called an oro-motor assessment. This allows us to look for any physical or physiological factors affecting the swallowing.

We do a swallowing assessment. That allows us to check their ability to swallow drinks and solids.

The feeding assessment (picnic) allows us to observe your child’s actions and behaviours at the table, how they make choices, what they touch and how, what they refuse and any aversion behaviours.

In this time we are also encouraging them to try some new foods or tastes as part of table-based games. We are seeing how stimulable or how receptive your child may be to try new tastes/textures.

Feeding / Swallow Therapy

Sensory Intervention

Sensory intervention is provided for children who have a diagnosis of Sensory Processing Disorder or have sensory processing difficulties. These difficulties may be isolated, or related to a diagnosis such as Autism Spectrum Disorder. A food chaining program^[5] is run as part of the sensory intervention. It involves identifying the tastes, temperatures, textures and foods that align with a child’s sensory preferences, as well as those that do not align with their sensory preferences. The program involves introducing new foods into a child’s diet that align with their sensory preferences.

 

Behavioural Intervention

Behavioural intervention is a widely recommended treatment and has some support for treating pediatric feeding disorders^[6]. It involves creating an environment that is conducive to successful and positive eating experiences, such as removing distractions, positioning the child appropriately at the table etc. It also involves praising positive feeding behaviours that children exhibit as part of encouraging them to repeat these behaviours (e.g. praising children for chewing, swallowing and staying at the table).

Referring on to other services

Other health professionals can also support you and your child with their feeding difficulties.

• GP/ Paediatrician
  You can self-refer to our speech pathology service. Due to complex nature of feeding and swallowing disorders, we will always recommend that you remain in touch with your GP, seeking their advice to manage your child’s condition. You may prefer a Paediatrician to manage this.
• Lactation Consultant/In-hospital Feeding Specialist Speech Pathologist
  If you are in hospital with a newborn who is having trouble feeding, you may be able to access specialist Speech Pathologists. If you are living at home and your baby is only bottle/breastfed and has not yet started on solids we will refer you to a Lactation Consultant
• Dietitian
  Once we have been successful in helping you introduce more textures to your child’s diet, we may recommend that you seek the advice of a Dietitian so they can support your child with their nutrition^[7].
• Occupational Therapy
  Children with oral sensory defensive behaviours often have have other sensory sensitivities such as a dislike of loud noise, labels on clothing, sock seams across toes, prefer not to wear clothes as they itch, can only calm when they have strong cuddles requiring occupational therapy. We can also recommend Occupational Therapy services to aid with management of sensory processing.
• Paediatric Dentist
  Oral sensory aversions can make brushing teeth a real battle. We can help recommend Paediatric Dentists who are sensitive to working with children with oral defensive behaviours to maintain good oral health
• Clinical Psychology
  When there are suspicions that there are underlying psychological origins, we may recommend an onward referral to Clinical Psychology for us to work together. If you have concerns for an adult with feeding/swallowing problems read about how Talkshop Speech Pathology can also help.