• Slow feedings( mealtimes typically longer than 30-40 minutes)
• Sudden change in feeding patterns
• New problems with feeding
• Cessation of or difficulty with breathing during feeding or drinking
• “Gurgly/wet” vocal quality before, during and after swallows
• Uncoordinated sucking and swallowing pattern during drinking
• Significant drooling or oral weakness observed
• History of recurrent pneumonia
• Irritability or behavior problems during meals
• Food refusal
• Reduced or limited intake
• Food refusal
• History of GERD
• Food selectivity by type and/or texture
• Oral motor deficits
• Delayed feeding development
• Food or swallowing phobias
• Mealtime tantrums
• Sleepiness during feedings
• Failure to gain weight over 2-3 months
• Unexplained weight loss
• Diagnosis of a disorder associated with feeding and swallowing difficulties
• Does not achieve age appropriate feeding behaviors
• Not spoon feeding by 9 months
• Does not transition off of puree textures
• Poor bottle/cup drinking

There are generally five things we do to evaluate your child for a feeding problem: 

1. Modified barium swallow study
2. Watch the child eat
3. Determine which foods are refused and accepted
4. Observe mealtime behaviors
5. Look for signs of GERD

The evaluation proceeds from there.

During an evaluation, we will be assessing the safety and structural integrity of the swallowing mechanism. We are looking to see if there is a physical problem (anatomically based) that may be interfering with your child’s ability to eat an age-appropriate diet safely. The feeding specialist may refer you to a swallow study (Modified Barium Swallow Study or MBS) if she feels that safety is compromised during feeding.

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.

The team will watch your child get the food (bolus) ready for swallowing. They are looking to see how well he chews his foods or pools liquid and transfer it to the back of the mouth for swallowing. Then they will look at the pharyngeal phase of swallowing – how efficiently the bolus passes through the pharynx. Here they ensure a strong enough swallow to propel the bolus to the esophagus and to make sure that ALL the food passes cohesively together (rule out pooling within sinus cavities within the pharynx). Pooling needs to be ruled out because if it happens, excess material can spill out after the intended swallow and cause penetration into the trachea and lungs. They will also look at his ability to clear (by coughing) his airway if it is penetrated. The team will also look to see if there are any changes, for better or worse, to the swallow over time. That is why a yearly MBS is recommended in certain cases.

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. We look at what chewing and feeding skills your child has achieved and which skills are still difficult for them.

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. The feeding consultant will ask for you to collect a five-day food repertoire, itemizing everything your child eats in a 5 day period. This helps us create a baseline of food textures, types , colors and consistencies that we use to build our feeding regiment. Children may be hypersensitive to tactile sensations and may refuse to 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.

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. 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. Research shows that many mealtime behaviors result from negative mealtime experiences. Together we work to overcome these challenges and create and overall positive and enjoyable mealtime experience.

In addition, we will also be assessing for underlying factors that may be contributing to feeding aversions and difficulties such as GERD and medical and birth history. Many infants and children with GERD, or reflux, have delayed feeding skills. Sometimes, pain that was caused by the GERD causes them to associate pain with feeding. This feeling may have caused them to refuse feeding altogether or refuse certain types or textures of foods. 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. Overt signs of GERD may have disappeared and may be managed by medications, but the child may still be suffering from GERD (stomach contents entering and burning the esophagus without vomiting). If pain associated with GERD is not managed effectively, it can lead to the development of 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. Whenever there is a delay in the acceptance of expected textures and consistencies, children become at a disadvantage because 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. Some children that are G-tube fed, have difficulties with oral feedings (once cleared by medical professionals) as a 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 affect their ability to know when they mouth is too full or make foods taste too bland which can affect their physical skills for eating as well as their desire to eat.