How do I know if my child needs feeding therapy? What are some different therapy options? How do I know what to bring to feeding therapy? Will my child grow out of their feeding challenges?
Hi, Chelsea here! I have been a pediatric speech-language pathologist since 2015. I have worked in a lot of different settings, and feeding therapy has been one of my favorite areas of the field! I am here to answer some common questions about feeding therapy and help ease the overwhelm.
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Part 1-3 Recap
This is a multi-part blog series. We have covered common reasons for needing speech therapy, where to go for therapy, how to select a therapist WHs of Speech Therapy: Who, What, When, Where, and Why, what to expect at an initial evaluation What to Expect at a Speech Therapy Evaluation, and what to expect at the first few therapy sessions Parent Roles in Speech Therapy.
I highly encourage you to go back through each of these previous posts if you haven’t already, because there is some valuable information in each. And while there are some differences between speech-language and feeding therapy, hence this separate post, there are also a lot of similarities. Additionally, the general process for an evaluation and starting therapy are similar. However, there are a few key differences, and we will highlight them here.
Why Might My Child Need Feeding Therapy?
There are a number of reasons your child may need “feeding therapy”. To be clear – I will refer to it as feeding therapy in this post, and I am specifically referring to speech therapy to address feeding skills. There are other professionals who do “feeding therapy”, the common one being occupational therapists, but it can also be addressed by counselors and dieticians. So, for simplicity’s sake, I mean the formerly mentioned.
There are 4 different phases of eating and swallowing. A disruption at any single phase can cause a feeding disorder or need for therapy. The four phases are summarized below:
- Oral prep Phase: The act of taking food to the mouth and manipulating it inside the mouth and preparing to swallow it.
- Oral Transit Phase: The act of pushing the food/liquid (e.g. “bolus”) from the mouth into the “throat” (pharynx) and initiating a swallow.
- Pharyngeal Phase: The bolus travels through the pharynx and gets directed into the correct “pipe” by closure of several muscles to protect the airway.
- Esophageal Phase: The esophagus opens to accept the bolus and then sends it down into the stomach by way of “peristalsis” (sequential squeezing).
Some common feeding disorders include:
- Pediatric Feeding Disorder: Taken directly from ASHA’s Practice Portal on Pediatric Feeding and Swallowing: “is any difficulty a person has with oral intake as compared to same age peers. PFD is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. Impaired oral intake is the inability to consume sufficient foods and liquids to meet nutritional and hydration requirements.”
- Avoidance/Restrictive Food Intake Disorder (ARFID): Taken directly from ASHA’s Practice Portal on Pediatric Feeding and Swallowing: ARFID is “an eating or a feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food, concern about aversive consequences of eating) associated with one (or more) of the following:
- significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- significant nutritional deficiency
- dependence on enteral feeding or oral nutritional supplements
- marked interference with psychosocial functioning”
- Dysphagia: Taken directly from ASHA’s Practice Portal on Pediatric Feeding and Swallowing: “a swallowing disorder involving difficulty processing and/or moving liquid and/or food boluses through the oral cavity, pharynx, esophagus, or gastroesophageal junction.”
Summary of Feeding Disorders
So, basically a child who has impaired oral intake of food or liquids for any particular reason, has significant “picky eating”, and/or has a swallowing function deficit may need feeding therapy.
What does this look like in real life? I will provide a few examples, not an exhaustive list below.
- An infant who has poor nursing skills or mother experiences pain with nursing.
- An infant who has difficulty transitioning to solid foods around 6 months of age. Read more on how to successfully start solid foods with your infant: Why Infants Don’t Need Baby Food When Starting Solid Food
- An infant who has difficulty learning to drink from a straw cup.
- An infant with recurring pneumonia, who may be silently aspirating liquid.
- A toddler who has persistent “picky eating” and refuses to eat anything other than chicken nuggets and mac n cheese (or other specific foods). Read more about that: Help! My Baby Doesn’t Like Solid Food
- A toddler who overstuffs their mouth and does not chew well. May often gag or choke on food.
- An elementary child who has tantrums at meal time, refuses any new or different foods, eats the same foods repeatedly and jags on them.
- An elementary child who refuses to eat at certain times or days (e.g. at school or at the babysitter’s) and is losing weight.
How do I start Feeding Therapy
If you have concerns with your child’s feeding skills, a good first step would be to discuss your concerns with your child’s healthcare provider. Now, I have already provided my disclaimer on this topic in a previous post: WHs of Speech Therapy: Who, What, When, Where, and Why, but please note that not all medical providers have a deep understanding of all the intricacies of oral and feeding skills.
If your child’s healthcare provider disagrees with you, but you still feel a feeding evaluation is warranted, you can request an order be sent to rule in/out the need for services, and you may even be able to self-refer. I will also say here that self-referral tends to be a little easier in the cases of speech and language skills. Feeding therapy often requires more of a medical setting, which often needs a physician’s referral.
Choosing a feeding therapist is likely more tricky than choosing a therapist to address speech and language skills. All therapists have their interests and skill sets, and we are not all good at all the things. Our field is too broad to do so. When selecting a feeding therapist, I highly recommend asking around for recommendations in your area. Read online bios or reviews to see what the therapist is interested in or specializes in. You may be able to speak to the therapist or office personnel to gather information to help you determine the right fit, as well.
You will likely need to choose a medical setting to find an experienced feeding therapist. Additionally, some feeding disorders warrant therapy to take place in this type of environment because of safety. You may find feeding therapy in University Clinics, Hospital Outpatient Clinics, Private Practice Clinics, or even other Private Practice settings.
While some school districts do allow their SLPs to address feeding, it is fairly unlikely that you will find feeding therapy through your school system. Early Intervention feeding therapy will vary by state and region, based on how “strictly” they follow the “developmental model” rather than the “medical model” of therapy service provision.
Once you have chosen where you want to go for services, you can schedule an evaluation (or wait on a waiting list). Each specific location will have referral requirements or things to complete prior to the initial evaluation. See What to Expect at a Speech Therapy Evaluation for more information on evaluation specifics.
Once you have completed necessary paperwork and engaged in some form of an intake (case history interview, intake forms, etc), the therapist will perform different types of assessment, and then you and the therapist will develop a plan for therapy. This will include specific recommendations and goals.
Feeding Assessments
A feeding therapist may need to perform a variety of assessment tools in order to fully understand your child’s eating skills and habits. Below I have listed some of the common ones:
Food Repertoire Form(s)
This is where you provide a list of foods that your child does and does not eat. I also like to include a section for “what does the family eat” to understand the type of diet that is in the home, what foods the family would like to see their child eat, and understand any cultural food habits.
Eating Schedule Form(s)
This will be a list of meals, snacks, and liquids with the timeframe of each that your child usually has on most days of the week.
Feeding Observation (also known as a “Bedside Swallow Evaluation” or a “Clinical Evaluation of Swallowing”)
All portions of the feeding assessment are important, but I would say feeding therapists would agree this is *almost always* the most important. This is where the therapist will observe your child eating. For babies, this will include nursing or bottle feeding. For older children, the therapist will want to observe how your child eats. I usually ask parents to bring a few preferred and non-preferred foods. However, some therapists use “clinic food” that is available in many outpatient settings.
Oral Motor Evaluation
This is when the oral structures are evaluated for intactness, range of motion, strength, and more. This evaluation could vary from simple “silly faces”, to an in-depth oral motor protocol using specialized tools, to a neurological innervation assessment. The type and depth of this assessment will depend on how your child presents, the setting, and the skill level of your therapist.
Instrumental Assessment
This may be needed to further assess the parts of eating that we cannot directly observe. This is most commonly done to rule in/out aspiration (e.g. food/liquid going into the lungs rather than the stomach) however, there are a number of other reasons to implement instrumental assessment.
FEES: A flexible endoscopic evaluation of swallowing. This is where a small camera is inserted into the nose and the therapist completing the study can observe the muscle function “from above”.
Videofluoroscopic Swallow Study (VFSS) or Modified Barium Swallow Study (MBSS): An evaluation of swallowing function with barium that is visualized radiographically (e.g. x-ray). This allows the therapist to observe where the food/liquid goes (e.g. into the esophagus or trachea) when it is swallowed.
There are strengths and limitations of both of these tests and which one your therapist recommends will be dependent on several factors, which you can ask about to have a full understanding.
Response to Therapeutic Interventions
At any point during the evaluation, the therapist may try some different strategies and see how the child responds.
A few examples, not an exhaustive list, are provided below:
- Change an infant’s position during nursing or their bottle.
- Change the nipple or the flow rate on the bottle.
- Stabilize a child’s feet in their chair.
- Offer a dip for a non-preferred food.
- Provide a “no thank you” plate for the child to remove their food.
- Model biting from a large piece while saying “bite and pull” to teach the child how to bite.
- Use a mirror for visual feedback.
- And many more.
Oftentimes parents don’t think of all the things and these simple changes can make a huge difference. These therapeutic strategies can help the therapist develop their treatment plan.
Please don’t be alarmed if your child does something they have never done before while with the therapist. And alternatively, if they have a meltdown and do not respond well, it is unlikely that you will surprise or scare your therapist. I always encourage parents to give therapy some time to work and try not to internalize or have guilt over whatever happens in therapy. We are here to help.
Once the evaluation is completed, your therapist will likely follow similar steps to what we described in Parent Roles in Speech Therapy.
A discussion about goals, recommendations, and a treatment plan will take place. From there, sessions will begin and there will be ongoing dynamic assessment, where the therapist will implement strategies, see how your child responds, give you homework, track the progress, and make changes as needed.
Final Notes
I know starting feeding therapy is a huge undertaking. You have to be committed to making the changes your therapist recommends and things often get more challenging before they get easier. As I discussed above, give it time to work. But also, do not be afraid to have real discussions with your child’s therapist about progress and concerns you may have. You are your child’s best advocate.
References:
Pediatric Feeding & Swallowing. American Speech-Language Hearing Association. Retrieved from: https://www.asha.org/practice-portal/clinical-topics/pediatric-feeding-and-swallowing/?srsltid=AfmBOoqRbKJqSVBlgu1lhnvtpDpHyrgnC5hmzPJFP5XYbWP1dek68SHU
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Flexible Endoscopic Evaluation of Swallowing (FEES). American Speech-Language Hearing Association. Retrieved from: https://www.asha.org/practice-portal/resources/flexible-endoscopic-evaluation-of-swallowing/?srsltid=AfmBOooEDp16Lw0qi4kGxUhGA7X5OZ0q-SFq6wxNivwYE527xm6wxLG_
Videofluoroscopic Swallowing Study (VFSS). American Speech-Language Hearing Association. Retrieved from: https://www.asha.org/public/speech/swallowing/videofluoroscopic-swallowing-study/?srsltid=AfmBOoqo6wLH8Me3so7YlZMzS8RFpFle8ifMghyyK6KaUokZEjy_9BdE
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