Paediatric Feeding

Question 1

Signs and symptoms of dysphagia/feeding difficulty in babies

Answer 1

• Difficulty latching with BF or bottle feeding
• Significant nipple pain or damage
• Weak or uncoordinated suck
• Significant fatigue with feeds
• Coughing, spluttering, gagging while feeding
• Frequent, large gulping swallows
• Biting or chomping on the breast or bottle
• Bottle/breastfeeding refusal/oral aversion
• Collaborative work with Dietitians around poor growth/ failure to thrive (FTT) as well as tube fed babies/children

Question 2

Signs and symptoms of dysphagia/feeding difficulty in children

Answer 2

• Refusal to eat solids
• Difficulties with cup drinking
• Difficulties with the textures of food (gagging on lumpy foods or finger foods)
• Fussy eating
• Food refusal/ oral aversion
• Inappropriate textures for developmental age
• Challenging mealtime behaviours
• Coughing/aspiration on fluids/foods
• Collaborative work with Dietitians around poor growth/ failure to thrive (FTT) as well as tube fed babies/children

Question 3

Factors for consideration in paediatric feeding assessment

Answer 3

• Obtain medical history
• Obtain feeding history
• Obtain developmental history
• Feeding observation (informal and formal)
• Feeding plan (including MDT considerations)

Question 4

How would you conduct a feeding assessment?

Answer 4

OMA
* Oral muscle assessment - Allows you to look at the structure and function of the:
- Cheeks
- Lips
- Jaw
- Tongue
- Palate
- Teeth and gums

**Oral Motor assessment – reflexes
* Gag
* Rooting
* phasic bite
* transverse tongue
* tongue protrusion
* sucking
* swallowing

Infant feeding assessment tips
 Always observe a full feed so you can assess how the baby is before, during and after a feeding.
 You can feel a non-nutritive suck by placing a gloved finger in the baby’s mouth during your OMA.
 You can see the bubbles in a baby bottle and hear swallows in both bottle- and breast-fed babies. These smaller cues will help your suck assessment.
 Breastfeeding: exclusive BF is recommended until around 6 months of age. Speech Pathologists working in this area are advanced level so please seek support.

Informal feeding ax in toddlers & children
* Always do an OMA
* Try to observe in a natural setting (home is ideal) or clinic – ideally around a feed time
* Ensure supportive seating (highchair, foot rest, tripp trapp/Mocka chair etc)
* Caregivers should feed their child, but you can demonstrate strategies
* Ask caregivers to organise the following
* 2 foods the child is eating well e.g., smooth puree
* 2 foods they are struggling with e.g., banana (finger food), mashed meat and vege (mixed texture) + bite dissolve
* A drink (+ sippy cup, straw or open cup)
* Blue book for growth (Dietitian support)
* 24 hour food diary is useful
* Observe structure and function of oral muscles when eating solids
* Observe chewing skills (up-down, diagonal, rotary chewing)
* What else can you see with their feeding?
- spitting of food
- storing of food
- gagging on any textures
- self-feeding of food and drinks (age dependent)
* Observe swallowing coordination of food and fluids
* Note the
- overall time taken to eat
- volume of intake eaten

• Consider sensory exploration willingness
• Observe the caregiver’s response to child’s feeding cues
• Ask the caregivers about what a “typical feed” looks like at home

Question 5

Management strategies to support safe and effective intake for infants - how does this link to the clinical presentation?

Answer 5

• Feeding strategies recommended (always practice with the caregivers)
• Follow up plan by the speech pathologist
• Any referrals (check with your supervisor)
• Instrumental swallow assessments
• Multidisciplinary team referrals

Considerations of positioning

Question 6

Management strategies to support safe and effective intake for toddlers/children - how does this link to the clinical presentation?

Answer 6

Firstly Explore:
Why is this toddler struggling?
- Is the current method safe?
- Is feeding adequate?
- Is feeding efficient?
- Is feeding developmentally appropriate?
- Is feeding positive (child and caregiver)?
Always think about the multidisciplinary aspects of feeding

Strategies for babies
* pacing
* thickener
* change in bottle (diff shaped teat, diff flow rate)
* change in position
* cue based feeding
* reviewing feeding regime

Strategies for toddlers
* texture change
* positioning of food
* bite dissolved finger foods
* texture of finger foods
* spoon or cup change
* highchair positioning
* reviewing feeding regime

Strategies for children
* Mealtime structure (when is food offered?)
* plating preferences (eg pre-plating or buffet style)
* Where food is being offered. eg dining table, sitting on the floor, while watching tv)
* how they’re sitting (OT support might be needed)
* feeding equipment (OT support might be needed)
* family-child mealtime enjoyment
* reviewing feeding regime (dietitian support might be needed)

Question 7

Prioritisation for intervention

Answer 7

1. Safety
2. Volume – how much are they eating
3. Efficiency - are they getting enough food to ensure their growth and development? (General norms are 15-20mins for snacks, 30-40 mins for meals)  babies that are taking too long to eat may actually be burning more calories through the process than taking in what they need
4. Family stress eg family member opinions, chaos/disharmony in the home/at meal times
5. Developmental level – eg still having puree pouches at 18 months
6. Difficult behaviours – eg sensory related, oro-motor delays
7. Child distress – often linked to family stress, often associated with preparation for meals. Such as toddler starts crying as soon as mum puts them in high chair. (known as oral aversion)