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Posted October 25, 2013
All Children's Speech Language Pathology Pediatric Feeding and Dysphagia Program

All Children's Speech Language Pathology Pediatric Feeding and Dysphagia Program

Eating, swallowing and growing well are things most of us take for granted. For some infants and children, however, this does not come easily at all. An estimated 25% of the pediatric population will experience some type of feeding issue. For premature babies and children born with developmental disabilities, this incidence climbs even higher, based on their early entry into life and the medical challenges they may face. Infants may not be able to eat on their own safely, compromising weight gain, health and overall development if left unchecked. Early identification, appropriate and effective treatment, well-coordinated care, and family education and support are key to addressing these issues.

Why choose the Speech Language Pathology Pediatric Feeding and Dysphagia Program at All Children’s Hospital Johns Hopkins Medicine?

All Children’s Speech Language and Feeding Department is dedicated to providing the most advanced, evidenced based care for the education, prevention, identification and treatment for feeding and swallowing disorders in infants and children and for supporting families in this endeavor as well. As part of a comprehensive medical program tied to a 259 bed pediatric hospital with one of the largest and highest acuity level neonatal intensive care units in the southeastern United States, our program and our highly trained pediatric dysphagia speech language pathologists (SLPs) are experienced and uniquely qualified in dealing with the feeding and swallowing issues of the most medically challenging children and their families.

Feeding and swallowing issues are extremely complex. The swallowing anatomy and physiology of children is different from that of adults and is constantly changing. Therefore, therapeutic techniques that are applicable to adults are not necessarily effective or appropriate for children, and techniques that facilitate feeding at one stage of a child’s development may not be effective at a later stage. Additionally, children are not always able to communicate the specific symptoms they are experiencing and may refuse to eat when there is an unidentified, underlying issue. Of all the allied health care professionals, SLPs are best trained to understand the intricacies of infant oral anatomy and swallowing function. A pediatric speech language pathologist with comprehensive training in all aspects of feeding and swallowing and the associated medical issues is vital to accurate diagnosis and effective treatment. At our main campus, as well as at each of our outpatient care centers, feeding services are provided by select Speech Pathologists who have master’s level education and who have undergone rigorous training to differentially diagnose and treat a variety of complex feeding issues to improve growth, safety and /or overall nutrition for children ranging from preterm babies to school age. Our SLPS are trained and experienced in the feeding issues associated with various medical conditions which may include, but are not limited to, the following:

  • Neurological disorders (e.g., cerebral palsy, meningitis, traumatic brain injury, encephalopathy)
  • Gastrointestinal conditions (e.g., reflux, "short gut" syndrome, eosinophilic esophagitis)
  • Failure to Thrive and malnutrition
  • Prematurity and/or low birth weight
  • Cardiac conditions
  • Craniofacial disorders (e.g. cleft lip/palate, Pierre Robin)
  • Respiratory difficulties and conditions affecting the airway (e.g. larynogmalacia, vocal cord paralysis/paresis)
  • Neurodevelopmental and Genetic disorders (e.g. autism spectrum, Down Syndrome, etc.)
  • Head and neck abnormalities
  • Muscle weakness in the face and neck
  • Multiple medical problems
  • Medications that may impact alertness and appetite
  • Sensory disorders that interfere with meeting nutritional needs

Outside of a pediatric hospital system, few other therapists have the exposure to and the experience with the variety, complexity and numbers of the infants and children seen for feeding and dysphagia at All Children’s, and few have the same degree of access to the equipment, resources and other specialists that contribute to the comprehensive care needed by these children.

How are feeding and swallowing problems identified in infants and children? 

Infants and children may exhibit a variety of symptoms indicative of a feeding or swallowing problem, some of which are more obvious than others. An infant or child who demonstrates one or more of these issues may be a candidate for a feeding and/or swallowing evaluation:

  • Poor weight gain or growth
  • Poor intake
  • Coughing, gagging, choking during feeding
  • Arching, crying, pulling away or other signs of discomfort during feeding
  • Difficulty calming or lack of alertness during feeding
  • Refusing food or liquid
  • Limited acceptance certain textures (e.g. chewable solids) or whole categories (e.g. vegetables) of food
  • Lengthy feeding times
  • Fatigues before taking expected amounts
  • Difficulty chewing
  • Difficulty breast feeding
  • Excessive drooling
  • Food/liquid coming out of the mouth or nose
  • Difficulty coordinating breathing with feeding
  • Increased congestion/wetness during/following meals
  • Wet or hoarse voice quality or low volume
  • Frequent spitting up or vomiting
  • Recurring pneumonia or respiratory infections
  • “Sleep feeding” or eating well only during in a drowsy state
  • Fear of swallowing, including following a traumatic choking incident
  • Color changes or eyes watering during feeding
  • Pocketing or spitting out solid food pieces
  • Difficulty advancing to age-appropriate textures/utensils
  • Significantly restricted diet or rigid food/mealtime preferences
  • Significant family struggles, frustrations with mealtime

What happens during a Feeding Evaluation at All Children’s Hospital Johns Hopkins Medicine?

Feeding evaluations through our program provides a comprehensive clinical evaluation during which an infant’s or child’s feeding and swallowing abilities are assessed.

A speech language pathologist specializing in feeding and dysphagia will:

  • Review the child’s medical records and talk with caregivers about the child's medical history, overall development and growth, feeding intake, mealtime schedule and environment, and symptoms/concerns
  • Examine the child’s oral reflexes and the strength and movement of the muscles involved in feeding and swallowing
  • Observe a typical feeding to observe foods offered and feeding materials utilized, the child’s positioning and posture, oral movements during eating and drinking, respiration and phonation (including cervical auscultation), parent-child interaction and behaviors during feeding, and indicators of any underlying issues that may impact eating
  • Outside of a pediatric hospital system, few other therapists have the exposure to and the experience with the variety, complexity and numbers of the infants and children seen for feeding and dysphagia at All Children’s.
  • Differentiate between typical developmental stages and true feeding concerns
  • Identify potential problems and/or risk factors associated with your child’s feeding and swallowing abilities, the most critical being safety and ability to meet nutritional needs
  • Demonstrate and test effectiveness of skilled therapeutic techniques in improving your child’s feeding, assist parents with these techniques and with navigating through the wide variety of nipple , bottle and cup systems available and determining the best fit for their child
  • Develop home and treatment programming as indicated
  • Recommend special tests or other referrals, if necessary, to evaluate swallowing (e.g. OPMS)

Specialized feeding evaluations are available to assist specific populations and concerns:

Infant Bottle and Breast Feeding Evaluations

Evaluating feeding and swallowing in infants is really a subspecialty of pediatric dysphagia and only those with an additional level of training are adequately equipped to provide the expert care needed. A knowledge of infant anatomy and physiology, reflexes, behavioral states and regulation, forms of nutrition and intake requirements, feeding equipment, feeding position, suck/swallow/ breathing patterns and coordination, support strategies, feeding transitions and other developmental changes is necessary to provide effective services to infants and their families. Our feeding program insures that those therapist assigned to evaluate infants are well prepared with the latest education and resources. Additionally, we also recognize the enormous benefits afforded to infants through breast feeding. Just as risk factors can impact bottle feeding, breastfed babies can encounter feeding and dysphagia issues that interfere with breast feeding as well. Our SLP staff will work closely with lactation consultants and families who desire to breast feed but are encountering unresolved difficulties to determine if infant’s oral’s oral musculature and/or sucking and swallowing are contributing to breastfeeding issues. Once identified, SLPs can provide therapeutic techniques or further recommendations to assist in addressing bottle feeding and breast feeding issues.

Acute Care Feeding and Swallowing Evaluations

For preterm infants to older infants and children hospitalized with a variety of acute and chronic medical conditions, our acute care SLPs work closely with nurses, physicians and other professionals to assist infants and families to identify and treat feeding and swallowing concerns that may contribute to medical issues in order to improve adequate and safe oral intake to support their medical management and facilitate discharge. They work to prepare families with the feeding techniques and to set them up for the outpatient services as needed so that they will be better able to feed their children successfully once they return home.

Acute Care Follow-up Feeding Evaluations

Acclimating to life at home with a premature and/or medically involved infant following discharge from the hospital may lead to further challenges. The family is accustomed to a supportive hospital environment and is now faced with the challenge of feeding their infant on their own. Infants who demonstrated feeding and swallowing difficulties while they were hospitalized are followed closely after they are discharged from All Children’s Hospital through our acute care follow-up feeding evaluations. Speech pathologists complete a follow-up feeding evaluation scheduled shortly after discharge to address any feeding issues and insure babies continue to eat well once they are home. They support families in using recommended therapy techniques and feeding materials, problem solve issues encountered at home, assist in feeding transitions, and determine if more regularly scheduled outpatient feeding treatment is indicated, helping insure the infant’s continued feeding progress and safety.

Oral Pharyngeal Motility Studies (OPMS)/Videofluoroscopic Swallow Studies (VFSS)

When swallowing is a concern and requires further evaluation, Oral Pharyngeal Motility Studies (OPMS), more commonly known as Videofluoroscopic Swallow Studies (VFSS), are the "gold standard.” This evaluation is completed in the main hospital building in our Radiology department. Following a clinical evaluation of feeding and swallowing skills, the speech language pathologist works together with the physician assistant and radiology technician under the guidance of a radiologist to complete the study. The infant or child eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on an X-ray. This allows viewing of the oral and pharyngeal anatomy and more complete analysis of the oral, pharyngeal and upper esophageal phases of swallow. This study will provide information regarding aspiration or risks for aspiration, as well as oral and pharyngeal delays (residue, pooling, timing, nasopharyngeal reflux, etc) and other specifics about the nature of a child’s swallowing disorder. Adaptations to facilitate improved swallowing for any areas of concern can be tested for effectiveness.

All Children's Speech Language Pathology Pediatric Feeding and Dysphagia Program

The influence of feeding equipment, bolus size, food consistency and rate of presentation also can be determined. Following the completion of the study,
the speech language pathologist will review all of this information with caregiver and communicate results with the referring physician to help determine any further recommendations and guide treatment planning.

How are feeding and swallowing disorders treated in children?

All Children's Speech Language Pathology and Feeding Department manages a large number of feeding and swallowing referrals. Given the complex needs of the variety of infants and children seen in our program, we know that “one size does not fit all.” Therefore, we individualize treatment plans for each child and offer a continuum of service delivery models to meet their needs. In all of these programs, our dysphagia therapists work closely with many other involved professionals, including nutritionists, occupational and physical therapists, lactation consultants, developmental specialists, nurses and physicians to assist families in coordinating services to facilitate continuity of care and optimal outcomes. For some children, a one-time feeding and swallowing evaluation may be all that is needed to get them on track. The speech language pathologist will work with the family to demonstrate specific techniques and provide them with a home program and later follow-up as needed. For other children, a period of more direct treatment may be needed.

Feeding and Dysphagia Therapy

Feeding and dysphagia therapy goals are identified and established based on our comprehensive evaluations. Therapy frequency may range from once per month to two or more times weekly for hour sessions. All therapy is individualized to meet the needs of the patient and their family. Parents and other caregivers participate in the sessions with hands on practice and coaching to empower families and maximize progress and carryover. Intake and weight gain are closely monitored to check progress. Goals for safety and meeting nutritional needs are prioritized.

Tube Weaning

The number of tube-fed infants and children has significantly increased in recent years. Children with a medical history of tube feeding can have some of the most challenging feeding problems. Often they don’t know what it feels like to be hungry or full. They may also have oral motor and sensory problems, and inexperience with feeding and feeding behaviors. Even when they are medically able to eat by mouth, the transition to oral feeding can be a challenging one. For children who are medically ready to eat orally but are having difficulty weaning from their feeding tube, we work closely with nutritionists and physicians to systematically assist families in the tube weaning process. Based on the individual, this may occur in more traditional, outpatient programming. For particularly challenging cases, more specialized programming may be needed.

Happy Mealtimes: An Intensive Feeding Program

All Children’s Intensive Feeding Program is one of the few programs of its kind in the country. This premier program is led by speech pathologists with specialized training in pediatric feeding to assist children over 18 months with some of the most complex feeding issues. The four week, intensive program is designed to improve the oral intake of children who want to wean from their feeding tubes as well as the intake of those who don’t have a feeding tube but are at risk for not meeting their nutritional needs. Patients and families are seen four times daily for feeding therapy while also receiving complementary therapies to address their complex needs. One on one parent training is provided to assist parents in managing aversive behaviors and using specific strategies to help their child become a successful oral eater. Our speech pathologists work together with a team of professionals that includes a pediatric nutritionist (to assist with caloric/nutritional needs) and a pediatric occupational therapist (to assist with sensory, motor and self-feeding concerns). This intense program is often successful when other less intensive feeding programs have failed because of its well trained staff, intensity, focus on family involvement, and close coordination of services. Families have traveled from around the country to access the expertise made available through this program. Followed-up with patients and families after discharge from the four week program continues for a 12 month period to monitor intake and weight gain and insure continued success and progress.

Contact us

All Children’s Hospital Speech Pathology Feeding and Dysphagia Program is dedicated to providing quality of care in a family centered, family supportive environment. If you have questions, we are happy to assist you or clarify in any way. For more information, please contact the Speech Language Pathology Department at (727) 767-4141.