Pediatric Feeding/Swallowing: Yesterday,

Today, and Tomorrow

Maureen A. Lefton-Greif, Ph.D., CCC-SLP, BCS-S,1,2,3,4 and
Joan C. Arvedson, Ph.D., CCC-SLP, BCS-S5,6

ABSTRACT

Speech-language pathologists (SLPs) have played primary

roles in the evaluation and management of children with feeding/
swallowing disorders for more than five decades. Medical, surgical, and
technological advances have improved the survival of young fragile
infants and children, many of whom will present with feeding/

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swallowing problems. Regardless of their underlying etiologies,
many of these children are at risk for aspiration-induced lung disease,
undernutrition or malnutrition, developmental deficits, and stressful
interactions with their caregivers. Unfortunately, our understanding of
the physiology/pathophysiology of swallowing and its maturation, the
development of standardized and efficacious evaluation and therapy
tools, and identification of functional outcomes have not kept pace with
our ability to identify children who are at increased risk for dysphagia
and the associated sequelae. Given this paucity of evidence to guide
practice in pediatrics, clinicians rely upon a combination of data
extrapolated from adults with dysphagia, anecdotal reports, and
institution-specific guidelines. This article focuses on updates in
population demographics and advances in evaluation and treatment
over the past decade and identifies future directions that may enable us
to meet the needs of the children who are in our care to attain functional
outcomes.

KEYWORDS: Dysphagia, deglutition, swallowing, pediatrics,

evaluation, management

1
Department of Pediatrics; 2The Eudowood Division of
Pediatric Respiratory Sciences; 3The Department of Oto-
laryngology-Head and Neck Surgery; 4Department of
Physical Medicine and Rehabilitation, Johns Hopkins
Medical Institutions, Baltimore, Maryland; 5Department
of Speech-Language Pathology and Audiology, Children’s
Hospital of Wisconsin; 6Division of Pediatric Gastroenter-
ology, Department of Pediatrics, Medical College of Wis-
consin, Milwaukee, Wisconsin.
Address for correspondence: Maureen A. Lefton-Greif,
Ph.D., CCC-SLP, BCS-S, Eudowood Division of Pediat-
ric Respiratory Sciences, Department of Pediatrics, the
298
Johns Hopkins University School of Medicine, David M.
Rubenstein Building, Suite 3017, 200 North Wolfe Street,
Baltimore, MD 21287 (e-mail: mlefton@jhmi.edu).
Forecasting the Future: Challenges and Opportunities
in Developmental Communication Disorders; Guest Edi-
tor, Nan Bernstein Ratner, Ed.D.
Semin Speech Lang 2016;37:298–309. Copyright
# 2016 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
4662.
DOI: http://dx.doi.org/10.1055/s-0036-1587702.
ISSN 0734-0478.
 PEDIATRIC FEEDING/SWALLOWING/LEFTON-GREIF, ARVEDSON
Learning Outcomes: As a result of this activity, the reader will be able to (1) describe factors involved in
increased complexity of feeding/swallowing disorders in infants with multiple medical/surgical etiologies; (2)
state three management processes with pros and cons for attaining functional outcomes; (3) list three
currently used tools for diagnosis of dysphagia; and (4) state three new technologies that may become useful
for pediatric patients with dysphagia.
S peech-language pathologists (SLPs)
have played primary roles in the evaluation
and treatment of infants and children with
feeding and swallowing disorders for more
than five decades.1 Approximately 20 years
ago, Seminars in Speech and Language (SSL)
devoted two issues to pediatric dysphagia to
provide SLPs with “current” information and to
help guide the care of affected children.2,3 A
decade later, a 10th anniversary issue of SSL
was dedicated to the same topic and focused on
providing “updates” including the impact of
advances in medical and surgical care and shifts
in the regulatory landscape.4 SLPs continue to
seek guidance in this high-risk area of practice
because opportunities for formal educational
preparation are variable, advances in medical
and surgical care have had an impact on the
populations of children being served, and there
is a greater understanding of the diagnostic and
management factors that are unique to children
with feeding/swallowing problems.5
Given the paucity of evidence in pediatrics
to guide clinical practice, clinicians rely upon a
combination of data extrapolated from adults
with dysphagia, anecdotal reports, and institu-
tion-specific guidelines. A recent article in SSL
by Ciucci and colleagues provided an important
review of the state of the art and science that
included descriptions of knowledge gaps in the
area of adult dysphagia.6 Areas needing eluci-
dation include “a deeper understanding of
physiology and neurophysiology, standardiza-
tion of evaluation, consensus, core sets of
dysphagia parameters for clinical and research
reporting, personalized algorithms for imple-
mentation of evidence-based practice, metrics
for therapy efficacy, and increased buy-in and
funding from agencies.”6(p.201) Although the
gaps identified by Ciucci and colleagues are
ubiquitous across the age spectrum, infants and
young children present with unique
considerations.
299
In this article, we seek to highlight updates
on population demographics and advances in
evaluation and treatment over the past decade,
and to identify future directions that may enable
us to meet the needs of the children who are in
our care earlier in their lives and more effec-
tively than current practices to achieve func-
tional outcomes. Speculation about the
uniqueness of factors associated with these
children who have dysphagia will be reviewed.
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SWALLOWING DISORDERS IN
INFANTS AND CHILDREN
The numbers of children with feeding and
swallowing disorders are increasing due at least
in part to improved recognition of these prob-
lems and advances in medical and surgical care
that have improved the survival of children with
histories of prematurity, low birth weight, and
complex medical conditions.7–9 Currently,
more than one-half million children in the
United States are diagnosed with dysphagia
annually, and at least 100,000 infants have
been given diagnoses of feeding/swallowing
disorders following short hospital stays.10,11
Dysphagia is a sign/symptom of a condi-
tion or constellation of conditions that deter-
mine its phenotypic expression, course, and in
some instances, its resolution. Children with
swallowing disorders, regardless of underlying
etiology(s), are at risk for aspiration-induced
lung disease, undernutrition or malnutrition,
developmental deficits, and stressful interac-
tions with their caregivers. Feeding and swal-
lowing processes are linked inextricably during
infancy and early childhood, and their disrup-
tions may result in long-term cumulative prob-
lems.12 However, feeding disorders without
dysphagia are beyond the scope of this article.
Fortunately, in the United States, the
frequency of preterm births has decreased and
survival of infants born at shorter gestational
300 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 37, NUMBER 4
ages has increased.13–16 Nonetheless, 40% of
children with feeding/swallowing disorders are
reported to have histories of preterm birth.17
Much of the attention to feeding/swallowing
disorders in these pediatric populations has
focused on preterm infants in neonatal intensive
care unit (NICU) settings and during follow-up
after hospital discharge. Critical to the care of
these infants is increased recognition that they
comprise a heterogeneous population, with
differing causes of preterm births and a wide
range of phenotypic variations. “Preterm birth
syndrome” has been proposed to account for
these factors and guide efforts to reduce preterm
births further and to improve investigations
across populations of children born preterm.18
In addition, there have been changes related to
the lower and upper age limits associated with
prematurity. Medical and surgical advances
have shifted the lower limits of viability to
shorter gestational periods. Currently, 23 to
25 weeks’ gestation is considered to be at the
edge of viability.19 This shift in viability has
been associated with increased medical fragility
and delayed attainment of medical stability,
weaning from supplemental oxygen, and acqui-
sition of feeding milestones.20 Recently, ques-
tions have been raised about using a gestational
age of 37 weeks to distinguish between preterm
and full-term births because this cutoff may not
coincide with functional maturity.21 Increases
in adverse outcomes are associated with preterm
births that are complicated by low birth weights
related to the prematurity or in some instances
intrauterine growth restriction. Moreover, this
combination of conditions is associated with
population-based disparities that include, but
are not limited to, increased morbidity, mortal-
ity, and financial burdens as well as the later
development of chronic medical conditions in
adulthood (e.g., diabetes, hypertension, and
heart disease).22 These children are also at
greater risk for chronic lung disease associated
with prematurity, which is associated with an
increased risk of swallowing dysfunction, and a
lower threshold to tolerate the associated respi-
ratory and nutritional sequelae.4,23,24 Taken
together, children born preterm are at increased
risk for swallowing problems associated with
respiratory–swallow incoordination, nutritional
demands associated with their respiratory sta-
2016
tus, and neurologic sequelae associated with
their prematurity. Feeding-related problems
for children with bronchopulmonary disease
may last years.25 Importantly, chronic aspira-
tion may result in persistent respiratory prob-
lems and lung injury.26,27 To date, the “amount”
and frequency of aspiration secondary to swal-
lowing dysfunction that can be tolerated is
unknown; however, it is likely that age, nutri-
tional status, individual differences, and overall
health contribute to “tolerance.” The impact of
aspiration on other organs is not known. Ani-
mal research has shown that acid instilled into
the airways (potential model for reflux) of pigs
caused varying degrees of injury to extrapulmo-
nary organs.28 Further investigation of whether
aspiration secondary to oropharyngeal dyspha-
gia results in more diffuse injury in humans is
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needed.
As with adults, children with conditions
associated with dysphagia are those that impact
the function of individual swallowing structures
(e.g., laryngomalacia, laryngeal cleft, or vocal
fold paralysis) or their coordination with other
structures (e.g., neurologic and neuromuscular
conditions that include cerebral palsy with a
wide range of sensorimotor deficits and
severity.29
Increasingly, children are presenting with
conditions that affect multiple aspects of feed-
ing/swallowing. For example, medical and sur-
gical advances have increased the survival of
children with cardiac conditions characterized
by single ventricle anatomy, and these children
are at increased risk for gastrointestinal com-
plications, feeding/swallowing problems, re-
duced stamina that interferes with feeding,
and high nutrition demands.30
Our understanding of the underlying eti-
ologies associated with swallowing dysfunction
is likely to change with advances in the field of
genetics and the understanding of epigenetic
modifications of the genetic (DNA) sequence.
Simply stated, genetics is the study of heredity.
Children inherit genes from both biological
parents and the combination of inherited genes
determine traits (phenotypes such as eye color)
as well as the risk of certain diseases and
disorders (e.g., CHARGE syndrome [colo-
boma of the eye, heart anomaly, choanal atresia,
retardation, and genital and ear anomalies]),
 PEDIATRIC FEEDING/SWALLOWING/LEFTON-GREIF, ARVEDSON
spinal muscular atrophy). OMIM (Online
Mendelian Inheritance in Man; www.omim.
org) provides an online updated catalog of
human genes and genetic disorders that focuses
on the relationship between genetic variation
and phenotypic expression. Currently, there are
326 entries that link “dysphagia” or “swallow-
ing” to genes and genetic disorders.31 Epige-
netics refers to genetic-environmental
interactions that alter phenotype (i.e., traits)
without changing the underlying genetic code
or DNA. Epigenetic changes can persist
throughout life and be passed on to future
generations. For more than several decades,
the medical community has been investigating
the interface between individualized (pheno-
type) versus generic genotypes.32,33 In the fu-
ture, epigenetic opportunities may be identified
and provide windows for modifiers (e.g., phar-
macologic therapies) to improve the course of
diseases (e.g., spinal muscular atrophy). Epige-
netic alterations may also be harmful. For
example, fetal nutrition has been implicated
in the development of adult onset diseases
(e.g., obesity and cardiovascular diseases).32
Over time, advances in epigenetics may help
identify specific populations at risk for dyspha-
gia and provide opportunities for interventions
that improve the underlying condition and
concomitant prognosis or limit the impact of
the consequences of dysphagia. This informa-
tion holds promise to enable SLPs to individu-
alize assessment and treatment of swallowing
and communication problems.34–36 We ac-
knowledge the challenges associated with the
integration of the explosion of information into
clinical care with evolving trends in health care.
Promising outcomes from cross-system
interventions have been demonstrated in adults
with dysphagia.37 Emerging evidence demon-
strates that feeding/swallowing problems at
young ages may offer insights regarding
cross-system opportunities during develop-
ment. Wolthuis-Stigter and colleagues found
that the inability of young infants to sustain
sucking and to use mature sucking patterns was
associated with abnormal neurodevelopmental
outcomes at 2 years of age.38 In another study,
Malas and colleagues found a higher incidence
of feeding/swallowing problems in children
later diagnosed with language impairments.39
301
ASSESSMENT OF SWALLOWING/
FEEDING IN PEDIATRICS
Clinic or Bedside Assessment
The first step for SLPs involves clinic or bedside
assessment (henceforth: clinic) and in some
instances instrumental swallow examination.
The clinic assessment is an important routine
component of feeding/swallowing status in
infants and young children. The specific types
of assessments are likely dictated by the setting,
the age of the child, and the child’s presenting
problems. SLPs face the same challenges with
these assessments as those reported for adults
with dysphagia. Challenges relate to the paucity
of quantitative or qualitative benchmarks and
the limited concordance between clinical find-
ings and aspiration on an instrumental swal-
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lowing examination.6,40 The reader is referred
to the recently published systematic review of
noninstrumental swallowing and feeding as-
sessments for infants and children by Hecka-
thorn and colleagues.41 The clinic assessment is
an essential component of the global process
because it enables SLPs to identify reasons for
the dysphagia, establish a baseline of behaviors,
introduce modifications and feeding routine
options, determine whether and which type of
instrumental assessment may be needed, and
evaluate whether the child is able to cooperate
with further assessments.42
A huge challenge facing clinicians involves
decision-making about the best ways to deter-
mine oral feeding readiness in medically fragile
children and in those who are supported by
relatively new technologies (e.g., high-flow
oxygen).43,44 Although scarce, objective data
are becoming available to improve clinical de-
cision-making, limit morbidities, and reduce
health care costs for very young children with
underlying lung disease. For example, recent
data have provided support for initiation of oral
feedings in carefully selected infants with low
levels of high-flow oxygen delivery for respira-
tory support.43,44 Another area under investi-
gation involves the use of objective salivary
biomarkers related to the neonate’s developing
brain and sensory and facial development in
relation to oral feeding success.45 In the future,
these biomarkers may enable clinicians to de-
termine when brain maturation supports the
302 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 37, NUMBER 4
initiation of oral feeding and may increase our
understanding of the mechanisms in the devel-
oping brain that underlie oral feeding readi-
ness.45 Investigations are needed to determine
the long-term outcomes associated with feed-
ing interventions as new technologies emerge.
Development of objective and reproducible
noninvasive measures that enhance the clinical
assessment is desperately needed. For example,
measures of swallow-respiratory coordination
can provide objective data that may guide
evaluations and the course of management.
However, such technologies are costly and labor
intensive and thus have not yet been transi-
tioned from research to routine clinical
care.46–48
Instrumental Swallowing Assessments
The videofluoroscopic swallow study (VFSS)
and fiberoptic endoscopic evaluation of swal-
lowing (FEES) are the two most common
instrumental swallowing examination tools
used with children. Readers are encouraged
to search the literature for multiple pertinent
articles related to these two swallow exami-
nations; some are listed in the references to
this article.42,49–51 Advantages and limita-
tions associated with these evaluation meth-
ods were reviewed for adults by Ciucci et al
and are essentially the same for children.6,52
Primary considerations that are unique for
children include concerns about radiation
exposure and the need to repeat evalua-
tions.42,49 Efforts to standardize the VFSS
procedure for children taking bottle feedings
are underway and hold promise for the future.
Instrumental swallowing examinations in
children will be reviewed in depth in this
journal in 2017.
Beyond the scope of this article are other
assessment modalities that provide important
and useful information and aid in decision-
making and include, but are not limited to,
magnetic resonance imaging, high-resolution
manometry alone or with simultaneous VFSS,
and impedance.53 These modalities may pro-
vide information on combined aspects of bolus
movement and pressure changes, and may help
detect the impact and consequences of dysfunc-
tional swallowing.
2016
MANAGEMENT OF INFANTS AND
CHILDREN WITH SWALLOWING/
FEEDING PROBLEMS: CURRENT
AND FUTURE
The complexities for high-risk infants and
children have increased as the survival of pre-
term and medically/surgically compromised in-
fants has increased as pointed out earlier in this
article and per reports by multiple authors.
SLPs need extensive knowledge in a wide range
of health care and medical areas to evaluate and
make management decisions that take into
account scope of practice for SLPs and the
American Speech-Language-Hearing Associa-
tion’s code of ethics.54,55 Decisions are made
best in the context of team approaches that may
vary considerably depending on availability of
resources. Regardless of the environment and
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geographic limitations, SLPs must never prac-
tice in isolation. As known for many years, this
area of practice carries the highest risk for SLPs
and those in their care. Not only is there
concern for lack of evidence for specific inter-
vention processes, there is great concern for
potential harm to children that could even
result in significant consequences including
death when decisions are made that place
children’s health and well-being in danger.
Management decision-making occurs dur-
ing every evaluation/examination, just as all
intervention sessions include evaluation of sta-
tus. Thus, it is not possible to separate evalua-
tion and management completely given the
integrated functions within each infant and
child as well as interaction. Frameworks that
are useful in management decision making
include but are not limited to The International
Classification of Function, Disability, and
Health (ICF) model from the World Health
Organization and the Rehabilitation Treat-
ment Taxonomy (RTT).
The International Classification of
Function, Disability, and Health Model
from the World Health Organization
The ICF provides a framework for classification
and function and has been applied to feeding
and swallowing in children.4,56 The framework
for classification of health conditions (disorders
or disease) includes Body Functions and
 PEDIATRIC FEEDING/SWALLOWING/LEFTON-GREIF, ARVEDSON
Structure, Activity, and Participation. This
framework aids in a holistic approach to assess-
ment and management rather than focusing on
impairments, which has been the traditional
approach for many therapy-focused professio-
nals. It focuses on function in the broad sense of
participation and possible interfering factors.
Definitions of impairments, activity limita-
tions, and participation restrictions are funda-
mental to decision-making.
Details and examples in relation to feeding
and swallowing can be found on the website
http://www.who.int/classifications/icf/en/.
This focus on functional participation sets the
stage for the future in decision-making by SLPs
and all other professionals involved in assess-
ment and management of children with feeding
and swallowing disorders.
Rehabilitation Treatment Taxonomy
RTT provides a framework using theory rather
than surface characteristics as a basis for speci-
fying the details of rehabilitation treatments.
Turkstra and colleagues stress the importance
of theory-driven system as the foundation from
which to consider hypotheses about how treat-
ments are supposed to work and of specification
of treatment methods as critical factors for
evidence-based practice across the discipline
of speech-language pathology.57 It seems per-
tinent that RTT has direct application in the
area of pediatric swallowing and feeding dis-
orders. This type of framework is essential for
the identification of key components of treat-
ment that underlie efficacy or isolate the critical
details to convey for replication of a given
treatment/intervention.57 SLPs involved in di-
rect assessment and management of infants and
children with feeding and swallowing disorders
will need to meet challenges that will be related
to possible specification of three elements of
treatment theory: targets (specific aspects of
function to be changed by treatment), ingre-
dients (specific actions taken by clinician to
effect changes in the target), and mechanism
of action (the known or hypothesized means by
which ingredients exert their effects.58 Quanti-
tative measurement that is accurate and tar-
geted appropriately for a child’s abilities and
health status is essential. Such measurements
303
are needed before interventions to establish
baselines and after interventions to understand
the effects of rehabilitation and associated
surgical and medical therapies.59 Recent initia-
tives have focused on the use of well-targeted
outcomes toolboxes, which may facilitate the
use of a common language for outcome meas-
ures. (See the National Institutes of Health
Toolbox for Assessment of Neurological and
Behavioral Function, which is comprised of a
multidimensional set of measures for ages 3 to
85, and Wright and Majnemer.59,60) Further
details are beyond the scope of this article.
Current Trends and Future Directions
Management decisions must take into account
nutrition status, medical and surgical stability,
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position/posture needs, oral sensorimotor facil-
itation, oropharyngeal swallow safety, and be-
havioral factors. Emphases may be placed on
one or more of these interrelated areas of
function. In recent years, we have become
increasingly aware of the importance of neuro-
developmental sensorimotor principles of
learning, along with experience-dependent
neural plasticity. Although the brain’s potential
for neural plasticity is present throughout life,
peak or sensitive periods appear to coincide with
rapid brain growth early in life.61,62 Interference
can occur with plasticity in response to one
experience that can inhibit acquisition of other
behaviors.62,63 Thus, when exposures or train-
ing have resulted in the practice of maladaptive
behaviors, it may be very difficult to transfer
from a specific therapeutic intervention to
functional tasks of eating and/or drinking.
The overriding goal of neural plasticity is to
maximize brain development; to achieve this
goal at the minimum we need to know critical
times and dose.62 Processes that train as directly
to the task as possible are now and will become
increasingly critical in the future as interven-
tions by SLPs and other therapists come under
scrutiny if demonstration of functional out-
comes cannot be documented sufficiently. It
has been clear for a long time that multiple
factors come into play with drinking, chewing,
swallowing tasks that involve not only the oral
and pharyngeal phases of swallowing but also
core strength, head control, respiratory support,
304 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 37, NUMBER 4
underlying movement patterns, and caregiver/
child interactions during feeding and apart from
feeding. Readers are reminded that develop-
ment of oral sensorimotor skills relates closely
to development of trunk and head control.
A few therapeutic intervention techniques/
processes commonly used with infants and
children will be described briefly, with both
advantages and concerns, as well as anticipated
future possibilities. Historically and currently,
therapeutic techniques parallel those strategies
that were originally described in the adult
literature, with the exception of some of the
strategies used in the NICU to facilitate oral
feeding in preterm and other medically fragile
infants. SLPs in the NICU environment are
faced with the smallest and most fragile infants
with need for extraordinary knowledge about
embryology and neurodevelopment, under-
standing of pulmonary and gastrointestinal
systems, so that they can provide guidance for
advancing oral feeding while always being
aware that a stable airway is a primary underly-
ing requirement to feed orally safely and avoid
creating or exacerbating pulmonary complica-
tions. Discussion about breast feeding and the
nutritional benefits of breast milk are beyond
the scope of this review.
Management/Therapies in the
Neonatal Intensive Care Unit:
Cue-Based Feeding
Basic requirements for oral feeding in infants
involve coordination of sucking, swallowing,
and breathing while sustaining alert awake
behavior and preserving cardiorespiratory sta-
bility. In recent years, changes have been made
from scheduled infant feedings at predeter-
mined (usually 3-hour) intervals, regardless of
level of alertness and hunger cues displayed, to
what is usually referred to as “cue-based feed-
ing.” Cue-based feeding facilitation is an indi-
vidualized approach based on behavioral
readiness signs and hunger cues to be managed
for the most part by the bedside nurse. In
selected instances, the SLP provides evaluation
and recommendations to nurses and parents
with follow-up as needed. This approach has
been shown to result in earlier attainment of full
oral feeding in premature infants.64,65 Advanc-
2016
ing feeding in infants who are small for gesta-
tional age (SGA) has additional challenges
regarding optimum timing for introduction of
enteral feeding, how fast feeding volumes can
be advanced, and which milk and which feeding
method is more appropriate in infants with
SGA.66 Arnon and colleagues reported that
stable SGA preterm infants on a very early
feeding regimen achieved full enteral feeding
and were discharged home significantly earlier
and without excess morbidity than controls on a
delayed regimen.67 These examples are given to
stress the utmost importance of adequate
knowledge and experience for SLPs in the
NICU. There is great need for specialized
training opportunities that SLPs do not receive
as part of a master’s program in most universi-
ties in the United States.5 Coordinated efforts
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by American Speech-Language-Hearing Asso-
ciation and university programs are needed to
improve professional preparation for SLPs to
remain an integral part of the NICU team.
Management/Therapies Crossing a
Broad Range of Ages and Etiologies:
Compensatory Strategies Including
Posture and Position Changes and
Adaptive Equipment
Strategies commonly used with adults are de-
signed to reduce, avoid, or bypass the effects of
impaired anatomy or physiology to redirect
bolus flow.6 Infants and young children are
less likely to be appropriate for tasks that
require direction following. Infants may be at
increased risk with strategies that have been
shown to be beneficial with adults (e.g., airway
obstruction with strategies dependent upon
neck flexion).68 Optimal trunk, neck, and
head support is fundamental to all approaches
for oral feeding facilitation. SLPs work closely
with physical and occupational therapists when
adaptive seating systems are needed, as well as
therapeutic approaches to improve core
strength and facilitation of broad sensorimotor
skills. As technological advances are made, it is
anticipated that approaches to improve all
aspects of sensorimotor skills will be altered
and hopefully improved. These changes are
likely to carry over to potential oral feeding
gains in many children.
 PEDIATRIC FEEDING/SWALLOWING/LEFTON-GREIF, ARVEDSON
Proper positioning of young infants is a
fundamental prerequisite to oral feeding,
whether at the breast or with bottle/nipple.
Developmental level, airway stability, and abil-
ity to follow directions guide decisions about
positioning. Traditionally, infants are held in
semireclined position in the feeder’s arms. A
recent study reported trends in physiologic
benefits (e.g., decreased variability of heart
rate) when infants were fed in elevated side-
lying position.69 However, another study
showed no difference in the feeding maturation
between side-lying and more traditional semi-
reclined.70 There are reports of infants suffo-
cating when breast-fed in a side-lying
position.71 The bottom line is that there is
“no one size fits all.” Taken together, these
studies point out the importance of individual-
ized recommendations, the identification of
appropriate infants, and monitoring based on
underlying neurophysiologic status to advance
safe oral feeding in functional ways.
Flow Rates and Thickening Liquids
Use of thickeners is a common intervention for
young infants and children of all ages with
limited to no evidence of efficacy and safety.
Thickened liquids are recommended on the
basis of clinical observations with suspicions of
possible aspiration, instrumental findings of
aspiration with thin liquids, and gastroesopha-
geal reflux signs and symptoms. Possible nega-
tive consequences are of particular concern in
preterm infants, as necrotizing enterocolitis has
been shown to be correlated with use of thick-
ened liquids (although a definitive relationship
has not yet established).72,73 The U.S. Food
and Drug Administration issued a consumer
advisory warning about the use of Simply
Thick® (Simply Thick LLC, St. Louis, MO)
in infants due to a potential association with
necrotizing enterocolitis. Currently, some
thickening agents are being marketed for use
with children 3 years and above. There is little
evidence that thickened liquids have major
positive impact on reducing potential aspira-
tion with oral feeding or with gastroesophageal
reflux.74 Although there is no “perfect” nipple,
adjustments of flow rates with thin liquids by
altering nipples and modifying internal bottle
305
hydrostatic pressures may assist the timing and
coordination of sucking, swallowing, and
breathing sequencing for bottle-feeders.75,76
Research is needed not only in the individual
aspects of nipples, bottle systems, and flow
rates, but also interrelationships of both com-
mercial and cereal-based thickeners and effects
on gastrointestinal tract and aspiration conse-
quences with thickened liquids compared with
thin liquids.77 One could hypothesize that
because the lungs are basically water soluble,
occasional aspiration of thin liquids would be
less damaging to lungs than even less frequent
aspiration of thickened liquid. Clearly research
is needed.
It is of concern that children are often
placed on thickened liquids with no plan to
provide a systematic process to allow children to
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improve their timing and coordination so that
they can learn to drink thin liquids. It would be
expected that the sensorimotor system adapts to
the heavier boluses that allow for slower move-
ment of material over the tongue as well as
timing for initiating a pharyngeal swallow. One
could consider other sensorimotor activities
apart from feeding that may be relevant. For
example, a runner who never runs faster than 10
minutes per mile is highly unlikely to run a race
at 7 minutes per mile. Practice is needed for all
activities that involve sensorimotor processes.
Oral feeding is no different. There are potential
negative consequences to the digestive tract as
well as the pulmonary system. Research is
desperately needed in all of these interrelated
areas to develop evidence-based practice guide-
lines that may benefit from the RTT framework
as discussed above.
Oral Sensorimotor Interventions
Evidence for effects of oral-motor interventions
with young infants and older children is limit-
ed.78,79 Overall, persons who use these inter-
ventions for feeding and swallowing do so
without peer-reviewed evidence reports in the
literature. Anecdotal reports by clinicians may
be helpful, but they are not sufficient to meet
the requirements of efficacy of treatment. As
children advance oral skills and expand textures
of foods, chewing becomes a focus. There are no
reports known to these authors in the literature
306 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 37, NUMBER 4
that describe therapeutic regimens and their
outcomes. An instrument has been developed
recently for determining the level of chewing
function in children.80 Knowledge of chewing
function level is useful to provide a common
language for professionals to define chewing
disorders. However, the need persists for deter-
mining intervention processes to achieve func-
tional chewing outcomes.
Sensory-Focused Interventions
Programs have been developed that provide
children with opportunities to have sensory
experiences without pressure to get food or
liquid into the mouth initially. Some of these
programs focus on opportunities for the child to
“play” with food by putting fingers and hands
into pudding, yogurt, or similar foods. These
sensory focuses could also include variations in
smell/aroma, textures, temperatures, and tastes
if the child puts the food to the mouth. Anec-
dotal reports have shown positive progress
toward oral feeding in some children. However,
until there are peer-reviewed reports in the
literature, it is not possible to report on efficacy
or efficiency related to the goal of advancing
oral feeding.
There is little information regarding neu-
romuscular electrical stimulation (NMES) in
infants and children, although this treatment
modality has gained rapid popularity among
clinicians and researchers in recent years. One
report revealed no difference in children who
were treated with NMES compared with simi-
lar children not treated with NMES.81 The
authors stated that there may be subgroups of
children who could benefit from NMES, but
they added that research is needed to determine
criteria and outcomes. Just as with adult groups,
it is important to understand ideal candidates,
optimum settings, and potential benefits of
NMES to guide clinical practice.6
Interventions: Future Directions
SLPs are typically primary providers of the
therapeutic interventions mentioned herein
(as well as other approaches not discussed
here given the limited space and overall pur-
poses of this article). There are many individual
2016
patient reports by SLPs of progress and indeed
attainment of age-appropriate oral feeding that
may include elimination of non–oral tube feed-
ing supplements for some. In coming years,
these kinds of anecdotal outcomes will not be
sufficient for initiation of or continuation of
interventions. Systematic approaches are nec-
essary and will need to be based on the ICF and/
or RTT models that address feeding and swal-
lowing with emphases on functional outcomes
in broad aspects of participation rather than on
handicap or disability. It is critical that we
become proactive in both clinical and research
areas as we build on the solid basis on which
SLP involvement with infants and children
who have a wide range of swallowing and
feeding disorders.
Downloaded by: Cornell. Copyrighted material.
CONCLUSION
In coming years, SLPs will need increased
knowledge across a wide range of domains in
addition to sensorimotor oral and pharyngeal
functions. As technological advances are made
along with improved medical and surgical in-
terventions for complex infants and children,
SLPs must demonstrate competencies, efficien-
cies, and ethical practice in areas of assessment
and management with infants and children
diagnosed with swallowing and feeding disor-
ders. The challenges are great. As a profession,
we need to keep asking: what are we trying to
achieve?59
ACKNOWLEDGMENTS
The authors appreciate the assistance provided
by Jeanne Pinto, M.A. in formatting this paper.
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