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The Complexity of Pediatric Feeding Difficulties

Girl not eating food

What does it mean when families describe to us that their child has eating difficulties?

It means that there is puzzle for the adults in that child’s life to piece together. We must

become private investigators. We must take the entire child and the environment into account.

Data collection can be essential. The family is the center of the investigation, and a

collaborative team of medical and developmental professionals must support them during what

seems to be a long process. Unfortunately, there is no quick fix to a pediatric feeding and/or

swallowing disturbance.

So, what are these adults, both parents and professionals looking at?

They are looking at the children’s history very carefully including pregnancy, birth, medical, all

developmental milestones and feeding skill progression from birth. They are looking for

contributing factors. Not actual causes. Why? Because there is never one isolated “cause” of a feeding disturbance in children. This is why PFDs (Pediatric Feeding Disorders) are so complex.

As a skilled feeding-swallowing therapist for over 25 years, I have learned to observe and make

professional referrals based on the data I collect from thorough histories, meals with the child

and reports from all caregivers who are involved. These are the major contributing domains

that I examine when I do a feeding and swallowing assessment with a family. However, there

can be other subcategories evaluated over time and during the treatment process.

  • Complete pregnancy, birth and post birth medical & feeding histories

  • Feeding and swallowing skill acquisition timeline

  • Look and listen to he child’s perspective on eating / drinking at meals and snacks (often they can show you with behavioral patterns or tell you what the problems are)

  • Health-related factors (allergies, breathing, snoring, constipation, gastroesophageal reflux, colic, surgeries, illnesses, all diagnoses, syndromes, neurological disorders)

  • Nutritional status (weight, growth trends, growth chart)

  • Appetite levels and eating patterns

  • Structure and function of the body (oral motor webbing, oral-facial structures, agility, stamina, consistency, breathing, digestion, motor skills, general body stability)

  • Developmental history

  • Seating, posture at feedings, snacks and meals

  • Comprehension and communication skills

  • Oral motor skills

  • Pharyngeal swallowing abilities

  • Sensory processing skills (all 5 senses plus common preferences or aversions)

  • Child’s food & liquid variety acceptance patterns

  • Food & liquid rejections or reactions

  • Emotional-behavioral barriers

  • Learning style and cognition

  • Eating experience (feeding history)

  • Home eating environments

  • Family feeding goals

  • Family food culture

  • Family relationship with food

  • Family’s perception of the child’s eating patterns

  • Food availability and consistency of feeding schedule

  • Child’s attention to food and motivation to eat

  • Emotional trauma

  • Environmental stressors

Now you can see how data can help to obtain the contributing factors so that an effective

treatment plan can be set forth. The Family is at the center of this because they know the child

best. They are at every meal and snack with the child. They often get mixed messages from

well-meaning professionals about what to do. They alter their reactions based upon the child’s

eating or attention patterns. This means that the family’s description of the child’s histories,

eating abilities and opinions are essential to obtaining this complex array of puzzle pieces.

Written documentation is needed to identify patterns and barriers in eating. This is how we

can formulate a team-based, functional and effective treatment plan.

The members of the team that can help the family the most includes any other caregivers or

teachers involved with the child. The professionals involved show include a registered dietitian

to ensure adequate current nutrition and hydration, then advance the child’s nutritional status

throughout treatment. Feeding and swallowing therapists or other team members cannot

assess a child’s nutritional status. A skilled developmentalist who can conduct a complete

developmental assessment. A speech-language pathologist with knowledge in feeding, oral

motor and swallowing development. An occupational therapist with knowledge of feeding and

sensory processing can lead this treatment process. A medical support team may include but

not limited to the child’s primary care physician, a pediatric gastroenterologist, allergist,

endocrinologist, otolaryngologist, pulmonologist, chiropractor, nurse, lactation consultant, child

psychologist, behaviorist, neurologist or aerodigestive team. Referrals for additional medical

and neurological testing depends exclusively upon what factors the family and the team

discovers. It is important to note that not every child will need all of these assessments.

However, if the treatment is not effective then the team needs to “Circle Back” and look again.

Children do very well with wrap-around feeding and swallowing services. This means that

supporting the child with eating problems is a steady process that cannot be rushed. However,

based upon the detailed ongoing feeding and swallowing an assessment, there are immediate

strategies can be set in place that helps the family feed their child and reduce stress. Such

strategies include home food access support via WIC, SNAP or other food financial support.

Scheduled kitchen routines for meals and snacks, graze reduction and food texture variety

rotation. Formal feeding therapy can consist of nutritional counseling, oral motor, dysphagia

therapy speech-language therapy, occupational therapy, seating assessment and emotional

support. For more information and resources see this wonderful resource

Cheryl Pelletier, M.S., CCC Speech-language Pathologist Feeding & Swallowing Specialist, Founder of Gnosh, Inc Private Practice Services on Cape Cod, MA & Chewing-Swallowing. Products can be reached at, or phone 508-720-CHEW (2439).

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