2018 Feeding Problems in Infants and Children

 

Feeding Problems in Infants and Children Assessment and Etiology  MS, CCC-SLP

Kathleen C. Borowitz,

a,

*

  MD

b

, Stephen M. Borowitz,

KEYWORDS  Infants     Children     Feeding problems     Dysphagia     Feeding evaluation   Development of feeding skills 

KEY POINTS  

  Feeding Feeding problems problems in infants infants and young children children are common. common.   Serious feeding problems are rare in otherwise healthy children who are growing and developing normally.

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  Most serious serious feeding problems problems occur in children children who have other medical, behavioral behavioral,, or

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developmental problems.  Serious feeding problems are best evaluated and treated by an interprofessional team of  health care providers.

INTRODUCTION Concerns about feeding problems in children have become increasingly common. It is unclear whether the incidence of feeding problems is rising or if parents and health care professionals have become more aware of them. As many as 50% of parents report their otherwise healthy children have feeding problems and as many as 80% of children with developmental delays may have difficulties feeding. 1,2 Parents worry about their child’s weight gain and potential developmental consequences, get frustrated by battles during mealtime, and worry about the social impact of their children eating a limited diet. The causes and associations of feeding issues in infancy and early childhood are widely varied and almost all feeding problems are multifactorial.  A feeding problem is identified when a child is not progressing through the typical course of steps to independent feeding of table foods. 3 Some children have difficu difficulty lty with eff effici icient ent,, sat satisfy isfying ing fee feeding ding exp experi erienc ences es beginn beginning ing at birt birth. h. Oth Others ers sta stallll or str strugg uggle le

Neither author has anything to disclose. a Department of Therapy Services, University of Virginia Health System, Box 386 HSC, Charlottesville, VA 22908, USA;   b Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Virginia, Box 386 HSC, Charlottesville, VA 22908, USA * Corresponding author. E-maill address: E-mai address:  [email protected]

Pediatr Clin N Am 65 (2018) 59–72 https://doi.org/10.1016/j.pcl.2017.08.021 0031-3955/18/ ª 2017 Elsevier Inc. All rights reserved.

 

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to move forward in accepting a variety of tastes and textures, and occasionally, children show a regression or sudden change in their feeding skills. Despite these these parental conce concerns, rns, seriou serious s feeding problem problems s that result in growth failure or nutritional deficiencies are uncommon in mostly healthy children who are developing opin g and gro growin wing g   norm normall ally. y. In thi this s gro group up of chi childre ldren, n, fee feeding ding prob problem lems s typi typical cally ly 4–8  A majority of these children are characterized as “picky” or resolv res olve e with time time.. “selective” eaters, meaning a child eats a limite limit ed variety of foods, is unwilling to try new foods, and/or eats slowly and deliberately. 9  Approximately half of parents characterize their preschool children as “picky eaters” and although the incidence of picky eating decreases as children get older, more than 10% of parents characterize their 6-year-old children as picky eaters.9 Many investigators contend that picky eating in the preschool age is part of normal development and, provided the child is growing and developing normally, in a majority of cases, no interventions are warranted other than reassuring reassuring the family, schedu scheduling ling regular follow-up, and review reviewing ing basic feeding guideli gui delines nes,, such as mainta maintaini ining ng a ple pleasa asant nt and neu neutra trall att attitu itude de throu througho ghout ut meals meals,, hav hav-ing regular and predictable meal times, serving age-appropriate foods, encouraging self-feeding self-fe eding when age appropriate, and avoidi avoiding ng distra distractions ctions during mealti mealtimes. mes.7,9  A majority of infants with more severe feeding disorders have medical and/or development opm ental al con conditi ditions ons tha thatt pre predisp dispose ose the them m to or are at lea least st ass associ ociate ated d with diff difficu icultie lties s 4–8 feeding, as outlined in  Box 1.

Box 1 Medical conditions predisposing to infant and early childhood feeding disorders Structural abnormalities of the aerodigestive system  Cleft lip and/or palate (including submucosal cleft)   Pierre Robin sequence   Macroglossia  Tracheoesophageal fistula   Laryngotracheomalacia   Laryngeal clefts   Esophageal atresia, stricture, or stenosis  Vascular rings/slings 

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Neuromuscular and developmental disorders   Cerebral palsy   Generalized hypotonia   Idiopathic   Due to metabolic metabolic or genetic genetic abnormalitie abnormalitiess (eg, trisomy 21 or Prader-Willi Prader-Willi syndrome)  Meningomyelocele with Chiari malformations   Congenital myopathies   Congenital neuropathies (eg, myasthenia gravis)   Hypoxic ischemic encephalopathy   Metabolic Metabolic encephalopathy encephalopathy (eg, organic academia or urea cycle defects)  

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    

Cardiorespiratory disorders   Congenital heart disease   Chronic lung disease/bronchopulmonary dysplasia   Acquired vocal cord paresis   

GI disorders   Gastroesophageal reflux disease     

   Food allergies Eosinophilic esophagitis   Constipation   Generalized motility disorders

 

Feeding Problems in Infants and Children

 Although there are several different ways to categorize the medical conditions that predispose infants and young children to having difficulties feeding, in most cases these conditions interfere with a child’s ability to perform the activities of feeding as a result of   Structural abnormalities of the face, oral cavity, or aerodigestive system    Neuromuscular dysfunction/incoordination    Inadeq Inadequate uate strength and/or rapid fatigu fatigue/lack e/lack of endura endurance nce 

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 Inability distress to coordinate suck/swallow/breathe normally as a result of respiratory   Nausea and/or discomfort during the feeding process Many infants and youn young g childre children n with feeding disorders are diagno diagnosed sed with gastr gastroo5 and d ma many ny in infa fant nts s wh who o ar are e dia diagn gnos osed ed wit with h ga gast stro roes esoph ophag agea eall re refl flux ux esophagea esoph ageall reflux reflux,, an 10–12 It seems unlikely, however, that gastroare reported to have feeding problems. esophageal reflux is a major causative factor of the feeding problems seen in infants and young children.7,13 Many infants suffering from the symptoms of gastroesophageal reflux have symptoms of colic and constipation, and, as such, the discomfort these infants seem to experience associated with feedings may not be the result of  the reflux per se but rather are the result of a more generalized motility disorder akin to visceral hyperalgesia syndrome in older children and adults. This may explain why treatment of infants with acid inhibitors does not diminish fussiness, gagging, sleep disturbance, or feeding refusal 14 and that even after the more typical symptoms of gas gastro troeso esopha phagea geall ref reflux lux hav have e res resolv olved, ed, man many y inf infant ants s con contin tinue ue to hav have e fee feedin ding g 11 difficulties. It is important to recognize that in healthy children, oral stimuli and feeding experiences early in life are pleasurable. In contrast, many children with complex medical issues may spend much of their early life in medical settings where they experience an abnormal sensory environment that often includes several aversive oral stimuli and an d a va vari riet ety y of ot othe herr me medic dical al inte interv rven enti tion ons s th that at ma may y ca caus use e a ch child ild to as asso soci ciat ate e discomfort rather than pleasure with feedings. Prolonged or frequent hospitalizations as a result of premature birth, congenital cardiac defects, or gastrointestinal (GI) defects or disorders result in an unpredictable and abnormal sensory and social environment me nt fo forr an infa infant nt or a yo youn ung g ch child ild.. Co Cond ndit itio ions ns th that at re requ quire ire su surg rger ery, y, mu mult ltipl iple e dia diagn gnos ostic tic procedures, or extended periods when a child is not fed by mouth disrupt the normal progression of feeding, communication development, and social interaction. These children may have few opportunities to observe adults or other children eating and they may not experience the sights, smells, and sounds of food preparation or be able to explore foods with their hands and mouths. These simple everyday experiences play an important role in the sensory and social aspects of eating and they are often missed or interrupted in infants with complex or severe medical problems. These early life experiences can result in maladaptive behaviors around feeding that persist long after the painful experiences have been eliminated because once learned, abno ab norm rmal al mo moto torr pa patt tter erns ns ar are e dif diffic ficul ultt to unle unlear arn. n. Th This is ma may y ex expla plain in wh why y th the e tr trea eatm tmen entt of  gastroesophageal reflux and the treatment of constipation are frequently not associated with improvement in feeding problems.7

NORMAL PROGRESSION OF FEEDING SKILLS Sucking/Drinking  At birth, term infants demonstrat demonstrate e root, suck, swallow, and gag reflexes that allow them to fee feed d imm immedi ediate ately. ly. The They y are abl able e to coo coord rdina inate te suc suck-s k-swal wallow low-br -brea eathe the dur during ing

 

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breastfeeding or bottle-feeding, but they are dependent on caregivers for positioning. Early Ear ly on, inf infant ants s dem demons onstra trate te a su suckl ckling ing pat patte tern rn tha thatt is cha charac racter terize ized d by ant anter erioriorposter pos terio iorr mov moveme ement nt of the to tongu ngue e alo along ng wit with h fai fairly rly wid wide e jaw exc excurs ursion ion.. Suc Suckli kling ng is hig highly hly automatic and reflexive. Newborns who are feeding comfortably have their arms and legs legs in flex flexio ion n wi with thou outt ex extr tran aneo eous us mo move veme ment nts, s, an and d th they ey ca can n ma main inta tain in a qu quie iet, t, al aler ertt stat state e during breastfeeding or bottle-feeding for at least 10 minutes at a time. By 4 months of  age, ag e, ref reflex lexive ive suc suckin king g fad fades, es, and su suckck-sw swall allow ow bec become omes s mor more e vol volun untar tary. y. Fe Feedi eding ng tim times es incre inc rease ase to 2020-25 25 min minute utes s for mos mostt inf infant ants. s. The su suckl ckling ing pat patte tern rn may per persis sistt unt untilil 6 months of age when more mature sucking emerges. Sucking is characterized by an up-a up -and nd-d -dow own n mo move veme ment nt of th the e to tong ngue ue an and d le less ss ja jaw w ex excu curs rsio ion. n. A co comb mbin inat atio ion n of su suck ckle le and an d su suck ck ma may y be se see en un unti till 9 mo mont nths hs of ag age, e, bu butt ch chil ildr dren en wh who o co con nti tinu nue e to de demo mons nstr trat ate e only a suckle pattern beyond 6 months of age are not showing the typical progression. Cups Cu ps are are ofte often n int intro rodu duce ced d for for liqu liquid id in inta take ke as ea earl rly y as 4 mo mon nth ths s to 6 mo mon nth ths s of ag age, e, bu butt it is not not un unti till 11 mo mont nths hs of ag age e th that at mo most st in infa fant nts s ca can n dri drink nk fr from om a cl clos osed ed cu cup p in inde depe pend nden entl tly y and effic efficient iently. ly.15,16 At between 12 months and 18 months of age, a child may still rely on bitin bit ing g th the e ed edge ge of th the e cu cup p or sp spou outt to he help lp st stab abililizethe izethe ja jaw. w. Mo Most st ch chilildr dren en ar are e ab able le to in inde de-pendently stabilize their jaw during cup drinking by 24 months of age and they hold the cup between their lips. Independent drinking from an open cup is usually not mastered until 18 months or 19 months of age. 15,16 Development of Taste Preferences Infants and young children s children  seem eem to have an innate preferen preference ce for sweet tastin tasting g foods that diminishes over time.17 There is increasing evidence, however, that their taste preferences are influenced and can be modified by both in utero and postnatal exposures and experiences. In utero events and exposures seem to influence taste and flavor preferences later in life and thus modulate the intake of certain foods as a child gets older. A mother’s food choices influence the flavor of the amniotic sac, and the flavors infants experience while they are in utero effect infants’ flavor preferences during early infancy as well as at weaning. 18  Analogously, the foods and drinks a mother consumes while she is nursing influence the flavor of her breast milk, and these experienc rie nces es effe effect ct an infa infant nts’ s’ su subs bseq eque uent nt lik likin ing g an and d ac acce cept ptan ance ce of th thes ese e fl flav avor ors s in foods.17,18 There seems to be a sensitive period in infants’ first several months of life during whic wh ich h th they ey are are rece recept ptiv ive e to a wi wide de va vari riet ety y of flav flavor ors, s, an and d th thei eirr tast taste e ex expe peri rien ence ces s du duri ring ng this period influence taste preferences later in childhood. 17,19  A majority of infants less than 4 month months s of age are willing to drink formulas conta containing ining hydrolyz hydrolyzed ed casein, such as Pregestimil, Alimentum and Nutramigen, which are extremely bitter and have an acrid aroma; however beyond 6 months of age, infants who have never been exposed to these formulas typically refuse to drink them. 20 Infants who are fed hydrolysate formulas in the first several months of life are more willing to eat savory, sour, or bitter-tasting cereals than are infants fed standard milk-based formulas. Moreover, comp co mpar ared ed with with ch child ildre ren n wh who o we were re ne neve verr fed fed a hy hydr drol olys ysat ate e fo form rmul ula, a, 55-ye year ar-o -old ld ch child ildre ren n who were fed a hydrolysate formula during infancy more readily eat ea t f o oods ods and drinks 17 with sour or bitter tastes or aromas, such as chicken and broccoli. These observations suggest infants should be exposed to a wide variety of flavors while mother is pregnant, during breast feeding, and as soon as complementary foods are added to the infant’s diet. Eating Solid Foods Likely as a result of the slow postnatal growth and maturation, humans have developed a unique pattern of transitional feeding. Humans are the only mammals that

 

Feeding Problems in Infants and Children

feed their young complementary foods before weaning and are the only primates that American n Academ Academy y wean offspring before they can forage indepe independentl ndently. y.21 Both the America of Pediatrics and the American Academy of Family Physicians recomm recommend end that solid 22,23 foods not be introduced into an infant’s diet until 6 months of age. Despite these recommendations, more than a third of mothers in the United States introduce solid food foods s into into th thei eirr infa infant nt’s ’s die diett bef befor ore e 4 mo mont nths hs of ag age e an and d app appro roxi xima mattely   10 10% % of  moth mo ther ers s intr introd oduc uce e so soli lid d food foods s in into to th thei eirr infa infant nt’s ’s di diet et be befo fore re 4 we week eks s of ag age. e.24 Similarly, in a majority of nonindustrialized populations, infants are typically fed solid foods beginning between 4 months and 6 months of age, with several societies introducing solids in the first several weeks of life.25 Much as there seems to be a sensitive period in the first several months of life when infants infan ts readily accept varied tastes,17,19 there also seems to be a critical or sensitive period when infants are most receptive to different food textures.26 Children who have been be en ex expo pose sed d to lump lumpy y or ch chun unky ky so soli lid d food foods s be befo fore re 9 mo mont nths hs of ag age e ar are e mo more re li like kely ly to eat a wide variety of fruits and vegetables and are less likely to have feeding problems at 7 years of age than are children who have not been exposed to lumpy or chunky foods until after 9 months of age. Furthermore, there is no evidence that introducing lumpy or chunky foods before 6 months of age is harmful or detrimental. 26  Although there remains debate about when it is best to begin introducing solid foods into an infant’s diet, all the available evidence suggests that provided the water and food supply are free of contamination and infants are provided adequate nutrition, there are no clear contraindications to feeding infants complementary foods at any age. Moreover, there is emerging evidence that early introduction of solid foods into infants’ diet may increase their willingness to eat and variety of fruits and vegetables later in life, decrease their ri their  risk sk of later feeding problems,26 and decrease their risk of  developing food allergies.27 In most developed countries, solid foods, usually in pureed form, are typically introduce du ced d be betw twee een n 4 mo mont nths hs an and d 6 mo mont nths hs of ag age. e. A Att th this is ag age, e, c chi hild ldre ren n op open en th thei eirr mo mout uths hs for a spoon, are able to use their tongue to move the bolus of food to the back of their mouth so they can swallow it, and are able to keep food in their mouth. Oral function progresses from sucking to a phasic bite or m or munching, unching, with a bite-and-release pattern 25 at between 5 months and 6 months of age. These oral skills correspond to and are dependent on the gross motor skills of good head control, sitting with support, and trun trunk k st stabi abilit lity. y. At th the e sa same me tim time, e, se sens nsor ory y ex expe perie rienc nces es to th the e ha hand nds s an and d mo mout uth h increase as the fine motor skills of bringing toys to the mouth, reaching for a spoon, using palmar grasp, and transferring objects hand to hand emerge. 28 This ability to explore textures with the hands and in the mouth is likely important to a child learning to accept varying and increasing food textures. By 7 months of age, most children can close their lips on the spoon and use their upper lip to clear the spoon. Sustained biting and the beginning of rotary chewing are usually seen between 9 months and 12 months of age and the food textures tolerated at this age progress from purees to ground or mashed table foods and some chopped table foods. By this age, most infants can sit independently. At 9 months of age, most children have a pincer grasp, which makes it easier for them to manipulate finger foods and begin self-feeding. Most babies can hold food in their hand at 8 months of age and have begun trying to use a spoon. By 15 months to 18 months, most children can feed themselves with a spoon.15,16 Between 8 months and 12 months, the first teeth have erupted and children can typically bite off crunchier foods. While chewing continues to mature, most children show interest and tolerance of nearly all textures without gagging. There is some evidence that chewing skills develop in response to a variety of food textures and

 

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th that at ch chil ildr dren en wh who o are are offe offere red d mo more re so soli lid d te text xtur ures es at 6 mo mont nths hs of ag age e ha have ve be bett tter er ch chew ew-ing skills at 12 months of age and are ar e mo more re accepting of and able to adequa adequately tely chew most table foods by 2 years of age.29,30 EVALUATING A FEEDING PROBLEM Feeding problems in infants and young children are best evaluated by an interprofessional team. Bringing together a team of people with varied perspectives and different types of expertise provides an ability to cons consider ider influence influences s of past and current medical problems, children’s growth and development and their oral motor function, the adequac qu acy y of a ch chilild’ d’s s nu nutr trit itio iona nall inta intake ke,, an and d th the e so soci cial al mi mililieu eu a ch chilild d lilive ves s in in.. Te Team am me memb mber ers s can vary dependin depending g on the experien experience ce and expertis expertise e available at a p particu articular lar institution. In most cases, the core team is composed of a pediatric speech-language pathologist (SLP), (SL P), a ped pediat iatric ric oc occu cupa patio tiona nall the thera rapis pist, t, a re regi giste stere red d pe pedia diatri tric c die dietic ticia ian, n, an and d a ped pediat iatric ric gastroenterologist. The pediatric SLP evaluates oral function and a child’s ability to handle an age-appropriate diet, looks for signs and symptoms of swallow dysfunction, and determines the need for and conducts an instrumental evaluation of swallow. The occupational therapist assesses fine motor development, self-feeding skills, and sensory issues. The pediatric gastroenterologist identifies, evaluates, and helps manage problems of gut motility, such as gastroesophageal reflux, poor gastric emptying, and chronic chroni c const constipation ipation as well as helping to manage enter enteral al feeding. The register registered ed pediatric dietician performs a comprehensive nutritional assessment, assesses the quantity and quality of dietary intake, and tries to incorporate cultural and family preferences for diet and mealtime routines. Depending on the child, additional team members could include a pediatric physical therapist, a child psychologist or psychiatrist, a pediatric social worker, a lactation consultant, and a pediatric otolaryngologist. In a majority of cases, children should undergo a comprehensive clinical assessment of their feeding and swallowing before any more invasive assessment is performed. During this assessment, clinicians can often determine if a child’s feeding problem is due to problems with the oral preparation (preparing liquid or food in the mouth to form a bolus), oral transit (moving the bolus back), or pharyngeal (initiating This s inf infororthe the sw swal allo low w an and d mo movi ving ng th the e bo bolu lus s th thro roug ugh h th the e ph phar aryn ynx) x) ph phas ase e of sw swal allo low. w.31 Thi mation defines the need and purpose of any more invasive study, such as a videofluoroscopic swallow study (VFSS) or flexible endoscopic evaluation of swallowing (FEES). These studies are performed when there are concerns of pooling, laryngeal penetration, or aspiration. Pooling refers to the collection of secretions or residue from a food bolus that remains in the hypophar hypopharynx ynx after a swallo swallow. w. Aspiration is identified when any food material enters the airway, falling below the level of the true vocal cords. cor ds. Pen Penetr etrati ation on occ occurs urs wh when en a   fo food od bolu bolus s ent enters ers the lar laryng yngeal eal ves vestibu tibule le but 32,33 remains above the vocal cords. The first part of any feeding assessment should be performing a comprehensive hist histor ory. y. A pa pare rent nt’s ’s de desc scri ript ptio ion n of th the e prob proble lem m ca can n re reve veal al issu issues es wi with th la lack ck of hu hung nger er sigsignals, lengthy times to feed, frequent coughing or choking, frequent vomiting during or after meals, limited tastes and textures accepted, inability or refusal to self-feed, and crying or behavioral outbursts during meals. Strong preferences for specific foods, utensils, position during meals, or location of meals, and even who the child accepts food from suggest suggest well-established patterns that interfere with the normal progress progression ion of acq acquir uiring ing fee feedin ding g ski skills. lls. Iss Issues ues with other car care e rou routin tines, es, suc such h as bat bathin hing, g, ora orall hygiene, and dressing, may reveal unusual or exaggerated responses to more generalized tactile input. Cultural influences about food choices and behavioral expectations need to be assessed as well.

 

Feeding Problems in Infants and Children

 After getting a complete understanding of a caregiver’s perception of a child’s current feeding difficulties, it is important to carefully review the child’s growth and development, the current diet, what textures the child eats, and a description of the typical feeding fee ding enviro environme nment. nt. Curr Current ent and pas pastt med medica icall and soc social ial iss issues ues that may hav have e effected feeding should be identified—in particular, did or does the child have any developmental disabilities or medical problems that might interfere with the normal feed feedin ing g pro proce cess ss or mi migh ghtt pred predisp ispos ose e the ch child ild to ex expe peri rien ence ce pa pain in wh while ile e eat atin ing g or be bein ing g fed (as outlined in   Box 1 )? A history of respiratory symptoms, such as coughing or chok ch okin ing g wit with h feed feeding ings, s, ch chro roni nic c upp upper er ai airw rway ay co cong nges esti tion on,, in inte term rmitt itten entt strid stridor or,, wheezing, or recurrent pneumonia may be the result of aspiration during eating.  As part of the assessment, a complete physical examination should also be performed. A great deal of information about a child’s gross and fine motor skills, expressive and receptive language abilities, and the parents’ expectations and interactive styl style e ca can n be glea gleane ned d by ob obse serv rving ing th the e ch chilild d an and d pa pare rent nt wh while ile taki taking ng th the e hi hist stor ory. y. More direct components of the physical examination should include a careful assessment of the face and oral structures, looking for facial symmetry and the shape and integrity of the hard and soft palates; movement of the velum; range of motion of  the tongue, lips, and jaw; the gag reflex; and the child’s ability to manage secretions. The examiner(s) should also ensure there are no unexpected abnormalities on the cardiorespiratory, abdominal and/or neurologic examinations that might predispose a chi child ld to diff difficu icultie lties s fee feedin ding. g. Dep Depend ending ing on a chi child’s ld’s age age,, dev develo elopme pmenta ntall sta status tus,, and disposition/personality, it is sometimes appropriate to defer the physical examination until after a feeding observation has been conducted. Feeding Observation Observation of a child eating foods typically offered at home using familiar utensils provides an opportunity to assess a child’s interest and response to the foods presented including the child’s willingness to touch and either self-feed or accept those food in the mouth, and the oral preparation, oral and pharyngeal phases of the swallow. It is also important to try to ascertain caregivers’ responses to a child during feeding. Parents may feel strong pressure to get a certain amount of food into a child when wh en th ther ere e is an ea earl rly y hist histor ory y of po poor or feed feedin ing g an and d slow slow we weig ight ht ga gain in.. Is th the e ch chil ild d allo allowe wed d the opportunity to self-feed and experience new tastes and textures? Many parents find that feeding a child is more efficient than letting the child attempt self-feeding and that smoother foods fed by spoon result in faster and increased intake. On the other hand, a lack of structure and mealtime expectations can lead to a limited diet and poor intake. What is the response to a coughing or choking episode, refusal of  a food food,, or sp spit itti ting ng ou outt of food food? ? Ma Mala lada dapt ptiv ive e feed feedin ing g be beha havi vior ors s ma may y ha have ve be been en in inad adve verrtently reinforced reinforced by parent parental al behav behaviors. iors.  Assessment of Tone, Posture, and Movement  Overall muscle tone, movement patterns, and control all influence oral function. For example, head control and trunk stability are necessary to stabilize the jaw for cup dr drin ink king ing an and d to use th the e up uppe perr lip lip to clea clean n foo food from from a sp spo oon on.. Ad Adeq equa uate te fi fine ne mo moto torr con on-trol to pi pic ck up food and brin ing g it to the mouth or loa load a spoon and tra ran nsfer the bit ite e to the mouth is neede needed d to reach certain feeding mileston milestones. es. Hypertonici Hypertonicity ty or hypoto hypotonicity nicity is often associated with exaggerated sensory responses, which may be expressed as refu refusa sall of ho hott or co cold ld fo food ods, s, refu refusa sall of ne new w ta tast stes es,, str stron ong g re refu fusa sall or ga gagg ggin ing g wit with h lu lump mpy y foods, thicker purees, or even soft solids. Some children show signs of seeking more intense inten se sensation in their mouth while eating by taking large bites or overs overstuffin tuffing g their mouths. Many of these children demonstrate clear preferences for strong tastes, such

 

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as salty or spicy foods, and/or have a preference for very crunchy textures. Lengthy chewing times, pocketing of food, or spitting out food after chewing without swallowing also suggests a sensory component to the feeding issue. Muscle tone and coordination influence the ability to manipulate liquids and solids in the mouth. A child must have the strength to bite off pieces of food; have sufficient control of the tongue to lateralize the food bolus for chewing; be able to close the lips to contain food and liqui liq uid d in th the e mo mout uth; h; an and d co coor ordin dinat ate e lip lips, s, to tong ngue ue,, ja jaw, w, and and so soft ft pa pala late te to co colle llect ct th the e fo food od into a bolus and propel it back for swallow. Increases in tone and changes in movement patterns may signal pain during eating.  Although it may be difficult to recognize pain with feeding in infants, extraneous movement of the arms and legs, repeated pulling off of the bottle or breast, arching or sudden fussing after only a few minutes of feeding, or lengthy comfort sucking at bottle or breast with little transf transfer er of milk may indica indicate te discomfort. Decreas Decreased ed appetit appetite, e, refus refusal al of previously accepted foods, signs of cramping, and complaint of localized pain can be associated with pain during or just after eating in children. Vocal Quality   Assessm ent of vocal quali  Assessment quality ty prior to observi observing ng feeding enables assessme assessment nt of any changes after food or liquid has been introduced. Dysphonia—a breathy, hoarse, or raspy quality to the voice—may indicate vocal cord edema or a paralysis or weakness in one of the vocal cords.congested Decreasedsounds vocal cord function a child at risk for aspiration. During eating, at the level ofplaces the larynx, a wet or gurgling voice, throat clearing, coughing, or multiple swallows to clear one bite suggest difficulty during the pharyngeal phase of the swallow and raise concerns for pooling, penetration, or aspiration even in the absence of a history of respiratory symptoms. Videofluoroscopic Swallow Study and Flexible Endoscopic Evaluation of Swallow   A clinical feeding evaluation may reveal signs or behaviors suggesting swallow difficulty; however, an instrumental evaluation of swallow is the only way to objectively confirm laryngeal penetration or aspiration. Instrumental assessment of swallow function can be accomplished by videofluoroscopy or by endoscopy.32 VFSS (sometimes called a modified barium swallow) is conducted in the fluoroscopy suite with an SLP and radiologist present. As much as possible, the child is positioned in the usual feeding position. Infants are usually positioned in an infant seat in a semireclined position and older children are put into a seated position and provided with lateral or head support as needed. Food and liquid are mixed with barium and presented to the child in the usual manner. The image is lateral, with the oral cavity and neck in view. VFSS allows a dynami dynamic c vi view ew of  of the oral preparatory, oral, pharyngeal, and upper 34 esophageal esoph ageal phases of swallo swallow. w. FEES is done at the bedside or in a clinic setting by an SLP with advanced training Infa fant nts s ca can n be po posi siti tion oned ed in an in infa fant nt se seat at or he held ld in and an d ex expe perie rienc nce e in th the e pro proce cedu dure re..35 In a typical feeding position by a parent or care provider. Older children are seated in a chair or in a parent’s lap. A small flexible endoscope is inserted through the nose to allow visualization of the pharyngeal and laryngeal structures. With the scope in place, the child can be fed a typical meal. This can be breastfeeding or bottle-feeding, drinking from a cup, and/or eating solid foods.36 The view through the scope is primarily superior, looking down into the laryngeal vestibule, thus allowing direct visualization of the nasopharynx, oropharynx, hypopharynx, and larynx during swallows. The oral and esophageal phases of the swallow cannot be seen with this technique.

 

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There are The are adv dva ant ntag ages es,, di dis sad adv van anta tag ges es,, an and d li limi mita tati tio ons to bo both th of th thes ese e assessments:  VFSS gives specific information about the oral phase of swallow, which may be key ke y in de dete term rmin inin ing g th the e ca caus use e of th the e sw swal allo lowi wing ng prob proble lem. m. It al also so prov provid ides es a vi view ew of  the passage of the bolus through the structures during the entire swallow.   The oral phase cannot be viewed with FEES, and there is a white-out period during the swallow when tissues contract and obscure the view of the bolus and 

structures.   FEES prov provides ides inf inform ormati ation on abo about ut lar laryng yngeal eal ana anatom tomy y and fun functi ction on and abo about ut secretion management that VFSS does not and also allows for a longer view  just before and immediately after the swallow.   VFSS can usually be completed with children of any age whereas FEES may be limited to children under 12 months and older than 4 years because it requires a child’s cooperation for the scope to be inserted. Babies can usually be quickly calmed with the presentation of the bottle, and children old enough to follow directions are often interested in the video and the camera and can often be coaxed into allowing the scope to be passed.   Food taken during VFSS must be mixed with barium, resulting in a change in taste and texture, whereas plain food or food with dye added to improve visibility is used during FEES. 



  be Althou Although gh FEES is invas invasive, ive, it thou is out nott risk any ionizing radiatio radiation can repe repeat ated ed mu mult ltip iple le ti time mes s wi with riassociated sk an and d ca can n with be us used ed to view view an en enti tire renfeed feso edin ing. g. 

  VFSS is a less invasiv invasive e procedure but does expose childre children n to ionizi ionizing ng radiation so must be time-limited. Most recent information suggests the long-term effects of radiation exposure are greatest in younger children. Reported effective doses for a typical VFSS in a child vary widely ranging from 0.08 mSv to 0.8 mSv. In compa co mparis rison on,, th the e do dose se of a ty typic pical al ch ches estt ra radio diogr grap aph h is 0. 0.05 05 mS mSv. v.34,37,38  A  screening time of 2 minutes to 3 minutes has been reported to be required to complete an evaluation, including a variety of food textures. Turning the fluoroscopy on and off during the study, limiting the numbe numberr of swallo swallows ws observed, and using a lower fluoroscopy pulse rate can limit the radiation dose. Ensuring that the study is done in a facili facility ty adhering to keeping exposu exposure re as low as reasonably achiev ach ievabl able e (AL (ALARA) ARA),, with pedi pediatr atric ic rad radiol iologi ogists sts and exp experi erienc enced ed SLP SLPs s and avoiding repeated studies, especially completed only weeks or months apart, is crucial to protecting children.

INTERVENTION Impressions from the clinical examination and any instrumental evaluation findings direct intervention strategies. The primary goal of any intervention is to help a child achieve age-appropriate feeding skills through positive feeding experiences while ensuring swallow safety and adequate nutrition and growth. Therapy may focus on behavioral interventions, oral motor treatments, physical and sensory treatments, adju ad jus stm tmen ents ts to di diet et,, an and d th the e me meth thod ods s of in inta take ke or a co comb mbin inat atio ion n of th thes ese e approaches. The family must collaborate with any behavioral interventions to reinforce appropriate responses to food during mealtimes and reduce interfering behaviors to be successful. Oral motor treatment to improve strength, movement, and coordination of the lips, tongue, jaw, soft palate, and pharynx may involve sensory stimulation to these areas as well as resist resistance ance,, chewin chewing, g, or swallowing exercises. exercises. Physic Physical al and occupational therapy may complement feeding therapy by the SLP and help a child develop

 

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postural control and self-feeding abilities and decrease aversive responses to tactile stimulation to the hands and mouth. Modifications of the diet may include changing the viscosity of liquids, increasing or decrea dec reasin sing g the con consis sisten tency cy of sol solids ids off offere ered, d, and add adding ing sup supplem plement ental al fee feeding dings s (eg, tube feedings, calorically dense formulas, or drinks) as needed. Changes during oral intake, such as altering position for feedings; altering the bottle nipple, cup, or straw to reduce or increase the flow rate; introducing compensatory maneuvers to improve bolus movement and control during swallow; and systematic introduction of new tastes and textures can be guided by the SLP or the therapy team. 39 SOME REPRESENTATIVE CASE STUDIES Case 1 KA is a 2-week-old boy with a hypoplastic aortic arch and slightly hypoplastic aortic valve who underwent reconstructive surgery during the first several days of life. He was extubated 4 days after surgery. The following day, the medical team consulted the SLP. During her consultation she noted a dysphonic cry and hyperactive gag; however, he was able to latch onto the bottle nipple and demonstrated short sucking bursts. His lip seal on the nipple was poor and he quickly showed signs of fatigue. He took only 5 mL by mouth during his initial feeding session but he did not cough or develop worsening congestion. During a session 2 days later, his hyperactive gag had diminished and he latched rapidly to the nipple and had a more vigorous suck on the bottle; however, this more effective extraction of milk from the bottle was associated with periodic coughing during the feeding. His voice remained dysphonic and his cough was weak. The feeding trial was discontinued because of concerns for laryngeal penetration and/  or asp aspira iratio tion. n. Th The e SLP rec recomm ommen ended ded a ped pediat iatric ric oto otolar laryng yngolo ology gy co cons nsult ultati ation on because of concerns for vocal cord paralysis or paresis associated with his cardiac surgery. FEES was completed by the SLP with the pediatric otolaryngologist in attendance. View Vie w of th the e lary laryng ngea eall ve vest stibu ibule le de demo mons nstr trat ated ed d dec ecre reas ased ed mo mobil bility ity of th the e le left ft vo voca call co cord. rd. Penetration and aspiration were observed while the child was fed thin liquid from a slow-flow nipple as well as an extra slow-flow nipple. When he was fed slightly thickened liquid from a slow-fl slow-flow ow nipple and he was positioned positioned in a side-l side-lying ying position with his right side down to promote more medial positioning of his left vocal cord, he was bett be tter er ab able le to prot protec ectt hi his s airw airway ay and and he ha had d on only ly ep epis isod odic ic la lary ryng ngea eall pe pene netr trat atio ion n an and d no aspiration. He was discharged from the hospital a week later feeding in this manner without any clinical suspicion of laryngeal penetration or aspiration. Case 2 SB is a 3-month-old boy who was the product of an uncomplicated term pregnancy, labor, and delivery. At a week of age he began experiencing repeated bouts of what seemed to be abdominal pain associated with eating and frequent bouts of vomiting. Thes Th ese e sy sympt mptom oms s wo wors rsen ened ed ov over er ti time me.. He wa was s in initi itial ally ly bre breas astfe tfed d an and d nu nurs rsed ed vigo vigoro rous usly ly for 5 minutes before suddenly pulling off the breast, arching, and crying. His mother eliminated elimina ted a wide variety of foods from her diet withou withoutt any improvemen improvementt in his symptoms. He was treated with probiotics, ranitidine, and omeprazole without improvement. Pyloric ultrasound and upper GI series were normal. At 2 months of age, his mother decided to stop breastfeeding and commence bottle-feedings, hoping feedings would become less stressful for both her and her baby. His symptoms did not improve with a protein hydrolysate formula or an amino acid–based formula. The

 

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family tried different bottles and nipples without any change in his symptoms. His parents observed that he fed best and seemed most comfortable feeding when he was nearly asleep. Despite his feeding difficulties, SB continued to grow and develop. On examination he was fussy but consolable. His weight was at the 25th percentile for age, his height at the 50th percentile, and his head circumference at the 50th percentile. His physical examination was entirely normal, including his oral examination. He had frequent episodes of crying and flailing while being held by his mother but quieted when put into a semireclined position and offered a bottle. He showed difficulty establishing a latch with frantic and disorganized movements but was able to latc latch h an and d im imme media diate tely ly sh show owed ed vi vigo goro rous us,, rhyt rhythm hmic ic su suck ckin ing g with with a ca calm lm stat state e fo forr se seve vera rall minutes, consuming approximately 20 mL before suddenly pulling away from the bottl tle e an and d arch archin ing g an and d cryi crying ng.. He ca calm lmed ed afte afterr a mi minu nute te or so an and d re resu sume med d fe feed edin ing g bu butt hi his s sucking bursts continued to be interspersed with crying/agitation and pulling off the nipple. His mother reported this pattern typical of a feeding at home, which often took up to an hour to complete. No vocal changes, congestion, or signs of penetration or aspiration were observed during feeding and, when actively sucking, SB was able to efficiently transfer milk from his bottle. Based on his history, previous evaluation, and feeding assessment, there was no need for instrumental evaluation of his swallowing mechanism. His feeding difficulties seemed to be the result of GI discomfort associated with feeding. Although he had symptoms consistent with gastroesophageal reflux, it seemed unlikely this was the source of his disco source discomfort, mfort, gi given ven nume numerous rous formu formula la chang changes es and trea treatment tment wit with h acid inhibitors did not offer him relief. Rather, he seemed to be suffering from extreme colic/  visceral hyperalgesia. He was treated with a low dose of gabapentin and within 5 days of sta startin rting g tthis his med medica icatio tion, n, his disc discomf omfort ort with fee feedin ding g aba abated ted.. At 6 mon months ths of age age,, tthe he gabapentin was discontinued and he continued to feed well from the bottle and began eating solid foods without any difficulty or discomfort. Case 3 JW is an 18-month-old boy without any history of serious illnesses who has been growing and developing normally. He was referred to the feeding clinic because he has been coughing and choking when he eats since he began eating table foods at 10 months of age. His coughing episodes frequently result in post-tussive vomiting. He had no problems with coughing, choking, or vomiting before solid foods were added into his diet. A chest radiograph was normal, and an upper GI series demonstrated strate d norma normall esoph esophagea ageall anato anatomy my and motilit motility. y. JW’s parents state that he coughs at nearly every meal and that even after he has a boutt of pos bou post-t t-tuss ussive ive vom vomitin iting, g, he res resume umes s eat eating ing.. Dur During ing her fee feeding ding eva evalua luatio tion, n, immediately after JW ate a cracker, the SLP heard congestion at the level of the larynx and an d a we wett vo voca call qu qual alit ity. y. Du Duri ring ng su subs bseq eque uent nt food food tr tria ials ls,, th ther ere e wa was s a su sugg gges esti tion on of po pool ol-ing and penetration as his congestion and vocal symptoms increased, and he would peri pe riod odic ical ally ly co coug ugh. h. He did did no nott se seem em to be in an any y di disc scom omfo fort rt,, and and he re rema main ined ed wi will llin ing g to eat. His parents had a tendency to present JW large pieces of solid foods in rapid succession.  Although there was no history of recurrent pneumonia or any other chronic or recurrent respiratory symptoms, the SLP was worried about the possibility of decreased sensat sen sation ion,, pha pharyn ryngea geall swa swallo llow w dysf dysfunc unctio tion, n, and chr chroni onic c asp aspira iration tion and rec recomm ommend ended ed performing VFSS. She recommended performing VFSS rather than FEES because, given his age and demeanor, it was unlikely he would be able to cooperate with FEES. VFSS demonstrated poor oral control of boluses of hard solids that required chewing and this resulted in premature spillage of the bolus into the hypopharynx,

 

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delayed trigg delayed triggering ering of his sw swallow, allow, and nume numerous rous episod episodes es of pe penetra netration; tion; h howeve owever, r, no aspiration aspirat ion was seen. Based Bas ed on the these se fin findin dings, gs, the aut author hors s rec recomm ommend ended ed down downgra gradin ding g JW’ JW’s s diet to smooth or soft solids and offering chopped or ground higher-texture solids in small bites. JW was also referred for speech and occupational therapy services to provide him with sensory stimulation to improve his oral/pharyngeal sensory responses to higher-textured foods, develop better chewing skills and improve JW’s self-feeding skills. Case 4  AP is an 8-year-old girl who has been healthy and growing and developing normally. She Sh e ha had d no hist histor ory y of as asth thma ma or ot othe herr resp respira irato tory ry symp sympto toms ms,, ec ecze zema ma,, or an any y pro proble blems ms swallowing. She was referred to the feeding clinic because of a 6-week history of  refusing to eat any solid foods. Her refusal to eat solid food began immediately after she sh e ch chok oked ed on a piec piece e of st stea eak k for for wh whic ich h he herr fath father er pe perf rfor orme med d th the e He Heim imlic lich h mane maneuv uver er.. Since then, she had consistently refused to eat any solid foods, including purees, complaining that the food “gets stuck” in her throat. She continued to drink liquids without any choking, gagging, or coughing. As a result of her refusal to eat any solid foods, she lost 7% of her body weight. Given she was entirely normal and had no difficul fic ulti ties es ea eati ting ng or sw swal allo lowin wing g pri prior or to he herr ch chok okin ing g ep epis isod ode, e, it se seem emed ed mo most st ap appro propri priat ate e to perform a clinical evaluation prior to any instrumental evaluation of her swallowing mechanism or her esophagus. In the clinic, she reported a sense of her “throat closing” ing” and and an inab inabili ility ty to sw swal allo low w th the e food food.. Aft After er ac ackn know owle ledg dgin ing g an and d va valid lidat atin ing g he herr se sens nse e of fear of choking, the SLP explained that fear and anxiety would produce tension in the muscles of her throat, which would indeed make it hard to swallow. The SLP then led her through several breathing exercises to help her relax, and together they practiced swallowing beginning with liquids and then moving to purees, soft solids, and finally hard solids. Using the relaxation breathing she had learned, taking very small bites, chewing thoroughly, and using liquid wash after each bite, she was able to succe successfull ssfully y swallo swallow w each consiste consistency. ncy. Througho Throughout ut the session, the SLP conti continunuously assessed her swallow and did not see any signs of swallow dysfunction, pain, or obstruction. AP’s confidence increased after she successfully swallowed each solid texture. She was given specific instructions for home oral intake using the techniques she had learned and practiced in clinic. Her mother reported that within an hour of  leaving the clinic, AP ate an entire fried chicken sandwich at a fast food restaurant. With Wi thin in a we week ek,, sh she e ha had d re resu sume med d he herr prev previo ious us diet diet an and d sh she e de deni nied ed an any y di diff ffic icul ulti ties es sw swal al-lowing or feeling as though food was “getting stuck.” She regained all the weight she lost. In this case, performing VFSS prior to a clinical assessment would have exposed  AP to unnecessary radiation and reinforced the idea that she was suffering from a serious seriou s illness. Ackno Acknowledgin wledging g that her sympto symptoms ms were real, giving her an explana explanation tion for for th thos ose e sy symp mpto toms ms,, an and d pr prov ovid idin ing g he herr wi with th a sa safe fe en envi viro ronm nmen entt an and d tech techni niqu ques es to he help lp her eat solid foods enabled her to overcome her fear of choking. SUMMARY Feeding problems in infants and young children are common. In otherwise healthy childre chi ldren n who are dev develo eloping ping and gro growin wing g nor normal mally, ly, fee feeding ding pro problem blems s are usu usuall ally y not serious, are transient, and can be managed conservatively by reassuring the family, providing them with anticipato anticipatory ry guidance, guidance, and providin providing g regula regularr follow follow-up. -up. A ma jority of more serious childhood feeding problems occur in children who have other medical, developmental, or behavioral problems. These more serious problems are

 

Feeding Problems in Infants and Children

best evaluated and treated by an interprofessional team who can identify and address issues in a child’s medical and/or developmental history, problems with oral motor control and function, problems with swallowing, and behavioral and/or sensory issues that may interfere with normal feeding progression. REFERENCES

1.   Miller CK. Updates on pediatric feeding and swallowing problems. Curr Opin Otolaryngol Head Neck Surg 2009;17:194–9. 2009;17:194–9. 2.  Phalen JA. Managing feeding problems and feeding disorders. Pediatr Rev 2013; 34:549–57.. 34:549–57 3.  Arts-Rodas D, Benoit D. Feeding problems in infancy and early childhood: identification and management. Paediatr Child Health 1998;3:21–7. 1998;3:21–7 . 4.  Ramasamy M, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol 2000; 30:34–46.. 30:34–46 5.  Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health 2003;39:299–304. 2003;39:299–304. 6.  Rommel N, De Meyer AM, Feenstra L, et al. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr 2003;37:75–84. 2003;37:75–84. 7.   Kerzne Kerznerr B, Milano K, MacLean MacLean WC, et al. A practic practical al approach to classifying classifying and managing managi ng feedin feeding g diffic difficulties ulties.. Pediatr 2015; 2015;135:3 135:344–53 44–53.. Organic nic and non nonorg organi anic c fee feeding ding diso disorde rders. rs. Ann Nut Nutrr Met Metab ab 201 2015; 5; 8.   Rybak Rybak A. Orga 66(Suppl 5):16–22. 5):16–22. 9.  Cano SC, Tiemeier H, Van Hoeken D, et al. Trajectories of picky eating during childhood: a general population study. Int J Eat Disord 2015;48:570–9. 2015;48:570–9 . 10.  Mathisen B, Worrall L, Masel J, et al. Feeding problems in in fants with gastrooesophageal reflux disease: a controlled study. J Paediatr Child Health 1999; 35:163–9.. 35:163–9 11.  Nelson SP, Chen EH, Syniar GM, et al. One-year follow-up of symptoms of gastroesophageal esoph ageal reflux during infanc infancy y. Pediatr Pediatrics ics 1998; 1998;102:e 102:e67 67.. 12.  Dellert S, Hyams J, Tree W, et al. Feeding resistance and gastroesophageal reflux in infancy. J Pediatr Gastroenterol Nutr 1993;17:66–71. 1993;17:66–71 . 13.  Kerzner B. Clinical investigation of feeding difficulties in young children: a practical approach. Clin Pediatr 2009;48:960–5. 2009;48:960–5 . 14.  Chen IL, Gao WY, Johnson AP, et al. Proton pump inhibitor use in infants: FDA reviewer experience. J Pediatr Gastroenterol Nutr 2012;54:8–14. 2012;54:8–14. 15.   Morris SE, Klein MD. Pre-feeding skills. 2nd edition. Tucson (AZ): Therapy Skill Builders; 2000. 2000. 16.   Carruth BR, Ziegler PJ, Gordon A, et al. Developmental milestones and selffee fe edi din ng be beh havio iorrs in in infa fan nts and to tod ddl dle ers. J Am Diet Assoc 2004; 104(1 Suppl 1):s51–6. 1):s51–6. 17.  Beauchamp GK, Mennella J. Early flavor learning and its impact on later feeding behavior. J Pediatr Gastroenterol Nutr 2009;43:S25–30. 2009;43:S25–30. 18.   Beauchamp GK, Mennella J. Flavor perception in human infants: development and functional significance. Digestion 2011;83(Suppl 1):1–6. 1):1–6 . 19.  Cooke LJ, Wardle J, Gibson EL, et al. Demographic, familial and trait predictors of fru fruit it and veg vegeta etable ble con consum sumptio ption n by pre presch school ool chi childre ldren. n. Publ Public ic Hea Health lth Nut Nutrr 2004;7:295–302.. 2004;7:295–302 20.   Me Menn nnel ella la J, Be Beau auch cham amp p GK GK.. De Deve velo lopm pmen enta tall ch chan ange ges s in th the e ac acce cepta ptanc nce e of protein hydrolysate formula. J Dev Behav Pediatr 1996;17:386–91. 1996;17:386–91 .

 

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21.  Sellen DW. Evolution of infant and young child feeding: implications for contemporary public health. Annu Rev Nutr 2007;27:123–48. 2007;27:123–48 . 22.   AAP Section on Breastfeeding. Breastfeeding. Breastfeedin Breastfeeding g and the use of human milk. Pediatrics 2012;129(3):3827-e841. 23. Americ American an Academy of Family Physic Physicians. ians. Breastfe Breastfeeding eding policy statemen statement. t. 2007. www.aafp.org/online/en/home/policy/policies/b/breastfeedingpolicy.. Available at:  at:   www.aafp.org/online/en/home/policy/policies/b/breastfeedingpolicy html.. Accessed April 23, 2017. html 24.  Clayton HB, Li R, Perrine CG, et al. Prevalence and reasons for introducing infants early to solid foods: variation by milk feeding type. Pediatrics 2013;131: e1108–14.. e1108–14 DW. Comparison of infant feeding patterns reported for non-industrial popp op25.   Sellen DW. ulations with current recommendations. J Nutr 2001;131:2707–15. 2001;131:2707–15. Coulthard ard H, Harris G, Emmett P. Delay Delayed ed introduction introduction of lumpy foods to childre children n 26.   Coulth during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age. Matern Child Nutr 2009;5:75–85. 2009;5:75–85 . 27.  Abrams EM, Greenhawt M, Fleischer DM, et al. Early solid food introduction: role in food allergy prevention and implications for breastfeeding. J Pediatr 2017;184: 13–8.. 13–8 28.   Car Carrut ruth h BR, Skin Skinner ner JD. Fee Feeding ding beh behavi aviors ors and oth other er mot motor or dev develo elopme pment nt in healthy children (2-24 months). J Am Coll Nutr 2002;21:88–96. 2002;21:88–96 . 29.  Gisel EG. Effect of food texture on the development of chewing of children between six months and two years of age. Dev Med Child Neurol 1991;33:69–79 . 30.   Wilson EM, Green JR, Weismer GA. A kinema kinematic tic description description of the temporal charcharacteristics of jaw motion for early chewing: preliminary findings. J Speech Lang Hear Res 2012;55:626–38. 2012;55:626–38. 31.   Logemann JA. Evaluation and treatment of swallowing disorders. 2nd edition. Austin (TX): Pro-Ed; 1998. 1998. Reynolds lds J, Carro Carrollll S, Sturdiv Sturdivant ant C. Fibero Fiberoptic ptic endoscopic endoscopic evaluation of swallow32.   Reyno ing: a multidisciplinary alternative for assessment of infants with dysphagia in the neonatal intensive care unit. Adv Neonatal Care 2016;16:37–43. 2016;16:37–43 . 33.   Fa Farne rneti ti D. Poo Poolin ling g sc scor ore: e: an and d en endo dosc scop opic ic mo model del of ev eval alua uatin ting g se seve verit rity y of dysphagia. dyspha gia. Acta Otorhin Otorhinolaryng olaryngol ol Ital 2008; 2008;28:13 28:135–40 5–40.. 34.   Hiorns MP, MP, Ryan MD. Curren Currentt practic practice e in paedia paediatric tric videof videofluoro luoroscopy scopy.. Pediatr Radiol 2006;36:911–9. 2006;36:911–9. 35. Ameri American can Speec Speech-La h-Languag nguage-Hea e-Hearing ring Asso Associatio ciation. n. Role of the spee speech-la ch-langua nguage ge pathologist in the performance and interpretation of endoscopic evaluation of swalwww.asha.org/policy ha.org/policy.. Accessed lowing: guidelines [Guidelines]. 2004. Available at:  at:  www.as April 5, 2017. 36.  Suterwala MS, Reynolds CS. Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit. J Perinatol 2017;37:404–8. 2017;37:404–8. 37.  Weir KA, McMahan SM, Long G, et al. Radiation doses to children during modified barium swallow studies. Pediatr Radiol 2007;37:283–90. 2007;37:283–90. 38.   Brenner D, Huda W. Effective dose: a useful concept in diagnostic radiology. Radiat Prot Dosimetry 2008;128:503–8. 2008;128:503–8. 39. Americ American an Speech Speech-Lang -Language-H uage-Hearing earing Associatio Association n (n. d). Pediatr Pediatric ic Dyspha Dysphagia. gia. (P (Pra ract ctic ice e Po Port rtal al). ). Av Avai aila labl ble e at: at:   http://www.asha.org/Practice-Portal/ClinicalTopics/Pediatric-Dysphagia.. Accessed April 24, 2017. Topics/Pediatric-Dysphagia