Mealtime Battles: Feeding Problems in Infancy and Early Childhood
Julie McDaniel, MS, CCC-SLP shares the common feeding issues in infants and early childhood.
Featured Speaker:
Julie McDaniel, MS
Julie McDaniel, MS, CCC-SLP, received her bachelor’s degree in education and master's degree in speech and language pathology from the University of Nebraska. Since graduating she has worked in skilled nursing, acute care and outpatient pediatrics, including working with alternative and augmentative communication devices and children with autism. She also has worked in acute rehab with stroke and traumatic brain injury patients, and helping those with swallowing and speech difficulties, and memory and cognitive deficits. Her work passions include working with premature infants and children with swallowing disorders and feeding tolerance issues. Transcription:
Mealtime Battles: Feeding Problems in Infancy and Early Childhood
Melanie Cole (Host): Welcome. Today we’re talking about feeding problems in infancy and early childhood. Joining me is Julie McDaniel. She’s a speech pathologist at Bryan Health. Julie, I’m so glad to have you with us today. Explain a little bit about what a feeding or swallowing disorder is and how do they differ?
Julie McDaniel, MS, CCC-SLP (Guest): So, a feeding disorder typically involves a child’s refusal to eat certain food groups or certain textures of foods. They may omit, for example, all meats or refuse all vegetables, or they may also demonstrate refusal of a certain texture like all wet foods, like fruits or mushy foods like a banana or mashed potatoes. Some infants and children will also come to us with some swallowing challenges. Swallowing basically happens in three main stages and impairments can occur at any of these phases. So, some examples of this may include difficulty sucking on a bottle or drinking out of a cup or a straw. They may have reduced oral motor coordination or strength to move food around in their mouth. A lot of kids come to us with difficulty with chewing age appropriate foods. They may also have difficulty transferring or moving food or liquid to the back of their mouth for swallowing, or they may even have trouble coordinating their suck, swallow and breathing, especially in infancy.
Melanie: Wow, you know, it’s such a comprehensive disorder and so many things that are involved. What health problems can be associated with feeding or swallowing difficulties in children?
Julie: There’s a variety of reasons children may have difficulty eating. Sometimes it just comes down to some kind of pain. Like maybe they have significant reflux, or, you know, some other kind of GI diagnosis. We see a lot of feeding difficulties in our infants that were born premature or those that have extremely low birth weight. There are some other diagnoses that can contribute to some feeding or swallowing challenges such as cerebral palsy, children with Down syndrome, those with various heart conditions, cleft lip or palate, and even children with a history of breathing or respiratory problems.
Melanie: Well, Julie, as a parent and you are as well, we know how scary it can be if we notice our children gasping or choking or having difficulty swallowing. What are some signs and symptoms—big red flags—for feeding and/or swallowing issues in young infants who are bottle feeding and how about infants who are now able to eat table foods? This is very scary for parents.
Julie: Yeah, absolutely. As a parent, you know, one of our main roles is feeding and, you know, nourishing our children. So, yeah, it can be very frightening. Some signs and symptoms of feeding or swallowing difficulties in young infants can be difficulty latching or sealing their lips around the bottle. This may result in a significant loss of fluids. So, now they have milk, you know, coming out of their mouth while they’re eating. Any time an infant is stressed when eating—they maybe arching their back or siphoning their body when feeding. That can be a sign that something else is going on. Any time they have any gulping or loud swallows, or they’re gasping for breath or you notice a difference in the way that they’re breathing during feeding, that can also be a sign or a symptom that there’s a difficulty. Certainly, any time they’re coughing or choking or they have a gurgling or horse voice quality during or after bottle feeding, and sometimes, too, there can be some concern when the infant is only eating while they’re asleep, but when they’re alert and awake, they’re very fussy and irritable and showing some signs of distress with that eating when they’re more alert. Infants can complete a bottle feeding within about 10 to 20 minutes. So, if it’s taking them much longer than 20 or 30 minutes, that can also be a sign that they’re having some difficulty in their feeding.
In terms of older infants or children who are now attempting to eat table foods, some of the difficulties we will often see in our clinic are parents reporting ongoing choking, gagging or sometimes coughing during meals. Sometimes children will frequently be spitting foods out of their mouth, and that can be a sign that maybe there’s some kind of oral motor weakness or oral motor impairment going on. If they have an inability to tolerate or consume age-appropriate food textures, that can be a red flag. For example, this may be an infant who is struggling to progress from a breast or bottle to baby food purees or could be a one year old who’s having difficulty with soft table foods or perhaps even a preschooler who isn’t able to eat more difficult food textures such as foods that produce juice, mixed consistency items like food or like pizza or even harder to chew foods, so, and a lot of our preschoolers that we do see sometimes they do come to us with a very limited food repertoire, meaning they have less than 20 different foods that they’re able to eat consistently and successfully, and certainly if they’re avoiding or they demonstrate an aversion of foods in a specific nutrition group or with a specific texture, that can also be a red flag.
Melanie: Well, thank you for that great information for parents. If an infant or child is referred for an evaluation, what’s involved in the process and also, tell us who is involved in the process and tell us about your multidisciplinary team?
Julie: Yeah. An evaluation typically includes a variety of team members. Especially here at Bryan, we really focus on a multidisciplinary approach to treating infants and children with any feeding or swallowing challenges. A lot of the times it includes a speech therapist, an occupational therapist, and a registered dietician, depending on what the feeding or swallowing concern is. So, when a child comes to us for an evaluation, we typically obtain a fairly detailed case history to gain a better understanding of any previous medical or feeding experiences that may have contributed to the child’s current difficulties. Whether this was a previous, you know, stay in our neonatal intensive care unit, or, you know, respiratory problems growing up, or significant reflux history, those kinds of things just so we can gain a better understanding about where they are at currently and maybe why. We typically assess a variety of different areas including their motor skills, their oral motor structure and function that is needed for feeding and swallowing as well as their sensory symptoms and nutritional or growth factors that might be contributing to their feeding or swallowing difficulties.
Melanie: So, tell us about a therapy session. I’m sure that parents want to know what they can expect from a session with you and your team. What’s it like for the child? What’s it like for the parents? Are they present for this? Tell us about it.
Julie: Absolutely. So, everybody—every child obviously comes with a different set of needs, and so every session might look a little bit different for each child, but we often encourage parents to be an active participant in these sessions. There are situations where sometimes the child might do better without mom or dad in the room, but we also have a one-way mirror, too, where they’re able to view in and look at the session and see, how we’re running the session, what strategies we’re using. So, that way, they can learn and take those strategies home with them as well, but in all of our therapy sessions, you know, we utilize food or liquid as our tools for our treatment. So, for most therapy sessions, our focus is not so much focused on the volume of food or liquid that the child is consuming, but we’re really focused on building skill. We choose specific foods or textures or flavors of food to work on specific skills that the child needs help developing or advancing. So, for example, if one of our goals is working on chewing skills, we’re going to choose foods that require that particular skill. You know, for instance, for example, if our skill is working on suck, swallow, breath coordination, we’re going to work on different positioning strategies and perhaps nipple flow rates for their bottle to help facilitate the development of that skill as well.
Host: So, what improvements can you make in a child’s feeding or swallowing skills through obviously correct diagnosis and treatment and these sessions? What do you see? What have your outcomes been?
Julie: For infants, we can really improve the safety and their quality of their feedings with appropriate positioning techniques, recommendations for nipple flow rates for bottles, and any other feeding strategies that can help their child’s feeding experience. We really want to focus on creating a positive feeding experience, not only for the child, but for the parents as well because feeding should be fun. It should be this nice reciprocal interaction between a parent and child versus being an experience that’s stressful. For infants and children that are eating solid table foods, we really aim to increase the child’s confidence and enjoyment with eating. Our overall goal is for children to be able to eat and swallow age appropriate food textures needed for adequate growth and nutrition. We really want children to feel comfortable trying new foods while also expanding their current food repertoire to a nice variety of proteins, starches and fruits or vegetables.
Host: As we wrap up, Julie, and this is such important information for parents to hear, how do you work with the families you mentioned that you encourage them to be involved and a part of the therapy session—how do you work with them so they can continue to progress their child’s skills at home and what would you like them to know about infant feeding and swallowing disorders and what you can do for them at Bryan Health?
Julie: Yeah, parents are provided with weekly education, you know, regarding their child’s performance in feeding therapy as well as home program recommendations. So, somebody’s recommendations might include, but are certainly not limited to providing them with the education on adequate or supportive positioning for feeding, and that’s true for infants all the way up to older kids who might need some additional support in order to be able to feed successfully. We often provide a lot of recommendations for certain bottles or certain flow rates as well as various spoons or even different cups to utilize at home to support their child where they’re currently at with their feeding skills so they can be as successful as possible at home. We often have a lot of discussions in regards to mealtime strategies and how we can create a positive mealtime environment and routine at home to maintain some consistency and some structure in their day, and then we also provide families with specific food textures that they can utilize at home to facilitate or advance a certain oral motor skill. I think overall the best advice I have is just to try to have patience with not only yourself but not only your child but yourself as well because feeding is hard. It’s very hard to learn. It’s not just this automatic thing. It’s development, just like so many other things. I think, keep in mind, too, when you’re at a mealtime, that although swallowing food might be the end goal, it’s not the only measurement of success. So, sometimes, children really just need to explore, touch, play, smell, or even taste foods multiple times before they’re willing to put it in their mouth on their own, and so I think it’s really important to praise and celebrate these victories, but overall, mealtimes should really, for the most part, be a fun and positive experience. So, if you feel like mealtimes have become a huge battle, if they’re stressful, or if parents are constantly reporting their child as being a picky eater or difficult to feed, they should certainly discuss those concerns with their pediatrician or family doctor, but I think most importantly, too, if your child is having difficulty with eating or at a mealtime, just want to assure parents that it’s not their fault and that there’s help available to make mealtime fun again.
Host: Excellent wrap up and thank you so much, Julie, for such great information for parents that are struggling with this, and it can be so frustrating and a little bit scary. So, thank you for telling us about your team and your approach to feeding and swallowing disorders and thanks to our Bryan Foundation partner Sampson Construction. That concludes this episode of Bryan Health Podcast. Head on over to our website at bryanhealth.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Bryan Health Podcasts. For more health tips and updates please follow us on your social channels. Until next time, I’m Melanie Cole.
Mealtime Battles: Feeding Problems in Infancy and Early Childhood
Melanie Cole (Host): Welcome. Today we’re talking about feeding problems in infancy and early childhood. Joining me is Julie McDaniel. She’s a speech pathologist at Bryan Health. Julie, I’m so glad to have you with us today. Explain a little bit about what a feeding or swallowing disorder is and how do they differ?
Julie McDaniel, MS, CCC-SLP (Guest): So, a feeding disorder typically involves a child’s refusal to eat certain food groups or certain textures of foods. They may omit, for example, all meats or refuse all vegetables, or they may also demonstrate refusal of a certain texture like all wet foods, like fruits or mushy foods like a banana or mashed potatoes. Some infants and children will also come to us with some swallowing challenges. Swallowing basically happens in three main stages and impairments can occur at any of these phases. So, some examples of this may include difficulty sucking on a bottle or drinking out of a cup or a straw. They may have reduced oral motor coordination or strength to move food around in their mouth. A lot of kids come to us with difficulty with chewing age appropriate foods. They may also have difficulty transferring or moving food or liquid to the back of their mouth for swallowing, or they may even have trouble coordinating their suck, swallow and breathing, especially in infancy.
Melanie: Wow, you know, it’s such a comprehensive disorder and so many things that are involved. What health problems can be associated with feeding or swallowing difficulties in children?
Julie: There’s a variety of reasons children may have difficulty eating. Sometimes it just comes down to some kind of pain. Like maybe they have significant reflux, or, you know, some other kind of GI diagnosis. We see a lot of feeding difficulties in our infants that were born premature or those that have extremely low birth weight. There are some other diagnoses that can contribute to some feeding or swallowing challenges such as cerebral palsy, children with Down syndrome, those with various heart conditions, cleft lip or palate, and even children with a history of breathing or respiratory problems.
Melanie: Well, Julie, as a parent and you are as well, we know how scary it can be if we notice our children gasping or choking or having difficulty swallowing. What are some signs and symptoms—big red flags—for feeding and/or swallowing issues in young infants who are bottle feeding and how about infants who are now able to eat table foods? This is very scary for parents.
Julie: Yeah, absolutely. As a parent, you know, one of our main roles is feeding and, you know, nourishing our children. So, yeah, it can be very frightening. Some signs and symptoms of feeding or swallowing difficulties in young infants can be difficulty latching or sealing their lips around the bottle. This may result in a significant loss of fluids. So, now they have milk, you know, coming out of their mouth while they’re eating. Any time an infant is stressed when eating—they maybe arching their back or siphoning their body when feeding. That can be a sign that something else is going on. Any time they have any gulping or loud swallows, or they’re gasping for breath or you notice a difference in the way that they’re breathing during feeding, that can also be a sign or a symptom that there’s a difficulty. Certainly, any time they’re coughing or choking or they have a gurgling or horse voice quality during or after bottle feeding, and sometimes, too, there can be some concern when the infant is only eating while they’re asleep, but when they’re alert and awake, they’re very fussy and irritable and showing some signs of distress with that eating when they’re more alert. Infants can complete a bottle feeding within about 10 to 20 minutes. So, if it’s taking them much longer than 20 or 30 minutes, that can also be a sign that they’re having some difficulty in their feeding.
In terms of older infants or children who are now attempting to eat table foods, some of the difficulties we will often see in our clinic are parents reporting ongoing choking, gagging or sometimes coughing during meals. Sometimes children will frequently be spitting foods out of their mouth, and that can be a sign that maybe there’s some kind of oral motor weakness or oral motor impairment going on. If they have an inability to tolerate or consume age-appropriate food textures, that can be a red flag. For example, this may be an infant who is struggling to progress from a breast or bottle to baby food purees or could be a one year old who’s having difficulty with soft table foods or perhaps even a preschooler who isn’t able to eat more difficult food textures such as foods that produce juice, mixed consistency items like food or like pizza or even harder to chew foods, so, and a lot of our preschoolers that we do see sometimes they do come to us with a very limited food repertoire, meaning they have less than 20 different foods that they’re able to eat consistently and successfully, and certainly if they’re avoiding or they demonstrate an aversion of foods in a specific nutrition group or with a specific texture, that can also be a red flag.
Melanie: Well, thank you for that great information for parents. If an infant or child is referred for an evaluation, what’s involved in the process and also, tell us who is involved in the process and tell us about your multidisciplinary team?
Julie: Yeah. An evaluation typically includes a variety of team members. Especially here at Bryan, we really focus on a multidisciplinary approach to treating infants and children with any feeding or swallowing challenges. A lot of the times it includes a speech therapist, an occupational therapist, and a registered dietician, depending on what the feeding or swallowing concern is. So, when a child comes to us for an evaluation, we typically obtain a fairly detailed case history to gain a better understanding of any previous medical or feeding experiences that may have contributed to the child’s current difficulties. Whether this was a previous, you know, stay in our neonatal intensive care unit, or, you know, respiratory problems growing up, or significant reflux history, those kinds of things just so we can gain a better understanding about where they are at currently and maybe why. We typically assess a variety of different areas including their motor skills, their oral motor structure and function that is needed for feeding and swallowing as well as their sensory symptoms and nutritional or growth factors that might be contributing to their feeding or swallowing difficulties.
Melanie: So, tell us about a therapy session. I’m sure that parents want to know what they can expect from a session with you and your team. What’s it like for the child? What’s it like for the parents? Are they present for this? Tell us about it.
Julie: Absolutely. So, everybody—every child obviously comes with a different set of needs, and so every session might look a little bit different for each child, but we often encourage parents to be an active participant in these sessions. There are situations where sometimes the child might do better without mom or dad in the room, but we also have a one-way mirror, too, where they’re able to view in and look at the session and see, how we’re running the session, what strategies we’re using. So, that way, they can learn and take those strategies home with them as well, but in all of our therapy sessions, you know, we utilize food or liquid as our tools for our treatment. So, for most therapy sessions, our focus is not so much focused on the volume of food or liquid that the child is consuming, but we’re really focused on building skill. We choose specific foods or textures or flavors of food to work on specific skills that the child needs help developing or advancing. So, for example, if one of our goals is working on chewing skills, we’re going to choose foods that require that particular skill. You know, for instance, for example, if our skill is working on suck, swallow, breath coordination, we’re going to work on different positioning strategies and perhaps nipple flow rates for their bottle to help facilitate the development of that skill as well.
Host: So, what improvements can you make in a child’s feeding or swallowing skills through obviously correct diagnosis and treatment and these sessions? What do you see? What have your outcomes been?
Julie: For infants, we can really improve the safety and their quality of their feedings with appropriate positioning techniques, recommendations for nipple flow rates for bottles, and any other feeding strategies that can help their child’s feeding experience. We really want to focus on creating a positive feeding experience, not only for the child, but for the parents as well because feeding should be fun. It should be this nice reciprocal interaction between a parent and child versus being an experience that’s stressful. For infants and children that are eating solid table foods, we really aim to increase the child’s confidence and enjoyment with eating. Our overall goal is for children to be able to eat and swallow age appropriate food textures needed for adequate growth and nutrition. We really want children to feel comfortable trying new foods while also expanding their current food repertoire to a nice variety of proteins, starches and fruits or vegetables.
Host: As we wrap up, Julie, and this is such important information for parents to hear, how do you work with the families you mentioned that you encourage them to be involved and a part of the therapy session—how do you work with them so they can continue to progress their child’s skills at home and what would you like them to know about infant feeding and swallowing disorders and what you can do for them at Bryan Health?
Julie: Yeah, parents are provided with weekly education, you know, regarding their child’s performance in feeding therapy as well as home program recommendations. So, somebody’s recommendations might include, but are certainly not limited to providing them with the education on adequate or supportive positioning for feeding, and that’s true for infants all the way up to older kids who might need some additional support in order to be able to feed successfully. We often provide a lot of recommendations for certain bottles or certain flow rates as well as various spoons or even different cups to utilize at home to support their child where they’re currently at with their feeding skills so they can be as successful as possible at home. We often have a lot of discussions in regards to mealtime strategies and how we can create a positive mealtime environment and routine at home to maintain some consistency and some structure in their day, and then we also provide families with specific food textures that they can utilize at home to facilitate or advance a certain oral motor skill. I think overall the best advice I have is just to try to have patience with not only yourself but not only your child but yourself as well because feeding is hard. It’s very hard to learn. It’s not just this automatic thing. It’s development, just like so many other things. I think, keep in mind, too, when you’re at a mealtime, that although swallowing food might be the end goal, it’s not the only measurement of success. So, sometimes, children really just need to explore, touch, play, smell, or even taste foods multiple times before they’re willing to put it in their mouth on their own, and so I think it’s really important to praise and celebrate these victories, but overall, mealtimes should really, for the most part, be a fun and positive experience. So, if you feel like mealtimes have become a huge battle, if they’re stressful, or if parents are constantly reporting their child as being a picky eater or difficult to feed, they should certainly discuss those concerns with their pediatrician or family doctor, but I think most importantly, too, if your child is having difficulty with eating or at a mealtime, just want to assure parents that it’s not their fault and that there’s help available to make mealtime fun again.
Host: Excellent wrap up and thank you so much, Julie, for such great information for parents that are struggling with this, and it can be so frustrating and a little bit scary. So, thank you for telling us about your team and your approach to feeding and swallowing disorders and thanks to our Bryan Foundation partner Sampson Construction. That concludes this episode of Bryan Health Podcast. Head on over to our website at bryanhealth.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Bryan Health Podcasts. For more health tips and updates please follow us on your social channels. Until next time, I’m Melanie Cole.