Selected Podcast
Treating Feeding and Swallowing Difficulties in Small Children
Tammy Navarro discusses feeding and swallowing difficulties in babies and small children, what parents need to watch out for and the treatment options available for this concerning disorder.
Featured Speaker:
Tammy Navarro, MS
Tammy Navarro, M.S., CCC-SLP, is a Speech Language Pathologist at Hendricks Regional Health. Transcription:
Treating Feeding and Swallowing Difficulties in Small Children
Melanie Cole (Host): You may not realize this or think about it, but children do have to learn the process of eating, and for some, they can develop issues or difficulties with feeding and swallowing, but there are treatments and therapies that are available to help them. My guest today is Tammy Navarro. She's a speech and language pathologist with Hendricks Regional Health. Tammy, what children's health problems can affect swallowing and feeding? How common is this?
Tammy Navarro, MS, CCC-SLP (Guest): Well, commonality about 25% to 40% or even 45% of all children have some form of a feeding disorder. 80% to 85% of developmentally delayed children have some form of eating disorders, and they can include a whole list of signs, and symptoms, and causes that are medically-based or behaviorally, psychosocial, just structurally-based. There was a recent publication that actually helped us come to a more uniformed definition of pediatric disorder. Basically it is defined as an impaired oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. So that just kind of gives us a broad perspective of all the different things that can cause disorder from infancy through childhood- early childhood and beyond.
Host: Are feeding disorders and swallowing disorders the same thing?
Tammy: So no, not necessarily. So feeding disorder with that definition I just gave you will include a swallowing disorder. Swallowing disorders then a little bit more in the realm of a speech language pathologist or even an occupational therapist who may have had extensive training in the area will cover things that cause an individual to have trouble handling food or liquids in the mouth that then get transferred into the throat area or the pharynx and then also further down into the esophagus. And that's where the swallowing comes in, is when food and liquid are transferred from the mouth into the throat area.
Host: Are there some certain conditions that a child might be born with that would contribute or make it more likely that they're going to have feeding disorders?
Tammy: Absolutely. So, there are congenital issues. So children can be born with more commonly known cleft lip and palate. They can have issues or structural kinds of issues in the throat area that- structures that protect the airway or structures that help transport food down; for example, the esophagus. There are other areas or congenital diseases that we may not associate with a swallowing dysfunction or feeding dysfunction such as heart disease. So congenital heart disease and then also pulmonary or breathing issues that children can be born with, and then a lot of common diagnoses like down syndrome, cerebral palsy, those types of things.
Host: Are there some signs that parents should look for? Obviously if a baby is nursing, breastfeeding, a mother might recognize if the child's not taking in food. If they're a little bit older, are there some red flags that parents should be looking for from infancy on?
Tammy: Absolutely. So, babies are basically born with that innate or instinct to breastfeed, or bottle feed if that's what they're offered. So coughing and choking obviously, having difficulty managing the liquid or the food in the mouth for older children. Lack of responsiveness, maybe showing signs of extreme hunger, but for some reason not latching onto the nipple. Children who are often called picky eaters, some can be mildly, or some can be extremely picky in the foods that they willingly consume. Frequent congestion, especially if it's associated with eating or drinking. Vomiting can occur. Crying at mealtime; oftentimes we'll see behavioral things occur with older kids that we may not necessarily associate with, a feeding disorder and chalk it up to just not wanting to do what Mom or Dad is asking them to do at the table, or refusing food. There could be an underlying medical condition that is causing these children to refuse food, because when they do eat them, there's a physical discomfort, something they're feeling that is causing them to associate it with a certain food or drink, and so they do the best they can to communicate that they don't want it without being able to say, "That hurts my tummy." Especially for younger kids who may not be able to express themselves very well yet.
Host: How are they diagnosed? If a parent brings this up with their pediatrician first, and says, "What do I do? This child is doing some of these symptoms, gagging, refluxing," whatever it is that they're noticing, they go to their pediatrician, then what is the next step? How is it diagnosed?
Tammy: It typically depends on the pediatrician and what specialist they're going to seek out first dependent on the symptoms. So a gastroenterologist may be their next step, sending them to do testing there. If it's food deficiency, they just eat a lot of grains, they won't eat vegetables or fruits, they may refer them on to a nutritionist to help determine how they can get their kids to eat more of the healthier choices that they're offering. If there are outward signs that parents are expressing, "They seem to cough and choke a lot whenever they're eating or drinking," then oftentimes they will get referred to a speech language pathologist to do an examination, which we can do either in the clinic, or we can do an instrumental type of assessment, especially if there is concern that something is going into the airway. And so we can do a modified barium swallow study in radiology. There's also a fiberoptic endoscopic swallow study where we use a flexible tube that goes through the nose to help you. What happens to the food or drink when it's swallowed? Where does it go, specifically regarding the airway?
Host: What treatment options are available, Tammy? Speak about some of the things that you would do with babies or small children. I mean, how intense is a feeding difficulty therapy session? Do the parents sit in on it? Do you teach them how to work with the kids when you're not around? Tell us about how that process works.
Tammy: Yeah, absolutely. I specifically - and a lot of feeding therapists are the same way - will want the caregiver, whether it's parents or grandparents, whoever is the primary caregiver, or at least someone who's involved with feeding that child frequently to sit in, because a lot of what we do in therapy is going to have to transfer into the home environment so that they can work on these things on a daily basis, where I may only see them once a week.
So we work on first deciding or determining what is going on exactly. If it is something that's happening in the mouth, let's say there's an oral structure deficiency, the tongue is weak, or there's lack of chewing, or an infant is having trouble latching on either to breast and/or bottle, then we determine what is happening, and then prescribe a regimen of exercises. Sometimes we may have to put into place strategies to help that infant or child be able to eat and drink until we can help get those structures working better with exercises, and teach that to the parent or caregiver, and then they carry over those types of things at home. I meet with them usually once a week to kind of follow up on how those things are going, assess where their function is at that point, and make adjustments to the program.
We also determine if we need to refer them off to additional members of a feeding disorder team which can be another doctor who specializes in a certain area, such as a gastroenterologist. Maybe determine if allergy testing might be required, send them off to a nutritionist to help parents determine how to better offer nutrients that this child might be missing. So there's typically a team that's involved, depending on what's going on with that particular infant or child.
Host: Give parents listening some tips, things that they can do at home, as you are doing your therapy and you're showing them some of those things. Give the parents listening something that maybe they could try today, or an exercise that they could do with their children. Give us just a little bit of an example of what it is like when you're working with these kids.
Tammy: So for example, an infant who may have trouble with- maybe they're choking or coughing frequently while nursing and/or bottle feeding. So oftentimes I'll also incorporate the help of a lactation consultant if moms are breastfeeding. They're better knowledgeable about this than I am particularly. There are some feeding therapists who also have that background and can help with those aspects as well. But I may recommend certain positions or holding postures for that infant to minimize the coughing or choking. If it's a bottle fed infant, we will assess their bottle nipple flow. Is that nipple flow to fast? Is it not fast enough? I may suggest that they hold them in let's say a sideline position. So you have your infant on your lap with their legs up against your belly, you hold their neck and head supported with your let's say non-dominant hand, and you're literally having them face the side versus facing you, and you have them somewhat elevated and you hold the bottle horizontally to their lips, and that can help minimize the liquid falling back into the throat area, where if they have trouble controlling that liquid, it will fall more into the cheeks, or even a little bit outside of the mouth and protect their airway as you're helping them through paced feeding, meaning you're stopping their intake flow intermittently to help them swallow within their mouth, and then regroup, and be able to take more safely. So it prevents them from having liquid fall into the throat area and potentially the airway as they're feeding and keeping them more comfortable.
With young children, if you can work on placing foods to the side of where their back molars would be if they don't have them yet, or if they have their back molars, place foods to the side and you can have them chew on things that a little bit harder to break apart, and you can help strengthen their jaws for chewing. It also helps stimulate tongue movement while you're in there to help move the tongue side to side that is necessary for carrying food over to the chewing surfaces to promote better chewing. Sometimes kids don't chew their food all the way, and will try to swallow them whole, and then gag or choke on them, so that's a little bit of an exercise you can do to work on chewing, and teaching them how to use those muscles better.
Host: Such great information, Tammy. As you wrap up for us, please give your best advice, what else you would like parents to know about feeding difficulties in children, how long they can expect the therapy to take before real results are seen, and their child is maybe released from therapy. Really what you would like them to know about feeding difficulties.
Tammy: Well first of all, I'd like the parents to trust in their instinct or gut feeling that something just isn't right. Oftentimes- too many times I have parents coming in once they are finally referred for evaluation and treatment, is that this was something that was ongoing since birth, or ongoing for a year, and unfortunately as they bring that up- bring their concerns up to their primary care physician or pediatrician, oftentimes they will say, "Well, let's give them more time. Let's wait and see." And unfortunately if you don't catch something like a feeding disorder early on as it's happening, there are so many things that can continue and have kind of a domino effect in making that situation more challenging as that child gets older.
So trust your instincts, advocate for your child and yourself, and demand that referral if you have to, versus waiting and seeing. That would be my first primary recommendation for parents.
In terms of feeding therapy and the length, it really is dependent on the situation. I will have infants referred to me, let's say with a more mild situation, where we can determine, "Oh, there's a structural challenge going on in the mouth. We need to help the baby develop some strength and better function and exercises." Or other referrals can be made that can help quickly resolve the situation, and I've able to discharge an infant as early as two to three months after we first meet. The older the child is, the longer that therapy is going to take, and it unfortunately can take years, especially if that child has developed- learned the behaviors because of let's say a medical condition that caused them to decide that they're not going to want to eat and become what many call a picky eater. We have to first identify that medical condition if it hasn't already, get the appropriate treatment in place, and then work with that child and their family to help them learn to be comfortable with foods and liquids, and gradually increase their choices and willingness to try new foods, and be able to meet their nutritional and hydration needs. The older the child, the longer that therapy can take.
Host: Really great information and so important, Tammy, for parents to hear from you, an expert in this area to describe the therapies that are available. Because feeding difficulties can be quite scary for parents. I know this, so thank you again for joining us. This is Health Talks with HRH - Hendricks Regional Health. For more information, please visit www.Hendricks.org. That's www.Hendricks.org. I'm Melanie Cole, thanks so much for tuning in today.
Treating Feeding and Swallowing Difficulties in Small Children
Melanie Cole (Host): You may not realize this or think about it, but children do have to learn the process of eating, and for some, they can develop issues or difficulties with feeding and swallowing, but there are treatments and therapies that are available to help them. My guest today is Tammy Navarro. She's a speech and language pathologist with Hendricks Regional Health. Tammy, what children's health problems can affect swallowing and feeding? How common is this?
Tammy Navarro, MS, CCC-SLP (Guest): Well, commonality about 25% to 40% or even 45% of all children have some form of a feeding disorder. 80% to 85% of developmentally delayed children have some form of eating disorders, and they can include a whole list of signs, and symptoms, and causes that are medically-based or behaviorally, psychosocial, just structurally-based. There was a recent publication that actually helped us come to a more uniformed definition of pediatric disorder. Basically it is defined as an impaired oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. So that just kind of gives us a broad perspective of all the different things that can cause disorder from infancy through childhood- early childhood and beyond.
Host: Are feeding disorders and swallowing disorders the same thing?
Tammy: So no, not necessarily. So feeding disorder with that definition I just gave you will include a swallowing disorder. Swallowing disorders then a little bit more in the realm of a speech language pathologist or even an occupational therapist who may have had extensive training in the area will cover things that cause an individual to have trouble handling food or liquids in the mouth that then get transferred into the throat area or the pharynx and then also further down into the esophagus. And that's where the swallowing comes in, is when food and liquid are transferred from the mouth into the throat area.
Host: Are there some certain conditions that a child might be born with that would contribute or make it more likely that they're going to have feeding disorders?
Tammy: Absolutely. So, there are congenital issues. So children can be born with more commonly known cleft lip and palate. They can have issues or structural kinds of issues in the throat area that- structures that protect the airway or structures that help transport food down; for example, the esophagus. There are other areas or congenital diseases that we may not associate with a swallowing dysfunction or feeding dysfunction such as heart disease. So congenital heart disease and then also pulmonary or breathing issues that children can be born with, and then a lot of common diagnoses like down syndrome, cerebral palsy, those types of things.
Host: Are there some signs that parents should look for? Obviously if a baby is nursing, breastfeeding, a mother might recognize if the child's not taking in food. If they're a little bit older, are there some red flags that parents should be looking for from infancy on?
Tammy: Absolutely. So, babies are basically born with that innate or instinct to breastfeed, or bottle feed if that's what they're offered. So coughing and choking obviously, having difficulty managing the liquid or the food in the mouth for older children. Lack of responsiveness, maybe showing signs of extreme hunger, but for some reason not latching onto the nipple. Children who are often called picky eaters, some can be mildly, or some can be extremely picky in the foods that they willingly consume. Frequent congestion, especially if it's associated with eating or drinking. Vomiting can occur. Crying at mealtime; oftentimes we'll see behavioral things occur with older kids that we may not necessarily associate with, a feeding disorder and chalk it up to just not wanting to do what Mom or Dad is asking them to do at the table, or refusing food. There could be an underlying medical condition that is causing these children to refuse food, because when they do eat them, there's a physical discomfort, something they're feeling that is causing them to associate it with a certain food or drink, and so they do the best they can to communicate that they don't want it without being able to say, "That hurts my tummy." Especially for younger kids who may not be able to express themselves very well yet.
Host: How are they diagnosed? If a parent brings this up with their pediatrician first, and says, "What do I do? This child is doing some of these symptoms, gagging, refluxing," whatever it is that they're noticing, they go to their pediatrician, then what is the next step? How is it diagnosed?
Tammy: It typically depends on the pediatrician and what specialist they're going to seek out first dependent on the symptoms. So a gastroenterologist may be their next step, sending them to do testing there. If it's food deficiency, they just eat a lot of grains, they won't eat vegetables or fruits, they may refer them on to a nutritionist to help determine how they can get their kids to eat more of the healthier choices that they're offering. If there are outward signs that parents are expressing, "They seem to cough and choke a lot whenever they're eating or drinking," then oftentimes they will get referred to a speech language pathologist to do an examination, which we can do either in the clinic, or we can do an instrumental type of assessment, especially if there is concern that something is going into the airway. And so we can do a modified barium swallow study in radiology. There's also a fiberoptic endoscopic swallow study where we use a flexible tube that goes through the nose to help you. What happens to the food or drink when it's swallowed? Where does it go, specifically regarding the airway?
Host: What treatment options are available, Tammy? Speak about some of the things that you would do with babies or small children. I mean, how intense is a feeding difficulty therapy session? Do the parents sit in on it? Do you teach them how to work with the kids when you're not around? Tell us about how that process works.
Tammy: Yeah, absolutely. I specifically - and a lot of feeding therapists are the same way - will want the caregiver, whether it's parents or grandparents, whoever is the primary caregiver, or at least someone who's involved with feeding that child frequently to sit in, because a lot of what we do in therapy is going to have to transfer into the home environment so that they can work on these things on a daily basis, where I may only see them once a week.
So we work on first deciding or determining what is going on exactly. If it is something that's happening in the mouth, let's say there's an oral structure deficiency, the tongue is weak, or there's lack of chewing, or an infant is having trouble latching on either to breast and/or bottle, then we determine what is happening, and then prescribe a regimen of exercises. Sometimes we may have to put into place strategies to help that infant or child be able to eat and drink until we can help get those structures working better with exercises, and teach that to the parent or caregiver, and then they carry over those types of things at home. I meet with them usually once a week to kind of follow up on how those things are going, assess where their function is at that point, and make adjustments to the program.
We also determine if we need to refer them off to additional members of a feeding disorder team which can be another doctor who specializes in a certain area, such as a gastroenterologist. Maybe determine if allergy testing might be required, send them off to a nutritionist to help parents determine how to better offer nutrients that this child might be missing. So there's typically a team that's involved, depending on what's going on with that particular infant or child.
Host: Give parents listening some tips, things that they can do at home, as you are doing your therapy and you're showing them some of those things. Give the parents listening something that maybe they could try today, or an exercise that they could do with their children. Give us just a little bit of an example of what it is like when you're working with these kids.
Tammy: So for example, an infant who may have trouble with- maybe they're choking or coughing frequently while nursing and/or bottle feeding. So oftentimes I'll also incorporate the help of a lactation consultant if moms are breastfeeding. They're better knowledgeable about this than I am particularly. There are some feeding therapists who also have that background and can help with those aspects as well. But I may recommend certain positions or holding postures for that infant to minimize the coughing or choking. If it's a bottle fed infant, we will assess their bottle nipple flow. Is that nipple flow to fast? Is it not fast enough? I may suggest that they hold them in let's say a sideline position. So you have your infant on your lap with their legs up against your belly, you hold their neck and head supported with your let's say non-dominant hand, and you're literally having them face the side versus facing you, and you have them somewhat elevated and you hold the bottle horizontally to their lips, and that can help minimize the liquid falling back into the throat area, where if they have trouble controlling that liquid, it will fall more into the cheeks, or even a little bit outside of the mouth and protect their airway as you're helping them through paced feeding, meaning you're stopping their intake flow intermittently to help them swallow within their mouth, and then regroup, and be able to take more safely. So it prevents them from having liquid fall into the throat area and potentially the airway as they're feeding and keeping them more comfortable.
With young children, if you can work on placing foods to the side of where their back molars would be if they don't have them yet, or if they have their back molars, place foods to the side and you can have them chew on things that a little bit harder to break apart, and you can help strengthen their jaws for chewing. It also helps stimulate tongue movement while you're in there to help move the tongue side to side that is necessary for carrying food over to the chewing surfaces to promote better chewing. Sometimes kids don't chew their food all the way, and will try to swallow them whole, and then gag or choke on them, so that's a little bit of an exercise you can do to work on chewing, and teaching them how to use those muscles better.
Host: Such great information, Tammy. As you wrap up for us, please give your best advice, what else you would like parents to know about feeding difficulties in children, how long they can expect the therapy to take before real results are seen, and their child is maybe released from therapy. Really what you would like them to know about feeding difficulties.
Tammy: Well first of all, I'd like the parents to trust in their instinct or gut feeling that something just isn't right. Oftentimes- too many times I have parents coming in once they are finally referred for evaluation and treatment, is that this was something that was ongoing since birth, or ongoing for a year, and unfortunately as they bring that up- bring their concerns up to their primary care physician or pediatrician, oftentimes they will say, "Well, let's give them more time. Let's wait and see." And unfortunately if you don't catch something like a feeding disorder early on as it's happening, there are so many things that can continue and have kind of a domino effect in making that situation more challenging as that child gets older.
So trust your instincts, advocate for your child and yourself, and demand that referral if you have to, versus waiting and seeing. That would be my first primary recommendation for parents.
In terms of feeding therapy and the length, it really is dependent on the situation. I will have infants referred to me, let's say with a more mild situation, where we can determine, "Oh, there's a structural challenge going on in the mouth. We need to help the baby develop some strength and better function and exercises." Or other referrals can be made that can help quickly resolve the situation, and I've able to discharge an infant as early as two to three months after we first meet. The older the child is, the longer that therapy is going to take, and it unfortunately can take years, especially if that child has developed- learned the behaviors because of let's say a medical condition that caused them to decide that they're not going to want to eat and become what many call a picky eater. We have to first identify that medical condition if it hasn't already, get the appropriate treatment in place, and then work with that child and their family to help them learn to be comfortable with foods and liquids, and gradually increase their choices and willingness to try new foods, and be able to meet their nutritional and hydration needs. The older the child, the longer that therapy can take.
Host: Really great information and so important, Tammy, for parents to hear from you, an expert in this area to describe the therapies that are available. Because feeding difficulties can be quite scary for parents. I know this, so thank you again for joining us. This is Health Talks with HRH - Hendricks Regional Health. For more information, please visit www.Hendricks.org. That's www.Hendricks.org. I'm Melanie Cole, thanks so much for tuning in today.